FDA and "Right to Repair" -- Nullum gratuitum grandium.

07/27/2021 01:45 PM | Peter Pitts

I had the privilege and pleasure earlier today of participating in the FDA’s webinar, “Remanufacturing of Medical Devices Draft Guidance and Strengthening Cybersecurity Practices Associated with Servicing of Medical Devices Discussion Paper.”

Bottom line – big problems – and it begins with accurately identifying where those problems come from.  According to Josh Silverstein, a CDRH Regulatory Advisor, a majority of the comments, complaints, and adverse event reports received by the FDA that referred to inadequate “servicing” causing or contributing to adverse events or deaths actually related to “remanufacturing.”

What’s the difference? That is a key question, and much of the FDA presentation was focused on clarifying definitions. It’s not as simple as “repair.” The nuances are many and they are all important ranging from reprocessing, servicing, reconditioning and rebuilding, to remanufacturing and repairing.

Importantly, the FDA made it clear from the outset that the draft guidance is not intended to adopt significant policy changes, but to clarify the agency’s current thinking on applicable definitions and “clarify, not change” various regulatory requirements.

Translation – regulation of medical device remanufacturing and servicing is going to become more risk-based, robust and regular – and this will be particularly true when it comes to on-site inspections. This isn’t surprising since the best way to keep people honest is to keep them guessing as to when and where an inspection might happen.

CDRH laid out six “Guiding Principles” –

1- Assess whether there is a change to the intended use

2- Determine whether the activities, individually and cumulatively, significantly change the safety or performance specifications of a finished device

3- Evaluate whether any changes to a device require a new marketing submission

4- Assess component, part, or material dimensional and performance specifications

5- Employ a risk-based approach

6- Adequately document decision-making

In short – there’s going to be a lot more requirements for responsibility and accountability on the part of those medical device owners who oversee, operate and remediate problems When it comes to FDA-regulated medical devices, “Right to Repair," doesn’t mean “cheap and easy.” The FDA has made that very clear. Anyone who thinks otherwise isn’t paying attention – or doesn’t want to.

And that doesn’t even include the discussion of medical device cybersecurity. Per Katelyn Bittleman, CDRH Policy Analyst, “Cybersecurity is a shared responsibility among all stakeholders. The FDA expects manufacturers to appropriately secure their devices to continue to assure the devices’ safety and effectiveness. Non-OEM servicing entities play an important role in maintaining the quality, safety, and efficacy of medical devices without compromising cybersecurity."

Nullum gratuitum grandium.
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Addressing "Temporary" Insanity

07/23/2021 05:05 AM | Peter Pitts

I just googled “temporary vaccine waiver” under “news” and got 31,900 hits.

Then I ran the same exercise for “Pfizer and BioNTech Announce Collaboration with Biovac to Manufacture and Distribute COVID-19 Vaccine Doses within Africa.” I got 1300 hits.

That’s upside down and unfortunate since it’s the Pfizer/BioNTech announcement that’s going to save lives.

Here’s the rest of the story:

Pfizer Inc. (NYSE: PFE) and BioNTech SE (Nasdaq: BNTX) today announced the signing of a letter of intent with The Biovac Institute (Pty) Ltd, known as “Biovac,” a Cape Town-based, South African biopharmaceutical company, to manufacture the Pfizer-BioNTech COVID-19 Vaccine for distribution within the African Union.

“We aim to enable people on all continents to manufacture and distribute our vaccine while ensuring the quality of the manufacturing process and the doses”

Biovac will perform manufacturing and distribution activities within Pfizer’s and BioNTech’s global COVID-19 vaccine supply chain and manufacturing network, which will now span three continents and include more than 20 manufacturing facilities. To facilitate Biovac’s involvement in the process, technical transfer, on-site development and equipment installation activities will begin immediately.

Pfizer and BioNTech expect that Biovac’s Cape Town facility will be incorporated into the vaccine supply chain by the end of 2021. Biovac will obtain drug substance from facilities in Europe, and manufacturing of finished doses will commence in 2022. At full operational capacity, the annual production will exceed 100 million finished doses annually. All doses will exclusively be distributed within the 55 member states that make up the African Union.
“From day one, our goal has been to provide fair and equitable access of the Pfizer-BioNTech COVID-19 Vaccine to everyone, everywhere,” said Albert Bourla, Chairman and Chief Executive Officer, Pfizer. “Our latest collaboration with Biovac is a shining example of the tireless work being done, in this instance to benefit Africa. We will continue to explore and pursue opportunities to bring new partners into our supply chain network, including in Latin America, to further accelerate access of COVID-19 vaccines.”

“We aim to enable people on all continents to manufacture and distribute our vaccine while ensuring the quality of the manufacturing process and the doses,” said Ugur Sahin, M.D., CEO and Co-founder of BioNTech. “We believe that our mRNA technology can be used to develop vaccine candidates addressing other diseases as well. This is why we will continue to evaluate sustainable approaches that will support the development and production of mRNA vaccines on the African continent.”

