Trump Nominates Former Pharmaceutical Executive as HHS Secretary

President Trump on Monday announced Alex Azar, a former pharmaceutical executive, as his choice to succeed Dr. Tom Price as secretary of Health & Human Services (HHS) (1). HHS is an 80,000-employee federal agency that oversees the Centers for Medicare and Medicaid Services, the Food and Drug Administration, the National Institutes of Health, and the Centers for Disease Control and Prevention. Price resigned in September following reports of his extensive use of government and charter air travel.

Azar, a lawyer, formerly headed Eli Lilly & Co.'s U.S. division. Before that, he served as HHS general counsel and deputy secretary during the George W. Bush administration. During that stint, he received praise for his management competence. Azar "will be a star for better healthcare and lower drug prices!" Trump tweeted.

Andy Slavitt, CMS administrator under the Obama administration, also a lawyer and former United Healthcare executive, offered cautious praise for Azar. "I have reason to hope he would make a good HHS secretary," Slavitt said in a written statement. "He ... has real-world experience enough to be pragmatic, and will hopefully avoid repeating the mistakes of his predecessor in over-politicizing Americans' access to healthcare."

If confirmed, Azar would inherit an agency currently torn by political and policy divisions in the wake of Price's departure (2). He will have to make key decisions to avoid further disruption in the individual health insurance market; how much leeway to give states to make big changes in their Medicaid expansion program; and face pressure to address rising prescription drug costs. One management issue Azar would quickly face is how to deal with Price's ambitious Reimagine HHS initiative to streamline the department's operations and with the White House’s proposal to slash the HHS' budget for 2018 by 18%.

Azar has been a sharp critic of the Affordable Care Act, saying in May that the ACA is "fundamentally broken" and "circling the drain." In June, he envisioned the Trump administration shifting the ACA in a more conservative direction even without repeal and replacement of the law. He also has opposed reducing prescription drug prices or allowing purchasing drugs from other countries where prices are lower.

If confirmed, Azar will represent a return to the recent tradition of selecting Secretaries of HHS with no medical background. Before, Price, only Dr. Otis Bowen (1985-9) and Dr. Louis Sullivan (1989-93) were physicians of the 11 non-interim Secretaries.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Meyer H. Can Trump's pick to lead HHS navigate the churning political waters of healthcare? Modern Healthcare. November 13, 2017. Available at: http://www.modernhealthcare.com/article/20171113/NEWS/171119968?utm_source=modernhealthcare&utm_medium=email&utm_content=20171113-NEWS-171119968&utm_campaign=am (accessed 11/14/17).
2. Pradhan R, Diamond D. Price investigation continues to roil HHS. Politico. November 13, 2017. Available at: https://www.politico.com/story/2017/11/13/tom-price-private-jets-probe-hhs-244793 (accessed 11/14/17).

Cite as: Robbins RA. Trump nominates former pharmaceutical executive as HHS secretary. Southwest J Pulm Crit Care. 2017;15(5):221-2. doi: https://doi.org/10.13175/swjpcc140-17 PDF

Arizona Averages Over 25 Opioid Overdoses Per Day

An Arizona Republic article and the Arizona Department of Health Services Director's blog, Dr. Cara Christ, brings the opioid crisis home (1,2). Christ states that over 3200 opioid overdoses with over 400 deaths occurred between June 15 and October 17 in Arizona. This averages to over 25 overdoses and 3 deaths per day.

Some of the data from Christ’s blog are below:

• Males 25-29 have the highest rates of suspected opioid overdoses.
• 37% of people experiencing a suspected opioid overdose had an opioid prescription in the two months prior to their overdose.
• The majority of overdoses occur at home.
• The most commonly cited pre-existing health conditions of those with suspected overdoses was chronic pain. Depression and other behavioral health conditions were also common health conditions noted.
• Meth and heroin were the most frequently cited drugs involved in reported neonatal abstinence syndrome.
• About 40% of people experiencing suspected opioid overdoses who had a prescription in the Controlled Substances Prescription Monitoring Program had been prescribed both benzodiazepines and opioids in 2017. When these medications are combined, it is so dangerous that the FDA gives it a “black box” warning.
• About 40% of people experiencing a suspected overdose that had prescription history in the Controlled Substances Prescription Monitoring Program (CSPMP) had received opioid prescriptions from 10 or more providers.
• Only about 25% of clinicians prescribing controlled substances checked the CSPMP prior to prescribing.

On October 16, a new mandate went into effect that requires clinicians to check the CSPMP prior to prescribing an opioid or benzodiazepine. Other states implementing such mandates have experienced reductions in people with 4 or more prescribers or pharmacies, reductions in opioid prescribing, and reductions in Morphine Milligram Equivalent daily doses.

