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PBS NewsHour

New Hepatitis-C drug raises hope at a hefty price

Inside of a Gilead Sciences Lab

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JUDY WOODRUFF: Now: Who should pay when drugs are very effective, but extremely expensive?

That’s an important question for the U.S. health care system as new treatments come along, and it’s a matter of real concern over a new drug that has a 90 percent to 100 percent chance of curing the hepatitis C virus. Its manufacturer announced record sales yesterday of more than $2 billion in just the first quarter of the year.

Profits, coverage and costs are all at issue, as Hari Sreenivasan reports.

HARI SREENIVASAN: Kim Bossley knows how fragile life can be. In 2005, Bossley was diagnosed with hepatitis C, a blood-borne virus that can destroy the body’s liver.

KIM BOSSLEY: I went from stage one to stage four, decomposed liver, very quickly.

HARI SREENIVASAN: News of her rapidly declining health was devastating for the 46-year-old mother of two.

KIM BOSSLEY: You fall into a depression when you’re diagnosed with hep C. Your own mortality rate hits you.

DR. GREGORY T. EVERSON, University of Colorado Hospital: That’s a pretty good response.

HARI SREENIVASAN: This fall, after nine years of battling the virus, Kim Bossley was accepted into a treatment trial with a new drug called Sovaldi.

DR. GREGORY T. EVERSON: So, Kim, we will check your labs here.

HARI SREENIVASAN: Almost immediately after taking Sovaldi, the hepatitis C virus disappeared.

DR. GREGORY T. EVERSON: Not detected, not detected, not detected.

HARI SREENIVASAN: Bossley’s doctor, Gregory Everson, is an expert on the hepatitis C virus. He says results with Sovaldi are remarkable.

DR. GREGORY T. EVERSON: Do you feel like you can do what you want to do on this treatment?



HARI SREENIVASAN: A hepatologist at the University of Colorado hospital, Everson has treated some 200 patients with the new drug.

DR. GREGORY T. EVERSON: Kim’s response is typical. Her viral load was in the millions — within a week or two, undetectable. That is what we’re seeing in almost all the patients we’re treating today. It’s really quite extraordinary.

HARI SREENIVASAN: In fact, across the United States, hepatitis C patients are experiencing the same dramatic results, so much so that Dr. Everson calls the new drug manufactured by Gilead Sciences a game-changer.

DR. GREGORY T. EVERSON: We’re not talking about chronic disease anymore. We’re talking about getting rid of the infection completely. We’re talking about a complete cure rate.

HARI SREENIVASAN: And that is welcome news for the three million Americans infected with the hepatitis virus, 25 percent of whom are projected to die from it.

Even better news, in December, the Food and Drug Administration approved Sovaldi. But as spectacular as Sovaldi appears to be, so too is its price tag. Each pill is $1,000. And at a typical treatment of 120 days, the drug’s extraordinary cost has raised concerns.

MATT SALO, National Association of Medical Directors: The new development is simultaneously very exciting in terms of its efficacy, but potentially very, very frightening in terms of its cost, because we’re talking about a nexus of a drug that is, on the face of it, very expensive.

HARI SREENIVASAN: Matt Salo heads the National Association of Medicaid Directors. He says states are scrambling to figure out how to pay for Sovaldi with government-funded insurance, particularly when existing drugs are 50 to 70 percent effective.

MATT SALO: Medicaid is actually kind of used to dealing with pharmaceutical treatments that are very expensive, but for small numbers of people. With hepatitis C, we know there are at least three million people and potentially as many as five million people in this country who have hepatitis C.

So when you multiply those two, you are really looking at a game-changer in terms of cost.

WOMAN: One a day of that one.

HARI SREENIVASAN: Kim Bossley’s treatments are free because she’s part of the study for those with advanced liver disease. And while she agrees the drug’s price tag is high, she says the combination of drugs she used before Sovaldi, interferon and ribavirin, were extremely rough.

KIM BOSSLEY: There is no comparison.

HARI SREENIVASAN: Her previous drug treatment, she says, caused exhaustion, depression and hair loss.

KIM BOSSLEY: It is a very harsh regimen. It’s very debilitating.

HARI SREENIVASAN: In fact, Dr. Everson said the existing drug treatments are so tough on his patients, many hepatitis C sufferers avoid them altogether.