“We are thrilled to collaborate with Pfizer and BioNTech to produce and distribute the Pfizer-BioNTech COVID-19 Vaccine within Africa. This is testament of the long-standing relationship we have had with Pfizer through the Prevenar 13 vaccine,” said Dr. Morena Makhoana, CEO of Biovac. “This is a critical step forward in strengthening sustainable access to a vaccine in the fight against this tragic, worldwide pandemic. We believe this collaboration will create opportunity to more broadly distribute vaccine doses to people in harder-to-reach communities, especially those on the African continent.”

Pfizer and BioNTech select contract manufacturers using a rigorous selection process based on several factors: quality, compliance, safety track record, technical capability, capacity availability, highly trained workforce, project management abilities, prior working relationship, and commitment to working with flexibility through a fast-paced program. Pfizer and Biovac have worked together since 2015 on the sterile formulation, fill, finish and distribution of the Prevenar 13 vaccine.

To date, Pfizer and BioNTech have shipped more than 1 billion COVID-19 vaccine doses to more than 100 countries or territories in every region of the world. The companies are firmly committed to working towards equitable and affordable access for COVID-19 vaccines for all people around the world, actively working with global governments as well as global health partners with the aim to provide 2 billion doses to low and middle income countries in 2021 and 2022 – 1 billion each year. This includes an agreement to supply 500 million doses to the U.S. Government at a not-for-profit price, that the government will, in turn, donate to the African Union and the COVAX 92 Advanced Market Commitment (AMC) countries, as well as a direct supply agreement with the COVAX facility for 40 million doses.
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About that FDA Report on Third Party Medical Device Servicing

07/20/2021 06:18 AM | Peter Pitts

The “Right to Repair” issue pertains to FDA-regulated medical devices and the unintended negative consequences for patient health and safety that would result if unregulated third-parties were allowed to work on these highly sophisticated pieces of equipment.

“Right to repair” advocates point to FDA’s 2018 report they claim led the agency to “take a pass” on regulating third party device servicing because they could find no evidence of a problem. Cheery-picked quotes describe third-party servicers as providing “high quality, safe, and effective servicing of medical devices … critical to the functioning of the U.S. healthcare system.”

This is out of context, wrong and dangerous. The fact of the matter is that the FDA report said the agency didn’t have enough data to make a definitive conclusion about third party servicing. The FDA doesn’t have that data because unregulated servicers aren’t required to register with the agency and FDA can’t even establish how many third-party servicers are actually out there – though the agency estimates there are between 16,000 - 21,000.

Further, the FDA’s 2018 report showed the majority of inadequate services reported should actually be categorized as remanufacturing, meaning that the device in question is no longer the device the FDA gave clearance/approval to. Big difference. Big problem.

In truth, the agency laid out a roadmap to address this issue and has been executing against it over the last several years through remanufacturing guidance and cybersecurity discussion papers. This is where the FDA should concentrate its efforts: educate, surveil and enforce actions on remanufacturing to ensure service activity doesn’t cross over into regulated activity.

On July 27, the FDA is holding a public meeting on this topic. It couldn’t come at a better time. The proper servicing and security of medical devices and other health care technologies mustn’t be allowed to be undermined by third-party servicing apologists willing to employ bad faith tactics and misrepresent the facts.
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On Cyber Security & Medical Device Servicing

07/19/2021 05:01 AM | Peter Pitts

The other week, the HHS Inspector General released a report about just how little oversight the Medicare program has over medical device cybersecurity (and what little discretion is does have, it rarely uses).

If you’ve been following the news lately, you’ll know that cybersecurity in the healthcare space is a big problem. Hospitals and health systems large and small have increasingly been on the receiving end of hacks, cyber-attacks and ransomware intrusions. Not to mention that an estimated 275 million medical images are currently vulnerable due to unsecured picture archiving communication systems.  HHS just released another alert about that just days after the Inspector General report came out.

The report focused on the role of Medicare accrediting organizations’ failure to keep proper tabs on whether hospitals were maintaining proper cybersecurity of their networked devices. According to the report: 

CMS’s survey protocol does not include requirements for networked device cybersecurity, and the AOs [accrediting organizations] do not use their discretion to require hospitals to have such cybersecurity plans. However, AOs sometimes review limited aspects of device cybersecurity.

For example, two AOs have equipment maintenance requirements that may yield limited insight into device cybersecurity.  If hospitals identify networked device cybersecurity as part of their emergency-preparedness risk assessments, AOs will review the mitigation plans. AOs told us that in practice, however, hospitals did not identify device cybersecurity in these risk assessments very often.

But most importantly, the OIG’s report underscored the lopsided cybersecurity expectations in the healthcare industry. Cybersecurity is supposed to be a shared responsibility between device manufacturers and providers. For their part, the manufacturers are tightly regulated by the FDA and are required ensure their products are secure through a carefully designed protocols subject to frequent updates. Alas, the best-designed devices in the world can’t compensate for negligence or poor practices on the part of the end-user.

Which brings me to the point I raised in The Hill recently about how unregulated medical device servicing poses serious risks for cybersecurity. Original equipment manufacturers and their servicers are regulated by the FDA. Third party servicers – who could really be anyone since there are no universal training and licensing requirements to service these devices either – are not. Third-party servicers claim they’re held to the same standards as OEMs due to hospital accreditation. The OIG report flies in the face of that claim.

