"When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov
''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.'' -Robert Ehrlich, drug advertising executive.
"Opinions are like sphincters, everyone has one." - Chris Rangel
From Bad to Worse: One of my regular correspondents on the medmal crisis front says that things are, indeed, very bad for malpractice insurance companies:
Medical-malpractice insurance underwriters in Pennsylvania lost $18 million last year, according to a new analysis by the state Department of Insurance that appears to underscore industry claims that Pennsylvania's tort system is driving insurers out of the state.
The analysis separated out the reserves that malpractice insurers sock away for future claims, a sum that the insurers typically count as losses. Even without those reserves in the loss column, 2002 was the fourth year in a row that insurance underwriters in Pennsylvania lost money, according to the analysis.
Medical-malpractice insurance underwriters in Pennsylvania paid out $345.4 million in claims last year, about 31 percent less than the $499 million that insurers received in premiums from doctors, the department said.
But while insurers earned $46.4 million in investment income, they also paid $136.9 million in legal costs and $81.1 million for taxes and other operating expenses.
The insurers also put away $209.4 million in reserves for future claims. In the interim, insurers invest the money in bonds or cash equivalencies, but interest rates have dropped in recent years, diminishing the their potential for revenue from the securities market.
There are only two companies in the state writing new policies at all, and one of them happens to be the same company I use. Maybe I've been too harsh on them. But, I'm going to be in trouble if the rates go up another $6,000 before the end of next month when I have to buy my own policy. posted by Sydney on
7/26/2003 02:47:00 PM
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The Descent of Man: To lower your cholesterol without expensive drugs and their side effects, try eating like an ape:
Jenkins and his team randomly assigned 46 men and women with high LDL cholesterol -- the so-called bad cholesterol -- to one of three vegetarian diet groups. The control group, those not on lovastatin -- a popular cholesterol-lowering drug -- or the specific diet being tested, ate meals low in saturated fats found in animal products such as beef and butter. The second group had the same low-fat diet, plus a daily 20-milligram treatment of lovastatin.
The last group received a diet high in foods identified in previous clinical trials to have cholesterol-lowering properties. They include foods such as oat bran bread and cereal, soy drinks, fruit and soy deli slices and roasted almonds. A typical dinner was tofu baked with eggplant, onions and sweet peppers, pearled barley and vegetables.
The investigators found the dietary approach used with the third group lowered levels of LDL cholesterol by almost 29 per cent, almost identical statistically to the 30.9 percent decrease among lovastatin users.
Participants were randomly assigned to undergo 1 of 3 interventions on an outpatient basis for 1 month: a diet very low in saturated fat, based on milled whole-wheat cereals and low-fat dairy foods (n = 16; control); the same diet plus lovastatin, 20 mg/d (n = 14); or a diet high in plant sterols (1.0 g/1000 kcal), soy protein (21.4 g/1000 kcal), viscous fibers (9.8 g/1000 kcal), and almonds (14 g/1000 kcal) (n = 16; dietary portfolio).
Vegetables and almonds would certainly be less expensive than our current mania for statins:
As he and colleagues reported in the July 23 issue of the Journal of the American Medical Association, Jenkins noted an estimated 1 million people in Great Britain and 6 million people in North America currently are treating high cholesterol by using statin drugs.
Data published in 2003 in the journal Diabetes Care indicate the annual cost of statin therapy, medication, monitoring and adverse events is between $600 and $2,1000 per person, depending on the LDL cholesterol level being treated.
