The Incremental Excuse

Aurora and the Rejection of Small Steps

In the aftermath of the tragedy at the Aurora, CO movie theater, the pundits, politicians and lobbyists were at it again with all of the typical arguments about gun control in full force. Both sides of the issue dusted off the same statements they’ve used following the shooting of Gaby Giffords, and the massacres at Fort Hood, Binghamton, Virginia Tech, Columbine and on and on. We weep, we mourn, we do it again.

At the core is the Second Amendment to the Constitution of the United States of America (ratified in 1791): A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.

One the one side:

·     The Second Amendment has been ridiculously over-interpreted. (The Fox show Family Guy took a satirical jab at the subject.)

·     We need to limit the number and type of guns available for sale to the public, especially those designed for combat.

·     We must ensure that those who own them do so legally after appropriate background checks and registration.

·     Ammunition that is designed to inflict maximal damage and penetrate body armor should be banned, as should high capacity magazines.

On the other side:

·     Our freedom is threatened and the country is undermined if the individual right to bear arms is in any way curtailed.

·     The Supreme Court of the United States has ruled that the Second Amendment protects an individual's right to possess a firearm whether or not it’s used in connection with service in a militia.

·     If we lived in a more moral society, we would not see people misusing guns.

·     Gun laws won’t stop the insane from finding ways to kill people.

Personally, I have a difficult time with the last four points but the last is particularly irksome – the rationale that inaction is the best option. The line is that stricter gun laws won’t cut down on violence. It might cut down on gun violence but the violent will find other ways to fulfill their intent.

It’s the same line of reasoning used to say that we shouldn’t invest in solar or wind energy because it would only be drop in the bucket compared to our overall energy needs. Opponents to the Affordable Care Act (aka Obamacare) want it replaced or repealed; there’s nothing to negotiate. Or, it could be taxes and the deficit. The so-called millionaire’s tax can’t get any traction because, the logic goes, it would do so little to cut into our national debt.

Enough! We have to start someplace. We’d like to get to the goal line in one play but we can’t. It’s not happening. “Whatever axiom you want to use – half a loaf is better than none or Voltaire’s “The perfect is the enemy of the good” (originally, Le mieux est l’ennemi du bien) – incrementalism is hard to accept but equally hard to forswear.” That’s what I wrote in my book, Camelot, Inc., and it seems appropriate to repeat it here.

We should remember that our country is nothing but a timeline of incremental advances. Many of the Founding Fathers wanted to abolish slavery, while others insisted that it remain. So, the Declaration of Independence was a compromise. It was a step. We had to wait nearly a hundred years for the Emancipation Proclamation and then another hundred for the Civil Rights Act.

Of course we must cherish our individual rights but we are one nation. Those who love the Constitution should think deeply about its first line: We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.

Please note the words “We” and “general welfare.” And notice also “union,” “Justice” and “domestic Tranquility.” The Founding Fathers would be in tears if they could see how we’ve misused and abused their words, and became one of the most violent societies on earth.

Compromise and incremental success may not seem satisfying, but it’s the way most things operate and succeed. Baby steps can sometimes add up to a completed marathon.

Congress and state legislatures across the country should take note. Indeed, we need to elect leaders with the courage and conviction to move the country forward. We need to reject the all-or-nothing mentality and reward the smaller but still important measures. We need to learn from the past, not live in it.

Between blog posts, I invite you to follow me on Twitter @pauloestreicher.

The Pharma Pricing Dilemma

How to Rebalance the Picture
There’s front page outrage in today’s The New York Times. The pharmaceutical industry is roasted again in “Drug Makers Raise Prices in Face of Health Care Reform.” How much of the criticism is deserved, and how much is a result of poor communications or inadequate reporting?

The article cited several studies that link big increases in drug costs to legislative efforts – like bumping up carpet prices just before the big sale, or the rush to raise interest rates and fees before credit card reforms become law. The most recent study was conducted for the AARP by Stephen Schondelmeyer, a professor of pharmaceutical economics at the University of Minnesota. It concluded that drug prices increased approximately nine percent in the face of an overall decline in the Consumer Price Index of 1.3 percent. He told the Times, “When we have major legislation anticipated, we see a run-up in price increases.”

Not so, said Merck spokesman Ron Rogers. “Price adjustments for our products have no connection to health care reform.” But Joseph Newhouse, a Harvard health economist, said he found a similar pattern of stiff increases after Congress added drug benefits to Medicare in 2006. He said, “They [the industry] try to maximize their profits.”

No kidding. Of course the industry, any industry, wants to maximize their profits. Indeed, there’s an obligation to employees and shareholders. The problem is one of perception. What is smart business that helps to guarantee the long term success of the enterprise, what is abuse or greed, and what is corporate desperation?