DR. GREGORY T. EVERSON: Most patients didn’t even want the treatments because of the side effects. People wouldn’t even come for treatment. They wouldn’t get their hepatitis C addressed.

HARI SREENIVASAN: And beyond the physical costs, Everson says there is a price for in the curing the virus.

DR. GREGORY T. EVERSON: It’s one of the costliest diseases when you get to the end stages, where people start to have complications of cirrhosis.

HARI SREENIVASAN: That point is echoed by John McHutchison, executive vice president at Gilead Sciences.

JOHN MCHUTCHISON, Gilead Sciences, Inc.: The costs of caring for patients with hepatitis C are not all up front. So whilst it might be expensive to treat somebody up front now, by curing somebody, you are preventing the costs of care of that patient later on, so, as their disease progresses over time, the cost of liver transplant, the cost of caring for somebody with liver cancer.

So if you can treat more people, and spend those dollars up front to cure those people, in the long-term, and over the long-term horizon, you will save the costs to the health care system.

NARRATOR: If you are one of the millions of people with hepatitis C, you haven’t been forgotten.

HARI SREENIVASAN: But while Gilead calls Sovaldi a cure, it is not a vaccine. Hepatitis C, which is transmitted through blood, can be contracted more than once. The most common way to get the virus is through I.V. drug use.

MATT SALO: One of the things to keep in mind with Sovaldi is that this is not an immunization. This doesn’t make someone hepatitis-free forever. And if you got hepatitis C because of certain risky behaviors and you go and you get, in effect, cured, there is nothing to prevent from you getting it again if you relapse back into those same behaviors.

HARI SREENIVASAN: Kim Bossley contracted the virus from a blood transfusion at her birth. Bossley was the first baby born to a mother who had undergone a kidney transplant. She was featured in “Good Housekeeping” magazine as a miracle baby. During the birth, Kim’s mother received a transfusion of blood infected with hepatitis C.

But neither knew they had the virus until getting sick later in life. Bossley’s mother ended up dying from the condition, something that makes Kim’s own condition even tougher.

KIM BOSSLEY: Seeing my mom suffer through the latter part of her stages, it really took a lot out of me, to the point where I finally had to — you know, this is not how mom or I want to live. You know, I want to fight. I want to find a cure.

HARI SREENIVASAN: As new sophisticated drugs to treat all kinds of conditions enter the market, Matt Salo says the question of costs will likely arise again.

MATT SALO: It’s not a Sovaldi question, per se, because this really is the tip of the iceberg. There are so many other drugs that have the potential of bringing on one hand, you know, incredible improvements in human life and health and well-being, but on the other hand extraordinary costs.

HARI SREENIVASAN: Salo would like to see a national dialogue about what insurers should cover.

MATT SALO: I think it is critically important that we start having that conversation about, how do we value health, what price health, and what price pharmaceuticals? I think this is an important conversation we need to have.

HARI SREENIVASAN: For her part, Kim Bossley has started a foundation to hep offset drug costs for other hepatitis patients.

GWEN IFILL: Online, you can read about how free samples can influence what doctors prescribe to their patients. That’s on our health page.

The post New Hepatitis-C drug raises hope at a hefty price appeared first on PBS NewsHour.

15-minute doctor visits take a toll on patient-physician relationships

Photo by Rebecca Emery/Getty Images

Photo by Rebecca Emery/Getty Images

Joan Eisenstodt didn’t have a stopwatch when she went to see an ear-nose-and-throat specialist recently, but she is certain the physician was not in the exam room with her for more than three or four minutes.

“He looked up my nose, said it was inflamed, told me to see the nurse for a prescription and was gone,” said the 66-year-old Washington, D.C., consultant, who was suffering from an acute sinus infection.

When she started protesting the doctor’s choice of medication, “He just cut me off totally,” she said. “I’ve never been in and out from a visit faster.”

These days, stories like Eisenstodt’s are increasingly common. Patients–and physicians–say they feel the time crunch as never before as doctors rush through appointments as if on roller skates to see more patients and perform more procedures to make up for flat or declining reimbursements.

It’s not unusual for primary care doctors’ appointments to be scheduled at 15-minute intervals. Some physicians who work for hospitals say they’ve been asked to see patients every 11 minutes.

