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Factors tied to parents’ intent to vaccinate teens for HPV
in a large study, said Kahee A. Mohammed, MD, of Saint Louis (Missouri) University Center for Outcomes Research, and associates.
Messages to boost HPV vaccination rates may need to be targeted based on maternal education, non-Hispanic white ethnicity, and provider recommendations, the researchers said.
Among unvaccinated girls, independent variables predicting parents’ intent to vaccinate teens for HPV were Hispanic race/ethnicity (AOR, 1.57), compared with non-Hispanic whites; mothers with less than a high school diploma (AOR, 1.86), compared with mothers with a college education; and a provider recommendation for HPV vaccine (AOR, 1.38).
Also, mothers with some college education were more likely to intend to vaccinate their sons (AOR, 1.21), but less likely to intend to vaccinate their daughters (AOR, .69) than mothers with a college education.
About 7% of the survey respondents said “not sure/don’t know” regarding their intent to vaccinate their teens. The largest percentage had boys (66%), were non-Hispanic whites (47%), lived in the South (38%), lived above the poverty line (62%), the mother was a college graduate (31%), and had never received a recommendation for HPV vaccination from a health care provider (75%).
“Health care providers should actively engage in discussions with parents about HPV and strongly recommend the vaccine to all eligible patients concurrently with other routinely administered vaccinations to dispel any potential negative assumptions or opinions regarding HPV vaccination, especially among girls,” Dr. Mohammed and his associates said.
Read more at (Prev Chronic Dis. 2017. doi: 10.5888/pcd14.160314).
in a large study, said Kahee A. Mohammed, MD, of Saint Louis (Missouri) University Center for Outcomes Research, and associates.
Messages to boost HPV vaccination rates may need to be targeted based on maternal education, non-Hispanic white ethnicity, and provider recommendations, the researchers said.
Among unvaccinated girls, independent variables predicting parents’ intent to vaccinate teens for HPV were Hispanic race/ethnicity (AOR, 1.57), compared with non-Hispanic whites; mothers with less than a high school diploma (AOR, 1.86), compared with mothers with a college education; and a provider recommendation for HPV vaccine (AOR, 1.38).
Also, mothers with some college education were more likely to intend to vaccinate their sons (AOR, 1.21), but less likely to intend to vaccinate their daughters (AOR, .69) than mothers with a college education.
About 7% of the survey respondents said “not sure/don’t know” regarding their intent to vaccinate their teens. The largest percentage had boys (66%), were non-Hispanic whites (47%), lived in the South (38%), lived above the poverty line (62%), the mother was a college graduate (31%), and had never received a recommendation for HPV vaccination from a health care provider (75%).
“Health care providers should actively engage in discussions with parents about HPV and strongly recommend the vaccine to all eligible patients concurrently with other routinely administered vaccinations to dispel any potential negative assumptions or opinions regarding HPV vaccination, especially among girls,” Dr. Mohammed and his associates said.
Read more at (Prev Chronic Dis. 2017. doi: 10.5888/pcd14.160314).
in a large study, said Kahee A. Mohammed, MD, of Saint Louis (Missouri) University Center for Outcomes Research, and associates.
Messages to boost HPV vaccination rates may need to be targeted based on maternal education, non-Hispanic white ethnicity, and provider recommendations, the researchers said.
Among unvaccinated girls, independent variables predicting parents’ intent to vaccinate teens for HPV were Hispanic race/ethnicity (AOR, 1.57), compared with non-Hispanic whites; mothers with less than a high school diploma (AOR, 1.86), compared with mothers with a college education; and a provider recommendation for HPV vaccine (AOR, 1.38).
Also, mothers with some college education were more likely to intend to vaccinate their sons (AOR, 1.21), but less likely to intend to vaccinate their daughters (AOR, .69) than mothers with a college education.
About 7% of the survey respondents said “not sure/don’t know” regarding their intent to vaccinate their teens. The largest percentage had boys (66%), were non-Hispanic whites (47%), lived in the South (38%), lived above the poverty line (62%), the mother was a college graduate (31%), and had never received a recommendation for HPV vaccination from a health care provider (75%).
“Health care providers should actively engage in discussions with parents about HPV and strongly recommend the vaccine to all eligible patients concurrently with other routinely administered vaccinations to dispel any potential negative assumptions or opinions regarding HPV vaccination, especially among girls,” Dr. Mohammed and his associates said.
Read more at (Prev Chronic Dis. 2017. doi: 10.5888/pcd14.160314).
FROM PREVENTING CHRONIC DISEASE
FDA approves Sapien 3 transcatheter valve for bioprosthetic valve failure
The Food and Drug Administration announced June 5 the approval of an expanded indication for the Sapien 3 Transcatheter Heart Valve (THV) for patients with symptomatic heart disease caused by failure of a previously placed bioprosthetic aortic or mitral valve who have a risk of death or severe complications from repeat surgery.
This is the first FDA approval for the expanded use of the Sapien 3 THV as a valve-in-valve treatment. Such procedures provide an alternative to repeat surgery.
“For the first time, a regulatory agency is approving a transcatheter heart valve as a valve-in-valve treatment when bioprosthetic mitral or aortic valves fail in patients who are at high or greater risk of complications from repeat surgery,” Bram Zuckerman, MD, director of the division of cardiovascular devices at the FDA’s Center for Devices and Radiological Health, said in a press release. “This new approval offers U.S. patients with failing surgical bioprosthetic aortic or mitral valves a less-invasive treatment option.”
Originally, the FDA approved the Sapien 3 THV for transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve replacement for patients with native aortic stenosis whose risk for death or severe complications from surgery is high or greater. Then in 2016, the FDA expanded the TAVR indication for Sapien 3 THV to include patients who are at intermediate surgical risk for death or complications.
Read the full press release on the FDA’s website.
The Food and Drug Administration announced June 5 the approval of an expanded indication for the Sapien 3 Transcatheter Heart Valve (THV) for patients with symptomatic heart disease caused by failure of a previously placed bioprosthetic aortic or mitral valve who have a risk of death or severe complications from repeat surgery.
This is the first FDA approval for the expanded use of the Sapien 3 THV as a valve-in-valve treatment. Such procedures provide an alternative to repeat surgery.
“For the first time, a regulatory agency is approving a transcatheter heart valve as a valve-in-valve treatment when bioprosthetic mitral or aortic valves fail in patients who are at high or greater risk of complications from repeat surgery,” Bram Zuckerman, MD, director of the division of cardiovascular devices at the FDA’s Center for Devices and Radiological Health, said in a press release. “This new approval offers U.S. patients with failing surgical bioprosthetic aortic or mitral valves a less-invasive treatment option.”
Originally, the FDA approved the Sapien 3 THV for transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve replacement for patients with native aortic stenosis whose risk for death or severe complications from surgery is high or greater. Then in 2016, the FDA expanded the TAVR indication for Sapien 3 THV to include patients who are at intermediate surgical risk for death or complications.
Read the full press release on the FDA’s website.
The Food and Drug Administration announced June 5 the approval of an expanded indication for the Sapien 3 Transcatheter Heart Valve (THV) for patients with symptomatic heart disease caused by failure of a previously placed bioprosthetic aortic or mitral valve who have a risk of death or severe complications from repeat surgery.
This is the first FDA approval for the expanded use of the Sapien 3 THV as a valve-in-valve treatment. Such procedures provide an alternative to repeat surgery.
“For the first time, a regulatory agency is approving a transcatheter heart valve as a valve-in-valve treatment when bioprosthetic mitral or aortic valves fail in patients who are at high or greater risk of complications from repeat surgery,” Bram Zuckerman, MD, director of the division of cardiovascular devices at the FDA’s Center for Devices and Radiological Health, said in a press release. “This new approval offers U.S. patients with failing surgical bioprosthetic aortic or mitral valves a less-invasive treatment option.”
Originally, the FDA approved the Sapien 3 THV for transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve replacement for patients with native aortic stenosis whose risk for death or severe complications from surgery is high or greater. Then in 2016, the FDA expanded the TAVR indication for Sapien 3 THV to include patients who are at intermediate surgical risk for death or complications.
Read the full press release on the FDA’s website.
Impairment persists despite treatment in adult ADHD
SAN DIEGO – Despite treatment with short- or long-acting medications, adults with attention-deficit/hyperactivity disorder report more impairment than do non-ADHD adults across several domains of daily life, and at certain times of day.
The findings, from a study presented at the annual meeting of the American Psychiatric Association, suggest that adults with ADHD have burdens that may persist despite medication.
The studies compared a cohort of 616 adults with a self-reported ADHD diagnosis and at least 6 months on medication, including short-acting stimulants, long-acting agents, or a combination of these. The researchers also recruited a comparison cohort of 200 non-ADHD adults.
“Interestingly, there was not only a difference between ADHD and non-ADHD groups, but there was also significant impairment reported among patients who are currently being treated for ADHD,” Alexandra Khachatryan, MPH, of Shire Pharmaceuticals, the study’s senior author, said in an interview. Ms. Khachatryan and her colleagues presented the findings at the APA.
For example, 44% of the ADHD respondents reported that the afternoon was the most challenging time of day, compared with 29% of non-ADHD participants (P less than .001). Mid-morning also was significantly more challenging for the ADHD group, with 26% reporting difficulties, compared with 17% of the non-ADHD cohort (P less than .01).
Other statistically significant between-group differences were seen related to managing affect and emotions, sustaining effort, working memory and recall, and interpersonal relationships.
“In addition to the burden patients report across the day, they also expressed significant challenges with psychosocial functioning and managing the demands of work, social, and family life despite treatment,” said Norman Atkins, PhD, of Shire, a coauthor of the study.
A separate poster by the same research group, using the same study data from the cohort of 616 currently treated adult ADHD patients (mean age 39, 70% female) looked at self-reported impairment across daily life domains by patients under different medication regimens.
Patients in the cohort were treated with short-acting stimulants (n = 166), long-acting stimulants (n = 201), or augmentation strategies (n = 249). The researchers found that afternoons and evenings were most difficult for patients regardless of treatment approach.
Ms. Khachatryan said the study was intended to help clinicians “understand what we’re offering patients and if we’re adequately meeting the needs of patients across the day. And we found that adults experience burden across the day despite being treated, and what they report as the most challenging times of day are the afternoon and evening hours,” when work, family, and household obligations are likely to be present.
Dr. Atkins added: “From an ADHD management perspective, the key takeaway is that these impairments occur across multiple settings and are most problematic at certain times of the day. It’s important for providers to have a meaningful conversation with their patients about their day-to-day challenges to fully appreciate how ADHD impacts their functioning so they can best optimize care.”
The researchers acknowledged as limitations of their study its high number of women participants, potentially reducing the generalizability of its findings; the reliance on self-reported outcomes; and between-group differences for the ADHD and non-ADHD groups that included differences in mean age (39 vs. 43, respectively) and full-time employment status (57% vs. 42%).
The study was sponsored by Shire Pharmaceuticals, with three of its five coauthors employed by the company.
SAN DIEGO – Despite treatment with short- or long-acting medications, adults with attention-deficit/hyperactivity disorder report more impairment than do non-ADHD adults across several domains of daily life, and at certain times of day.