If the goal is to get rid of the “blind spots” that lead to cybersecurity incidents, ensuring that those who control repairs and maintenance of these highly sophisticated pieces of health care technology are FDA-regulated makes the most sense to me. Hiding behind accreditations that Medicare isn’t watching doesn’t. It’s clear no one is watching the proverbial coup on the hospitals’ end.

If hospitals and imaging providers can’t keep tabs on their own cyber security, how can we expect them to handle the servicing of highly sophisticated medical devices?
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U.S. PIRG's "Right-to-Repair" position is Ill-considered and anti-patient

06/21/2021 11:19 AM | Peter Pitts

According to the U.S. PIRG, “Manufacturers of ventilators, dialysis machines and other critical medical devices routinely restrict access to essential repair materials. That leaves hospital repair technicians, commonly known as biomeds, without the tools they need to fix medical equipment as soon as it breaks. Instead, they have to wait days, weeks or even a month for a manufacturer-branded technician to travel onsite and make the repair well within the biomed’s capabilities. In the meantime, that broken ventilator can’t be used to deliver life-saving treatment to a patient.”

As my grandmother used to say, “A half-truth is a whole lie.”

At first glance, “Right-to-Repair seems like a good idea. Why not make it easier for consumers to fix their broken electronics, without having to pay a costly sum to the original manufacturer? But, as HL Mencken reminds us, “For every complex problem there is an answer that is clear, simple, and wrong.” The reality is that Right-to -Repair presents many dangerous unintended consequences. The Number One problem is that it compromises patient safety.

The core of Right-to-Repair laws is to require innovative technology companies to make product repair information, replacement parts, and tools readily available to consumers and third-party repair shops. Should that be the case for devices such as Automated External Defibrillators and hospital ventilators? What about electrocardiograph (ECG) machines? Can physicians and patients be confident in non-FDA compliant vendors without the advanced training and technical ability to properly repair and recalibrate life-saving machines? Who could argue that “anyone can do it?”

Well – U.S. PIRG for one.

By allowing third parties without any FDA competence to repair regulated, complicated medical devices, Right-to-Repair also opens the door to breaches in cybersecurity. According to the FDA, “Cybersecurity is a widespread issue affecting medical devices connected to the Internet, networks, and other devices. Cybersecurity is the process of preventing unauthorized access, modification, misuse or denial of use, or the unauthorized use of information that is stored, accessed, or transferred from a medical device to an external recipient.”

In a recent FDA discussion paper, “Strengthening Cybersecurity Practices Associated with Servicing Medical Devices: Challenges and Opportunities,” the agency asks, “How can entities that service medical devices contribute to strengthening the cybersecurity of medical devices?” According to the discussion paper, “FDA defines service to be the repair and/or preventive or routine maintenance of one or more parts in a finished device, after distribution, for purposes of returning it to the safety and performance specifications established by the original equipment manufacturer (OEM) and to meet its original intended use.” In other words, the first step in advancing medical device cybersecurity is to limit and ensure that those who control repairs and maintenance of these highly sophisticated pieces of healthcare technology are regulated FDA manufacturers.

On July 27th, the FDA is holding a public meeting on this topic. It couldn’t be timelier. The proper servicing and security of medical devices and other healthcare technologies is too important for uniformed posturing. U.S. PIRG should know better.

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Speaker Pelosi's Mistaken HR 3-Peat

04/22/2021 05:15 AM | Peter Pitts

Word on the street is that H.R. 3 is going to be reintroduced today.

New Congress. Same bad ideas. A hit parade of bad ideas.  For example:

An International Pricing Index. Patients often lose access to the best medicines when their government adopts price controls. Of the drugs launched in the last seven years, only 60% were available in Sweden. And only half made it to patients in Canada. In the United States, meanwhile, nearly 90% of those medicines were available. Americans will no longer enjoy generous access to the newest drugs if we embrace price controls. Importing the socialist pricing tactics of foreign governments is no way to stand up for Medicare patients. Bad idea when it comes from the White House, Bad idea when it comes from the People’s House.

Direct Government Negotiation. Is the direct federal negotiation of drug prices a good idea? Consider the “non-interference clause” that currently prohibits such actions in Medicare Part D — the federal program that subsidizes prescription drugs for seniors. A repeal of the non-interference clause would result in a sharp increase in Medicare drug prices and a substantial decline in patient choice.

The Congressional Budget Office observed that Part D plans have “secured rebates somewhat larger than the average rebates observed in commercial health plans.” According to the CBO, to achieve any significant savings, the government would have to follow through on its threats of “not allowing [certain] drug[s] to be prescribed.” In other words, the government would drop some drugs from Medicare’s coverage to save money. That would be a raw deal for patients. The average Part D plan provides access to more than 95 percent of the top 200 Medicare Part D Drugs. (PS/ The Non-Interference Clause was written by Senators Ted Kennedy and Tom Daschle.)

