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DBL%20Hendrix%20small.png College chemistry, 1983

Derek Lowe The 2002 Model

Dbl%20new%20portrait%20B%26W.png After 10 years of blogging. . .

Derek Lowe, an Arkansan by birth, got his BA from Hendrix College and his PhD in organic chemistry from Duke before spending time in Germany on a Humboldt Fellowship on his post-doc. He's worked for several major pharmaceutical companies since 1989 on drug discovery projects against schizophrenia, Alzheimer's, diabetes, osteoporosis and other diseases. To contact Derek email him directly: derekb.lowe@gmail.com Twitter: Dereklowe

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January 2, 2007

That Can't Be Right - Try Again

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Posted by Derek

There was an interview in yesterday's New York Times with Harvard Business School professor Clayton Christensen. (Not one of your shy and retiring professors, I should add). He's saying that the US healthcare system is terribly inefficient, and proposes (among other things) that some diagnostic tasks be opened up to a larger field of practitioners than just M.D.s. That's a worthy topic of discussion, but for one of the pure med-blogs, I'd say, rather than over here.

What struck me about the interview was something else - the tone of some of the questions. It's part of an "Armchair MBA" series by William J. Holstein, but the interview seems to have been conducted by Elizabeth Olson, so I'm not sure of the source. Here's the part that gave me pause:

Q. An example of what you mean?

A. A hundred years ago, there was a big disease that nobody understood and was often fatal, called consumption. . .what we thought was a single disease was a whole bunch of different diseases. You had tuberculosis there, at least three types, and you had pneumonia. We thought it was all one disease. So the care had to be left with doctors because they were the ones with the training and the judgment, but once you could precisely diagnose the cause of the disease, you could then develop a cure. It was so rules-based that you didn’t need a doctor any longer. Today a technician can diagnose those diseases and a nurse can treat them.

Q. Are you saying doctors rather than the pharmaceutical industry are the root cause of what’s gone wrong?

A. The pharmaceutical industry has been focused on therapy, not diagnosis. The medical profession has simply accepted that many of these diseases are well-diagnosed, when in fact they aren’t. As a consequence, we haven’t moved the health care profession into a world where nurses can provide diagnosis and care. Regulation is keeping the treatment in expensive hospitals when in fact much lower cost-delivery models are available.

Q. Wouldn’t your solution require a dramatically different regulatory environment?

A. It differs state by state. In Massachusetts, nurses cannot write prescriptions. But in Minnesota, nurse practitioners can. So there has emerged in Minnesota a clinic called the MinuteClinic. These clinics operate in Target stores and CVS drugstores. They are staffed only by nurse practitioners. There’s a big sign on the door that says, “We treat these 16 rules-based disorders.” They include strep throat, pink eye, urinary tract infection, earaches and sinus infections.

These are things for which very unambiguous, “go, no-go” tests exist. You’re in and out in 15 minutes or it’s free, and it’s a $39 flat fee. These things are just booming because high-quality health care at that level is defined by convenience and accessibility. That’s a commoditization of the expertise. . .

Q. Aren’t the pharmaceutical companies also profiting?

A. They are. But in general, pharmaceutical breakthroughs that involve a precise diagnosis of a disease and an effective therapy save the system a tremendous amount of money even though the drugs may appear to be high-cost.

Now, I've never found the tone of the NYT's business section particularly warm where drug companies were concerned. But this really seems to be pushing things along. "You mean it isn't all Big Pharma's fault? But your idea would still allow them to make money!" Do I have my gain setting turned up too far, or is this as obvious to other readers as it is to me?

Comments (27) + TrackBacks (0) | Category: Press Coverage


COMMENTS

1. TW Andrews on January 2, 2007 11:22 PM writes...

Sure, the "big companies are evil" storyline is pretty obvious, but this sort of chin scratching is all that one can reasonably hope for from the Times.

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2. Chrispy on January 3, 2007 12:06 AM writes...


I like the flat fee, 15 minute thing. I resent having to wait every time I go to the doctors office, only to be rotated through one of the waiting rooms and get all of like 5 minutes of attention for my one hour invested.

BUT rules based medicine only works with really clear cut conditions, and a lot of medicine is unclear. It would be tragic if someone went to one of those 15 minute jobbies and they had meningitis or malaria -- they would need a referral and the ball could get dropped.