The findings, from a study presented at the annual meeting of the American Psychiatric Association, suggest that adults with ADHD have burdens that may persist despite medication.
The studies compared a cohort of 616 adults with a self-reported ADHD diagnosis and at least 6 months on medication, including short-acting stimulants, long-acting agents, or a combination of these. The researchers also recruited a comparison cohort of 200 non-ADHD adults.
“Interestingly, there was not only a difference between ADHD and non-ADHD groups, but there was also significant impairment reported among patients who are currently being treated for ADHD,” Alexandra Khachatryan, MPH, of Shire Pharmaceuticals, the study’s senior author, said in an interview. Ms. Khachatryan and her colleagues presented the findings at the APA.
For example, 44% of the ADHD respondents reported that the afternoon was the most challenging time of day, compared with 29% of non-ADHD participants (P less than .001). Mid-morning also was significantly more challenging for the ADHD group, with 26% reporting difficulties, compared with 17% of the non-ADHD cohort (P less than .01).
Other statistically significant between-group differences were seen related to managing affect and emotions, sustaining effort, working memory and recall, and interpersonal relationships.
“In addition to the burden patients report across the day, they also expressed significant challenges with psychosocial functioning and managing the demands of work, social, and family life despite treatment,” said Norman Atkins, PhD, of Shire, a coauthor of the study.
A separate poster by the same research group, using the same study data from the cohort of 616 currently treated adult ADHD patients (mean age 39, 70% female) looked at self-reported impairment across daily life domains by patients under different medication regimens.
Patients in the cohort were treated with short-acting stimulants (n = 166), long-acting stimulants (n = 201), or augmentation strategies (n = 249). The researchers found that afternoons and evenings were most difficult for patients regardless of treatment approach.
Ms. Khachatryan said the study was intended to help clinicians “understand what we’re offering patients and if we’re adequately meeting the needs of patients across the day. And we found that adults experience burden across the day despite being treated, and what they report as the most challenging times of day are the afternoon and evening hours,” when work, family, and household obligations are likely to be present.
Dr. Atkins added: “From an ADHD management perspective, the key takeaway is that these impairments occur across multiple settings and are most problematic at certain times of the day. It’s important for providers to have a meaningful conversation with their patients about their day-to-day challenges to fully appreciate how ADHD impacts their functioning so they can best optimize care.”
The researchers acknowledged as limitations of their study its high number of women participants, potentially reducing the generalizability of its findings; the reliance on self-reported outcomes; and between-group differences for the ADHD and non-ADHD groups that included differences in mean age (39 vs. 43, respectively) and full-time employment status (57% vs. 42%).
The study was sponsored by Shire Pharmaceuticals, with three of its five coauthors employed by the company.
SAN DIEGO – Despite treatment with short- or long-acting medications, adults with attention-deficit/hyperactivity disorder report more impairment than do non-ADHD adults across several domains of daily life, and at certain times of day.
The findings, from a study presented at the annual meeting of the American Psychiatric Association, suggest that adults with ADHD have burdens that may persist despite medication.
The studies compared a cohort of 616 adults with a self-reported ADHD diagnosis and at least 6 months on medication, including short-acting stimulants, long-acting agents, or a combination of these. The researchers also recruited a comparison cohort of 200 non-ADHD adults.
“Interestingly, there was not only a difference between ADHD and non-ADHD groups, but there was also significant impairment reported among patients who are currently being treated for ADHD,” Alexandra Khachatryan, MPH, of Shire Pharmaceuticals, the study’s senior author, said in an interview. Ms. Khachatryan and her colleagues presented the findings at the APA.
For example, 44% of the ADHD respondents reported that the afternoon was the most challenging time of day, compared with 29% of non-ADHD participants (P less than .001). Mid-morning also was significantly more challenging for the ADHD group, with 26% reporting difficulties, compared with 17% of the non-ADHD cohort (P less than .01).
Other statistically significant between-group differences were seen related to managing affect and emotions, sustaining effort, working memory and recall, and interpersonal relationships.
“In addition to the burden patients report across the day, they also expressed significant challenges with psychosocial functioning and managing the demands of work, social, and family life despite treatment,” said Norman Atkins, PhD, of Shire, a coauthor of the study.
A separate poster by the same research group, using the same study data from the cohort of 616 currently treated adult ADHD patients (mean age 39, 70% female) looked at self-reported impairment across daily life domains by patients under different medication regimens.
Patients in the cohort were treated with short-acting stimulants (n = 166), long-acting stimulants (n = 201), or augmentation strategies (n = 249). The researchers found that afternoons and evenings were most difficult for patients regardless of treatment approach.
Ms. Khachatryan said the study was intended to help clinicians “understand what we’re offering patients and if we’re adequately meeting the needs of patients across the day. And we found that adults experience burden across the day despite being treated, and what they report as the most challenging times of day are the afternoon and evening hours,” when work, family, and household obligations are likely to be present.
Dr. Atkins added: “From an ADHD management perspective, the key takeaway is that these impairments occur across multiple settings and are most problematic at certain times of the day. It’s important for providers to have a meaningful conversation with their patients about their day-to-day challenges to fully appreciate how ADHD impacts their functioning so they can best optimize care.”
The researchers acknowledged as limitations of their study its high number of women participants, potentially reducing the generalizability of its findings; the reliance on self-reported outcomes; and between-group differences for the ADHD and non-ADHD groups that included differences in mean age (39 vs. 43, respectively) and full-time employment status (57% vs. 42%).
The study was sponsored by Shire Pharmaceuticals, with three of its five coauthors employed by the company.
AT APA
Isotretinoin not associated with increased depression risk, in meta-analysis
A meta-analysis of 31 studies examining the relationship between isotretinoin treatment for acne and depression found no significant association. Rather, the treatment of acne was associated with improved symptoms of depression.
Researchers have been evaluating isotretinoin’s possible association with depression since 1983. Many studies have failed to find an association or have been inconclusive. One study found a statistically significant association between isotretinoin treatment and depression, but there are also depression risks associated with not treating a patient with severe acne.
Gathering the existing literature into a meta-analysis allowed the researchers to assess possible confounding factors in the individual studies, such as sex, length of treatment, and cumulative isotretinoin dose.
“In our meta-analysis, we pooled the results of 1,411 patients who received depression evaluations at baseline and after treatment, which revealed a significant improvement in the depression scores,” wrote Yu-Chen Huang, MD, of the department of dermatology, Taipei Medical University, Taiwan, and Ying-Chih Cheng, MD, of National Taiwan University. The 31 studies included 3 population-based studies, 8 controlled studies, and 20 prospective, open-label studies, and were published through September 2016.
Prevalence of depression also significantly dropped after treatment (relative risk, .588), they wrote, but they pointed out that “some studies described newly developed depression during treatment.” They referred to one controlled study in which “new onset of depression was noted in both the isotretinoin and antibiotic groups, implying that depression is associated with acne, independently of isotretinoin” (World J Psychiatr. 2016 Mar 22;6[1]:136-42). “Thus, physicians should consider the possibility of depression among all acne patients regardless of the treatment method,” they added.
They also concluded that some patients “might be more prone to depression regardless of acne or other conditions. Thus, closely monitoring acne patients for depression is essential to identify patients at a high risk.”
The full study can be found at: J Am Acad Dermatol. 2017 Jun;76[6]:1068-76.
A meta-analysis of 31 studies examining the relationship between isotretinoin treatment for acne and depression found no significant association. Rather, the treatment of acne was associated with improved symptoms of depression.
Researchers have been evaluating isotretinoin’s possible association with depression since 1983. Many studies have failed to find an association or have been inconclusive. One study found a statistically significant association between isotretinoin treatment and depression, but there are also depression risks associated with not treating a patient with severe acne.
Gathering the existing literature into a meta-analysis allowed the researchers to assess possible confounding factors in the individual studies, such as sex, length of treatment, and cumulative isotretinoin dose.
“In our meta-analysis, we pooled the results of 1,411 patients who received depression evaluations at baseline and after treatment, which revealed a significant improvement in the depression scores,” wrote Yu-Chen Huang, MD, of the department of dermatology, Taipei Medical University, Taiwan, and Ying-Chih Cheng, MD, of National Taiwan University. The 31 studies included 3 population-based studies, 8 controlled studies, and 20 prospective, open-label studies, and were published through September 2016.
Prevalence of depression also significantly dropped after treatment (relative risk, .588), they wrote, but they pointed out that “some studies described newly developed depression during treatment.” They referred to one controlled study in which “new onset of depression was noted in both the isotretinoin and antibiotic groups, implying that depression is associated with acne, independently of isotretinoin” (World J Psychiatr. 2016 Mar 22;6[1]:136-42). “Thus, physicians should consider the possibility of depression among all acne patients regardless of the treatment method,” they added.
They also concluded that some patients “might be more prone to depression regardless of acne or other conditions. Thus, closely monitoring acne patients for depression is essential to identify patients at a high risk.”
The full study can be found at: J Am Acad Dermatol. 2017 Jun;76[6]:1068-76.
A meta-analysis of 31 studies examining the relationship between isotretinoin treatment for acne and depression found no significant association. Rather, the treatment of acne was associated with improved symptoms of depression.
Researchers have been evaluating isotretinoin’s possible association with depression since 1983. Many studies have failed to find an association or have been inconclusive. One study found a statistically significant association between isotretinoin treatment and depression, but there are also depression risks associated with not treating a patient with severe acne.
Gathering the existing literature into a meta-analysis allowed the researchers to assess possible confounding factors in the individual studies, such as sex, length of treatment, and cumulative isotretinoin dose.
“In our meta-analysis, we pooled the results of 1,411 patients who received depression evaluations at baseline and after treatment, which revealed a significant improvement in the depression scores,” wrote Yu-Chen Huang, MD, of the department of dermatology, Taipei Medical University, Taiwan, and Ying-Chih Cheng, MD, of National Taiwan University. The 31 studies included 3 population-based studies, 8 controlled studies, and 20 prospective, open-label studies, and were published through September 2016.
Prevalence of depression also significantly dropped after treatment (relative risk, .588), they wrote, but they pointed out that “some studies described newly developed depression during treatment.” They referred to one controlled study in which “new onset of depression was noted in both the isotretinoin and antibiotic groups, implying that depression is associated with acne, independently of isotretinoin” (World J Psychiatr. 2016 Mar 22;6[1]:136-42). “Thus, physicians should consider the possibility of depression among all acne patients regardless of the treatment method,” they added.
They also concluded that some patients “might be more prone to depression regardless of acne or other conditions. Thus, closely monitoring acne patients for depression is essential to identify patients at a high risk.”
The full study can be found at: J Am Acad Dermatol. 2017 Jun;76[6]:1068-76.
FROM THE JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY
It matters how you phrase a child’s flu vaccine recommendation
Vaccine hesitant parents were more likely to change their minds about flu vaccine for their children when pediatricians or pediatric nurse practitioners used a presumptive recommendation that their children get the vaccine, pursued the recommendation if the parent was resistant, and combined their recommendation for the flu vaccine with other childhood vaccines, said Annika M. Hofstetter, MD, PhD, of the University of Washington, Seattle, and her associates.