Rebates to Off-Set Price Hikes. When Americans say, “My drugs are too expensive,” what they generally mean is that their co-pays at the pharmacy are too expensive. And they’re right. But co-pays aren’t tied to list prices. Consider this: payers negotiate discounts of between 30-50% of the list price – and then base the co-pay off of the list price. What happens to the discount? They pocket the difference. When payers say that higher co-pays are a result of higher list prices they are lying. Surprisingly absent from H.R. 3 is any call for pricing transparency. Shameful.

The primary difference from the previous version is that this “new” itereation will not specify how the funds will be used – Speaker Pelosi’s goal is to use this as a pay-for in the American Family Act

H.R. 3 is a cruel joke. Cruel to patients.
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New CMPI Book: The Value Equation

01/07/2021 06:11 AM | Peter Pitts

The Value Equation Charts Pathway for 21st Century Medical Innovation
Former FDA Associate Commissioner Details Urgency of Advancing the Healthcare Ecosystem

In his new book, The Value Equation: A Journey Through the Innovation Ecosystem in the Time of COVID, Peter Pitts argues that healthcare innovation saves lives, saves money, promotes economic growth, and provides hope for hundreds of millions of people (both patients and care-givers) in the United States and around the world. But that innovation isn’t easy and the path forward is neither smooth not brightly lit.

The Value Equation features essays by Pitts and a host of experts covering a wide range of “urgencies” including the urgency of innovation, quality, information sharing, 21st century medicines regulation, safety, the evolving patient voice, value-based healthcare technology assessment and the lessons learned from COVID-19.

According to Professor Pitts, President of the Center for Medicine in the Public Interest, a Visiting Professor at the University of Paris Descartes School of Medicine and a former FDA Associate Commissioner, “There are many roadblocks beyond those of discovery and development. The complicated and conflicting dynamics of politics, perspectives on healthcare economics, of friction between payers, providers, manufacturers, and regulators, the battle for better patient education, and the need for a more forceful and factual debate over the value of innovation all create the need for a more balanced and robust debate.”

“Excellence,” wrote Aristotle, “is never an accident. It is always the result of high intention, sincere effort, and intelligent execution; it represents the wise choice of many alternatives. Choice, not chance, determines your destiny.” The Value Equation address many of these choices – and their consequences.

The Value Equation: A Journey Through the Innovation Ecosystem in the Time of COVID is necessary reading for anyone interested in charting a new, urgent path forward for patient-centric healthcare innovation.

To speak with Peter Pitts or receive a copy of The Value Equation: A Journey Through the Innovation Ecosystem in the Time of COVID, please contact Mario Coluccio at mcoluccio@cmpi.org.
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The Dangers of Foreign Entanglements

11/23/2020 08:36 AM | Peter Pitts

CMS anticipates one implication of the President’s insistence on foreign price controls is that Medicare beneficiaries will lose access to medicines because of the policy:

“While there are significant savings as a result of this model, a portion of the savings is attributable to beneficiaries not accessing their drugs through the Medicare benefit, along with the associated lost utilization. This estimate does not capture any impacts to other program costs as a result of lower utilization.”

This rule is bad not only for the future of healthcare innovation but also for patient outcomes.

Actions have consequences.
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UnitedHealthcare to HCPs: Das is nicht alles

10/05/2020 05:22 AM | Peter Pitts

UnitedHealthcare is demanding that HCPs rat out their patients who are using copay coupons. Per a letter sent by United Healthcare to HCPs, “Effective 1/1/21 providers must submit specialty medication medical claims and manufacturer copay coupon reimbursement information to UnitedHealthcare.”

By way of explanation, UH offer the following:

“In order to align employer costs for specialty medications with actual member out of pocket and deductibles, UnitedHealthcare is launching the Accumulator Adjustment Medical Benefit program. This program requires providers to submit patient information received from drug manufacturer copay coupon programs which are applied to a member’s cost share when billing for specialty medications as a medical benefit drug claim.”

That’s right, UH has the chutzpah to refer to this as a “medical benefit program." Talk about a large dose of Orwellian NewSpeak. Shame on UH for behaving like a 21st century Stasi.

(With a big hat tip to Adam Fein over at Drug Channels.)
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An Importation Poison Pill

09/25/2020 04:30 AM | Peter Pitts

Meanwhile back at the ranch – drug importation.

In the midst of a global pandemic, a Presidential election and a Supreme Court vacancy the FDA has issues its “Safe Importation Action Plan.”

Per the FDA press release:

The final rule implements a provision of federal law that allows FDA-authorized programs to import certain prescription drugs from Canada under specific conditions that ensure the importation poses no additional risk to the public’s health and safety while achieving a significant reduction in the cost of covered products to the American consumer.

The FDA spells out two pathways.

Under Pathway 1, a Notice of Proposed Rulemaking (“NPRM”) would rely on the authority in the Federal Food, Drug, and Cosmetic Act (“FD&C Act”) section 804 to authorize demonstration projects to allow importation of drugs from Canada. The NPRM would include conditions to ensure the importation poses no additional risk to the public’s health and safety and that it will achieve significant cost savings to the American consumer.

