Good afternoon readers.
I've added a "Categories" section to the sidebar so you can easily navigate my writings on a plethora of health policy subjects! For the always confusing Medicare Part D see Medicare. Perhaps you hate health care blogging and would rather hear my opinions on Ivy league students and egg nog? Then Miscellaneous is the place to be!
Enjoy.
Ezra's got a great post up about RU-486 naysayers:
You can't argue with his loss, but let's put this in perspective. Including his daughter, there are four deaths that can potentially be linked to RU-486. But: "Each year, use of NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) accounts for an estimated 7,600 deaths and 76,000 hospitalizations in the United States." (NSAIDs include aspirin, ibuprofen, naproxen, diclofenac, ketoprofen, and tiaprofenic acid.)I second his opinion, and raise him an article about liver poisoning due to tylenol:Medicine kills people. Medical treatment kills people. Being in hospitals kills people. Medical errors kill people. Improper treatment protocols kill people. Now, doctors, hospitals, and pharmaceuticals cure more than they kill, and we as a society have decided easing our headaches and muscle pains is worth 7,600 deaths a year, but pretending that medicine is safe and RU-486 is dangerous is just crap.
Dr. Davern and a team of colleagues from other centers led by Dr. Anne Larson at the University of Washington Medical Center in Seattle, tracked the 662 consecutive patients who showed up with acute liver failure at 23 transplant centers across the United States from 1998 to 2003.Even tylenol, considered a very safe drug, can cause accidental liver poisoning. Like Plan B before it, it's important to recognize that politics, not safety, is the name of this game.Acetaminophen poisoning was to blame in nearly half the patients, the scientists found. The proportion of cases linked to the drug rose to 51 percent in 2003 from 28 percent in 1998. Not all the poisonings were accidental. An estimated 44 percent were suicide attempts by people who swallowed fistfuls of pills.
Looks like it's shaping up to be a more personal blogging day. But that's okay, right? You guys love me for more than my wonky, right? That's what I thought.
The New York Times continues today with its series on being a patient in the United States (am I the only one who finds their choice of topics a bit strange and the series fairly weak?) Today they've zeroed in on the mean nasty doctor:
Ms. Wong had come across a bane of the medical profession: the difficult doctor. These doctors may be arrogant or rude, highhanded or dismissive. They drive away patients who need help, and some have been magnets for malpractice claims.Strange subject matter, it may be, but something I have years of experience with. I could go on and on about the nasty doctors I've encountered in my eons of patientdom, but I'll focus on one, because it was a fairly formative experience for me.And while such doctors have always been part of medicine, medical organizations say they fear that they are increasingly common - doctors, under pressure to see more patients, are spending less and less time with each one and are replacing long discussions with laboratory tests and scans - and that most problem doctors apparently have no idea of their patients' opinions of them.
When I was young I suffered from chronic sinus infections. I went to see an ear nose and throat specialist who determined that I should have my aednoids removed and the holes of my sinuses widened for better drainage. (Sounds like a ball, right? I have these hilarious pictures of me holding frozen peas on my nose after surgery.) The doctor possessed an awkward bedside manner that suggested he didn't see many people under 18 and wasn't quite sure what to do with them. That, and his first name was "Festus". Festus [last name] III. The third! That poor man.
In any case, in one of my appointments I told him that I wanted to be a doctor. This declaration led to an extensive diatribe on how medicine is "different" these days, how it's just a "business" now, how he has no time to see patients, how it's horrible and I don't want to do that.
Needless to say, this conversation upset me. Here I was expecting praise and declarations of how noble the profession is, etc, and I got the exact opposite. But it also made a major impact, and it was the first time that anyone (doctor or no) had spoken honestly and with flourish to me about all the problems in medicine. Was it the catalyst that led me to a health policy career? Probably not. But hearing about the problems straight from the doctor's mouth made me think a little differently about my future career.
So, what's your mean nasty doctor story?
So, I love the holiday season. I just do. Maybe it's because I'm not that far removed from the excitement of Santa. Maybe it's because I lived in California for four years and the only snow I got was when I came home to Kansas. Maybe.
Except that the real reason is I love egg nog (of the non alcoholic, store bought variety). And I don't see why egg nog has to be confined to the holidays. I like to drink it in my coffee every morning; when I go to coffeeshops I love egg nog lattes. I want to be able to order those year round!
Apparently my love takes after our beloved first president:
Our first President, George Washington, was quite a fan of eggnog and devised his own recipe that included rye whiskey, rum and sherry. It was reputed to be a stiff drink that only the most courageous were willing to try.Yum!
Over at Dr. Andy there's a post on gifted children. He makes some interesting calculations about the approximate number of gifted (top 1% IQ) children born every year and the number of people entering Ivy Leagues:
The top 1% represents ~40,000 kids/year. . . later the article talks about "the more mundane variety of Ivy League-aspiring kids". But given 8 Ivys with say 1500 students/class, we get 12,000 kids/year. Making some assumptions about the number of similar schools (Stanford, MIT, etc) and how well Ivies and similar schools attract the most talented students, I'd say the Ivy League does represent about this top 1%. Maybe not exactly, but pretty close.Now, I've never had my IQ tested so whether I qualify as "gifted" is up for debate. I'd personally be thrilled to be considered in the top 1% of the population in terms of brain power.
I have, however, met a slew of Ivy (and similar institutions') students, and I can assure you they are by no means representative of the top 1%. Frankly, I get the impression from many that they were just over-driven workaholics, and if you engage them in conversation you'll find that wall of work crumbles easily when it comes to complex ideas. So while the numbers might make sense, all kinds of barriers keep that top 1% from ever acheiving it (poor schools, unstable home life, no money for college except state school). Those actually attending the Ivys had the wherewithall to work their asses off, the luck to go to a decent high school, and parents who could foot the bill (that or they're incredibly brave and willing to take on $100,000 in debt).
That being said, I've met wonderful people at Ivys who absolutely deserve to go on to great success. Many do belong in that top category. But I'm just unconvinced that the whole student body qualifies as the top 1% of this country's sizeable brain power.
And now I will proceed to drink my morning coffee out of my "Miss Smarty" mug (must be a sign, right?)
As many of you probably know, Merck announced yesterday that it will be cutting 7,000 jobs. It's a reaction to a slew of bad news for the pharmaceutical companies, including losing patent protection, Vioxx and other drug problems, and declining sales. Unfortunately for Pharma, the public is less than sympathetic:
The backlash among consumers upset about problematic drugs such as Vioxx was evident in a recent Harris poll measuring public attitudes toward industries. The October survey found that just 9 percent of Americans believed the pharmaceutical industry to be honest and trustworthy. Some 51 percent of the 1,833 adults polled said drug makers should be subject to more government regulation, second to only the oil industry, which was at 55 percent.Ouch. A 9% approval rating is pretty awful, but the obvious result of lawsuits and other bad press. Most companies aren't reacting by trying to design better drugs for their key markets (heart disease), but their business model in general:
The company characterized the actions as the first phase of a worldwide restructuring aimed at lowering costs, improving efficiency and boosting competitiveness.They are, however, going after the lucrative heroic image markets:
The big drug companies are likely to focus more on developing vaccines and treatments for cancer, AIDS and other life-threatening illnesses, said analyst David Moskowitz of Arlington investment bank Friedman, Billings, Ramsey Group Inc.I find the evolution of Pharma's business model fascinating. One thing that always concerned me about the huge drug companies is that they have little incentive to develop drugs for rare diseases because so few people can take them. Instead they focused on huge lucrative markets -- heart disease, ED drugs, depression, etc. But the backlash brought by these drugs has pushed Pharma to offer more hope to the terrifying diagnosis of cancer or AIDS. Whether they can actually do so, and whether that pricing power is sufficient remains to be seen."These products have smaller markets than for other major drugs like those for cardiovascular disease," Moskowitz said. "But we are finding out that these products carry significant pricing power, and that is piquing the interest of the major pharmaceutical companies."
