Relevant and even prescient commentary on news, politics and the economy.

Joe Biden: “How Are We to Pay for Single Payer Healthcare Alias Medicare for All?”

Joe knows the answer to this question and he is baiting the other candidates. Joe has a history of supporting big business interests as witnessed by his aggressive support of the banking industry with bankruptcy laws favoring banking against the needs of citizens and with a special intended harshness when it comes to student loans. Joe has sponsored or cosponsored every bankruptcy bill since 1997. With his question and his healthcare bill, I believe Joe  is courting the healthcare industry and the healthcare insurance industry’s support. Other candidates need to call Joe out on this.

Before moving to Medicare4All or a form of it, we need to attack the costs of healthcare which are rising at a clip greater than inflation.

Much of the payment for improved healthcare will come from negotiating with pharmaceutical companies, reducing the increasing cost of hospital inpatient and outpatient care, rolling back unnecessary pricing increases, reducing costs to 120% of Medicare costs today, etc. There are enough cost targets to attack which should provide a wealth of lower costs and funding for expansion. Healthcare Cost Drivers Pharma, Doctors, and Hospitals

Kocher and Berwick gave an outstanding recital of how we will get from Medicare and Commercial Insurance to just Single Payer Medicare4All. “While Considering Medicare For All: Policies For Making Health Care In The United States Better.” It is unlikely, Congress will move on Medicare4All in the beginning. It will take time. Today’s Medicare is not free from issues.

As the Director of Medicare and Medicaid and upon departing the position, Donald Berwick made this observation of today’s Medicare:

“20 to 30 percent of health spending is ‘waste’ that yields no benefit to patients, and that some of the needless spending is a result of onerous, archaic regulations enforced by Medicare and Medicaid.

He listed five reasons for what he described as the ‘extremely high level of waste.’ They are overtreatment of patients, the failure to coordinate care, the administrative complexity of the health care system, burdensome rules and fraud.

Much is done that does not help patients at all and many physicians know it.”

Within the PPACA, the issues with ACOs must be fixed. The initial PPACA ACO strategy has given hospitals the ability to exploit the market through consolidation, eliminating or minimizing competition in regions, leading to increased pricing, and enabling the employment of specialist doctors, making them “must haves” in insurance networks. As planned, the ACOs should have generated administrative cost synergy and quality benefits instead of enabling ACOs to consolidate and control prices.

Single payer does not use ACOs. In single payer, the government will pay hospitals, healthcare professionals, pharmaceutical and healthcare supply companies. The government will also set the budgets for hospitals and healthcare. Single Payer in Vermont was going to fail and failed due to cost because it used 3 ACOs to manage its plan. Bernie Sanders is also using ACOs in his plan. “Why the Bernie Sanders Bill Is Not Single Payer” The only fear I have of this type of arrangement is the influence of the healthcare industry on those determining pricing and accepting costs. The healthcare industry is attempting to establish a methodology using value brought to the patient clinically and in quality of life with resulting benefits to the health-care system and society also. It is an argument on the issue of the morality of higher prices. Single Payer will have to contend with this as much of the pricing argument is not justified.

The plan should be to gradually move from insurance administered healthcare (what Kocher and Berwick propose) to a single payer system similar to what Sanders proposes but minus ACOs. As I explained, there are enough cost targets to pay for much of the implementation to be derived from reducing costs in the present healthcare system.

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Why Are There More Uninsured Kids?

Ms. Seema Verma is the Administrator of the Centers for Medicare & Medicaid Services. She is the over seer of Trump’s attempts to repeal the ACA. She is smiling now as there has been a reduction in the numbers of people enrolled in public healthcare such as Medicaid and CHIPS. Why did this occur? States having work requirements for Medicaid, adding more red tape to the application process, cutbacks in in outreach and enrollment funds by the Administration, and instill fear, a chilling purposeful effect, to cause immigrant and mixed-status families to not enroll and even withdraw their children from Medicaid/CHIP. The fear of being deported or given a lower status because you are dependent upon Medicaid and other government programs does much to keep them away and in hiding.

Georgetown University Health Policy Institute, Center for Children and Families sorts through the data provided by the Census Bureau in one of its Current Population Surveys. The Bureau actually released a mini-special report focusing on children, “Uninsured Rate for Children Increases To 5.5% in 2018.” The percentage represents a loss of  ~425,000 insured by these programs or 0.6 percentage points decrease from the previous year. A job well done by Administrator Verma.

Joan Alker: What do we know about the kids who have higher uninsured rates?

