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The Battle over Biologics; Interview with Dr. Denis Cortese; An Epidemic People Are Ignoring: Skin Cancer

Aired March 20, 2010 - 07:30   ET


DR. SANJAY GUPTA, CNN HOST: Good morning. I'm Dr. Sanjay Gupta.

Welcome to a special place -- a place where you're going to learn how to live longer and stronger. I'm your doctor. I'm also your coach.

And there's battle going on out there over biologics. Maybe something you've never heard of, but that could be the reason we pay so much for drug costs.

Speaking of costs incidentally, go to hospitals around America. The concern is always that we pay too much and get too little. But there are places doing it right. We'll talk to the leader of one of those places.

And, finally, a medical mystery. Potentially, an epidemic out there that so many people are ignoring. Do you know what it is? We'll tell you.

Let's get started.


GUPTA: We start, though, with news to affect your wallet. There's a battle going on out there, this battle over biologics.

Now, this is the part of health care reform that you may have never heard of. The power of big pharmaceutical companies and the wonder drugs that they make are all very expensive. We know that. They're likely to stay that way for at least a dozen years, and you can blame it on the power of lobbyists.

Here's CNN's senior congressional correspondent Dana Bash. She's been investigating the story.


DANA BASH, CNN SR. CONGRESSIONAL CORRESPONDENT (voice-over): To watch Jim Greenwood is to watch old-fashioned, bare-knuckled Washington lobbying.

JIM GREENWOOD, BIOTECHNOLOGY INDUSTRY ORGANIZATION: I went office to office in the House and in the Senate with my little molecule of ... BASH: And pushed a provision buried inside the health care bill that could save the pharmaceutical industry he works for billions in profits -- opponents say at the expense of you, the consumer.

(on camera): What happened?

KATHLEEN JAEGER, GENERIC PHARMACEUTICAL ASSOCIATION: Well, I think what happened is, unfortunately, politics trumped policy.

BASH: So, what that's all about? Nothing short of miracle drugs, and the crossroads between how much it costs to make them and what you pay for them.

(voice-over): The drugs are called biologics, made from living organisms and programmed to target specific, hard-to-treat maladies.

DR. GAIL WASSERMAN, MEDIMMUNE, DEVELOPMENT: We have protein biologics now for multiple sclerosis or for respiratory syncytial virus infection or for oncology.

BASH: And they sell for blockbuster prices. Biologics are cash cows. Consumers spend more than $40 billion a year on them.

Sharon Brown says the biologic Enbrel rescues her from debilitating rheumatoid arthritis. Listen to the cost.

SHARON BROWN: $1,591.80 -- that's for four injections.

BASH: Her insurance has a cap, so she takes the weekly drug every other week.

BROWN: I just cannot simply afford the medication.

BASH (on camera): For chemical drugs like these, there is a law that allows generics which are cheaper. But it doesn't apply to biologics like Sharon Brown's Enbrel.

So, Democrats in their health care legislation which they say is aimed at lowering costs decided to make a path for generic biologics, which would bring the cost of the drugs down.

(voice-over): To do that, the president wanted to give brand biologics exclusive rights for seven years before cheaper generics could enter the market. But the pharmaceutical industry lobbied for more, 12 years, and prevailed. Their argument? Development takes an average of 12 years and a billion-plus dollars.

GREENWOOD: If we want people to invest in new cures for cancer and diabetes and for AIDS and all of that, then you have to make sure that they're going have some chance to get their return on their investment.

BASH: And keeping them honest, brand name biologics had major reinforcements to make their case. Last year, pharmaceutical manufacturers spent more than $263 million in lobbying. Do the math, that's more than $721,000 a day. And in 2008, they gave $30 million in campaign contributions, a record half of that to Democrats.

JAEGER: You know, the brand industry with their deep pockets have made some really great friends in the Democratic, you know, Party.

BASH: To be sure, the generics lobby did have powerful allies, not just the president but AARP, unions and more. But brand name biologics outspent them and worked the system.

Jim Greenwood isn't just the president of BIO. He's a former member of Congress.

(on camera): You are a former member of the club.


BASH: That helps.

GREENWOOD: Well, it helps in this way. It helps -- I know what people want -- what they need, what kind of information they need before they vote.

BASH (voice-over): The result in this committee and others, many Democrats voted to give brand name biologics a longer corner on the market.