The fact is that the US system is very good if cost is no object, but if you have insurance companies or poverty between you and your health care the US system pretty much blows.

The pharmaceutical companies do OK with the small molecules, but Lord help you if you get cancer and need therapy with Avastin ($100k/yr) or you need Cerezyme for your Gaucher's disease ($200k/yr).

It is hard to look at these prices and think that at some level the desperately sick are not getting gouged. Not by all of the pharma companies all of the time, but by some of the companies too much of the time. These folks (Genentech, Genzyme are you listening?) are going to kill the golden goose.

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3. Jeff Bonwick on January 3, 2007 12:45 AM writes...

Part of the problem is deceptive language. When you read that "drug companies profit from people's suffering", of course it sounds evil. But it's also inaccurate. In fact, drug companies profit from alleviating people's suffering.

The problem with the anti-pharma thesis can be seen most clearly by considering not what it opposes, but what it implicitly advocates: that millions of people should suffer and die to prevent a handful of people from prospering. It's hard to imagine a more deeply immoral proposition.

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4. Petros on January 3, 2007 2:50 AM writes...

Following on from Crispy's comment

There are some examples of high priced small molecule therapeutics. Celgene's recently launched Revlimid, a slightly modified form of thalidomide, comes in at around $75,000 per year!

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5. Jim on January 3, 2007 9:22 AM writes...

Living in MN, the minute clinic thing gets mostly good, but slightly mixed reviews. As a parent, you know when your kid has an ear infection, and it's nice to be able to go get a prescription quickly. If you have a sinus infection, you can get an Rx as long as you answer the question "how long have you had these symptoms?" correctly (Answer: at least 10 days). It seems to me to be akin to living in Europe and getting a script from your pharamcist.

As for the tone of the article, Derek, I think you're overreacting a bit, but there's definitely an undercurrent there.

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6. John Thacker on January 3, 2007 9:32 AM writes...

The pharmaceutical companies do OK with the small molecules, but Lord help you if you get cancer and need therapy with Avastin ($100k/yr) or you need Cerezyme for your Gaucher's disease ($200k/yr).

Well, Lord help you if you're in the UK at want Cerezyme for your Gaucher's disease, since the NHS initially said it wasn't worth it on a cost-benefit analysis.

Drug research is expensive. The trend of the VA and European health services of waiting until the R&D costs are already paid by people in the US and their insurers is really not a great long-term thing.

Drug patents run out after 18 years. Generics are not fantastically expensive. Of course it's horribly frustrating and awful when some new treatment does better against a disease than the older ones, but is far more expensive. I hardly see too much difference from the patient perspective between paying an astronomical sum in the US for a new drug or not having it available at all via the VA or a national health services, though.

Of course, the US system does perhaps encourage doctors to prescribe and people to take the latest and greatest best new drugs more than perhaps they "should," or more than a strict cost-benefit analysis would provide. However, if that's your point of view, you should realize that you're not actually arguing for greater access and use of the latest therapies.

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7. Morten on January 3, 2007 9:42 AM writes...

Christensen is blaming the pharmaceutical industry for not making molecular diagnostic kits to accompany the therapies they develop. He is right too. A couple of good diagnostic kits would make a large part of the legion of sales people employed by Pfizer redundant. And the industry would be able to make 2 sales per disease, people would get well quicker, doctors could spend more time on the interesting cases, everybody wins.
The MinuteClinic is a brilliant idea in my mind.

Permalink to Comment

8. Dave L on January 3, 2007 10:27 AM writes...

Better yet, for $39 the Minute clinic should just hand out Kevin Trudeu's "books" and undercut evil pharma altogether. How simple it will be to diagnose the illness then hand the customer the "book" with the appropriate page bookmarked. If the customer gets sick with some other disease they'll have Kevin's "book" and be able to treat themselves thereby reducing the burden of future repeat business. The clinics should also stock-up on apple cider vinegar. I hear that's the miracle cure.

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9. Gavin Fischer on January 3, 2007 11:03 AM writes...

He gets his facts wrong about Nurse Practitioners. In Massachussetts, and in every state in the US I am aware of, Nurse Practiotioners are allowed to write presciptions. NURSES are not allowed to write prescriptions in any state I am aware of. The difference is a masters degree vs a bachelors or less (depending on the kind of nurse).


