Special medicare watch

SPECIAL MEDICARE WATCH May 22, 2008 ===================== 1. Globe and Mail (May 22, 2008) Centralization: a step back for Alberta health care? Premier must explain how ending regionalization will improve innovation, access and quality of care By Andre Picard 2. Government of British Columbia (May 21, 2008) Ministry of Health - News Release & Backgrounder Government Accepts Drug Plan Recommendations 3. Multinational Monitor (May 16, 2008) Pharmaceutical Payola -- Drug Marketing to Doctors 4. Globe and Mail (May 22, 2008) Increasing pharmacists' powers raises concerns By Carly Weeks 5. Ottawa Sun (May 21, 2008) Docs too busy to follow up Study finds health system neglects chronic disease By Donna Casey ===================== 1.____________________________________________ Globe and Mail (May 22, 2008) Centralization: a step back for Alberta health care? Premier must explain how ending regionalization will improve innovation, access and quality of care By Andre Picard Last week, the Alberta government announced it was creating the Alberta Health Services Board. On the surface, it is a mundane bureaucratic change. But the government of Premier Ed Stelmach is essentially striking a death blow to regionalization - stripping the regions of the power to shape services to local needs and muzzling the public voice in health care. The AHSB will be responsible for the delivery of all health-care services in the province, while the Ministry of Health and Wellness will continue to be responsible for policy. The AHSB will replace the province's nine regional health authorities, the Alberta Mental Health Board, the Alberta Cancer Board and the Alberta Alcohol and Drug Abuse Commission with a single entity. Mr. Stelmach made some feel-good utterances about a "new governance model" that will "clarify roles and responsibilities" and create a "21st-century health-care system" that is "more effective and efficient." In reality, the government is centralizing power to a degree that would make Pierre Trudeau blush. Worse yet, the purpose seems unclear aside from exacting some political revenge; the Premier's principal rival for the Conservative leadership was Jim Dinning, a former chair of the Calgary Health Region and a strong proponent of regionalization. As difficult as it is to get excited about decision-making structures and governance, they really do matter to the delivery and quality of care and, ultimately, to patients. A bit of history is in order. Fifteen years ago, Alberta's provincial ministry of health managed 128 hospital boards, 25 public health boards and 40 long-term care boards. The centralized system was a mess and spending was out-of-control - as it was in most provinces. In 1994, the province introduced what was arguably the most dramatic change in health-care delivery in Canadian history, creating 17 health regions with appointed boards. The change was brutal - particularly because it was coupled with steep budget cuts - but the health regions were responsive and care improved. In 2003, the health regions were re-organized to create nine regions. Sadly, the government backed down on the election of board members and they were all appointed. Still, the regions were able to put pressure on the government for more money and for greater investments in infrastructure and research. Regionalization made government uncomfortable, but it also dramatically improved patient care. The regions were innovative and bold. Capital Health (Edmonton area) - which impartial observers have described as the best health system in North America, if not the world - created the impressive Mazankowski Alberta Heart Institute in addition to leading the way on electronic health records and reducing wait times. Not to mention that it is efficient, with probably the lowest administrative costs in Canada's health system. The Calgary Health Region, for its part, is light years ahead of the rest of the country on patient safety. It is creating a model for health-care delivery for the next generation with its Medical Ward of the 21st Century project, and doing groundbreaking work on managing chronic diseases such as diabetes. And its alternative payment plans for health professionals are finally dragging us out of the fee-for-service era. These achievements did not come about magically but with leadership and accountability, along with a healthy rivalry between Edmonton and Calgary that pushed each to excel. It would be a mistake to romanticize regionalization and overstate its benefits. The provinces expected miracles of the regions, beginning with the naive idea that devolving power would somehow save money. Perhaps regionalization has not lived up to expectations but, more than anything else, the failings of regions have been due to a lack of provincial leadership. Provinces have steadfastly refused to set health goals so their performance can be measured and judged. Accountability at the provincial level is virtually non-existent. Changes that occur on a provincial level are almost always restrained and incremental. And, worst of all, provinces have never allowed anything but a token voice to the patient and the public health-care system. Every province has instituted regionalization to varying degrees, but Alberta did it best. Until now. It is difficult to imagine how concentrating power back into a secretive, plodding ministry of health is going to improve care. The government will argue, of course, that the Alberta Health Services Board will operate at arm's length. But there is every indication that the leash will be short and new advisory councils will not hold much sway. Ultimately though, what matters is not structural change but the vision behind it. What Mr. Stelmach's government needs to articulate is how the new structure is going to promote innovation, improve access and bolster the quality of care. So far, all it has offered up is empty rhetoric, making this nothing but a power grab. 2.