The researchers recruited 17 pediatricians and pediatric nurse practitioners from eight primary care pediatric practices in the Seattle area to take part in 50 videotaped visits with parents during the 2011-2012 and 2013-2014 flu seasons.
(83% vs. 33%; P less than .01), Dr. Hofstetter and her colleagues said. The various communication patterns did not appear to negatively affect the way parents rated their visit experiences.
Read more at Vaccine. 2017;35:2709-15.
Vaccine hesitant parents were more likely to change their minds about flu vaccine for their children when pediatricians or pediatric nurse practitioners used a presumptive recommendation that their children get the vaccine, pursued the recommendation if the parent was resistant, and combined their recommendation for the flu vaccine with other childhood vaccines, said Annika M. Hofstetter, MD, PhD, of the University of Washington, Seattle, and her associates.
The researchers recruited 17 pediatricians and pediatric nurse practitioners from eight primary care pediatric practices in the Seattle area to take part in 50 videotaped visits with parents during the 2011-2012 and 2013-2014 flu seasons.
(83% vs. 33%; P less than .01), Dr. Hofstetter and her colleagues said. The various communication patterns did not appear to negatively affect the way parents rated their visit experiences.
Read more at Vaccine. 2017;35:2709-15.
Vaccine hesitant parents were more likely to change their minds about flu vaccine for their children when pediatricians or pediatric nurse practitioners used a presumptive recommendation that their children get the vaccine, pursued the recommendation if the parent was resistant, and combined their recommendation for the flu vaccine with other childhood vaccines, said Annika M. Hofstetter, MD, PhD, of the University of Washington, Seattle, and her associates.
The researchers recruited 17 pediatricians and pediatric nurse practitioners from eight primary care pediatric practices in the Seattle area to take part in 50 videotaped visits with parents during the 2011-2012 and 2013-2014 flu seasons.
(83% vs. 33%; P less than .01), Dr. Hofstetter and her colleagues said. The various communication patterns did not appear to negatively affect the way parents rated their visit experiences.
Read more at Vaccine. 2017;35:2709-15.
FROM VACCINE
Former Pharma reps’ new mission: To school docs on high drug costs
As a drug salesman, Mike Courtney worked hard to make health care expensive. He wined and dined doctors, golfed with them and bought lunch for their entire staffs – all to promote pills often costing thousands of dollars a year.
Now he’s on a different mission. When Mr. Courtney calls on doctors these days, he champions generic drugs that frequently cost pennies and work just as well as the kinds of pricey brands he used to push.
Instead of Big Pharma, he works for Capital District Physicians’ Health Plan (CDPHP), an Albany, N.Y., insurer. Instead of maximizing pill profits, his job is to save millions of dollars by educating doctors about expensive prescriptions and the stratagems used to sell them.
“Having come from Big Pharma, I do really feel my soul has been cleansed,” laughs Mr. Courtney, who formerly worked for Pfizer and Johnson & Johnson. “I do feel like I’m more in touch with the physicians” and plan members, he added.
Costs for prescription drugs have been rising faster than those for any other health segment, marked by high-profile cases such as the reported 400% increase for Mylan’s EpiPen and 5,000% spike for Turing Pharmaceuticals’ Daraprim.
Health plans and others paying those costs are fighting back. Many have tried to give doctors academic research on pill effectiveness or simply removed high-cost drugs from coverage lists.
Consumer groups and medical societies have tried to spread the word about expensive drugs. Startup GoodRx lets patients compare retail prices online.
CDPHP is one of the few insurers to have taken the battle against pricey pills a step further. It is recruiting across enemy lines, hiring former pharma representatives and staffing what may be a new job category: a sales force for cost-effective medicine.
“Insurers are taking matters into their own hands,” said Lea Prevel Katsanis, a marketing professor at Canada’s Concordia University who specializes in the pharmaceutical industry. “They’re saying, ‘We can’t really rely on drug companies to talk to doctors about what’s cost-efficient.’ ”
If insurance companies can curb drug costs, premiums paid by employers, taxpayers, and consumers need not rise as fast.
Two years ago, when one company increased the cost of a common diabetes medicine to 20 times what it had been a few years earlier, Mr. Courtney and five other former pharma and medical-device reps working for CDPHP knew what to do.
Valeant Pharmaceuticals had cranked up the price of one common dosage of its Glumetza medicine for lowering blood sugar to an astonishing $81,270 a year, according to Truven Health Analytics, a data firm. Meanwhile a similar, generic version can be bought for as little as a penny a pill.
Because Glumetza was on CDPHP’s list of approved drugs, the insurer and its members had to pay for it when doctors prescribed it, resulting in millions in extra costs and stinging copayments for patients.
Eric Schnakenberg, MD, an upstate New York family medicine doctor, was shocked when patients began complaining about what he assumed was an inexpensive prescription. Doctors are famously unaware about the cost of the care they order, a situation exploited by drug sellers and other vendors.
While physicians’ electronic prescribing programs and even pharmaceutical guides like the Physicians’ Desk Reference contain prescribing information – some are even peppered with ads – they contain no specific information about prices. Drug sales reps who visit their offices don’t highlight high prices as they drop off free samples, and drug makers can quietly, but substantially, hike the price of a drug from one year to the next.
“As physicians, we’re blindsided by that,” Dr. Schnakenberg said. “We get patient complaints saying, ‘Hey, I can’t afford this,’ and we say: ‘It’s cheap!’ ”
After Mr. Courtney and his colleagues alerted doctors to what Valeant was up to, all but a handful of the 60 plan members who were taking Glumetza switched to metformin, the generic alternative. That saved about $5 million in a year.
Following an outcry over its practices, Valeant agreed last year to raise annual prices by no more than single-digit percentages, the company said through a spokesman. But such hikes could still outpace the inflation rate.
Using ‘Those Powers For Good’
Cardiologist John Bennett got the idea to hire pharma reps a few years ago, after he became CDPHP’s chief executive. He knew reps are smart, genial, and motivated. Overhiring by pharma had put many back on the job market.
His sales pitch to them, he says half-jokingly, was: “You know everything they taught you in Big Pharma? How would you like to use those powers for good?”
Pharma companies spend billions on TV ads, doctor blandishments, and expensive salespeople to keep prescriptions flowing.
Pfizer, Johnson & Johnson, and other sellers responded to critics a few years ago by restricting gifts of entertainment, coffee mugs, and some meals. But the industry’s ethics code still allows lavish consulting contracts for doctors and sponsorship of physician conferences as well as meals for doctors and their staffs who listen to an “informational presentation” from sales reps touting expensive pills.
“When those products go generic, nobody’s promoting them anymore,” Mr. Courtney said. Generics makers lack big marketing budgets. CDPHP’s remedy: The insurer promotes generics with its own reps.
“It’s a great idea,” said Alan Sorensen, an economist at the University of Wisconsin who has studied drug prices. “Even a small moving of the needle on their [doctors’] prescribing behavior can have a pretty big impact on costs.”
At first the team concentrated on educating doctors about cheaper alternatives to Lipitor, a widely prescribed cholesterol-lowering medicine, and Nexium, for stomach problems. That saved around $10 million the first year, much in the form of copayments that would have been owed by plan members.
Recently the plan has focused on Seroquel, a branded antipsychotic that costs far more than a similar generic. Switching to the generic saves $600 to $1,000 a month, estimates Eileen Wood, the insurer’s vice president of pharmacy and health quality.
CDPHP’s repurposed reps have helped keep the insurer’s annual drug-cost increases to single-digit percentages, whereas without them and other measures “we would certainly be well into double-digit” increases, she said.
Educating doctors about drug costs is part of a larger push for “transparency” in an industry where Princeton economist Uwe Reinhardt says consumers face the same experience as somebody shopping in Macy’s blindfolded.
Current research by the University of Wisconsin’s Mr. Sorensen finds physicians with access to data about drug prices and insurance coverage are more likely to prescribe generics.
That gives Mr. Courtney and his colleagues a fighting chance, even if, he said, “we don’t have the freewheeling, unlimited green Amex card like I did back in the day.”
KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation. Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.
As a drug salesman, Mike Courtney worked hard to make health care expensive. He wined and dined doctors, golfed with them and bought lunch for their entire staffs – all to promote pills often costing thousands of dollars a year.
Now he’s on a different mission. When Mr. Courtney calls on doctors these days, he champions generic drugs that frequently cost pennies and work just as well as the kinds of pricey brands he used to push.
Instead of Big Pharma, he works for Capital District Physicians’ Health Plan (CDPHP), an Albany, N.Y., insurer. Instead of maximizing pill profits, his job is to save millions of dollars by educating doctors about expensive prescriptions and the stratagems used to sell them.
“Having come from Big Pharma, I do really feel my soul has been cleansed,” laughs Mr. Courtney, who formerly worked for Pfizer and Johnson & Johnson. “I do feel like I’m more in touch with the physicians” and plan members, he added.
Costs for prescription drugs have been rising faster than those for any other health segment, marked by high-profile cases such as the reported 400% increase for Mylan’s EpiPen and 5,000% spike for Turing Pharmaceuticals’ Daraprim.
Health plans and others paying those costs are fighting back. Many have tried to give doctors academic research on pill effectiveness or simply removed high-cost drugs from coverage lists.
Consumer groups and medical societies have tried to spread the word about expensive drugs. Startup GoodRx lets patients compare retail prices online.
CDPHP is one of the few insurers to have taken the battle against pricey pills a step further. It is recruiting across enemy lines, hiring former pharma representatives and staffing what may be a new job category: a sales force for cost-effective medicine.
“Insurers are taking matters into their own hands,” said Lea Prevel Katsanis, a marketing professor at Canada’s Concordia University who specializes in the pharmaceutical industry. “They’re saying, ‘We can’t really rely on drug companies to talk to doctors about what’s cost-efficient.’ ”
If insurance companies can curb drug costs, premiums paid by employers, taxpayers, and consumers need not rise as fast.
Two years ago, when one company increased the cost of a common diabetes medicine to 20 times what it had been a few years earlier, Mr. Courtney and five other former pharma and medical-device reps working for CDPHP knew what to do.
Valeant Pharmaceuticals had cranked up the price of one common dosage of its Glumetza medicine for lowering blood sugar to an astonishing $81,270 a year, according to Truven Health Analytics, a data firm. Meanwhile a similar, generic version can be bought for as little as a penny a pill.
Because Glumetza was on CDPHP’s list of approved drugs, the insurer and its members had to pay for it when doctors prescribed it, resulting in millions in extra costs and stinging copayments for patients.
Eric Schnakenberg, MD, an upstate New York family medicine doctor, was shocked when patients began complaining about what he assumed was an inexpensive prescription. Doctors are famously unaware about the cost of the care they order, a situation exploited by drug sellers and other vendors.
While physicians’ electronic prescribing programs and even pharmaceutical guides like the Physicians’ Desk Reference contain prescribing information – some are even peppered with ads – they contain no specific information about prices. Drug sales reps who visit their offices don’t highlight high prices as they drop off free samples, and drug makers can quietly, but substantially, hike the price of a drug from one year to the next.
