Jack E. Fincham

Financial realities affect political support for health care reform.

It is certainly not a surprise to anyone that the influence of lobbyists on many pieces of legislation is significant, pervasive, and effective in achieving specific goals of parochial interest groups. One can guess as to the influence the contributions have on many aspect of what extends into laws affecting many aspects of our lives. The effects (of perhaps funding shifts to other items) on health care, health care systems, health insurance programs, health professions, health professionals, and health professional educational programs are blatant and oppressive because of neglect of other worthy funding points. National Institutes of Health (NIH) funding for research, significant amounts of which can and has funded research conducted by faculty members within our academy in our schools and colleges of pharmacy, has remained virtually stagnant since 2003.1 Other research funding has been neglected as well. How can worthy funding options, ever so important to our colleagues, compete with the entrenched special interest groups significantly impacting how money is spent in the United States? State legislative funding for public schools and colleges also entails examining competing options supported by lobbying entities with far deeper pockets that any public university can ever hope to muster. Our publically funded higher education institutions are expressly prohibited from political contribution schemes, as they well should be. Meanwhile, funding for higher education supported by state legislatures has at best remained stagnant or has been significantly reduced presently and in the recent and not so recent past. n nFollow the Money nThe passage of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173) is a case in point of how funding follows lobbyists’ collective activities. The Medicare Part D Drug Program as a part of this legislation overtly favored pharmaceutical manufacturers, insurers, and pharmacy benefit management companies in an egregious fashion. Pharmaceutical companies were and are allowed to do business as usual with multiple pricing levels, and they retain the ability to raise prices at will. The MMA legislation specifically prohibits the Centers for Medicare and Medicaid Services (CMS) from negotiating with pharmaceutical companies for advantageous prices that these same companies provide freely elsewhere. The Federal Supply Schedule (FSS) pricing has allowed the Veterans Health Administration (VA) to purchase drugs at reduced prices and the federal 340B Drug Pricing Program provides access to reduced price prescription drugs to over 12, 000 health care facilities certified in the United States. Pharmaceutical companies remain profitable even with these reduced pricing programs partly due to their ability to shift price hikes elsewhere in a multi-layered process of drug pricing. n nThe current health care reform proposal that has passed in the US Senate contains no requirement for governmental negotiation for prescription drugs within Medicare Part D. The House of Representatives bill does contain a requirement for direct price negotiation between the Secretary of Health and Human Services and pharmaceutical companies. This among other differences will be hammered out in the Senate and House joint negotiations in committee. n nTo provide for optimum participation by Medicare Part D prescription drug plans (PDPs) and Medicare Advantage (MA-PDPs, as a component of managed care Medicare Part C) drug plans, incentive were a component of the MMA legislation which provided PDPs and MA-PDPs significant subsidies containing upfront funding to allow for these companies to participate with an assurance of profitability.2 In effect, participating plans were given a profitability fallback regardless of what happened with enrollment into their plans by eligible seniors, and were thus risk averse from a lack of enrollment and/or profitability with their proffered plans. n nAs the legislation was written and enabled, for the first year of the program, due to overpayment to PDP and MA sponsors, Part D plan sponsors owed Medicaid a net total of

Potentially inappropriate medication use and healthcare expenditures in the US community-dwelling elderly.

4.4 billion for the year 2006. This amount of overpayment has been reduced to

Dramatic Need for Cooperation and Advocacy Within the Academy and Beyond

600 million for 2007—a significant reduction, but this amount remains sizeable. These overestimated payments provided to plans were to be returned to Medicare. However, to further complicate this matter, CMS had no mechanisms in place to collect funds from such overpayments. It was finally set in play and accomplished well into 2007 for the 2006 payments, as such, sponsors held significant amounts of money for an extended period of time. Lobbyists exerted pressure to pass the MMA in the form in which it was enacted.

Phosphodiesterase 5 Inhibitors for Erectile Dysfunction

Background:Potentially inappropriate medication (PIM) use is a major source of drug-related problems in the elderly. Few studies have quantified the effect of PIM use on total healthcare expenditures in the United States. Objectives:We sought to determine the relationship between PIM use and healthcare expenditure and to estimate the annual incremental healthcare expenditures related to PIM use in the community-dwelling elderly population in the United States in 2001. Methods:This was a retrospective cohort study. Participants were age 65 years or older who had no PIM use in rounds 1 and 2 of the 2000–2001 Medical Expenditure Panel Survey, a nationally representative survey of the US noninstitutionalized population. On the basis of the 2002 Beers criteria, PIM users were identified as those who had been prescribed at least one PIM during specified time periods in the study. Propensity scores were used to match PIM users and nonusers in the analysis examining differences in total healthcare expenditures. Results:PIM utilization is a significant predictor for higher healthcare expenditures (P < 0.05). A conservative estimate of the incremental healthcare expenditures related to PIM use in the community-dwelling elderly population would be

Using the health belief model to predict initial drug therapy defaulting

7.2 billion (95% confidence interval,

The effect of adjunctive mood stabilizers on antipsychotic utilization pattern and health resource utilization for Medicaid enrollees with schizophrenia

3.4 billion–

Pharmacy and the U.S. health care system

15.7 billion) in the United States in 2001. Conclusions:PIM use is a major patient safety concern that results in increased healthcare expenditures. This study emphasizes the need for continued provider education to inform prescribers of the potential risks of using certain medications in the elderly and to improve prescribing practices.

