Right Thing to Do: Making the Case for Drug Pricing Transparency
Americans spent $419 billion on prescription drugs in 2015, up nearly 12 percent from the previous year. Estimates for 2016 project an increase of as much as 13 percent.
Although spending on new drugs and increased use of existing drugs explain some of last year's spending spike (2.7 percent and 0.5 percent, respectively), more than 8 percent represents price increases for existing drugs. As manufacturers continue to raise prices, spending will continue to soar.
The combination hepatitis C drug ledipasvir-sofosbuvir (Harvoni) led the industry in 2015 with $14.3 billion in sales. Small wonder, when the typical 12-week, once-a-day course of treatment for patients with hepatitis C infection costs a whopping $94,500 overall.
Similarly, the treatment regimen for another hep C drug made by the same manufacturer -- Gilead Sciences Inc. -- consists of the same 84 pills taken over a 12-week course. At $1,000 a pill, sales for sofosbuvir (Sovaldi) also add up quickly. (That same pill, by the way, costs less than $5 in some other countries). Many find the discrepancy outrageous, but the drug's manufacturer was determined to weather any backlash when it set the price.
Of course, one manufacturer alone isn't responsible for a problem this big. Last year, Turing Pharmaceuticals and its (then) CEO Martin Shkreli generated headlines for making a similar egregious and unconscionable price increase. Turing, which holds sole rights to market pyrimethamine in the United States -- where it is sold only as the brand-name medication Daraprim -- boosted the price of the drug, which is used to treat toxoplasmosis and prevent malaria, from $13.50 per pill to $750.
Needless to say, the rising costs of prescription medications -- both brand-name and generic versions -- continues to create affordability challenges for patients and payers alike.
Many of the medications routinely prescribed by family physicians for conditions such as asthma have been priced out of the reach of many patients, including those with health insurance. Lifesaving medications such as epinephrine for anaphylaxis and naloxone for opioid overdose reversal have also been subject to unjustified price increases.
Pharmaceutical company practices, such as "pay for delay" tactics that protect existing drug patents and delay the entry of generic medications to the market, stymie access to these less costly therapeutic alternatives and violate AAFP policy meant to ensure the availability of formulary medications that demonstrate "a proper balance of cost, efficacy, quality and ease of use to optimize individual outcomes in the context of resource conservation."
I recently attempted to prescribe antiretroviral medications for a young man I had screened and diagnosed with HIV. He was devastated by the news but willing to start treatment right away. Imagine how disheartened he felt when the pharmacist told him he needed to pay $1,129.35 toward his deductible before he could buy the lifesaving medications for $45 per month. My patient asked me if he should quit his job to qualify for a public assistance program. Instead, I'm helping him acquire supplemental assistance through the Maryland AIDS Drug Assistance Program.
How can family physicians advocate for making medications more affordable? Supporting legislation at the state and federal level could help.
Although more than two-thirds of states have adopted some type of anti-price-gouging statute, the laws do not specifically extend to pharmaceutical costs. Most address unjustified price increases for certain commodities during emergencies, such as raising the price of snow shovels during a snowstorm.
In June, Vermont became the first state to require drug manufacturers to justify large price increases. However, this was only a first step because many critical actionable elements were removed from the bill before passage. Moreover, the Vermont legislation did not include specific price-gouging provisions to address unjustified increases in drug prices.
In California, state Sen. Ed Hernandez recently withdrew his drug bill from consideration after it was weakened by several amendments. That bill would have required payers to report data on pharmaceutical drug costs to state regulators, and it also would have required drug manufacturers to notify payers, pharmacy managers and state agencies of impending price increases.
However, a November ballot initiative in California, Proposition 61, would prevent state agencies from paying more for a medication than the amount paid by the Department of Veterans Affairs (VA), which receives a discount off average manufacturer prices.
In addition to state-based efforts to promote drug pricing transparency, several national proposals intended to foster transparency have emerged, including measures to allow the federal government greater negotiating power and to limit manufacturers' ability to engage in anticompetitive practices that keep prices high.
- The MAC Transparency Act (H.R. 244) would reform how maximum allowable costs (MAC) lists are determined and how frequently pharmacy benefits managers update them. It also would establish an appeals process for pharmacies to dispute reimbursements and would extend reforms to Medicare Part D, TRICARE and the Federal Employees Health Benefits Program.
- The Medicare Prescription Drug Price Negotiation Act (H.R. 3061/S. 31) would give Medicare the same negotiating power that exists within the VA, which pays roughly 40 percent less for medications than Medicare Part D plans.