  • Hispanic children saw a large jump of 1 percentage point from 7.7% to 8.7%. White children were the other racial category to see a statistically significant increase, clear evidence of impact of the Administration’s ongoing campaign of hostility and intimidation directed at immigrant families and the recent issuance of the public charge rule will only make this worse. Many of the children are born in America citizens who have immigrant parents.
  • Young children (age 0-5) saw a large increase as well with their uninsured rate jumping from 4.5% to 5.3%. Without healthcare, a young child’s health care needs are less likely to be met and this is especially troubling when they are in this critical time period when a child’s brain develops rapidly and is building a foundation for future educational and economic success.  Regular visits to a pediatrician for checkups helps children in being healthy and disease and disorders are caught early on in the development.
  • Children in the South are the worst off regionally and saw the highest increases in uninsured jumping from 6.5% as a region to 7.7%. As can be expected, southern states such as Texas, Florida, and Georgia have some of the highest rates of uninsured children in the country already.

More data on the impact of the new polices will be available month end when more American Community Survey looks at the state specific changes for children.

Three main Causes for the increased uninsured:

  •  As I mentioned earlier, mixed families with parents being legal or illegal immigrants and the children citizens. People are afraid of being deported or having their children snatched from them. No prior modern administration has ever separated children from their parents unless their was an overwhelming need to do so such as healthcare.
  •  The administration and Congress’s cuts in outreach and enrollment funding to undermine ACA, one of Barack Obama’s achievements and Trump’s failure to repeal.  Outreach grants for CHIP were delayed significantly by the purposeful congressional funding CHIP till the end of 2017. CHIP was not accepting new enrollments due to a lack of funding and some states cut back. People missed the deadlines as a result. Another purposeful ploy.
  •  Besides ignoring the problems on the increased uninsured rates for children, Seema Verma and CMS are supporting state efforts to tighten up eligibility in CHIP and put in place  stricter verification procedures causing eligible children to lose coverage.

More to Come on What Can be Done.

Why are There More Uninsured Kids and What Can We Do About It?,” Center for Children and Families, Joan Alker, September 12, 2019.

Children’s Public Health Insurance Coverage Lower Than in 2017,” US Census Bureau, Edward R. Berchick and Laryssa Mykyta, September 10, 2019.

Bill H – run75441

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Healthcare News PBM Profits, Expensive Drug(s), Food Protein, and the Opioid Scam

Cigna gets major boost from Express Scripts in Q2,” Robert King, FierceHealthcare, August 1, 2019

And some claim PBMs do not matter in the cost of healthcare? Cigna healthcare insurance generated ~ $38 billion in revenue the second quarter 2019 and a major increase due mostly to a merger with pharmacy benefit manager (PBM) Express Scripts.

According to company financial results released Thursday, Cigna’s pharmacy services business generated $23.5 billion in revenue in the second quarter which represents a massive increase compared to the $1.1 billion generated in the second quarter of 2018. The company reported $1.41 billion in net income.

The major reason for the spike is the gain from the membership and resources achieved from the deal for Express Scripts. Cigna completed the $67 billion merger with the PBM giant late last year.

More Plant-Based Protein in Diet May Add Years,” Nicole Lou, MedPageToday, August 27, 2019

“Significant reductions were found (specifically) in mortalities related to cardiovascular disease. Norie Sawada, MD, PhD, of Japan’s National Cancer Center in Tokyo reported and colleagues reported a positive result in a prospective cohort study of plant protein being substituted for meat protein. It was reported in recent JAMA Internal Medicine study, “Association of Animal and Plant Protein Intake With All-Cause and Cause-Specific Mortality.”

The JAMA study (Association of Animal and Plant Protein Intake With All-Cause and Cause-Specific Mortality) suggests diets with higher plant-based protein intake may contribute to long-term health and longevity. In this cohort study; 70,696 Japanese adults were followed up on for a mean period of 18 years. The outcome associated a higher intake of plant protein resulted in lower total mortality. Moreover, the substitution of plant protein for animal protein, mainly for red or processed meat protein, was associated with lower risk of total, cancer-related, and cardiovascular disease–related mortality.

Furthermore, switching out 3% of daily calories from red meat to plant protein — approximately 260 g of a soy-based food for the average person eating 2,000 calories per day — was linked in statistical models (not through analysis of individuals who actually changed their diets) to reductions in mortality risk.

It is no secret retail drives the meat processing market where large manufacturers and meat packers are big enough to control the market and can drive the pricing down or up per each of cattle. Smaller cattle producers can be driven out of the market as they do not have the massive volume ability to lower their costs of production past a certain point. The criticisms of the plant based protein study I have read are similar to the criticism I have read limiting opioid prescriptions in which they advocate do not limit opioid at all. We could all do with less red meat in our diets which still remains a reality.

The $6 Million Drug Claim, Katie Thomas and Reed Abelson, NYT, August 25, 2019

The link should take you to a different site other than the NYT where you can read the article.

Alexion Pharmaceuticals manufactures Strensiq a drug used to treat a rare bone disease perinatal/infantile and juvenile – onset hypophosphatasia. Adult Dawn Patterson also suffers from the same disease, the excruciating pain from it, which leaves her struggling to work or care for her family. It is a rare disease found more often in children and even rarer in adults.

