Latest Drugwonks' Blog
Senator Claire McCaskill (D, MO) thinks that the FDA’s draft guidance on off-label communications is "a startling potential change in policy.â€
Um, no.
Someone should point out to the Senator that the “policy†that counts here is the First Amendment -- and there’s no question that it applies to commercial free speech. Judge Royce Lamberth (US District Court in DC) unambiguously ruled that restriction of off-label information, especially peer-reviewed journals, violates the First Amendment.
So much for the “startling change of policy.†(Was the Senator not briefed on this issue before she made her pronouncement? Sloppy staff work.)
Or, to quote Stephen Mahinka (veteran health care attorney and partner at Morgan Lewis), for the Senator (and her best pal Jerry Avorn) to imply a “startling change†is "intellectually dishonest or evidence that they are ignorant of the legal context.â€
Ouch.
Um, no.
Someone should point out to the Senator that the “policy†that counts here is the First Amendment -- and there’s no question that it applies to commercial free speech. Judge Royce Lamberth (US District Court in DC) unambiguously ruled that restriction of off-label information, especially peer-reviewed journals, violates the First Amendment.
So much for the “startling change of policy.†(Was the Senator not briefed on this issue before she made her pronouncement? Sloppy staff work.)
Or, to quote Stephen Mahinka (veteran health care attorney and partner at Morgan Lewis), for the Senator (and her best pal Jerry Avorn) to imply a “startling change†is "intellectually dishonest or evidence that they are ignorant of the legal context.â€
Ouch.
In CMPI’s new paper, “The Hazards of Harassing Doctors:Regulation and Reaction in Trans-Atlantic Healthcare," Dr. Alphonse Crespo, a Swiss physician, points out that focusing on cost-savings rather than patient care has unintended – but highly predictable consequences:
“Obsession with cost-containment has brought about regulatory measures that significantly affect the independence of German doctors. The “Drugs Saving Package†voted by the German parliament, introduces penalties for prescription of “expensive†drugs and rewards physicians who restrict their prescriptions to low-cost copy generics. This ethically objectionable legal gimmickry - akin to bribing physicians not to treat to the best of their ability - was one of the sparks of the doctor protest movement. A recent survey suggests that 65% of German physicians condemn bureaucratic tampering with prescriptions. Public perceptions echo their concerns. Questioned on this issue, 60% of people at large reckon that they will no longer get the best possible treatment from their doctors. Judging by media coverage, most Germans sympathize with their doctors' plight but express scepticism as to their ability to influence government health care policy and budgeting.â€
Dr. Crespo’s complete essay and the complete paper can be found under the “Reports†heading at http://www.cmpi.org.
“Obsession with cost-containment has brought about regulatory measures that significantly affect the independence of German doctors. The “Drugs Saving Package†voted by the German parliament, introduces penalties for prescription of “expensive†drugs and rewards physicians who restrict their prescriptions to low-cost copy generics. This ethically objectionable legal gimmickry - akin to bribing physicians not to treat to the best of their ability - was one of the sparks of the doctor protest movement. A recent survey suggests that 65% of German physicians condemn bureaucratic tampering with prescriptions. Public perceptions echo their concerns. Questioned on this issue, 60% of people at large reckon that they will no longer get the best possible treatment from their doctors. Judging by media coverage, most Germans sympathize with their doctors' plight but express scepticism as to their ability to influence government health care policy and budgeting.â€
Dr. Crespo’s complete essay and the complete paper can be found under the “Reports†heading at http://www.cmpi.org.
How can the WSJ run a piece on using genetics to redirect failed medicines to smaller groups of patients that are high responders and then engage in an orgy of second guessing about Vytorin? The Vytorin case is a clear example of seeking ways to personalize medicine and stratifying statin therapy according to particular pathways...but the thirst for headlines trumps science-based reporting.
http://online.wsj.com/article/SB120632582431058683.html?mod=home_health_right
DItto FiercePharma's continuing fearmongering on SSRIs.... It cites an "expert" who claims "People might have realized that the claims being made for the drug were overblown and coy to the point of being fraudulent."