- The Preserve Access to Affordable Generics Act (S. 2019) would prevent drug companies from buying competitors and/or paying incentives to delay generic drug companies from producing new products.
- The Medicaid Generic Drug Price Fairness Act (H.R. 2391/S. 1394) would require generic drug companies to provide a rebate to Medicaid if price increases exceed the rate of inflation.
- Under the Medicare Prescription Drug Savings and Choice Act (H.R. 3261), the Agency for Healthcare Research and Quality would assess a drug's clinical effectiveness, comparative effectiveness, safety and prescription adherence as part of the drug formulary review process.
- The Safe and Affordable Drugs from Canada Act (S. 122) would permit patients to import a 90-day supply of medication from Canada. It also would require the federal government to develop a list of approved Canadian pharmacies to ensure consumer safety.
- The Price Relief, Innovation and Competition for Essential Drugs Act (H.R. 5573/S. 3094) would shorten the exclusivity period before brand-name biological products could be offered as generics from 12 years to seven.
Unfortunately, movement on these bills is unlikely before the November election, and they would have to be reintroduced during the next Congress. But following these proposals through to enactment is vitally important to ensure the health and financial well-being of Americans.
Also of concern is the fact that there is little insight into the background and financial interests of the experts that the nation's largest pharmacy benefits management companies rely on to decide which drugs will be covered and which won't. AAFP guidelines on patient-centered formularies state, "Formulary changes must be made known to physicians and pharmacies prior to implementation."
As family physicians, we have the opportunity to advocate for our patients' expanded access to affordable medicines, and as an organization, we can amplify that sentiment throughout the house of medicine and to state and federal governments, as well as to corporations that control much of what impacts the patients we serve.
Richard Bruno, M.D., M.P.H., is the resident member of the AAFP Board of Directors.
Men's Health Campaign Offers Opportunity to Tout Family Medicine
A report on men's health the AAFP released on Aug. 9 gave Academy leaders an opportunity to tell the media about the importance of having a family physician. Two AAFP officers conducted interviews with 39 media outlets in less than six hours.[Read More]
Leveling the Playing Field: AAFP Tackles Flu Vaccine Supply Issues
Family physicians often receive their flu vaccine weeks after retail clinics get theirs. The AAFP is talking with vaccine manufacturers and other stakeholders to resolve the disparity.[Read More]
Let's All Commit to Reverse the Opioid Epidemic
Last week, AMA President Steven Stack, M.D., issued a letter entitled "Confronting a Crisis: An Open Letter to America's Physicians on the Opioid Epidemic." We have been working closely with the AMA and other physician organizations on this issue through the AMA Task Force to Reduce Opioid Abuse.
As family physicians, we see the havoc opioid abuse is causing families and communities across the United States. That's why we're working hard to provide adequate pain management for our patients who need it, while at the same time, raising awareness that addiction to opioids is a national health crisis.
© 2016 Sheri Porter/AAFP
I am discussing the nation's opioid crisis with Surgeon General Vivek Murthy, M.D., M.B.A. We met April 18 in Washington to discuss possible collaborations between the Academy and the surgeon general's office.
A recent AAFP study showed that opioids are not our first choice when we're treating patients with chronic pain -- four other treatment methods (physical and occupational therapy, oral non-aspirin nonsteroidal anti-inflammatory drugs, acetaminophen, and antidepressants) are prescribed or recommended for our patients dealing with non-malignant chronic pain before opioids. While this is not a surprise to you, it is important to share this information with patients, payers, legislators and policy makers.
Please know that your AAFP is working closely with other organizations to combat the scourge of opioid abuse -- the White House, HHS, the surgeon general of the United States, and the CDC to name a few. And we have multiple resources readily available to you -- with more to come in early June.
We all need to do our part to end this epidemic. Showing our resolve, by voluntarily increasing our individual CME hours dedicated to opioids and pain management, is a step that we can each take. The AAFP has collated the CME on this topic to make it easier for you to locate, complete and report your hours. Please log in and refresh your knowledge on these critical issues.
Family physicians are dedicated to being a part of the solution to help slow this national crisis. Please join me. Together, we can address this devastating epidemic -- balancing pain relief for our patients in need with our sincere desire to always do no harm.
Wanda Filer, M.D., M.B.A., is president of the AAFP.
FPs Can Be Trusted Guides When the Dying Don't Specify Wishes
Each day when I walked into his hospital room, I greeted him with, "Hello there, Mr. Gold! How are you?" His cerebral amyloid angiopathy, resulting strokes and severe dementia had left him chronically debilitated and nonverbal, but his gazing eyes were enough for me to acknowledge our shared humanity.