SEN. SHERROD BROWN (D), OHIO: This language now is anti- competitive. It will help the drug companies reap billions of dollars more in profits. It will restrict access to all kinds of life-saving drugs for people, and too many Democrats side with the drug industry.

BASH: Thanks, in large part, to the money and manpower behind their Washington lobbying.

Dana Bash, CNN, Capitol Hill.


GUPTA: All right. Dana, thank you.

And later on, I'm going to be talking with the former head of the Mayo Clinic. Here's why -- it's one of the hospitals in this country that really seems to get it right. Patients get great care, and also, the costs are kept relatively low. He says most of us aren't getting what we pay for. We're going to have that ahead.

And do you know what causes low blood pressure? One viewer e- mailed us, wanted to know. We'll answer in "Ask the Doctor." That's next.

Stay with us.


GUPTA: We're back with the program. Every week at this time, I'm going to answer your questions. Think of this as your own appointment. No waiting. No insurance necessary.

Let's get right to a question from Iris in Gainesville who asks this, "What is hypotension?"

It's interesting. You know, a lot of people ask about this and a lot of people don't know necessarily about hypotension or hypertension, what the differences are.

Hypotension is also known as low blood pressure. It happens when blood pressure during and after each heart beat is much lower than usual. And what that means obviously is your heart, your brain, other parts of the body are simply not getting enough blood.

And unlike high blood pressure, there's no specific threshold your day-to-day blood pressure has to hit before it's considered too low. Some people simply run low. That's what you may have heard at the doctor's office, but there's sort of a guide, anything below 90 over 60 would be considered low.

Now, hypotension is often the number one cause of people fainting. It happens a lot when you get dehydrated. Blurry vision can also occur when someone's blood pressure starts to get low. They also may have clammy skin.

What's interesting, though, is that simply hydrating, more often than not, is the number one way you can take care of this. Too many people are simply dehydrated.

Your diet could also be playing a role here. If you're low in sodium, for example, we always talk about people taking too much salt, too much sodium, but there are also people who simply don't take enough.

There are also some medications to watch. Medications like diuretics, alpha blockers, beta blockers, drugs for Parkinson's disease, certain type of antidepressants. They can cause it as well -- conditions like pregnancy, heart problems, allergic reaction, severe infections, blood loss, of course, lack of nutrients in your diet.

Look, this is something that affects a lot of people, but as always, consult with your doctor and direct any questions if you have any concerns.


GUPTA: Now for "Fit Nation" this week, we're going to talk about something that I'm very interested in. I think about this all the time. People say they don't have enough time to exercise. Well, a lot of people say, look, that's not an excuse anymore. There's some new research out there that says you can exercise less and get just as fit. Now, this is going to sound a little bit gimmicky. But stay with me here. The key to all this is what's known as, something known as HIT, high interval training. Researchers found that just 20 minutes of high intensity exercising thus burns more calories and possibly build more muscle than someone who jogs leisurely for even an hour.

Here's why. If you exercise very intensely for a minute, take a break for a minute, exercise for a minute, take a break and so on and so forth for about 20 minutes or so, so you get 10 minutes of hard exercise at the end, and 10 minutes of a little bit more rest. And what they found was, first of all, your heart rate, while it did drop during the rest periods, it did not drop significantly. So you were continuing to have an aerobic workout, possibly even anaerobic workout.

The second thing was your endurance measured after a period of time seemed to be almost as good as someone who did the longer, more leisurely workouts. So, a lot of benefit at least, according to the study, in a much shorter time.

Now, there's all types of exercise that could work. You know, cycling, running, swimming. These sports are better for this type of training. So, here's something I thought of. If you're running, for example, you find a hill that takes about minute to run up. Then walk back down the hill. Then run it back up. Keep doing this back and forth for 20 minutes.

Bottom line here: take a look at your fitness goal and if lack of time is an issue -- for a lot of people it is -- then the short duration high intensity intervals could be a solution that works for you. Little bit of advice there.

Straight ahead: I'm going to talk with a man who ran one of the best hospitals in the country and what he says the keys are to saving your money and getting better care. That's next.


GUPTA: And welcome back to SGMD.

Today, I'm with Dr. Denny Cortese. Now, he's foundation professor at the business and engineering schools at Arizona State University. Until very recently, he was president and CEO of the Mayo Clinic in Minnesota.

As many people know, Mayo is famous for delivering high quality care and also doing it very efficiently. Not surprisingly, given these times, Dr. Cortese is very much in demand nowadays.