“As physicians, we’re blindsided by that,” Dr. Schnakenberg said. “We get patient complaints saying, ‘Hey, I can’t afford this,’ and we say: ‘It’s cheap!’ ”
After Mr. Courtney and his colleagues alerted doctors to what Valeant was up to, all but a handful of the 60 plan members who were taking Glumetza switched to metformin, the generic alternative. That saved about $5 million in a year.
Following an outcry over its practices, Valeant agreed last year to raise annual prices by no more than single-digit percentages, the company said through a spokesman. But such hikes could still outpace the inflation rate.
Using ‘Those Powers For Good’
Cardiologist John Bennett got the idea to hire pharma reps a few years ago, after he became CDPHP’s chief executive. He knew reps are smart, genial, and motivated. Overhiring by pharma had put many back on the job market.
His sales pitch to them, he says half-jokingly, was: “You know everything they taught you in Big Pharma? How would you like to use those powers for good?”
Pharma companies spend billions on TV ads, doctor blandishments, and expensive salespeople to keep prescriptions flowing.
Pfizer, Johnson & Johnson, and other sellers responded to critics a few years ago by restricting gifts of entertainment, coffee mugs, and some meals. But the industry’s ethics code still allows lavish consulting contracts for doctors and sponsorship of physician conferences as well as meals for doctors and their staffs who listen to an “informational presentation” from sales reps touting expensive pills.
“When those products go generic, nobody’s promoting them anymore,” Mr. Courtney said. Generics makers lack big marketing budgets. CDPHP’s remedy: The insurer promotes generics with its own reps.
“It’s a great idea,” said Alan Sorensen, an economist at the University of Wisconsin who has studied drug prices. “Even a small moving of the needle on their [doctors’] prescribing behavior can have a pretty big impact on costs.”
At first the team concentrated on educating doctors about cheaper alternatives to Lipitor, a widely prescribed cholesterol-lowering medicine, and Nexium, for stomach problems. That saved around $10 million the first year, much in the form of copayments that would have been owed by plan members.
Recently the plan has focused on Seroquel, a branded antipsychotic that costs far more than a similar generic. Switching to the generic saves $600 to $1,000 a month, estimates Eileen Wood, the insurer’s vice president of pharmacy and health quality.
CDPHP’s repurposed reps have helped keep the insurer’s annual drug-cost increases to single-digit percentages, whereas without them and other measures “we would certainly be well into double-digit” increases, she said.
Educating doctors about drug costs is part of a larger push for “transparency” in an industry where Princeton economist Uwe Reinhardt says consumers face the same experience as somebody shopping in Macy’s blindfolded.
Current research by the University of Wisconsin’s Mr. Sorensen finds physicians with access to data about drug prices and insurance coverage are more likely to prescribe generics.
That gives Mr. Courtney and his colleagues a fighting chance, even if, he said, “we don’t have the freewheeling, unlimited green Amex card like I did back in the day.”
KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation. Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.
As a drug salesman, Mike Courtney worked hard to make health care expensive. He wined and dined doctors, golfed with them and bought lunch for their entire staffs – all to promote pills often costing thousands of dollars a year.
Now he’s on a different mission. When Mr. Courtney calls on doctors these days, he champions generic drugs that frequently cost pennies and work just as well as the kinds of pricey brands he used to push.
Instead of Big Pharma, he works for Capital District Physicians’ Health Plan (CDPHP), an Albany, N.Y., insurer. Instead of maximizing pill profits, his job is to save millions of dollars by educating doctors about expensive prescriptions and the stratagems used to sell them.
“Having come from Big Pharma, I do really feel my soul has been cleansed,” laughs Mr. Courtney, who formerly worked for Pfizer and Johnson & Johnson. “I do feel like I’m more in touch with the physicians” and plan members, he added.
Costs for prescription drugs have been rising faster than those for any other health segment, marked by high-profile cases such as the reported 400% increase for Mylan’s EpiPen and 5,000% spike for Turing Pharmaceuticals’ Daraprim.
Health plans and others paying those costs are fighting back. Many have tried to give doctors academic research on pill effectiveness or simply removed high-cost drugs from coverage lists.
Consumer groups and medical societies have tried to spread the word about expensive drugs. Startup GoodRx lets patients compare retail prices online.
CDPHP is one of the few insurers to have taken the battle against pricey pills a step further. It is recruiting across enemy lines, hiring former pharma representatives and staffing what may be a new job category: a sales force for cost-effective medicine.
“Insurers are taking matters into their own hands,” said Lea Prevel Katsanis, a marketing professor at Canada’s Concordia University who specializes in the pharmaceutical industry. “They’re saying, ‘We can’t really rely on drug companies to talk to doctors about what’s cost-efficient.’ ”
If insurance companies can curb drug costs, premiums paid by employers, taxpayers, and consumers need not rise as fast.
Two years ago, when one company increased the cost of a common diabetes medicine to 20 times what it had been a few years earlier, Mr. Courtney and five other former pharma and medical-device reps working for CDPHP knew what to do.
Valeant Pharmaceuticals had cranked up the price of one common dosage of its Glumetza medicine for lowering blood sugar to an astonishing $81,270 a year, according to Truven Health Analytics, a data firm. Meanwhile a similar, generic version can be bought for as little as a penny a pill.
Because Glumetza was on CDPHP’s list of approved drugs, the insurer and its members had to pay for it when doctors prescribed it, resulting in millions in extra costs and stinging copayments for patients.
Eric Schnakenberg, MD, an upstate New York family medicine doctor, was shocked when patients began complaining about what he assumed was an inexpensive prescription. Doctors are famously unaware about the cost of the care they order, a situation exploited by drug sellers and other vendors.
While physicians’ electronic prescribing programs and even pharmaceutical guides like the Physicians’ Desk Reference contain prescribing information – some are even peppered with ads – they contain no specific information about prices. Drug sales reps who visit their offices don’t highlight high prices as they drop off free samples, and drug makers can quietly, but substantially, hike the price of a drug from one year to the next.
“As physicians, we’re blindsided by that,” Dr. Schnakenberg said. “We get patient complaints saying, ‘Hey, I can’t afford this,’ and we say: ‘It’s cheap!’ ”
After Mr. Courtney and his colleagues alerted doctors to what Valeant was up to, all but a handful of the 60 plan members who were taking Glumetza switched to metformin, the generic alternative. That saved about $5 million in a year.
Following an outcry over its practices, Valeant agreed last year to raise annual prices by no more than single-digit percentages, the company said through a spokesman. But such hikes could still outpace the inflation rate.
Using ‘Those Powers For Good’
Cardiologist John Bennett got the idea to hire pharma reps a few years ago, after he became CDPHP’s chief executive. He knew reps are smart, genial, and motivated. Overhiring by pharma had put many back on the job market.
His sales pitch to them, he says half-jokingly, was: “You know everything they taught you in Big Pharma? How would you like to use those powers for good?”
Pharma companies spend billions on TV ads, doctor blandishments, and expensive salespeople to keep prescriptions flowing.
Pfizer, Johnson & Johnson, and other sellers responded to critics a few years ago by restricting gifts of entertainment, coffee mugs, and some meals. But the industry’s ethics code still allows lavish consulting contracts for doctors and sponsorship of physician conferences as well as meals for doctors and their staffs who listen to an “informational presentation” from sales reps touting expensive pills.
“When those products go generic, nobody’s promoting them anymore,” Mr. Courtney said. Generics makers lack big marketing budgets. CDPHP’s remedy: The insurer promotes generics with its own reps.
“It’s a great idea,” said Alan Sorensen, an economist at the University of Wisconsin who has studied drug prices. “Even a small moving of the needle on their [doctors’] prescribing behavior can have a pretty big impact on costs.”
At first the team concentrated on educating doctors about cheaper alternatives to Lipitor, a widely prescribed cholesterol-lowering medicine, and Nexium, for stomach problems. That saved around $10 million the first year, much in the form of copayments that would have been owed by plan members.
Recently the plan has focused on Seroquel, a branded antipsychotic that costs far more than a similar generic. Switching to the generic saves $600 to $1,000 a month, estimates Eileen Wood, the insurer’s vice president of pharmacy and health quality.
CDPHP’s repurposed reps have helped keep the insurer’s annual drug-cost increases to single-digit percentages, whereas without them and other measures “we would certainly be well into double-digit” increases, she said.
Educating doctors about drug costs is part of a larger push for “transparency” in an industry where Princeton economist Uwe Reinhardt says consumers face the same experience as somebody shopping in Macy’s blindfolded.
Current research by the University of Wisconsin’s Mr. Sorensen finds physicians with access to data about drug prices and insurance coverage are more likely to prescribe generics.
That gives Mr. Courtney and his colleagues a fighting chance, even if, he said, “we don’t have the freewheeling, unlimited green Amex card like I did back in the day.”
KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation. Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.
Medicare Advantage enrollment up again in 2017
Enrollment in Medicare Advantage plans increased for the 13th consecutive year in 2017 and now represents one-third of all Medicare beneficiaries, according to the Kaiser Family Foundation.
Currently, 19 million beneficiaries are enrolled in Medicare Advantage, more than triple the number who were enrolled when the program hit its low point of 5.3 million (13% of all beneficiaries) in 2003 and 2004 and 71% higher since the Affordable Care Act was passed in 2010, Kaiser said in a recent report.
As growth continues, however, so does concentration among the private firms administering the plans. In 2017, UnitedHealthcare and Humana together account for 41% of enrollment in Medicare Advantage, “and, in 17 states, one company has more than half of all Medicare Advantage enrollment – an indicator that these markets may not be very competitive,” they noted.
Enrollment in Medicare Advantage plans increased for the 13th consecutive year in 2017 and now represents one-third of all Medicare beneficiaries, according to the Kaiser Family Foundation.
Currently, 19 million beneficiaries are enrolled in Medicare Advantage, more than triple the number who were enrolled when the program hit its low point of 5.3 million (13% of all beneficiaries) in 2003 and 2004 and 71% higher since the Affordable Care Act was passed in 2010, Kaiser said in a recent report.
As growth continues, however, so does concentration among the private firms administering the plans. In 2017, UnitedHealthcare and Humana together account for 41% of enrollment in Medicare Advantage, “and, in 17 states, one company has more than half of all Medicare Advantage enrollment – an indicator that these markets may not be very competitive,” they noted.
Enrollment in Medicare Advantage plans increased for the 13th consecutive year in 2017 and now represents one-third of all Medicare beneficiaries, according to the Kaiser Family Foundation.
Currently, 19 million beneficiaries are enrolled in Medicare Advantage, more than triple the number who were enrolled when the program hit its low point of 5.3 million (13% of all beneficiaries) in 2003 and 2004 and 71% higher since the Affordable Care Act was passed in 2010, Kaiser said in a recent report.
As growth continues, however, so does concentration among the private firms administering the plans. In 2017, UnitedHealthcare and Humana together account for 41% of enrollment in Medicare Advantage, “and, in 17 states, one company has more than half of all Medicare Advantage enrollment – an indicator that these markets may not be very competitive,” they noted.