Although the study is a small one, it does appear to find the same trends in cholesterol lowering for the "ape diet" and the traditional low-cholesterol diet combined with statin therapy. (For those with access to the full paper, here's a conversion table to translate the cholesterol results to the units of measurement traditionally used in the U.S.). The ape diet group started out with an average cholesterol level of 268 and brought it down to 209 in four weeks. Their bad cholesterol (LDL) went from an average of 178 to 126. The statin group, who were also following a low cholesterol diet, lowered their cholesterol from 256 to 199, and their LDL from 172 to 117. The traditional diet alone was the most disappointing. In that group total cholesterol went from 246 to 230, and their LDL from 165 to 152. None of the groups lowered their LDL cholesterol to less than 100 as is currently recommended for diabetics or people with coronary artery disease, so fruit and nuts aren't likely to supplant the current statin mania any time soon. posted by Sydney on
7/26/2003 08:23:00 AM
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Friday, July 25, 2003
More on Damascus Road: Reader's comments on tort reform and malpractice insurance companies:
When an insurance company cannot accurately predict a risk they overprice the premiums. That is what is happening today. The new element in this area is that law firms are now very rich and very powerful. Before they would only take a case if they were pretty sure they could win. Now they will file 50 lawsuits with the hopes of only winning one.
It takes about $5,000 to $10,000 to investigate and defend even a frivolous lawsuit. Your annual premium will pay for the defense of one or two frivolous lawsuits.
The insurance companies are panicking about this situation and you are feeling their pain.
If tort reform was passed predictability would come back to the medical malpractice area and premiums would drop like a rock.
Insurance companies cannot make excessive profits for very long because the market is very competitive when the risk is predictable.
But even proponents of tort reform say they don't expect rates to decline once it's passed, although they do expect them to hold steady. I can't help but wonder if they're price gouging now so they can enjoy high premiums for some time to come, even after the passage of tort reform.
Although these questions from another reader point out that tort reform is still for the greater good:
I read your post on the insurance hikes and agree that it seems rather outlandish that the rates are going up that quickly. So my questions to you are:
(1) Is your insurance company using lawsuits as the justification for their hikes?
Yes, they are. They've now lumped my county in with the county north of us, a county with a large population of aggressive trial lawyers. My county used to be considered alone when they made their risk calcuations. That's actually a justifiable move since the trial lawyers from up north advertise down here. Maybe part of tort reform should include requiring attorneys to live and practice in the county in which they file suit.
(2) If they are proving their critics right, citing lawsuits and then padding the financial effects to line their pockets (which, given fluctuations in lawsuits, would be enormously easy to do), wouldn't tort reform deny them that rationale? Or, based on your history with the insurance companies, would you say they are likely to keep the rates as high as they are and find another rationale?
I think they'll keep them high, although they probably won't raise them at the accelerated rate and frequency which they're now doing. As the first reader pointed out, competition is likely to keep the rates steady once tort reform passes:
(3) Could the fact that there are so few insurance companies be related to fears of anyone else offering it due to said lawsuits, and is it possible that tort reform would then clear the way for increased competition, lower rates, and better client services? Or is there another reason that there are so few good companies out there?
Tort reform would probably encourage more new companies to enter the market - and old ones to re-enter markets they left. Perhaps that would help bring down premiums after all, especially since doctors are now getting used to the idea of shopping around for new malpractice insurance. Often, when a physician changes insurance companies, he has to spend a lot of money for a "tail" to cover any suit that could arise in the future from the years he was covered by the first company. That makes it expensive to switch insurance companies. But, in the current environment, doctors have been forced to find new coverage because their insurance carriers either went bankrupt or left their area. As a result, more doctors are purchasing the more expensive policies that don't require tail coverage if terminated. So, maybe competition would bring the prices down.
Tort reform is still a cause worth supporting. Even if you think the malpractice insurance companies are milking the current crisis.
posted by Sydney on
7/25/2003 07:18:00 AM
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Thursday, July 24, 2003
Prostate Problems: Once again, our current methods for screening for prostate cancer are found to be inadequate. The conclusions being drawn from the current study, however, are dubious:
The Harvard Medical School researchers are advising that more doctors lower the threshold -- from 4.1 on the Prostate-Specific Antigen test to 2.6 -- for when they recommend biopsies to determine if men indeed have cancer. The goal: catching prostate cancer -- which kills nearly 30,000 men a year and is particularly rampant among African Americans -- before it spreads outside the prostate gland.