This is good news; we need more and better cancer and AIDS therapies. But we have to keep an important factor in mind, one that Matthew Holt has been drilling in lately. Therapies like those for cancer and AIDS are prohibitively expensive. Rounds can easily total $200,000. We, at some point, have to take a realistic look at health care costs and how much we're willing to pay. If my loved one would die without a $200,000 treatment I know I wouldn't blink in requesting it. If most of us believe that, we need to accept the reality of the cost. If that means employer-sponsored health care, it means major increases in premiums and cost sharing. If it means universal insurance, it means tax increases. Obviously waste can be cut out, and some spending can be brought under control. But new expensive therapies will continue down the pipe line.
Unfortuantely our politicians have skillfully insulated us against spending without feeling the pinch (can we say multi-billion dollar deficit?). Someday we will have to take an honest accounting of what good health care is worth, and that day is getting closer.
You all might remember my post asking for advice about getting a flu shot. I never called around trying to find one, which is apparently a good thing because I might have had some trouble:
Three in four doctors responding to a California Medical Association survey had not received their full vaccine supplies as of Nov. 3. More than half of them had not obtained any vaccine, and 70 percent had to reject high-risk patients' requests for flu shots.So, last year there wasn't enough vaccine, and this year we're making sure non-medical locations receive it first?What went wrong? According to the Union-Tribune article, vaccine manufacturers preferentially shipped supplies of vaccine to high-volume customers, like big-box stores such as Costco, Wal-Mart, and Albertsons on the west coast of the US. Quoting Dr. Wayne True, a physician in La Mesa, "This year's vaccines are going to where the money is - to the 'big box' customers first." Physicians often "go through pharmaceutical distributors for their vaccine supplies, while some big retailers are able to place bulk orders directly from vaccine manufacturers.
A reader sent me an email describing the same problem this weekend. He has a small practice in Pennsylvania and has also had a difficult time attaining vaccines:
For my practice, I was unable to purchase AT ANY PRICE 30-40 shots which would have been all I needed, and the health departments also have had to cancel their shot clinics too, even for the senior centers.For young and healthy (like me), it's easy to head over to Costco or the grocery store to get a flu shot. The elderly depend on their local docs. And they need these flu shots the most. My close friend's grandfather was just hospitalized with pneumonia. Getting these people preventative care is vital, and for many of them it's a matter of life and death.
Roy Poses, who authored the original post at Health Care Renewal, expresses this sentiment eloquently:
As a physician, it seems to me that the true measure of a health care system is how it takes care of the sickest and neediest patients. Here we have a system that can supply influenza vaccine to relatively healthy people who show up at big-box stores, but not to sick, high-risk patients in doctors' offices.This problem is also a consequence of free-market policies in relation to health care, and a perfect example of why CDHC proponents are wrong. The market, in this case (and many others related to health care) rewarded those with the most money and reduced access for the sickest and most immobile people. That's not wrong from the market's standpoint -- certainly it's serving its function. But people need more in this situation, and that's why we have regulated markets. When it comes to health care, those regulations provide essential protection so people don't die from the flu because their doctor couldn't order flu shots. It's really that simple, and breaking down competition barriers won't help a smidgen when big box retailers are providing health products.
Update: I was at the doctor's office today and, sure enough, there was a sign on the door saying they don't have any flu shots this season because the manufacturer wouldn't deliver them until December, so they cancelled the order.
Via the New York Times, more bad news on the Medicare Part D front:
Bush administration officials say they have received scores of complaints about the aggressive tactics used by some insurance companies and agents to market Medicare's new prescription drug benefit . . . Possible violations reported to Medicare officials in the past few weeks include uninvited door-to-door solicitation of business and misrepresentation of insurance products.These accusations, if true, are the inevitable consequence of horribly designed policy. (For more on the absurdity of the bill, see my posts here and here). If you enact a program that no one understands, certain less-than-moral companies will use illegal tactics to try to get prospective customers' attention (i.e. door-to-door solicitation, pretending to be from SSA or MMS).Federal and state officials said they had also received complaints that some insurance agents identified themselves as working for the Social Security Administration or the federal Centers for Medicare and Medicaid Services. Insurers are rushing into the Medicare market, offering drug coverage to 42 million people who are 65 and older or disabled. The new drug benefit is heavily subsidized by the federal government, but will be delivered by private health plans and insurers. Many of the insurers have little experience with Medicare.
When the bill passed in 2003, I was chiefly pursuing pre-med and paying little attention to the hubub around it. Now that the enrollment period has begun and my brain is primarily concerned with policy, I continue to find myself astounded that the senate actually passed this wolf in sheep's clothing of a bill (a wolf who happens to be very, very friendly with PhRMA).
I'm just totally disgusted. Paying for pharmaceuticals is a real problem for millions of people (not just seniors, by the way), and the best our legislators can do is this? A program that no one can even figure out how to sign up for while the companies proffering it employ illegal tactics to entice enrollees? This legislation is just one more nail in the coffin of American-style health care. One day people will look back and think, "Gee, that sure was unnecessary". And that's a damn shame.
There's probably not much use in responding to this, but I can't help myself:
Here's one way I think of the matter. Suppose we had taxpayer provision of 'universal' grocery needs. That is, we are all taxed to stock supermarket shelves, and in return for these higher taxes that we pay, each of us is accorded by government the 'right' to take from each supermarket whatever grocery items we 'need.'Let's take the grocery analogy. First, most people know exactly what food they need and the consequences of eating said food. We know getting an apple instead of a candy bar is bad for our health and might make us fat. We don't have to go to a "food consultant" every time before we buy food in order to attain it, nor do we need someone to give us a prescription for our food. We also know that we need food every day, at least three times a day.Isn't it obvious that each of us, having to pay no marginal cost of whatever grocery items we take from supermarkets, will take more than we need -- or, at least, try to take more than we need? Isn't it obvious that, having to pay no marginal cost of whatever grocery items we take, we will consume wastefully? Isn't it obvious that the prices of grocery items (and the actual costs, including queuing, of acquiring such items) will rise to heights far higher than those that we pay now with our private system of supplying groceries?
Let's compare that to going to the doctor or hospital. You can't even get health care without an appointment (unless you're going to the ER). Then the expert tells you what you need and orders it for you. You can't treat yourself (but you can feed yourself). And it's an infrequent endeavor for most people -- rarely do you need health care 3 times a day, every day.
So we can't treat ourselves and we don't need health care very often. The urge to eat every time you're hungry is surely greater than the urge to see the doctor, especially for routine care. No one becomes like a kid in a candy store when going to the hospital. (Can you imagine going in and saying "give me that operation and that procedure, Oh, and a colonoscopy too, while you're at it!")
