En los pacientes de Medicare es común que se repitan los tests

NUEVA YORK (Reuters Health) – La mitad o más de los

beneficiarios de Medicare repiten los tests cardíacos,

pulmonares, estomacales o vesical en tres años, señala un

estudio.

Esas pruebas no deberían repetirse. Es más, en algunos

casos, como el ecocardiograma o la prueba de esfuerzo cardíaco,

existen recomendaciones en contra de su uso rutinario.

“Nos sorprendió la frecuencia con la que se repiten estas

pruebas”, dijo el autor principal, doctor H. Gilbert Welch, del

Instituto para las Políticas de Salud y la Práctica Clínica de

Dartmouth, New Hampshire. “O esos pacientes desarrollan nuevas

enfermedades continuamente o hay médicos que repiten los

estudios como rutina”.

Con su equipo analizó el uso de seis tests en 743.478

beneficiarios de Medicare: ecocardiograma (ultrasonido

cardíaco), prueba de esfuerzo cardíaco, test de función

pulmonar, tomografía de tórax, cistoscopía (exploración de la

vejiga con una sonda) y endoscopía superior (examen el tracto

gastrointestinal superior).

Todas las pruebas eran diagnósticas, es decir que se

realizan en personas con síntomas para que los médicos puedan

realizar un diagnóstico. Cuestan entre 200 y más de 1000

dólares.

En el período 2004-2006, entre el 7 por ciento (cistoscopía)

y el 29 por ciento (ecocardiograma) de los adultos mayores se

habían realizado esos tests por lo menos una vez.

A menudo, esos exámenes se repetían: el 35 por ciento de los

pacientes a quienes se le había indicado una endoscopía del

tracto superior volvió a hacerse la prueba en tres años. Lo

mismo ocurrió con el 55 por ciento que se había realizado un

ecocardiograma. Para el resto de los exámenes, los resultados

estuvieron dentro de ese rango.

El intervalo promedio para la repetición de los tests fue de

entre cuatro y 14 meses, según publica el equipo en Archives of

Internal Medicine.

Welch aclaró que la única excepción médica para repetir

estas pruebas es cuando los pacientes desarrollan un nuevo

conjunto de síntomas que los médicos controlan después de la

primera prueba. Pero los incentivos económicos suelen lograr que

se pidan más exámenes, sin importar la finalidad.

En el caso de un ecocardiograma, por ejemplo, “si es un

cardiólogo quien lo solicita y lo va a interpretar (…) quizás

exista un incentivo económico para sobreutilizar la prueba”,

dijo la doctora Rachel Werner, de University of Pennsylvania,

Filadelfia. “El hecho es que cobramos más por hacer más”,

agregó. Y no siempre es lo mejor.

“Los pacientes comprendieron la importancia de no usar

medicamentos innecesarios. Pero pienso que la noción

generalizada es que un test diagnóstico nunca hará daño”, dijo

Welch. Pero agregó: “Cuando lo realizamos, podríamos distraernos

con un resultado circunstancial”. Son esos resultados los que

exigen nuevas pruebas y, quizás, un tratamiento innecesario.

Su equipo halló también que las ciudades donde se realizaba

la mayor cantidad de pruebas diagnósticas iniciales también

registraban los porcentajes más altos de repetición de esos

tests.

FUENTE: Archives of Internal Medicine, online 19 de

noviembre del 2012.

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Elmo left behind on ‘Sesame Street’ as actor exits

NEW YORK (AP) — Even on “Sesame Street,” where everything is famously A-OK, problems can arise for its residents.

And that includes the Muppets. Cookie Monster grapples with an eating disorder. Oscar the Grouch gets cranky. Mr. Snuffleupagus gets the blues.

But Elmo seemed immune to any of that. Since enjoying his breakout success more than two decades ago, the 3 1/2-year-old red monster has radiated good cheer, love and trilling giggles. No wonder everyone — adults as well as children — adores him.

The key to Elmo is “his innocence, his positiveness and his sweetness,” according to Kevin Clash, the man who created him and once told The Associated Press, “I would love to be totally like Elmo.”

Now Clash has been scandalously separated from Elmo and from “Sesame Street,” the TV series where he reigned behind the scenes for 28 years.

