AARP: Stakeholder for Waste and Moneyed Interests?

AARP, you lost whatever presumed credibility you thought you had with one article in the current issue of your magazine. I am talking about the hard copy of “All the President’s Scans: Our Commander in Chief Regularly Gets An Extensive Physical: Should You?” – part of your Spring 2016 Health Special in AARP: The Magazine, out this weekend. The hard copy is far more slick and glossy than what’s online, replete with pics of the three most recent presidents getting comprehensive physicals for everything under the sun, with smiles on their faces. These were not online. BTW, readers, you can get a copy of it at your local library if you don’t see it at your doctor’s office or are not getting it as an AARP member. Readers note: to get a Medicare Supplement, AARP requires that you join AARP.

 

Pitching High

 

Readers over age 50 (AARP’s target audience) might be tempted to look for an executive physical after reading this article. AARP tells you right away where to go for it in the first paragraph: “Cooper Clinic, Cleveland Clinic, UCLA, Duke and many other major hospitals offer them,” the author writes, warning you that “you could pay upward of $2,000 to $3,000 out of pocket for this.”

Like concierge care before this, executive physicals can embellish a doctor’s base considerably and enlarge what people pay for healthcare. First, a sliver of the upper middle class is conned to pay for these tests because, after all, what’s more important than your health? Pretty soon, demand increases broadly and prices go up for all.

As Good as a Cruise

The nuts and bolts of this executive physical are written about like brochures for a cruise. Nothing but upbeat information, you’ll find here. No downsides. It’s clear that AARP will satisfy many of its funders: for example, academic medical centers, providers looking for volume, and purveyors of imaging and screening tests. But those groups have their own stake and it conflicts with that of aging Americans, no matter what their health status.

Here’s the potpourri of tests that AARP claims “could help” you and provide superlative care:

  • Blood pressure readings taken all day long;
  • Blood test and urinalysis;
  • A thorough head-to-toe physical exam instead of the “old-fashioned once-over;”
  • Specialist exams all done in one day;
  • Multi-expert Q&As;
  • Body fat tests;
  • Cancer screenings, including mammography, colon, and PSA – and even a total-body CT scan, with the caveat that “some detractors think that ultra-early detection can lead to unnecessary treatments.”
  • Eye exams, which could lead you to “new medications that may help stop the spread of macular degeneration, one of the leading causes of blindness in older people” and blood vessel changes in the eyes, suggestive of uncontrolled hypertension.
  • Strength and flexibility assessment, which can lead you to physical therapy for pain relief, balance improvement, and strength improvement;
  • A stress test – EKG showing early heart problems;
  • A sit-down to summarize all the above.

Harm and The “Detractors”

The absence of attention to how so many of these tests have been demonstrated to be wasteful and even harmful is concerning.

AARP, you owe it to your readers to not masquerade advertisements as journalism. Aging Americans have shrinking pocketbooks and this “advice” is a disservice to readers. You scoff at the so-called “detractors,” as if they are few when they are many, completely overlooking the body of scientific research, clinical practice guidelines, and state of knowledge about these tests, which many, as opposed to few, question. Major health authorities question many of these tests, discussed a bit in this blog in numerous posts, and many other places. Overuse is concerning, harms are unacceptable.

For policymakers looking for stakeholders to represent aging Americans, please look outside of AARP. It does not represent us. I submit that AARP’s voice is with waste and the moneyed interests in healthcare, the providers, the establishment, and white Americans aspiring to be part of it.

 

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Readers might be interested in more nuanced discussion of these issues, as covered previously in this blog:

Cardiovascular Care and the Bush Effect

MR Imaging, Electronic Test Ordering Creates Waste

Back Pain Trends Worth Reversing

 What’s Next for Prostate Cancer Screening and Treatment?

Caveat Emptor: Testosterone Replacement Therapy Ads Soar

 

..and many more.

 

Finally, my shameless self-promotion here, but PLEASE take this seriously.

 

I need more paid, honest work to do! Please contact me! I am not ready to retire.

 

Why Sanofi’s Zaltrap Deal Won’t Help Patients

A nurse prepares a patient for an infusion drug for cancer. Credit: National Cancer Institute.

