The Trump administration moved forward on Wednesday with its plan to lower prescription drug prices by requiring drugmakers to display the list price “in a legible textual statement at the end of the advertisement.”

Secretary of Health and Human Services Alex Azar said today that when it comes to changing prescription drug prices, “putting prices in TV ads may be the most significant single step any administration has ever taken.” But patient advocates are not convinced it will have an immediate impact on drug pricing.

The rule would apply to prescriptions that cost more than $35 per month or courses of treatment, which are covered by Medicare. The rule is very specific, requiring that the price be displayed, “for sufficient duration and in a size and style of font that allows the information to be read easily.”

Industry groups have fought this move since it was announced in October. They adopted voluntary rules, that would have directed ad viewers to a website with more detailed cost information. Today, in a statement, the Pharmaceutical Research and Manufacturers of America (PhRMA) wrote that the list price is confusing since that’s not what most people pay.

The rule addresses that by requiring an additional statement that reads, “If you have health insurance that covers drugs, your cost may be different.”

PhRMA also said that the rule raises “First Amendment and statutory concerns.”

Court challenges may be coming. The legal authority given by the White House is based on the laws that require Medicare and Medicaid to be run in a cost-effective manner, according to the rule.

Rachel Sachs, an associate professor of law at Washington University in St. Louis and an expert in drug-pricing regulation, told NPR and Kaiser Health News in October that could be a weak legal argument since most drugs are marketed to the broader public, not just Medicare and Medicaid beneficiaries.

Consumer and patient advocates generally hailed the move as a step towards greater price transparency, but questioned whether it would do much to lower high prices.

“We don’t believe that disclosing list prices will shame drug corporations into lowering list prices,” says Ben Wakana, executive director of Patients for Affordable Drug Prices. “Drug companies have been shamed about their price increases for years. They appear to be completely comfortable with the shame as long as it is bringing them in the billions of dollars a year that they make from their outrageous prices.”

He gives the government credit for trying to do something on health prices, noting “taking action on this issue is hard.” But he thinks some of the administration’s other ideas to lower prices — announced in a plan released last May — might have a bigger impact.

Critics have pointed out the government’s plan for enforcing the rule is weak, as NPR reported last fall. The plan for enforcement involves competitors policing each other by bringing legal action against competitors who aren’t compliant, Azar said in Wednesday’s press briefing. He calls it “a quite effective mechanism of enforcement.”

Azar defended the government’s authority to issue the new rule. “This is not without precedent,” he told reporters. “We have for over 50 years required that car manufacturers and car dealers post the sticker price of cars on the windows of their cars and be transparent about — even though there are negotiations and everything else — because it’s a starting point that’s an important part of consumer fairness.”

The car-buying analogy doesn’t work very well for drugs, notes Adrienne Faerber, a lecturer at the Dartmouth Institute for Health Policy and Clinical Practice.

“When you go to the car dealer and you see that sticker price and you can negotiate a better price that can fit your budget directly with the car dealership,” she explains. But, she says, drug prices are negotiated through layers of middlemen: “So you don’t get to negotiate based on these prices like you would with a car.”

In other words, car shoppers have a lot more choices that sick patients do, and a lot more bargaining power.

Faerber says certainly displaying the list price won’t “magically flip a switch and cut a percentage or two off of the total drug costs.” But she says it will be interesting to see how patients react to high list prices on their TV screens.

“Consumers are going to start wondering what are people getting for that money,” she says.

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The 50-something man with a shaved head and brown eyes was unresponsive when the paramedics wheeled him into the emergency room. His pockets were empty: He had no wallet, no cellphone and not a single scrap of paper that might reveal his identity to the nurses and doctors working to save his life. His body lacked any distinguishing scars or tattoos.

Almost two years after he was hit by a car on busy Santa Monica Boulevard in January 2017 and was transported to Los Angeles County+USC Medical Center with a devastating brain injury, no one had come looking for him or reported him missing. The man died in the hospital, still a John Doe.

Hospital staffs sometimes must play detective when an unidentified patient arrives for care. Establishing identity helps avoid the treatment risks that come with not knowing a patient’s medical history. The workers also strive to find next of kin to help make medical decisions.

“We’re looking for a surrogate decision-maker, a person who can help us,” says Jan Crary, supervising clinical social worker at LA County+USC, whose team is frequently called on to identify unidentified patients.

The hospital also needs a name to collect payment from private insurance or government health programs such as Medicaid or Medicare.

But federal privacy laws can make uncovering a patient’s identity challenging for staff members at hospitals nationwide.

At LA County+USC, social workers pick through personal bags and clothing, search the contacts of an unlocked cellphone for names of family members or friends and scour receipts or crumpled pieces of paper for any trace of a patient’s identity. They quiz the paramedics who brought in the patient or the dispatchers who took the call.

They also make note of any tattoos and piercings and even try to track down dental records. It’s more difficult to check fingerprints because that’s done through law enforcement, which will get involved only if the case has a criminal aspect, Crary says.