Clash spoke of “personal matters” as the cause of his resignation Tuesday after an unthinkable nine-day stretch that began with an unnamed man in his 20s claiming he had sex with Clash at age 16. That allegation was quickly recanted. But then came another accusation of sexual abuse, and a lawsuit.

That second accuser, a 24-year-old college student named Cecil Singleton, said the actor had engaged in sexual behavior with him when he was 15. He is suing Clash for $ 5 million.

“I am deeply sorry to be leaving,” said Clash in his parting statement, “and am looking forward to resolving these personal matters privately.”

But privacy may no longer be possible for Clash, the 52-year-old divorced father of a grown daughter who acknowledged last week that he is gay. Singleton’s lawyer, Jeff Herman, said he has been contacted by two other potential victims of Clash and expects additional legal action.

At a news conference Tuesday, Singleton said he and Clash met on a gay chat line and then, for a two-week period, they engaged in sexual contact, though not intercourse. Sex with a person under 17 is a felony in New York if the perpetrator is 21 or older.

Singleton said he didn’t know Clash’s profession until years later, when he Googled the man’s name.

“I was shocked when I found out what he did for a living,” said Singleton.

Now that career has ended for Clash, who, in his dream job as a puppeteer for “Sesame Street,” was assigned a little-used puppet now known as Elmo, then turned him into a star. In the process, Clash won 23 daytime Emmy awards and one prime-time Emmy. He published his 2006 autobiography, “My Life as a Furry Red Monster,” and was the subject of the 2011 documentary “Being Elmo: A Puppeteer’s Journey.”

Elmo overshadowed Big Bird and other “Sesame” Muppets in popularity and screen time, while marginalizing the cast of live actors. Since 1998, he has had his own show-within-a-show on “Sesame Street” in addition to appearances elsewhere in the hour.

He is also a major moneymaker for Sesame Workshop, the New York-based company that produces the show, and for licensees. At his merchandising height in 1996, he inspired the Tickle Me Elmo doll, which became a cultural phenomenon and that Christmas season’s hottest toy.

This year’s Elmo dolls, “LOL Elmo,” which giggles, and “Let’s Rock! Elmo,” which sings and comes with a microphone and drum set, haven’t made any of this year’s hot toy lists. Even so, Elmo toys probably account for one-half to two-thirds of the $ 75 million in annual sales the “Sesame Street” toy line generates for toy maker Hasbro, estimates BMO Capital Markets analyst Gerrick Johnson.

Johnson said he wasn’t sure how this week’s news might affect sales of Elmo toys this holiday.

“How many people are going to want to explain to their kid why they’re not getting an Elmo?” he asked.

On Tuesday, Hasbro issued a statement saying “We are confident that Elmo will remain an integral part of Sesame Street and that Sesame Street toys will continue to delight children for years to come.”

Despite his resignation, Clash will remain an integral part of “Sesame Street” for the foreseeable future. Taping of season No. 44 will wrap by mid-December and will begin airing next September, according to someone close to the show who spoke on condition of anonymity because the person was not authorized to publicly discuss details of its production. That means new episodes with Clash performing as Elmo will presumably continue well into 2014.

As for who might take over as Elmo, other “Sesame Street” puppeteers were already being trained to serve as Clash’s stand-in, Sesame Workshop said. It’s part of an understudy policy being adopted for all the major Muppet characters.

But no one knows how Elmo will fare going forward. Will the jokes spurred by Clash’s downfall leave a lasting mark on Elmo’s image? Will there be parents who see him tainted by association with the man who brought him to life?

In the wake of a personal tragedy that may still be unfolding, Elmo’s innocence, positiveness and sweetness will be put to the test.

___

AP Television Writer David Bauder and AP Retail Writer Mae Anderson contributed to this report.

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Greek PM presses for deal on loan

ATHENS, Greece (AP) — Greece has reacted with dismay to the European Union‘s failure to agree to release vital rescue loan funds for the debt-ridden country, with the prime minister warning it was not just Greece’s future that hangs in the balance.

The delay prolongs uncertainty over the future of Greece, which faces a messy default that would threaten the entire euro currency used by 17 EU nations.

Prime Minister Antonis Samaras stressed that Greece has done what its creditors from the EU and International Monetary Fund required. “Our partners, along with the IMF, also must do what they have committed to doing,” he said.

