Healthy Policy

New Stuff

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.

Safe or Unsafe?

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.)

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.

I second his opinion, and raise him an article about liver poisoning due to tylenol:

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.

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.

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.

Mean Ol' Docs!

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.

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.

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.

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?

I heart egg nog

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!

Off Topic Blogging

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?)

Big Changes in Pharma Land

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.

"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."

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.

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.

Whence and Wither Flu Shots

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.

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.

So, last year there wasn't enough vaccine, and this year we're making sure non-medical locations receive it first?

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.

Horrible Legislation Strikes Again!

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.

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.

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).

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.

Why Health Care is Different from Groceries

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.'

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 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.

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.

Why we need review boards.

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.

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.

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.

Update: Health Care Renewal has more