Dawns husband’s union covers the cost of the drug. The union is suffering sticker shock from the mounting bills for treatments of her and her two of her children who also have the disease. In 2018, the union faced a potential $6 million bill for the Patterson household with an estimated a lifetime cost of $60 million to treat the family over 10 years.

The cost of Strensig as well as other drugs is coming under increased scrutiny and debate over whether any drug should cost $millions of dollars after cost of R&D and start up are recovered. Americans are being priced out of lifesaving treatments as drug companies maximize their profits well beyond start up costs. It has been found, the investment of $1 invested in R&D has provided $14.50 in revenue for cancer drugs (World Health Organization).

As I reported in “Cigna gets major boost from Express Scripts in Q2” (above), Pharmacy Benefit Managers are taking a hefty cut in the process in representing insurance companies with manufacturers. In an earlier post “Can you Patent the Sun,” I had talked more on the topic of costs and company reasoning to set higher prices. Manufacturers are pricing new and older drugs higher and establishing a pseudo morality to maximize their profits.

The US is more vulnerable than is European countries only because Europe sets pricing rather than allow the market to do so.

Opioid Maker Turned Blind Eye to Diversion, Kristina Fiore, MedPage Today, August 28, 2019

In newly unsealed documents, Mallinckrodt employees were worried the existing programs to prevent opioid diversion were not working. One former employee testified about Mallinckrodt not having a computerized system from 2008 to 2009 for tracking unusual orders. Employees had to use their judgment to identify suspicious sales. U.S. Drug Enforcement Agents met with Mallinckrodt PLC and informed the company the agency viewed it “as the kingpin within the prescription drug cartel.”

Superior Court for the State of Alaska Third Judicial District in Anchorage, State of Alaska, Plaintiff vs. Mallinckrodt PLC, Mallinckrodt LLC, and SPECGX LLC.

“In reality, however Mallinckrodt shipped opioids into Alaska without an adequate system in place to prevent diversion of its opioids and to investigate, report, and refuse to fill orders that it knew or should have known were suspicious, breaching both its common law duties and its statutory duties under Alaska law. Despite its legal and ethical duty to report “suspicious orders” of its drugs, and, upon information and belief, ample red flags of potential diversion, Mallinckrodt has never once reported a single prescriber to state law enforcement or the Alaska State Medical Board. Instead, Mallinckrodt incentivized distributors to flood the State with opioids beyond even what the expanded market for chronic pain market could bear.”

Mallinckrodt Was Required to and Failed to Maintain Effective Controls Against Diversion and to Report Suspicious Prescribers. , Page 35, B

There are multiple state lawsuits being filed federal courts nationwide claiming pharmaceutical companies misled people as to the safety of opioid usage.

Opioid settlement would divide money based on local impact, Geoff Mulvihill and Andrew Welsh-Huggins, AP, August 30, 2019

Purdue the maker of OxyContin is negotiating a multi-billion-dollar settlement to resolve a crush of lawsuits over the nation’s opioid crisis. The settlement contains formulas for dividing up the money amongst state and local governments across the country.

The formulas would take into account several factors; opioid distribution in a given jurisdiction, the number of people who misuse opioids, and the number of overdose deaths.

Spelling out the way the settlement is to be split is meant to prevent squabbles over the money avoiding the mistakes experienced with the hundreds of billions of dollars received under the nationwide settlement with Big Tobacco during the 1990s.

September 8; States Attorneys and Purdue have reached an impasse and it is expected Purdue will now file for bankruptcy. It is not clear what the breakdown is over. One of the four states attorneys negotiating with Purdue, Pennsylvania’s Josh Shapiro said Saturday he intends to sue the Sackler family as other states have.

“I think they are a group of sanctimonious billionaires who lied and cheated so they could make a handsome profit. I truly believe that they have blood on their hands.”

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Purdue Offers Up $10 – 12 Billion to Settle All Lawsuits – MedPage Update

Just revealed:

The opioid/OxyContin maker Purdue and members of the billionaire Sackler family owning the company have offered to settle thousands of lawsuits against the company for $10 to $12 billion. according to people briefed on the offer. More than 2,000 states, cities, and counties across America are pursuing the OxyContin maker over the large bills for cleaning up the opioid crisis — and are deciding whether to accept the offer by Friday. The Financial Times is reporting on this offer from the Sacklers and Purdue.

On August 26, Purdue paid $270 million to Oklahoma and Teva Pharmaceuticals paid $75 million also to Oklahoma.

From the Financial Times: “Purdue said it believes a ‘constructive global resolution is the best way forward’ and is working with state attorneys-general and other plaintiffs to achieve it. While Purdue Pharma is prepared to defend itself vigorously in the opioid litigation, the company has made clear that it sees little good coming from years of wasteful litigation and appeals”.

For all the harm done to this nation due to purposeful deceit and lies on the use of opioids claiming it was not addictive, someone needs to go to prison from the Sackler family.

Purdue Exposed

Medpage Today, Kristina Fiore, August 28,2019

I suspect with the new information being available, Purdue finally threw in the towel and offered a settlement. I also suspect this will impact other companies decisions to appeal as J & J is doing.

