Is ACA effective in decreasing healthcare costs?

I enjoyed learning about the healthcare system in America and comparing our system to healthcare systems of different countries around the world through our presentations. In particular, it never struck me of how inefficient U.S. healthcare system was until I saw the statistics that was presented in Dr. Bella’s slides. I was particularly shocked to find out that our health care spending was more than 2 times the average spending of other countries.
 I never had a clear idea of the impact of the Affordable Care Act on our healthcare system but the Healthcare in the US presentation gave me a better understanding of the problems within the US healthcare system and the goals of the ACA. Despite ACA’s attempts to lower health care costs by providing more preventative services, increasing access to healthcare via insurance, I still question the effectiveness of ACA. The main purpose of ACA is to eventually slowdown U.S. healthcare spending but I believe ACA could potentially contribute to increase spending. Since more people are insured, insurance companies must spend more money on the chronic diseases of newly insured people, which adds to the cost. Also, more insured means more people will use health care services, fill prescriptions (and sometimes for unnecessary purposes), which will only add to unnecessary healthcare spending. The quality of care may also decrease, since doctors and other health professionals are forced to see many more patients. However, there are definitely advantages to the ACA, such as preventing insurance companies to avoid covering patients with pre-existing conditions, and more coverage for youth under 26. I am still skeptical of how the ACA will decrease healthcare spending in the long run and improve health outcomes.

Through the discussions we had in class, I've realized that changing the U.S. health system is a lot more complicated than I thought. The more I think about it, and as we've talked about it in class, this country’s healthcare somewhat reflects this nation’s cultural beliefs centered on individualism and capitalism. Personally, I believe that universal health care in the United States will be very difficult to achieve because this country is so focused on capitalism and independence, thus I don’t think people will be willing to make sacrifices to provide that access. For example, in countries that provide Universal Health Care such as South Korea and Germany, many healthcare professionals, particularly doctors, make less than a fraction of what they make in the United States. Due to the high cost for professional schools in America, I believe most healthcare professionals will not tolerate the low income. If we did implement UHC in the United States, I believe the whole country will need to be restructured.

Overall, it was very valuable for me to get an understanding of healthcare system in America and comparing it to healthcare systems globally. 

Pharmacists' Autonomy in Decision Making

The global healthcare presentations highlighted the varying roles of pharmacists across the world. After hearing about their roles, it was apparent that the United States provides us with greater opportunity to practice and apply the knowledge and skills we are fortunate to gain from our education. We also have greater opportunity to decide which field of pharmacy we choose to practice in and I personally have a greater appreciation for my education because of the resources I am provided. With that being said, I also believe that we, as pharmacists, must remain the accessible healthcare professionals we have been regarded as by our patients. As one of the most trusted professions, our patients turn to us for their healthcare needs and questions and therefore rely on our expertise and overall clinical judgment that guides the care we provide. I firmly believe that we are obligated to provide care to our patients without infringing on their rights to this care. This brings me to our last couple class discussions about ethics and moral beliefs and their association with our roles as pharmacists.

As a pharmacist, I will willingly take on the responsibility of upholding the health of my patients. I believe this includes providing care that is based on evidence based medicine and clinical judgment. According to the American Pharmacists Association, pharmacists must “apply their knowledge, experience, and skills to the best of their ability to assure optimal outcomes for their patients”. APhA also possesses a refusal clause that seems contradictory to this statement. If a pharmacist’s moral or ethical belief supersedes their discretion in providing care, they are not assuring “optimal outcomes for their patients”. Yes, they may be able to refer them somewhere that provides the care they are refusing, however this creates a barrier that ultimately results in delayed care to patients. Class discussion brought up some excellent examples about circumstances that could prove problematic if a pharmacist utilizes their moral/religious beliefs to guide the care they provide such as contraceptive and emergency contraceptive dispensing and substance abuse maintenance therapy.