He said that “it is not just the future of our country, but the stability of the entire eurozone” that depend on the success of negotiations in coming days.

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Obama praises Netanyahu on Gaza cease-fire

Egypt's Foreign Minister Mohamed Kamel Am, Secretary of State Hillary Clinton and Egypt's President Mohammed Morsi …President Barack Obama praised Israeli Prime Minister Benjamin Netanyahu on Wednesday for agreeing to an Egypt-crafted cease-fire with Palestinian militants in Gaza. Obama, speaking to Netanyahu by telephone, also underlined America's unwavering support for Israel's security and said he hoped to "intensify" U.S. assistance.

"The president commended the prime minister for agreeing to the Egyptian cease-fire proposal—which the president recommended the prime minister do—while reiterating that Israel maintains the right to defend itself," the White House said in a summary of the conversation.

Obama "expressed his appreciation for the prime minister's efforts to work with the new Egyptian government to achieve a sustainable cease-fire and a more durable solution to this problem," the White House said. Netanyahu initiated the call, according to an Obama aide.

The president's press office released the statement to reporters moments into a joint press conference in Cairo where Secretary of State Hillary Clinton and Egyptian Foreign Minister Mohamed Kamel Amr announced the cease-fire.

The emphasis on Egypt's role has been a cornerstone of the American effort ever since Israel answered persistent rocket fire by Gaza's Hamas rulers with punishing airstrikes in a steadily escalating conflict. The country shares a border with Gaza, and President Mohammed Morsi is seen in Washington as someone able to influence the militant Islamist organization's decision-making.

Obama also highlighted American backing of Israel. "The president made clear that no country can be expected to tolerate rocket attacks against civilians," the White House said.

"The president said that the United States would use the opportunity offered by a cease-fire to intensify efforts to help Israel address its security needs, especially the issue of the smuggling of weapons and explosives into Gaza," it said.

"The president said that he was committed to seeking additional funding for Iron Dome and other U.S.-Israel missile defense programs," the White House said.

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Facebook proposes to end voting on privacy issues

NEW YORK (AP) — Facebook is proposing to end its practice of letting users vote on changes to its privacy policies. The company says it will continue to let users comment on proposed updates.

The world’s biggest social media company plans to announce Wednesday that its voting mechanism, which is triggered only if enough people comment on proposed changes, has become a system that emphasizes the quantity of responses over the quality of discussion.

Facebook began letting users vote on privacy changes in 2009. Since then, it has gone public and its user base has ballooned from around 200 million to more than 1 billion. As part of the 2009 policy, users’ votes only count if more than 30 percent of all Facebook’s active users partake.

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No increase in heart disease after food poisoning

NEW YORK (Reuters Health) – Despite earlier evidence tying an outbreak of E. coli infections in Canada to later heart disease, an expanded follow up study finds no link between the two.

“Although we definitely want to avoid anyone getting infected in the first place, this new information is reassuring for those who develop an infection from E. coli O157:H7,” Dr. Amit Garg, one of the authors of the study, said in a press release issued by the Canadian Medical Association Journal (CMAJ), which published the study.

This strain of E. coli bacteria polluted the drinking water supply of Walkerton, Ontario in May of 2000, sickening more than 2,300 people and resulting in seven deaths.

Food-borne E. coli infections – which affect about 265,000 people each year in the U.S., according to the Centers for Disease Control and Prevention – can damage the kidneys and lead to high blood pressure. That has raised concerns that they might also contribute to heart disease and stroke.

“There’s anecdotal evidence that certain infections immediately predate heart attack or stroke,” said Dr. Deepak Bhatt, the chief of Cardiology at VA Boston Healthcare System, who was not involved in the study.

“It’s not been clear whether it’s the infection or inflammation (from the infection) or coincidence,” Bhatt, also a professor at Harvard Medical School, told Reuters Health.

To see whether an E. coli outbreak could increase the risk of heart disease and stroke, Garg, a professor at Western University, Lawson Health Research Institute in London, Ontario, and his colleagues collected data on affected individuals from the 2000 event at a health clinic where they had annual visits.

Initially, the group seemed to have a higher risk for heart disease and stroke compared to people who had not suffered an E. coli infection. The researchers point out, however, that nearly half of the participants dropped out of the study, making those findings difficult to interpret.

