"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
A Step Too Far: We went to a new neighborhood pizza parlor tonight. One of the menu items was doughless pizza. Yuck. Should have asked how many they've sold. posted by Sydney on
1/24/2004 09:08:00 PM
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Obesity Costs: I posted this as an update to the orignal post below, but the study that purports to show that obesity is costing billions of tax dollars may be statistical hype. The abstract is here (the full paper requires a subscription). This description of their methods is not encouraging, however:
We developed an econometric model that predicts medical expenditures. We used this model and state-representative data to quantify obesity-attributable medical expenditures.
Howard Dean Syndrome: Howard Dean concession has entered the medical lexicon. From a story about preparations for the arrival of sextuplets at a local hospital:
"If you're not nervous, you're foolish,'' said Dr. Anand Kantak, Children's director of neonatology. ``There's a healthy level of nervousness you have to have. A healthy nervous tension. What you don't want (in the delivery room) is adrenaline excitement. You want to avoid being too hyped up -- you know, the Howard Dean syndrome.''
Expanding Healthcare: Ramesh Ponnuru looks at association health plans as a means to expand the health insurance market and finds them wanting. He proposes a better idea:
Cannon thinks there's a better idea: reviving an old bill by Kentucky Republican representative Ernie Fletcher (who is now his state's governor) to let people buy insurance from any other state — and thus, at the same time, buy that state's regulatory regime. If you don't like the mandates in your state, you would be able to buy insurance from a state with less onerous regulations. If, on the other hand, it's really true that people would not want cheap no-frills health insurance, they may prefer to stay in high-mandate states. I think it's more likely that a choice-based approach would exert pressure against state overregulation.
The AHP bill, on the other hand, might increase the pressure for federal regulation. It is true that a choice-of-law policy would, in a sense, give up the cost advantages of creating a national pool. But a national pool could in theory emerge anyway if the market evolved that way. (If some state, for example, became what Delaware is for the law of corporate chartering.) So bring back Fletcher's bill. It would be good for health care, and it could be a model for deregulation in the future.
Pediatric Depression: The FDA task-force on SSRI's in children has declared them safe and effective:
Last fall, the U.S. Food and Drug Administration issued a recommendation against the use of Paxil in children under 18 and set up a task force to re-analyze studies to assess whether the benefits of this class of drugs outweigh possible risks. The FDA panel is to hold a public hearing on the issue Feb. 2.
Meanwhile, the task force, composed of experts in child and adolescent psychiatry and suicidal behavior, analyzed half a dozen large studies on SSRIs involving a total of 2,000 children and found strong evidence the drugs are effective in alleviating depression and anxiety and do not pose a greater risk for suicidal thoughts or actions.
'We were perplexed by the United Kingdom's decision to ban the use of SSRIs in children,' said Dr. Joseph Coyle, a professor of psychiatry and neuroscience at Harvard Medical School and past president of the scientific group. 'Withholding what appears to be effective treatment for childhood depression can be clinically disastrous.'
'We can't think of a good reason why one SSRI [Prozac] should work better than another,' said Dr. J. John Mann, a professor of psychiatry at Columbia University College of Physicians and Surgeons in New York and the other co-chairman of the task force.
The panel of scientists recommends that doctors continue to use SSRIs to treat depression in children and adolescents and monitor benefits and side effects.
The real danger in SSRI's is their over-use rather than their side-effects. There are a lot of parents and counselors out there who are eager to medicate away all the angst of adolescence. But, it's good to know that they're once again an option for the truly depressed teenager. posted by Sydney on
1/22/2004 09:33:00 AM
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The Mad and the Good: After Iowans recognized the madness of Dr. Dean the candidate, Bard Parker noticed that Chris Matthews tried to pin the blame on his wife:
Just thought you like to know that Chris Matthews was just on the air beating up on Howard Dean's campaign manager about Dr. Steinberg's abscence from the campaign in Iowa, and implying it cost him the caucus.
Mr. Trippi was stating that Dr. Steinberg was running a "family practice", "taking care of a seven-year old daughter of someone she has taken care of for twenty-five years"
Ain't politics grand?