There is my pedantic correction for the day....

Gavin

Permalink to Comment

10. Laura King on January 3, 2007 11:06 AM writes...

I think the article here manages to focus on the ease of modern drugs at treating common illnesses under the guise of talking about changing health care and the role of pharmaceutical companies in your personal health. What I wish had been touched upon if only briefly is the public understanding, through scientific advancement and education, of what illness really is--what causes our common symptoms, what can alleviate or cure them. With that increase in general understanding does naturally come a decrease in the need to rely on a heavily trained individual to help you diagnose and manage your basic ear infections or strep throat, but creates a problem also of the illusion of knowledge. I as an individual can be aware that my symptoms are likely strep throat: Im an educated scientist, and better, my parents are doctors, so I've been surrounded by medical discussion for a long time. I can easily come to the conclusion with my personal knowledge or the help of the internet that I have strep throat, present my case to a person capable of writing me a basic scrip, and feeling like I've saved time. If that were the last case, I'd have been in trouble: the strep was a peritonsillar abscess, but I had no idea because it just felt like nodes swelling. Rare, sure--dangerous, too.

My point through all of this is while we can easily treat ourselves for what we consider basic nuisance illness (an evolving definition as our understanding and medications evolve), we will continue to use medical professionals because we don't personally have the time to analyze our case objectively and ask what can sometimes be the necessary questions to both truly eliminate the illness or prescribe the right treatment, one that isn't going to interfere with current medications or be an allergen (I for instance am allergic to zithromax and imitrex, and found both out the hard way).

Permalink to Comment

11. Bruce Grant on January 3, 2007 11:48 AM writes...

I had the same reaction as you to the interviewer's obvious desire to return and chew the big-bad-pharma bone some more, even before reaching the end of your post.

Permalink to Comment

12. RKN on January 3, 2007 11:49 AM writes...

He gets his facts wrong about Nurse Practitioners. In Massachussetts, and in every state in the US I am aware of, Nurse Practiotioners are allowed to write presciptions.

Yes and no. My wife has been an NP in oncology for about 12 years. In private practice in Alaska she had full prescriptive authority up to and including class I (II?) narcotics. In Ohio, she works in basically the same capacity she did in Alaska, i.e. outpatient oncology, but her complaint here is the severe restriction of her prescriptive authority. That authority is regulated by the state, and supposedly would be less restrictive if she didn't work in conjucnction with a teaching hospital. Regulations like this really do differ from state to state.

Permalink to Comment

13. milkshake on January 3, 2007 11:53 AM writes...

Here is one frightening and common scenario: A guy with lots of personal problems is depressed and wants to get better. So asks his primary-care physician for a referal to a shrink. Because HMOs are cheap and cutting corners, the shrink turn out to be actualy a psychologist with a MS degree. The psychologist does some "behaviour therapy" which mostly consist of explaining to the patient that nothing is ever his fault.
The psychologist then calls a nurse to prescribe some SSRIs. SSRIs are very safe, right?

Unfortunately the patient problems are related to a borderline bipolar disorder that has gone undiagnosed (he has never seen a shrink before). Therefore the patient will not get better. SSRIs will turn his frequent depression into episodes of frank mania. He may end up doing something nutty that will put him in jail or cemetery.

Permalink to Comment

14. Steve on January 3, 2007 5:07 PM writes...

In response to "milkshake"'s comment: I ask "freightening and common scenerio" where?! No nurse practitioner is going to prescribe anything without their own assessment of a patient. This "scenerio" that you talk about is ludacris and just isn't likely.

As an Nurse Practitioner (NP), I can tell you this first-hand. Certainly, we can listen to a reccomendation from a mental health professional or any other member of the healthcare team. However, our privledge to prescribe is based on our ability to assess that patient. We aren't freely handing out scripts because somebody asked us to.

Permalink to Comment

15. Anonymous on January 3, 2007 5:41 PM writes...

Last time I went to a clinic, I never saw a doctor. I saw a very competent nurse practitioner instead. I don't see much difference from the Minnesota model.

The fact is that the US system is very good if cost is no object, but if you have insurance companies or poverty between you and your health care the US system pretty much blows.

Such scholarly studies as I have seen say otherwise.

As for the tone of the article, Derek, I think you're overreacting a bit, but there's definitely an undercurrent there.