But the "expert" is none other than David Healy, whose flawed study about SSRI's and suicide triggered a series of events which lead to less SSRI use and more suicide. And Healy makes millions shilling for trial attorneys as an expert witness.
Some expert. Some reporting.
http://www.iht.com/articles/ap/2008/03/24/europe/EU-MED-Drug-Data-Laws.php
http://www.fiercepharma.com/story/could-full-data-disclosure-avert-scandal/2008-03-24?utm_medium=nl&utm_source=link
http://online.wsj.com/article/SB120632582431058683.html?mod=home_health_right
DItto FiercePharma's continuing fearmongering on SSRIs.... It cites an "expert" who claims "People might have realized that the claims being made for the drug were overblown and coy to the point of being fraudulent."
But the "expert" is none other than David Healy, whose flawed study about SSRI's and suicide triggered a series of events which lead to less SSRI use and more suicide. And Healy makes millions shilling for trial attorneys as an expert witness.
Some expert. Some reporting.
http://www.iht.com/articles/ap/2008/03/24/europe/EU-MED-Drug-Data-Laws.php
http://www.fiercepharma.com/story/could-full-data-disclosure-avert-scandal/2008-03-24?utm_medium=nl&utm_source=link
Interesting article in today’s Wall Street Journal on the use of genetic tools to resuscitate failed compounds.
Here how the story begins:
“As pharmaceutical makers find it increasingly difficult to bring new drugs to market, they are turning to genetic tools to seek uses for medicines that failed to make it out of the development pipeline.
The discovery of new links between genes and diseases can help not only to design new treatments, but to salvage drugs that are shelved when they come up short in clinical trials.â€
And here’s the rest of the story:
http://online.wsj.com/article/SB120631682077958247.html?mod=dist_smartbrief
The better understanding of genetic tools (via a robust collaboration of industry, academia, and government) will both expedite failure (which lowers the cost of R&D) and provide a broader spectrum for success (which rewards it).
Sound familiar? Correct – the Critical Path.
Here how the story begins:
“As pharmaceutical makers find it increasingly difficult to bring new drugs to market, they are turning to genetic tools to seek uses for medicines that failed to make it out of the development pipeline.
The discovery of new links between genes and diseases can help not only to design new treatments, but to salvage drugs that are shelved when they come up short in clinical trials.â€
And here’s the rest of the story:
http://online.wsj.com/article/SB120631682077958247.html?mod=dist_smartbrief
The better understanding of genetic tools (via a robust collaboration of industry, academia, and government) will both expedite failure (which lowers the cost of R&D) and provide a broader spectrum for success (which rewards it).
Sound familiar? Correct – the Critical Path.
Our regulatory cousins to the north have begun the process of creating a biosimilar regulatory framework.
Health Canada recently posted on its website a draft guidance containing requirements for sponsors seeking to submit applications for “subsequent-entry biologics†once patents on biologic products start to expire. The agency says it could approve subsequent-entry products under existing drug regulations until laws are amended to include the new approval pathway.
Were the draft to become final, a subsequent-entry biologic sponsor would have to show that its proposed product is similar to a previously approved biologic, relying in part on publicly available safety and efficacy data. Interchangeability and substitutability would not be automatic but would be decided on a case-by-case basis, according to the draft guidance. Health Canada says it plans to publish additional guidance documents on specific product classes.
A subsequent-entry biologic would not automatically be approved for all the same indications as the reference product, and data would be required to support each indication in most cases. A subsequent-entry biologic also would have a product monograph different from that of the reference product.
Health Canada recently posted on its website a draft guidance containing requirements for sponsors seeking to submit applications for “subsequent-entry biologics†once patents on biologic products start to expire. The agency says it could approve subsequent-entry products under existing drug regulations until laws are amended to include the new approval pathway.
Were the draft to become final, a subsequent-entry biologic sponsor would have to show that its proposed product is similar to a previously approved biologic, relying in part on publicly available safety and efficacy data. Interchangeability and substitutability would not be automatic but would be decided on a case-by-case basis, according to the draft guidance. Health Canada says it plans to publish additional guidance documents on specific product classes.
A subsequent-entry biologic would not automatically be approved for all the same indications as the reference product, and data would be required to support each indication in most cases. A subsequent-entry biologic also would have a product monograph different from that of the reference product.