In the current study, the group included 153 people who experienced severe illness during the outbreak, 414 people with mild illness, 331 people from Walkerton who did not get sick and more than 11,000 people who lived in neighboring towns that were spared from the E. coli outbreak.

In the decade following the outbreak, people who became severely sick were no more likely to later suffer a heart attack or stroke than people who lived outside of Walkerton.

In contrast, people who suffered a mild illness were actually 36 percent less likely to die from heart disease or stroke than residents of the surrounding communities.

Among people with a mild reaction to the infection, about 6 percent died during the study period, compared to about 10 percent of people who lived outside of the outbreak.

The reason is not totally clear. The authors write in their study that perhaps people in the mild-illness group didn’t get that sick from the infection – and also had a lower risk of cardiovascular death – because they were healthier than average.

(Garg would not agree to an interview with Reuters Health unless he was able to review major portions of this article in advance, a practice that violates Reuters’ policy to protect journalistic independence.)

STILL UNCLEAR?

The results from the study don’t necessarily mean infections don’t increase the risk of cardiovascular disease, said Dr. Liam Smeeth, a professor at the London School of Hygiene and Tropical Medicine, who was not part of the study.

Smeeth told Reuters Health that research has shown that any impact on the coronary arteries from infection and subsequent inflammation is short-lived, and perhaps the numbers in the Walkerton study were not big enough, or the increased risk not large enough, to be detected.

“It’s not crystal clear because it was a relatively small study,” he said.

Bhatt agreed that the findings don’t prove or disprove the idea that infections could be involved in heart disease, and it’s also possible that the type of infection might matter.

He said that it’s important to rule out the types that don’t contribute.

“I think the study’s important because it makes it very, very much less likely that gastrointestinal infections in some way are linked to atherosclerosis, and I think that finding is useful because probably investigators in the future shouldn’t focus on this area as far as causes of atherosclerosis and heart attack and stroke,” he said.

SOURCE: http://bit.ly/Te450j CMAJ, online November 19, 2012.

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U.S. fiscal impact of great concern to Canada: Canada’s Harper

TORONTO (Reuters) – Any fiscal problems that would significantly slow the U.S. economy would be of great concern to Canada, Canadian Prime Minister Stephen Harper said on Monday.

The United States needed a credible medium-term fiscal plan, Harper said at a business forum in Ottawa, adding that he was following the U.S. fiscal debate with “great interest.”

(Reporting by Solarina Ho)

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Hamas leader: Cease-fire with Israel is close

JERUSALEM (AP) — A diplomatic push to end Israel's nearly weeklong offensive in the Gaza Strip gained momentum Tuesday, with Egypt's president predicting that airstrikes would end within hours and Israel's prime minister saying his country would be a "willing partner" to a cease-fire with the Islamic militant group Hamas.

As international diplomats raced across the region to cement a deal, a senior Hamas official said an agreement was close even as relentless airstrikes and rocket attacks between the two sides continued. President Barack Obama dispatched Secretary of State Hillary Rodham Clinton to the Mideast from Cambodia, where she had accompanied him on a visit.

"We haven't struck the deal yet, but we are progressing and it will most likely be tonight," Moussa Abu Marzouk said Tuesday from Cairo, where cease-fire talks were being held.

Egyptian President Mohammed Morsi, perhaps the most important interlocutor between Hamas, which rules the Palestinian territory, and the Israelis, said the negotiations between the two sides will yield "positive results" during the coming hours.

In Brussels, a senior official of the European Union's foreign service said a cease-fire would include an end of Israeli airstrikes and targeted killings in Gaza, the opening of Gaza crossing points and an end to rocket attacks on Israel. The official spoke on condition of anonymity because he was not authorized to speak to the media.

Violence raged on as the talks continued. An airstrike late Tuesday killed two journalists who work for the Hamas TV station, Al-Aqsa, according to a statement from the channel. The men were in a car hit by an airstrike, Gaza health official Ashraf al-Kidra said. Israel claims that many Hamas journalists are involved in militant activities. Earlier this week it targeted the station's offices, saying it served as a Hamas communications post.

By Tuesday, 128 Palestinians, including at least 54 civilians, were killed since Israel began an air onslaught that has so far included nearly 1,500 strikes. Some 840 people have been wounded, including 225 children, Gaza health officials said.