And the problem may worsen as millions of consumers who gained health coverage through the Affordable Care Act begin to seek care — some of whom may have seen doctors rarely, if at all, and have a slew of untreated problems.

“Doctors have one eye on the patient and one eye on the clock,” said David J. Rothman, who studies the history of medicine at Columbia University’s College of Physicians and Surgeons.

By all accounts, short visits take a toll on the doctor-patient relationship, which is considered a key ingredient of good care, and may represent a missed opportunity for getting patients more actively involved in their own health. There is less of a dialogue between patient and doctor, studies show, increasing the odds patients will leave the office frustrated.

Shorter visits also increase the likelihood the patient will leave with a prescription for medication, rather than for behavioral change — like trying to lose a few pounds, or going to the gym.

Physicians don’t like to be rushed either, but for primary care physicians, time is, quite literally, money. Unlike specialists, they don’t do procedures like biopsies or colonoscopies, which generate revenue, but instead, are still paid mostly per visit, with only minor adjustments for those that go longer.

And many doctors may face greater financial pressure as many insurers offering new plans through the health law’s exchanges pay them even less, offering instead to send them large numbers of patients.

This fee-for-service payment model, which still dominates U.S. health care, rewards doctors who see patients in bulk, said Dr. Reid B. Blackwelder, president of the American Academy of Family Physicians, who practices in Kingsport, Tenn.

“Doctors are thinking, ‘I have to meet my bottom line, pay my overhead, pay my staff and keep my doors open. So it’s a hamster wheel, and they’re seeing more and more patients … And what ends up happening is the 15-minute visit,” he said.

Struggling For Control

Dr. Richard J. Baron, president of the American Board of Internal Medicine, said that patients and physicians often wrangle over control of that visit – a “struggle for control” over the allocation of time

Sometimes the struggle is overt – as when a patients pulls out a long list of complaints as soon as the doctors comes in.

Sometimes, it’s more subtle. When Judy Weinstein went to see her doctor in Manhattan recently, she knew she would get only 20 minutes with him – even though it was an annual physical, and she had waited nine months for the appointment.

So when the doctor asked if he could have a medical student shadow him, she put her foot down.

“I said, ‘Y’know, I would prefer not. I get 20 minutes of your divided attention as it is – it’s never undivided, ever – and I need to not have any distractions. I need you focused on me.’“

How did visits get so truncated? No one knows exactly why 15 minutes became the norm, but many experts trace the time crunch back to Medicare’s 1992 adoption of a byzantine formula that relies on “relative value units,” or RVUs, to calculate doctors’ fees.

If you must know, the actual formula is: (Work RVU x Geographic Index + Practice Expenses RVU x Geographic Index + Liability Insurance RVU x Geographic Index) x Medicare Conversion Factor.

That was a switch for Medicare, which had previously paid physicians based on prevailing or so-called usual and customary fees. But runaway inflation and widespread inequities dictated a change. RVUs were supposed to take into account the physician’s effort and cost of running a practice, not necessarily how much time he or she spent with patients.

The typical office visit for a primary care patient was pegged at 1.3 RVUs, and the American Medical Association coding guidelines for that type of visit suggested a 15-minute consult.

Private insurers, in turn, piggybacked on Medicare’s fee schedule, said Princeton health economist Uwe Reinhardt. Then, in the 1990s, he said, “managed care came in and hit doctors with brutal force.”

Doctors who participated in managed care networks had to give insurers discounts on their rates; in exchange, the insurers promised to steer ever more patients their way.

To avoid income cuts, Reinhardt said, “doctors had to see more patients – instead of doing three an hour, they did four.”

Rushed Doctors Listen Less

How doctors structure the precious 15-minute visit varies – often quite dramatically. Generally, they start by asking the patient how they are and why they came in, trying to zero in on the “chief complaint” — the medical term for the patient’s primary reason for the visit.

But most patients have more than one issue to discuss, said Dr. Alex Lickerman, an internist who has taught medical students at University of Chicago and is director of the university’s Student Health and Counseling Services.

“The patient is thinking: ‘I’m taking the afternoon off work for this appointment. I’ve waited three months for it. I’ve got a list of things to discuss.’