For nearly a month, I took care of him on our inpatient service, treating him through seizures, aspiration pneumonias, intubations and extubations. I learned at his funeral service that he had gone by the nickname "Cuz," and when asked by the pastor to give a few words, I admitted that I had not had the benefit of knowing my patient in his prime. However, I had the distinct honor of helping him through his final days. And I was inspired by the love his family showered on him.
Every day, I sat down with Mrs. Gold (not the family's real name) and discussed the care plan, hopeful that her husband could return home to her capable care. But as his situation progressively worsened, it became clear that he might not ever make it home from the hospital.
She struggled with granting an "allow natural death" status that would forfend the high-caliber interventions that were becoming more and more futile. The only direction she had received from her husband on this difficult topic before his illness was that if his heart stopped, he wanted to be brought back.
Never mentioned in their conversations was a scenario in which he had progressive dementia and organ failure. Never discussed was the option of withdrawing care in the context of loss of dignity and quality of life.
So, in this situation neither of them had foreseen, she was doing her best to extrapolate what his end-of-life preferences would be from the minimal information he had imparted.
Reluctantly, she agreed to press on with full code interventions. By the second intubation, the palliative care team and I discussed with her the option of in-hospital hospice, where he could be extubated and spend his final days in the company of family without invasive tubes, lines, bells and whistles. He passed there peacefully, but his family's ordeal may have been less traumatic if he had made his wishes clear.
The Health is Primary campaign released patient materials earlier this year that discuss palliative care and advance directives, and American Family Physician has a collection of journal articles related to end-of-life care that include content for patients as well as physicians. These tools can help your practice and your patients with end-of-life discussions.
Often, family members are put in situations that require them to make decisions on behalf of their loved ones. Sometimes they disagree on how these decisions should be made or carried out. Difficult conversations can often be managed skillfully by family doctors who have developed trust and intimate knowledge of those they care for. Being able to give people a wide array of options is an honor. Putting the needs of those we serve above our own is an even higher honor.
Helping Mrs. Gold through this process was deeply inspiring for me. In the closing paragraphs of Mr. Gold's funeral service program, she quoted an anonymous poem: "So I gave to you life's greatest gift, the gift of letting go."
It's worth noting that a growing number of dying patients will soon have the ability to control their fate, allowing them to experience a far different process than my patient in Maryland. A new law in California that goes into effect June 9 will allow qualified patients the ability to self-administer a prescribed medication to aid in the dying process. For many, this would be preferred to the common hospital scenario of prolonged suffering, often alone.
The California AFP has responded with a set of resources that includes a series of four podcasts (each less than 10 minutes) on end-of-life conversations, an American Board of Family Medicine Part IV (Performance in Practice) Maintenance of Certification Module, a guide to weaving palliative care into your practice and additional information on the new California law (which is similar to laws already in place in Washington and Oregon).
Richard Bruno, M.D., M.P.H., is the resident member of the AAFP Board of Directors.
Seeing the Diseases Vaccines Prevent Illustrates Importance of Immunizations
Editor's Note: In recognition of National Infant Immunization Week, the AAFP is participating in a blog relay to discuss the critical role vaccines play in protecting children, families and communities against vaccine-preventable diseases. You can follow the conversation on social media using #NIIW.
It was a hot, humid day in Cap-Haitien. I was a premed student serving as both an extra pair of hands and as a medical interpreter during my first medical mission trip to Haiti.
The magic of being in the country of my roots enveloped my senses. A deep sense of pride swelled within me as I heard the ocean in the distance, smelled the spices that I had grown up eating and marveled at the intense beauty of the terrain. However, that pride was repeatedly flattened by grief from the immense poverty that surrounded me. Even though it has been more than 10 years since that trip, the images of so many people in need of the type of care I had taken for granted continue to drive me today.
I remember seeing a teenager stiff from tetanus and unable to swallow. His mother held him and pleaded for help.
I held an infant, feverish with pneumonia, who improved after my group paid for penicillin, IV fluids and oxygen.
We forget that American children used to routinely die from diseases that now can be prevented by vaccines. However, this is not the reality in many countries.
Today marks the beginning of National Infant Immunization Week which highlights the importance of protecting infants from vaccine-preventable diseases and celebrates the achievements of immunization programs across the country.
As a family doctor, one of the most important roles I play in my patients' lives is preventing disease and improving health. Every day I discuss the role of vaccines in health maintenance with my patients as a means to protect them and at-risk populations.