STAT News Wins Legal Fight Over Purdue Documents

A trove of documents detailing Purdue Pharma’s role in the opioid epidemic will be made public, STAT News reported, as the Kentucky Supreme Court denied the company’s request to review lower courts’ decisions to release them.

STAT waged a 3.5-year legal battle to make those records public. While some remain under seal, the outlet posted a sought-after video deposition of Richard Sackler. It had obtained a transcript of that deposition in February, which gained further attention when comedian John Oliver hired famous actors including Bryan Cranston and Michael Keaton to re-enact it.

The documents promise new information on how Purdue promoted its oxycodone product OxyContin and what, exactly, its executives knew about its risk of addiction. Among those documents are depositions of other Purdue executives; physician testimony; emails and memos about marketing strategies; internal reports on clinical trials; and communications about earlier legal cases.

All of the documents were part of Kentucky’s lawsuit against Purdue over its alleged illegal marketing of OxyContin. That suit was settled in 2015, with Purdue shelling out $24 million.

Purdue may soon be paying a far higher bill, with media including NBC News reporting that the company has pitched a $10 to $12-billion settlement in the consolidated cases set to go to trial before a federal judge in Ohio in October.

This does not bode well for Purdue, its settlement, or threat of years of litigation. The smoking gun was always there and pieces of it can be found in previous posts of mine. Relating the US Senate Joint Committee numbers to when Oxycontin was introduced after 1995 and the incremental increase in deaths from opioids, the use of a part of the Porter and Jink letter to the NEJM which said opioids were not addictive “minus the part where it said when used in a hospital setting,” the abuse of the Porter and Jink letter in the number of citations, the millions spent in lobbying state legislatures to block new laws, etc.

John Oliver uses Keaton and Cranston to portray Richard Sackler in this 20 minute Clip. It is worth watching. “the launch (Oxycontin) would be followed by a blizzard of prescriptions that will bury the competition. The blizzard will be so deep, dense, and white,.”

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J & J and It’s Subsidiary Janssen’s Actions “Created a Public Nuisance”

“The court found that Johnson & Johnson’s actions had created a “public nuisance,” which Oklahoma law defines to mean an act (or failure to act) that ‘annoys, injures or endangers’ the health and safety of an ‘entire community.’

In a 42-page opinion, Oklahoma State Judge Thad Balkman details how Johnson & Johnson’s sales and marketing assured doctors the appearance of addiction in patients due to the use of J & J opioid products was actually evidence of ‘under-treated pain’ and required the prescribing of more opioids. Sales representatives used these aggressive marketing tactics to target prescription-happy doctors referred to as ‘Key Customers’ in internal correspondence.”

I can not help but feel there comes a time when one must look at the continuing misuse of opioids under a doctor’s care and wonder what the doctors were thinking.

Multiple times I have written on the deadliness of opioids. To market and promote the use of opioids, the pharmaceutical industry deliberately took one sentence of a letter written by Doctors Porter and Jink to the NEJM in 1980 and claimed the use of opioids as safe in all environments and not mentioning Porters and Jink’s study was done in a hospital setting.

Addition Rare in Patients Treated with Narcotics, NEJM 1980: “Recently, we examined our current files to determine the incidence of narcotic addiction in 39,946 hospitalized medical patients who were monitored consecutively. Although there were 11,882 patients who received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients who had no history of addiction. The addiction was considered major in only one instance. The drugs implicated were meperidine in two patients, Percodan in one, and hydromorphone in one. We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.” Boston Collaborative Surveillance Drug Program, Boston University Medical Center, Waltham NA 02154

From 1980 till 2015 the letter was cited 491 of 608 times affirming the use of opioids does not cause addiction. There was a significant increase in citation after the introduction of OxyContin in 1995. The “median number” of citations of a NEJM letter was 11 times in total. The citation of one sentence in whole or partially was many times more.

In Prescription Painkiller Addiction: A Gateway to Heroin Addiction,” Recall Report documents the start of the explosion in opioid use tying it to the introduction of OxyContin by Purdue Pharma in 1995/96.

The United States Congress Joint Economic Committee provides two charts detailing the total “number” of deaths per year from overdoses solely from opioids and Overdoses from all drugs during the time period of 1968 to 2015. The bar chart on the right represents the “numbers” of deaths per 100,000 (rate) of population from Overdoses solely from opioids and Overdoses from all drugs during the time period of 1968 to 2015. There has been arguments made there is no discernable evidence showing the impact of prescription opioids on the numbers of deaths. These two charts certainly points in a direction of the impact of prescribed opioids on the death rate.

Up till seeing the Joint Committee data, I had not seen earlier data. In these charts can be seen the additional yearly data predating 1980 when the Jick and Porter letter had been written to the NEJM going back as 1968. This data is important to see the magnitude of the introduction of prescribed opioids such as Oxycontin and the influence of them and the pharmaceutical industry on the usage of opioids said to be a safe drug to use outside of supervision.