I got excited when I read the New York Times story Nov. 9 (“Sanofi Halves Price of Cancer Drug Zaltrap After Sloan-Kettering Rejection)”. Zaltrap is an intravenous infusion drug for metastatic colorectal cancer. It is used for advanced cancer that is resistant to or has progressed with platinum-based chemotherapy. With a list price of  $11,000 per patient per month, Zaltrap is about double the cost of Genentech’s Avastin. Sloan-Kettering doctors rejected Zaltrap, claiming it offered no added value over Avastin, and it costs twice as much.

Doctors from Sloan-Kettering Cancer Center, one of the nation’s flagship cancer hospitals, didn’t do it quietly; they published an op-ed in the NYTimes Oct. 14, titled “In Cancer Care, Cost Matters.” They wrote:

“Soaring spending has presented the medical community with a new obligation. When choosing treatments for a patient, we have to consider the financial strains they may cause alongside the benefits they might deliver.”

The importance of getting bang for your buck, or value in healthcare, has been a huge sticking point in health policy circles in the United States. In fact, politicians of all stripes are quick to point to health outcomes data that show that despite the United States spending in the top tier of all nations for healthcare, health outcomes are far lower.

Unfortunately, the story in The Times Nov. 9 to Sloan-Kettering, could easily have been misread as a victory for affordability for patients. The headline states “Sanofi halves price…”. Sadly, the Zaltrap half-off deal is not a list price reduction at all. It is just a business discount plan for hospitals and oncologists. As Lisa Jaffe Hubbell, who uses high-cost disease modifying drugs for a noncancerous, chronic condition told me:

“It won’t help patients, will it? Our copay will be based on full price, the docs will pocket the extra from insurance companies. It doesn’t really help anyone who is in need of help paying for healthcare.”

Another woman with stage IV breast cancer explained to me that she has been deemed ineligible for any discount for her high-priced cancer drugs because she is insured. In general, drug discount plans go to the uninsured. She emailed me:

“The drug I took for five years was re-patented three times while I was on it, as I recall. It was orders of magnitude more expensive than the old standby tamoxifen for only a slight advantage in efficacy.”

As The Times points out, Medicare patients are unlikely to see a lower price for Zaltrap for a long while until the discount is incorporated into Medicare payment calculations for Part B, which covers physician-administered drugs. In addition, oncologists have long marked up drugs that they administer for insurers and patients.

Fortunately, Sloan-Kettering doctors are on the patients’ side and question whether Sanofi’s discount will make Zaltrap more affordable for patients. Peter Bach, MD, told me: “I don’t know if they’re going through steps to ensure reimbursement goes down to follow price or not. I’m hoping that is in their plans. If not, then yes, the windfall goes to providers, and our concern is the costs passed on to patients.” Leonard Saltz, MD, the op-ed coauthor, and gastroenterology oncologist, from Sloan Kettering also called Sanofi to task in the Nov. 9 NYT article for missing the boat in making Zaltrap affordable for patients.

But pharmaceutical price fixing is nothing new, according to Frederic Kaye, MD, professor of hematology and oncology at the University of Florida in Gainesville, Florida. “I saw this happen for the first time in the late 1980s when a veterinary pill levamisole, which cost pennies for the treatment of heartworm, underwent a 100 times price escalation when it was used for treating colon cancer. There was outrage at the time over lack of regulations for price fixing, but you see almost 25 years later, it is the same.”

Sanofi’s drug discount plan is clearly a business imperative. If one of the US flagship cancer treatment centers says that they will not use Zaltrap, others could follow. But the refusal to lower Zaltrap’s list price is worrisome because patient copays are based on price.

More importantly, if the Sanofi plan becomes the pharmaceutical industry’s MO in the era of value-based healthcare, patients will still gain no financial relief from the high cost of drugs. Value-based healthcare will be something for facilities and hospitals.

These days, you have to critically review the hoopla about “patient-centered health care” and the allegedly positive partnerships shaping healthcare. Were patients included when it really mattered in drafting this drug discount program? We need to maintain a high level of skepticism about deals made strictly between drug companies and hospitals, or arrangements made between industry and physicians, or industry and health plans. It’s been said before and it must be said again: “Nothing about me [the patient] that pertains to me should be done without me at the table.”

This story appeared first as a guest blog on Scientific American guest blogs, Nov. 19, 2012.