Monthly Archives: December 2017

The CDC Bans Words “Science Based” and “Evidence Based”: Is this 2017 or 1984 and the Thought Police?

“The thought police would get him just the same. He had committed–would have committed, even if he had never set pen to paper–the essential crime that contained all others in itself. Thoughtcrime, they called it. Thoughtcrime was not a thing that could be concealed forever. You might dodge successfully for a while, even for years, but sooner or later they were bound to get you.”
– George Orwell, 1984, Book 1, Chapter 1

This week’s announcement in the Washington Post that the CDC has banned certain words in budget documents elicited outrage throughout the scientific community.  Science and innovation is dependent on the ability of researchers to ask novel questions and push the limits of current thinking.  Creativity, free expression and stoking controversy are an important part of the research process.  In Orwell’s 1984, censorship was the basis of the society and the Thought Police were a feared government agency.  It now appears that the current administration has enlisted Orwellian principles in the American scientific community.  If this is type of censorship is allowed to grow and expand, all of us will suffer—and patients and advancements in Medicine will suffer the most.

Banning Words and Thoughts

According to the Washington Post report, the following words have been banned in all budget communications at the CDC:

Fetus

Transgender

Diversity

Evidence Based

Vulnerable

Science Based

Entitlement

My first reaction to this report was disbelief.  REALLY? There is no way this could happen in modern America….We have come so far in the way we address questions in medicine and respond to public health issues.  From Zika to flu shots—from issues surrounding the treatment of transgender people to ways in which we can better serve underserved populations—science is blind and researchers should be dedicated to improving patient outcomes irrespective of political rhetoric.

However, after the publication of the repot in the Post, the division of Health and Human Services pushed back quickly and argued that the CDC and HHS remains committed to the use of scientific evidence to guide their recommendations for health policy.  Other Federal spokespeople have admitted that the reason for the “banned words” was to help expedite the budgeting process in Congress.  By avoiding certain words in budgetary documents, the agency leadership felt that it would be easier to get their budgetary requests through a Republican-controlled Congress.

For me, none of this really holds water.  Censorship—either direct or indirect—has no place in a government agency dedicated to science and the advancement and development of public health related policy.  As a Duke trained cardiologist, I have always been taught that the BEST way to treat patients is to use the best available scientific evidence from randomized controlled clinical trials (RCTs) in conjunction with clinical judgement to diagnoses and treat my patients.  Politics and censorship has never played a role in the way in which I practice medicine.

How Censorship Can Affect Science?

If allowed, censorship can stifle new advancements in Medicine.  Imagine a world in which Jonas Salk was not allowed to develop a Polio vaccine—or a world in which researchers were not allowed to develop a treatment for the AIDS virus—hundreds of thousands of people all over the world would suffer and die.  Much of our research funding comes from government agencies such as the National Institute of Health (NIH) and public health policy is also set by multiple government agencies including the FDA and the CDC.  IF we allow censorship, then the grant approval process and funding of research projects may be politically motivated.

It’s Time for Action

Politics has no place in science.  Science is neither Republican or Democrat—science is HUMAN and transcends race, gender and religion.  Science is all about passion, compassion, drive and innovation.  Science brings people together—politics divide us.  While HHS has now pushed back at the Washington Post report, the seeds of censorship in medicine have been planted.  As physicians, researchers, scientists and patients we cannot allow this type of behavior to be swept under the carpet.  All of us have a responsibility to express our outrage—reach out to your representatives in Congress today.  As for me, I will be in Washington DC this week to express mine on behalf of all physician scientists and patients.  For my colleagues in Medicine I implore you all:  Continue to innovate—continue to ask the hard questions—continue to think independently—Let’s all stay a step ahead of the “Thought Police” in our nation’s capital.