One additional example I wanted to bring up centers on the autonomous role that pharmacists possess. I believe that pharmacists should not exercise their religious/moral beliefs within their scope of practice and their clinical judgment should guide the care they provide. I do however believe clinical judgment needs to be addressed as well. As a pharmacy technician a few years ago, I encountered a pharmacist who chose to withhold dispensing medication to a patient. The medications this patient requested were for a controlled pain reliever and an antibiotic, however when the patient came to pick them up, he decided he only wanted the controlled substance. The rationale for this pharmacist’s refusal to dispense both medications was based on the fact that he believed the patient should get the antibiotic, not just the pain reliever, and therefore refused to dispense the pain reliever if the patient did not want the antibiotic. This instance made the patient extremely frustrated and he was ultimately forced to go to another pharmacy. I am torn about my feelings about this encounter because although the pharmacist did not use his religious belief to guide his decision, he used his clinical judgment that eventually resulted in the patient not getting any medication. I believe we can only do so much as pharmacists to ensure patients take their medications appropriately and that the patient also has a responsibility to safeguard their health. Looking back, I feel it was the pharmacist’s obligation to have counseled the patient about the importance of taking the prescribed antibiotic along with the pain medication. He did not provide this service and just refused both medications if the patient was unwilling to purchase the antibiotic. The pharmacist created a barrier for this patient even though I do feel he thought it was in the patient’s best interest. Ultimately, I do see both sides of this situation. I feel like pharmacists should be able to make this decision based on the clinical judgment they have acquired in their years of education. The topic of autonomy is a convoluted one that is situation dependent and I believe pharmacists should practice with a patient-centered focus.

Thanks to class discussion, I have a strong sense of purpose. I am proud of the profession I am entering which allows me to exercise my clinical judgment so I can ensure I am providing the best care I can to my patients. I do believe that those who feel their moral or ethical views may interfere with the care they provide should explore other professional options. They are obligated to provide care that safeguards their patients, however their scope of practice should also be based on clinical judgment with a patient-centered focus. Pharmacist autonomy is not a black and white subject so I believe that pharmacists need to be aware of this when they enter the work force.

Why It's Not Easy To Change

Americans can easily point out the negatives qualities of the US Healthcare System. Furthermore, the high cost and, ironically, poorer outcomes are even obvious to other countries. As we discussed in lecture, health care spending is at an astronomical high of 17.1% of the national GDP. Yet, the US health system ranks 37^th in the world by WHO, which is way behind countries such as France, Germany, and Japan. It is clear we need to restructure the healthcare design. Before taking this course, I naively believed that such reform would be relatively easy to make by modeling another country’s healthcare system. After all, I believed it would be better to model off a successful system rather than blindly adjusting our current failing system towards something unknown and untested. In fact, we are already spending so much changing Medicare and Medicaid that it may save more money, and lead to better health outcomes, in the long term to restructure our healthcare system off a proven model. For a long time, I believed that this would be a great solution; however, my perspective has greatly changed through this course.

Through the Global Healthcare Presentations, I learned that even though many of the European countries had similar health insurance and healthcare ideas, their ways of delivering it and the challenges of each were unique to their culture. Therefore, the US would simply not be able to copy another country’s healthcare system. Some of the unique problems the US faces include the uneven health insurance coverage and rising premiums, the growing usage of expensive new medical technologies and prescription drugs, and our individualistic mindsets. These are all problems that we have discussed in lecture or during discussions, but there are so many more interesting reasons that I would like to talk about. Two of these are the pay of healthcare providers and the US political system.  

A major reason I believe that hinders healthcare reform in the US is healthcare providers’ salaries. Compared to healthcare providers in the high performing countries, the US salaries are much greater. While this is good for us, I believe it plays a role in the high health insurance costs and the dearth of primary care physicians in the US. In fact, the US has fewer physicians per capita; most are overspecialized and thus neglect primary and preventive care.

I also believe that the US political infrastructure, which is inefficient in itself, plays a large role as to why healthcare in the US is so stagnant. Just passing one healthcare bill through the Supreme Court takes years; for example, the pharmacy provider status bill has been taking years, and was just reintroduced in 2015. This system wastes time, resources, and money. Most importantly, this leads to increasing healthcare costs with poorer outcomes as necessary changes are not being made at a timely rate.

These are two other points that I believe are also playing a major role in our current healthcare system crisis. This course has made me much more aware of what is going on globally in regards to healthcare, and I have realized that our current problems are deeply rooted in American culture. I have learned a lot from this course, and my perspective regarding how the US should go about changing the healthcare system has definitely changed as a result. 

The Risperdal Controversy

                The discussions of pharmaceutical industry and ethics seemed relevant to this particular controversy. Risperidone is an antipsychotic medication currently approved for autistic disorder, bipolar disorder, and schizophrenia. Sold as Risperdal, it was a blockbuster drug for Janssen Pharmaceuticals (part of Johnson & Johnson), bringing in $30 billion in profit. Although this drug is commonly used, its origins are surrounded in controversy.