Unidentified patients are often pedestrians or cyclists who left their IDs at home and were struck by vehicles, says Crary. They might also be people with severe cognitive impairment, such as Alzheimer’s disease, patients in a psychotic state or drug users who have overdosed. The hardest patients to identify are ones who are socially isolated, including homeless people — whose admissions to hospitals have grown sharply in recent years.

In the last three years, the number of patients who arrived unidentified at LA County+USC ticked up from 1,131 in 2016 to 1,176 in 2018, according to data provided by the hospital.

If a patient remains unidentified for too long, staff at the hospital will make up an ID, usually beginning with the letter “M” or “F” for gender, followed by a number and a random name, Crary says.

Other hospitals resort to similar tactics to ease billing and treatment. In Nevada, hospitals have an electronic system that assigns unidentified patients a “trauma alias,” says Christopher Lake, executive director of community resilience at the Nevada Hospital Association.

The deadly mass shooting at a Las Vegas concert in October 2017 presented a challenge for local hospitals that sought to identify the victims. Most concertgoers were wearing wristbands with scannable chips that contained their names and credit card numbers so they could buy beer and souvenirs.

On the night of the shooting, the final day of a three-day event, many patrons were so comfortable with the wristbands that they carried no wallets or purses.

More than 800 people were injured that night and rushed to numerous hospitals, none of which were equipped with the devices to scan the wristbands.

Staff at the hospitals worked to identify patients by their tattoos, scars or other distinguishing features, as well as photographs on social media, says Lake. But it was a struggle, especially for smaller hospitals, he says.

The Health Insurance Portability and Accountability Act, a federal law intended to ensure the privacy of personal medical data, can sometimes make an identification more arduous because a hospital may not want to release information on unidentified patients to people inquiring about missing persons.

In 2016, a man with Alzheimer’s disease was admitted to a New York hospital through the emergency department as an unidentified patient and assigned the name “Trauma XXX.”

The police and family members inquired about him at the hospital several times but were told he was not there. After a week — as hundreds of friends, family members and law enforcement officials searched for the man — a doctor who worked at the hospital saw a news story about him on television and realized he was the hospital’s unidentified patient.

Hospital officials later told the man’s son that because he had not explicitly asked for “Trauma XXX,” they could not give him information that might have helped him identify his father.

Prompted by that mix-up, the New York State Missing Persons Clearinghouse drafted a set of guidelines for hospital administrators who receive information requests about missing people from the police or family members. The new guidelines include about two dozen steps for hospitals to follow, including notifying the front desk, entering detailed physical descriptions into a database, taking DNA samples and monitoring emails and faxes about missing people.

California guidelines stipulate that if a patient is unidentified and cognitively incapacitated, “the hospital may disclose only the minimum necessary information that is directly relevant to locating a patient’s next-of-kin, if doing so is in the best interest of the patient.”

At LA County+USC, most John Does are quickly identified: They either regain consciousness or, as in a majority of cases, friends or relatives call asking about them, Crary says.

Still, the hospital does not always succeed. From 2016 to 2018, 10 John and Jane Does remained unidentified during their stays (of varying lengths of time) at LA County+USC. Some died at the hospital; others went to nursing homes with made-up names.

But Crary says she and her team pursue every avenue in search of an identity.

Once, an unidentified and distinguished-looking older man with a neatly trimmed beard was rushed into the emergency room, unable to speak and delirious with what was later diagnosed as encephalitis.

Suspecting the well-groomed man likely had a loved one who had reported him missing, Crary checked with police stations in the area. She learned, instead, that this John Doe was wanted in several states for sexual assault.

“It is a case that I will never forget,” Crary says. “The truth is that I am more elated when we are able to identify a patient and locate family for a beautiful reunification, rather than finding a felon.”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN is not affiliated with Kaiser Permanente.

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It’s early morning in an operating theater at Providence Hospital in Portland, Ore. A middle-aged woman lies on the operating table, wrapped in blankets. Surgeons are about to cut out a cancerous growth in her stomach.

But first, anesthesiologist Brian Chesebro puts her under by placing a mask over her face.

“Now I’m breathing for her with this mask,” he says. “And I’m delivering sevoflurane to her through this breathing circuit.”

Sevoflurane is one of the most commonly used anesthesiology gases. The other big one is desflurane. There are others, too, like nitrous oxide, commonly known as laughing gas.

Whichever gas patients get, they breathe it in — but only about 5% is actually metabolized. The rest is exhaled. And to make sure the gas doesn’t knock out anyone else in the operating room, it’s sucked into a ventilation system.

And then? It’s vented up and out through the roof, to mingle with other greenhouse gases.

These two gases are actually fairly similar medically; sevoflurane needs to be more carefully monitored and titrated in some patients, but that’s not difficult, Chesebro says.