The other side of this story is not told particularly well, and it’s hard to determine if it’s the lack of space accorded the pharmaceutical industry by the Times, the lack of a compelling message by the industry or both. The article states that “Drug makers say they have valid business reasons for the price increases” but then fails to explore it further.

Ken Johnson, senior vice president of the Pharmaceutical Research and Manufacturers of America (PhRMA), does manage to get a shot in by criticizing the study methodology and its sponsor. “In AARP’s skewed view of the world, medicines are always looked at as a cost and never seen as a savings – even though medicines often reduce unnecessary hospitalization, help avoid costly medical procedures and increase productivity through better prevention and management of chronic diseases,” he said.

Yes, good points, but readers are still left with questions and concerns. And, what about the cost of failure – the part of the price increases that are necessitated by the sheer difficulty of bringing new, differentiated medicines to the market? The reality is that, without the ability to replace innovative products lost to generic competition, outsized price increases will continue to play an outsized role in pharmaceutical profitability.

So, what needs to be done in order to achieve some balance, some greater understanding of the complexities in healthcare costs?

Provide proof. The industry must deliver concise, compelling and understandable information. Any spokesperson should be able to recite at least three pieces of evidence to support their position. And, if you believe the methodology of the offending study is flawed, develop your own bullet proof information.

Utilize credible supporters. The extreme pricing contention was delivered by two academics, a consumer group and an industry analyst. The industry’s position was staked out by the pharmaceutical trade association. It’s clear where most readers will place their trust.

Strike the right tone. Lashing out may be tempting but it could have the effect of creating sympathy for your adversary. And, in this case, the object of PhRMA’s annoyance – the AARP – represents millions of the industry’s customers.

Think about the timing. It may be that, as Catherine Arnold of Credit Suisse said, “If you’re going to take price increases, here and now might be the place to do that, because the next year and the year after that might be tough.” But, if these price increases cancel out some of the savings promised by the industry during negotiations over health insurance reform, don’t be surprised if some legislators attempt to exact new concessions with renewed determination.
----------------------------------------------------------------------

Between blog posts, you can follow me on Twitter.

A Healthcare Answer For Some But Not All

The Internet Is Another Health Disparity That Must Be Addressed If you ask your friends, relatives and colleagues if they’ve used the Internet to find healthcare information, I’d be willing to bet the answer would be yes. There’s no question that the Internet is an ever more important healthcare tool. The ability to capture and consolidate information into electronic medical records; search and share health and wellness resources, and enhance communications between professionals and patients are among the many benefits of the web. It’s OK to cheer but just not too loudly.

The problem is that our friends, relatives and colleagues aren’t everyone – not by a long shot. According to Neilsen Online, there’s a whopping 277,636,000 Internet users in the U.S. The flip side of this seemingly good news is that it leaves about 30 million Americans disconnected from the world wide web and, thus, unable to access important healthcare tools and information.

The web is no panacea, of course. You may have read some of my previous articles where I pointed out the problems of web-based healthcare information. Because there’s so much junk science reported and repeated in cyberspace, it can be a case of information doing more harm than good. Still, there’s a growing list of important applications that will not be available to all who could benefit from them.

Take Keas, for example, the new company that boasts Google Health and Microsoft HealthVault as partners. Keas seeks to marry personal data and health information to produce personalized health plans for individuals. Delivered right to your desktop or smart phone might be diet and exercise advice, an explanation of lab results, different treatment options or reminders to take a medication.

During the healthcare reform debates, we heard repeatedly that a key to lowering costs is to have a healthier nation and that this goal will only be possible if individuals take more responsibility for their health. While we could achieve a lot if plain old common sense was applied more often, tools like those being developed by Keas could play an important role in both learning about and managing one’s health.

If experts are telling us that things like electronic medical records, on-line health information and personalized health plans are important to healthcare reform efforts and our own personal well being then we need to be thinking about two kinds of health disparities: insurance coverage and Internet access. Creative, cost-effective ways to distribute computers and expand broadband access must take on new urgency. The benefits would be manifold.

And, access should include more than the ability to go on-line. Access is meaningless if one can’t interpret what one has found. Even for those with Internet connections, there’s an enormous deficit in health literacy that threatens the public health, such as sensationalized claims that lead people to take potentially dangerous alternative medicines or parents to refuse vaccinations for their children other than for legitimate medical reasons. If there’s any hope in increasing coverage and quality while containing (or even lowering) costs, more attention must be placed on expanding access to and understanding of healthcare information.
--------------------------------------------------------------------------

Between blog posts, you can follow me on Twitter.