Two interesting reader comments on the issue of government-sponsored counter-detailing as discussed in yesterday's blog entry "Close(d) Encounters."
Names have been withheld to protect the intelligent:
Dear DrugWonks:
What I think is interesting is whether this will become part of P4P proposals. If the government funds these counter-detailers, what happens if a physician refuses to see them? Are they reported to CMS? Are there repercussions for those physicians? Will they get more reimbursement if they see the government counter-detailers? If generic prescribing habits are part of P4P, as some propose, will this be part of it as well. Interesting to think about.
Dear DrugWonks:
I’d want to make sure the gov't detailers have to go by the same rules as the Rx companies -- FDA approved claims, FDA approved materials, no off label etc. Isn’t more info good?
PS, good luck getting a gov't employee to get in to see a doctor without pens and pizza if they don’t have cutting edge science to share
And if pharma detailers drive up the cost of Rx, won’t their detailers do the same?
Names have been withheld to protect the intelligent:
Dear DrugWonks:
What I think is interesting is whether this will become part of P4P proposals. If the government funds these counter-detailers, what happens if a physician refuses to see them? Are they reported to CMS? Are there repercussions for those physicians? Will they get more reimbursement if they see the government counter-detailers? If generic prescribing habits are part of P4P, as some propose, will this be part of it as well. Interesting to think about.
Dear DrugWonks:
I’d want to make sure the gov't detailers have to go by the same rules as the Rx companies -- FDA approved claims, FDA approved materials, no off label etc. Isn’t more info good?
PS, good luck getting a gov't employee to get in to see a doctor without pens and pizza if they don’t have cutting edge science to share
And if pharma detailers drive up the cost of Rx, won’t their detailers do the same?
For those in Soros/Essential Action camp who fervently believe the way to develop drugs for global health is to have the government coordinate and run trials with IP seized from private companies, the latest HIV vaccine failures underscore the ideologically riven fecklessness of their position.
The notion that prizes to investigators plus a pittance to those who develop and manufacture medicines under a government-run clinical trial operation will yield breakthroughs is naive: the risky part, the hard part, the part requiring hundreds of billions of dollars a year, is development. That is why commercialization is critical to medical progress, as are profits.
The Soros/Essential Action model is based on hatred of capitalism not science. And in the end, it will doom the dying around the world to continued suffering. The groups will have their press clippings and accolades from the Left and those in need of breakthroughs will have nothing. Such is the perverted definition of "progress" advanced by George Soros and Essential Action
The notion that prizes to investigators plus a pittance to those who develop and manufacture medicines under a government-run clinical trial operation will yield breakthroughs is naive: the risky part, the hard part, the part requiring hundreds of billions of dollars a year, is development. That is why commercialization is critical to medical progress, as are profits.
The Soros/Essential Action model is based on hatred of capitalism not science. And in the end, it will doom the dying around the world to continued suffering. The groups will have their press clippings and accolades from the Left and those in need of breakthroughs will have nothing. Such is the perverted definition of "progress" advanced by George Soros and Essential Action
Did you see the house editorial in today’s New York Times, “Countering the Drug Salesmen�
Here’s the link:
http://www.nytimes.com/2008/03/20/opinion/20thu2.html?_r=1&ref=opinion&oref=slogin
The editorial supports planned legislation by Senators Herb Kohl, Democrat of Wisconsin, and Richard Durbin, Democrat of Illinois that would authorize federal grants to prepare “objective†educational materials designed to provide physicians with “unbiased†guidance on the safety and effectiveness of drugs. Such materials, along with a government-funded “counter-detailing†force are meant to offset the one-sided sales pitches America’s physicians get from pharmaceutical company representatives. The Times believes that, “The end result should be better care, quite often at lower cost.â€
The Times shares the hope of Senators Kohl and Durbin that this government-funded scheme “would pay for itself by lowering drug costs to federal programs.â€
Perhaps, but at what cost to patient care? And what about the fact that “unbiased†and “objective†are in the eyes of the beholder?
Clearly pharmaceutical companies detail because they believe it is in the interest of both the public health and their own commercial imperatives. Nothing wrong with that. Self-interest and public interest are not mutually exclusive.