Dr. Cortese, thanks so much for joining us.

DR. DENIS CORTESE, FORMER MAYO CLINIC CEO: You're welcome. And it's real pleasure to be with you, Sanjay.

GUPTA: How did you decide to go into medicine? When did you decide that? What inspires you? CORTESE: That's an interesting question. But I've known I wanted to be in medicine since I was 13. I've developed an interest back then. I don't know exactly why.

But I do know I was playing a fair number of sports as I went through junior high and high school, and I always enjoyed and admired the team physician and he was a local practitioner in the community where I grew up in Cheltenham, Pennsylvania.

GUPTA: You've had, obviously, a remarkable career, and, you know, most recently, as president and CEO of the Mayo Clinic. But did you ever get disenchanted with medicine? Ever have second thoughts?

CORTESE: Oh, no, never. I would -- if I go back and did it over again, I'd do the same thing. The miserable part about medicine is all of the surrounding things, the insurance and the billing and all of the rest of that. But the caring for patients is the most exciting thing, and taking new knowledge, and bringing it to the care of patients is the main reason for physicians I think to be practicing.


CORTESE: It's a great profession.

GUPTA: You know, what's remarkable about Mayo is that it's obviously a world class institution -- often referenced as the place where medicine is practiced and you get the best medicine, perhaps in the world. But you also do it with less cost and much more efficiently.

How do those two things go hand in hand? It seems -- most people think about those two things as being opposite. If you provide the high quality care and you have the Mayo Clinic brand, it's going to costs more. Why doesn't it?

CORTESE: First of all, within -- I've been at Mayo Clinic for 40 years practicing medicine. And I can tell you, during those 40 years, we paid just about no attention to the specific total amount of cost we were incurring on people. As a matter of fact, many of us would have thought that we were a high cost organization.

However, what we did concentrate on was not amount that we were costing. We concentrated on what were the needs of the patient, what did they really need have done and, also, the incentive that physicians were all already on a salary. So, we weren't incented to do more if we didn't have to.

Somehow, when people, many years later, looked at the outcomes of that kind of a practice model, it turns out that we're less expensive. And the main reason it is less expensive is because we tend to do fewer things to people than might be occurring elsewhere. We tend to have fewer days in the hospital, fewer days in ICU, fewer procedures that are being done, fewer excess testing and that sort of thing.

GUPTA: And that seems like where we should have evolved, right, as a medical establishment. I would say that most doctors, most health care providers want to do those things. Why doesn't it happen except for the places -- some of the places you just mentioned?

CORTESE: There are many places in the country that have done this with different models and as they have done that, as the patients -- as the care has become safer, with better outcomes in every instance, it's turned out to be lower expense, also.

GUPTA: We have to take a short break now. I'm going to be back with Dr. Denis Cortese in just a moment.

Stay with SGMD.


GUPTA: We are back with Dr. Denny Cortese. He's foundation professor at the business school and engineering school at Arizona State University. Until recently, he was president and CEO of the Mayo Clinic in Minnesota. They're known for their high quality and their unique approach for patient care at lower cost as well.

The mantra right now, as you well know, is that this is a country that costs -- I mean, charges and pays way too much and gets too little in return. Who's wearing the black hat? Is there someone that you point to and say, there's the problem? There's the black hat in all this?

CORTESE: You know, I don't think there's any one place to point to. I think it's been an evolution over many years.

Over the past several years, payment has really been linked very much to whatever is done. We ended up with a model that is now called "fee for service," where we are paid for doing things to people.

The ultimate of that, if carried to the extreme, would be the sicker you are, the more money we make as physicians. The more times you come into our office, the more money we make. The more procedures we do, the more money we make.

That's just the opposite of what high value care should be all about. Do we pay the most amount of money to people that may do procedures or should we be paying a little more money to nurses and primary care doctors to keep you from needing those procedures?

GUPTA: Are there greedy people in the system the way you just outlined it? Doctors greedy, pharmaceutical companies greedy, insurance companies greedy -- is that what has driven some of this?

CORTESE: I think so. I think that's been part of it. There's an element of greed there. There's always the element of fraud that is lurking in there.

And to me, whatever those ancillary drivers are that have pushed prices up have been sort of caused by the fact that the country has not focused on getting its money worth out of health care.