State Judge Thad Balkman’s verdict will be appealed in higher state courts. If upheld, it will go to the federal courts. J & J is not a company without financial resource and they will contest this verdict as far as they can take it. The importance of the verdict is in holding a company, a citizen amongst us as declared by SCOTUS responsible for the abuse of opioids as shown in the numbers presented in this post, in earlier posts, and in the related documentation presented in all of my posts on opioids.

Reference Data

What the Oklahoma Johnson & Johnson Verdict Means for the Future of Opioid Litigation, Jay Willis, Microsoft News, August 27, 2019

Opioid Use since 1968 and Why It’s Abuse Increased, run75441 (Bill H), April 7, 2019

The Rise in Opioid Overdose Deaths, US Senate Joint Economic Committee, August 01 2017

Prescription Painkiller Addiction: A Gateway to Heroin Addiction, Recall Report

run75441 (Bill H)

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“pruning the tree when spring starts”

End of month July and Pfizer is spinning off Upjohn to generic drug/device company Mylan NV. Pfizer bought 57% of the unnamed (mid – 2020) new company. This move comes under Pfizer CEO Albert Bourla who took over the reins from Ian Read in January, 2019. Bourla has been with Pfizer for 25 years. Before becoming the CEO, Bourla was the Chief Operating Officer (COO) overseeing the company’s commercial strategy, manufacturing, and global product development functions.

CEO Bourla has been making strategic moves following what he has called a “pruning the tree when spring starts and Pfizer is in the spring of high growth” strategy. What caught my eye is this one comment in the Wall Street Journal about remaking Pfizer into a company focused on patent-protected prescription medicines with the potential for significant sales growth from a more diversified but slower-growing player. To me, this translate into a; “hey the Mylan EpiPen strategy worked, lets do the same with other products” strategy.

To date, he has overseen a restructuring at the company and made smaller deals to boost Pfizer’s pipeline of cancer and other drugs under development. Still not the biggest deal which would make Pfizer a giant. He has been guiding the combining of a division selling Advil, vitamins, bathroom found meds with GlaxoSmithKline PLC’s own consumer-health business to be spun off in a joint venture. Nothing earth-shattering there.

CEO Bourla focus for Pfizer on higher profit, exclusive, prescription drugs while moving the rest of its lower profit operations into other ventures. Off-patent drugs such as Lipitor and Viagra having lower profit margins would be targeted for joint ventures and Pfizer would still retain sizeable amounts of cash flow from these drugs to fund R&D. Pfizer is shifting the declining brands to Upjohn. The intent is to consolidate this business with Upjohn and merge Upjohn with the EpiPen company Mylan and rename the two.

The new Pittsburgh – based unnamed company is expected to be among the world’s largest sellers of generic and off-patent medicines with more than $19 billion in yearly sales. Pfizer Shareholders will own 57% of the new company and Mylan shareholders would the rest. Pfizer would be paid $12 billion raised from new debt acquired from the joint venture. Upjohn would return to the US from its corporate base in Shanghai, a reversal of its earlier inversion.

To me, this is a strategic move along the lines of Pfizer selling off the marketing of EpiPen to Mylan and keeping the manufacturing of it. Pfizer owned Meridian Medical Technologies manufactured EpiPen for Mylan and it will now be a part of the sale to Mylan. EpiPen was a huge success story for Mylan. A quadrant strategy of milking of a cash cow to fund new ventures.

Including EpiPen, “Mylan’s operating profit for its Specialty segment grew from about 35% in 2012 to roughly 60% in the second quarter of 2016.” Most of this can be traced back to the change in design of the EpiPen (cap) , exclusivity of it due to design changes which was covered by patents, and the rejection of Teva’s generic by the FDA due to a difference in application.

Add to this strategy story, Eli Lilly’s Alex Azar’s success profiteering off of the decades old diabetes drug Humalog and one can begin is imagine what the new “unnamed” company’s role will be under CEO Albert Bourla’s direction . . . more of the same.

In its analysis, World Health Organization determined the expenditure of one dollar in R&D being covered by $14.50 profit for cancer pharmaceuticals or more than enough to recoup expenditures for R&D and provide a healthy return for investors. The generics Upjohn will acquire have more than paid back the costs of R&D and are more than likely to be in a decline in producing profits. The question then becomes how to enhance the return on these generics.

Mylan changed Pfizer’s EpiPen design to achieve patented exclusivity. Teva could not duplicate it as a generic because patients could not use the Mylan instructions in applying the Teva generic. According to FDA’a rules, the Teva product could not be cast as a generic for the Mylan EpiPen in the marketplace as it could “not” be used in the same manner..

EIi Lilly’s Humalog, same formulation as what was made decades ago. The list price for one vial of Humalog has nearly tripled over the last decade. No new and improved or patent changes. Lilly appears to be taking increased profits from the price changes and passing on a larger slice to Pharmaceutical Benefit Managers to gain preference by healthcare insurance plans represented by the PBMs.