Low payment for pulmonary rehab explained
A new review of 2015 Medicare data clearly points fingers at hospitals for the historically low payment rates for pulmonary rehabilitation.
To fully understand these data, everyone involved in the delivery of pulmonary rehabilitation services needs to know some of the specifics regarding Medicare’s rate setting process for hospital outpatient services. Those services are paid on the basis of a prospective payment methodology, similar to the DRG system for inpatient services. Under the outpatient system, APCs (ambulatory payment classifications) are computed with two key data sources, both provided by hospitals.
The second key component used by CMS for rate setting is the hospital cost report, submitted annually to CMS tied to the individual hospital’s fiscal year. This flow of data to CMS is ongoing because of differing fiscal years and is somewhat attributable to changes in Medicare proposed rates for the following year, published in July, compared with final rates, published in early November.
The other key historical fact that needs emphasis is what happened in 2010 when CMS began reimbursing for pulmonary rehab under new HCPCS code G0424. Clearly, there were no charge data to examine, so the Agency had to do a bit of guesswork, estimating what would be a reasonable payment. CMS turned to payment information tied to codes G0237 and G0238, codes that had been used by many institutions for the previous decade for billing pulmonary rehab. But one critical difference existed. The new code, G0424, was a 1-hour code, while G0237-38 were 15-minute codes. Over the next 2 years, even CMS cited the failure of hospitals to adjust their charges to reflect all the component services included in this new, bundled 1-hour code, compared with the unbundled 15-minute code.
The new review of CMS data bears out this problem. With approximately 1,350 institutions billing for hospital outpatient pulmonary rehab via code G0424, there is incredibly wide variance in charge data. The range is from a high of $1,981 to a low of $44, with 1,350 institutions in-between. The average charge was $247, but the difference between the lowest charge and the highest charge is approximately 44-fold.
For cost report data, the spread is from $1,265 to $4 (yes, $4, based on data provided to CMS). Approximately 750 hospitals, more than half, submit data to CMS reflecting costs associated with the delivery of pulmonary rehab, per hour, at $50 or less.
There are probably several reasons why hospitals behave this way. First, there is the historical phenomenon cited by CMS that it often takes years for hospitals to adjust charges appropriately when any new HCPCS code is adopted by CMS. And, in fact, CMS cited pulmonary rehab as a glaring example of that failure by hospitals. Second, there is the cost report data, and we believe it, too, falls victim to hospital neglect. We can understand that a service such as pulmonary rehab falls so far below the radar by chargemasters, hospital administrators and others associated with information submitted to CMS that little attention is paid to accuracy of charges or administrative costs culled from the hospital cost report. And then, there is the matter of community relations. The hospitals at the very high end of the spectrum in terms of charges ($1,100 and up) are unlikely to build good community relations if they let people know of those charges. Ironically, it is fair to presume that hospitals do pay very close attention to their charges and cost report data for very high-end hospital outpatient services, micro-examining that information to ensure desirable payment rates.
So, the critical challenge to the pulmonary community is to focus on those two very specific bits of data submitted by hospitals to CMS: what a hospital identifies as the “charge” for code G0424 and is then entered on every claim submitted to G0424; and second, information correlated to the administrative aspects of pulmonary rehab that hospitals submit to CMS annually in their cost report to CMS. Until those adjustments are made, pulmonary rehab will live with unacceptable payment rates.
A new review of 2015 Medicare data clearly points fingers at hospitals for the historically low payment rates for pulmonary rehabilitation.
To fully understand these data, everyone involved in the delivery of pulmonary rehabilitation services needs to know some of the specifics regarding Medicare’s rate setting process for hospital outpatient services. Those services are paid on the basis of a prospective payment methodology, similar to the DRG system for inpatient services. Under the outpatient system, APCs (ambulatory payment classifications) are computed with two key data sources, both provided by hospitals.
The second key component used by CMS for rate setting is the hospital cost report, submitted annually to CMS tied to the individual hospital’s fiscal year. This flow of data to CMS is ongoing because of differing fiscal years and is somewhat attributable to changes in Medicare proposed rates for the following year, published in July, compared with final rates, published in early November.
The other key historical fact that needs emphasis is what happened in 2010 when CMS began reimbursing for pulmonary rehab under new HCPCS code G0424. Clearly, there were no charge data to examine, so the Agency had to do a bit of guesswork, estimating what would be a reasonable payment. CMS turned to payment information tied to codes G0237 and G0238, codes that had been used by many institutions for the previous decade for billing pulmonary rehab. But one critical difference existed. The new code, G0424, was a 1-hour code, while G0237-38 were 15-minute codes. Over the next 2 years, even CMS cited the failure of hospitals to adjust their charges to reflect all the component services included in this new, bundled 1-hour code, compared with the unbundled 15-minute code.
The new review of CMS data bears out this problem. With approximately 1,350 institutions billing for hospital outpatient pulmonary rehab via code G0424, there is incredibly wide variance in charge data. The range is from a high of $1,981 to a low of $44, with 1,350 institutions in-between. The average charge was $247, but the difference between the lowest charge and the highest charge is approximately 44-fold.
For cost report data, the spread is from $1,265 to $4 (yes, $4, based on data provided to CMS). Approximately 750 hospitals, more than half, submit data to CMS reflecting costs associated with the delivery of pulmonary rehab, per hour, at $50 or less.
There are probably several reasons why hospitals behave this way. First, there is the historical phenomenon cited by CMS that it often takes years for hospitals to adjust charges appropriately when any new HCPCS code is adopted by CMS. And, in fact, CMS cited pulmonary rehab as a glaring example of that failure by hospitals. Second, there is the cost report data, and we believe it, too, falls victim to hospital neglect. We can understand that a service such as pulmonary rehab falls so far below the radar by chargemasters, hospital administrators and others associated with information submitted to CMS that little attention is paid to accuracy of charges or administrative costs culled from the hospital cost report. And then, there is the matter of community relations. The hospitals at the very high end of the spectrum in terms of charges ($1,100 and up) are unlikely to build good community relations if they let people know of those charges. Ironically, it is fair to presume that hospitals do pay very close attention to their charges and cost report data for very high-end hospital outpatient services, micro-examining that information to ensure desirable payment rates.
So, the critical challenge to the pulmonary community is to focus on those two very specific bits of data submitted by hospitals to CMS: what a hospital identifies as the “charge” for code G0424 and is then entered on every claim submitted to G0424; and second, information correlated to the administrative aspects of pulmonary rehab that hospitals submit to CMS annually in their cost report to CMS. Until those adjustments are made, pulmonary rehab will live with unacceptable payment rates.
A new review of 2015 Medicare data clearly points fingers at hospitals for the historically low payment rates for pulmonary rehabilitation.
To fully understand these data, everyone involved in the delivery of pulmonary rehabilitation services needs to know some of the specifics regarding Medicare’s rate setting process for hospital outpatient services. Those services are paid on the basis of a prospective payment methodology, similar to the DRG system for inpatient services. Under the outpatient system, APCs (ambulatory payment classifications) are computed with two key data sources, both provided by hospitals.
The second key component used by CMS for rate setting is the hospital cost report, submitted annually to CMS tied to the individual hospital’s fiscal year. This flow of data to CMS is ongoing because of differing fiscal years and is somewhat attributable to changes in Medicare proposed rates for the following year, published in July, compared with final rates, published in early November.
The other key historical fact that needs emphasis is what happened in 2010 when CMS began reimbursing for pulmonary rehab under new HCPCS code G0424. Clearly, there were no charge data to examine, so the Agency had to do a bit of guesswork, estimating what would be a reasonable payment. CMS turned to payment information tied to codes G0237 and G0238, codes that had been used by many institutions for the previous decade for billing pulmonary rehab. But one critical difference existed. The new code, G0424, was a 1-hour code, while G0237-38 were 15-minute codes. Over the next 2 years, even CMS cited the failure of hospitals to adjust their charges to reflect all the component services included in this new, bundled 1-hour code, compared with the unbundled 15-minute code.
The new review of CMS data bears out this problem. With approximately 1,350 institutions billing for hospital outpatient pulmonary rehab via code G0424, there is incredibly wide variance in charge data. The range is from a high of $1,981 to a low of $44, with 1,350 institutions in-between. The average charge was $247, but the difference between the lowest charge and the highest charge is approximately 44-fold.
For cost report data, the spread is from $1,265 to $4 (yes, $4, based on data provided to CMS). Approximately 750 hospitals, more than half, submit data to CMS reflecting costs associated with the delivery of pulmonary rehab, per hour, at $50 or less.
There are probably several reasons why hospitals behave this way. First, there is the historical phenomenon cited by CMS that it often takes years for hospitals to adjust charges appropriately when any new HCPCS code is adopted by CMS. And, in fact, CMS cited pulmonary rehab as a glaring example of that failure by hospitals. Second, there is the cost report data, and we believe it, too, falls victim to hospital neglect. We can understand that a service such as pulmonary rehab falls so far below the radar by chargemasters, hospital administrators and others associated with information submitted to CMS that little attention is paid to accuracy of charges or administrative costs culled from the hospital cost report. And then, there is the matter of community relations. The hospitals at the very high end of the spectrum in terms of charges ($1,100 and up) are unlikely to build good community relations if they let people know of those charges. Ironically, it is fair to presume that hospitals do pay very close attention to their charges and cost report data for very high-end hospital outpatient services, micro-examining that information to ensure desirable payment rates.
So, the critical challenge to the pulmonary community is to focus on those two very specific bits of data submitted by hospitals to CMS: what a hospital identifies as the “charge” for code G0424 and is then entered on every claim submitted to G0424; and second, information correlated to the administrative aspects of pulmonary rehab that hospitals submit to CMS annually in their cost report to CMS. Until those adjustments are made, pulmonary rehab will live with unacceptable payment rates.
From the EVP/ CEO
It is an incredible honor to be recently confirmed as the EVP/CEO for the CHEST organization. As a 23-year veteran of CHEST, I have had the privilege of working with and for many of our leaders, volunteers, and members. Being only the fifth person to lead the organization in an executive leadership role is both humbling and invigorating. CHEST is a dynamic and innovative organization, with a mission to “champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research.” That mission resonates deeply with me on a personal level, because my mother had COPD. Toward the end of her life, I saw firsthand how it impacted her quality of life and her ability to be a mother and grandmother, and I also saw the important role her pulmonologist and re
I am both fortunate and grateful to have such a phenomenal professional staff to work with here at CHEST and to have the outstanding leadership of our Presidents, Past Presidents, Boards, Committees, and NetWorks – all of which have been tremendously supportive during the past 9 months as I filled the Interim EVP role. I am also deeply grateful to those of you who choose to be members and Fellows of CHEST and to be engaged as volunteer leadership, faculty, content experts, authors, and more. It is your time, energy, involvement, and vision that make this organization what it is. The fact that you choose to give some of your valuable time toward helping CHEST achieve its mission and vision is so greatly appreciated by all of us in this organization. Thank you for all that you do for CHEST.