GUPTA: Let me broach one topic with you, which is -- which is a tough one to explain. But there's -- the criticisms that you hear are often centered around rationing. Will there be rationing of care? And the term that makes people's eyes glaze over, frankly, Dr. Cortese, is comparative effectiveness -- this idea that you figure out what works and you pay for those things or reimburse for those things. And things that don't work, you don't necessarily pay for those things or it's not as easy for those particular procedures or treatments.

Is that a type of rationing? And let me take it a step further, given your background -- how much of medicine is an art versus science?

CORTESE: With regard to comparative effectiveness. What that really means is, if I -- if I were sick and I were a patient and let's say I had high blood pressure, and given my circumstance, maybe my genes, my proteins, my family history, there might be two or three drugs that are available for me. Well, the patients and the doctors ought to be interested in what is the comparative effectiveness for each one of those three.

Effectiveness means what might be best for that person? What might work best for that particular person? Comparative effectiveness is the science side of the question.

Now, when you end up working with a patient in making the final treatment, you may have to bring in the art of medicine, because the way you treat a patient going forward might very, very much depending on their personal needs, their family needs, and some patients will decide and say, "Doctor, thank you very much, but I prefer no treatment, just keep me comfortable."

So, you can use the art of medicine in the way we provide those care. But we should use science in the way we make a decision.

GUPTA: You're such an important voice in all this, and I'm delighted to be able to speak to you and hope to speak to you much more often in the future. Thanks so much for joining us.

CORTESE: OK. Well, you're welcome. Thank you.


GUPTA: Welcome back to the program.

And a quick update now on Baby Patricia. As you may remember, she's a 2-month-old rescued after spending five days in the rubble following Haiti's earthquake. She had multiple serious injuries and was flown to Miami for urgent care.

A few weeks ago, a couple came forward claiming to be the baby's parents and DNA testing has now confirmed that. Her parents now are free to take Jenny. That's her real name, incidentally, back home to Haiti once her treatment in Florida is done.

And on Monday, former Presidents George W. Bush and Bill Clinton are going to travel to Haiti to meet with officials involve in relief efforts. They're going on behalf of the Clinton/Bush Haiti Fund. That was, of course, created to raise money after January's earthquake.

And we got some time now for a medical mystery of the week. This is a disease that so many people are ignoring but is now becoming an epidemic. The answer is skin cancer, specifically nonmelanoma skin cancer.

Now, researchers say skin cancer has become an epidemic in the United States. Nonmelanoma skin cancer rates have more than doubled in the last 15 years. A lot of this is payback for people not paying attention in the '60s and '70s, not taking adequate sun prevention.

What surprised me the most about these cancers, though, is that it affects individuals more than all other cancers combined. The reason: people still aren't protecting themselves against the sun. Most people think it's not going to happen to me. Also, people are living longer and getting more diseases just like this one.

You see, skin cancers typically begins to develop in our younger years when most of us spend too much unprotected time but then it starts to accumulate over time. We're talking specifically about nonmelanoma skin cancers. There are two types: basal cell carcinoma and squamous cell carcinoma.

And as we're taking a look at these images -- first of all, that's an image of the skin and you can see that little lesion in the middle there. That is what basal cell carcinoma looks like. If you take a little bit of a closer look, what you're looking for is sort of that indented area on the side there, on the top. That can be a little bit of a red flag that maybe you should go see your dermatologist.

There's also squamous cell carcinoma. And a lot of people heard about this as well. Take a look. It tends to be al little rougher, a little patchier, tends to have more of a scaly sort of nature to it. That is squamous cell carcinoma.

Both of them incidentally are rarely fatal. But if left untreated, they can be very painful. They can cause deformities and cause all kinds of scarring as well.

A lot of people ask: how do I know when something is potentially a problem? Well, really, it's as simple as the ABCDs. You may have heard this before.

But, "A," what you're looking for when looking at a suspicious mole or a suspicious, lesion, asymmetry, half of it looks different. The borders, for "B," could be rough or scaly. The colors -- tan, brown, black or red, or if it's changing color. That can be for incidence as well. And the diameter: larger than a pencil eraser. Those are things that you really need to pay attention to.

The biggest thing, if those things are changing, that raises your level of concern, certainly. Make a trip to the dermatologist then and certainly get it checked out.

Well, if you missed any part of today's show, be sure to check out my podcast at

And remember, this is the place for the answers to all of your medical questions. Thanks for watching.

I'm Dr. Sanjay Gupta. More news on CNN starts right now.