Boudreaux continues:
What am I missing? Why do so many people -- including some faculty members tenured at presigious Departments of Economics -- fantasize that if we collectivize medical-care provision, ordinary people will be made better off?Why do so many people fantasize that ordinary people will be made better off? Seriously? Oh, I don't know, maybe because premiums have risen horribly, the industry is trying to hold down costs by shifting them to patients, and 45 milllion people have no insurance at all. But having the government guarantee coverage would greatly ease those problems for ordinary people, who struggle paying their medical bills and fear losing their coverage. I'd say that's a pretty big benefit.
This is just totally inexcusable and unbelievable.
Penlac Nail Lacquer rarely cures the nail fungus it is designed to treat, yet it costs $130 a thimbleful. As a result, more than 20 state Medicaid programs and dozens of private health insurers require doctors to get advance permission to prescribe it. But not New York Medicaid, which spent $12 million on the drug last year, more than eight times as much as any other state.What an utter waste of money. But what this really shows is a desperate need for an advisory board -- one that makes the efficacy of various therapies and pharmaceuticals clear for all health care payers to examine. While some people know that Prilosec is the same as Nexium, it's not general information. It's crucial that this information is easily accessible to help reign in spending.New York spent $74 million last year, far more than any other state, on Nexium, the "new Purple Pill" for heartburn. The drug is virtually identical to Prilosec, available at one-sixth the cost over the counter, and so at least 20 state Medicaid programs and many private health insurance companies severely restrict its use. Only now, two years after other states began imposing limits on Nexium, has New York moved to restrict it.
And those amounts are pocket change compared with the $348 million or more that New York could have saved if it were as aggressive as a state like Michigan in setting the prices it pays pharmacies for the drugs they dispense.
Update: Health Care Renewal has more
Hey everyone, I'm back! Thanks to all the well-wishers and commentors while I was gone. The appointment went well; I won't be having surgery for at least 2 and half weeks, possibly much longer. So rest assured I'll providing my usual commentary until then.
For now, I want to point you all to Graham, who wrote on Atul Gawande's recent New Yorker interview. The post originally caught my attention because someone highly recommended me Gawande's book, Complications: A Surgeon's Notes on an Imperfect Science.
In the magazine, Gawande comments on malpractice:
Are American doctors in a tougher position than those in, say, Great Britain or Canada?Gawande's point seems pretty solid to me. Health care costs for a disabled child or chronically critical loved one can easily reach $1 million, and when heatlh care coverage isn't assured, that's a terrifying sum.The major difference between malpractice here and in Great Britain and Canada turns out not to be in the number of lawsuits. At this point, the U.K. and Canada seem to be catching up with our rate of lawsuits. The big difference is that the awards are far smaller. This is partly because of the traditions of their court systems, but it’s also because they have universal health coverage. Patients in those systems already have their medical expenses covered for their lifetime, as well as some disability benefits. So malpractice awards are restricted to other costs—lost wages, or compensation for suffering, for example—and these are much smaller costs on the whole.
It makes sense, except that he's wrong. This Health Affairs article found that the average payment per judement in the UK was 36% higher than the average payment in the U.S.
Surprisingly, U.S. malpractice payments (including both cases that resulted in a judgment for the plaintiff and cases resulting in a settlement) were lower, on average, than those in Canada and the United Kingdom. In 2001 the average payment in the United States was $265,103, which was higher than in Australia but 14 percent below Canada and 36 percent below the United Kingdom. While U.S. media and public attention have focused on multimillion-dollar awards at the upper end of the range, the average was actually smaller than in Canada and the United Kingdom in 2001.So, I'm not entirely sure where Gawande is getting his numbers from, but there's a serious disconnect here. If the UK payments had been 5% higher than U.S. payments, that'd be one thing. But the average UK payment here was $411,171 to the U.S.'s $265,103.
I'm hoping to see some good letters to the editor point this out. Anyone else have an idea if this could be a reasonable discrepancy? Or is Gawande just flat out wrong?
Dear Readers,
I know it's a bit early to leave, but circumstances have over-taken my blogging abilities for Tuesday.
If you read my handy About page, you'll see that my knee will be going under the knife soon. Of course, I need to consult with some doctors before that can happen.
Which leads me to the explanation of my absence. While you are spending your Tuesday doing the usual, I'll be in St. Louis (here, exactly) getting my knee looked at. I'll be gone the entire day because it's four hour drive from Kansas City, and I'll be returning home immediately after the appointment.
So while I know you'll miss me terribly, I promise to be back on Wednesday. In the meantime, let me make some reading suggestions:
Over My Med Body! is a supremely enertaining blog by a Stanford med student.
Kaiser is a great place to get lost for hours. You can find research on almost any topic related to health policy, and I always learn something essential.
My column archive if you haven't read them already
And if you're health cared out and want mindless entertainment, Go Fug Yourself is the spot for all your making fun of bad celebrity clothing needs.
Enjoy!
Sincerely,
Kate
I've always taken a "liberal" approach in my thinking towards health care, which also happens to be the subject of Thomas Bodenheimer's article in this month's Health Affairs. He expertly flushes out the regressive way we pay for health care in the U.S., and it's a point I think those who ascribe to a "liberal" approach should be well aware of:
In 2002, 52 percent of health care services were financed through out-of-pocket payments and premiums, which are regressive, while 44 percent were funded through government revenues, which are proportional. The sum total of health care financing is regressive. In 1999 the poorest quintile of households spent 18 percent of income on health care, while those in the highest income quintile spent only 3 percent. The liberal perspective, based on equality, would likely substitute proportional employer-employee contributions and progressive taxes for regressive insurance premiums and out-of-pocket payments.Italics mine
First, it's great framework for understanding exactly why paying for health care is regressive: out-of-pocket payments and premiums are generally the same, and therefore make up different percentages of income. That being said, the gap between the top 20% and bottom 20% shouldn't be so huge, should it? According to this research, the bottom 20% spends six times that of the top 20% on health care.
And I'd really like to see how HSA's are going to affect this differential. I'm thinking they'll only make it worse. An average $4,000 deductible for a family is no joke.
But what this all underscores goes way beyond the "problem" of the uninsured. It's the very basis upon which we pay for our care. It's incredibly unequal, and it deserves more attention.
My latest column over at Campus Progress is up. This week's installment focuses on HSAs, as in, what exactly is that?
My employer offers Health Savings Accounts. Um, what exactly is it and should I get one?And will they cover the uninsured?Health Savings Accounts, known in the health policy world as HSAs, are a new way of paying for your health expenses. HSAs are a type of bank account offering tax benefits that you use only to pay for medical bills. HSAs were authorized by the Medicare Prescription Drug, Improvement, and Modernization Act in 2003 (of the confusing new drug benefit fame), and they’re becoming quite popular. Insurance companies like Blue Cross and Blue Shield, Aetna, and United Health Group sell them, and employers like Wal-Mart offer them to their employees. Over 2.4 million people have signed up for HSAs, and analysts estimate that by 2010 there will be $10 to $26 billion dollars in such accounts
Why is there so much hype over HSAs? Are they going to cover the uninsured?Dying to know more? Go read it all.I’m glad you asked. So far there aren’t any concerted efforts to make HSAs the main cure for the uninsured. This is, in part, because many employers of the uninsured don’t offer health insurance, period, let alone HSAs.The hype is about health care spending in general, which has been steadily rising, and premium costs in particular, which have increased 73% over the last five years.