In recent years, the College has continued to realize the following significant achievements:
1. Growth of our educational programs in simulation, skills training, and procedures;
2. The building and of our new global HQ and Innovation, Simulation, and Training Center;
3. An increasingly global footprint as we deliver education to our physician and advance practice provider members and nonmembers in the US and around the world;
4. Increasing development of digital publications and essential content, such as our journal; CHEST®, CHEST-SEEK ™ products, e-learning modules, evidence-based guidelines, and more that can be served up to anyone on any device;
5. Growth and maturation of our CHEST Foundation and its research and service awards;
6. Expansion of patient education initiatives and materials;
7. Development of a data warehouse that will allow us to serve our members and partners more effectively; and
8. Far too many more achievements to list here.
Since taking on the EVP/CEO role, I’ve been asked what do I consider my primary responsibilities to be. I think this is best summed up by Rick Moyers, in The Nonprofit Chief Executive’s Ten Basic Responsibilities (BoardSource, 2006). In it, he outlines the executive’s responsibilities as follows:
1. Commit to the mission.
2. Lead the staff and manage the organization.
3. Exercise responsible financial stewardship.
4. Lead and manage fundraising.
5. Follow the highest ethical standards, ensure accountability, and comply with the law.
6. Engage the board in planning and lead the implementation.
7. Develop future leadership.
8. Build external relationships and serve as an advocate.
9. Ensure the quality and effectiveness of programs.
10. Support the board.
These 10 basic responsibilities provide the framework and foundation for how I plan to serve as EVP/CEO of CHEST. In many cases, I’ve been doing much of this as a senior executive at CHEST for the past 23 years, and I look forward to continuing to build on that foundation.
I am also often asked what my vision for the organization is, as its new EVP/CEO. And my answer is simple: to ensure that the American College of Chest Physicians stays relevant in this environment of change and disruption, that it continues to fulfill its mission, and that members, leadership, volunteers, and staff work together, make a positive impact on patient care, and, ultimately, have fun doing the good work of CHEST. This organization has an outstanding reputation, legacy, and brand. I will do everything I can to maintain and improve upon those key attributes.
It is my ultimate responsibility to ensure that we operationalize the educational programs and activities that align with the strategic plan and achieve the organizational goals of CHEST, which have been set by your Boards and Committees. I look forward to proudly and humbly serving as the CHEST evangelist and advocate to our members, patients, partners, and sister societies. I look forward to hearing from you, our members, about how CHEST is doing, and how we can continue to meet – and exceed – your educational and professional needs.
It is an incredible honor to be recently confirmed as the EVP/CEO for the CHEST organization. As a 23-year veteran of CHEST, I have had the privilege of working with and for many of our leaders, volunteers, and members. Being only the fifth person to lead the organization in an executive leadership role is both humbling and invigorating. CHEST is a dynamic and innovative organization, with a mission to “champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research.” That mission resonates deeply with me on a personal level, because my mother had COPD. Toward the end of her life, I saw firsthand how it impacted her quality of life and her ability to be a mother and grandmother, and I also saw the important role her pulmonologist and re
I am both fortunate and grateful to have such a phenomenal professional staff to work with here at CHEST and to have the outstanding leadership of our Presidents, Past Presidents, Boards, Committees, and NetWorks – all of which have been tremendously supportive during the past 9 months as I filled the Interim EVP role. I am also deeply grateful to those of you who choose to be members and Fellows of CHEST and to be engaged as volunteer leadership, faculty, content experts, authors, and more. It is your time, energy, involvement, and vision that make this organization what it is. The fact that you choose to give some of your valuable time toward helping CHEST achieve its mission and vision is so greatly appreciated by all of us in this organization. Thank you for all that you do for CHEST.
In recent years, the College has continued to realize the following significant achievements:
1. Growth of our educational programs in simulation, skills training, and procedures;
2. The building and of our new global HQ and Innovation, Simulation, and Training Center;
3. An increasingly global footprint as we deliver education to our physician and advance practice provider members and nonmembers in the US and around the world;
4. Increasing development of digital publications and essential content, such as our journal; CHEST®, CHEST-SEEK ™ products, e-learning modules, evidence-based guidelines, and more that can be served up to anyone on any device;
5. Growth and maturation of our CHEST Foundation and its research and service awards;
6. Expansion of patient education initiatives and materials;
7. Development of a data warehouse that will allow us to serve our members and partners more effectively; and
8. Far too many more achievements to list here.
Since taking on the EVP/CEO role, I’ve been asked what do I consider my primary responsibilities to be. I think this is best summed up by Rick Moyers, in The Nonprofit Chief Executive’s Ten Basic Responsibilities (BoardSource, 2006). In it, he outlines the executive’s responsibilities as follows:
1. Commit to the mission.
2. Lead the staff and manage the organization.
3. Exercise responsible financial stewardship.
4. Lead and manage fundraising.
5. Follow the highest ethical standards, ensure accountability, and comply with the law.
6. Engage the board in planning and lead the implementation.
7. Develop future leadership.
8. Build external relationships and serve as an advocate.
9. Ensure the quality and effectiveness of programs.
10. Support the board.
These 10 basic responsibilities provide the framework and foundation for how I plan to serve as EVP/CEO of CHEST. In many cases, I’ve been doing much of this as a senior executive at CHEST for the past 23 years, and I look forward to continuing to build on that foundation.
I am also often asked what my vision for the organization is, as its new EVP/CEO. And my answer is simple: to ensure that the American College of Chest Physicians stays relevant in this environment of change and disruption, that it continues to fulfill its mission, and that members, leadership, volunteers, and staff work together, make a positive impact on patient care, and, ultimately, have fun doing the good work of CHEST. This organization has an outstanding reputation, legacy, and brand. I will do everything I can to maintain and improve upon those key attributes.
It is my ultimate responsibility to ensure that we operationalize the educational programs and activities that align with the strategic plan and achieve the organizational goals of CHEST, which have been set by your Boards and Committees. I look forward to proudly and humbly serving as the CHEST evangelist and advocate to our members, patients, partners, and sister societies. I look forward to hearing from you, our members, about how CHEST is doing, and how we can continue to meet – and exceed – your educational and professional needs.
It is an incredible honor to be recently confirmed as the EVP/CEO for the CHEST organization. As a 23-year veteran of CHEST, I have had the privilege of working with and for many of our leaders, volunteers, and members. Being only the fifth person to lead the organization in an executive leadership role is both humbling and invigorating. CHEST is a dynamic and innovative organization, with a mission to “champion the prevention, diagnosis, and treatment of chest diseases through education, communication, and research.” That mission resonates deeply with me on a personal level, because my mother had COPD. Toward the end of her life, I saw firsthand how it impacted her quality of life and her ability to be a mother and grandmother, and I also saw the important role her pulmonologist and re
I am both fortunate and grateful to have such a phenomenal professional staff to work with here at CHEST and to have the outstanding leadership of our Presidents, Past Presidents, Boards, Committees, and NetWorks – all of which have been tremendously supportive during the past 9 months as I filled the Interim EVP role. I am also deeply grateful to those of you who choose to be members and Fellows of CHEST and to be engaged as volunteer leadership, faculty, content experts, authors, and more. It is your time, energy, involvement, and vision that make this organization what it is. The fact that you choose to give some of your valuable time toward helping CHEST achieve its mission and vision is so greatly appreciated by all of us in this organization. Thank you for all that you do for CHEST.
In recent years, the College has continued to realize the following significant achievements:
1. Growth of our educational programs in simulation, skills training, and procedures;
2. The building and of our new global HQ and Innovation, Simulation, and Training Center;
3. An increasingly global footprint as we deliver education to our physician and advance practice provider members and nonmembers in the US and around the world;
4. Increasing development of digital publications and essential content, such as our journal; CHEST®, CHEST-SEEK ™ products, e-learning modules, evidence-based guidelines, and more that can be served up to anyone on any device;
5. Growth and maturation of our CHEST Foundation and its research and service awards;
6. Expansion of patient education initiatives and materials;
7. Development of a data warehouse that will allow us to serve our members and partners more effectively; and
8. Far too many more achievements to list here.
Since taking on the EVP/CEO role, I’ve been asked what do I consider my primary responsibilities to be. I think this is best summed up by Rick Moyers, in The Nonprofit Chief Executive’s Ten Basic Responsibilities (BoardSource, 2006). In it, he outlines the executive’s responsibilities as follows:
1. Commit to the mission.
2. Lead the staff and manage the organization.
3. Exercise responsible financial stewardship.
4. Lead and manage fundraising.
5. Follow the highest ethical standards, ensure accountability, and comply with the law.
6. Engage the board in planning and lead the implementation.
7. Develop future leadership.
8. Build external relationships and serve as an advocate.
9. Ensure the quality and effectiveness of programs.
10. Support the board.
These 10 basic responsibilities provide the framework and foundation for how I plan to serve as EVP/CEO of CHEST. In many cases, I’ve been doing much of this as a senior executive at CHEST for the past 23 years, and I look forward to continuing to build on that foundation.
I am also often asked what my vision for the organization is, as its new EVP/CEO. And my answer is simple: to ensure that the American College of Chest Physicians stays relevant in this environment of change and disruption, that it continues to fulfill its mission, and that members, leadership, volunteers, and staff work together, make a positive impact on patient care, and, ultimately, have fun doing the good work of CHEST. This organization has an outstanding reputation, legacy, and brand. I will do everything I can to maintain and improve upon those key attributes.
It is my ultimate responsibility to ensure that we operationalize the educational programs and activities that align with the strategic plan and achieve the organizational goals of CHEST, which have been set by your Boards and Committees. I look forward to proudly and humbly serving as the CHEST evangelist and advocate to our members, patients, partners, and sister societies. I look forward to hearing from you, our members, about how CHEST is doing, and how we can continue to meet – and exceed – your educational and professional needs.
Pulmonary Perspectives® China’s Pulmonary Crisis
Over the past 2 years, we had the opportunity to participate in an annual cross-cultural exchange that has broadened our horizons. Xi’an, the ancient capital of China and home of the Terracotta warriors, is a sprawling megapolis similar to Los Angeles. In the southern suburb of Huxian, US trained pulmonary, neurosurgical, and critical care physicians from Cooper University Hospital and Morehouse School of Medicine partnered with physicians of Ji-Ren Teaching Hospital to deliver a Chinese Medical Association accredited continuing medical education conference. The conference agenda included a variety of pulmonary and critical care topics highlighting sepsis, neurovascular disease, and lung cancer screening and diagnosis. We also provided a hands-on workshop for point of care ultrasound, and, in return, received education about Chinese medicine.
We found our hosts appreciative and hospitable, and they treated us with the highest level of respect (the cornerstone of Chinese culture). The audience was receptive and very interested in learning. However, while we were impressed with their rapid growth and interest in incorporating western medicine into their daily practice, it was impossible to overlook the major pulmonary health-care concerns threatening their communities. Tobacco use was omnipresent, and the haze of air pollution made the sky a constant shade of grey. In both public and private spaces, powerful echoes of a once familiar America resonated, and they served to underscore the obstacles the Chinese medical community now faces in caring for their country’s pulmonary health.