Three Israeli civilians have also been killed and dozens wounded since the fighting began last week, the numbers possibly kept down by a rocket-defense system that Israel developed with U.S. funding. More than 1,000 rockets have been fired at Israel this week, the military said.

Late Tuesday, a Palestinian rocket hit a house in the central Israeli city of Rishon Letzion, wounding two people and badly damaging the top two floors of the building, police spokesman Micky Rosenfeld said.

With the death toll rising, the international community stepped up efforts to bring a halt to the fighting that began last Wednesday with an Israel's assassination of the Hamas military chief.

"If a long-term solution can be put in place through diplomatic means, then Israel would be a willing partner to such a solution. But if stronger military action proves necessary to stop the constant barrage of rockets, Israel wouldn't hesitate to do what is necessary to defend our people," Israeli Prime Minister Benjamin Netanyahu said during a joint press conference in Jerusalem with visiting U.N. chief Ban Ki-moon.

Ban condemned Palestinian rocket attacks, but urged Israel to show "maximum restraint."

"Further escalation benefits no one," he said.

Minutes before Ban's arrival in Jerusalem from Egypt, Palestinian militants fired a rocket toward the holy city. Earlier Tuesday, a man identified as Hamas' militant commander urged his fighters to keep up attacks on Israel, even as Israeli airstrikes killed a senior Hamas militant identified as Amin al-Dada and five others in a separate attack on a car, according to Gaza health officials.

Israeli warplanes dropped leaflets on several Gaza neighborhoods asking residents to evacuate and head toward the center of Gaza City along specific roads. The army "is not targeting any of you, and doesn't want to harm you or your families," the leaflets said. Palestinian militants urged residents to ignore the warnings, calling them "psychological warfare."

Clinton was scheduled to meet with Netanyahu in Jerusalem, Palestinian President Mahmoud Abbas in the West Bank and Egyptian leaders in Cairo. Turkey's foreign minister and a delegation of Arab League foreign ministers traveled to Gaza on a separate truce mission. Airstrikes continued to hit Gaza even as they entered the territory.

"Turkey is standing by you," Turkish Foreign Minister Ahmet Davutoglu told the Hamas prime minister in Gaza, Ismail Haniyeh. "Our demand is clear. Israel should end its aggression immediately and lift the inhumane blockade imposed on Gaza."

It was unclear how diplomatic efforts to achieve a cease-fire and stave off a threatened Israeli ground invasion into Gaza were hampered by the hard-to-bridge positions staked out by both sides — and by the persistent attacks. Tens of thousands of Israeli soldiers have been dispatched to the Gaza border in case of a decision to invade.

Residents of Jerusalem ran for cover Tuesday as sirens sounded after Palestinians fired a rocket toward the holy city for the second time since the fighting started last Wednesday.

Rosenfeld said the rocket landed harmlessly in an open area in Gush Etzion, a collection of Jewish West Bank settlements southeast of the city. Last Friday's attempt to hit Jerusalem, nearly 80 kilometers (50 miles) from Gaza, landed in the same area. No one was wounded in either attack.

Jerusalem had previously been considered beyond the range of Gaza rockets — and an unlikely target because it is home to the Al-Aqsa Mosque compound, Islam's third-holiest shrine.

In a sign of the difficulty diplomats will have in forging such a cease-fire, a man identified as Mohammed Deif, Hamas' elusive military commander, urged his fighters to keep up attacks on Israel.

Speaking from hiding on Hamas-run TV and radio, Deif said Hamas "must invest all resources to uproot this aggressor from our land," a reference to Israel.

Deif is one of the founders of Hamas' military wing and was its top commander until he was seriously wounded in an Israeli airstrike in 2003. He was replaced as the de facto leader by Ahmed Jabari, who was assassinated by Israel last week in the opening salvo of its latest Gaza offensive.

The U.S. considers Hamas, which has killed hundreds of Israelis in suicide and other attacks, to be a terror group and does not meet with its officials. The Obama administration blames Hamas for the latest eruption of violence and says Israel has the right to defend itself. At the same time, it has warned against a ground invasion, saying it could send casualties spiraling.

Netanyahu said earlier Tuesday that Israel was exploring a diplomatic solution, but wouldn't balk at a broader military operation.