____________________________________________ Government of British Columbia (May 21, 2008) Ministry of Health - News Release Government Accepts Drug Plan Recommendations VICTORIA - Government has accepted all of the recommendations from the Pharmaceutical Task Force, announced Health Minister George Abbott today. "The task force has provided us with insightful analysis on improving patient care and enhancing the quality, safety and value of our world-class PharmaCare program," said Abbott. "Their advice and recommendations will strengthen our significant investments in this vital area of the public health system, so that patients in B.C. continue to benefit from a public drug plan that is based on the best scientific evidence and sustainable for future generations." In November 2007, the nine-member task force - made up of clinical professionals, academics, pharmaceutical industry leaders and government policy-makers - was charged with advising government on key areas of pharmaceutical policy within the health system. Their report offers recommendations aimed at creating a more streamlined and transparent drug review process while delivering the best patient outcomes and the best value to British Columbians. "The Ministry of Health will begin working with stakeholders on some recommendations immediately, while others are more complex and will take some time to plan and implement," said Abbott. "Our work to enhance the Province's pharmaceutical policy has the interests of patients as our foremost consideration, while assuring maximum value for taxpayers." Government's implementation of the recommendations will be guided by six principles: 1. The best interests of the patient are paramount. 2. The B.C. government is obliged to seek the best value possible for taxpayer 3. The foundation of all drug benefit decisions will be predicated upon a transparent 4. The B.C. government is committed to fair, open and transparent procurement 5. All persons involved in making decisions respecting the procurement of goods and services by government must be free from conflict of interest, both real and perceived. 6. The B.C. government values a healthy, competitive pharmaceutical industry that will continue to provide both financial and human resource investments in B.C. "The task force heard from a wide range of stakeholders, whose views were united by the common thread that patients must have access to the best care and treatment possible," said George Morfitt, alternate chair of the Pharmaceutical Task Force. "It has been our privilege to undertake this challenging task, and we trust our conclusions will guide the province to a constructive way forward with the evolution of pharmaceutical policy in British Columbia." B.C. faces increasing demand for prescriptions each year - with a 46-per-cent increase over the past four years from 18.3 claims per patient in 2002 to 26.8 claims per patient in 2006. In the past two years, PharmaCare has added more than 480 individual generic drugs and more than 50 brand drugs to its formulary. Since 2001, PharmaCare's budget has increased by more than 50 per cent, from $654 million to $1.016 billion in 2008/09. PharmaCare subsidizes eligible prescription drugs and designated medical supplies, protecting British Columbians from high drug costs. PharmaCare provides financial assistance to British Columbians under Fair PharmaCare and other specialty plans. More than 23 million prescriptions are now covered each year under the B.C. PharmaCare program. The Report of the Pharmaceutical Task Force can be found on the Ministry of Health website at: . BACKGROUNDER - PHARMACEUTICAL TASK FORCE REPORT COMPLETE The Pharmaceutical Task Force's report made 12 recommendations to government regarding PharmaCare's policy, programs, services and drug approval process. Recommendation 1 - Priority attention should be focused on development of an enhanced Formulary Management System together with improved stakeholder engagement and appeal mechanisms. This work should be led by the Pharmaceutical Services Division and include meaningful engagement with stakeholders, including patients, healthcare professionals, disease specialists, research leaders and industry. Recommendation 2 - The Ministry of Health should act to establish new target review/listing decision guidelines with the goal of substantially improving B.C.'s performance on time-to-listing decisions. Progress on this front must be publicly reported and consistently benchmarked against the performance of other jurisdictions. Recommendation 3 - The Drug Benefit Committee should be reconstituted as the Drug Benefit Council to more appropriately reflect the arm's-length role it is expected to carry out in the review processes applicable to consideration of new therapies. Recommendation 4 - The Ministry of Health should establish a new Drug Review Resource Committee (DRRC) to carry out the drug submission review role currently performed by the Therapeutics Initiative. This new DRRC should also provide for a registry of experts that will substantially widen the array of expertise available to offer advice and recommendations on the therapeutic value and cost-effectiveness of new drug therapies. Recommendation 5 - The membership of the Drug Benefit Committee should be modified to include the participation of at least three public members selected through a process external to the Pharmaceutical Services