Thankfully, we are in an era where terrible diseases like polio, Haemophilus influenzae type B and measles are no longer commonplace in our country. However, in California (where I live), there are many parents who still choose not to vaccinate their children despite overwhelming evidence that demonstrates the safety and effectiveness of immunizations. As a result, we have witnessed the devastating effects of disease outbreaks.
Family physicians and other primary care stakeholders in my state have had to work hard mitigating a measles outbreak and the dangerous rise of pertussis, or whooping cough, in recent years.
The importance of vaccination resonates with me, personally, as a mother of three. When I returned to work after the birth of my youngest child, I had to consider exposing my child to potential antigens brought home from work. I was concerned that the decisions of others could affect the health of my own newborn.
I changed my practice and became more proactive in educating parents about vaccinations. Some parents entrusted their children to my counsel. For others, I decided that I may not be the right physician for them. Although I was torn between caring for patients and doing no harm, I knew I could not withhold vaccinations from a child who lacks the ability to make an informed decision. I also knew that not vaccinating families put others in our community at risk. With that said, I have gladly welcomed families who may have questions about immunizations or decide to use a catch-up schedule.
In California, we have adopted a law that emphasizes an individual's obligation to protect others. Specifically, it eliminates religious and personal belief exemptions for vaccines. This is an important step because the benefits of immunizations are not confined to the individual. Vaccination -- or lack of it -- can affect others unknowingly. Consider the newborn, too young to get vaccinated, or the immunocompromised person undergoing chemotherapy.
In a world that is so interconnected, we must be diligent to protect those at most risk, our children. Giving children the recommended immunizations by age 2 is the best way to protect them from more than a dozen serious -- but preventable -- diseases.
The CDC is right to trumpet the role immunizations have played in reducing the burden of illness in our society. Primary care physicians can add our voice by posting information in our waiting rooms and exam rooms. The CDC also has resources to help physicians get the word out by working with local media, using social media and more. We all can do our part.
It is easy to forget our past and to ignore the fact that the threat of preventable disease is palpable in other countries. For me, I remember those days on the mission field and the children whose fates were sealed without the option of prevention that too many among the privileged are rejecting.
Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.
Thoughts on Empathy Under the Northern Lights
The other night I was treated to a spectacular display of the aurora borealis. The sky glowed with shimmering light in a spectrum of green and red. It is amazing how something as ephemeral and yet complex as solar wind interacting with Earth’s magnetic field and atmosphere can create such beauty.
At the same time, I have been thinking a lot lately about empathy and how it relates to patient care, burnout and electronic health records (EHRs). Like the northern lights, empathy has a scientific basis, but is still nebulous and beautiful.
I use empathy as a diagnostic tool. My mind is geared to understand and mirror the emotions of others. Although I use logic and evidence-based medicine, I cannot deny that a large part of my assessment in the exam room is based on my reaction to how the patient feels. Our brains are uniquely wired for precisely this process and the trillions of neural connections along with experience trigger patterns of diagnosis. The way a patient moves onto the exam table, the small facial expressions, eye contact, skin color and the way the heart beats mean as much to me as do the history and lab work. I use all of this information to answer the fundamental question: Is this patient sick or not?
To feel what someone else is feeling is a gift given to us by an evolutionary legacy of living as social animals, and I use this gift in my work each day. Several years ago I walked into an exam room and within seconds realized that my 4-year-old patient had cancer. Knowing instantaneously what my diagnosis would be, I dedicated the remainder of the visit to fleshing out the history, conducting a physical exam and obtaining lab work that would identify her leukemia. This is not the only time this has happened to me, and I am not alone.
When the aurora is bright, the light comes in shimmering streamers from multiple directions at once across a large part of the sky. It is not sequential or directional, but manifests as parallel lines of color and light that come in waves and swirls.
Advances in neuroscience, such as functional magnetic resonance imaging, have shown us similar action in specific parts of the brain correlated with empathy. The neurologic basis of empathy is extremely complex and involves multiple areas of the brain. Memory is connected to our senses. Interpretation of visual cues is balanced with experience. Mirror neurons, the cingulate gyrus, and anterior insula, are all involved and all of this parallel processing occurs beneath the level of cognition. There is a good body of evidence to show that the same parts of the brain activate in response to pain -- whether it is personal or vicarious -- through empathy.
Our patients need this connection as well. As physicians we use empathy as a diagnostic tool, but both we and our patients need it to cope with disease at hand. Touch and eye contact have been shown to be an essential part of the physician-patient relationship and healing in and of themselves. A patient of mine once told me that she wished someone could see through her eyes and feel what it is to live with her chronic condition. The reality is that I try. I must because that is how our brains are wired. Empathy requires that to some degree, I model what others are feeling.