I'd say Joe Trippi doesn't know much about either his candidate or his candidate's wife.
Another reader comments on Dr. Steinburg's specialty and questions whether it really should be a factor in her decision to stay away from his campaign:
I can identify here. I have a serious, potentially fatal blood disorder, and I see one of the top hematologists in the country for it. If he were a she, and her husband was running for the presidency, I wouldn't be inconvenienced one bit. (In fact it would be kind of a kick to see him/her on TV all the time.)
My top expert is a very busy man. He sees patients only one day a week, does research, travels the world to go to various conferences, publishes frequently, etc. So he often delegates day-to-day care to associates. This is not unusual, I would think.
He attracts a large cadre of young, very talented docs who are interested in cutting-edge medicine. These guys often see patients and learn from the master.
A friend of mine who also sees the same heme doc recently had a bone marrow transplant. The procedure is fraught with danger, but obviously the work is not done by my top hem doc, it is done by hospital staff docs, nurses, etc. There is a routine for even these procedures, procedures which are being fine-tuned constantly.
I suspect that Dr. Steinburg is more like my local hem doc. She works with the top hem doc in deciding on treatments and administering them. If my local heme doc left town for 12 months, I'd do just fine. She's good, but she's not one of the top experts in the country.
You may recall the saying, 'the cemeteries are full of irreplaceable people'.
Dr. Steinburg's distance from her husband must give people pause; is he so unbearable she can't stand being with him?
(It's probably moot now since it looks as though Dr. Dean is dead meat, or will be soon.)
Well, after that Monday night scream you've got to think his personality might have something to do with her decision, but it's still not such an easy thing to abandon a medical practice - at least not one that you own. The difference between Dr. Steinburg and the academic is that the academic's salary is paid by the university. If he chooses to practice part time, he doesn't have to worry about covering the cost of over-head, the university will. A doctor in private practice has to keep earning the money to pay for her rent, malpractice, staff, utilities, etc. The profit margin in medicine is very small. Cutting down by one or two days a week can erase a doctor's income. It also means two days when you're not available to your patients. And that means that a certain percentage of patients will leave and go to someone who is more accessible.
As far as patient attachment to doctors, that varies with the patient. Some people couldn't care less who treats them. But others become very disconcerted if there's a change in doctors. I know a significant proportion of my cancer patients are very devoted to their oncologists.
And community hematologists/oncologists do much more than just follow the advice of tertiary care center specialists. They decide the appropriate therapy for all but the rarest of cases, and manage the consequences of that therapy. If Dr. Steinburg signed her patients over to her partners for a couple of days a week, she'd risk losing some of those patients, or taxing her partners beyond their limits by increasing their work load. Her decision is a reasonable one, and one that the media should respect.
posted by Sydney on
1/22/2004 08:20:00 AM
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Wages of Sin: If gluttony is a sin, then we may soon see sin taxes for the obese. At least we will if this new study on the cost of obesity gets much notice. It claims that $39 billion dollars of our tax dollars go to treating obesity. The research won't be in print until tomorrow, so it's impossible to dissect it, but here's the summary from the Atlanta Journal-Constitution :
The new study -- which doesn't include children, whose obesity rates are soaring -- found that 5.7 percent of the nation's health care expenses are for treatment of obesity. That is roughly the same percentage spent on treatment for the effects of smoking.
The burden is greater for taxpayer-funded programs: 6.8 percent of Medicare costs and 10.6 percent of Medicaid costs are spent on treatment of obesity.
Medicare is a federal program for seniors and the disabled, and Medicaid is a federal and state program for the poor.
The study, the first to break down obesity costs by state, focuses on all medical expenses incurred by obese people that exceed the medical expenses of the non-obese. This included all costs for all medical treatment, whether paid by private insurance or public programs. Indirect costs, such as lost productivity and time away from work, were not considered.
If the study looked at the use of healthcare dollars by people over a certain weight, then it might be valid. But, if it just looked at "obesity-related illnesses" such as heart failure, diabetes, hypertension, and coronary artery disease, and caclulated an estimated cost based on the percentage of obese people in the population, then it isn't valid.
But what's concerning is this statement by one of the researchers:
This allows each state to see how much they spend on obesity," said Eric Finkelstein, an RTI researcher. "It should encourage states and employers to figure out how to reduce these costs.
And how would they do that? Refuse to pay for the medical care of the obese? That's inhumane. We don't refuse coverage of the HIV infected because they aquired their infection through sexual promiscuity or intravenous drug abuse. We don't refuse coverage of prenatal care and delivery of unwed mothers because their condition is self-inflicted. But such is the nature of the "war on obesity" that something punitive is bound to result. Remember, the only difference between the sins of the obese and the sins of others (alcoholics, drug abusers, the sexually promiscuous, etc.) is that the wages of their sin can't be hidden from the public eye.
UPDATE: The abstract is here, but the full paper requires a subscription. This description of their methods from the abstract is not encouraging, however:
We developed an econometric model that predicts medical expenditures. We used this model and state-representative data to quantify obesity-attributable medical expenditures.
Despite the almost complete absence of scientific basis for these [medical malpractice] claims, cerebral palsy cases remain enormously attractive to lawyers,' Huber wrote.
The judgments or settlements related to medical malpractice lawsuits that focused on brain-damaged infants with cerebral palsy helped Edwards amass a personal fortune estimated at between $12.8 and $60 million. He and his wife own three homes, each worth more than $1 million, according to Edwards' Senate financial disclosure forms. Edwards' old law firm reportedly kept between 25 and 40 percent of the jury awards/settlements during the time he worked there.
According to the Center for Public Integrity, Edwards was able to win 'more than $152 million' based on his involvement in 63 lawsuits alone. The legal profession recognized Edwards' achievements by inducting him into the prestigious legal society called the Inner Circle of Advocates, which includes the nation's top 100 lawyers. Lawyers Weekly also cited Edwards as one of America's 'Lawyers of the Year' in 1996.
...Dr. Lorne Hall, one of the physicians with whom Edwards reached a confidential settlement in a malpractice case involving cerebral palsy, agreed, telling The Charlotte Observer in 2003 that "[Edwards] knows how to pick cases, and he knows the ones he can win."
Hall said Edwards was "very polished, very polite, dressed to the T's, smiling at the ladies." But the anonymous source for this story said Edwards displayed a "belligerent attitude" toward the medical profession.
"He sued nurses, doctors, hospitals. The reputation he had was -- he never wanted to hear that nobody did anything wrong. If you even walked by the door of an alleged malpractice incident, you were gong to cough up money too," the source said.
Saint Anthony's Fire: Italian kids celebrate the feast of St. Anthony by lighting up. (You can read more about the other St. Anthony's fire here.)
posted by Sydney on
1/20/2004 11:15:00 PM
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State of the Union's Healthcare: The President devoted a significant portion of his state of the union address to healthcare. Not surprising since it's an election year:
Our Nation's health care system, like our economy, is also in a time of change. Amazing medical technologies are improving and saving lives. This dramatic progress has brought its own challenge, in the rising costs of medical care and health insurance. Members of Congress, we must work together to help control those costs and extend the benefits of modern medicine throughout our country.
Meeting these goals requires bipartisan effort - and two months ago, you showed the way. By strengthening Medicare and adding a prescription drug benefit, you kept a basic commitment to our seniors: You are giving them the modern medicine they deserve.
Starting this year, under the law you passed, seniors can choose to receive a drug discount card, saving them 10 to 25 percent off the retail price of most prescription drugs - and millions of low-income seniors can get an additional 600 dollars to buy medicine. Beginning next year, seniors will have new coverage for preventive screenings against diabetes and heart disease, and seniors just entering Medicare can receive wellness exams.
In January of 2006, seniors can get prescription drug coverage under Medicare. For a monthly premium of about 35 dollars, most seniors who do not have that coverage today can expect to see their drug bills cut roughly in half. Under this reform, senior citizens will be able to keep their Medicare just as it is, or they can choose a Medicare plan that fits them best - just as you, as Members of Congress, can choose an insurance plan that meets your needs. And starting this year, millions of Americans will be able to save money tax-free for their medical expenses, in a health savings account.