                Risperdal was developed after Johnson & Johnson’s patent life for its other antipsychotics ended. It was initially approved solely for treatment of schizophrenia in adults. Johnson & Johnson, however, utilized illegal marketing methods to cater to other populations and indications in the 1990s and 2000s. Despite disapproval from the FDA, the company adopted a number of methods to promote the drug, including paying doctors consulting fees for prescribing the drug and lobbying states to give formulary preference to Risperdal over generic antipsychotics. Risperdal was marketed as effective for treating symptoms such as agitation and confusion in dementia patients. Johnson & Johnson also partnered with Omnicare, a long-term care pharmacy. Under this agreement, long-term care doctors and pharmacists would recommend the use of Risperdal and profits would be shared between the two companies. Johnson & Johnson also created a sales force to specifically target older individuals. Marketing was also directed towards children for unapproved (at the time) indications such as autism, OCD, and ADHD. The company even considered giving lollipops and toys with samples of the drug. By the year 2000, about 20% of Risperdal sales were for children and teens, and by 2004, the drug was bringing in over $3 billion annually. Use in children was not FDA approved until 2006.

                In addition to illegal marketing, Janssen Pharmaceuticals was accused of inaccurately disclosing the risks of the drug on the label. Company scientists were blamed in depicting risk levels for side effects to be lower than they actually were. Prescribers and users were not well-informed about the risk of stroke in the elderly or the risk of male gynecomastia. By the time proper warnings were put on labels, some males had been taking the drug for years and had already begun developing breasts that can only be removed by mastectomy.

                Due to these issues, Johnson & Johnson faced multiple lawsuits resulting in millions of dollars payed to men who experienced gynecomastia. The company plead guilty to illegal marketing to the elderly and misbranding and paid over $2 billion in penalties and settlements. These payments, however, pale in comparison to the billions of dollars that the company made in profits. As mentioned in a previous class, this was “just the cost of doing business.” Furthermore, the executives in charge of marketing did not face repercussions. For example, Alex Gorsky, who was in charge of marketing during the controversy, ended up being promoted to CEO, making millions annually, and receiving awards for “integrity” and “social responsibility.”

                Although much of the publicity around the Risperdal issue is negative and lacks the company’s perspective, the controversy highlights many problems in the regulation of drug marketing. This case demonstrated a company’s disregard for FDA mandates and lax application of safety regulations. Furthermore, there was minimal to no consequences for company executives. Going forward, I feel there has to be greater transparency and accountability in the pharmaceutical industry. In previous classes, I learned how companies can withhold data, and I feel that this complicates decision making by prescribers and patients. There have been efforts to curb the pharmaceutical industry’s marketing tactics, and I think further control is needed to ensure that the race for profits does not jeopardize patient care.

References:

https://www.justice.gov/opa/speech/attorney-general-eric-holder-delivers-remarks-johnson-johnson-press-conference

http://articles.philly.com/2015-02-26/news/59504751_1_robyn-reed-frenze-risperdal-breasts

http://www.nytimes.com/2013/11/05/business/johnson-johnson-to-settle-risperdal-improper-marketing-case.html?_r=0

http://www.nytimes.com/2015/09/17/opinion/nicholas-kristof-when-crime-pays-jjs-drug-risperdal.html

https://www.drugwatch.com/2015/11/10/johnson-and-johnson-loses-risperdal-verdict/

Medical Marijuana - The Debate Continues

On Monday, the discussion of Canada’s Schedule I substances was brought up and it got me thinking about how drugs are classified in the U.S. A Schedule I drug in the U.S. is any drug that has a high potential for abuse and has no accepted medical use. Marijuana is listed as a Schedule I drug, however it is legal medicinally in 23 states and in Washington D.C. This disparity has always confused me – it poses several problems for health care professionals, patients, and health care in general. How can the best form of health care be delivered if everyone from the state to federal level is not on the same team?

To get around the federal legal restrictions, physicians can only recommend medical cannabis, not prescribe it. Without doctors’ prescribing power, patients are typically left to decide what to take, which can be harmful if they are not educated on the safest forms of treatment. Some physicians feel uncomfortable recommending medical marijuana because they do not trust the unregulated and uncontrolled safety of the supply chain.

The states that have legalized medicinal marijuana all have different requirements pertaining to dosage forms offered and what qualifies a patient for treatment. They also have different requirements for how much cannabis or cannabis-containing product a person can own. For instance, Texas only legalizes medicinal cannabis oil for epilepsy (no other condition) if they have not responded to any other treatments. However, in California, there is a completely opposite law. Under the Compassionate Use Act (Proposition 215), patients are legally protected if they are diagnosed with an illness where use of marijuana is “deemed appropriate and has been recommended by a physician.”