Division. Government may also wish to consider ensuring that at least one member of the Drug Benefit Committee has broad economic expertise to supplement the existing expertise that is focused more narrowly on health economics. Recommendation 6 - No members of the Therapeutics Initiative or, in the alternative, no participant in a Drug Coverage Review Team should participate as members in the work of the Drug Benefit Council. Recommendation 7 - The Pharmaceutical Services Division should initiate a negotiation process with drug manufacturers and with representatives of community pharmacy and pharmacists to establish new price and reimbursement arrangements and increased competition in respect of generic pharmaceutical products. If the parties are unable to conclude an acceptable agreement within six months, the government should move unilaterally to address the needs of the Province through legislation or through other means. Recommendation 8 - To increase the level of overall funding transparency, negotiations with pharmacists and community pharmacy should provide for a new framework for compensation in respect of dispensing and other professional services provided by pharmacists. The framework should address those professional services that can be effectively and efficiently provided by pharmacists and should be linked to transparent accountability agreements to maintain and, ideally, improve point-of-care services to patients. Recommendation 9 - The Pharmaceutical Services Division should adopt a cautious approach to broadened utilization of tendering processes. The process adopted should mirror tendering processes used in other areas of government characterized by a process that is transparent, fair, open and includes understandable evaluation criteria. Increased tendering should provide for reasonable levels of patient choice, avoid the deployment of older inferior products and, where possible, arrangements that provide for participation of multiple suppliers. Recommendation 10 - The deputy minister of the Ministry of Health should commit to participate in an annual accountability session to hear from patient groups, from industry and from other key stakeholders regarding improved relations and the strengthening of the common objectives of patient care and choice. Recommendation 11 - Given that B.C. was a lead jurisdiction in calling for the implementation of the Common Drug Review, action should be taken to: • Ensure B.C.'s decision-making processes include similar timelines to those used by the Common Drug Review and a greater level of commitment to openness and transparency; and • That any unnecessary overlap between the Common Drug Review and B.C. formulary management system are reduced to the fullest extent possible. • Recommendation 12 - Subject to Recommendation 4, if the Therapeutics Initiative (TI) is maintained, action must be taken in the following areas: • The governance, membership and accountability standards associated with the operation of the TI will require substantial improvement; • Steps must also be taken to renew and revitalize the panel of experts the TI relies • The function of the TI should be focused on therapeutic evaluation. Activities beyond that core mandate, such as public education, should be reassigned to the ministry's Drug Utilization Branch where an accountable process can be implemented to assure unbiased and evidence-based practices; • The practice of having members of the Therapeutics Initiative also participating in the work of the Drug Benefit Committee should be terminated. Media contact: Sarah Plank Manager, Media Relations Ministry of Health 250 952-1887 (media line) For more information on government services or to subscribe to the Province's news feeds using RSS, visit the Province's website at: 3.____________________________________________ Multinational Monitor (May 16, 2008) Pharmaceutical Payola -- Drug Marketing to Doctors Last week, a Congressional committee properly raked Big Pharma over the coals for misleading advertising of pharmaceuticals. A hearing of the House Energy and Commerce Committee's oversight subcommittee focused on advertising campaigns for three drugs, including the remarkable case of Robert Jarvik. Jarvik is featured in endlessly re-run ads for Pfizer's blockbuster cholesterol drug Lipitor. Known as the inventor of the Jarvik artificial heart, he is not a cardiologist, not a licensed medical doctor and not authorized to prescribe pharmaceuticals. He's shown in the ads engaged in vigorous rowing activity, but in fact he doesn't row. Pfizer pulled the ads in February after controversy started brewing. Among industrialized countries, only the United States and New Zealand permit drug companies to market directly to consumers. It's a bad idea, it drives bad medicine, and it should be banned. But although it has the highest profile, direct-to-consumer advertising is a small part of Pharma's marketing machine. Researchers Marc-André Gagnon and Joel Lexchin conclude in a recent issue of the journal PLOS Medicine that direct-to-consumer ads make up less than a tenth of industry marketing expenditures ($4 billion of $57.5 billion in 2004). And Gagnon and Lexchin's estimate of $57.5 billion on marketing excludes many industry expenditures that are really driven by marketing, including clinical trials conducted for marketing purposes. The bulk of the industry marketing effort -- more than 70 percent by Gagnon and Lexchin's calculation -- is directed at doctors. Why? Because it works. The companies spend huge amounts paying firms that carefully track what doctors prescribe, and then they use the information to tailor messages to doctors, distribute samples and develop