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CVS, Aetna and REM: It’s The End Of The {Healthcare} World As We Know it

This week, it was announced that two of the largest players in the American healthcare market have agreed to merge in a deal worth nearly 70 billion dollars.  This merger represents a departure from the traditional way in which doctors, patients, insurers and pharmacists have interacted for decades.  In the past, insurers and pharmacies have existed in separate silos.  As I discussed in a recent Op Ed, this old system was far from perfect.  Pharmacy benefit managers (PBMs) have taken advantage of patients, doctors and drug manufacturers and have served to raise the cost of medicines through demanding kickbacks known as “rebates”.  As bad as PBMs have been for healthcare, this new merger may actually be WORSE.  Now, mergers such as the CVS/Aetna deal will essentially bring the “Soprano-like” PBMs in house.  In addition, in the last several years, CVS has ventured into the healthcare provider market as well—staffing primary care “clinics” with pharmacists and nurse practitioners in retail stores (note the glaring absences of physicians in the CVS care model).  While CVS argues that the combination of a health insurance company and a pharmacy (that provides primary care services) will streamline patient care and lower costs, I believe it is likely to do just the opposite.

What IS the Likely  Impact of the Insurance Company/Pharmacy/Clinical Services Mega Store on Healthcare?

If this merger is allowed to proceed, all players (except for the mega CVS/Aetna conglomerate) in the US healthcare system will suffer negative consequences.

  1. Diminished Choice

Currently, many patients have limited access to drugs due to the role in which PBMs play in negotiating prices and determining what is on “formulary”.  This less than transparent process basically involves a system of bids from manufacturers where the highest bidder (for a rebate that is pocketed by the PBM) wins the preferred formulary status.  In addition, the PBMs can require patients to deal with a process of “step therapy” where they are forced to use less expensive (and potentially less effective drugs) than originally prescribed by their physician prior to being allowed to take the intended therapy.  If this acquisition is allowed to proceed, we will see even less choice.  Now, an insurer (who is motivated financially to prohibit access to more expensive therapies) will be partnered with a pharmacy who can potentially decide to only stock certain medications.  Price fixing may become the norm—if you are an Aetna customer, you may be only allowed to purchase your medications from CVS—even if there are cheaper options for you elsewhere.

  1. Rising Costs

When there is less competition, the consumer always suffers.  If we allow CVS and Aetna to merge, we are likely to see costs rise.  Healthcare consumers will not be allowed to shop around for less costly purchasing options.  I foresee a system where Aetna is able to dictate that ALL covered medications must be purchased from CVS.  If

  1. The Demise of the Doctor Patient Relationship

Medicine is defined by the way in which doctors and patients interact.  Trust is built over years of interactions—not in a minute clinic.  By removing the physician from the healthcare equation (as this merger is likely to do), patients will no longer be able to bond with a provider who can help them make difficult healthcare choices as they age.  Minute clinic staff tends to be more transient that physicians that work in long standing practices and medical groups.  While minute clinics can certainly be a great way to triage and treat simple, common primary care issues such as colds and flu, it is not a great venue for long term care of chronic disease.  Highly trained physicians who have completed between 3 and 10 years of Residency and Fellowship training AFTER the completion of their medical degrees are better equipped to make difficult diagnoses and manage complex diseases over time.  As a for profit entity, CVS is focused on cost containment—and Nurse Practitioners are far cheaper staff than board certified physicians.  In an ideal world, NPs and physicians work together and co-manage patients as each professional brings a unique perspective and a unique skill set to the clinical arena.

  1. Poorer Outcomes

When we focus purely on the economics of healthcare rather than evidence based medicine for therapy choice, outcomes will most certainly be less favorable.  If the CVS/Aetna merger is allowed to proceed, I expect all clinical decisions by CVS minute clinic staff will be based on treatment protocols and algorithms that are developed to contain cost.  Let’s be realistic—CVS and Aetna are in this to make money for their executives and their stockholders—the patient is really not their top priority.  Care delivered only by a Nurse Practitioner in a minute clinic is not the same as the care delivered by a Residency and/or Fellowship trained physician in a continuity clinic.

Ultimately, it is my hope that regulatory bodies in Washington DC will recognize this planned acquisition for what it is—an assault on the way in which medicine is practiced in the United States.  We continue to allow for profit corporations to dominate the decision making when it comes to healthcare policy.  WE must act to change this paradigm and PUT PATIENTS FIRST.  As Michael Stipe of the rock band R.E.M. wrote in his song, “world serves its own needs , don’t mis-serve your own needs”  If we do not act, this merger will be the first of many and will likely be “The End of  The {Healthcare} World As We Know It”

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