"I prefer a diplomatic solution," Netanyahu said in a statement after meeting with Germany's Foreign Minister Guido Westerwelle, who is also in the region trying to advance peace efforts. "But if the fire continues, we will be forced to take broader measures and will not hesitate to do so."

Westerwelle said a truce must be urgently pursued, "but of course, there is one precondition for everything else, and this is a stop of the missile attacks against Israel."

The conflict erupted last week, when a resurgence in rocket fire from Gaza set off the Israeli offensive, which included hundreds of airstrikes on militants' underground rocket launchers and weapons' stores.

The onslaught turned deadlier over the weekend, as airstrikes began targeting the homes of suspected Hamas activists, leading to a spike in civilian casualties. Israel sent warnings in some cases, witnesses said, but in other instances missiles hit suddenly, burying residents under the rubble of their homes.

Hamas is deeply rooted in densely populated Gaza, and the movement's activists live in the midst of ordinary Gazans. Israel says militants are using civilians as human shields, both for their own safety and to launch rocket strikes from residential neighborhoods.

Early Tuesday, Israeli aircraft targeted another Hamas symbol of power, the headquarters of the bank senior Hamas officials set up to sidestep international sanctions on the militant group's rule. The inside of the bank was destroyed. A building supply business in the basement was damaged.

Fuad Hijazi and two of his toddler sons were killed Monday evening when missiles struck their one-story shack in northern Gaza, leaving a crater about two to three meters (seven to 10 feet) deep in the densely populated neighborhood. Residents said the father was not a militant.

The conflict showed signs of spilling into the West Bank, as hundreds of Palestinian protesters in the town of Jenin clashed with Israeli forces during a demonstration against Israel's Gaza offensive.

Two Palestinian protesters were killed in anti-Israel demonstrations in the West Bank on Monday, according to Palestinian officials. Separate clashes occurred Tuesday in Ramallah, the seat of the Palestinian government, during the funeral for one of the dead.

Palestinian President Mahmoud Abbas, who lost control of Gaza to Hamas in 2007, now governs from the West Bank. Abbas claims to represent both areas, and there is widespread sympathy among West Bank Palestinians for their brethren in Gaza.

Israel demands an end to rocket fire from Gaza and a halt to weapons smuggling into Gaza through tunnels under the border with Egypt. It also wants international guarantees that Hamas will not rearm or use Egypt's Sinai region, which abuts both Gaza and southern Israel, to attack Israelis.

Hamas wants Israel to halt all attacks on Gaza and lift tight restrictions on trade and movement in and out of the territory that have been in place since Hamas seized Gaza by force in 2007. Israel has rejected such demands in the past.

___

Associated Press writers Hamza Hendawi in Cairo, and Karin Laub and Ibrahim Barzak in Gaza City, Gaza Strip, contributed to this report.

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Interpublic exits Facebook

(Reuters) – Interpublic Group of Cos said it sold its remaining investment in Facebook Inc for $ 95 million in cash.

Interpublic said it expects to record a pre-tax gain of $ 94 million. It had recorded a pre-tax gain of $ 132.2 million for the third quarter of last year from the sale of half of its 0.4 percent stake in Facebook.

Interpublic paid less than $ 5 million for the stake in 2006.

Shares of Facebook, which debuted with a market value of more than $ 100 billion in May, have lost nearly half their value since then on concerns about money-making prospects.

“We decided to sell our remaining shares in Facebook as our investment was no longer strategic in nature,” Chief Executive Michael Roth said in a statement.

Interpublic also authorized an increase in its existing share repurchase program to $ 400 million from $ 300 million. The company repurchased shares worth $ 151 million, as of September 30.

Shares of the company were up 1 percent at $ 10 on the New York Stock Exchange on Tuesday.

Facebook shares were marginally up at $ 23.00 on the Nasdaq.

(Reporting by Sruthi Ramakrishnan in Bangalore; Editing by Joyjeet Das)

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Why Sanofi’s Zaltrap Deal Won t Help Patients

Nurse administers chemotherapy to patient. Credit: National Cancer Institute.

