Mar 18, 2019

Axios Vitals

By Caitlin Owens
Caitlin Owens

Good morning ... Welcome spring, welcome warm(ish) weather, welcome allergies.

1 big thing: Competition doesn't always drive down drug prices
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Data: Centers for Medicare & Medicaid Services; Chart: Harry Stevens/Axios

Competition doesn't always lead to lower drug prices, at least in the class of drugs administered by a doctor, according to new Medicare payment data.

  • Most of the drugs with the biggest price increases from 2016 to 2017 had at least 2 versions on the market.

Why it matters: This data only captures one year of price changes, but casts doubt on the idea that competition is a foolproof way to constrain drug prices.

Yes, but: Most drugs with more than 5 competing products did see price decreases in 2016.

  • Of the 17 drugs covered by Medicare Part B with more than 10 competing products on the market, just 5 of them — or 29% — saw price increases. And only 35% of the drugs with 6-10 competing products saw a price increase.
  • By contrast, of the 162 drugs with just 1 product on the market, 69%, saw price increases from 2016 to 2017. And of the 125 drugs with 2-5 products, prices increased for 58% of them.
  • This analysis excludes drugs that were used by fewer than than 300 patients. It also doesn't take into account drugs picked up at the pharmacy counter, or price decreases that may have occurred when competition for a drug first entered the market, as it looks at only one year of data.

While some of these drugs cost mere pennies per dosage, each insurance claim can include multiple doses.

  • Insulin delivered through a pump — which had 16 competitors — cost on average $9.45 per dosage in 2017, but the average claim was $958.65.

The bottom line: Drugs with monopoly power aren't the only ones that can raise their prices.

  • Even with competition, "you can’t count on continual price decreases," said Vanderbilt's Stacie Dusetzina after reviewing the data.
2. HHS surges ahead on work requirements

Legal challenges aren't slowing down the Trump administration's push to reframe Medicaid as something closer to a welfare program, Axios' Sam Baker writes.

Driving the news: The Centers for Medicare & Medicaid Services on Friday approved Ohio's proposal to add work requirements to its Medicaid program.

  • Just a day earlier, Justice Department lawyers were back before the same federal judge who ruled against work requirements last year, urging him to let the policy move forward now.

Where it stands: CMS has approved work requirements for 8 states, 3 of which have begun enforcing those rules. Several more applications are still pending.

By the numbers: Ohio expects roughly 18,000 people to lose their Medicaid eligibility this year because of the new rules.

  • In Arkansas, the first state to begin enforcing its work requirements, 18,000 people lost their coverage in the first 6 months.

Those coverage losses are central to the lawsuits challenging these new rules.

  • Federal law says the process through which CMS is approving these waivers should be used for ideas that serve Medicaid's goals as a source of health care coverage.
  • Critics argue that work requirements don't advance Medicaid as a health care program, as evidenced by the fact that they cause so many people to lose their coverage.
  • Judge James Boasberg seemed inclined to agree with that argument last year when he put Kentucky's work requirements on ice, and echoed similar concerns again last week as he weighed fresh challenges to both Kentucky and Arkansas' rules. 
3. We're prescribing opioids less, but for longer
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Adapted from a Journal of the American Medical Association report; Cartogram: Lazaro Gamio/Axios

How we prescribe opioids changed between 2006 and 2017 and varies state by state, according to a new study in the Journal of the American Medical Association.

The bad news: The average duration per prescription and the prescribing rate of long-term opioid prescriptions increased.

  • "Duration of use is the strongest predictor of opioid use disorder and overdose," the study's authors write. Every additional week that someone uses opioids, there's a 20% increased risk of developing an opioid use disorder or having an overdose.

The good news: Between 2006 and 2017, the amount of opioids prescribed per person decreased, as did the prescribing rate for high-dosage opioids, short-term opioid prescriptions, and extended-release and long-acting opioid formulations.

  • High dosages and longer-acting formulations also increase a person's risk of becoming addicted or overdosing.
  • The decline in short-term opioid prescriptions could mean that providers are encouraging other forms of pain management.
4. When doctors have non-competes

Non-compete clauses in employment contracts are increasingly common in the medical sector, which can mean that patients lose contact with their providers when they switch practices, the New York Times reports.

  • One survey of nearly 2,000 primary care doctors in 5 states found that 45% had non-competes.
  • The non-compete clauses aim to prevent providers from taking patients with them if they move to a competing practice or start their own.
  • Even when patients track down their doctors, they sometimes won't be admitted into the doctors' new practices. That's because hospitals and clinics say they have to respect the terms of the providers' prior business agreements.

But doctors say that continuity of care is important for patients, especially those who have ongoing medical issues.

  • Some states don't enforce n0n-compete clauses against doctors, and others place limits on the contracts. Legal scholars disagree on whether they're binding in health care.
5. AI is leaving new surgeons unprepared

Doctors are finishing their residencies licensed to use robots in the operating room, but most were barely trained to do so, my colleague Steve LeVine reports.

Social scientist Matthew Beane noticed this over two years observing surgeons in teaching hospitals.

  • At fault, Beane reported, is how hospitals have introduced machines and artificial intelligence to the workplace — a way that has left a large part of the new generation of doctors lacking crucial surgery skills.

How it works: In surgery, you need four hands — the surgeon's own, plus those of a resident to pull and hold once an incision is made. Even six hands may be required — a second resident.

  • But with DaVinci, the standard operating room robot, surgeons can manage procedures alone with hand and foot controls — and Beane found they typically do, mostly with the objective of efficiency and reducing mistakes.
  • "So the resident gets 10 to 20 times less practice," said Beane, a professor at the University of California, Santa Barbara. "Most residents by and large leave without knowing how to use this tool. They are licensed to use it, but not practiced."
6. While you were weekending
  • Major heart-health organizations are now recommending that healthy people shouldn't take aspirin to prevent a first heart attack or cardiovascular disease, WSJ reports.
  • Apple is teaming up with Johnson & Johnson to do a study on whether the Apple Watch can help prevent heart attack, stroke or other causes of death, Stat reports.
  • NYT digs into the swarm of lobbyists who are eager to stop FDA commissioner Scott Gottlieb's unfinished work on e-cigarettes as he leaves the agency.
  • Stat explores the battle over whether "compounding" — the practice of slightly altering a drug — can be used to combat high drug prices by providing alternative choices.
Caitlin Owens

Have a great week. All tips and feedback are appreciated: