10 Digital Solutions to Make India the Best-Governed Nation
A 10-point digital roadmap for Mr Narendra Modi, that protects our assets, ensures that the right projects are undertaken, and delivers justice, equality, and liberty for all
Prime Minister Narendra Modi has inherited an India with major challenges: an economy that fails to distribute the needs but pushes the wants; an environment that is being irreversibly stripped off; a hassle-filled life where red tape, fraud, corruption and indifference are ever increasing; failed land-use management is destroying India’s forests, mountains, rivers, streams, and farms, and at the same time flooding its courts with disputes. Over and above all this, it is almost impossible to make the right projects happen in the right place at the right time wasting thousands of crores of tax-payers’ money
To remove all these ills, Mr Modi has to redesign the way governance works. What should he do to redesign governance quickly? Here is a roadmap that focuses on the need to protect the assets of the country, and to ensure that the right projects are being undertaken, where no one is denied benefits, where justice, equality, and liberty are within reach, the future scenarios are shared, and democracy is not a distant dream.
1. Change the way money is spent
Every budget item on the central, state and local government is for some project, activity or event, at a specified location. By introducing the requirement to geotag, or display the location on the map, each item, in addition to its purpose, details, status and citizen comments, could be uploaded on a single website,, a process that will change the way money gets spent.

Such a budget map would not only display where every rupee is going or has gone, but also show if the transfers from one agency to another, or from the central to state to local governments actually got spent on purposes for which it was intended. Such budget maps would ensure that the projects are not over budget, and run under different heads, or by different agencies. It would show how evenly funds are distributed for the governance of different regions and also identify purposes or budgets that are not equitable and fair.

All the PM needs to do is to implement a policy whereby no budget items will be included, nor disbursals be made without the location of the budget head being uploaded on
2. Protect the country from land mafia
Today, the Survey of India protects the maps of the country, not its land. There is no public directory or map of all the survey numbers of the 32.87 lakh square km across the 595 districts in the country. There is no account of the changes happening in land use across the country. Land records and property records are not standardised across the country.

Requiring that all survey maps be geo-tagged, or their exact location on the district map be shown based on latitude and longitude, and display the survey land-use, ownership details, and any legal issues on a single website will change the way land use happens across the country. Requiring that the North East point of every property have an official GPS device on it will alert a land use information system of any movement of this point.

Such a change will also allow Development Plans to be monitored and implemented. It will make land acquisition easier as well as partitioning property without violating land use. It can help find land for the landless, provide benefits to single property owners and prevent the speculation of land at the cost of the country’s land-use requirement.
Such a system could possibly allow authenticated account holders to search and view land-use, proposed use as per DP, encroachments, ownership, tenancy, and other claims by logging in to their account. The information they seek on individual properties will leave a trail for purposes of security.
All that the PM needs to do to initiate this is to require geotagging of every survey number by the Survey of India before any new land use activity is permitted on it.
3. Protect assets of the country
While our national anthem boasts of our rivers, forests, and mountains, they are fast being lost to encroachment, mining and indiscriminate changes in land use. The indiscriminate felling of trees to make way for roads, real-estate or to use them as timber is wiping out India’s carbon absorption capacity, monsoon attracting potential, soil retention ability and even the flood buffering and ground-water recharge potential.
Requiring that every stream, river, lake, mountain and forest area boundaries are geotagged with physical markers at their boundaries will ensure a public alert on any alteration. Requiring each tree with a width bigger than 2 inches to be tagged with a RFID (Radio frequency ID, or a small chip that stores information that can be read from a distance by a RFID reader and can be used to do a periodic tree census) along with its geolocation will protect the trees and ensure the country’s valuable assets are not stolen or destroyed. This will also ensure that the forests, rivers, wetlands, fields and wastelands are better conserved as also the built-up environment across India.
A policy requiring all government assets be geotagged will enable identification of all the offices, land, equipment, and vehicles owned by various government agencies and the process of auditing them will be much simpler.
In this regard, PM needs to direct the Ministry of Environment and Forests and the Survey of India to work together to tag all the natural heritage of the country within a fixed time. He needs to ensure that the Finance Ministry does not release any budget for capital expenditure to any government agency that has not geotagged their movable and immovable assets.
4. Hassle free rights
An ID cannot be the enabler of an entitlement or a right; it can be a basis to audit the delivery. To ensure that no one is denied any service, entitlement or right for want of ID the government may require that each agency delivering any entitlement or right will capture the ID of the person benefiting from their service, entitlement or right. Such a record should be maintained to identify the beneficiary for future transactions for the delivery of rights without any hassles while permitting any audit of the delivery of entitlements and rights. All those having taken benefits would be listed on for public audit.
Although the government has information on every citizen it has no mechanism to identify beneficiaries proactively without requiring a single form from those who wish to benefit from a scheme. This is both a waste of resources as also a way to exclude those who may really qualify.
The government would overcome this by internally connecting the birth, marriage, address registration and death records without requiring any form, id numbers or id from citizens to create a National Population Register. This would then be used to proactively identify the benefits each person is entitled to. This would also ensure that no citizen would need to submit to government any document issued by the government itself. While automatic entitlements and benefits could be provided to beneficiaries identified by the NPR, manual benefits should continue to those not automatically included in NPR.
To enable this the PM ought to create a separate beneficiaries department within the Registrar General of India’s office to proactively create and display the beneficiaries lists on maps.
5. User managed shared ID
The UID is not a proof of identity. It is not even a proof of address. Nor is it is even a proof of existence: it does not prove that the person with a UID is a real person.
The UID is merely a random number assigned to unverified and unaudited data submitted by third parties paid per record. It provides no way to verify if the 12-digit number is one issued by the UIDAI, or even who submitted the biometric and demographic data. Worse, there is no way to tell if this number belongs to a real individual, or to the individual who submits the number, or is even a number generated through a diligent process, or by an authentic enroller, registrar, or the UIDAI. What is unbelievable is the identity solution cannot authenticate its own genuineness, the genuineness of its enrollers, registrars or of the UIDAI itself.
The use of such unauditable, unverifiable and 'unauthenticate-able' number to authenticate identity, to serve as the basis for governance, to be used to deliver benefits, rights and entitlements, to be used to open bank accounts and transfer money, and to create citizen registers or electoral rolls will seriously compromise governance, national security and the rule of law.
Just as the UK PM, David Cameroon’s, government kept their election promise and scrapped their National ID project PM Modi should ensure the UID and its database are completely purged in the interest of the governance, national security, the rule of law and justice.
In place of the UID a the government can enable a Shared ID at as was designed in Pune to allow citizens to create, own and share their own ID with complete control on who can see or use the ID and logs of access by third parties to their information. The citizens can access information on incentives, schemes, and programs they automatically qualified for or availed based on their profile. They can also access information on demography, energy use, water use, land use, mobility and other details in their neighbourhood after logging in to their account on
The PM will need to declare the scrapping of the UID. He will need to create with the Registrar General of India a department to allow anyone to create and maintain their own Shared ID.
6. Audit of digital assets
Although the government creates, maintains and uses many digital assets there is no audit of the digital records or the processes that create the digital record. To ensure the authenticity of the digital assets the government would need to establish an audit cell with Comptroller Auditor General (CAG) to audit all digital records, processes to create the digital records and undertake annual audits of delivery of service, entitlement or right and seek the creation of a register of the excluded to ensure no one will be excluded from rights.
The PM would need to ask the CAG to create a special cell to audit the digital assets. The audit reports and a list of those excluded from rights would be displayed at
7. Monitor the impact of governance
The projects and budgets allocated as a result of the policies and legislation result in impacting the lives and environment of people in each of the 595 districts. Providing information that enables monitoring and correction of the budget expended and projects executed in each district at would ensure that departments and ministries work to accomplish missions, not procedures. Various missions to ensure resource conservation, access, inclusion, peace, harmony, health, sufficiency, public interest, justice, liberty, equality, dignity would be monitored on this website.
The website would also project the need for workers in different occupations like agriculture, manufacturing and various services within each district and the required school capacity in the district to deliver bridge the gap. It would track energy demand and the current energy mix of coal, oil, natural gas, hydroelectricity, nuclear, solar, wind and other renewables to deliver to the district and beyond. It would track the agricultural produce and the districts deficit or surplus, the water demand and the sources to deliver the water. It would track the public transportation corridors and mobility within and between neighbouring districts. It would monitor the land-use and implementation of development plans. It would monitor the spread of habitats.
The PM would need to ensure that each project has to have a clear mission and a way to provide real-time impact to further resource conservation, access, inclusion, peace, harmony, health, sufficiency, public interest, justice, liberty, equality, dignity to accomplish the mission before being approved.
8. Anytime, anywhere voting
Ensuring democracy is an expensive, unverifiable and unauditable process. There is no way to ensure that your vote was cast for the candidate of your choice or if it continues to be till it is counted. There is no way to audit the votes counted against a candidate and certify that all the votes polled by the candidate are from real and legitimate voters and not from illegitimate rigging of EVMs. The voting process currently imposes elaborate barriers to being able to cast votes.
By enabling an indigenous mobile and internet-based anytime-anywhere voting system that is publicly auditable without compromising the privacy of the voter the government will take democracy closer to being real. It will enable freer, easier and auditable elections across the country at a fraction of the current cost.
9. Exploring impact scenarios of policy and legislation
While the planning Commission of India has been making five year plans to match resource allocations to projected demands, there is no way to explore the impact of different policies or legislation on different sectors and over the long-term span of 50-100 years. This is particularly important as much of the critical nation building works over 20-30 year periods. For example it takes 20 years for a cohort born now to come into the working population. It takes about 20-30 years to build and commission power plants. It, therefore, stands to reason that the future scenarios over 50-100 years need to be studied.
By building and displaying such a long term projection computer model of India that allows to explore the consequences of various policies on the demography, economy, environment and resource challenges accessible to all on the government will create less policy resistance and greater alignment to shared goals.
Such a website would also allow the sharing of scenarios resulting from the implementation of various policies and acts that are in force and allow the stakeholders to comment and make suggestions for revisions of policies and legislation.
The PM will have to commission the development of such a model along the lines built by late Prof. Malcolm Slesser of Edinburgh and Strathclyde universities for various countries across the world, the World III model built by Prof. Donella and Dennis Meadows then of MIT, or the National Model being built by Prof. Jay Forrester of MIT. Such a computer model of India will allow us to explore the consequences of various policies on the demography, economy, environment, and resource challenges. The model will be accessible to all and provide standard scenarios of various policies and acts that are in force to allow stakeholders to comment and make suggestions for revisions of policy or acts.
10. Bringing justice to all
With over 3,000 plus central acts India is over-legislated. Even for those in the legal profession finding or knowing the applicable laws is non-trivial. By allowing search and discovery of applicable laws for a set of keywords on the government will do great service in bringing access to the legal framework to all.
While the court system may continue to battle its challenges to provide justice in time the government could well provide a repository of elders in each district who will support alternative dispute resolution. This can reduce the delay in seeking justice and restore the confidence in the rule of law and delivery of justice.
Much of the justice process is today beyond the access of the common man. By enabling for submission of cases of public interest violations as well as violations of justice, liberty, dignity and equality of which the courts take suo-moto cognisance. By enabling the issues submitted on this website and not taken up by the courts to be taken up by the elders of the district involved in alternate dispute resolution mechanisms, the government will ensure and entrench public interest, respect for justice, liberty, dignity and equality.
The PM needs to ensure that the Law Ministry takes up these projects on priority.
Henry David Thoreau believed “that government is best which governs least;” and “That government is best which governs not at all”. By implementing the roadmap, PM Modi can truly transform the government into the best government yet, not just in India but across the world.
(Anupam Saraph is a Professor, Future Designer, former governance and IT advisor to Goa Chief Minister Manohar Parrikar and the World Economic Forum)




3 years ago

LOCK and KEYS r 4 GENTLEMEN like people not 4 THIEVES like first to set the mind set of Gov.,Employees and than only VALUE in implementing 10 DIGIT solution in Governance.


3 years ago

the comment on UDIAI seems to be absurd, may be some irreducible minimum mistakes here and there which are bound to happen and branding overall procedure as farce is unacceptable instead suggestion may be made to correct and make it user friendly at the same time foolproof.It has also been inferred the people as fools who spent their time in ques to respond .so much money has been spent .It should not go waste as we cannot afford it .suggestion should be productive and worth following as unique identity is required to have better planning and control

Umapathy chennai

Lalit S Kathpalia

3 years ago

This is a fantastic article. Well thought and is very relevant and to the point on effective Governance enabled by a Digital Strategy. I am also happy to say that this article is neutral in its tone focusing on what can be accomplished and how thus making benefits realization possible. The only problem and which is not the authors is whether the PM or PMO buy this.


3 years ago

What about Uniform Civil Code.
It is necessary that for a country which achieved independence 1947 and it is 67 years that we are dividing people of India on the basis of Caste, Community, Tribes, backwardness etc.
It is extremely that we ought to have one law for everyone. And before this law everyone shall be equal. No discrimination of any sort then only we can progress.
Author has also forgotten to mention need for large power projects, harnessing the river waters by building dams and canals and hydro-electric power projects. Good sanitation, i.e. well managed toilets along the highway and at required junctions.
Digital solutions no doubt is a good suggestion, but it is a small step towards administrative reform.

Dipankar Dutta

3 years ago

The concept is great but considering the resources needed, seems utopian.


Rakesh Goyal

In Reply to Dipankar Dutta 3 years ago

If there is a will, there is a way. These can be implemented. One by one. May take some time. But, will vested interests allow this???

c v manian

3 years ago

Dear Sir
Anupam Saraph's article made some valid points. But can he provide some first cut numbers on the money, time and effort that will be involved. UPA's UID has collected lot of information and has a major database. We must not fritter away these efforts and must modify them to suit the current requirements. If bogus menthol has been there, it must be weeded out by physical verification. Voter data base could be used as a countercheck. All things in India needs effort and cooperation, but whatever that needs to be done, must be done for the future of the nation.
C V Manian

Radhakrishnan Subbiah

3 years ago

Nice to know that we have such future-designers who are optimistically active and willing to share their ideas. Everything is not lost for India. Good.I, for one, whenever I try to comprehend where are we & what are we doing and in which direction we are moving, I end up shell-shocked to realise that everything in India is politicised, corrupted to the core and regressive.Leading to, not stagnation, but accelerating backwards!! For example, take the law of the land (3000 legislations)and the kind of people handling these.Every other day some judge is accused of heinous acts,police apathy/corruption is etched very deep in people's psyche (police seem to be there only for themselves and not for the people who pay their salaries).. so deep that a sane citizen will not even touch them with a 100 foot pole. Net result , govt, law & order institutions have become the den of most undesirable people(??). Where did they come from? From within our society. Means the society is corrupt!! So, the future designers wanting to improve the situation, need to focus on how to un-corrupt this society first.There is an age old proven approach...let all the sane citizens ( not corrupted yet)pray to the Creator-Protector, for salvation. It is said that even if 2% of the population do this sincerely,he'll respond. I can hear some saying ,why go to this god or that god, why not do it ourseleves. To them, I say, please look at Arvind Kejriwal, his intentions were good, but where is he today? One Kejriwal here, another there, is always surrounded by this corrupt society, which'll make sure that the status-quo is maintained or dragged down.Only individuals ,acting on their own, praying sincerely for intervention from above can save the sane humans. I am not discouraging future-designers, but only pointing to the starting point, for the design to take strong roots and grow healthy.

Vivek Ananth

3 years ago

This is actually good stuf.


3 years ago

artical 'Subsidy-kills'all know but no one speak about CAST CATEGORY-RESERVATION for in jobs.,and very recent but kept all in silence over to get a Residential flat transfer in CIDCO region u hv. to produce a DOMICILE CERTIFICATE speak some thing that Kills constitutional right U/S-14


3 years ago

The greatest disappointment is the utter failure of the UID scheme entrusted to a star Executive with full powers and MOS Status.
It has turned out to be a national disgrace.
Must be scrapped.
IC Rao


3 years ago

Shri Anupamji,
In what order of effective results these can be implemented to begin with and in what time frame, such information may prove beneficial to take up this huge task by the present government. If you could share which of these have been implemented in Goa, it could boost the necessity and effective solutions for other States and the entire nation.
Mr. Rakesh Goyal has also raised same point.


3 years ago

Interesting and thought provoking. Thank you for publishing this. Please get them to read this.


3 years ago

What we see presently is absence of result oriented approach by Govt employees which should include all levels incl IAS. Govt Babus are sitting in their cozy office rooms only to direct the Janata to a court of law for getting a decision which can be implemented by them. They dont properly respond to RTI queries. Please include one major point , that is, the punishment and penalty clauses to Govt employees in their service condition for their non-functioning and non-effectiveness in governance. Once this is done political masters will be compelled to give result.
Second point should be that EDucation and Health should be made Free and available to people closest to their homes. I agree with stricter action against Land Mafia.
3rd issue is PR exercises in approaching/ listening to the people's grievances directly.

Sucheta Dalal

3 years ago

Dr Saraf

What a brilliant article. Thank you so much for writing this for us. We citizens must make every effort to get the Prime Minister to read this and implement it!


Nagesh Kini

In Reply to Sucheta Dalal 3 years ago

I entirely agree with Sucheta - a great article!
As one in the audit profession for long and dealing with authorities at all levels I believe the entire government set up needs a total revisit by revamping - first scrapping the many Raj-era laws, making the CAG functioning more effective, totally simplifying and rationalizing the direct tax laws,
making the PAN card more complete by incorporating the address.
All these don't have to wait and can get started right away.

Amiit Gupta

3 years ago

Dear reader please make a strong will to implement this good idea with in 5 years timeline. Collectively nice idea for better government procedure..

Red Bull agrees to pay $13 million to customers for false advertising

The energy drink company has agreed to offer a $10 cash reimbursement or $15 in Red Bull products to any consumer in the US who bought a Red Bull product since 1 January 2002


Red Bull has consented to cough up some $13 million in customer refunds to settle a class-action lawsuit over false advertising.

The energy drink company has agreed to offer a $10 cash reimbursement or $15 in Red Bull products to any consumer in the US who bought a Red Bull product since 1 January 2002. While denying all wrongdoing, Red Bull will also potentially have to pay nearly $5 million in plaintiff attorney fees. And that’s in addition to the $13 million.

The complaint centered around the allegation “that the functional benefits of consuming Red Bull are not superior to the benefits from ingesting an equivalent amount of alternate sources of caffeine, and that consumers have been misled by Red Bull advertising to believe the drink is a superior source of energy beyond caffeine,” the settlement states.

To receive a cash refund or $15 in free products, a consumer will need to submit a valid claim form. No receipts necessary.

For more of our coverage on energy drinks, click here.



The obscure drug with a growing Medicare tab

Experts question the effectiveness of HP Acthar Gel, a drug made from pigs’ pituitary glands. Yet it cost US Medicare more than $141 million in 2012, up from $7 million in 2008


This story was co-published with The New York Times' The Upshot.

An obscure injectable medication made from pigs' pituitary glands has surged up the list of drugs that cost Medicare the most money, taking a growing bite out of the program's resources.

Medicare's tab for the medication, H.P. Acthar Gel, jumped twentyfold from 2008 to 2012, reaching $141.5 million, according to Medicare prescribing data requested by ProPublica. The bill for 2013 is likely to be even higher, exceeding $220 million.

Acthar's explosive growth illustrates how Medicare's prescription drug program — perhaps more than private health insurers and even other public health programs — is struggling to contain the taxpayer burden of expensive therapies aimed at rare conditions.

Many outside experts say there's insufficient evidence that the drug works better than much cheaper options for treating multiple sclerosis relapses and a rare kidney disease, conditions for which it is often prescribed. In the absence of such scientific studies, some private health insurance companies, as well as Tricare, the military's health care program, have curtailed or eliminated spending on Acthar. Proponents of the drug say it is a worthy option for patients who have failed on other therapies.

But Medicare has imposed no limits, leaving such decisions to the private insurers paid to administer its drug program on the government's behalf. Medicare accounted for around a quarter of Questcor Pharmaceuticals's sales of Acthar in 2012 — and that proportion is growing.

Medicare cannot bar access to medications like Acthar, even in the face of rising expense and questions about efficacy, Aaron Albright, a spokesman for the Centers for Medicare and Medicaid Services, said in a written statement. The law mandates that Medicare's drug program, known as Part D, cover drugs for the uses authorized by the Food and Drug Administration, he said.

Since Acthar came on the market in 1952, the rules about F.D.A. approval have changed. At the time, drug companies simply had to demonstrate that a drug was safe, rather than that it was effective. Acthar was initially authorized as a treatment for more than 50 diseases and conditions. (The list has since been cut to 19.)

Acthar isn't prescribed often, just 3,387 times in Medicare in 2012. But Part D spent an average of $41,763 per prescription, making it one of the most expensive drugs around.
The drug ranked 139th that year, in terms of total cost, out of more than 3,000 drugs prescribed in Medicare. In 2008, it ranked around 660th.