I got excited when I read the New York Times story Nov. 9 (“Sanofi Halves Price of Cancer Drug Zaltrap After Sloan-Kettering Rejection)”. Zaltrap is an intravenous infusion colon cancer drug for metastatic colorectal cancer that is resistant to or has progressed with platinum-based chemotherapy. With a list price of $ 11,000 per patient per month, Zaltrap is about double the cost of Genentech’s Avastin. Sloan Kettering doctors rejected Zaltrap, claiming it offered no added value over Avastin, because it works no better than Avastin, and costs twice as much. Doctors from Sloan-Kettering Cancer Center, one the United States flagship cancer hospitals, published an op-ed in the NYTimes Oct. 14, titled “In Cancer Care, Cost Matters,” arguing that hospitals need to put their foot down when drugs are outrageously expensive with no added value. They wrote: “Soaring spending has presented the medical community with a new obligation. When choosing treatments for a patient, we have to consider the financial strains they may cause alongside the benefits they might deliver.” The importance of getting bang for your buck, or value in healthcare, has been a huge point in health policy circles in the United States. In fact, politicians of all stripes are quick to point to health outcomes data that show that despite the United States spending in the top tier of all nations for healthcare, health outcomes are far lower. What Sanofi announced in its response Nov. 8 to Sloan-Kettering, one could have easily thought that it was a victory for patients. However, the New York Times headline stating “Sanofi halves price…” is misleading. Sadly, the Zaltrap half-off deal is not a list price reduction at all. It is just a business discount plan for hospitals and oncologists. As Lisa Jane Hubbell, who uses high-cost disease modifying drugs for a noncancerous, chronic condition told me: “It won’t help patients, will it? Our copay will be based on full price, the docs will pocket the extra from insurance companies. It doesn’t really help anyone who is in need of help paying for healthcare.” Another woman with stage IV breast cancer says that she has been deemed ineligible for any discount for her high-priced cancer drugs because she is insured. In general, drug discount plans go to the uninsured. She emailed me: “The drug I took for five years was re-patented three times while I was on it, as I recall. It was orders of magnitude more expensive than the old standby tamoxifen for only a slight advantage in efficacy.” As The Times points out, Medicare patients are unlikely to see a lower price for Zaltrap for a long while until the discount is incorporated into Medicare payment calculations for Part B, which covers physician-administered drugs. In addition, oncologists have long marked up drugs that they administer for insurers and patients. Fortunately, Sloan-Kettering doctors are on the patients’ side and question whether Sanofi’s discount will make Zaltrap more affordable for patients. Peter Bach, MD, told me: “I don’t know if they’re going through steps to ensure reimbursement goes down to follow price or not. I’m hoping that is in their plans. If not, then yes, the windfall goes to providers, and our concern is the costs passed on to patients.” Leonard Saltzman, MD, the op-ed coauthor, and gastroenterology oncologist, from Sloan Kettering also called Sanofi to task for missing the boat in making Zaltrap affordable for patients. But pharmaceutical price fixing is nothing new, according to Frederic Kaye, MD, professor of hematology and oncology at the University of South Florida in Gainesville, Florida. “I saw this happen for the first time in the late 1980s when a veterinary pill levamisole, which cost pennies for the treatment of heartworm, underwent a 100 times price escalation when it was used for treating colon cancer. There was outrage at the time over lack of regulations for price fixing, but you see almost 25 years later, it is the same.” Sanofi’s drug discount plan is clearly a business imperative. If one of the US flagship cancer treatment centers says that they will not use Zaltrap, others could follow. But the refusal to lower Zaltrap’s list price is worrisome because patient copays are based on price. More importantly, if the Sanofi plan becomes the pharmaceutical industry’s modus operandi to the era of value-based healthcare, patients will still remain out in the cold, without any added relief for the high cost of drugs. Value-based healthcare will be something for facilities and hospitals and leave patients out in the cold. These days, you have to critically review the hoopla about “patient-centered health care” and the allegedly positive partnerships shaping healthcare. Were patients included when it really mattered in drafting this drug discount program? We need to maintain a high level of skepticism about deals made strictly between drug companies and hospitals, or arrangements made between industry and physicians, or industry and health plans. It’s been said before and it must be said again: “Nothing about me [the patient] that pertains to me should be done without me at the table.”  

Follow Scientific American on Twitter @SciAm and @SciamBlogs. Visit ScientificAmerican.com for the latest in science, health and technology news.
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