“The doctor is thinking, ‘I’ve got 15 minutes.’ There is almost a built-in tension,” Lickerman said.

A 1999 study of 29 family physician practices found that doctors let patients speak for only 23 seconds before redirecting them; Only one in four patients got to finish his or her statement. Studies show that doctors’ visits have not gotten shorter on average in recent decades and may actually have gotten a few minutes longer. The mean time spent with a physician across specialties was 20.8 minutes in 2010, the latest year available, up from 16.3 minutes in 1991-1992 and 18.9 minutes in 2000, according to the National Center for Health Statistics; that includes visits with internists, family docs and pediatricians, which all increased by about two and a half minutes.

In 1992, most visits – about 70 percent — lasted 15 minutes or less; by 2010, only half of doctor visits were that short (the data is from the National Ambulatory Medical Care Survey, an annual nationally representative sample survey of visits to physicians).

This doesn’t necessarily mean the patient experience is improving. Medical schools drill students in the art of taking a careful medical history, but studies have found doctors often fall short in the listening department. It turns out they have a bad habit of interrupting.

A 1999 study of 29 family physician practices found that doctors let patients speak for only 23 seconds before redirecting them; only one in four patients got to finish their statement. A University of South Carolina study in 2001 found primary care patients were interrupted after 12 seconds, if not by the health care provider then by a beeper or a knock on the door.

Yet making the patient feel they have been heard may be one of the most important elements of doctoring, Lickerman said.

“People feel dissatisfied when they don’t get a chance to say what they have to say,” he said. “I will sometimes boast that I can make people feel they ‘got their money’s worth’ in five minutes. It’s not the actual time or lack of time people are complaining about – it’s how that time felt.”

This KHN story was produced in collaboration with USA Today. Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

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Do free samples influence the way doctors prescribe drugs?

Photo by Flickr user ep_jhu

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HARI SREENIVASAN:  If you ever felt lucky that you got a free sample of a prescription drug from a doctor, it may actually be costing you in the long run. A new study from Stanford University’s School of Medicine found that doctors who are allowed to hand out free samples, often prescribe those expensive drugs versus doctors who don’t have access to free samples. We’re joined from California by Professor Alfred Lane, who teaches pediatrics and dermatology at Stanford and is a senior author of the study. So you looked specifically at the practice of dermatology, what did you find?

DR. ALFRED LANE:  Yes, we found that those physicians across the United States who use samples are much more likely to write for higher prescriptions. The average cost of a first visit for acne or rosacea was over $450 for medication for the physicians that use samples. And we compared it to our clinic where we have no samples where the average cost was only 200-hundred dollars. So at least twice as more expensive were the prescription costs from the physicians who use samples.

HARI SREENIVASAN:  And now this was focused on dermatologists and these particular types of medicines. But how does this translate out – is this a wider practice that’s happening in different fields as well?

DR. ALFRED LANE:  Well, the reason for the study is I noticed in my practice once we did not have samples that I was writing for more generics and the patients referred from dermatologists were on more expensive medications. And so we tried to look at it, and in the data we found that it is true that dermatologists are using samples more than other specialties over the last ten years. And a lot of that has to do with the use of what’s called branded generics or generics that now are under brand name, and they’re very expensive.

HARI SREENIVASAN:  So now, the drug companies would come back and say listen, don’t these free samples help the poor who might not able to afford the medications or help them get immediately on the drug?

DR. ALFRED LANE:  That’s what dermatologists and that’s what physicians will often say, but the data is very clear that the poor patients are not the ones who usually get the samples. We didn’t look at that in our study, but that’s been shown in other studies.

HARI SREENIVASAN:  And so is there a connection between the amount of money the drug companies now spend – is this basically, are free samples essentially the marketing right off?

DR. ALFRED LANE: Yeah, so it looks like there’s at least over six-billion dollars a year that are spent by pharmaceutical companies in sampling. And so that cost eventually has to be paid by someone. And the price of the generic drug may be quite a bit less than what’s called brand name or branded generic. And it’s only the branded generics or the branded drugs that are sampled. So those are the ones that the dermatologists are channeled into writing prescriptions for.

HARI SREENIVASAN: And what about the argument that samples are the way to get the most recent medications into the hands of doctors?