''We're lowering the bar,'' said Dr. Cosme A. Gomez, a urological oncologist and chief of urology at Baptist and South Miami hospitals.
The researchers are assuming that every case of prostate cancer they detect is potentially lethal, but as the article points out in the end, that isn't necessarily the case. In fact, most men don't die from their prostate cancer, they live and die with it. And if it weren't for the PSA and the biopsy, they'd die never realizing they had it. The real challenge in screening for prostate cancer is not to find methods that detect it earlier, but to find a screening method that can differentiate aggressive prostate cancer from the benign, slow-growing type.
Road to Damascus Moment: I'm beginning to have my doubts about the medical malpractice insurance companies. Yesterday, I discovered that the rate for my insurance went up again, by $6,000. In May, a year's worth of coverage from my current insurance company was $8,000 a year. In June, the price went up to $15,000 a year. Now, in July, they're saying it's $21,000 a year. They won't tell me how much it will cost in September, when I start paying for my own policy. The agent says the company "just won't quote a price for September policies until after August 1."
I still believe that tort reform is essential if the current liability crisis is going to be curtailed, but it strains belief to think that the insurance company has to increase premiums by several thousand dollars a month to make ends meet. We live in a litiginous world, but the jury awards and lawsuits haven't been exploding at that rapid a rate. In fact, everything about the insurance company suggests they know they're in the catbird seat. In addition to ramping up prices every month, they're slow to process applications, and their insurance agents take days to return calls. It's as if they don't care about attracting customers. They've got enough gold to mine already. So why do I stick with them? Because they're one of the few companies in our area that are still "A" rated, a quality that's essential to maintain hospital privileges. And because, until yesterday, I thought they were a good company.
Before yesterday, when I read things like this, I tended to dismiss it as trial-lawyer propaganda. But now, I've got considerable doubts as to whether the insurance companies can be trusted to offer fair market prices for their product. We just might need some sort of regulation of premiums to prevent price gouging if we're going to prevent the continued decline in access to care that the crisis is causing. I hate to admit it, but the insurance companies are proving their critics right.
The Dark Side: F/X has a medical show with a twist - totally corrupt doctors:
"Nip/Tuck" is unusual, but the show is like FX's other critical hit, "The Shield," in one way: just as that police drama twisted convention to focus on corrupt cops, "Nip/Tuck" showcases young, talented surgeons who do not save lives. They do not even improve them.
Most of their patients are beautiful, neurotically insecure women who need hobbies, not larger breasts or smaller noses. The doctors turn away a badly burned child who needs pro bono skin grafts but not a suspicious Latin American who speaks no English and has a briefcase brimming with cash.
...The clients who demand nips, tucks and far more radical procedures do not find happiness. "I don't want to be pretty," the aspiring model whom Christian lured from bed to the operating room whispers pleadingly. "I want to be better. I want to be perfect." He dumps her before her stitches come out.
At the risk of sounding like those Italian-Americans who complain that The Sopranos sullies their reputation - this kind of show isn't exactly what the profession needs right now, in the midst of our current litigation crisis. Where's Ben Casey when you need him?
posted by Sydney on
7/22/2003 10:58:00 PM
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Steel Magnolias: The magnolia isn't just a thing of beauty, it's also a potential cancer fighter:
The investigators separated the natural magnolia mixture chromatographically and tested the fractions for their ability to prevent the growth of an endothelial cell line in culture. Endothelial cells make up the walls of blood vessels. They identified honokiol, a compound previously studied by Japanese researchers in herbal medicines, as the active component of the magnolia extract. Honokiol reduced the growth of endothelial cells by driving them into apoptosis, a self-destruction program activated by cells when their growth signals are disrupted. Importantly for the specificity of its anti-tumor activity, honokiol inhibited the growth of endothelial cells more than other kinds of cells.