Ya think? A question like

Aren’t the pharmaceutical companies also profiting?

betrays a belief that profiting from providing useful therapeutics is somehow wrong. It is no overreaction to be irritated by this.

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16. SRC on January 3, 2007 6:00 PM writes...

The NYT is envious of anyone turning a profit. Check their stock chart, unless you're prone to vertigo.

Permalink to Comment

17. milkshake on January 3, 2007 8:18 PM writes...

"No nurse practitioner is going to prescribe anything without their own assessment of a patient"

Dear Nurse - I think you would be very surprised what is going on. Blue Cross/Blue Shield, 4th floor, HMS at Harvard Square, Cambridge, MA. (I will skip some details here. Let's say that from the information I have, they had just one certified nurse for the entire floor for signing the prescriptions - but the actual medication choice and dosages were suggested by psycholochologists with a degree in "behavioral sciences".)

Permalink to Comment

18. jelleric on January 4, 2007 1:43 AM writes...

This discussion is very interesting. As a former M.S. organic chemist turned future nurse practitioner, I see both sides of the coin. Here is something I found on the internet a few months ago.

States where NPs can prescribe (including controlled substances) independent of any physician involvement: AK, AZ, DC, IA, ME, MT, NH, NM, OR, UT, WA, WI, WY.

States where NPs can prescribe (including controlled substances) with some degree of physician involvement: AR, CA, CO, CT, DE, FL, GA, HI, ID, IL, IN, KS, MA, MI, MN, NC, ND, NE, NJ, NY, OK, PA, RI, SC, SD, TN, VT, WV.

States where NPs can prescribe (excluding controlled substances) with some degree of physician involvement: AL, KY, LA, MO, MS, NV, OH, TX, VA.

Permalink to Comment

19. RKN on January 4, 2007 9:44 AM writes...

He gets his facts wrong about Nurse Practitioners. In Massachussetts, and in every state in the US I am aware of, Nurse Practiotioners are allowed to write presciptions.

Yes and no. My wife has been an NP in oncology for about 12 years. In private practice in Alaska she had full prescriptive authority up to and including class I (II?) narcotics. In Ohio, she works in basically the same capacity she did in Alaska, i.e. outpatient oncology, but her complaint here is the severe restriction of her prescriptive authority. That authority is regulated by the state, and supposedly would be less restrictive if she didn't work in conjucnction with a teaching hospital. Regulations like this really do differ from state to state.

Permalink to Comment

20. biff on January 4, 2007 2:35 PM writes...

@Milkshake / @Steve, regarding the back and forth about "No nurse practitioner is going to prescribe anything without their own assessment of a patient":

Well, no truly ethical and professional practitioner (NP, PA, or physician) is going to prescribe anything without their own assessment of a patient.

However, it's folly to suggest that the credential of "M.D." makes any difference about prescribing with or without true assessments. How many doctors will write a scrip for an antibiotic at a parent's request without even seeing the kid? Perhaps not most, but it certainly does happen.

Credentials are not guarantors of ethics.

Permalink to Comment

21. markm on January 4, 2007 4:31 PM writes...

In regards to Milkshake's scenario: Plenty of pediatricians (MD's, not NP's) prescribe Ritalin based on an assessment by a school psychologists.

Permalink to Comment

22. Chrispy on January 4, 2007 7:00 PM writes...

Anonymous,

Regarding your comment about my assertation that the US healthcare system pretty much blows unless you're wealthy:

"Such scholarly studies as I have seen say otherwise." Really?

Perhaps you missed the WHO World Health Report?

Here's the top 100 countries for health care systems. (This one may be a couple of years old.)

The US spends the MOST on healthcare per capita but is 37th in the ranking -- right under Costa Rica. Pretty dismal, I think!