Under Pathway 2, manufacturers could import versions of FDA-approved drug products that they sell in foreign countries that are the same as the U.S. versions. Under this pathway, manufacturers would use a new National Drug Code (NDC) for those products, potentially allowing them to offer a lower price than what their current distribution contracts require.

Assuming that Pathway 2 is a non-starter, let’s have a look at some key codicils of Pathway 1:

Non-Eligible Drugs: The NPRM would restate the exclusions listed in section 804(a)(3); namely, controlled substances, biological products, infused drugs, intravenously injected drugs, drugs inhaled during surgery, and certain parenteral drugs would be excluded from this pathway. The NPRM would additionally exclude any drug with a REMS.

The NPRM will help address this issue by requiring applicants to demonstrate how they will. comply with: track and trace requirements to allow drug tracing from manufacture to pharmacy; certain labeling requirements to ensure the imported drugs meet all labeling requirements of the FD&C Act; requirements to ensure foreign sellers engaged in the distribution of the imported drugs are registered;  importation entry requirements (e.g., providing certain electronic information demonstrating that each shipment should be allowed into the U.S.); and post-importation requirements such as adverse event reporting, procedures to facilitate recalls, and cGMP for certain manufacturing activities such as relabeling.

Cost Requirements: The NPRM would explain the requirement for demonstrating that drugs imported under this pathway must result in a significant reduction in the cost of covered drug products to the American consumer. As such, the NPRM would seek feedback on the best way to identify the expected acquisition cost of the imported drug, the cost of assuring the drug is safely imported, and the mechanism for delivering those savings to the consumer (as opposed to the savings being absorbed by the supply chain).

Transparency: The NPRM would require some indication in the labeling that drugs imported under this program were originally intended for distribution in Canada. In particular, the NPRM would seek comment on requiring that the label include the NDC, part of which would be unique to drugs imported under this program.

One item of importance not addressed in the agency’s plan is whether or not the Canadian government will change its position and allow American importation programs. That’s more than a minor detail. Canadian officials have already stated that “Canada does not support actions that could adversely affect the supply of prescription drugs in Canada and potentially raise costs of prescription drugs for Canadians.”

If Ottawa maintains its no-go policy, it’s an importation poison pill.

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The End of the Era of Smoking?

09/23/2020 02:52 PM | Robert Goldberg

Since becoming Juul’s CEO in 2019, K.C Crosthwaite has cut the company’s workforce in half and pulled most of its well-known e-cigarette products off the market, thereby deliberately cutting sales.

To Crosthwaite that’s progress.  Juul’s rapid growth was the target of got anti-smoking groups, suburban moms terrified their kids – who were getting high and drinking with parental foreknowledge if not consent – would become addicted to nicotine and media coverage that framed Juul as a trojan horse for increased cigarette use.   

Slowing down and paring back growth is tied to Crosthwaite’s goal of building up a body of evidence demonstrating that the use of the device reduces the harm of smoking.  Most critically, in August “Juul submitted a Premarket Tobacco Product Application (PMTA) for the JUUL device as well as its Virginia Tobacco and Menthol flavored JUULpod.”

As part of that submission, JUUL has provided data on the persistence and rates of switching to their product from cigarettes.  It turns out that 43 percent of dual users (people who smoke cigarettes and use JUUL devices) switched entirely to an e-cigarette over a 12-month period.  

Additionally, JUUL has been monitoring the effect of programs it has in place to limit and reduce underage use of its products. JUUL has generated real-world evidence demonstrating that uptake by people 21 and younger declined.

Speaking at the (virtual) Global Tobacco & Nicotine Forum (GTNF) Crosthwaite noted that the emergence of non-combustible products has created a historic opportunity to drive down cigarette use around the world.  Unfortunately, most public health agencies are outlawing or limiting e-cigarette sales while allowing tobacco sales to continue.  The same agencies have made a point of inflating and identify the risks of e-cigarettes so that most consumers think they are riskier than tobacco.  No wonder that cigarette consumption has been increasing, a trend that began before the pandemic and continues even now. 

As Crosthwaite pointed out, the rebound in cigarette sales due to the fearmongering and counterproductive regulation of non-combustible nicotine products increases the risk of tobacco-related death and disease.  Let’s hope the PMTA process can be used to move past such obstacles so that we can continue to eradicate smoking from the planet. 




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How Can Health Data Ownership Overcome the Interoperability Barrier?

08/17/2020 12:36 PM | Robert Goldberg

My interview with Seqster CEO Ardy Arianpour on how his company's platform for generating personal health records solves the interoperability and data assess challenges.   Read More & Comment...

Are We Suffering From COVID Overreaction??

08/17/2020 12:34 PM | Robert Goldberg

My interview with Paul Offit on pandemic hysteria.  Read More & Comment...

When it comes to CBD, what you don't know CAN hurt you

07/10/2020 09:27 AM | Peter Pitts

Per Congressional mandate, the FDA has submitted a report to Congress on the state of the CBD marketplace.

The report outlines studies the agency has performed on the contents and quality of cannabis-derived products that it has tested over the past six years. As predicted in my testimony at the FDA’s June 2019 Part 15 hearing, there is significant inconsistencies between cannabinoids concentrations that are listed on labels and what the products actually contain.  Some relevant verbatims from the FDA report:

“FDA recognizes the significant public interest in CBD products,” the agency wrote. “However, there are many questions about the characteristics of currently marketed CBD products because the Agency lacks significant information on what CBD-containing products are on the market and there are little data available on those products themselves.”