Worth Considering: There was an op-ed in the New York Times yesterday that had some good ideas about tort reform, by a lawyer, no less:
Creating a reliable system of medical justice, however, requires changing one aspect of the system that is so ingrained it is hardly even part of the debate: the jury. Expert judges, not juries, must decide what is a valid claim.
Even modest legislative reform is routinely resisted as trespassing on the hallowed right to take every issue to a jury. But this right is generally misunderstood. In criminal prosecutions, juries play a critical role as our protection against abuses of government power. Juries are our defense. But in a civil case, where citizens can use the justice system as an offensive weapon, the most important social value is predictability.
...Today, however, juries are being asked to decide not only disputed facts but standards of medical care. How does a jury know how to do that? More important, how does a doctor know what standards to abide by? Every time a sick person gets sicker, it's easy to come up with a theory of what a doctor might have done differently. Chemotherapy didn't work, but maybe radiation would have.
Since the earliest days of the common law, there has always been a tension between what's a legal standard and what's a disputed fact. Until recent decades, however, this distinction didn't matter much to society. Social mores kept people from suing except in egregious cases. No longer. Now lawsuits are limited only by the imaginations of self-appointed victims and their lawyers. Drawing the line can be difficult for a judge, but not drawing the line transforms justice into a free-for-all.
..Defenders of the current system take pride in the fact that each case goes to the vote of the people. But that's not the rule of law; law that changes from case to case is the opposite of law. Shifting decisions about standards of care to judges from juries seems radical, but doing so is essential to restore a critical precept of American justice: that like cases be decided alike.
The victim of unreliable justice is society as a whole, not just doctors. That's why reform must focus not only on protecting one group with caps on damages, but also on achieving a reliable foundation of law for all.
Fat and Cancer: So, does a high-fat diet cause breast cancer? The authors of a recent study in The Lancet think so:
The study, published in this week's Lancet medical journal, was conducted at Cambridge University in England and involved 13,070 women who kept diet records from 1993-97.
The researchers set out to discover whether the reason the previous follow-up studies found no link was that the method they used to examine dietary habits - a food frequency questionnaire - was too inaccurate. They also had the women keep a daily diary in which they recorded everything they ate.
By 2002, 168 of the women had developed breast cancer. Each of those cases was matched with four healthy women of the same age who had filled out the questionnaires and diaries around the same time as the women who developed breast cancer had.
The total group was divided into five equal categories of about 170, according to how much fat they ate each day. Two methods were used to place the women in one of the five categories; one based on the questionnaire and one on the daily diary.
The researchers calculated separately for both methods the difference in breast cancer risk between the women who ate the least fat and those who ate the most fat.
``The effects just weren't seen with food frequency questionnaires,'' said investigator Sheila Bingham, deputy director of the human nutrition unit at Cambridge University. She called the questionnaire a ``very crude method'' that was not reliable.
However, when the food diaries were used to categorize the women, those who ate the diet highest in saturated fat were twice as likely to develop breast cancer as those who ate the least.
Of those in the lowest category, 14 percent developed breast cancer, compared with 20 percent, in the highest class. The more fat that was consumed, the higher the risk of breast cancer.
The abstract of the study is here, but it doesn't shed much light on the subject. (Access to the entire paper requires a very expensive subscription.) Judging from the synopses of the study found in the papers, the only thing that can be said with certitude is that researchers aren't very good at measuring what sorts of food people eat, and how much.
Surveys and questionnaires are known to be inaccurate methods of gathering information, so it's somewhat surprising to find that food frequency questionnaires are evidently the standard in nutritional research. So much so, that the "discovery" of their inaccuracy is making news.