1776 Déjà Vu?

So Much Hinges On So Few

One of my children was just watching the movie version of 1776, the musical show about the events leading up to and including the signing of the Declaration of Independence. In the Broadway account, the fate of the document, the fate of the world, came down to James Wilson of Pennsylvania. Pennsylvania was, indeed, torn between reconciliation and war with England. In a last gasp appeal, John Adams spoke out. "It would be a pity for a man who has handed down hundreds of wise decisions from the bench to be remembered only for the one unwise decision he made in Congress." Wilson (who, in reality, spoke forcefully for independence) relented. He didn't want the attention or the responsibility. "Mr. Adams is correct about one thing," he said. "If I vote with you [John Dickinson], I'll be the one who prevented American independence."

Healthcare reform and the signing of the Declaration of Independence may not be in the same league of American milestones, but the parallel struck me. Of course, there have been many, many instances where critical decisions came down to one unsuspecting or unprepared (or manipulative) person. But here we are. With the so-called public option going down to defeat in the Senate Finance Committee, it is now highly unlikely that any subsequent amendments with such a provision will survive.

And what does that mean? The table is set for Senator Olympia Snowe to play James Wilson. Sixty votes will be needed for passage and it's looking more and more like achieving meaningful (though highly compromised and far from perfect) healthcare reform any time in the foreseeable future will rest with the capable centrist from Maine.

The optics aren't pretty -- the old saying about laws being like sausages comes to mind. And what got us to this point hasn't been any more attractive. The raucous Town Hall meetings over the summer -- the shouting down of elected officials and the perpetuation of false claims -- did not instill confidence in the process of creating legislation. Politicians need to pay more attention to this point. The substance is important but, when it comes to building trust and unity, the visuals and the tone mean a great deal, too.

While one voice may decide the fate of healthcare reform, it's interesting to note which voices went largely unheard. The most vocal weren't those with the most to gain -- the roughly 46 million without insurance. The squeakiest wheels were found on those who believed that reform will diminish their care or cost them more money. They had the best access to the media, the best messaging consultants. So much for Life, Liberty and the Pursuit of Happiness for the rest.

Yet, some major groups that were lined up against previous reform efforts -- most notably the pharmaceutical industry and organized medicine -- are now advertising their support. Despite the bad press over the haranguing and arguing, there has been much more engagement, much more deal making and number crunching. Making a business case, not just an emotional one, may be the winning formula this time around.

-----------------------------------------------------------------------------

Between blog posts, you can follow me on Twitter.

Homework for America

Read First, Debate Healthcare Reform Second
Healthcare reform has been discussed since Teddy Roosevelt’s time. We’ve made improvements throughout the years, of course. But they’ve always come with a struggle. The issues and arguments we hear today – excessive cost, loss of choice, the proper role of government – are not new. So, should the Democrats be surprised that some angry people are showing up at their Town Hall meetings?

Probably not. The trend had already been set. Unfortunately, though, we’ve seen an escalation in anger and a decrease in civility at public events over the years. What promised to be a vigorous negotiation over the latest round of healthcare reform proposals has turned into some ugly confrontations. True, America is all about standing up for ones beliefs and having the freedom to do so in public. What we have seen, however, is not a respectful give and take. There’s not nearly enough discourse and debate, and there’s entirely too much ranting and raving. The bottom line is that there’s precious little communicating going on.

Indeed, debate is about putting forth a proposition and allowing a rebuttal. Instead, healthcare reform is being hijacked by a loud minority of citizens who have no actual interest in participating in a productive conversation. For them, it’s not a question of finding a solution, thrashing out a compromise on problematic provisions, or discussing to what extent the government should play a role. It’s about no government. Rather than becoming a rallying point for a common good, healthcare reform has become yet another “wedge issue” like abortion, school prayer or creationism. It’s another example of the polarization of America , the land of the disappearing middle ground, where threats and intimidation can displace rational thought. Agreeing to disagree is becoming less of an option.

When challenged, when asked to stop the heckling, the healthcare reform protesters exclaim “This is America. It’s my Constitutional right!” And, they’re right… to a point. It’s not alright to inhibit the speech of others. We should want debate. We should want to exchange views. We should want the facts. We should want to communicate.

Invoking the Constitution is interesting, though. I’m wondering just how many Americans have actually read it. The protesters should remember that some of its first words are to “form a more perfect union” and to “promote the general welfare.”

So here’s the homework assignment America: read the Constitution. Know what you’re talking about when you use it to defend your rights. And, while you’re at it, read a few good biographies of the “founding fathers.” See for yourselves what their intentions were in creating our United States.

A special homework assignment is given to all of the politicians and political pundits out there. Read the healthcare reform proposals for yourselves before you talk about the potential pluses and minuses. This is for the public good as well as your own (unless you want to be embarrassed by a poor grasp of the facts). For example, over the past few weeks there have been repeated warnings about government “death panels” that will decide who lives and who dies. On former Senator Fred Thompson’s radio show, former New York Lieutenant Governor Elizabeth McCaughey said, “Congress would make it mandatory – absolutely require – that every five years, people in Medicare have a required counseling session that will tell them how to end their life sooner, how to decline nutrition, how to decline being hydrated, how to go into hospice care.” Politifact.com awarded her its “pants on fire” rating for its complete lack of truth. And former Speaker of the House Newt Gingrich was corrected twice by “This Week” host George Stephanopoulis this past Sunday. Mr. Gingrich waved him off and implied that something along those lines were buried somewhere in the 1000+ page proposal. (Again, it’s not.)