The same at the other diabetes med manufacturers Sanofi and Novo. Sanofi, a diabetes drug manufacturer and competitor to Eli Lilly gave insurers and pharmacy benefit managers rebates totaling more than half of its gross sales in the U.S. last year, resulting in net price declines across its portfolio despite list price hikes taken on dozens of its prescription products.

What is occurring is “shadow pricing” increases where one company raises pricing and the others follow.

A lawsuit filed in 2017 alleged three companies (Eli Lilly, Novo Nordisk, and Sanofi) intentionally raised the list prices on their drugs to gain favorable treatment from pharmacy benefit managers, who work with health insurers and drug makers and help decide how a drug will be covered on a list of approved drugs. Insurance companies do not pay manufacturer list pricing. The PBMs negotiate a rebate to the insurance companies from which they take a portion of it for themselves. The insured gets the net price after Rebates are paid to insurance company minus the PBM bonus for negotiated price.

It is in this circus of net profits after rebates and bonuses, I believe the Upjohn/Mylan “nameless” new company battle will be fought to increase Pfizer’s profit. This is not like the EpiPen medical device where a change in design of the pen can be made and a new patent secured. Some drugs may be changed which would result in a new patent. I suspect much of Upjohn/Mylan product profit improvement will be fought by getting preference from Pharmacy Benefit Managers.

CEO Albert Bourla will be watching the new company to see how successful they are in creating preference with PBMs and the resulting profit.

Why are our drugs so Costly? Watch the YouTube Presentation to Understand why Drugs are so Expensive to You.

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Science Backed Home Healthcare Remedies

From treehuggers, “Home Remedies,” Melissa Breyer, August 12, 2019

treehugger publication was also a part of Slate’s “Green Challenge” which Slate started publishing in conjunction with treehugger.org. a decade plus few years or so ago.

Chicken Soup for a Cold?

Toronto-based dietitian and Director of Food and Nutrition at Medcan, Leslie Beck:

“There is no evidence to prove that eating chicken soup is effective at treating the common cold. However, it’s not a total bust.” She continues;

“A 2000 University of Nebraska study found homemade chicken soup containing chicken, lots of vegetables, parsley, salt and pepper inhibits the activity of inflammation-causing white blood cells in blood samples taken from volunteers. It was thought this could reduce the flow of mucus and ease a stuffy nose. An earlier 1978 study found sipping hot chicken soup increased the velocity of nasal secretions in 15 healthy volunteers, an outcome possibly helping clear a stuffed-up nose. It was also found the effect lasted only 30 minutes and drinking hot water had the same effect.”

Another conclusion found in the same 1978 study was “Hot chicken soup, either through the aroma sensed at the posterior nares or through a mechanism related to taste, appears to possess an additional substance for increasing nasal mucus velocity.”

A 1998 UCLA report Coping with Allergies and Asthma notes, “chicken soup may improve the ability of the tiny hairline projections in the nose (called cilia) to prevent infectious particles from afflicting the body.”

It does lessen the sniffles . . .

Honey for Coughs

In “What works best for kids’ colds? Not medicine,” the author Melissa Breyer writes about a study showing honey outperforms the popular cough suppressant dextromethorphan (DM) in treating cough symptoms in children.

Dr. Shonna Yin from the N.Y.U. School of Medicine says that comfort for sick kids can come in the form of “plenty of fluids to keep children well hydrated, and honey for a cough in children over a year old.”

Prunes?

Science backs up the efficacy of prunes in helping improve regularity and better than psyllium. A half a cup of prunes has around 6 grams of fiber for around 200 calories. They also have the natural sugar, sorbitol, which can act as a laxative for some people.

Ginger for Nausea

Ginger is commonly used for medicinal purposes in Asian, Indian, and Arabic herbal traditions. In China, ginger has been used to aid all types of digestion disorders for more than 2,000 years. Health care professionals recommend ginger to help prevent or treat nausea and vomiting and as a digestive aid for mild stomach upset. Germany’s Commission E has approved ginger as a treatment for indigestion and motion sickness.

Hot or cold ginger tea can be made by grating or slicing fresh ginger and letting it steep in boiled water for 10 minutes or longer if you like it spicy. Hot, spicy, ginger tea with lemon and honey also does wonders for a stuffy nose as well.

How to Make Ginger Ale using Ginger.

Lavender to induce Sleep

Sleep expert Richard Shane, PhD ; “Research shows that smelling lavender decreases heart rate and blood pressure the key elements of relaxation (Reader’s Digest). The two main chemicals in lavender have been shown to have sedative and pain-relieving effects.”

2005 study found an exposure to lavender essential oil increased the percentage of deep or slow-wave sleep (SWS) in men and women. The study’s subjects reported “increased vigor the morning after exposure to lavender exposure corroborating the restorative SWS increase. Lavender serves as a mild sedative and has practical applications as a novel, nonphotic method for promoting deep sleep in young men and women and for producing gender-dependent sleep effects.”