HSAs are part of a new brand of health care initiatives known as Consumer Directed Health Care (CDHC). These initiatives, chiefly supported by free-market advocates, seek to control health care spending by shifting more of the cost onto patients. The idea is that if people see the bill for their health care, they’re more likely to seek out the lowest price for care and cut out unnecessary spending. The landmark RAND Health Insurance experiment, which used high deductible health plans, demonstrated that patients will reduce their consumption of care in these insurance arrangements. The problem is that they sought less care in all areas – necessary and unnecessary both.
As if we all didn't know about the looming disaster with baby-boomers retiring, the New York Times has more on spending cuts in Medicare:
The Bush administration is headed for a clash with the nation's doctors over a federal plan to cut their Medicare fees by 4.4 percent next year, even as the government tries to measure the quality of care they provide.Yeah, a 25% cut in physician fees for Medicare is really not going to fly for long.Doctors say that if the cut occurs, some physicians will be less willing to accept new Medicare patients.
Administration officials said that on Monday they would publish a final rule cutting 4.4 percent from the amount paid to doctors for each service provided to Medicare patients in 2006. They said the cut was required by a formula in the Medicare law. But doctors pointed out that President Bush had not proposed any specific legislation to avert the cut.
In a report to Congress in April, Medicare's trustees said the formula would produce cuts totaling roughly 25 percent from 2006 to 2011, while doctors' costs are expected to rise 15 percent.
As part of my effort to blog the current Health Affairs issue, I want to touch on a point Thomas Bodenheimer makes in "The Political Divide in Health Care: A Liberal Perspective". I have a special soft spot for Bodenheimer, mostly because he authored the first substantial text I read on health policy: Understanding Health Policy. It reads like an entertaining text book and it's a great discussion of the structure of the American health system. I definitely recommend it to anyone looking to deepen their understanding.
Soft spot aside, Bodenheimer makes an essential distinction in health care polling:
A 2004 Opinion Research Corporation survey of U.S. adults found 76 percent agreeing that access to health care should be a right. In a 2003 Pew Forum on Religion and Public Life survey, 72 percent of U.S. adults, including 51% of Republicans, agreed that the government should provide universal health care even if it meant repealing most of the Bush tax cuts . . . One caveat concerns the impact of taxes on public opinion. A 1994 survey found that fewer than half of the respondents would pay more taxes to finance universal health insurance. A 1993 survey found that 64 percent were willing to pay more taxes for that purpose. Many respondents balked at paying even the tiny sum of $100 per year. If respondents were told that increased taxes reduced out-of-pocket health care payments, more than half were willing to pay an additional $1,000 a year.The tax side of health care polling is key here. It's one thing for people to agree that they want universal insurance. It's a whole other side of the beast when you ask how much they would be willing to pay. And herein lies part of would-be reformers' problem.
We rely too heavily on polls examining support for universal insurance. Past efforts suffered severely because, though people want universal insurance in theory, they're unsure how much it means to them once it gets complicated. Is the health care situation different in 2005 than 1992? Absolutely, but one thing doesn't change -- reformers must convince the public that taxes need to be increased if the reform plan calls for it. And polling must be done beforehand to figure out the acceptable trade-offs. In the 1993 survey, most people were willing to put up to $1,000 more a year if it meant lower out-of-pocket payments. These trade-offs are extremely important issues to take into consideration when designing health care reform.
So while I always enjoy polls reflecting the public's enthusiasm for universal insurance, we must take care to extend those polls to their logical end -- how much are they willing to change to get that guarantee?
As it's the weekend and I'm not feeling a big policy post, I figured I should at least point the direction to something to waste your time with. The Straight Dope is basically a collection of those old wives tale questions answered with absurdist flourish. From one of my personal favorites, Which will keep you drier, running through the rain or walking?
But wait, you say. What about those pesky aerodynamic effects? The requisite math is a bit daunting, but never fear. Heedless of his delicate health or his already low reputation with the neighbors, your columnist spent a recent rainy Saturday running down the street like an idiot brandishing pieces of red construction paper clipped to cardboard, the better to snag and count raindrops. Methodology: three trials of two runs each over a fixed distance, once running, once walking. Winds: calm. Angle of attack of paper relative to ground: 45 degrees. Results:There's your classic sampling, very scientific indeed. Head to the site to get all your life-long questions answered!Trial #1. Running, 15 seconds to run course; 213 drops. Walking, 40 seconds; couldn't count drops, paper soaked. Shortened course.
Trial #2. Running, 7 seconds; 131 drops. Walking, 20 seconds; 216 drops.
Trial #3. Running, 7 seconds; 147 drops. Walking, 17 seconds; 221 drops.
From Blue Cross Blue Shield News:
The Philadelphia Inquirer on Thursday examined pharmaceutical companies that plan to eliminate charitable prescription drug programs for seniors enrolled in the new Medicare prescription drug benefit. Last year, the pharmaceutical industry donated $4.1 billion wholesale value in prescription drugs through tax-deductible charities. However, under a decision released last week by the HHS Office of Inspector General, Medicare beneficiaries who enroll in the new prescription drug benefit will lose eligibility for the medications donated through the charities. According to the Inquirer, an estimated three million to four million Medicare beneficiaries nationwide will lose access to prescription drugs under the charitable programs on Jan. 1, 2006, as a result of the decision.No joke on ending charity coverage, which, although quite uncharitable, makes sense from a financial standpoint. Why should they give drugs away for free when people can access them for full cost (thanks to lobbying for no price negotiations)? But PhRMA's decision to push for donated pharmaceuticals in the donut hole (for explanation look here) seems totally out of left field. Considering the monumental lobbying effort to get the disaster-of-a-benefit passed, I must admit I'm shocked to see PhRMA doing something, well, nice. Kudos.Rx Company Response
Some pharmaceutical companies -- such as Pfizer, Bristol-Myers Squibb and Merck -- have said that they will allow Medicare beneficiaries to decide whether to enroll in the prescription drug benefit or continue to receive medications through their charitable programs. Amy Rose, a spokesperson for Merck, said, "Our broad interest is making sure that the people who need them have access to their medicines. That's the overall goal of everyone in the industry." However, other pharmaceutical companies -- such as AstraZeneca, Wyeth and GlaxoSmithKline -- have said that they will eliminate their charitable programs for Medicare beneficiaries, regardless of whether they decide to enroll in the prescription drug benefit. Carla Burigatto, a spokesperson for AstraZeneca, said, "Our program always has been to provide access for people with no other coverage." Title II Community Aids National Network, a coalition of HIV/AIDS groups, has called on federal officials to revise the HHS OIG decision. In addition, the Pharmaceutical Research and Manufacturers of America has asked CMS to clarify the decision to allow Medicare beneficiaries who enroll in the prescription drug benefit to retain access to medications under their charitable programs "when their expenses hit a gap in coverage -- the so-called doughnut hole," in which annual prescription drug costs reach between $2,250 and $5,100, the Inquirer reports (Ginsberg, Philadelphia Inquirer, 11/17).
If you want to know more about Medicare Part D, Kaiser's got an excellent list of resources.