In medical school I was taught that it was important to empathize, but not sympathize. The intended lesson was for physicians in training to learn how to go home at the end of each day and be unaffected by the pain and suffering that we witnessed in the medical world. But our neuroanatomy precludes this model of training, especially in family medicine. We have to use every tool at our disposal to care for an undifferentiated complex population, and empathy is supremely important. However, there is a cost. We feel our patient’s pain. I have learned how to grieve efficiently.
Computers work differently, in series rather than in parallel and often the complex interplay experienced in the exam room does not translate to an electronic record. Further, stressful events may limit the use of an EHR entirely. I recently had such an experience. There was a tragic accident during a snowstorm, and after resuscitation I could not transfer my patient to a tertiary care hospital because of the weather. For 12 hours, I sat at her bedside with her family, completely in tune with my dying patient, her family and the team I was working with. For days after, I found that I was unable to use my EHR. I could see patients. I needed to see patients. But I could not use the EHR. It was like I had EHR aphasia, and it frustrated me immensely.
The burnout rate among family physicians has increased significantly since the advent of the EHR. There are many reasons for this, including increased administrative burden, less time per patient, and less time for family and exercise, which all leaves us with a feeling of decreased autonomy. Perhaps one of the problems is that computers are interfering with our ability to connect with our patients. Checking boxes decreases our ability to hold eye contact, and computers often get in the way of patient care. We need this connection as much as our patients do.
We feel the pain of our patients. To deny this is to discount one of the primary ways that we interact with one another. Our brains are wired to feel what others are feeling, and we need empathy if we are to care for our patients. And as with all gifts, there is a cost. We take some of our patient’s pain onto ourselves and share their burden. We need to recognize that as a result we often are grieving, and that this is the natural consequence of what we do.
We need to take care of ourselves physically and emotionally, turn to loved ones, have faith in a higher power and appreciate beauty where we find it. That was exactly my intention when I walked outside late that cold night to watch and to wonder at the phenomenon of the aurora borealis.
John Cullen, M.D., is a member of the AAFP Board of Directors.
Meet the Press: Why Working With the Media Makes Sense
When I woke up on March 17, I found more than three dozen messages from AAFP members in my voicemail and email. They weren’t calling or writing to tell me Happy St. Patrick’s Day.
The previous evening, The New York Times had posted a lengthy feature story about the challenge of balancing the need to curb opioid abuse with the need to help patients who have legitimate pain in a primary care practice. That practice, in this case, happened to be mine. A reporter and a photographer spent several days in Milford, Neb., shadowing me, interviewing my patients (and their families) and taking photographs. The result was an excellent, in-depth piece that makes it clear for any legislator, regulator or payer paying attention that this is not a situation that calls for a quick fix. This is a complex problem that will require a well-considered solution. Our patients do not need a one-size-fits-all approach to health care, and our members do not need a government-approved algorithm to determine treatment.
The family physicians who contacted me thanked me for helping tell this important story. Some said it must have been "onerous" to have a journalist in my exam rooms for several days. The reality is that I didn't mind at all, and my patients were eager to tell their stories -- often sharing extremely personal details with The Times and its 2.1 million readers. Nebraska is one of many states taking measures to limit opioid prescribing, and patients with compression fractures, cancer, fibromyalgia and more shared how such limitations will affect their ability to manage their pain and, thus, their ability to function and go about their daily routines.
My patients are not drug seekers but everyday people with their own perspectives on an issue that affects them greatly. They personalized the issue for a wide audience.
After spending a few days with me, the journalist got it. At one point, reporter Jan Hoffman said to me, "These aren't pain patients. They're just patients."
These are people with complex conditions and co-morbidities that are intertwined. Their pain is just one chapter of a much longer book. By sharing these stories we hope people can begin to understand how complicated this issue truly is.
When I met with legislators recently on Capitol Hill, they were eager for a solution to the opioid crisis. "We have to do something" was a frequent refrain. It's true that we have rising numbers of overdoses and accidental deaths, but it also is true that we need a well-developed plan and not a Band-Aid. If we move too rapidly, the complexity of the situation could get lost. We also need to stop pointing fingers at doctors and patients and get to the issue of treating pain effectively.
During her time with me, Jan saw patients dealing with issues like renal failure, heart failure and an array of physical problems. At one point, she asked me, "Is there anything you don't do?" Not only did she walk away with a greater understanding of the opioid issue, Jan also saw the breadth and depth of family medicine.