But what about the breast cancer and fat intake association supposedly found in this study? The evidence isn't all that impressive. For one thing, the sample size of women with breast cancer was very small - just 170. And within that small sample, the difference in breast cancer rates between those who ate the least fat and those who ate the most was also quite small - six percentage points. Then, there's the question of just how they gathered the food diary information. Did women record everything they ate everyday throughout the study? Apparently not:
Women taking part in the study, the European Prospective Investigation of Cancer and Nutrition (EPIC), kept a food diary over seven days detailing what they ate, including brand names, and how much they consumed.
Researchers then analysed the nutritional content of the diets and followed up the state of the women’s health up to seven years later. The diaries were completed during 1993 and 1997 by participants over the age of 45 and the results were assessed last September.
Sorry, but one week in a life is hardly representative of a lifetime's dietary habits. Overall, it's a very weak case.
Despicable: There are crimes and then there are crimes:
Nineteen South Floridians have been charged with diluting lifesaving medications to combat cancer, AIDS, and other ailments.
Consisting of four bogus drug wholesalers, the ring made millions selling, in some cases, bottles of chalk and tap water to terminally ill patients, according to charging documents.
The concoctions were shipped by UPS to chain pharmacies throughout Florida and other states, including Maryland, Texas and Missouri. posted by Sydney on
7/22/2003 07:20:00 AM
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Force Majeure: Our town flooded last night. Although, in our house, we didn't realize it until about 10PM when my husband went down to the basement and found the children's toys floating from room to room. We normally have a very dry basement. So dry, we have carpet in it. So dry, that's where we keep the television. Oh well. At least the carpet was very old. At least we didn't just pay to have it cleaned:
On Sixth Street in Cuyahoga Falls, Jeanne Lane and her husband, Charles, just had their basement carpet professionally cleaned Monday afternoon -- only to have it ruined within the hour.
``It started raining at 5:30 p.m. and the carpet guy left at 5:45 p.m.,'' Jeanne Lane recalled. ``I said to myself, `This does not look good.' At 6, the whole street was flooded. The next thing I knew, the water was pounding in my basement.''
Medical History/Art: This exhibit on "health consumers in a medical age" sounds interesting. Although my computer doesn't possess the software to let me browse through it, this description from The Lancet sounds enticing:
Paddy Hartley's Rosary, made of blue Viagra tablets and green/cream Prozac capsules (resembling lapis lazuli and jade) strung together with suture silk, is physically and emotionally seductive, guaranteeing believers sex and happiness.
Helpful Canada: Since medical marijuana is now legal in Canada, the government-run healthcare system has found it necessary to publish a manual on its correct use:
Health Canada is set to release a user's manual for medical marijuana this week - a move a city cop can't help but chuckle over.
"It's another drastic waste of taxpayers' money," said city police Sgt. Peter Kawalilak, president of the Alberta Federation of Police Associations.
"If people are bound and determined to use this drug ... I'm sure they already know how."
If they don't know how, they aren't likely to get much help from the manual. It advises against smoking it. Although it manages to mention oral and rectal methods of delivery, the overall message is that there's no evidence it works any better than other medications for nausea and pain. posted by Sydney on
7/21/2003 07:47:00 AM
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To Whose Benefit? A reader sends this observation on senior drug benefits:
One question that isn’t asked very much is whether the drugs used by seniors actually increase their life expectancy. The statistic I heard a number of years ago was that at the turn of the century anyone who reached the age of 65 could expect 15 more years of life. Is this number much different now? If so, how much is contributed by drugs? And which drugs are the ones that contribute? My own uneducated guess would be that antibiotics are the primary drugs that would make such a contribution since they handle infection so well.
In any case, as one who is 50 now, I think that this drug benefit is simply to enrich the drug companies.
Average life expectancy still hovers around 75, so it's the rare person who lives beyond 80. Off hand, I'd say it's true that antibiotics have made the greatest contribution to extending mortality. However, there are some drugs that have made a difference for certain disease groups. The newer diabetic drugs and asthma/emphysema drugs have probably extended the mortality of diabetics and asthmatics and former smokers. But it's debatable whether or not expensive cholesterol medication improves mortality to any significant extent in the elderly, or whether expensive Alzheimer's medication improves the quality of life in the later years.