continuing medical education programs. Gagnon and Lexchin report that Pharma spends more than $20 billion a year on "detailers" -- the pharma reps that knock on doctor doors, ply the staff with free coffee and lunches, distribute samples ($16 billion worth), and prod docs to prescribe their drugs. This is complemented by a host of tactics that in other circumstances might be called bribes. "Virtually all physicians in America take cash or gifts from the drug companies," says Melody Petersen, author of Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs, and a former New York Times reporter. "A recent survey said 94 percent of physicians took something of value from the drug companies. Some doctors take hundreds of thousands of dollars a year from these companies, and there’s no law that says they can’t." Petersen says she "had no idea this was so extensive until one day I was writing a story about Celebrex and Vioxx -- this was before Vioxx was taken off the market. The story was about the marketing battle between these two pain drugs. I called one of the large societies of rheumatologists and asked for an expert on arthritis. I specifically said I needed an expert who was not being paid as a consultant to one of the manufacturers of these drugs. A staff person said, 'We have lots of people you can talk to, but all of these doctors are consultants to one or both of the drug companies.'" Drug companies hire doctors to give lectures, and they hire other doctors as "consultants" to go to fancy dinners and listen to the lectures. "There are more than 500,000 of these dinners or events in America every year," Petersen says. The drug companies weave these diverse strategems into an elaborate tapestry -- not infrequently to push drugs for inappropriate purposes. One eye-opening case that Petersen details in Our Daily Meds concerns Neurontin, a mediocre drug for epilepsy that Warner-Lambert illegally peddled as an unapproved treatment for bipolar disorder, migraines, attention deficit disorder in children and other conditions. The drug does not work for most of these conditions. Many persons were injured by taking excessive doses of Neurontin, and many others wasted money and emotional energy on hopeless Neurontin treatment strategies. Warner-Lambert ultimately paid $430 million to settle criminal and civil charges related to Neurontin marketing, but Petersen says that, even so, the illegal marketing scheme was clearly profitable for Warner-Lambert (and Pfizer, which acquired Warner-Lambert in 2000). Petersen's account of the Neurontin nightmare draws heavily on a whistleblower, David Franklin. She summarizes the central theme of the story Franklin revealed: "The company got doctors to prescribe the drug for all these experimental uses by paying them. They paid physicians to give speeches to other physicians at restaurants or hotels or resorts. The doctors not only enjoyed a nice meal or a weekend vacation, they often also received a $500 check for attending. The physicians giving lectures at these parties were often trained by the drug company’s ad firm to describe how Neurontin could work for conditions like bipolar. … The company tracked the doctors’ prescriptions before and after these dinners or weekend retreats. The executives saw how well it worked." Which raises an interesting question: How is that industry can so effectively manipulate highly trained doctors? Answers Adriane Fugh-Berman, a doctor and Georgetown University professor who runs PharmedOut, a project that focuses on how pharmaceutical companies influence prescribing decisions and encourages physicians to educate themselves from non-industry sources: "Physicians are trained in medicine, not psychological manipulation. Every bit of flattery, friendship and information offered by reps is aimed at selling drugs." There is no simple solution to these problems, though ending patent-based marketing monopolies would transform pharmaceutical marketing practices and likely eliminate most abuses. In the meantime, a ban on Pharma gifts to doctors would be a modest step forward. In the United States, notes Petersen, "radio disc jockeys can’t take cash from music companies. But when it comes to something like medicines -- which mean life or death for people -- doctors can take as much money as they want from the drug companies. We need a law to stop that." 4.____________________________________________ Globe and Mail (May 22, 2008) Increasing pharmacists' powers raises concerns By Carly Weeks Getting a prescription refilled or changed in Canada is set to become much easier, but the move to expand the powers of pharmacists is sparking controversy in the country's medical community. New Brunswick will become one of the first provinces to move forward with legislation to significantly boost the ability of pharmacists to play a greater role in patient prescriptions. Under proposed changes announced this week, pharmacists would not only provide refills without having to check with the doctor, but could also alter a patient's prescription or assign new medications for minor conditions. Similar rules are already in place in Alberta and other provinces are in various stages of enhancing the role of pharmacists. These moves will provide greater convenience to Canadians, who may not have immediate access to a doctor for a new prescription, allow pharmacists to better monitor a patient's response to treatment, and reduce the burden on overworked doctor's offices, said Janet Cooper, senior director of professional affairs at the Canadian Pharmacists Association. "There's been a lot of movement in the last year," Ms. Cooper said. "It's about better medication management for Canadians." But