An Old, Familiar Foe
The China National Tobacco Corporation (CNTC) is the largest tobacco company in the world, as well as China’s most profitable state-owned enterprise (Pratt, A, et al. WHO Report. 2017. ISBN 9789290617907 [http://www.wpro.who.int/china/publications/2017_china_tobacco_control_report_en_web_final.pdf?ua=1]). As such, the CNTC controls every aspect of its production and supply chain with the force of the federal government and also exerts heavy influence over regulatory policy. It controls about 98% of domestic crop production and manages to price cigarettes just short of one American dollar per pack, yet contributes about $170 billion annually to the government (Rich, et al. Nicotine Tob Res. 2012;14[3]:258). This accounted for nearly 7% of total governmental revenue in 2015 (Pratt, 2017).
To date, nearly 44% of the world’s cigarettes are manufactured and consumed in China (Pratt 2017, Rich 2012). In 2015, more than 315 million Chinese adults were daily smokers, or about 28% of the adult population and nearly half of all men (Pratt, 2017). This is about double the proportion of US smokers (about 15.1%) and more than eight times the 36.5 million daily smokers in the United States (CDC Online Tobacco Use Report, 2016 [https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/]). However, to visit China is not only to know a love for tobacco, but also an overwhelming guest and gift culture. Gift giving and hospitality is central to the Chinese identity, from business meetings to afternoon tea. Given their economy and such rich supply, people gift cigarettes to one another at all times for nearly any occasion. Unfortunately, tobacco smoke in China is as inescapable as its health consequences.
The direct effects of smoking on China’s pulmonary health have been catastrophic. Cancers of the lung and bronchus constitute their most common malignancy across both sexes, accounting for the majority of the annual 4.3 million new cancer diagnoses (Chen et al. CA Cancer J Clin. 2016;66[2]:115). In Chinese men, lung cancer is the second most common cancer before the age of 60, and over the age of 75, it is the most common malignancy and also accounts for the majority of that group’s cancer mortality. Women fare only slightly better, with breast cancer being their most common malignancy, but with lung cancer remaining the most pervasive across all age groups, and, by far, the most deadly (Chen, 2016). All told, of the projected 2.8 million cancer deaths occurring in 2015 in China, 21% were directly a result of lung cancer.
Likewise, COPD also threatens China. The Global Burden of Disease study conducted in 2004 demonstrated that nearly 3 million people die of COPD each year. Chinese adults over the age of 40 had an overall prevalence of COPD of 9% for the last decade, though this may be higher given the high rate of underdiagnosis in rural China (Fang X, et al. Chest. 2011;139[4]:920). After 2004, the Chinese Ministry of Health affirmed that COPD was the fourth leading cause of mortality in urban areas, but third in rural ones (Fang, 2011). When investigators analyzed deaths secondary to cor pulmonale coexisting with COPD, they found COPD-related mortality increased to 179.9 for men and 141.3 for women per 100,000 persons, which is about double the COPD mortality for other countries in the Asian-Pacific region (Reilly K, et al. Am J Epidemiol. 2008;167[8]:998). 
Both cancer and COPD in China disproportionately affect those in rural areas and with lower socioeconomic status, with smoking being the most potent causative exposure. On average, the annual direct and indirect per-patient cost of treating COPD amounted to about $2,000, comprising about 40% of a family’s total annual income (Fang, 2011). The cost of treating malignancy is even more expensive, but the higher likelihood of death results in an additional 10% to 20% reduction of family income when a working family member dies (Pratt, 2016). Taken together, and especially since rural Chinese citizens spend close to 20% of their income on tobacco products, the pulmonary health consequences of smoking are a significant driver of both health and economic inequality.
The Air We Breathe
Air pollution comprises a second pulmonary insult to China’s health. The International Agency for Research on Cancer designated particulate matter (PM) as a class I carcinogen (Kurt O, et al. Curr Opin Pulm Med. 2016;22[2]:138). PM forms from combustion of bio-mass fuel, as well as from dust storms or construction. Once particulates are smaller than 2.5 microns (PM2.5), they cause substantial harm to the pulmonary microenvironment. Guo and colleagues demonstrated markedly increased lung cancer risks associated with spatial mapping of ozone and PM2.5 concentrations (Guo Y, et al. Environ Res. 2016;144;60). PM2.5 also doubles the odds of contracting COPD in nonsmoking adults, conferring as much as a three-fold risk of contracting the disease in nonsmoking women (Fang, 2011).
Apart from causing pulmonary disease, studies also implicate air pollution as frequently causing exacerbations of existing disease. One study found an incremental increase in ED visits for respiratory illnesses for every 10 µg/m3 above the median PM2.5 level (Xu, et al. PLoS One. 2016;11(4): e0153099). In 2013, 83% of Chinese lived in places where PM2.5 levels exceeded China’s own ambient air standard. In this cohort, elevated PM2.5 levels contributed directly to 300,000 premature deaths from lung cancer and COPD, with PM2.5 causing 1.2 million premature deaths overall (Liu J, et al. Sci Total Environ. 2016;568;1253).
Moving Forward
The Chinese have few illusions about these pulmonary concerns, and they are making progress. The government recently introduced stricter smoking controls in Beijing and Shanghai and continues to explore ways to decrease emissions. President Xi has put forward strong initiatives to improve the health of the Chinese. However, the nation is trying to balance its national priorities in the context of a fluid, and, at times, perilous geopolitical climate. In some ways, their position is not too dissimilar from the US geopolitical and health-care situation of the 1970s. While challenging, the issue of Chinese health care should not overshadow the remarkable resources or the truly remarkable culture of their people. Friendship, cooperation, the reduction of suffering: these are ideals where all clinicians find common ground, regardless of nationality.
Dr. Mackay is Chief Fellow of Critical Care Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey; Dr. Flenaugh is Associate Professor of Medicine, Division Chief of Pulmonary and Critical Care Medicine, Director of Advance Diagnostic and Interventional Pulmonary, Morehouse School of Medicine, Atlanta, Georgia.
Editor’s Note
This excellent, up-close Pulmonary Perspective details observations of Drs. Mackay and Flenaugh as they have participated in cross-cultural exchanges in 
The American College of Chest Physicians, likewise concerned about pulmonary health in China, has approached the problem on a different front, working closely with partners, such as the Chinese Thoracic Society, the Chinese Association of Chest Physicians, and the Chinese Medical Doctor Association, to implement China’s first ever fellowship program offering standardized training in PCCM for Chinese physicians. Read more at http://www.mdedge.com/chestphysician/article/131179/society-news/pccm-endorsed-pilot-subspecialty-chinese-national-health.
Nitin Puri, MD, FCCP, is the section editor of Pulmonary Perspectives.
Over the past 2 years, we had the opportunity to participate in an annual cross-cultural exchange that has broadened our horizons. Xi’an, the ancient capital of China and home of the Terracotta warriors, is a sprawling megapolis similar to Los Angeles. In the southern suburb of Huxian, US trained pulmonary, neurosurgical, and critical care physicians from Cooper University Hospital and Morehouse School of Medicine partnered with physicians of Ji-Ren Teaching Hospital to deliver a Chinese Medical Association accredited continuing medical education conference. The conference agenda included a variety of pulmonary and critical care topics highlighting sepsis, neurovascular disease, and lung cancer screening and diagnosis. We also provided a hands-on workshop for point of care ultrasound, and, in return, received education about Chinese medicine.
We found our hosts appreciative and hospitable, and they treated us with the highest level of respect (the cornerstone of Chinese culture). The audience was receptive and very interested in learning. However, while we were impressed with their rapid growth and interest in incorporating western medicine into their daily practice, it was impossible to overlook the major pulmonary health-care concerns threatening their communities. Tobacco use was omnipresent, and the haze of air pollution made the sky a constant shade of grey. In both public and private spaces, powerful echoes of a once familiar America resonated, and they served to underscore the obstacles the Chinese medical community now faces in caring for their country’s pulmonary health.
An Old, Familiar Foe
The China National Tobacco Corporation (CNTC) is the largest tobacco company in the world, as well as China’s most profitable state-owned enterprise (Pratt, A, et al. WHO Report. 2017. ISBN 9789290617907 [http://www.wpro.who.int/china/publications/2017_china_tobacco_control_report_en_web_final.pdf?ua=1]). As such, the CNTC controls every aspect of its production and supply chain with the force of the federal government and also exerts heavy influence over regulatory policy. It controls about 98% of domestic crop production and manages to price cigarettes just short of one American dollar per pack, yet contributes about $170 billion annually to the government (Rich, et al. Nicotine Tob Res. 2012;14[3]:258). This accounted for nearly 7% of total governmental revenue in 2015 (Pratt, 2017).
To date, nearly 44% of the world’s cigarettes are manufactured and consumed in China (Pratt 2017, Rich 2012). In 2015, more than 315 million Chinese adults were daily smokers, or about 28% of the adult population and nearly half of all men (Pratt, 2017). This is about double the proportion of US smokers (about 15.1%) and more than eight times the 36.5 million daily smokers in the United States (CDC Online Tobacco Use Report, 2016 [https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/]). However, to visit China is not only to know a love for tobacco, but also an overwhelming guest and gift culture. Gift giving and hospitality is central to the Chinese identity, from business meetings to afternoon tea. Given their economy and such rich supply, people gift cigarettes to one another at all times for nearly any occasion. Unfortunately, tobacco smoke in China is as inescapable as its health consequences.
The direct effects of smoking on China’s pulmonary health have been catastrophic. Cancers of the lung and bronchus constitute their most common malignancy across both sexes, accounting for the majority of the annual 4.3 million new cancer diagnoses (Chen et al. CA Cancer J Clin. 2016;66[2]:115). In Chinese men, lung cancer is the second most common cancer before the age of 60, and over the age of 75, it is the most common malignancy and also accounts for the majority of that group’s cancer mortality. Women fare only slightly better, with breast cancer being their most common malignancy, but with lung cancer remaining the most pervasive across all age groups, and, by far, the most deadly (Chen, 2016). All told, of the projected 2.8 million cancer deaths occurring in 2015 in China, 21% were directly a result of lung cancer.
Likewise, COPD also threatens China. The Global Burden of Disease study conducted in 2004 demonstrated that nearly 3 million people die of COPD each year. Chinese adults over the age of 40 had an overall prevalence of COPD of 9% for the last decade, though this may be higher given the high rate of underdiagnosis in rural China (Fang X, et al. Chest. 2011;139[4]:920). After 2004, the Chinese Ministry of Health affirmed that COPD was the fourth leading cause of mortality in urban areas, but third in rural ones (Fang, 2011). When investigators analyzed deaths secondary to cor pulmonale coexisting with COPD, they found COPD-related mortality increased to 179.9 for men and 141.3 for women per 100,000 persons, which is about double the COPD mortality for other countries in the Asian-Pacific region (Reilly K, et al. Am J Epidemiol. 2008;167[8]:998).
Both cancer and COPD in China disproportionately affect those in rural areas and with lower socioeconomic status, with smoking being the most potent causative exposure. On average, the annual direct and indirect per-patient cost of treating COPD amounted to about $2,000, comprising about 40% of a family’s total annual income (Fang, 2011). The cost of treating malignancy is even more expensive, but the higher likelihood of death results in an additional 10% to 20% reduction of family income when a working family member dies (Pratt, 2016). Taken together, and especially since rural Chinese citizens spend close to 20% of their income on tobacco products, the pulmonary health consequences of smoking are a significant driver of both health and economic inequality.