But it’s only honest to point out that the government has significant self-interest too – Uncle Sam is the largest “payer†in the nation. So the more drugs these government-funded workers classify as "wasteful," the more money the government saves. Such a conflict is hardly" unbiased.â€
Ultimately, as the European model has shown time and again, budget analysts and Big Brother-funded anti-pharmaceutical “truth squads†will deliver the findings their “funders†wants to see -- that newer, pricier pills are no more effective than their older, cheaper counterparts. And the result will be the same as well -- Medicare, Medicaid, and the Department of Veterans Affairs will stop covering these more innovative medicines, forcing physicians to prescribe only the drugs that the government will pay for, not the ones that are best for patients.
That’s what “government†care really delivers.
Here’s the link:
http://www.nytimes.com/2008/03/20/opinion/20thu2.html?_r=1&ref=opinion&oref=slogin
The editorial supports planned legislation by Senators Herb Kohl, Democrat of Wisconsin, and Richard Durbin, Democrat of Illinois that would authorize federal grants to prepare “objective†educational materials designed to provide physicians with “unbiased†guidance on the safety and effectiveness of drugs. Such materials, along with a government-funded “counter-detailing†force are meant to offset the one-sided sales pitches America’s physicians get from pharmaceutical company representatives. The Times believes that, “The end result should be better care, quite often at lower cost.â€
The Times shares the hope of Senators Kohl and Durbin that this government-funded scheme “would pay for itself by lowering drug costs to federal programs.â€
Perhaps, but at what cost to patient care? And what about the fact that “unbiased†and “objective†are in the eyes of the beholder?
Clearly pharmaceutical companies detail because they believe it is in the interest of both the public health and their own commercial imperatives. Nothing wrong with that. Self-interest and public interest are not mutually exclusive.
But it’s only honest to point out that the government has significant self-interest too – Uncle Sam is the largest “payer†in the nation. So the more drugs these government-funded workers classify as "wasteful," the more money the government saves. Such a conflict is hardly" unbiased.â€
Ultimately, as the European model has shown time and again, budget analysts and Big Brother-funded anti-pharmaceutical “truth squads†will deliver the findings their “funders†wants to see -- that newer, pricier pills are no more effective than their older, cheaper counterparts. And the result will be the same as well -- Medicare, Medicaid, and the Department of Veterans Affairs will stop covering these more innovative medicines, forcing physicians to prescribe only the drugs that the government will pay for, not the ones that are best for patients.
That’s what “government†care really delivers.
Check out H.R. 5605, the “Physicians Payments Sunshine Act of 2008. The sponsor is Peter DeFazio (D-OR) and one of the co-sponsors is Pete Stark (D-CA). Here's a link to the proposed legislation:
Download file
(Another of the co-sponsors is Representative Dennis Kucinich – glad he’s getting back to work after the grueling primary season.)
The bill calls for the reporting of absolutely everything (and they thought of everything) over $25.00 considered “a transfer of value†to a physician.
(What’s the AWP for a large pizza and a liter of Diet Coke these days?)
The penalties are between $10,000 - $100,000 and multiple offenders can say adios to their corporate deductions for advertising related expenses.
According to Mr. Stark, “The Sunshine Act will help enable Medicare beneficiaries to determine if their doctors are acting in patients’ best interests. It may even convince doctors to quit taking what can only be described as industry kickbacks."
Kickbacks? That’s a pretty strong accusation. Mr. Stark should apologize to America’s physicians and to the pharmaceutical industry he slanders so easily. And as far as America’s Medicare beneficiaries, Mr. Stark might also want to mention that the Medicare Drug Benefit (Part D) doesn’t "pay" doctors.
Mr. DeFazio issued some equally thoughtful and measured comments:
"If the billions of dollars drug companies spend taking doctors on trips to the Caribbean and to expensive dinners at the country’s finest restaurants are above-board, then the pharmaceutical industry should support our legislation. This bill will keep the pharmaceutical industry honest."
Speaking of “honesty,†Mr. DeFazio should own up to the fact that the aforementioned boondoggle trips and are against the rules.