In the short-term, senior drug benefits may benefit the drug companies the most, but as with any government-subsidized program there comes a point where the government suddenly realizes they're spending too much money. They don't cut the benefit, though. Instead, they cut the payments. So, in the long run, it will probably cost drug companies money. It won't be long before you hear them complaining about low reimbursements from Medicare - just like doctors.
UPDATE: A reader sends the following correction about life expectancy rates:
According to the year 2000 life tables, per 100,000 live births, the number expected to survive to at least age 80 is 51,037. That's higher than even I had supposed, and much higher than you suggest when you state "it's the rare person who lives beyond 80". On the contrary, it appears a bit better than even money that any random newborn will live to age 80, because, according to the tables, a bit more than half do so.
BTW, the life expectancy at several more advanced ages is as follows:
age 65 = 17.9 years, total expected lifetime therefore 82.9 years
age 70 = 15.1 years, total expected lifetime therefore 85.1 years
age 80 = 8.6 years, total expected lifetime therefore 88.6 years
age 85 = 6.7 years, total expected lifetime therefore 91.7 years.
The confusion springs, I think, from the common expression of "life expectancy" as the expectancy at birth. However, the expectancy of total lifetime continually changes as we age. And thank goodness for that!
I admint to being surprised that the number of us that can expect to live to age 80 is so large. But I knew it wasn't "rare".
I stand corrected.
UPDATE II: The original reader sends this further observation:
To take this one step further. The difference for life expectancy for people 65 years old is 2.9 years in a hundred years of medicine. Think about the difference in a hundred years to the access to clean water and food that has taken place. Think about the fact that there is social security which gives people more access to money. There are a lot of other more important factors than medicine that explain this extension in life expectancy. It drives me nuts that the discussion about the prescription drug benefits never deals with the question whether it is actually going to help anyone particularly. More medicine is not better medicine.
Through the first six months of this year, lawyers gave presidential candidates $13.6 million and were, as an industry, the largest contributors to presidential campaigns, according to preliminary figures compiled by the Center for Responsive Politics, a nonpartisan research group. The vast majority, $11.4 million, went to Democrats, who tend to oppose a cap on medical malpractice awards. The occupational information in campaign finance reports does not distinguish between trial lawyers and other attorneys.
Senator John Edwards, the North Carolina Democrat who is a former trial lawyer, raised more money from other attorneys, $6.2 million, than all of his Democratic presidential rivals combined. He pulled in $1.4 million of the $6 million that lawyers contributed in the second quarter of this year and $4.8 million of the $7.6 million in the first quarter.
...Lawyers, skittish about discussing just how much money they or their firms have contributed, say they are being sought out for donations by state and local politicians as well as by their own legal associations. Lawyers say that whenever possible, they are writing checks.
....Thornton and Naumes, a Boston firm, gave $20,350 to Democratic presidential candidates in the first three months of this year, with $16,750 going to Senator John F. Kerry of Massachusetts. Baron and Budd, an environmental justice law firm in Dallas, contributed $56,250 to Edwards and $50,500 to the Democratic National Committee. And Beasley Allen, a plaintiffs law firm in Alabama, gave Edwards $51,600.
That's a lot of money for one law firm. But, then again, they expect a good return on their investment. posted by Sydney on
7/21/2003 07:19:00 AM
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The Lost Weekend: It did turn out to be a long weekend. One of those when the pager goes off every twenty to thirty minutes, non-stop. Morning and night. The kind that unravels the sleeve of care that sleep is supposed to knit. Everything takes twice as long thanks to fatigue and interruptions. The only hope for sanity is to occupy oneself with tasks that beg for interruption - like cleaning the house. So, that's why no blogging occurred this weekend. And no emails got answered. Apologies. posted by Sydney on
7/21/2003 07:07:00 AM
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