Some truth in what mom and grandmother thought for their children and grand children. Maybe they did know best?

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“4 out of 5 mass Shooters Were Not Diagnosed with Mental Iillness,

half showed no signs of a prior, undiagnosed illness.” Sen. Chris Murphy (D-CT), and plainly speaking, they were not mentally ill.

Yesterday on Monday morning;

President Trump: “Mental illness and hatred pulls the trigger, not the gun. We must reform our mental health laws to better identify mentally disturbed individuals who may commit acts of violence and make sure those people not only get treatment and if necessary, involuntary confinement.” This is coming from a narcistic man who behaves irradicably and irrationally.

In response to President Trump’s remarks, Senator Chris Murphy (D-CT).

“Nineteen of 20 murderers had no diagnosis of a mental illness. Four out of 5 mass shooters had no mental illness diagnosis, and half showed no signs of a prior, undiagnosed illness. Framing mass shootings as just a mental illness problem is a gun industry trope. Period. Stop.”

In any case, the courts make little allowance for mental illness or for those who plead insanity. Those who are mentally ill and convicted of felony are locked away at level 4 prisons with the general population and the treatment is minimal. Trump’s “lock them up” comment of involuntary confinement just takes it one step further than the courts and without their interference.

Back to Senator Murphy and social media comments: some commenters agreed with Senator Murphy’s point about the validity of linking such events to mental illness as these comments only serve to stigmatize anyone with a mental illness. Other commenters questioned whether it is possible for a person to kill multiple strangers, at random, and not be mentally ill. One Twitter commenter; “So a healthy person does this?”

Yes, it can be a healthy normal person more often than not.

A much-cited 2016 review by forensic psychiatrists James L. Knoll IV MD and George D. Annas MD, SUNY Upstate Medical University in Syracuse New York may have been what Senator Murphy was referencing to in his comments.

Both doctors Knoll and Annas acknowledged the public and the media find the question of “mental illness” hard to resist.

“After all, who but a madman would execute innocent people in broad daylight, while planning to commit suicide or waiting to be killed by police?”

Adding to Knoll and Annas’s findings as well as other research; only a “minority” of mass shootings (however defined) have been perpetrated by individuals having recognized mental disorders.

“Few perpetrators of mass shootings have had verified histories of being in psychiatric treatment for serious mental illness.”

Again Knoll and Annas: Such individuals can function (perhaps marginally) in society and do not typically seek out mental health treatment. In most cases, it cannot fairly be said that a perpetrator ‘fell through the cracks’ of the mental health system. Rather, these individuals typically plan their actions well outside the awareness of mental health professionals.”

Mass shooters may not meet the criteria of a disorder as stated in DSM-5 – “Diagnostic and Statistical Manual of Mental Disorders.” They may have an ill-defined trouble of the mind, harboring anger or revenge and for which the field of mental health field has no immediate, quick-acting ‘treatment. “Psychiatrists and in particular forensic psychiatrists understand that dark and depraved acts are frequently committed for other reasons besides mental illness and more often committed for those other reasons.”

Can the matter of a hidden anger or other undefined trouble be resolved by labeling it ‘mental illness’ and calling for greater scrutiny of ‘troubled’ individuals? Knoll believes we would solve nothing by doing so and even risk making matters worse. This mindset makes us vulnerable to creating new and misguided laws. Such attempts further the medieval notion of equating mental illness with ‘evil’ or criminal behavior.

Mental health treatment has its limits is not designed to detect and uncover potential violent extremists. Formal psychiatric screening is not likely to identify those who may commit massacres.

Noting the wave of mass shootings beginning in the late 1990s; there was another propellant besides guns and mental illness both of which existed for a long time, and to which Knoll added the media as another. “It seems difficult to deny that the media coverage since the late 90s” has made it certain that those who commit heinous crimes become celebrities through the development of an online “Columbiner culture” glorifying the Columbine High School shooters and the others following in their footsteps.

We must eliminate the media attention gained from mass shooting.

Conundrum: Why Isn’t Killing 22 People ‘Mental Illness’?” — Psychiatrists say the question is beside the point, MedPage Today, John Gever, Managing Editor, August 5, 2019

Mass Shootings and Mental Illness,” Gun Violence and Mental Illness. James L. Knoll M.D. and George D. Annas M.D.

The Health 202: Trump blamed mental illness for mass shootings. The reality is more complicated” The Washington Post, Paige Winfield Cunningham

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Medicaid expansion saved lives

We use large-scale federal survey data linked to administrative death records to investigate the relationship between Medicaid enrollment and mortality. Our analysis compares changes in mortality for near-elderly adults in states with and without Affordable Care Act Medicaid expansions. We identify adults most likely to benefit using survey information on socioeconomic and citizenship status, and public program participation.