From new RAND Health research:
Local produce prices are one of the factors most-strongly associated with weight gain, and children in areas with higher produce prices (adjusted for income and cost-of-living) gained more weight than comparable children in areas with lower produce prices relative to income and cost-of-living.Growing up in Suburban Kansas, grocery stores are plentiful and cheap; almost every family has a car and the public schools are among the best in the nation. Head 15 minutes into urban Kansas City, the schools have lost accreditation, houses are dilapidated, grocery stores are packed with dusty boxed food and bruised produce. Obvious symptoms of poverty, yes, but research like this RAND study is important to tease out the uncontrollable consequences. The poor have little access to affordable produce, and are therefore more likely to be obese, and therefore more likely to be obese as an adult and experience lifelong health problems as a consequence (diabetes, high blood pressure, etc). With more health problems they'll miss more work days and be less productive, not to mention more likely to be uninsured. With cycles like these, is it any wonder that poverty is endemic and cyclic?
Via Matthew Holt there's bad news on the Tamiflu front:
The FDA said there were 32 reports of "neuropsychiatric" adverse events, 31 of which happened in Japan, and included abnormal behavior, hallucinations, convulsions and encephalitis. The agency said it received a report of two patients, ages 12 and 13, jumping out of their windows after receiving two doses of Tamiflu.This is discouraging, to say the least, considering Tamiflu is the chief treatment for bird flu (and probably the only treatment). This development is even worse given recent reports from China:
The Chinese government announced late Wednesday that it had confirmed the country's first three cases of bird flu in people, an admission that marked a potentially far-reaching change in how China handles the emergence of new diseases.The good news is China's newfound forth-rightness; the bad news is Bird Flu continues to march its way across the globe and our most promising treatment might be unsuitable for children, one of the more susceptible groups to death.The Chinese Health Ministry said Wednesday evening that bird flu had been confirmed in a 9-year-old boy and his 12-year-old sister in Hunan Province, in central China, and a 24-year-old woman in Anhui Province, in east-central China. The boy has recovered and was released from a hospital last weekend; the girl and the woman, a poultry worker, died.
In any case, I think I'll go get that flu shot...
So, I've never gotten a flu shot before, but I'm starting to think maybe I should. Anyone experienced the magic of a flu-free winter thanks to the shot? Gotten sick anyways? What's the consensus?
I promised more on the Medicare drug benefit this week so I think it's time to revisit. Fortunately my wonky contact at The Century Foundation, Leif Wellington Haase, has penned a "Good and Bad and Ugly" overview of the new benefit. We're optimistic people around here, let's start with highlights of the good:
• No state, even sparsely populated Alaska, has fewer than eleven drug plans. States such as California and New York feature more than forty choices.That's some serious relief for people who need it; it's also good to know everyone gets to choose from at least 11 plans. Of course, those choosing from 40 plans have a difficult road ahead of them. So what's the bad?• Premiums are on average about 14 percent lower than anticipated. Every state in the continental United States will have at least one drug plan with a monthly premium below $20.
• According to a recent study by PriceWaterhouseCoopers, beneficiaries with incomes of $14,500 or less (150 percent of the federal poverty level) will save 90 percent in out-of-pocket costs under the new coverage.
• Even though the efforts at educating beneficiaries have been strong, they have been plagued by troubling glitches. After the government released its online plan comparison feature last week—itself well behind schedule—it failed to include the prices plans will charge for specific drugs. This makes it difficult or impossible for older Americans to make educated choices about whether to join a plan, or which one to select.Beneficiaries not signing up is a bigger deal than meets the eye. That's because insurance companies are spending enormous amounts publicizing their plans, and insuring for drugs is not a very profitable way of doing business (one reason so many plans have dropped drug coverage in recent years.) If this plan fails and the various plans go under, it'll send shockwaves through the system, disrupting the costs of HMO-Medicare plans, and it could encourage even more companies to drop drug coverage. The immense complexity of the system is acting as a huge disincentive to sign up, and so far there are too few effective measures forming bridges over those troubled waters.• Medicare beneficiaries are still reluctant to sign up. A Gallup poll released in early October showed that over half of Medicare beneficiaries didn't plan to sign up for a prescription drug plan. Fewer than a quarter said that they would definitely join the program.
Unfortunately, it gets even worse:
• Beneficiaries who sign up for a drug plan after May 15, 2006 will face substantially higher premiums.This is an essential point to realize about the new benefit -- if you are eligible and don't sign up, you are charged 1% more every month you don't sign up, for the rest of the time you're enrolled in Medicare part D. That means if you wait a year, you will pay 12% higher than the average plan cost. If premiums rise, so will the amount you're penalized. According to the Chicago Tribune, seniors who wait four years before signing up may end up paying almost 50 percent more for the rest of their lives. That's quite a penalty.
It's just another dimension that makes the new benefit a shameful piece of legislation. If you're going to penalize people for not signing up, make it easier, for God's sake. I'm still shaking my head that this bill ever passed...
Via Ezra, Steve Pearlstein has some interesting ideas:
Rather than falling back into the political set-piece of defending the status quo and demonizing Republicans for another round heartless budget and tax cuts, Democrats might have used the opportunity to change the terms of the debate. With the governors at their side, they could have pushed Congress to take the next step in transforming Medicaid from an entitlement program for the poor into a means-tested health insurer of last resort for all Americans.Italics mine.
How, exactly, does this represent a good idea for Democrats? Announcing a plan to create a health insurer of last resort isn't a homerun for taking back the senate or getting a president elected. "Last resort" doesn't signify quality; it signifies disaster (i.e. I tried that parking break as a last resort before driving off a cliff). Nor is it something that middle class Americans want to be involved in.
Fortunately, other members of the punditocracy (i.e. Ezra) have a scenario that's much more appealing:
Expand FEHBP, the program that currently insures nine million government employees and uses community rating (which means everyone, no matter their health issues, gets charged the same premiums, so nobody is priced out), by opening it to small businesses and individuals . . . Then, once this quasi-national health system is running parallel to the patchwork of private insurers, let Americans make their own choice on what looks most attractive. Let the new FEHBP and the old system compete and see which consumers prefer.FEHBP, the Federal Employees Health Benefits Program, provides excellent comprehensive coverage at reasonable prices. An extension of high quality insurance is something a wide group of the population would support, without associations of poverty and "last resorts". Not only would they get behind it -- they deserve no less than the quality of insurance we give our elected representatives. The longer we fool around with programs that cover the most marginalized parts of society (we already have one!), the longer until we can fix the problem affecting everyone -- inadequate care, increased cost shifting to patients, and loss of health insurance.
Via New York Times:
The rate of Caesarean sections in the U.S. has climbed to an all-time high, despite efforts by public health authorities to bring down the number of such deliveries, the government said Tuesday.C-sections are riskier than normal delivery, cost a hell of a lot more, and take longer to recover from. Something needs to change here...Nearly 1.2 million C-sections were performed in 2004, accounting for 29.1 percent of all births that year, the National Center for Health Statistics reported. That is up from 27.5 percent in 2003 and 20.7 in 1996.
As most of you know, seniors could begin signing up for Medicare Part D yesterday. I have to admit, being young and writing a column targeted towards college students has let this slip under my radar. That is until I was listening to NPR yesterday and Talk of the Nation had two guests discussing the new benefit. It's a scary state of affairs, for both seniors and their kids/grandkids alike who help them decide on a course of action.
My grandparent's six children currently split their pharmaceutical bills every month (which can be no small chunk of change -- $450 last month according to my mom). My mom and I were running some errands when the program came on, and she was insistent (not that I would complain!) on listening to the program so we can figure out what my grandparents should do.
I came away from that program even more confused. And if I'm confused, you know seniors are drowning under the information flood. There are many details essential for consideration that news articles don't discuss. I'll be blogging on them the next few days, so here's to hoping we can understand this better!
For today, it's important to realize the donut-hole nature of these plans. Graham of Over My Med Body! does a great job explaining this:
For the first $2,250, you and Medicare split the drug bill (Medicare pays 75%). After that, for the next $2,850 of drug costs, you, the patient, have to pick up the entire tab. Once $5,100 is reached ($2,250 + $2,850), Medicare kicks back in, paying 95%. People call this donut coverage; you get to eat a bite until you get to the middle, then you get nothing, but then you get donut again once (if) you get to the other side.So if seniors have exhorbitant prescription bills, they will still have to pay past a certain amount of expenditure. What makes these plans even more frustrating is that insurers can pick and choose what prescriptions are covered. Seniors want to figure out if their plan covers all the drugs they currently take, or they could end up paying out of pocket before the "hole" in the plan kicks in. This is no small task for many couples, especially those with serious medical problems. It's also important for seniors to make sure their plan covers their pharmacy, or if not, that their plan covers another convenient pharmacy.
Am I the only one who feels like it's just plain cruel to do this to people who've lived through the last 65 years? Now that they've finally reached "golden years" we say, "Hey! You want prescriptions! Come here!" and then whack them in the back of the head with a bat. This benefit is a total disaster.
The Government Accountability Office (GAO) released its report of the procedure involved in denying Barr Laboratory’s application to make Plan B available over the counter. Those following the debacle already know about the fishy reasons for rejection, but the GAO's report is a pretty stunning indictment (if you're new to the debate, I am nepotistically recommending my column over at Campus Progress as background).
According to the GAO several things were unusual about this approval process (from the report, but I've put them in bullet form for your easy reading pleasure):
• The directors of the offices that reviewed the application, who would normally have been responsible for signing the Plan B action letter, disagreed with the decision and did not sign the not-approvable letter for Plan B. The Director of the Office of New Drugs also disagreed and did not sign the letter.Okay, those are pretty serious irregularities.• FDA’s high-level management was more involved in the review of Plan B than in those of other OTC switch applications.
• There are conflicting accounts of whether the decision to not approve the application was made before the reviews were completed
• The rationale for the Acting Director’s decision was novel and did not follow FDA’s traditional practices.
The directors of the office that reviewed the application didn't sign the letter? Along with the director of the Office of New Drugs? That brings up some deeply troubling questions about the FDA. If the heads of department who are supposed to sign the letter do not, who makes the final call? The acting director, who is appointed by the current administration (Bush admin, in this case). It's clear the FDA should require all parties' signatures to prevent this kind of blatant politicking.
And there's even more politicking to be had:
The Plan B decision was not typical of the other 67 proposed prescription-to- OTC switch decisions made by FDA from 1994 through 2004. The Plan B OTC switch application was the only one during this period that was not approved after the advisory committees recommended approval. The Plan B action letter was the only one signed by someone other than the officials who would normally sign the letter. Further, there are no age-related marketing restrictions for any prescription or OTC contraceptives that FDA has approved, and FDA has not required pediatric studies for them. FDA identified no issues that would require age-related restrictions in the review of the original prescription Plan B new drug application.Italics mine
As for the age question, numerous studies have shown that young girls, even if they're physically given Plan B to take home, show no increase in risky sexual behavior.
The science is against opponents of Plan B on every turn. Not only did the advisory panel conclude that Plan B is not an abortifacient (as anti-choice zealots claim), not only do numerous studies show no increase in risky behavior (despite the unusual request of having to prove this at all), but it's been used for years around the world and considered perfectly safe.
Clearly the FDA isn't concerned about science, but instead rejected an application due purely to politics. Because of their initial rejection, Barr had to revise its application to exclude girls under 16. What infuriates me so much about this is, of anyone, girls under 16 would be most profoundly affected by unplanned pregnancy. And the least able to get their own doctor appointment (you can't get a driver's license before 16, for God's sake) to get the prescription.
So what sorry excuse are opponents of Plan B using now that the report is public? The New York Times reported one response:
"We question the integrity of the investigative process that results in such partial conclusions by the G.A.O.," Ms. Zawisza said.I hate to break it to you, lady, but GAO stands for "Government Accountability Office". The whole point is they're supposed to investigate, impartially, what goes on in the government. Calling them partial is quite a red herring.
Lester Crawford already resigned over this -- I'm not sure many more people can be held accountable. And that's what's really sad -- there's nothing to be done but write blog posts and write your senators, and I don't expect much change to come out of that. I usually try to be more optimistic about individual power to change and what not, but it's clear in this case that it doesn't much matter.
Another part of Moran's essay features a nifty graph of Medicare versus VA spending.
There is much, much more to this graph besides the cost containment difference. Since 1995 the number of patients in the VA system has doubled to about 5.2 million. This is while over 12,000 staff were cut and the cost per patient was reduced by half. The VA often out performs the private sector -- check out these results
In 1990, before Baltimore began tracking its performance, rates of screening for breast and cervical cancer were 50 percent and 17 percent, respectively. In 2003, they were 88 percent and 87 percent.The VA is a beautiful thing, people.
Medicare officials point out that the VA has the advantage of being an integrated delivery system -- that is, a health plan in which most of the doctors are salaried employees and all care is coordinated and tracked. In Medicare, physicians work for themselves and patients are free to pick and choose their services.
Hello Newcomers! Of course, you're all newcomers, being that the site is brand new, but I hope you'll put me in your bookmarks and become oldcomers. I switched to this respectable typepad site after my blogger blog (epiphanies? -- originally an "everything" blog) got taken over by the health policy side of my brain. Dying to know more about this mysterious change? Check out the handy About page featuring, among other things, my obsession with fine pale ales.
Below you'll find some posts on articles from the recent Health Affairs issue on health care reform, a little on Pharma, a little on Canada, and other helpings of health care content. Don't worry, I'll post on other stuff sometimes too.
I'd love it if you leave comments (email works also), and most importantly, come again! I believe this is the beginning of a beautiful thing, me and typepad. . .
In the last post I talked about Moran’s vision of the nature of insurance in the next 50 years, essentially a breakdown of the current system that leaves us with only catastrophic coverage and a patchwork of publicly subsidized care. These major shifts in cost sharing would obviously have unexpected consequences for competition. One contradiction, in particular, has always perturbed me in respect to CDHC and HDHPs. Tremendously expensive tests and treatments (like $2000 MRIs) can blow your deductible in one hour. That equates to a significant decrease in demand for those therapies. It's one thing to have your doctor's visits add up to a deductible over a year, but quite another to spend it all in one sitting.
This is exactly what Moran predicts:
First, facing a much larger share of the first-dollar cost of expensive therapies, patients will be much more price-sensitive than they are now. Second, having transferred most of the first-dollar risks to the beneficiaries, health plan sponsors will focus their cost containment efforts more sharply on the big-ticket items that represent an increasing share of their costs. The combined effect of these two sets of pressures will push back strongly against manufacturers’ pricing flexibility. Increasingly, the question of whether a high-cost technology is covered at all by an insurance plan will become the most important determinant of product economics.Clearly this is the opposite intention of many CHDC proponents, in addition to sharing the honor of being a chief critique of a single-payer plan. (The number one retort I get from those unpersuaded by single-payer claims is, "What about all the innovation because we have a competitive system?")