Two states (Connecticut and Minnesota) have made it legal for pharmacists to dispense medical marijuana. Dispensing centers in these states are pharmacist-led and pharmacists work with patients to determine dosing regimens based on their condition. I got to wondering – how comfortable would you feel preparing a dosing regimen for a substance that has very minimal clinical data and is also classified as illegal by the federal government? Perhaps rescheduling medical marijuana to a Schedule II drug would allow for more clinical studies approved by the FDA. Uncertainties about risks, benefits, and quality control could be answered. But until then, it seems like a gray area will remain.

Vaccination: Undoing the Damage that has Been Done

In our discussion about global healthcare, we talked in depth about the incredible effect that widespread vaccination has had on getting rid of some diseases, and on lessening the burden of others. I was amazed to learn that, in a short 13 years, between 1967 and 1980, a campaign was able successfully eradicated smallpox. It really made me think about what kinds of things can be accomplished if countries work together and are willing to put money into a cause. But it also made me angry, because it made me think about how, despite the presence of these wonderful medical resources, people are still getting preventable illnesses due to fears about vaccination. The fact that cases of diseases like measles and whooping cough are reappearing is horrifying to me. Here we are, one of the most developed countries in the world, battling against diseases that we know exactly how to prevent. It made me feel embarrassed. However, I also wanted to try to understand why this was happening. Why were people so quick to believe the opinions of a few, rather than the overwhelming body of evidence?

               Before taking this class, I knew nothing about Andrew Wakefield, the British doctor who was responsible for falsely claiming that vaccines were unsafe and may cause autism. Up till this point, the extent of my knowledge was that controversy over vaccines and autism had come from Jenny McCarthy.  It makes sense to me that reading something like this, written by a doctor, could certainly shake the faith of British citizens, and, in turn, Americans too. Also, it was pointed out in the article from the Lancet that after Dr. Wakefield came out with this story, large amounts of upsetting anecdotal evidence from parents emerged. There were many parents, I’m sure, who had autistic children and now felt as though they could have an answer to their child’s condition. Doctors are widely known as people that can be trusted- for parents, they are the authorities on the health of their children. I can understand why hearing this could be very jarring. What I can’t comprehend is why this is still an issue. Evidence came out showing that the data in Dr. Wakefield’s paper was falsified. Huge amounts of evidence have come out since disproving his hypothesis. I understand that parents are worried about their children, but the risk of having a child who gets sick from a preventable illness is also scary, and much more real.

               The only conclusion that I can come to is that there is still a lack of understanding about the safety of vaccines, and a general suspicion for the health care industry, for various reasons.While I still don’t completely understand why the anti-vaccination movement has spread as far as it has, I am sure of one thing. As a future health care professional, I believe that it is my job to help educate Americans about vaccinations. Recent trends are very scary, and if they continue, diseases that have thought we would never need to worry about could come back. I understand that not all people have open minds, but if all pharmacists play a role in education, perhaps we can play a part in stopping this dangerous trend once and for all.

               

BEHIND THE VEIL OF THE PHARMACEUTICAL INDUSTRY

Learning more about how the industry functions has been even more eye opening to me. I was already one to advocate for pharma and already be interested in pursuing a career in the pharma world. There is a tight blockade still yet, between the public, which slightly includes myself, and what is really going on behind closed doors with incentives, propaganda, etc … versus the reality unknown to me.

There are more than two sides to the coin with this one. In other words, it’s not black or white. From my stand point and from what I know through colleagues who work in the industry, I can see why the costs can be so high in drug development and when it first hits the market. With all of the money it takes to just get a drug up and running for phases one through four, I can justify the price of prescriptions at first patent. However, at the same time, it is also hard for me to justify pricing for prescription drugs when a patient is not able to afford the ones that they need to improve their quality of life.

I remember when someone close to me had breast cancer, and at the time the anti-nausea medicine that she needed with her chemotherapy was only covered by insurance for a certain quantity. What insurance covered was the bare minimum, so anything past what was covered cost more than three hundred dollars per pill. Thanks to the community pharmacist at the time, who was very adamant and not backing down with the insurance company, managed to get her the amount that she really needed. Not everybody is granted this grace. This is such a compelling thing to witness first hand that the cost of prescriptions, for those who are in dire need, can seem inflated to the ceiling and completely unaffordable.

The hard part for me, for which I feel I may always struggle with, unless I work in the industry and see the flip side with my own eyes, is the question of: is the high cost of one pill justifiable? For now, that is still something that I will continue to sit with, continue to follow up as best I can and hopefully gain the opportunity to see things from the other side of the fence in hopes of some sense of closure to this issue.