“FDA believes that understanding the characteristics of marketed CBD products is critical to making informed decisions about how best to protect public health in the current marketplace."

“Of the 102 products that indicated a specific amount of CBD, 18 products (18%) contained less than 80 percent of the amount of CBD indicated, 46 products (45 percent) contained CBD within 20 percent of the amount indicated, and 38 products (37 percent) contained more than 120 percent of the amount of CBD indicated.”

Only one of 133 samples had potentially hazardous materials.

Well – that’s reassuring.

FDA is undertaking a more extensive CBD product testing effort that will involve using “a sampling methodology to create a representative, random sample of the current CBD product marketplace.”

“The Agency is purchasing data on brands, product categories, and distribution channels for CBD products.” The FDA is also “in the process of developing its own comprehensive list of brands operating in the CBD market space by assembling data from targeted internet searches and analytics. FDA intends to leverage both data sets to randomly sample products across brands, product categories, and distribution channels, while favoring products with a higher market share.”

The sampling is expected to cover cannabis tinctures, oils, extracts, capsules, powders, waters and other beverages, food items, cosmetics, personal lubricants, tampons, vape cartridges and products sold for pets.

It is unlikely the FDA’s bark will be worse than its bite.

Per the FDA, “Together, this information will provide the Agency with a better understanding of product characteristics in the current CBD marketplace and will help protect and promote public health.”
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Copay Accumulators. Soon to be banned in Boston?

07/07/2020 03:23 PM | Peter Pitts

A new study out of the Bay State regarding the importance of copay assistance programs and the downside of accumulators. 

The Massachusetts Health Policy Commission (HPC) examined copay accumulators and the use and impact of prescription drug coupons in Massachusetts.  (The Massachusetts HPC is an independent state agency charged with monitoring health care spending growth in Massachusetts and providing data-driven policy recommendations regarding health care delivery and payment system reform.)
 
Of note, the study finds that, “Continued growth in high deductible plan enrollment, coupled with increasing drug prices, suggests that patient affordability challenges will only increase. Eliminating the availability of coupons at this time – without substantial protections for patient affordability – would likely create serious challenges for many patients in the Commonwealth.” 
 
As to copay accumulators, “they are unlikely to encourage patients to use lower cost alternatives. Copay accumulators shift costs from the payer to the manufacturer and patient, potentially resulting in lower premiums. However, copay accumulators may preserve the affordability challenges that patients originally faced in their plan design, which could lead to lower access and adherence. In addition, these programs may increase administrative complexity for payers and PBMs and add confusion to patients navigating an increasingly complicated health care system.”
 
Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passion, they cannot alter the state of facts and evidence – John Adams
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Patients Rising Podcast on Safer and Cheaper Drugs With Janet Woodcock

06/23/2020 06:20 AM | Robert Goldberg

Enjoy!

Patients Rising Podcast 16  Read More & Comment...

The QALY is Discriminatory

06/23/2020 06:18 AM | Robert Goldberg

Real Clear Health

Should Our Health Care System Place a Dollar Value on Lives?
By Charles Camosy & Robert Goldberg
June 22, 2020
The COVID-19 pandemic is proving to be a catalyst for a long-overdue discussion in this country about our health care system and whether some lives should be considered more valuable than others. Are some Americans comparably more expendable and less deserving of measures to save or extend their lives?

Earlier this month, Oklahoma provided the nation what we believe is the only just answer: it banned state agencies from deciding who gets treatments based upon a bureaucratic measure of the value of life called a QALY.


Those who haven’t heard of the acronym QALY should get to know it. It stands for Quality Adjusted Life Year and it is a scoreboard that divides our population into health care winners and losers. QALYs are used to prioritize the use of ventilators and hospital beds for the younger and healthier and able-bodied—while denying care to those with lesser physical or mental capabilities.

And it’s used by policymakers to decide who should get new medicines, including those to treat COVID-19. Increasingly, unelected and unaccountable organizations such as the Institute of Clinical and Economic Review (ICER) are being used by policymakers, government health programs and insurers to ration care. ICER’s use of QALYs in making these recommendations is inherently discriminatory and may even violate the federal civil rights of the elderly and disabled to be treated equally in medical facilities which get federal funds.

As if this huge moral and legal problem with using QALYs wasn’t bad enough, there are other problems. For instance, ICER arbitrarily decided that an additional year of healthy life is worth $50,000. This dollar value was established in 1982 to determine how much kidney dialysis would be needed to keep someone with kidney failure alive. This while the EPA assumes an additional year of life is worth up to $3 million.

Further, the QALY benchmark inherently assumes people with disabilities or older or harder to treat are worth less. People with disability or your underlying illness – be it heart disease or diabetes – your QALY score is lower and the value assessment scorekeepers will likely recommend that insurance coverage simply isn’t warranted. And if you are someone with a rare disorder such as ALS or Parkinson’s your worth is lower still.