We find a 0.13 percentage point decline in annual mortality, a 9.3 percent reduction over the sample mean, associated with Medicaid expansion for this population. The effect is driven by a reduction in disease-related deaths and grows over time. We find no evidence of differential pre-treatment trends in outcomes and no effects among placebo groups.

Sarah Miller Sean Altekruse Norman Johnson Laura R. Wherry, NBER WP Working Paper 26081

I’ve been waiting for this. ACA Medicaid expansion is a policy experiment. The states which did not expand Medicaid made it easy to see if Medicaid saves lives. Obviously it does.

Via Axios where Sam Baker wrote; “expansion states saw a mortality rate that’s about 0.2% lower than nonexpansion states, the authors write — which would translate to roughly 15,600 lives, had the expansion not been optional for states.”

So Republican reactionary idiots have killed roughly 15,600 people so far through refusal to expand Medicaid alone. For comparison “In 2017, the estimated number of murders in the nation was 17,284” (just a number for comparison, I am not saying Republican legislators are murderers).

I don’t read Axios. I clicked there from Steve Benen

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Democratic Presidential Candidates Addressing Maternal Healthcare

Back in April, I finished up an article for ConsumerSafety.Org called A Woman’s Right to Safe Healthcare Outcomes. The topics covered in this as given to me by ConsumerSafety.Org were Clinical Trials, Essure, and Maternal Mortality. All of the topics dealt with women’s healthcare. Of the three issues addressed, I found Maternal Mortality to be the most compelling.

I told the story of a white upper middle class couple, Lauren Bloomstein a nurse and her husband Larry a surgeon. They went to the hospital to have their first baby. Lauren was a healthy young woman who did everything right. Unfortunately Lauren’s OB before and during her delivery missed many of the signs she was suffering from preeclampsia or high blood pressure. Lauren died after giving birth to a healthy baby girl. It is not unusual for doctors failing to heed the warning signs a women or her symptoms are alerting them too.

The warning signs of life-endangering problems were there, were missed (pain in the kidney area), or ignored (abnormal high blood pressure for Lauren). Excuses for other causes of the pain (reflux) were made, and pain killers administered to dull the pain and other symptoms (blood pressure) not explored while she deteriorated in front of her husband who suspected preeclampsia. The missing part of this was the protocol to diagnose early on and prevent Lauren from slipping into late stages of preeclampsia. This is not an isolated incidence as the deaths of women giving birth keep increasing as evidenced in the chart.

Even with the PPACA, expanded Medicaid in place; and when compared to their Canadian sisters, American women are three times more likely to die from the start of a pregnancy up till one year after the birth of a child (defined by the Centers for Disease Control). The death rate for American women is 26.4 deaths per 100,000 as opposed to 7.3 deaths per 100,000 in Canada (Chart). The ratio worsens when compared to Scandinavia countries as American women are six times as likely to die as Scandinavian women.

There are two stories, one for economically secure women and another for minority, native American, rural, and lower income women.

The statistics worsens for women of color with their being more likely to die in pregnancy or childbirth and are nearly four times more likely to die from pregnancy-related causes than white women. In high-risk pregnancies, African-American women are 5.6 times more likely to die than white women. Amongst women diagnosed with pregnancy-induced hypertension (eclampsia and pre-eclampsia), African-American and Latina women were 9.9 and 7.9 times in danger of dying than white women with the same complications. Native American and Alaskan Native women experience similar discriminatory care. Half of all U.S. births are covered by Medicaid and covers women up to two months past delivery leaving a substantial gap after child birth when other issues can arise.

Barbara Levy, vice president for health policy/advocacy at the American Congress of Obstetricians and Gynecologists; “We worry a lot about vulnerable little babies and we don’t pay enough attention to those things catastrophic for women.”

The emphasis has been on safe baby care and safe birthing which lead to a significant decline in baby mortality. As reported in a Propublica, NPR report, the difference in “maternal mortality numbers contrast sharply with the impressive progress in saving babies’ lives.” Maternal death rates while giving birth and up to one year later has increased by an approximate 10 deaths per 100,000 since 2000 till 2015 or greater than the 9.2 deaths per 100,000 in the U.K, (Chart).

In my email account, I found my usual Health Affairs article with a lead off title “The Maternal Health Crisis: Policies of 2020 Candidates

“Many of the Democratic presidential candidates met in Columbia, SC at the Planned Parenthood Women’s Health Forum to share their reproductive health proposals, including plans for maternity care. On Thursday, June 26th, they will engage in their first debate. Donald Trump launched his re-election bid on June 18th, 2019. While his campaign website does not include any specific reference to maternal mortality, members of his administration have recently brought attention to rural maternal health challenges.

This renewed focus on maternity care is desperately needed: U.S. rates of maternal mortality are the highest in the developed world and have been rising since the 1990s, with women giving birth today more likely to die in childbirth than their mothers. These adverse outcomes are also marked by significant racial disparities, with non-Hispanic black and American Indian/Alaska Native women at least 3 times as likely as non-Hispanic white women to die around the time of childbirth.”

About time.

run75441 (Bill H)

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