michael schurr, there is a reason why PFE underperformed the other drug companies: the pall of deaths from coronary artery disease ( CAD ) continues to hang over Viagra. CAD the No 1 killer in America. Look at the WSJ article below to see how poorly the No1 killer is diagnosed and treated. So to prescribe Viagra is to accelerate the no 1 killer and to invite thousands of lawsuits from dead or crippled folks. The big Institutions have their own doctor-analysts and they know all this so they will not bit with big volume buing. The big brokerages must continue to recommend id so they can bail out the clients they put in in PFE.
This is why Humana and Prudential first and soon a whole throng of Insurance companies will nix Viagra. The cost of trating the No1 killer is astronomical; ( 1, 2, 3 angiplasties, followed by 1 or 2 coronary art bypasses, plus edless monitoring test, doctors viists, time off work, disability ets; it's a nightmare). And their decision will stand in court because they have a right not to pay for poorly tested drugs lie Viagra. And they will win because they willclaim that PFE only tested 20 patients with CAD on nitro out of 4000 which is not a representaative sample of the ED population's CAD disease incidence and which giaves people a false sense of security. The patient alimants will be able to allege the same.
So this is Viagra's swan song: one bockbuster quarter, occasioned by media hype and American's undying belief that for every illness there is a pill ( there isn't ).
In the end we'll be lucky if Viagra can be given to some of the younger ( ie no CAD ) patients with psychogenic ED and a few older without it ( there aren't too many of those . The remaining ED patients will go back to the same choices: the needle, the vacuum pump and MUSE.
United HealthCare Finds Drugs,
Tests Are Often Underutilized
By THOMAS M. BURTON
Staff Reporter of THE WALL STREET JOURNAL
MINNETONKA, Minn. -- Doctors often deride managed-care companies as meddling and stingy with medical care. But maybe doctors need to be managed.
A study by the nation's biggest managed-care company, United HealthCare Corp., is finding that many doctors who treat its patients don't follow standard guidelines for medical practice. It shows that these doctors routinely fail to prescribe essential drugs and diagnostic tests for conditions ranging from heart disease to diabetes.
"I was absolutely blown away by these results," says Lee N. Newcomer, United Health's medical director and himself an oncologist.
Using United's motherlode of computerized medical-billing and pharmacy records, Dr. Newcomer is heading a continuing survey of how medicine is practiced in the U.S. To date, United has evaluated only 1,600 cardiologists and internists in four states, Colorado, North Carolina, Ohio and Texas -- just a fraction of the 200,000 doctors in its nationwide network.
But so far, Dr. Newcomer says, "Mediocre is the best word that describes this clinical performance."
Cardiology Results
Of the cardiologists studied, many failed to prescribe widely recommended drugs such as beta blockers for heart-attack survivors and "ACE inhibitors" for chronic heart-failure patients -- drugs that current medical literature describes as essential for most such patients.
In handling diabetics, internists in Ohio gave glucose-monitoring tests, called "glycated hemoglobin" tests, to only 59% of patients during one year. The percentages were 60% in North Carolina, 65% in Colorado and 67% in Texas. Without the test to monitor glucose, diabetic patients can go blind, suffer strokes or have heart attacks, require amputations or endure kidney failure requiring transplants or dialysis. All diabetics should get at least one such test every year, says Kenneth S. Polonsky, chief of endocrinology and a diabetes specialist at the University of Chicago Medical Center. Dr. Polonsky isn't connected to United Health.
Despite the managed-care industry's reputation for withholding care, United plans to use this information to get doctors to do more tests and prescribe more drugs. The motivation isn't pure altruism. "I can buy a lot of beta blockers by avoiding the cost of treating a second heart attack," Dr. Newcomer says.
Study to Be Expanded
United Health, based in this Minneapolis suburb, soon will evaluate other fields, beginning with pediatrics and obstetrics, and plans to grade 20,000 doctors in 20 states by the end of 1998. By next year, most of the approximately 200,000 doctors in its network will be graded to see how they stack up against accepted medical norms. In fact, the company's chief executive, William W. McGuire, emphasizes that a central goal of United's recent decision to acquire Humana Inc. for $5.4 billion was to achieve efficiencies that would enable United to build better computer systems to analyze the medical success rates of doctors and hospitals.
Once United gathers a wealth of performance-related information about doctors and hospitals, it plans to make it available to the 10.4 million patients in its health plans across the U.S.
United's findings in the four states are consistent with other studies. While leading academic hospitals generally provide impressive health care, the treatment given the average American often doesn't meet generally accepted standards.
Some Other Reports
A 1995 report in the Journal of the American Medical Association found that only 16.3% of Medicare patients treated for diabetes in three states received the glucose test during the year and that only 45.9% of them got an eye exam to check for deterioration. In 1993, another JAMA article concluded that in seven managed-care plans, 16% of hysterectomies were performed for inappropriate reasons and that an additional 25% were done despite uncertain clinical benefit. There have been similarly disappointing findings related to Pap smears, well-child care, ear infections and prenatal care.
And in 1991, Harvard School of Public Health researchers examined records of thousands of New York state medical cases and found that about 2.8% of patients were avoidably sickened by their medical treatment and that about 0.5% were killed by it. Extrapolating from that, Arnold Milstein, medical director of the Pacific Business Group on Health, a group of 33 major California employers, likens the avoidable medical-care-related deaths in the U.S. to "one 747 crashing every day at O'Hare Airport."
In a report last year, medical-quality experts at Rand Corp., a not-for-profit research firm in Santa Monica, Calif., concluded that "for most care that has been studied, there are large gaps between the care that people should receive and the care they do receive."