Several of the top prescribers of Acthar have financial ties to the drug's maker, Questcor. These doctors typically receive research grants, payments for delivering speeches on behalf of the company or compensation for serving on advisory boards.


But some in the medical community say the program's soaring bill for Acthar shows Medicare needs to do more to safeguard taxpayer dollars.

Dr. Lily Jung Henson, medical director of neurology at Swedish Medical Center's Ballard campus in Seattle, said she rarely prescribes Acthar for her multiple sclerosis patients. Medicare, she said, should at least push for more studies to determine whether Acthar works.

She said of her patients, "I certainly prescribe enough expensive drugs to them that I think are worthwhile, that I can't afford to waste their money by giving them a drug that I can't convince myself has been effective."

Questcor Buys In, Increasing the Drug Price

Until the mid-2000s, Acthar didn't rate as a concern for Medicare, a program for those 65 and over and for the disabled, because it was prescribed primarily for a rare infant seizure disorder and it wasn't expensive.

That changed after Questcor bought the drug in 2001. The company has increased the drug's price sharply since 2007, and it began marketing it for a broad menu of uses. It even funded a charity to help cover patient co-pays, taking the sting out of the drug's out-of-pocket cost to consumers, Barron's and The New York Times have reported.

The company has disclosed in filings with the Securities and Exchange Commission that two United States attorney's offices and the S.E.C. are investigating its promotional practices.

Questcor declined to answer questions for this article, issuing a statement saying that it adheres to federal rules and that its promotional activities are "in line with industry best practices." The company has suggested that investors shorting its stock may be trying to plant negative stories in the news media.

Questcor is about to be purchased by Mallinckrodt, another drug company, for about $5.7 billion in cash and stock. At a June conference, Mark Trudeau, Mallinckrodt's president and chief executive, defended Acthar's price to analysts, saying "it's actually pretty, pretty inexpensive" relative to the cost of other treatments for patients who need it.

In 2008, Acthar accounted for only 202 prescriptions in Medicare, costing around $7 million. But the tally more than doubled from 2010 to 2011 — and doubled again from 2011 to 2012.

Acthar is still used rarely relative to more mainstream medications, but each five-dose vial costs about $32,000. (The average Medicare prescription price is higher because some prescriptions are for more than one vial.) Although it long ago lost patent protection, the drug is a complex biologic agent, and the manufacturing process is a trade secret.

Medicare covers drugs that are even more expensive. A new drug called Sovaldi, which cures the liver disease hepatitis C, costs $84,000 for a 12-week course of treatment. Experts estimate that Medicare could spend between $2 billion and $6.5 billion on Sovaldi this year alone.

What differentiates Acthar from other specialty drugs isn't cost, but rather its age and the dearth of studies proving its efficacy, said Ronny Gal, a senior research analyst at Sanford C. Bernstein.

"They had to prove nothing," Gal said. "Essentially, it got grandfathered indications from a day that preceded the way we look at drugs now."

A handful of practitioners — several of whom have ties to Questcor — have helped to drive the increase in Acthar prescriptions in Medicare.

The top 15 prescribers of Acthar accounted for 10 percent of Medicare prescriptions, an unusually high proportion, ProPublica's analysis showed. The top four were paid by Questcor either as promotional speakers, researchers or both.

The No. 1 prescriber, William Shaffer, a neurologist in Greeley, Colo., gives promotional talks for the company. He wrote 78 prescriptions for Acthar in 2012, costing Medicare more than $4 million.

Shaffer, who has multiple sclerosis himself, said he was introduced to Acthar by a Questcor sales representative whose pitch he initially rejected. Then one day, the representative came in when Shaffer was seeing a multiple sclerosis patient grappling with a relapse that other drugs hadn't helped. "What the hell, let's try it," Shaffer recalled saying, writing his first Acthar prescription.

When the patient came back six weeks later and said he felt better than he had in 20 years, Shaffer was a convert. "I've started using it more and more and I've had amazing results with it, without the side effects of steroids," he said. "I had one woman ask me if Jesus made it. Another guy calls it liquid gold."

Shaffer has used the drug himself, too, and said it worked for him.

Other specialists who treat multiple sclerosis patients are more skeptical about Acthar's value. Dr. Claire Riley, director of the Multiple Sclerosis Clinical Care & Research Center at Columbia University, said she uses Acthar infrequently and wants evidence that it works differently for multiple sclerosis relapses than a widely used, far less expensive medication called methylprednisolone or Solu-Medrol.