But this has nothing to do with honesty and everything to do with posturing – and hidden agendas. (One of the groups supporting this legislation is Consumers Union – yes, the same organization that receives millions of dollars from foundations supported by the generic drug industry.)
The concept that big bad Pharma is to blame for everything, and that a $25.15 pizza party is at the heart of the destruction of medical ethics, isn’t just simplistic and sophistic but deleterious to a serious conversation about the issue.
H. R. 5605 is just another example of superbity from our legislative Sultans of Sanctimony.
Download file
(Another of the co-sponsors is Representative Dennis Kucinich – glad he’s getting back to work after the grueling primary season.)
The bill calls for the reporting of absolutely everything (and they thought of everything) over $25.00 considered “a transfer of value†to a physician.
(What’s the AWP for a large pizza and a liter of Diet Coke these days?)
The penalties are between $10,000 - $100,000 and multiple offenders can say adios to their corporate deductions for advertising related expenses.
According to Mr. Stark, “The Sunshine Act will help enable Medicare beneficiaries to determine if their doctors are acting in patients’ best interests. It may even convince doctors to quit taking what can only be described as industry kickbacks."
Kickbacks? That’s a pretty strong accusation. Mr. Stark should apologize to America’s physicians and to the pharmaceutical industry he slanders so easily. And as far as America’s Medicare beneficiaries, Mr. Stark might also want to mention that the Medicare Drug Benefit (Part D) doesn’t "pay" doctors.
Mr. DeFazio issued some equally thoughtful and measured comments:
"If the billions of dollars drug companies spend taking doctors on trips to the Caribbean and to expensive dinners at the country’s finest restaurants are above-board, then the pharmaceutical industry should support our legislation. This bill will keep the pharmaceutical industry honest."
Speaking of “honesty,†Mr. DeFazio should own up to the fact that the aforementioned boondoggle trips and are against the rules.
But this has nothing to do with honesty and everything to do with posturing – and hidden agendas. (One of the groups supporting this legislation is Consumers Union – yes, the same organization that receives millions of dollars from foundations supported by the generic drug industry.)
The concept that big bad Pharma is to blame for everything, and that a $25.15 pizza party is at the heart of the destruction of medical ethics, isn’t just simplistic and sophistic but deleterious to a serious conversation about the issue.
H. R. 5605 is just another example of superbity from our legislative Sultans of Sanctimony.
The Center for Medicine in the Public Interest will shortly publish a series of essays on the consequences of physican disempowerment in both the US and the EU. The title of this collection is "The Hazards of Harassing Doctors," and features contributions by Dr. Alphonse Crespo (a Swiss physician) and Dr. Marc Siegel (an American).
The thoughtful introduction is penned by Dr. Fred Goodwin, CMPI board member and Research Professor of Psychiatry at The George Washington University and Director of the University’s Center on Neuroscience, Medical Progress, and Society. Dr. Goodwin is the former Director of the National Institute of Mental Health
Here is a taste of Dr. Goodwin's take on the situation.
William Osler, generally regarded as the father of modern medicine wrote "If you listen carefully to the patient they will tell you the diagnosis." Arriving at a diagnosis and appropriate treatment plan has always represented collaboration between individual patients and their personal physician.
But today physicians are increasingly seeing the decisions that they and their individual patient reach about a specific treatment plan second guessed by distant “third parties†(working for government or insurance bureaucracies) who, of course do not –indeed cannot- know the physician or the unique individual circumstances of a particular patient. Lacking any knowledge of the patient or the doctor, these bureaucrats must fall back on general “guidelines†as the basis for approval or rejection of a particular treatment. Having served on guideline development bodies I can tell you that, at best, they represent the kind of “lowest common denominator†conclusions necessary to get the many different opinions represented on a committee to coalesce into a consensus. At worst guidelines represent a deliberate effort to drive down the cost of treatment by emphasizing “one size fits all†treatment approaches. While the physician-patient relationship theoretically remains the fulcrum of good medical practice and medical progress, in reality it is rapidly being replaced – on both sides of the Atlantic – by guidelines.