I signed this measure proudly, and any attempt to limit the choices of our seniors, or to take away their prescription drug coverage under Medicare, will meet my veto.
On the critical issue of health care, our goal is to ensure that Americans can choose and afford private health care coverage that best fits their individual needs. To make insurance more affordable, Congress must act to address rapidly rising health care costs. Small businesses should be able to band together and negotiate for lower insurance rates, so they can cover more workers with health insurance - I urge you to pass Association Health Plans. I ask you to give lower-income Americans a refundable tax credit that would allow millions to buy their own basic health insurance. By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care. To protect the doctor-patient relationship, and keep good doctors doing good work, we must eliminate wasteful and frivolous medical lawsuits. And tonight I propose that individuals who buy catastrophic health care coverage, as part of our new health savings accounts, be allowed to deduct 100 percent of the premiums from their taxes.
Being able to purchase health insurance with tax-free dollars is a help, but we also need to be able to buy health insurance as individuals - and not just through employers, which is a tough thing to do right now. And, while computerized health records may reduce mistakes (or they may just substitute a different set of mistakes), they are also very expensive. As long as reimbursement remains low and malpractice premiums continue to soar, few physicians will be able to adopt electronic systems in the office. But, at least he addressed the malpractice crisis, too. posted by Sydney on
1/20/2004 10:52:00 PM
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Historical Roots: The New England Journal had a review last week of the malpractice crisis, which included a summary of its root causes (requires subscription). People really did sue less in the past, and it wasn't because they liked their doctors more:
Despite several bursts of malpractice litigation in the 1800s, suing physicians was an arduous undertaking until the latter half of the 20th century. At that time, the judiciary began dismantling barriers that plaintiffs faced in bringing tort litigation. This change occurred in many areas of accident law but was particularly prominent in medical malpractice in the 1960s and early 1970s. Judges discarded rules that had traditionally posed obstacles to litigation. For example, most jurisdictions rolled back charitable immunity for hospitals. Courts also moved toward national standards of care and abandoned strict interpretations of the "locality rule," which had required plaintiffs to find expert witnesses within the defendant's immediate practice community. At the same time, expansion of doctrines such as informed consent and res ipsa loquitur (the rule that certain events, such as the retention of instruments after surgery, carry an inference of negligence) paved new pathways to the courtroom. The more plaintiff-friendly environment fostered by these changes altered the cost–benefit calculus for plaintiffs' attorneys, leading to a steady growth in litigation.
Generic Bargains: Brand name drugs may be cheaper in Canada, but generic drugs cost more, according to the FDA:
To back that contention, the FDA analyzed price data collected by the medical research company IMS Health. Included were seven drugs whose generic versions are top-selling treatments for chronic disease: the anti-depressant Prozac; blood pressure medicines Lopressor, Prinivil and Vasotec; Xanax for anxiety; Klonopin for seizures; and Glucophage for diabetes.
Comparing both brand-name and generic versions in Canada, the U.S. generic versions of all but the diabetes drug proved significantly cheaper, the study concluded.
The study measured average price per milligram, not what the patient pays per bottle, which can vary in dose and pill number. Among the findings:
• Xanax had the highest disparity. The Canadian brand was about nine times the price, per milligram, of the U.S. generic. Next was Vasotec at five times the price of the U.S. generic.
• Canada's generics ranged from fluoxetine, or generic Prozac, at 1.3 times the U.S. price, to alprazolam, or generic Xanax, at four times the U.S. price. One generic, the version of Vasotec called enalapril, is not sold in Canada.
• Glucophage was the exception. The U.S. generic cost 39 percent more per milligram than Canada's brand-name version.
I guess Canada doesn't bother cutting deals with generic drug companies. Or maybe generic drug companies don't cut deals with Canada. (Probably can't afford to.) You can compare prices across borders at this website.
posted by Sydney on
1/18/2004 08:45:00 AM
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