some medical associations and experts fear the expanded role could set a dangerous precedent. Many physicians agree it makes sense to let pharmacists refill prescriptions as long as a patient's health has not changed. However, they worry about the possibility that pharmacists will start to prescribe new medications on an increasing basis. "If a pharmacist initiates treatment for a condition that's not diagnosed by a physician, then I think they're putting themselves and the patients at risk," said Brian Day, president of the Canadian Medical Association. Provinces such as New Brunswick are moving to allow pharmacists to diagnose and prescribe treatment for minor conditions. Other provinces could follow suit, Ms. Cooper said. But that doesn't represent any threat to patients because pharmacists would be limited in what they could prescribe. They would only assign new medications for minor problems such as coughs, colds or skin rashes, she said. "I can understand their [doctors'] concern, but pharmacists in general are quite cautious. I'm not concerned they're going to go out and do things outside their knowledge level," she said. Despite those intentions, medical associations across Canada remain anxious that allowing pharmacists to prescribe new drugs to patients could be a risky move and may lead to a further expansion of those powers in the future, according to the British Columbia Medical Association. "Whether it's the first step in a staircase to more privileges, that's a concern," said Bill Mackie, the association's president-elect. "Our hope is that it's just to facilitate, make life easier for patients and doctors." The move toward expanding pharmacists' powers has rapidly taken shape in the past two years and many experts, including Dr. Mackie, say it's difficult to tell what the implications may be. But some experts predict that serious conflict-of-interest concerns will arise once a majority of the country's pharmacists have greater power to prescribe drugs. If pharmacists are able to choose which company's medication a patient will receive, the industry must adopt strict guidelines to prevent them from choosing a product that may represent a financial gain for the drug store, said Alan Cassels, a drug policy researcher at the University of Victoria. "When you have a person who's doing both activities [prescribing and dispensing], it can lead to irrational prescribing and the profit motive getting in the way of good care," he said. "They're professional, but they are businessmen, let's not forget that." But the Canadian Pharmacists Association said that argument has no merit and that pharmacists are not swayed by financial incentive. The association is not looking into guidelines or other policies to address potential conflict of interest because it's not an issue that will realistically affect the way pharmacists do their jobs, Ms. Cooper said. "We've heard that raised a lot," she said. "The pharmacists are going to make evidence-based decisions. They're going to make sure they're prescribing the right drug for that patient." 5.____________________________________________ Ottawa Sun (May 21, 2008) Docs too busy to follow up Study finds health system neglects chronic disease By Donna Casey Dr. Erin Keely admits it -- your local veterinary clinic or dentist's office does a better job at followups than her clinic for diabetes patients. The chief of endocrinology and metabolism at the Ottawa Hospital says it's "disappointing but not surprising" that people with chronic diseases miss their foot and eye exams and blood sugar tests. With a family doctor shortage and no credible tracking system for appointments and tests, many of Keely's patients are getting sicker from a health system that's neglecting chronic disease. That's the conclusion of a study released yesterday by the Ontario Health Quality Council, an independent agency funded by the provincial ministry of health. The 2008 report Health Care in Ontario: The Big Picture found that only half of the tests and treatments recommended for people with diabetes are being performed. Council chair Ray Hession said Ontario's health care system has "some very, very worrying evidence of weakness and chronic disease is a major one." POTENTIAL TO SAVE LIVES The study found 8,000 lives could be saved a year through better management of diabetes and heart disease through followups on routine tests. More than 60% of Ontarians say they have to wait up to two days to see their doctor after becoming sick. The survey found that 400,000 residents are looking for a family doctor but can't find one. Many of those are people with complex medical conditions, said Keely. While specialists encourage diabetes patients to "take ownership" of their disease, Keely acknowledges health problems can get lost in the "fragmented care" of the disease. "It can be completely overwhelming for people with diabetes. They are asked to do a lot," said Keely, adding the disease "is not a problem that can be solved in a 10- or 15-minute physician-patient visit." Hession said Ontario needs to push through with an electronic health record strategy to help track people with chronic disease. With an estimated price tag of $8 billion, Hession said governments "get a bit spooked at taking those kind of risks." But e-health systems in the U.K. and in the U.S. Veteran Health Administration have shown "the payoffs are enormous," said Hession. "If we don't do that, there will be a continuation of relative mediocrity," he said. No virus found in this incoming message. Checked by AVG. Version: 8.0.100 / Virus Database: 269.24.0/1460 - Release Date: 22/05/2008 7:06 AM

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