United Health's research plan already worries some doctors. "I wonder if they're going to use this information against me," says Spencer Tilley Jr., a Greensboro, N.C., cardiologist who was found to have prescribed beta blockers for 75% of his heart-attack patients. In concept, he believes United's studies are "great things to do." But he adds: "The managed-care industry has not created an atmosphere of trust... . Managed-care people don't care about the doctors. Nobody does."
United Health responds that it will use the report cards only to help improve performance, not punish doctors. But distrust runs so deep that many doctors scoff at the notion of a managed-care company wanting to help them. "It's like when the IRS comes in and says they want to help you," says James Weissman, a doctor in Greensboro, N.C., who nevertheless says he favors the effort.
Some experts also worry that a grading system could be used as evidence in malpractice suits against United Health and any doctor who scores poorly.
Nobody expects the grading system to start a physician stampede out of United Health. It feeds a lot of patients to participating doctors, who aren't United employees but rather independent physicians authorized to handle patients who are members of United HealthCare HMOs or other medical plans.
Doctors and hospitals aren't accustomed to being graded, of course. In 1992, the federal government stopped publishing a list of death rates at U.S. hospitals, succumbing to criticism that the list wasn't adjusted for the severity of cases. As a result, U.S. patients often know less about the hospitals and doctors to whom they entrust their lives than about the cars and toasters they buy.
Private Pressure
Now, in the absence of a government spotlight, some American corporations and insurers have begun to wield their market clout to force hospitals to divulge their surgical success rates -- and then they use those findings to adjust payments to the hospitals. In the vanguard are Pacific Business Group and Anthem Blue Cross and Blue Shield, an Ohio-based insurer. Among the most advanced efforts at managed-care and HMO companies, observers say, is United Health's, although some view its work as just the first step.
"This is a reasonable place to start, because holding up a mirror to medical practice is a step forward," says Michael Pine, a Chicago-based medical consultant. "But the issue ultimately isn't the prescribing of ACE inhibitors. The issue is who is giving the best treatment of heart failure."
Before United began its study, Dr. Newcomer says, "we had been just going along fat, dumb and happy, assuming these doctors were doing a good job." He still thinks most want to. He says they simply haven't set up systems to remind patients about tests or checklists to remind themselves to see whether a patient is taking a certain medicine. This is in sharp contrast to dentists' offices, which call to nag patients about teeth-cleaning time.
Physicians "concentrate on you when you're in the room, but there's no follow-up mechanism," Dr. Newcomer says.
Dr. Newcomer, who launched the current grading program in the past two years, says he agreed with the thinking behind the plan: "If a package-delivery man can track letter delivery by the minute, then it is reasonable to expect medical professionals to track their results."
Imperfect Approach
Dr. Newcomer concedes his team's reliance on computerized records of medical and pharmacy bills isn't a perfect system. Treatments can be coded improperly on bills, or a patient may occasionally have a test done by a doctor outside the United system. But in dozens of Wall Street Journal interviews with United Health doctors in the four states, physicians raised only minor quibbles over accuracy.
And many welcomed the feedback, even when it was critical. "My initial attitude was that all I need is for somebody else to tell me how to practice medicine," says Waenard L. Miller, a Plano, Texas, cardiologist. "But I think United HealthCare did something that is important. And they did it in a nonthreatening way."
He says he was surprised to learn he himself didn't always meet the guidelines. "I'm 51 years old," he says, "and almost none of these standards were talked about during medical school and training. They are virtually all subsequent standards." Like other doctors interviewed, he says "there are really no arguments" over the guidelines.
In some cases, such as mammograms, the relatively low numbers may reflect patients' reluctance about radiation or failure to act on doctors' advice. Between 74% and 78% of women between ages 52 and 64 got a mammogram during a one-year period in United Health's evaluation. Some radiologists say that number is actually impressive. "If you get your numbers to 70%, that's very good," says Michael A. Cohen, radiologist and director of the Guttman Diagnostic Center at New York's Memorial Sloan-Kettering Cancer Center. "I think United Health will use this number as a base from which to improve."
But other results were alarming. For example, the American College of Cardiology recommends that heart-attack patients get beta blockers, drugs given to avoid a second incident, for weeks, months or years. Yet only 37% of recent heart-attack patients treated by Ohio cardiologists received the drugs within 60 days of the attack, United Health found.
Some Patient Resistance
Some patients don't like beta blockers because they can cause difficulties in concentrating in some people or produce sexual dysfunction in some men. But Matthew Sorrentino, a University of Chicago cardiologist who isn't a United Health physician, considers 37% "too low. It should probably be two-thirds." He describes the numbers United Health uncovered as "disappointing."
Dr. Sorrentino adds that ACE inhibitors are "pretty much agreed upon across the board" to treat patients with chronic heart failure. Yet internal-medicine specialists prescribed the drugs only 50% to 63% of the time in North Carolina, Ohio and Texas. In Colorado, the number was 70%.
There are also about one million Americans with a type of irregular heartbeat, called atrial fibrillation, that can lead to strokes. The American Heart Association recommends using anticoagulants such as warfarin to prevent them, even though such drugs can cause bleeding. (A Texas doctor in the United Health system had a good reason for not prescribing them to one patient, a rodeo cowboy who could bleed to death after an injury.)
Nevertheless, United found that such patients got anticoagulants at a startlingly low rate -- between 12% and 25% -- in three of the states. Only Ohio cardiologists prescribed them for 50% of patients.
But some experts worry that a system for grading doctors will have little impact at all. Since United began presenting results to doctors last fall, only a handful say they have changed their practice. United is hoping that that number will rise.
"The docs say they've got to do better, but then nothing happens," Dr. Newcomer says. "That's my biggest frustration."
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