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America pays higher prices for drugs because the government doesn’t negotiate with insurers. The government doesn’t negotiate with insurers in part because we have a powerful pharmaceutical industry that lobbies the government not to, but also in part because we’re not willing to have the government say, “Nope, we’ve decided you can’t sell your expensive treatment here,” which is a major way that other governments get their bargaining power. Telling Americans they can’t have stuff is really politically unpopular, so we mostly don’t do that. Instead, we pay some of the highest prices in the world for prescription drugs. That sounds terrible! But it also has a benefit: Those profits give drug companies the necessary incentive for innovation. (Megan McArdle, 12/7)

Congress has voted to change the way new prescription drugs are approved, in a way that could endanger patients. ... The bill in question would direct the Food and Drug Administration to consider “real-world evidence” in deciding whether a new drug is safe and effective -- that is, evidence (such as observational studies or patient registries) not derived from randomized clinical trials, the gold standard for evaluation. It would also compel the FDA to take into account individual patients’ subjective experiences. And it could open the door to allowing outside experts, rather than just FDA staff, get more involved in reviewing new drugs or devices. Proponents say these changes are needed to speed the review process and bring new drugs to market. But that is a solution in search of a problem. (12/7)

Last week, Jennifer Jacobs of Bloomberg reported that Pete Hegseth, the founder of Concerned Veterans for America, was being considered by President-Elect Donald Trump for the cabinet position of Secretary of Veterans Affairs. While Trump’s cabinet picks have routinely exceeded expectations, picking Hegseth would achieve something rarer: the nomination of the single best qualified person to lead the VA. (Avik Roy, 12/8)

Kratom, an herbal supplement that was once a quiet member among the legion of botanical products sold in the United States, exploded onto the national scene in August 2016 when the Drug Enforcement Administration announced plans to classify it as a Schedule 1 controlled substance. As such, it would join heroin, LSD, ecstasy, marijuana, and other so-called recreational drugs as a substance with “a high potential for abuse and the potential to create severe psychological and/or physical dependence.” The DEA withdrew its call to ban kratom, and instead asked for public comments on the product. The comment period closed Dec. 1. We believe that a move to make kratom a Schedule 1 controlled substance is premature and shortsighted, from both the scientific and clinical perspective. It would make it nearly impossible for researchers to fully examine its safety and clinical uses. (Walter C. Prozialeck and Anita Gupta, 12/7)

Taking care of older patients can be a challenge. Some have multiple health conditions, and many are homebound, making a trip to see their primary care doctor almost impossible. House calls will almost certainly become a way to improve the care of our geriatric patients and will become an essential piece of the provision of care in the future. In fact, legislation being discussed in Congress would help make home-based medical care a financial reality. Making house calls sounds simple. But we worry that physicians-in-training aren’t learning the skills they need to care for their patients at home. (Katherine T. O’Brien and June M. McKoy, 12/7)

Concerns about the mental health of future physicians have existed for decades. For example, in 1936, Strecker et al described 4 levels of impairment of psychologic functioning of medical students. In this issue of JAMA, 80 years later, the studies by Rotenstein and colleagues and by Wasson and colleagues shed new light on the issue of poor mental health of medical students by examining 2 different aspects of the problem. (Stuart J. Slavin, 12/6)

Changes in personnel on the inpatient service, including residents and attending physicians, create uncertainty. Residents who are leaving the service rotation and handing off the patients to the next resident team generally prefer the service to be neat and tidy, to involve little for the next team to have to do immediately, and, perhaps most importantly, to be small. Accordingly, some teams will work especially hard to discharge patients before service change, even though certain patients cannot and should not be discharged because they are too sick, or have social or financial issues preventing safe discharge. Thus, patients remaining after a service change may differ in important ways from those who are able to be discharged. (Vineet M. Arora and Jeanne M. Farnan, 12/6)

Outcomes measures have replaced process measures as the new currency of quality. For example, the quality of care for patients with diabetes is now measured by results of hemoglobin A1C tests, not just the percentage of patients who received the test. The same shift has occurred in graduate medical education (GME). Competency-based education serves to hold residency programs accountable for the outcomes of its graduates. (Lia S. Logio, 12/6)