I'm excited to see such a well-written story with a family medicine perspective in a publication with such a large audience. Our stories -- and also our patients’ stories -- have power and value in our states and communities when we tell them at the local level. Showing your local media and/or your legislators how issues affect family physicians and the families we care for is time well spent.
Robert Wergin, M.D., is Board chair of the AAFP.
FPs Must Demystify Colorectal Cancer Screening
During the nearly two decades I worked as a health correspondent for our local NBC affiliate, my cameraman was a kind, funny man who seemed to know everyone in town. Phil not only was my colleague but also my friend.
Phil and I talked about the health segments we were working on, and he also frequently asked my opinion about health issues he and his family members were dealing with. He wanted my perspective on immunizations, medications and more.
Unfortunately, one health topic Phil never asked me about was colorectal cancer. I was heartbroken when I learned this wonderful man recently died a preventable death just a few weeks shy of his 61st birthday.
If Phil had asked me about colorectal cancer, I would have told him that his age and his race put him at increased risk, and screening would have been appropriate. Blacks have the highest incidence of colorectal cancer and the highest mortality rates of all racial groups.
Colorectal cancer is the second-leading cause of cancer deaths in the United States, yet nearly one-third of adults ages 50 to 75 aren't screened as recommended. Two years ago, the AAFP joined the National Colorectal Cancer Roundtable, which seeks to increase the percentage of adults ages 50 and older who are screened to 80 percent by 2018. It has been estimated that reaching that goal would avert roughly 280,000 new cancer cases and 200,000 cancer deaths within 20 years.
Family physicians can help by screening patients -- or referring patients to screening when appropriate -- and also by answering questions and demystifying the process.
It's worth noting that the U.S. Preventive Services Task Force issued a draft of updated screening recommendations in October. The Academy has offered feedback for the final recommendation, which is pending.
Others are doing research to learn how we can increase screening rates and close gaps in care. For example, the Patient-Centered Outcomes Research Institute (PCORI) -- an independent nonprofit that seeks to improve the quality and relevance of evidence available to help patients, physicians and others make informed health decisions -- is funding several projects related to colorectal cancer screening and treatment.
- Screening rates are substantially lower among Hispanics than non-Hispanic whites. A project at Thomas Jefferson University aims to improve screening rates among Hispanics by implementing an intervention that will identify the participant's preferred screening test and work with patients and their primary care providers to facilitate testing.
- A project at Indiana University will provide clinical evidence and patient input to guide decision-aid designers on how to present patients with comparative effectiveness information about screening methods.
- A North Carolina project aims to survey more than 1,000 colorectal cancer patients to develop measures for use in improving communications between physicians and patients.
Years ago, I lost an aunt to colorectal cancer in an era when screening was not yet widely accepted. She often was on my mind when I spent years lobbying in my state's capital for legislation that now requires insurers to cover screening.
Today, patients have more access to care and more options for potentially life-saving screening. It is up to us to ensure that they understand their risks and their choices.
Wanda Filer, M.D., M.B.A., is president of the AAFP.
E-prescribing Holds Potential to Curb Opioid Abuse
Nearly 2 million Americans have substance use disorders involving prescription pain relievers. Roughly 44 of them will die today, and 44 more the day after that, because prescription opioid abuse leads to more than 16,000 deaths each year.
The problem is complex, and there are no easy answers. However, one step we should all be considering seems obvious. Since Vermont came on board in August, electronic prescribing of controlled substances is now possible in all 50 states. E-prescribing provides better tracking and reduces diversion by creating a direct link between the physician and the pharmacy.
According to a report published in May 2015, nearly three-fourths of U.S. pharmacies were capable of receiving electronic prescriptions for controlled substances in 2014. Based on recent conversations with industry sources, the number now may be closer to 85 percent.
So if e-prescribing is the answer to reducing death and diversion, physicians must be rushing to get on board, right?
According to that same May 2015 report, only 1.4 percent of physicians who write physicians for controlled substances are set up to do so electronically. The fault, however, doesn't lie solely with prescribers.
In many cases, physicians are handcuffed by the limitations of their electronic health records systems and vendors' reluctance to make any changes without additional investments. Instead, they would prefer to nickel and dime physicians while people continue to die.
Family physicians are repeatedly asked by payers, the administration and others to make changes that require investment. Last year, the Academy joined a White House-led effort to curb opioid abuse. As part of that initiative, the Academy set goals to increase
- family physician education in appropriate opioid prescribing practices,
- the number of family physicians who complete training in how to provide medication-assisted treatment for opioid addiction, and
- overall awareness about opioid abuse and pain management.