The CSPMP requires registration and login but is relatively easy to use (3). You can search not only in Arizona but other states as well. Personally, as a pulmonary consultant I infrequently prescribe opioids or benzodiazepines. However, I have used the website once to check a benzodiazepam prescription for a patient I suspect might be addicted. No other prescriptions were found. It at least gave me some assurance that he was not obtaining prescriptions from multiple practioners while we attempt to wean him off this medication.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. McCrory C. More than 400 opioid-overdose deaths reported in Arizona since June 15. Arizona Republic. October 27, 2017. Available at: http://www.azcentral.com/story/news/local/arizona/2017/10/27/more-than-400-opioid-overdose-deaths-reported-arizona-since-june-15/809157001/ (accessed 10/28/17).
2. Christ CM. Opioid update: latest data and emergency rules update. October 17, 2017. Available at: http://directorsblog.health.azdhs.gov/opioid-update-latest-data-and-emergency-rules-update/ (accessed 10/28/17).
3. Arizona Board of Pharmacy. Arizona PMP Aware. Available at: https://pharmacypmp.az.gov/ (accessed 10/28/17).

Cite as: Robbins RA. Arizona averages over 25 opioid overdoses per day. Southwest J Pulm Crit Care. 2017;15(4):179-80. doi: https://doi.org/10.13175/swjpcc133-17 PDF 

Maryvale Hospital to Close

Abrazo Health Care has announced that it intends to close Maryvale Hospital effective December 18, 2017. Maryvale Hospital has had declining admissions and was realigned as a satellite facility of Abrazo West Campus in Goodyear in May 2017. Abrazo said they hoped to place most of the 300 Maryvale employees at other Abrazo medical centers.

Richard A. Robbins, MD

Editor, SWJPCC

Cite as: Robbins RA. Maryvale hospital to close. Southwest J Pulm Crit Care. 2017;15(4):164. doi: https://doi.org/10.13175/swjpcc129-17 PDF 

California Enacts Drug Pricing Transparency Bill

The Mercury News is reporting that California governor Jerry Brown signed a bill Monday making drug pricing more transparent (1). The legislation requires pharmaceutical companies to notify health insurers and government health plans at least 60 days before making price hikes and explain the reason for the increase. The pharmaceutical industry had lobbied hard against the measure, worried that it could become a national model and the first big step toward price controls. “The essence of this bill is pretty simple,” Brown told a room filled with supporters of Senate Bill 17. “Californians have a right to know why their medical costs are out of control, especially when the pharmaceutical profits are soaring. That’s the take-away message.”

“It is disappointing that Gov. Brown has decided to sign a bill that is based on misleading rhetoric instead of what’s in the best interest of patients,” said Priscilla VanderVeer, spokeswoman for the Washington, D.C.-based Pharmaceutical Research and Manufacturers of America. She added that there is “no evidence that SB 17 will lower drug costs for patients.”

The bill does not actually control drug prices, leading some critics to suggest it is toothless. However, the bill’s backers say that transparency in other health care sectors has been successful in reducing costs. Anthony Wright, executive director of Health Access California, agreed. He said the advance notice and information required under SB 17 “is invaluable” to large health care purchasers such as insurers, union trusts and employers, and would enable them to drive a better deal for consumers.

Brown also signed a related bill on Monday. Assembly Bill 265 will prohibit prescription drug manufacturers from offering discounts for name-brand drugs, if a less-expensive equivalent brand is available, preventing the use of higher-priced drugs when unnecessary.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Seipel T. Gov. Brown signs drug pricing transparency bill. The Mercury News. October 8, 2017 (updated October 9). Available at: http://www.mercurynews.com/2017/10/08/gov-brown-to-sign-drug-price-transparency-bill/ (accessed 8/10/17).

Cite as: Robbins RA. California enacts drug pricing trasparency bill. Southwest J Pulm Crit Care. 2017;15(4):159. doi: https://doi.org/10.13175/swjpcc122-17 PDF 

Senate Health Bill Lacks 50 Votes Needed to Proceed

Yesterday (7/17), two additional Senators – Sen. Roberts (R-KS) and Sen. Lee (R-NE) joined Senators Paul (R-KY) and Collins (R-ME) in announcing their intention to vote “no” on the motion to proceed on considering the Senate ACA repeal and replace legislation – effectively blocking Senate consideration of the current Senate Republican health care bill. Senators Paul, Lee and Roberts opposed the bill for not going far enough, while Senator Collins expressed her concern the bill goes too far.

With the 4 publicly announced NO votes – Senator Majority Leader Mitch McConnell does not have the 50 votes needed to begin debate on the bill, let alone assure final passage.

Speculation now turns to what happens next. President Trump has tweeted his preference to let Obamacare fail as a way to force Democrats to negotiate new legislation. Senator McConnell has suggested a series of symbolic votes on full repeal with multi-year delay to work on a replacement plan or voting on the House passed bill. However, three moderate senators, Capito (R-WV), Collins (R-ME) and Murkowski (R-AK), announced today they will not support procedural votes on an immediate ACA repeal bill.  Alternatively, Congress may abandon the health reform effort for the time being and pivot to other legislative priorities (tax reform and infrastructure). The failure of McConnell to lead the Senate effort may clear the way for a bipartisan effort to address the shortfalls of the ACA.

Please keep in mind the House repeal and replace effort “died” before the House ultimately passed its repeal legislation, so while the Senate effort looks to be “permanently stalled” it is probably premature to call it “dead.”

Nuala S. Moore

American Thoracic Society

Washington, DC USA

Cite as: Moore NS. Senate health bill lacks 50 votes needed to proceed. Southwest J Pulm Crit Care. 2017;15(1):45. doi: https://doi.org/10.13175/swjpcc093-17 PDF