Generally, unless there’s a reason in a particular case to use one over the other, anesthesiologists simply tend to pick one of the two gases and stick with it. Few understand that one — desflurane — is much worse for the environment.

And that bothered Chesebro. He grew up on a ranch in Montana that focused on sustainability. “Part of growing up on a ranch is taking care of the land and being a good steward,” he says.

Now he lives in the city with his three kids and has gradually started to worry about their environmental future. “When I look around and I see stewardship on display today, it’s discouraging,” he says. “I got depressed for a while, and so I hit the pause button on myself and said, ‘Well, what’s the very best that I can do?’ “

He spent hours of his own time researching anesthesiology gases. And he learned desflurane is 20 times as powerful in trapping heat in Earth’s atmosphere as sevoflurane. It also lasts for 14 years in the atmosphere, whereas sevoflurane breaks down in just one year.

Opening a big black notebook, filled with diagrams and tiny writing, he shows how he computed the amount of each gas the doctors in his group practice used. Then he shared their carbon footprint with them.

“All I’m doing is showing them their data,” Chesebro says. “It’s not really combative. It’s demonstrative. Ha, ha ha.”

One of the doctors he shared his analysis with was Michael Hartmeyer, who works at the Oregon Anesthesiology Group with Chesebro. “I wish I had known earlier,” Hartmeyer says. “I would have changed my practice a long time ago.”

Hartmeyer says he was stunned when Chesebro explained that his use of desflurane was the greenhouse gas equivalent of driving a fleet of 12 humvees for the duration of each surgical procedure. It’s “only” half a hummer if he uses sevoflurane. Hartmeyer notes that outside the operating room he drives a Prius.

“You try to be good,” he says. “You take shorter showers or [don’t] leave lights on, or whatever else. But you know there’s always more that we could probably do. But this was, far and away, a relatively easy thing that I could do that made a huge impact.”

The anesthesiology carts that get brought into operating theaters tend to have a row of gases to choose from. So Hartmeyer was able to switch pretty much overnight.

Other anesthesiologists made the switch, too. And it didn’t hurt that sevoflurane is considerably cheaper.

Hartmeyer’s change saved his hospital $13,000 a year.

When Chesebro shared his findings with the anesthesia departments at all eight Providence Health hospitals in Oregon, they prioritized the use of sevoflurane. They now save about $500,000 per year.

Providence’s chief executive, Lisa Vance, says the hospital system didn’t change its use of the gas because of the money. It changed because the World Health Organization now says climate change is the No. 1 public health issue of the 21st century — and because of Chesebro.

Vance said Chesebro teared up in front of 2,000 people when talking about the gas, his children and the Lorax from Dr. Seuss. “Unless someone like you cares a whole awful lot, nothing’s going to get better — it’s not,” says Vance, quoting the book.

Jodi Sherman, an associate professor of anesthesiology at Yale School of Medicine, calls Chesebro’s efforts remarkable and important.

She says several hospitals around the country have tried to make this shift, but with mixed results. Some just gave anesthesiologists the information, and not much changed. Other hospitals took desflurane away, but that left many anesthesiologists feeling disrespected and angry.

She thinks Chesebro succeeded because he chose to persuade his colleagues — using data. He showed doctors their choice of gas, plotted against their greenhouse impact. And it helped that he showed them over and over, so doctors could compare their progress with that of their peers.

“Providing ongoing reports to providers is the best way for this movement to catch on and grow,” she says. It can reinforce over time, she adds, not just what their carbon footprint is, but also what progress they’re making.

Sherman says efforts such as Chesebro’s are sorely needed because the U.S. health sector is responsible for about 10% of the nation’s greenhouse gases. “We clinicians are very much focused on taking care of the patient in front of us,” she says. “We tend to not think about what’s happening to the community health, public health — because we’re so focused on the patient in front of us.”

In an emailed statement, Baxter International, the manufacturer of the anesthesia gas, says it is important to provide a range of options for patients. The firm also says inhaled anesthetics have a climate impact of 0.01% of fossil fuels.

“The overall impact of anesthetic agents on global warming is low, relative to other societal contributors, especially when you consider the critical role these products have in performing safe surgical procedures,” the statement reads.

It’s a fair point, Chesebro says, but he has a counterargument.

“Well, if it’s there, it’s bad. And if I can reduce my life’s footprint by a factor of six … why wouldn’t you do it?”

The surgery Chesebro was involved in that morning at Providence was a success. Chesebro estimates that by using sevoflurane on his patient, the same greenhouse gases were produced as in a 40-mile drive across the Portland region.

If he had used desflurane instead, he says, it would have been like driving the more than 1,200 miles from Seattle to San Diego.

Now Chesebro’s hospital bosses are hoping other doctors will follow his lead, research their own pet peeve, and maybe solve a problem no one’s thinking about.

This story is part of NPR’s reporting partnership with Oregon Public Broadcasting and Kaiser Health News, which is an independent journalism program of the Kaiser Family Foundation and not affiliated with Kaiser Permanente.

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