The Importance of Survey Research Standards

There is no question of the need for advocacy within pharmacy and the health professions. Collective voices need to be heard, and those for whom pharmacists provide care and services need others to advocate for them simply because they have no voice in many discussions. Currently in pharmacy and the wider health professions, there are many points of contention and debate. This is not a new phenomenon; it has existed for decades. In 2010, the American Pharmacists Association and the American Society of Health-System Pharmacists (1) collaborated on a discussion paper that suggests that the rapid expansion of pharmacy schools satellite campuses and the increasing class sizes enrolled in pharmacy colleges and schools needs to be thoughtfully reconsidered. Voices within the academy have also called for careful consideration of expansion plans for programs. These arguments are juxtaposed with suggestions that there are too many health care institutions or affiliated clinics in North America, some of which are an easy stroll across the street from one another. Some believe there are too many pharmacy organizations as well, all of which were under one umbrella before being split up decades ago. The point of this editorial is not to take sides in the debate over supply of health professionals and services or to criticize any entity, but rather to lament the lack of cohesion among all affinity groups in advocating for one special interest above all else: the graduates of pharmacy education programs. Regardless of vested interests, all pharmacy educators should hold the practice options available to graduates and future graduates in the highest importance of all that we represent, advocate for, or suggest allegiance to. Other Professions Filling the Expanding Need for Physician Extender Services Nurse practitioners (NP) and physician assistants (PA) have worked hard to take advantage of the tenets behind much of the Patient Protection and Affordable Care Act passed in 2010. Despite political posturing, many provisions of this health reform legislation have been implemented and experts believe that many of the preventive health services components put in play by this legislation will not be reversed in the future regardless of the fate of the overall Act. In mid-December 2011, the components dealing with payment and service provision for preventive obesity counseling and services imbedded in the legislation began to be operationalized for enrollees of Medicare. Physician extenders will provide many of these and other types of future needed services. Our previous research (2,3) found that consumers are willing to use physician extenders (eg, NPs) when seeking care for acute conditions requiring medical care services. Many if not all of these retail clinic-based physician extenders are located within pharmacies. There are numerous opportunities for professional collaboration between pharmacists and other physician extenders (NPs and PAs). The health professions striving to avail the opportunities presented by disruptive innovations such as retail clinic and the increasing demand for primary health care services do not need to do so at the expense of each other. There are tremendous opportunities for outreach and collaborative efforts, many in place already, that need expansion for the benefit of all--most importantly the patients served. These professions (NPs, PAs) have achieved tremendous success by working within and across their specific professional associations, practitioner groups, and health professional schools, and with colleagues to advocate for the benefits of PA- and NP-provided health care services. This has not been achieved without tremendous organizational and collaborative synergy uniting segments within these professions that may not always agree with all aspects of what disparate affinity groups might advocate for. These processes have been documented extensively in the literature, and most certainly provide blueprints for the pharmacy professions future advocacy and cooperation with physician extender groups and physicians. …

Faculty Role in Classroom Engagement and Attendance

OBJECTIVE To review the pharmacologic and clinical trial data of the Food and Drug Administration–approved phosphodiesterase 5 (PDE5) inhibitors for the treatment of erectile dysfunction (ED). DATA SOURCES Primary research and review articles were identified through a search of ScienceDirect, PubMed/MEDLINE, and International Pharmaceutical Abstracts (1990–August 2004). The following search terms were used in the Medicine Dentistry and Pharmacology, Toxicology, and Pharmaceutical Sciences subcategories: phosphodiesterase 5 inhibitor, PDE5 inhibitor, erectile dysfunction, sildenafil, vardenafil, tadalafil, prostatectomy, and diabetes. Web of Science (1990–August 2004) was used to search for additional abstracts using the same search terms as above. The package inserts for sildenafil, vardenafil, and tadalafil were also consulted. STUDY SELECTION AND DATA EXTRACTION All identified research, review articles, and abstracts were assessed for relevance, and all relevant information was included. Priority was given to the primary medical literature and clinical trial reports. DATA SYNTHESIS ED is a common disorder in males with increased prevalence associated with age and presence of cardiovascular disease, prostatectomy, or diabetes mellitus. Sildenafil, vardenafil, and tadalafil are selective PDE5 inhibitors currently available for treatment of ED. Their pharmacology and pharmacokinetics vary slightly, but with potentially important clinical differences in duration of activity; all have similar clinical efficacy and adverse effect profiles in patients with ED of various causes. CONCLUSIONS Sildenafil, vardenafil, and tadalafil are safe and effective PDE5 inhibitors for the treatment of ED.

The effects of differences in state drug product selection laws on pharmacists' substitution behavior.

In a study of HMO patients, a Health Belief Model (HBM) questionnaire was tested to determine whether initially drug defaulting patients could be differentiated from initially compliant patients. The results of discriminant analysis indicated that individuals in the two groups could be correctly classified at a level of 68.7%. The variables on which the initially defaulting sample collectively scored less on, and which produced the most discrimination between the two groups, were: feedback from physicians on how to take a newly prescribed drug: belief in benefits of medical care for symptoms or illnesses; convenience factors including travel, need for day care and time off from work without pay needed for medical services; length of HMO membership; and education. A total of 20% of the variance in the derived discriminant function could be accounted for by the two groups. The results indicate the utility of the HBM as a tool of prediction for this form of noncompliance, and suggest possible other patient behaviors that may be able to be predicted by the model. The results further suggest the need for increased communication between providers and patients in the health care setting.