Further, ICER claims that no matter how valuable a drug is — even if it cures — we should only spend $1 billion a year on it. Their rationale: since new drugs might be needed to be taken for a long time, the people who use them might live longer if they stay on a medicine, then total health care spending will increase. By comparison, as ICER states, medicines that help people who are healthy are more ‘cost-effective.’

Recently ICER rushed out a price recommendation of $4300 for remdesivir, the new drug that treatments people hospitalized with COVID-19. In making that assessment, ICER ignores circumstances that any ethical person would consider.

Remdesivir, at the very least, reduces the amount of time people spend in the hospital with COVID-19 by four days. $38,755, depending on the cost-sharing provisions of their health plan.  That doesn’t include post- COVID-19 cost or the fact that for every additional day in the ICU, readmission and death rates post hospitalization climb. It also doesn’t include that fact that if Remdesivir had been available before the pandemic, we wouldn’t have had the overflow of ICU patients.  Cutting length of stay by four days would have increased hospital bed turnover, freeing up enough ICU and non-critical care capacity.  And that would have meant not shutting down the economy.

And yet the talk is about rationing drugs like Remdesivir. Incredibly, those that would be harmed most by rationing are precisely the people who suffered most because of the policies designed to free up hospitalization. Rationing would target the frail veterans who were herded into nursing homes where they died and those whose care was already delayed despite the very people at greatest risk of COVID-19.

The pandemic exposed the fact ICER’s justification for rationing has little to do with scarcity and lot to do with protecting a set of relationships and institutions that support a culture who discards the most vulnerable.

This throwaway culture has a primary value: maintaining a consumerist lifestyle. Proponents of this kind of rationing claim that health care spending – particularly money spent on those with the greatest unmet need – will not be as economically efficient. In an example of brutal honesty, then, groups like ICER want to obtain good outcomes by excluding care and other resources for those who need it the most.  

The QALY systematically deprives those who have been marginalized the same right to health and those of us who are more privileged take for granted. It makes a mockery of our nation’s founding claim that all of us are created equal.

As we move into – and beyond – this new phase of the pandemic, we should follow Oklahoma’s lead. We should reject a discriminatory culture reinforced by QALY-based policies. And we should support a counterculture in which the marginalized are encountered, embraced, cared for, and protected in the fullness of human equality before the law.

Charles C. Camosy is Associate Professor of Theological and Social Ethics at Fordham University and author of “Resisting Throwaway Culture: How a Consistent Life Ethic Can Unite a Fractured People, New City Press”, 2019.  Robert Goldberg is Vice President, Center for Medicine in the Public Interest and co-cost of the Patients Rising podcast.  Read More & Comment...

The Young and the COVID Restless

06/21/2020 01:52 PM | Peter Pitts

Big h/t to Scott Gottlieb:

Bernstein Research shows a correlation between mobility trends and COVID-19 outbreaks; predicts states like Arizona, Arkansas, Alabama, Mississippi, North Carolina, South Carolina are likely to see intensification in the epidemic on top of recent increases. Google mobility data shows that areas of “high-mobility” (states in more advanced stages of “opening) and lower levels of testing most at risk.

Conclusion – Smart opening must be matched with enhanced personal responsibility. What messages are most useful and impactful for un-masked youth?
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Silencing Science

06/11/2020 09:40 AM | Robert Goldberg

It is all well and good for everyone to set aside time to reflect on the death of George Floyd and determine what we can do to ensure that such occurrences continue to become increasingly rare. 

So, I have no problem when two leading scientific publications -- Science and Nature -- devote one day of tweeting to focus on the tragedy. 

I do have a problem when such publications allow themselves to be bullied and hijacked by individuals and groups demanding that publications scrap the scientific method because, they claim, it reinforces something called white privilege and systemic racism. 

We have seen what subverting and enslaving science to ideologically and racially warped ideologies produces: Repression, slavery and eugenics. That triad of tools has been used by totalitarian regimes and unhinged movements throughout history. When the institutions and cultural constructs that defend freedom of thought, expression and action cower or cave to such forces, human dignity is debased at the very least.  At the worst, it leads to censure and coercion as both ends and means. 

Science and Nature may have opened the door to a disaster created by forces that are racist and anti-Semitic, forces that crave control without any justification except the fervent belief that they – not you or me – should be in charge.  My guess is that other publications will engage in online virtual signaling and more to demonstrate how woke and guilty they really are.  

Increasingly I am reminded of something Jacob Bronowski, a mathematician and defender of science said in his PBS series entitled, The Ascent of Man.  Here is a link to the video.

“There are two parts to the human dilemma. One is the belief that the end justifies the means. That push-button philosophy, that deliberate deafness to suffering has become the monster in the war machine. The other is the betrayal of the human spirit. The assertion of dogma closes the mind and turns a nation, a civilization into a regiment of ghosts — obedient ghosts, or tortured ghosts.

It’s said that science will dehumanize people and turn them into numbers. That’s false — tragically false.

Look for yourself.

This is the concentration camp and crematorium at Auschwitz. This is where people were turned into numbers. Into this pond were flushed the ashes of some four million people. And that was not done by gas — it was done by arrogance, it was done by dogma, it was done by ignorance.”