Long-term care aside, it's clear Moran expects the total demise of the system as we know it, with oft-pessimistic flourish at both the public and politician's lack of control over the result.
It is natural to consider whether the public will be sufficiently accepting of these changes to permit such a new financing structure to actually emerge. This may not matter: The forces at work here may well be so large as to dominate the impassioned efforts of partisans of all persuasions to achieve any alternative outcome, no matter how well supported by public opinion.Despite his deep cynicism for the possibility, 2008 must become a ripe year for major reform.
It’s essential that health care framing moves beyond a political game. The actual ability to deliver high quality, affordable care is infinitely more important than debates between private market and regulation solutions. It doesn't seem that either side has figured out how to satisfactorily control for both along with innovation. This entire country -- not just us policy wonks -- needs to think hard about such bleak portrayals of health care delivery in the future.
Quality health care is important to Americans, but we've got to figure out a way to bring it past the hype of terrorism, Supreme Court nominees, and gas prices. Certainly some scenarios (completely unaffordable health insurance and no way to get care, doctors disappearing from everywhere but metropolitan areas) are just as scary. While I’m unsure as to what the best approach would be, we’ve got a little less than three years to figure it out. It’s time to get crackin’.
This month's issue of Health Affairs, Rethinking Health Reform, features a slew of articles focusing on, you guessed it, reform! I started with Donald Moran's essay "Whence and Whither Health Insurance? A Revisionist History". Moran offers an unexpected analysis of the clash between "regulation" and "competition" ideologies.
Moran writes:
Although it is easy to become preoccupied with this "health policy as ideological struggle" model, doing so risks missing the important fact that the ground on which this battle is waged is not stable but has been shifting slowly but steadily over time. Although the labels used to characterize health policy issues have proved durable throughout the course of "modern history," the character of the issues themselves has changed subtly, but importantly, during this period. To see this, it is necessary to take a longer view of the trends driving U.S. health policy.What, exactly, are these trends? Moran points to key pieces of legislation that resulted in an explosion in the supply of medical care. The Hill-Burton Act (1946) greatly increased funding for hospitals, the Professions Education Act (1963) helped with medical professional supply, and the enactment of Medicare and Medicaid (1965) rounds out the group with insurance programs designed to help Americans afford these new services. This flood of supply, thanks to the insulating nature of insurance, resulted in the corresponding flood of demand we've been swimming in for the last forty years.
The private sector tried to control the rising waters of supply and demand through major shifts in the composition of the insurance pool. Bills like ERISA strained the healthy workers at large empoyers from the risk pool, leaving small businesses unable to cope with premuim increases.
In the 1970s and into the 1980s, plan sponsors’ strategies were largely financial. The enactment of the Employee Retirement Income Security Act (ERISA) of 1974 (P.L. 93-406) provided a regulatory framework congenial to conversion of employer-sponsored plans to self-funded status . . . Its major advantage in the first ten to fifteen years of its existence was the one-time—but sizable—financial impact of withdrawing the relatively healthy workforce of larger employers from the broader health care risk pool, to directly finance their lower costs in lieu of paying premiums. Over time, the health benefit management industry engineered products, such as so-called minimum premium plans, permitting ever-smaller companies to take advantage of self-funded options. . . This trend sharply increased the risk profile of the small-group and individual insurance markets, which now faced materially higher premiums and uncertain access to the market. Ultimately, concerns about these impacts led public policy-makers to enact market reforms . . . to halt further erosion. These actions, however, could not reverse the aggregate financial effect of the departure of a large share of the workforce from the insured pool in the 1970s and 1980s. During 1994–2001, the number of people covered by commercial non-group policies declined from 31.9 million to 23.3 million.
So, where does this leave us? Supply constraints have clearly not been able to put a lid on rising costs. In terms of private-sector fixes, Moran is unconvinced that trends towards high deductible health plans (HDHPs), driven in large part by conflict over the employer/employee share of health care costs, will be a solution either. Especially considering the evaporating nature of risk-pooling. Instead, Moran predicts employer based insurance (except in catastrophic form) will be voted off the island by the end of the decade.
Moran envisions the emergence of a public/private hybrid; with public financing focusing on low-tech, direct service; private financing concentrating on a catastrophic insurance market offering a meager pool for uber-expensive technologies. I'm unsure that this kind of system, even with the collapse of private insurance, is at all possible. When you think about rising rates of obesity (hello type II diabetes) it appears that many Americans will require ongoing -- not catastrophic -- care. Patchwork direct service care paid for by some public financing can't possibly cover all that.
The New York Times reports on the faltering image of drug manufacturers:
A year after Merck's withdrawal of its arthritis medicine Vioxx led to an industrywide credibility crisis, the Food and Drug Administration is blocking new medicines that might previously have passed muster. Doctors are writing fewer prescriptions for antidepressants and other drugs whose safety has been challenged, like hormone replacement therapies for women in menopause.First, I can't believe it's been a year since Vioxx was pulled. Second, this is great news for patients. Generic drugs are no different than their much more expensive counterparts, and those that have been on the market longer are often essentially the same as the new drugs (the whole "me-too" phenomenon). Unnecessary therapies, HRT in particular, should be reduced. They have serious risks associated with their use, and it's something patients should weigh carefully.Meanwhile, insurers and some states are taking advantage of the backlash against the industry to try shifting patients to older, generic drugs, arguing that they work as well as newer and more expensive branded medicines. Overall, prescriptions continue to rise slightly, but an increasing share of prescriptions are going to generic drugs. Also, consumers seem to be less responsive to aggressive drug marketing.
Then there's the recent announcement about Ortho-Evra, the birth control patch. Apparently it delivers 60% more hormones than the Pill because estrogen is absorbed directly into the bloodstream rather than through the digestive system. The result? An increased risk of blood clot and stroke due to higher hormone levels.
Thursday's warning comes four months after reports that patch users die and suffer blood clots at a rate three times higher than women taking the pill.Citing federal death and injury reports, The Associated Press found that about a dozen women, most in their late teens and early 20s, died in 2004 from blood clots believed to be related to the birth-control patch, and dozens more survived strokes and other clot-related problems.
This is a major oversight on the part of the manufacturer. When oral contraceptives were first introduced in the 1960's the hormone levels were astronomical compared those on the market today. Drug designers learned that a low dose of hormones is just as effective and reduces the risk of complications. Knowing all these things, and considering the simple difference between orally taking medication and putting it into the bloodstream, it seems careless. Surely this could have been avoided.
What's worse is how young these women were - late teens and early twenties. I was actually considering switching to the patch because it seemed easier -- I'm glad I didn't follow through.