The Academy also joined the AMA Task Force to Reduce Opioid Abuse, a group of more than two dozen physician organizations seeking to identify best practices to combat abuse and implement those practices nationwide.
The White House asked for our help, and we've responded. Family physicians are taking more education about opioids and pain management. According to the American Board of Family Medicine, more than 22,700 family physicians have completed the ABFM's pain management self-assessment module in the past six years. Furthermore, in each of the past four years, more than 16,000 family physicians per year have reported CME credits related to pain management or opioids, and those FPs reported completing an average of eight CME credits on this important topic.
Now it is time for electronic health record system vendors to also take responsibility for public health and ensure physicians have the tools available to address this crisis without the burden of another crippling expense.
Wanda Filer, M.D., M.B.A., is president of the AAFP.
Win-Win? Cardiology Project Could Benefit Patients, FPs
Cardiovascular disease (CVD) is the leading cause of death in the United States, claiming more the 600,000 lives each year. That's more than the population of Wyoming.
CVD accounts for 17 percent of U.S. health expenditures, and those costs are expected to triple between 2010 and 2030. Improving prevention and care processes, however, could substantially reduce morbidity, mortality and the costs associated with CVD, and the AAFP is participating in work that aims to do just that.
I recently attended a meeting at the Brookings Institution in Washington with representatives from the American College of Cardiology, the American College of Osteopathic Family Physicians and the American College of Physicians, as well as CMS, private-payer organizations, health systems, medical schools, research groups and the Veterans Health Administration. Our goal for this meeting, and the conference calls that preceded it, is ultimately to produce a policy paper that would serve as a model to improve the way primary care physicians and cardiologists work together.
The end product could result not only in better care for our patients, but more equitable pay for primary care. Our patients and our practices both have a lot to gain in the process.
It was interesting to see how much common ground primary care has with our subspecialty colleagues. We discussed numerous opportunities to close gaps in care, reduce overtreatment and address undertreatment.
Inadequate communication between physicians, patients and caregivers is one obvious problem we agreed on, and universal dismay was expressed -- from primary care, cardiology and payers -- about the state of electronic health record systems. Current products are not meeting needs and are a barrier to innovation.
We also agreed that physicians -- regardless of specialty -- need more time with our patients than what is typically possible in the fee-for-service world of health care. Cardiology is still firmly based in that fee-for-service model. Roughly three-fourths of practices are owned by health systems. Meanwhile, a recent study showed that roughly one-third of family physicians already are pursuing value-based payment.
So how do we pull the cardiologists into our patient-centered neighborhood? A representative from CareFirst BlueCross BlueShield pointed out that the payer has had tremendous success with the patient-centered medical home (PCMH) model, lowering both ER visits and readmission rates related to CVD. Primary care practices, he said, are receiving better payment as a result of this hard work. Health systems representatives also pointed to the PCMH as a means to improve quality and lower costs.
In addition to how we might work better together, we also discussed how improving care, coordination and communication could also affect payment, including pay-for-performance programs, bundled payments, shared savings and more.
This project, which is an initiative of the new Duke-Margolis Center for Health Policy, still has a long way to go. There will be followup work still to come. But the possibilities are intriguing, and if we can get it right, this could serve as a model for how primary care works with other subspecialties, as well.
Wanda Filer, M.D., M.B.A., is president of the AAFP.
U.S. Needs More Than Baby Steps on Paid Maternity Leave
Maybe, just maybe, Americans are finally waking up to a truth that has already been accepted globally: Paid maternity leave has far-reaching health implications for both mothers and their children, including facilitating breastfeeding.
Last month, Air Force Secretary Deborah Lee James said that branch of the U.S. military will triple its paid maternity leave benefit to 18 weeks, following the example set by the Navy back in August.
The international corporate world also took some big steps in the past year. Nestlé, the largest food and beverage marketer in the world, announced that it was extending its paid parental leave for primary caretakers from six weeks to 14 weeks for its workers globally, and it also will allow employees to take 12 unpaid weeks.
Nestlé CEO Paul Bulcke said in an interview with Fortune that supporting breastfeeding was one of the primary drivers behind changing the company's policy. That's an interesting step for a company that has been boycotted off and on for decades for the way it markets its infant formula.
The World Health Organization recommends that women should breastfeed for as long as two years, and the AAFP recommends breastfeeding for at least 12 months. (The Academy's breastfeeding toolkit has resources for moms and practices.)