The Air We Breathe
Air pollution comprises a second pulmonary insult to China’s health. The International Agency for Research on Cancer designated particulate matter (PM) as a class I carcinogen (Kurt O, et al. Curr Opin Pulm Med. 2016;22[2]:138). PM forms from combustion of bio-mass fuel, as well as from dust storms or construction. Once particulates are smaller than 2.5 microns (PM2.5), they cause substantial harm to the pulmonary microenvironment. Guo and colleagues demonstrated markedly increased lung cancer risks associated with spatial mapping of ozone and PM2.5 concentrations (Guo Y, et al. Environ Res. 2016;144;60). PM2.5 also doubles the odds of contracting COPD in nonsmoking adults, conferring as much as a three-fold risk of contracting the disease in nonsmoking women (Fang, 2011).
Apart from causing pulmonary disease, studies also implicate air pollution as frequently causing exacerbations of existing disease. One study found an incremental increase in ED visits for respiratory illnesses for every 10 µg/m3 above the median PM2.5 level (Xu, et al. PLoS One. 2016;11(4): e0153099). In 2013, 83% of Chinese lived in places where PM2.5 levels exceeded China’s own ambient air standard. In this cohort, elevated PM2.5 levels contributed directly to 300,000 premature deaths from lung cancer and COPD, with PM2.5 causing 1.2 million premature deaths overall (Liu J, et al. Sci Total Environ. 2016;568;1253).
Moving Forward
The Chinese have few illusions about these pulmonary concerns, and they are making progress. The government recently introduced stricter smoking controls in Beijing and Shanghai and continues to explore ways to decrease emissions. President Xi has put forward strong initiatives to improve the health of the Chinese. However, the nation is trying to balance its national priorities in the context of a fluid, and, at times, perilous geopolitical climate. In some ways, their position is not too dissimilar from the US geopolitical and health-care situation of the 1970s. While challenging, the issue of Chinese health care should not overshadow the remarkable resources or the truly remarkable culture of their people. Friendship, cooperation, the reduction of suffering: these are ideals where all clinicians find common ground, regardless of nationality.
Dr. Mackay is Chief Fellow of Critical Care Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey; Dr. Flenaugh is Associate Professor of Medicine, Division Chief of Pulmonary and Critical Care Medicine, Director of Advance Diagnostic and Interventional Pulmonary, Morehouse School of Medicine, Atlanta, Georgia.
Editor’s Note
This excellent, up-close Pulmonary Perspective details observations of Drs. Mackay and Flenaugh as they have participated in cross-cultural exchanges in
The American College of Chest Physicians, likewise concerned about pulmonary health in China, has approached the problem on a different front, working closely with partners, such as the Chinese Thoracic Society, the Chinese Association of Chest Physicians, and the Chinese Medical Doctor Association, to implement China’s first ever fellowship program offering standardized training in PCCM for Chinese physicians. Read more at http://www.mdedge.com/chestphysician/article/131179/society-news/pccm-endorsed-pilot-subspecialty-chinese-national-health.
Nitin Puri, MD, FCCP, is the section editor of Pulmonary Perspectives.
Over the past 2 years, we had the opportunity to participate in an annual cross-cultural exchange that has broadened our horizons. Xi’an, the ancient capital of China and home of the Terracotta warriors, is a sprawling megapolis similar to Los Angeles. In the southern suburb of Huxian, US trained pulmonary, neurosurgical, and critical care physicians from Cooper University Hospital and Morehouse School of Medicine partnered with physicians of Ji-Ren Teaching Hospital to deliver a Chinese Medical Association accredited continuing medical education conference. The conference agenda included a variety of pulmonary and critical care topics highlighting sepsis, neurovascular disease, and lung cancer screening and diagnosis. We also provided a hands-on workshop for point of care ultrasound, and, in return, received education about Chinese medicine.
We found our hosts appreciative and hospitable, and they treated us with the highest level of respect (the cornerstone of Chinese culture). The audience was receptive and very interested in learning. However, while we were impressed with their rapid growth and interest in incorporating western medicine into their daily practice, it was impossible to overlook the major pulmonary health-care concerns threatening their communities. Tobacco use was omnipresent, and the haze of air pollution made the sky a constant shade of grey. In both public and private spaces, powerful echoes of a once familiar America resonated, and they served to underscore the obstacles the Chinese medical community now faces in caring for their country’s pulmonary health.
An Old, Familiar Foe
The China National Tobacco Corporation (CNTC) is the largest tobacco company in the world, as well as China’s most profitable state-owned enterprise (Pratt, A, et al. WHO Report. 2017. ISBN 9789290617907 [http://www.wpro.who.int/china/publications/2017_china_tobacco_control_report_en_web_final.pdf?ua=1]). As such, the CNTC controls every aspect of its production and supply chain with the force of the federal government and also exerts heavy influence over regulatory policy. It controls about 98% of domestic crop production and manages to price cigarettes just short of one American dollar per pack, yet contributes about $170 billion annually to the government (Rich, et al. Nicotine Tob Res. 2012;14[3]:258). This accounted for nearly 7% of total governmental revenue in 2015 (Pratt, 2017).
To date, nearly 44% of the world’s cigarettes are manufactured and consumed in China (Pratt 2017, Rich 2012). In 2015, more than 315 million Chinese adults were daily smokers, or about 28% of the adult population and nearly half of all men (Pratt, 2017). This is about double the proportion of US smokers (about 15.1%) and more than eight times the 36.5 million daily smokers in the United States (CDC Online Tobacco Use Report, 2016 [https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/]). However, to visit China is not only to know a love for tobacco, but also an overwhelming guest and gift culture. Gift giving and hospitality is central to the Chinese identity, from business meetings to afternoon tea. Given their economy and such rich supply, people gift cigarettes to one another at all times for nearly any occasion. Unfortunately, tobacco smoke in China is as inescapable as its health consequences.
The direct effects of smoking on China’s pulmonary health have been catastrophic. Cancers of the lung and bronchus constitute their most common malignancy across both sexes, accounting for the majority of the annual 4.3 million new cancer diagnoses (Chen et al. CA Cancer J Clin. 2016;66[2]:115). In Chinese men, lung cancer is the second most common cancer before the age of 60, and over the age of 75, it is the most common malignancy and also accounts for the majority of that group’s cancer mortality. Women fare only slightly better, with breast cancer being their most common malignancy, but with lung cancer remaining the most pervasive across all age groups, and, by far, the most deadly (Chen, 2016). All told, of the projected 2.8 million cancer deaths occurring in 2015 in China, 21% were directly a result of lung cancer.
Likewise, COPD also threatens China. The Global Burden of Disease study conducted in 2004 demonstrated that nearly 3 million people die of COPD each year. Chinese adults over the age of 40 had an overall prevalence of COPD of 9% for the last decade, though this may be higher given the high rate of underdiagnosis in rural China (Fang X, et al. Chest. 2011;139[4]:920). After 2004, the Chinese Ministry of Health affirmed that COPD was the fourth leading cause of mortality in urban areas, but third in rural ones (Fang, 2011). When investigators analyzed deaths secondary to cor pulmonale coexisting with COPD, they found COPD-related mortality increased to 179.9 for men and 141.3 for women per 100,000 persons, which is about double the COPD mortality for other countries in the Asian-Pacific region (Reilly K, et al. Am J Epidemiol. 2008;167[8]:998).
Both cancer and COPD in China disproportionately affect those in rural areas and with lower socioeconomic status, with smoking being the most potent causative exposure. On average, the annual direct and indirect per-patient cost of treating COPD amounted to about $2,000, comprising about 40% of a family’s total annual income (Fang, 2011). The cost of treating malignancy is even more expensive, but the higher likelihood of death results in an additional 10% to 20% reduction of family income when a working family member dies (Pratt, 2016). Taken together, and especially since rural Chinese citizens spend close to 20% of their income on tobacco products, the pulmonary health consequences of smoking are a significant driver of both health and economic inequality.
The Air We Breathe
Air pollution comprises a second pulmonary insult to China’s health. The International Agency for Research on Cancer designated particulate matter (PM) as a class I carcinogen (Kurt O, et al. Curr Opin Pulm Med. 2016;22[2]:138). PM forms from combustion of bio-mass fuel, as well as from dust storms or construction. Once particulates are smaller than 2.5 microns (PM2.5), they cause substantial harm to the pulmonary microenvironment. Guo and colleagues demonstrated markedly increased lung cancer risks associated with spatial mapping of ozone and PM2.5 concentrations (Guo Y, et al. Environ Res. 2016;144;60). PM2.5 also doubles the odds of contracting COPD in nonsmoking adults, conferring as much as a three-fold risk of contracting the disease in nonsmoking women (Fang, 2011).
Apart from causing pulmonary disease, studies also implicate air pollution as frequently causing exacerbations of existing disease. One study found an incremental increase in ED visits for respiratory illnesses for every 10 µg/m3 above the median PM2.5 level (Xu, et al. PLoS One. 2016;11(4): e0153099). In 2013, 83% of Chinese lived in places where PM2.5 levels exceeded China’s own ambient air standard. In this cohort, elevated PM2.5 levels contributed directly to 300,000 premature deaths from lung cancer and COPD, with PM2.5 causing 1.2 million premature deaths overall (Liu J, et al. Sci Total Environ. 2016;568;1253).
Moving Forward
The Chinese have few illusions about these pulmonary concerns, and they are making progress. The government recently introduced stricter smoking controls in Beijing and Shanghai and continues to explore ways to decrease emissions. President Xi has put forward strong initiatives to improve the health of the Chinese. However, the nation is trying to balance its national priorities in the context of a fluid, and, at times, perilous geopolitical climate. In some ways, their position is not too dissimilar from the US geopolitical and health-care situation of the 1970s. While challenging, the issue of Chinese health care should not overshadow the remarkable resources or the truly remarkable culture of their people. Friendship, cooperation, the reduction of suffering: these are ideals where all clinicians find common ground, regardless of nationality.
Dr. Mackay is Chief Fellow of Critical Care Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey; Dr. Flenaugh is Associate Professor of Medicine, Division Chief of Pulmonary and Critical Care Medicine, Director of Advance Diagnostic and Interventional Pulmonary, Morehouse School of Medicine, Atlanta, Georgia.
Editor’s Note
This excellent, up-close Pulmonary Perspective details observations of Drs. Mackay and Flenaugh as they have participated in cross-cultural exchanges in
The American College of Chest Physicians, likewise concerned about pulmonary health in China, has approached the problem on a different front, working closely with partners, such as the Chinese Thoracic Society, the Chinese Association of Chest Physicians, and the Chinese Medical Doctor Association, to implement China’s first ever fellowship program offering standardized training in PCCM for Chinese physicians. Read more at http://www.mdedge.com/chestphysician/article/131179/society-news/pccm-endorsed-pilot-subspecialty-chinese-national-health.
Nitin Puri, MD, FCCP, is the section editor of Pulmonary Perspectives.