This movement towards guideline-driven medicine to which access to healthcare and physician reimbursement is increasingly linked, is based on the assumption that variations in medical practice are not only wasteful, but also potentially dangerous. Eliminating variations in clinical practice, we are told, will increase quality and save billions that could be poured into covering more uninsured or increasing coverage. The key to standardizing treatments – and outcomes – therefore are guidelines based on a combination of retrospective analysis of randomized clinical trials and the results of large prospective studies that compare the cost and effectiveness of established treatments or drugs in certain disease areas.
I bring a special perspective to this subject because of my professional background. On the one hand I have been a practicing physician for nearly 40 years and during almost all of those 40 years I was medical researcher and policy maker at the National Institute of Mental Health (NIMH). Incidentally my long experience in a part time private practice came about as a consequence of government salaries at the time not being competitive with academia so that a private practice was allowed in order to retain talent.
I was director of NIMH during the health care reform efforts of the first Clinton administration and, as such, I participated in some high level meetings of groups that were part of the effort. It is now well known that the perspective of practicing physicians was not included in this health care reform effort and my involvement was as the government’s principal mental health official, not as a clinician. Indeed I doubt that any of the other participants in the meetings I attended even knew that outside of my government job I was a physician in the private practice of a medical specialty.
I present this history so that the reader can understand what I am about to say. The meetings I attended had a surreal “Alice in Wonderland†quality. Here were all of these intelligent, well educated, well intended professionals discussing meta-analyses of controlled clinical trials, outcomes research, etc, etc, and yet it seemed that that none of them really understood what clinical practice was all about – it’s about enormous individual differences even among patients with the same diagnosis, it’s about cross-over trials where the physician uses each individual patient as their own control, trying treatment B when treatment A isn’t working, etc, etc Today’s advocates for coercive guideline driven medicine (as opposed to guidelines which are advisory to the doctor and the patient) seem to be cut from the same cloth as the people I encountered on those committees in the early 90s, except that now the lure of saving money and increasing the profits of managed care companies provides a new level of passion and intensity to these efforts.
In Europe, doctors are limited by reimbursement patterns and practice guidelines designed to control costs. This trend is growing in the United States. Yet there is no evidence that limiting access based on reviews of clinical literature or large scales trials either improves outcomes or saves money. On the contrary, the outcomes evidence suggests that seeking to elimination variations in practice and prescribing is actually more costly and contributes to morbidity.
The practice guidelines themselves are not the problem, it is how they are applied and for what purpose. Voluntary guidelines provide the intelligent physician with a benchmark from which to mark a patient’s progress or the impact of prevention. I have been involved in the development of practice guidelines for the treatment of mental illness for nearly three decades. It is a given that by the time there are developed, the guidelines themselves are outdated as new clinical insights and biomedical discoveries inform and shape both diagnosis and prescribing. The rigid imposition of guidelines regarding what to prescribe and how to treat insure that doctors cannot tailor treatments to the patient or deliver the best care.
Finally, the emphasis on cost-containment undermines continuity of care. The recognition that someone with mental illness is twice as likely to suffer from heart disease, diabetes or hypertension reveals the interaction of disease pathways which themselves have been show to be highly individualized. The evidence-based medicine movement fails to incorporate such insights. Rather, by emphasizing studies that evaluate the treatment of one aspect of a particular disease in a vacuum, the EBM movement is contributing to fragmentation of care.
Clinical decision-making is becoming increasingly centralized and the domains of economists or physicians who crunch numbers but never practice medicine.
Watch this space for more excerpts from this new and timely publication.
The thoughtful introduction is penned by Dr. Fred Goodwin, CMPI board member and Research Professor of Psychiatry at The George Washington University and Director of the University’s Center on Neuroscience, Medical Progress, and Society. Dr. Goodwin is the former Director of the National Institute of Mental Health
Here is a taste of Dr. Goodwin's take on the situation.
William Osler, generally regarded as the father of modern medicine wrote "If you listen carefully to the patient they will tell you the diagnosis." Arriving at a diagnosis and appropriate treatment plan has always represented collaboration between individual patients and their personal physician.