I’m hopeful the situation will improve. I saw a good sign at the President’s Town Hall in New Hampshire on Tuesday. The huge crowd was well behaved. Views were expressed, questions were asked and responses were returned. Why the difference? Perhaps people were more deferential toward the President than they were toward members of Congress. Perhaps it was the heavy presence of Secret Service agents. Or, perhaps it was because the attendees were a true cross section of America. Unlike the Town Hall meetings held by members of Congress, people were admitted to the Presidential Town Hall by a lottery – they were randomly selected. Thus, it was impossible to stack the deck with partisans and troublemakers. Whatever the reason(s), let’s continue to communicate knowledgeably, passionately and respectfully.

-------------------------------------------------------------------------------

Between blog posts, you can follow me on Twitter.

Hide or Seek?

It’s Time for the Healthcare Industry to Find New Footing
There's plenty of blame to go around these days. We’ve all seen angry fingers pointed at the tobacco companies for pushing products they knew to be hazardous and additive. There were hearings before Congress, lawsuits and some new restrictions on marketing to teens.

HMOs came under fire for denying medical claims and access to potentially life-saving interventions. Lawsuits and some high-profile reversals in coverage decisions ensued.

Big oil and oil speculators had us over the figurative barrel when a gallon of gas went over $4.00 a gallon. With the collapsing economy, gasoline prices have fallen by more than 50 percent (though the price of oil has fallen by more than 70 percent).

The list continues with the biopharmaceutical industry. Despite cost assistance programs, there are still too many patients who choose between filling a prescription and buying other necessities. They may not have insurance or their co-pays for medications may be enough to tip a limited budget into the red. There has been some relief with the implementation of the Medicare drug benefit and more has just been promised by President Obama in his address to Congress.

Now, there’s another group to vilify – the financial industry. Predatory lenders, over-compensated CEOs and Ponzi-scheming money (mis)managers.

Though sometimes pushed from the front page by competing bad news from the banking and housing crisis, there are still plenty of stories out there that help fan the flames on healthcare. And they’re not just about cost and access: law suits and investigations on drug promotions, side effects, data disclosure and fraud help to keep the fury fresh. (We all know that a healthy fraction of the drug, device and diagnostic industries’ low reputation is self-inflicted, but that’s a whole other discussion.)

All of this has helped to divert some attention away from the issues and concerns of those healthcare sectors that are involved with discovery and innovation. Indeed, true healthcare reform – expanding access, and improving care and efficiency – will be difficult to achieve unless we enhance our ability to detect, treat, cure and prevent diseases.

So, what kind of visibility should the biopharmaceutical, device and diagnostic sectors be seeking right now, especially when the chairs are empty at HHS, FDA, NIH, CDC and CMS? One option is to do nothing and enjoy the relative calm (compared to what the financial sector is experiencing). To some, it’s schadenfreude – a nice change to see public anger and resentment trained somewhere else. Another option is to fill the void with new ideas, new approaches and reengage our publics.

For a snapshot of the current messages coming out of the key industry trade associations, I went to their web sites. The most prominent feature on PhRMA’s homepage highlights Meredith Baxter’s battle with breast cancer. Also, there are links for prescription assistance, healthcare reform and medicines in development. Likewise, the AdvaMed web site has a number of links to interesting content. However, neither have a clean, clear set of rallying points. BIO is a little closer to at least part of what I think we need. There’s a CNBC interview with association president James Greenwood from their CEO & Investor Conference. He makes a clear connection between healthcare and the economy – the need to “expand access to health care while expanding incentives to innovate.”

Like housing, banking and automobiles, biotech is in a crisis. Perhaps this is one of the messages that needs to be amplified and expanded to gain more relevancy with more audiences. The scary facts are that a quarter of biotech companies have six months or less of cash. Half have 12 months or less. The editorial in the February issue of Nature Biotechnology remarks that “many promising products now face financial oblivion.”

Yes, we need healthcare reform to expand access. Yet, without the underpinnings of new research, and new diagnostics and therapeutics, we will lose the capacity to consistently improve health. The transformation from trial-and-error approaches to DNA-guided medicine, ensuring that we get the right medicine in the right dose, will be pushed back by who knows how long. And, our economic competitiveness, our lead in innovation, will wane.

Certainly, the public doesn’t want to hear that healthcare, like the other sectors mentioned above, is looking for a bail-out. But some heads need to come together and think about new ways to build support for a remarkable but hobbled industry.