DR. ALFRED LANE: Well, sometimes that’s not the best thing. There are studies with cardiovascular disease that sometimes the recent medications are not studied as well, and the risk of death or dying from the use of samples can be there. In dermatology, we don’t see that. But the other problem is that the recent medications have not been proven better than the generic in most situations.

HARI SREENIVASAN: So the six-point-three billions dollars, those are essentially costs passed onto the consumer?

DR. ALFRED LANE: That’s exactly right. And one of the focuses of our study was for the dermatologists to realize that although they think they’re helping the patients, they are really being manipulated to write for more expensive medications with no proven benefit of those medications over the generic drugs.

HARI SREENIVASAN: All right, Professor Alfred Lane joining us from Stanford, thanks so much.

DR. ALFRED LANE: Thank you.

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New clinical trials underway for advanced lung cancer patients


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HARI SREENIVASAN: Another medical story that caught our attention this week. Word of what’s described as a pioneering clinical trial for patients with advanced lung cancer. What’s novel is not necessarily the drugs being used, but how many and how they’re being targeted. Dr. Mark Kris, an oncologist at Memorial Sloan Kettering Cancer Center, joins us. So what are they doing in the U.K. with this clinical trial? What’s so interesting about it?

DR. MARK KRIS: They are taking a discovery that was made here almost ten years ago now where specific genes are damaged in lung tumors. And the damage brought on by those genes makes those cancer cells very susceptible to medications. So if you find one of these genetic changes and give a patient a drug targeting that, almost surely their cancer will shrink and normal tissues are not affected. I mean it’s exactly what oncologists hope to do. What they’re doing now in the U.K. is developing a nationwide program partnering with pharmaceutical companies that are developers of these drugs to do the testing in a much more generalized way and to test for many of these different gene mutations at the same time. So in essence a patient might have ten chances to find something in the tumor that’s in their body. Ten chances to get a medication. And also the pharmaceutical companies supplying drugs to go along with the discovery of those genetic markers and help individual patients.

HARI SREENIVASAN: And that’s different because we’re used to clinical trials that are one drug at a time or one gene at a time.

DR. MARK KRIS: Exactly. And also ten years ago before these mutations were discovered, everyone with a lung cancer got the same chemotherapy. Sometimes it helped, sometimes it didn’t. And we always wanted to know what is it that makes an individual’s cancer shrink or not. And this genetic information is the way we can do that, and we can really move much toward this goal of what we call personalized medicine. The right drug for the right patient.

HARI SREENIVASAN:  So if this personalized medicine trial, so to speak, happens successfully in the U.K., does that mean something like that can happen here on a larger scale in the U.S.?

DR. MARK KRIS: Well, it’s actually happening all over the world right now. And we have already completed a program here in the U.S., the Lung Cancer Mutation Consortium, where 14 hospitals did something very much like this. There are programs in France as well. It’s a whole world-wide movement. And the fact that the U.K is doing it, they’re a little sometimes slower to embrace these new technologies and new drugs. And the fact that they’re doing it says that this technology, that this idea, is becoming more and more mainstream. And it’s really going to accelerate progress.

HARI SREENIVASAN: And so tell me about how this is going to make this larger shift in terms of personalized medicine, almost on a genetic level, targeting each patient with a specific drug that could cure their cancer.

DR. MARK KRIS: So the way that it is happening now is that when the cancer is first discovered, these genetic tests are done. In the panel we have at Sloan Kettering, MSK Impact, we test for 340 different genes. And then what we try to do is find the drugs that are most likely to help a person whose cancer is driven by these genes. These genes make a cancer cell horribly dependent on the proteins that these ankA genes produce. They call it ankA gene addiction, In other words, Achilles’ heel has been the term that’s been used. So if you find that arrow to go after the Achilles’ heel, the cancer cells die. And the beautiful thing about it is these drugs are much less destructive to normal people. The other thing is if you know this person’s cancer cells don’t have this medicine, then we wouldn’t recommend that medicine to a patient. Previously, it was one size fits all. Every person with the illness got the same medicine.

HARI SREENIVASAN: Dr. Mark Kris, an oncologist at Memorial Sloan Kettering. Thanks so much.

DR. MARK KRIS: Thank you.

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