When people believe that they have absolute knowledge, with no test in reality, this is how they behave. This is what men do when they aspire to the knowledge of gods.”



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CMPI Led Study Shows Value of New Cancer Drugs

05/19/2020 07:05 AM | Robert Goldberg

Health Economic Research Study Presented at ISPOR, and Published in the Journal Value in Health, Demonstrates Reduction in Total Cost of Care with Increased Use of New Medicines for Treatment of Patients with Pancreatic Cancer

More effective, better tolerated oral therapies for pancreatic cancer may lead to further reduction of burden on the healthcare system
NEW YORK--(BUSINESS WIRE)-- Tyme Technologies, Inc. (NASDAQ: TYME), an emerging biotechnology company developing cancer metabolism based therapies (CMBTs™), announced the results of a health economic outcomes study demonstrating that the therapeutic benefit of increasing the use of novel medicines is so great that it is driving a decrease in the actual total cost of healthcare. The supporting data from the study are being presented at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Virtual Meeting held from May 18 to May 20 and published in the Society’s peer-reviewed journal value in Health.

Health technology assessment programs are increasingly using real-world, longitudinal patient data to assess the effect of new medicines on total cost of care. This study analyzed such data to measure the impact of new pancreatic cancer therapies on other, non-drug medical expenditures.

“Our study looked at treatment inflation-adjusted expenses per patient for pancreatic cancer care between 2009 and 2016 and found that for every additional $1 spent on medicines for pancreatic cancer in 2016, there was a reduction in non-drug spending of $8 – $9,” said Robert Goldberg, Ph.D., Vice President and Co-Founder of the Center for Medicine in the Public Interest. “The value of advancing and accessing next-generation novel therapies is apparent from our total cost of care analysis looking at both medical and pharmacotherapy costs.”

The study showed that between 2009 and 2016, average inflation-adjusted per patient spending on pancreatic cancer care declined from $37,000 to $10,000. Prescription drug spending increased during the same time period from $2,200 to $6,100 per person (inflation adjusted). In effect, for every additional dollar spent on disease-altering therapies for pancreatic cancer between 2009 and 2016, there was a reduction in non-drug spending of $8 – $9.

Furthermore, there was a decline in the length of stay in hospital settings and a decrease in hospital deaths for this cohort of patients with pancreatic cancer. From 2009 to 2016, the mean length of stay decreased by 1 day. The proportion of deaths in hospitals during that time period also decreased by 2.8%.

The analyses also evaluated hemorrhage complicating a procedure, including Whipple surgeries. Hemorrhages are estimated to occur in 7.2 to 8.5% of those patients who have undergone a pancreatectomy and are associated with longer and more expensive hospital stays. Patients who were discharged from inpatient settings after being diagnosed with a complicating hemorrhage appeared to be routed to less intensive settings of care. In particular, the proportion of those discharged into home health care, as opposed to short term hospital care or another institution, increased by 1.2% between 2009 and 2016.

The study analyzed longitudinal patient-level data from the Medical Expenditure Panel Survey (MEPS, 1996 – 2017). The study evaluated 80 patients who had a diagnosis of pancreatic cancer and available prescription data. Individual age and employment status were accounted for as covariates. Notably, the data revealed that while prescription medicine expenses have increased as part of the total cost of treating patients with pancreatic cancer over the last ten years, the overall healthcare cost of treating pancreatic cancer patients has gone down.

All analyses were performed using R version 3.6.1 on Ubuntu 19.04. Means and standard deviations were computed for the raw and inflation-adjusted total health care costs excluding drug spending. Study averages were computed for the total health care costs, including prescription medicine costs for the period between 2009-2016 which included approval and/or use of novel treatment approaches such as Abraxane® (nab-paclitaxel), FOLFIRINOX and erlotinib. The prescription medicines expenses, and proportion of healthcare spending were also plotted along with a LOESS curve using the same parameters. All expenditures are adjusted for inflation using 2012 U.S. Dollars.

As a result of this health economic outcomes study, further analysis of a larger, longitudinal set of patient-level data is needed to more fully explore the relationship between spending on medical innovation, and reduction in total cost of patient care, as well as improvements in quality of life.

Details of this study are being presented at the ISPOR Virtual Meeting held from May 18 to May 20. For more information on ISPOR’s virtual program please visit the conference website at: https://www.ispor.org/conferences-education/conferences/upcoming-conferences/ispor-2020.

The health economic outcomes poster on pancreatic cancer presented at the ISPOR virtual conference is as follows:

Title: Using longitudinal patient level data to assess the value of new pancreatic cancer treatments on total health spending.

Authors: Robert Goldberg1, Michele Korfin2, Giuseppe Del Priore2, Semmie Kim2, Vincent J. Picozzi3, M Mandelson3, Victoria G. Manax4

Institutions: Center for Medicine in the Public Interest, NY, NY1,Tyme Technologies, Inc., NY, NY2, Virginia Mason Medical Center, Seattle, WA3, Pancreatic Cancer Action Network, Manhattan Beach, CA4  Read More & Comment...