It is well documented that breastfeeding is healthy for both mothers and babies, boosting immunity, increasing bonding, reducing risk of postpartum depression and decreasing risk of morbid obesity in babies. With an ever-growing amount of data that support breastfeeding, why does our country have such a dismal rate of mothers who breastfeed past the first six months of life?
Roughly 80 percent of U.S. mothers are breastfeeding during the first 48 hours postpartum, according to the CDC. That drops to approximately 20 percent by six months. Disparities become more pronounced when looking further into the demographics. Women who breastfeed beyond six months tend to be Caucasian, have higher household incomes, stay home and be more educated. Those least likely to breastfeed tend to be black working moms who are less educated and are from homes with lower household incomes.
Although there are many factors that contribute to these shameful statistics, a major one is the persistent lack of parental leave for the vast majority of U.S. workers. This is despite studies that indicate mothers who have sufficient time to transition into parenting not only are more successful with breastfeeding, they also use less sick days, are more productive, suffer less burnout and demonstrate more loyalty to their employer.
The United States is the only industrialized country in the world that does not support some kind of paid parental leave. Many people have little or no time off, even unpaid. Particularly for those affected by poor postnatal outcomes, taking time off could mean risking one's job.
Some might argue that the Family Medical Leave Act, which guarantees one's job after return from a leave due to birth, adoption or the serious illness of a loved one for up to 12 weeks, is sufficient. However, the law does not require the leave to be paid and it generally applies only to people who have worked at least 12 months for an employer who has at least 50 employees.
Unfortunately, only about 12 percent of U.S. employers offer paid maternity or paternity leave, according to the Society for Human Resource Management. That's down from 17 percent in 2010.
No one can deny that becoming a parent is a life-defining moment, one that requires time to which to adjust. However, how can one take that time when there are bills to pay? In my second year of residency, I took only two weeks off after delivering my second child because I was allotted only eight weeks of paid time off and I already had used five weeks for bedrest. (I needed my last week of vacation time for job interviews.)
So why is paid leave so important to one’s ability to breastfeed? Simply put, if I have to return to work before my milk even has time to be established, then how can I be successful in maintaining my supply? Furthermore, women are expected, or perhaps feel pressured, to make up for the time they were away on leave.
Becoming a mother is one of the hardest, yet most rewarding, accomplishments I have under my belt. Let’s not lessen the impact and powerful message working mothers make when they embrace their many important roles both in and out of work. We should celebrate our many roles, including providing nourishment for our children.
Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.
Telehealth Is Family Medicine’s Next Big Opportunity
Perhaps, like me, you've noticed that telehealth really hasn't lived up to its promise here in the United States. Although you may find the technology in niche markets, like satellite hospital consultations, there is hardly a transformative, mainstream movement of consumer access to family physician services online or by smartphone.
Yet the trends are unmistakable:
- Estimates vary, but perhaps 20 percent of what family physicians do in the office could be accomplished remotely. I would even go so far to say that much of what is happening now in retail clinics could be safely performed as a telehealth visit. (Will retail health be disrupted next?)
- Although the fee-for-service model has barely paid for telemedicine, the advent of new models such as direct primary care and accountable care organizations could create a sustainable funding source for services that were previously not paid for.
- Regulators at the state and national level are continuing to modernize the laws around telehealth and telemedicine to encourage physicians to engage patients remotely within clear boundaries that are safe and have utility to consumers.
- The proliferation of Bluetooth-enabled biosensors that can communicate with smartphones and sync data to cloud-based health information exchanges allow for remote monitoring of patients. These patients are empowered to decide with whom they will share that information. For some patients and family physicians, this might allow for a novel telehealth visit with vitals.
So what does the United States need to do to start participating more? Well, according to the American Telemedicine Association, we are about halfway there. State legislatures and policymakers must continue to remove regulatory barriers such as only requiring insurers to pay for telehealth for rural patients, because suburban and urban areas also have health care disparities and access problems.
Family physicians should not be required to document a barrier to an in-person visit before a health benefit plan covers telemedicine. And nothing should require the use of telemedicine when in-person care by a participating physician is available within the member’s geographic area, or when a family physician determines it is inappropriate. In other words, actual plan networks cannot be remote.
I am amazed at how many patients in this economy may have a tablet computer or a smartphone, but not an automobile. Moreover, just as we use Skype and Facetime with friends and family more than with strangers, I predict the strongest future for telehealth will be between family physicians and their long-time patients, not between strangers connecting to chat.
John Bender, M.D., M.B.A., is a member of the AAFP Board of Directors.
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