"I am absolutely appalled by how expensive it is, but I do think we need to have an open mind about whether it can help people," she said. "And if it can't, then we really shouldn't use it much at all."

Kidney specialists are similarly divided on Acthar's cost-benefit equation.
Jerry Meng, a nephrologist in Meridian, Idaho, and one of Medicare's top prescribers of the drug, said he began using it because the standard therapy for a rare kidney condition known as idiopathic nephrotic syndrome can be harmful for those with weak immune systems.

"From a side effect profile, it's the lesser of all evils," said Meng, who was trained by Questcor to give promotional talks about Acthar but has not been paid to deliver any.
Meng said he hasn't hesitated to prescribe the drug because patients receive assistance on co-pays from the drugmaker, an outside charity or some other entity. "I haven't had a patient tell me that they've had to stop the medication because they couldn't afford it," he said.

Other kidney doctors say Acthar is essentially a "hail mary" pass when all else fails.
"The major problem with this treatment as I see it is the cost of the vial, and quite honestly, let's face it, let's be candid, this got approved at a time when the approval process was nowhere near as rigorous as it is today, " said Patrick Nachman, a nephrologist at the University of North Carolina.

Insurers Begin to Restrict Access

In the past few years, many commercial and public health plans have begun to take a less openhanded approach to Acthar than Medicare.

Insurers such as Aetna, Cigna and UnitedHealthcare have moved to restrict access to the drug, citing the lack of evidence that it works better than other treatments for many conditions. At a recent conference hosted by Sanford C. Bernstein, Dr. Ed Pazella, Aetna's national medical director for pharmacy policy and strategy, explained the shift on Acthar.


Questcor's "combination of aggressive marketing and aggressive price increases finally caused it to become a line item that a finance guy looked at and said: 'What the hell are we paying for this? Why? What is it?' And that's when we started looking at what's our policy around this stuff," Pazella said. (A recording of Pazella's remarks was shared with ProPublica.)

Such efforts are consistent with a broader push to control health costs that has led to a significant slowing in the rate at which those costs have risen in the last five years.
Some public programs have come to similar conclusions about Acthar.



Last year, after seeing a dramatic rise in Acthar prescriptions, the military's health system restricted the drug's use to infantile spasm, the condition it was mainly prescribed for before Questcor's promotional push. Research showed that too many prescriptions had been written for patients with conditions "for which there is little supportable evidence" that Acthar is effective, the Defense Health Agency spokesman Kevin Dwyer said in an email.

Acthar usage has plummeted since the new rules went into effect. Tricare covered 725 prescriptions for the drug last year, at a cost of $34.4 million (before rebates), according to data obtained under the Freedom of Information Act. Through the first five months of this year, it covered only 91 prescriptions.

Some state Medicaid programs for the poor have also limited Acthar's use to infant seizures. Despite these restrictions, Medicaid's spending on Acthar rose sharply last year after the government dropped rules requiring Questcor to give back almost the entire cost of the drug to states in rebates.

In his written response to questions, Albright, the Medicare spokesman, did not address whether Acthar's rising cost had caught the attention of Medicare officials. The agency declined an interview request. The health insurers that administer Medicare's drug program can impose restrictions, he said, but they are not required to do so. Some insurers' rules are more restrictive than others.

Jonathan Blum, until recently the principal deputy administrator at the Centers for Medicare and Medicaid Services, said in an interview that the time may have come for Congress to rethink Medicare's limited role in assessing drugs and the legal prohibition against Medicare's negotiation of drug prices.

"I personally think over time, the program is going to face more demands by Congress and the public to intervene, or at least use moral persuasion, to challenge or counter-pricing strategies that don't serve the best interests of the program," he said.

Such changes would most likely face stiff opposition. When the Centers for Medicare and Medicaid Services tried to change the rules governing Part D this year to allow restrictions on certain categories of drugs, backlash from the pharmaceutical industry and patient groups was so fierce that the agency was forced to back down.

Gal, the analyst at Sanford C. Bernstein, said Acthar's story was "just an extreme case of the fundamental tensions in the system," with cost on one side and demand on the other. "At the end of the day, there's a limited amount of money in the system, and medicine is being rationed."

For more information about Medicare's prescription drug program, read our story about how the program failed to monitor providers with questionable prescription patterns.



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