But today physicians are increasingly seeing the decisions that they and their individual patient reach about a specific treatment plan second guessed by distant “third parties†(working for government or insurance bureaucracies) who, of course do not –indeed cannot- know the physician or the unique individual circumstances of a particular patient. Lacking any knowledge of the patient or the doctor, these bureaucrats must fall back on general “guidelines†as the basis for approval or rejection of a particular treatment. Having served on guideline development bodies I can tell you that, at best, they represent the kind of “lowest common denominator†conclusions necessary to get the many different opinions represented on a committee to coalesce into a consensus. At worst guidelines represent a deliberate effort to drive down the cost of treatment by emphasizing “one size fits all†treatment approaches. While the physician-patient relationship theoretically remains the fulcrum of good medical practice and medical progress, in reality it is rapidly being replaced – on both sides of the Atlantic – by guidelines.
This movement towards guideline-driven medicine to which access to healthcare and physician reimbursement is increasingly linked, is based on the assumption that variations in medical practice are not only wasteful, but also potentially dangerous. Eliminating variations in clinical practice, we are told, will increase quality and save billions that could be poured into covering more uninsured or increasing coverage. The key to standardizing treatments – and outcomes – therefore are guidelines based on a combination of retrospective analysis of randomized clinical trials and the results of large prospective studies that compare the cost and effectiveness of established treatments or drugs in certain disease areas.
I bring a special perspective to this subject because of my professional background. On the one hand I have been a practicing physician for nearly 40 years and during almost all of those 40 years I was medical researcher and policy maker at the National Institute of Mental Health (NIMH). Incidentally my long experience in a part time private practice came about as a consequence of government salaries at the time not being competitive with academia so that a private practice was allowed in order to retain talent.
I was director of NIMH during the health care reform efforts of the first Clinton administration and, as such, I participated in some high level meetings of groups that were part of the effort. It is now well known that the perspective of practicing physicians was not included in this health care reform effort and my involvement was as the government’s principal mental health official, not as a clinician. Indeed I doubt that any of the other participants in the meetings I attended even knew that outside of my government job I was a physician in the private practice of a medical specialty.
I present this history so that the reader can understand what I am about to say. The meetings I attended had a surreal “Alice in Wonderland†quality. Here were all of these intelligent, well educated, well intended professionals discussing meta-analyses of controlled clinical trials, outcomes research, etc, etc, and yet it seemed that that none of them really understood what clinical practice was all about – it’s about enormous individual differences even among patients with the same diagnosis, it’s about cross-over trials where the physician uses each individual patient as their own control, trying treatment B when treatment A isn’t working, etc, etc Today’s advocates for coercive guideline driven medicine (as opposed to guidelines which are advisory to the doctor and the patient) seem to be cut from the same cloth as the people I encountered on those committees in the early 90s, except that now the lure of saving money and increasing the profits of managed care companies provides a new level of passion and intensity to these efforts.
In Europe, doctors are limited by reimbursement patterns and practice guidelines designed to control costs. This trend is growing in the United States. Yet there is no evidence that limiting access based on reviews of clinical literature or large scales trials either improves outcomes or saves money. On the contrary, the outcomes evidence suggests that seeking to elimination variations in practice and prescribing is actually more costly and contributes to morbidity.
The practice guidelines themselves are not the problem, it is how they are applied and for what purpose. Voluntary guidelines provide the intelligent physician with a benchmark from which to mark a patient’s progress or the impact of prevention. I have been involved in the development of practice guidelines for the treatment of mental illness for nearly three decades. It is a given that by the time there are developed, the guidelines themselves are outdated as new clinical insights and biomedical discoveries inform and shape both diagnosis and prescribing. The rigid imposition of guidelines regarding what to prescribe and how to treat insure that doctors cannot tailor treatments to the patient or deliver the best care.
Finally, the emphasis on cost-containment undermines continuity of care. The recognition that someone with mental illness is twice as likely to suffer from heart disease, diabetes or hypertension reveals the interaction of disease pathways which themselves have been show to be highly individualized. The evidence-based medicine movement fails to incorporate such insights. Rather, by emphasizing studies that evaluate the treatment of one aspect of a particular disease in a vacuum, the EBM movement is contributing to fragmentation of care.
Clinical decision-making is becoming increasingly centralized and the domains of economists or physicians who crunch numbers but never practice medicine.
Watch this space for more excerpts from this new and timely publication.
Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.