Due in large part to all the bad press (now there's no way I'll get a patch subscription), sales are dropping:
But at some, including Pfizer and Merck, the largest and third-largest American companies in terms of revenue, sales are stagnant and profits are falling, leading to layoffs and - for the first time in years - cuts in research budgets.After making more than all the other 490 Fortune 500 companies combined(at least until 2003, when oil took frist place), it's about time the pharmaceutical industry be held accountable for its oft-disregard for patients and their pocketbooks. But the cuts shouldn't be in their research budgets -- the problem is in the products themselves, and in the case of Ortho Evra, it seems more research was needed. Their profit margins need to fall back in line with other major corporations. Pfizer alone will make $8 billion in profits this year. Surely they can figure out how to recoup the negative press and make drugs safer with that much money.In the third quarter, United States sales of prescription drugs fell 3 percent at Bristol-Myers Squibb, 4.5 percent at Johnson & Johnson, and 15 percent at Pfizer. Merck said its overall revenues fell 2 percent despite favorable foreign exchange trends.
Last week a little post of mine on frustration with US health care made some noise here and here. I have to admit I was taken by suprise that my complaining got so much attention.
Much of that attention demanded that I give proof for my accusations! Well, if you read the post closely you'd see I wasn't making any claims except the simple fact that our health system has its problems, waiting being one of them. But today I'm going to give all those naysayers some satisfaction by debunking another huge myth about the perils of Canadian medicine: that many thousands of desperate Canadians cross the border every year seeking medical care because of unsatisfactory care at home, be it long waits, lack of new technology, or [insert appropriate false claim about Canadian care here.]
Three years ago, long before this blog came into existence, Health Affairs ran an article on Canadians seeking care in the US. The authors used some nifty methodology, including surveying numerous US hospitals along the border, as well as institutions generally regarded as "America's Best Hospitals". On the Canadian side, they used the National Population Health Survey (which literally asks, "In the past twelve months did you receive any health care services in the United States?" and "Did you go there primarily to get these services?"), as well as querying insurance companies on the Canadian side about the popularity of policies that cover US institutions.
Before I pull back the curtain to reveal their astounding findings, let's make a couple things clear. Many Canadians travel in the US every year. It is expected that this fact will show up in statistics. Further, I assume there are some very wealthy Canadians who will always say "No thanks" to waiting lists, and hop over to the US. I believe that is a reasonable assumption, and a fact of life that I'm comfortable with.
So what did the authors find?
In terms of hospitals along the border offering advanced treatments or special diagnostic technology (i.e. CT scans and MRIs), about 640 Canadians were seen, along with 270 for procedures like cataract surgery. They compare this to about 375,000 and 44,000 similar procedures in the region of Quebec alone during the same period. If you divide the total number of Canadians seeking those treatments in the US, divided by the number in Quebec alone that's about 0.09%. Not even a tenth of a percent.
But the most striking stats come from the Canadian National Population Health Survey (NPHS). From the article:
Only 90 of 18,000 respondents to the 1996 Canadian NPHS indicated that they had received care in the United States during the previous twelve months, and only twenty had indicated that they had gone to the United States expressly for the purpose of getting that care.
But let's give this number some context. We've all heard about seniors getting their prescriptions from Canada. (Hell, even driving to visit my sister at college in rural Kansas, I saw a billboard for "Canada Drug of Topeka!") But how many seniors really do that? Is it exaggerated, like the claims of Canadians coming stateside?
Polling data from 2003 (approximately a year after the Health Affairs article) indicates that 8% answered YES to the following question:
"Have you ever bought prescription drugs from Canada or other countries outside the United States in order to pay a lower price?"
If 8% of the 18,000 Canadians polled in NPHS had expressly sought care in the United States, that would be 1,440. Not 20, as the survey showed.
In other words, we have 72 times the number of Canadians seeking care in the US going to Canada (or at least calling there) to get prescriptions.
Honestly, what's really wrong with this picture?
[Source: Katz, Steven J et al. "Phantoms in the Snow: Canadians' Use Of Health Care Services In The United States." Health Affairs May/June 2002.
MedPundit says:
Count me unconvinced that computerized records will be the savior of medicine. It's just managed care in another guiseHuh. That's an interesting take, I suppose, considering the most recent Health Affairs research on electronic medical records (EMRs):
Effective EMR implementation and networking could eventually save more than $81 billion annually—by improving health care efficiency and safety—and that HIT-enabled prevention and management of chronic disease could eventually double those savings while increasing health and other social benefits.Really though, it just seems totally ridiculous to me to oppose something that will obviously save so much money and greatly improve care on principle.
Yes, it's a more efficient method of storing and retrieving information. And yes, it's a method of reducing errors, although it also introduces new system-specific errors. The government's paramount goal in pushing a nationally-connected healthcare record is to be able to monitor and prescribe what kind of treatment everyone gets.A little paranoid, no? If anything it's the insurance companies in doctor's and patient's faces trying to dictate care.
Take my Dad, for example. He broke a bone in his foot. His doctor prescribed a nifty little ultrasound machine that is supposed to stimulate bone growth. He took said nifty machine home with him from the doctor's office and began using it. Three weeks later he gets a letter from the insurance company that this device is not, in fact, covered. Care to take a guess for the cost of this little machine? (It's about 6 inches by 6 inches) $3,000.
No one at the doctor's office mentioned that insurance plans won't cover it. They just gave it to him, and now he owes three grand.
It's one thing to oppose the cost of implementing EMRs and HIT (health information technology) advances, which is why the government is leading the charge (see the VA and recent grants for practices to buy HIT software). I'd like to think things like EMRs could help patients avoid these problems(i.e. the doctor or nurse having a message pop up when they type in a treatment that this patient's insurance does NOT cover this treatment). Of course, if there's only one insurer we take out the guess work.
But simple ideological opposition to HIT exposes a disregard for quality care and selfish concern for the amount of hassle in learning a new system.
I know there's been a lot of talk on Consumer Directed Health Care (CHDC) on this site lately. I'm going to continue on that meme today, because there are some fundamental issues worth considering if we're going to continue down that road (we're already on it, you can be sure of that).
David Adler over at The New Republic has an interesting piece on Consumer-directed health care in South Africa. Basically about half of the country's privately-insured are enrolled in high deductible plans. But the introduction of HDHPs (high deductible health plans) has had some unanticipated side effects:
The result was an unprecedented restructuring of the insurance market. The young and healthy migrated to the new consumer-driven plans and away from traditional employer-based schemes. Meanwhile, the old and infirm were left in traditional insurance schemes.That seems like a predictable response, right? Is it really such a big deal to have insurance segmented in this way?
The answer is, absolutely. Health insurance in the U.S. went through a massive restructuring after commercial insurers switched to experience rating and drowned Blue Cross in the 1950's. Blue Cross had offered moderately priced health plans to all workers through community rating, but other commercial insurers could offer cheaper plans to select groups of individuals through experience rating. The inevitable result was that all the young and strapping moved over to cheaper plans while the old and infirm had to stay with Blue Cross. Stuck with a bunch of high-cost patients, Blue Cross had no choice but to switch to experience rating as well. Which they did.
Now South Africa has experienced the same thing, except this time it was brought on by HDHPs. It's reasonable to believe the same could happen here as well as more and more people enroll in HDHPs. If that's the case, all these plans are going to do is cause a fundamental restructuring of health insurance as more and more people are sectioned off according to their health status. Again.
And what's worse?
At a macroeconomic level, however, there is less cause for celebration. Private health care costs have hardly been contained. In fact, the opposite is the case. Between 1996 and 2001, the cost of specialty care increased 43 percent, and the cost of hospital care rose 65 percent. This represents a marked increase from the inflation rates for the five years prior. There have also been substantial increases in plans' administrative costs.
Especially when another country has proven exactly what we fear.