1 France
2 Italy
3 San Marino
4 Andorra
5 Malta
6 Singapore
7 Spain
8 Oman
9 Austria
10 Japan
11 Norway
12 Portugal
13 Monaco
14 Greece
15 Iceland
16 Luxembourg
17 Netherlands
18 United Kingdom
19 Ireland
20 Switzerland
21 Belgium
22 Colombia
23 Sweden
24 Cyprus
25 Germany
26 Saudi Arabia
27 United Arab Emirates
28 Israel
29 Morocco
30 Canada
31 Finland
32 Australia
33 Chile
34 Denmark
35 Dominica
36 Costa Rica
37 United States of America
38 Slovenia
39 Cuba
40 Brunei
41 New Zealand
42 Bahrain
43 Croatia
44 Qatar
45 Kuwait
46 Barbados
47 Thailand
48 Czech Republic
49 Malaysia
50 Poland
51 Dominican Republic
52 Tunisia
53 Jamaica
54 Venezuela
55 Albania
56 Seychelles
57 Paraguay
58 South Korea
59 Senegal
60 Philippines
61 Mexico
62 Slovakia
63 Egypt
64 Kazakhstan
65 Uruguay
66 Hungary
67 Trinidad and Tobago
68 Saint Lucia
69 Belize
70 Turkey
71 Nicaragua
72 Belarus
73 Lithuania
74 Saint Vincent and the Grenadines
75 Argentina
76 Sri Lanka
77 Estonia
78 Guatemala
79 Ukraine
80 Solomon Islands
81 Algeria
82 Palau
83 Jordan
84 Mauritius
85 Grenada
86 Antigua and Barbuda
87 Libya
88 Bangladesh
89 Macedonia
90 Bosnia-Herzegovina
91 Lebanon
92 Indonesia
93 Iran
94 Bahamas
95 Panama
96 Fiji
97 Benin
98 Nauru
99 Romania
100 Saint Kitts and Nevis

Permalink to Comment

23. SRC on January 4, 2007 11:35 PM writes...

The US spends the MOST on healthcare per capita but is 37th in the ranking -- right under Costa Rica.

Cheap shot, and intellectually mendacious. First, an topic observation that Americans generally pay more for proprietary products than other countries, whose healthcare systems constitute monopsonies and therefore are able to force pharmaceutical companies to sell them drugs essentially on a cost-plus basis over their marginal costs.

Second. other countries write off the terminally ill. We don't, and as a consequence the terminally ill consume a vast proportion of health care resources in the US. As an anecdotal example, my wife's aunt was diagnosed with breast cancer, but, being above a certain age, the NHS in Britain wrote her off essentially without treatment (apart from palliative efforts), and she died shortly thereafter. Total expense: about a hundred quid for painkillers.

On the other hand, my father, in a similar situation with renal cell carcinoma in the US, in the course of several operations and months in the ICU, incurred expenses of almost $1MM before he died too, despite having almost no chance of recovering.

Similar situations obtain with, e.g., premature infants. The US expends vast sums on heroic efforts to save preemies, whereas other countries write them off as stillborn, thereby at one stroke sparing themselves enormous outlays and improving their infant mortality statistics.

You have to have lived in another country to appreciate the difference in perspective. Other countries don't spend as much on healthcare for the same reason they don't have space programs - they can't afford it, and don't place quite the same value on the individual as Americans do.

Permalink to Comment

24. Anonymous BMS Researcher on January 5, 2007 8:15 AM writes...

RE: SRC's comments on the heroic efforts in the US on care for the terminally ill. Some time back I read somewhere a figure for the percentage of Medicare dollars spent in the last six months before the patient's death. Does any other reader have this figure, or comparable figures for other countries?

Permalink to Comment

25. Andrea Gallagher on January 5, 2007 3:08 PM writes...

While I would also roll my eyes at the slanted questions, be aware that they probably work in our favor in the mind of the reader.

There is a phenomenon psychologists call "innoculation" where a person who it presented with a weak argument for a position and hears it refuted is then more resistant to a stronger argument for the same position.

It won't play out that way for all readers, but every little helps...

Permalink to Comment

26. Chrispy on January 6, 2007 1:07 AM writes...


Apologies, SRC,

I think I might have muddled the pretty straightforward point from the WHO, which was really not a cost-benefit analysis. Their study was on QUALITY of healthcare, things like lifespan, infant mortality -- essentially how well societies were doing at keeping their citizens healthy.

My only point was that coming in at 37th is pretty lame if you're spending the most. And if, as you contend, we're spending all this money on saving near-hopeless cases then clearly our approach is not working (even without consideration of cost) according to the statistics in the WHO report.

Permalink to Comment

27. Bid Boomerang on March 29, 2012 2:13 PM writes...

Speaking of 2010 5th Starter Free Agent Reclamation Project X, whats on the top of MLBTR right now?

Permalink to Comment

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