It’s NOT a Health Care System

The Times reports on bribes given to health care providers to prescribe their patent protected product.  In this case it’s a addicting medication.

Dr. Judson Somerville, a pain specialist in Laredo, Tex., received $67,000 in speaking fees, travel and meals in 2013 to promote a powerful and addictive painkiller called Subsys, according to a new federal database of payments that drug companies make to physicians.

But while Insys Therapeutics, the Arizona company that makes the product, was paying Dr. Somerville to promote it, he was under investigation by the Texas Medical Board. Last December, the board ordered him to stop prescribing painkillers after it found that he had authorized employees to hand out pre-signed prescriptions to patients and after it learned that three of his patients had died in 2012 of drug overdoses, most likely from drugs that he had prescribed.

Read the article and weep!

Medicynical Note:  Health care in the U.S. is not systematically provided and the way it is delivered is not a “system” to provide it.   Rather what patients received is carefully designed “system” to maximize revenue for providers, hospitals, insurers, technology developers and pharmaceutical manufacturers.  The well-being of their stock holders and investors are much more important to them than the well-being of patients. 

Pre-existing Illness, or why you should not travel to the U.S.

Yet another mind boggling adventure in the American healthcare.

Jennifer Huculak-Kimmel, a Saskatchewan resident and Canadian citizen, was six months pregnant when she and her husband, Darren, decided to travel to Hawaii on vacation. She checked with her doctor, who said it would be fine to take the trip, and bought travel insurance just in case. When her water broke and she had to be airlifted to a Honolulu hospital, she should have been able to take advantage of her six weeks of mandatory bed rest, reassured that she had taken the right steps to ensure proper healthcare coverage. Right?

Wrong.

After about a week in the hospital, Blue Cross contacted the couple to let them know that their coverage had been denied because of a preexisting condition — a bladder infection that had not threatened the pregnancy. The insurance company maintained its stance, despite the company receiving a letter from Huculak-Kimmel’s Canadian doctor ensuring them that the pregnancy was not high-risk. They would be responsible for the hospital bill, which, due to the baby’s premature birth and critical condition (the baby had to stay in a neonatal intensive care unit, which cost more than $10,000 per day) had risen to $950,000.

Medicynical note:  Another unique adventure in health care in the United States.  The only country in the industrialized world with a category of bankruptcy related to health care expenses.  

And our republican friends support the right of insurers to deny coverage if you are sick (pre-existing illness).  Yet another sign that our health care system isn’t about health care but rather about money.  Yet another example of American exceptionalism.

 

Medically Induced Bankruptcy: An American Disease

In the U.S. we have no system of health care but rather a well oiled revenue generating infrastructure that incidentally provides care while charging excessive amounts.  This distorts our entire economy.  We spend nearly 20% of the GDP for medical related expenditures.  It’s literally your money or your life (Thank you Marcia Angell).

Even with the affordable care act in force this still happens.

The woman tells WISC-TV [via Reddit] that in Sept. 2013 she went into cardiac arrest and was taken by ambulance to a hospital that was out of her insurance network instead of the one — only a few blocks farther away — that accepts her Anthem Blue Cross coverage.

Had she gone to the in-network hospital, she’d only have been hit with about $1,500 in expenses. But since she was taken to the other hospital, she now has to pay the huge difference between what her insurance company paid the hospital and what the hospital charges.

“I was in a coma,” explains the woman. “I couldn’t very well wake up and say, ‘Hey, take me to the next hospital.’”

Read the article for more.

Medicynical note:  For my friends who think the “free market” is the solution and that we merely need to shop for the best price and become informed before purchasing,  this woman’s situation typifies health care.  It is not discretionary, it is often emergent, there may not be another option locally, pricing is unclear,  often obfuscated and not fully apparent at the start. 

The U.S. remains the only industrialized country in the world without a national health program, the only country in which people go bankrupt from health care expenses, which are by far the highest in the world. 

And the newly elected republican congress wants to make things worse.  America is truly exceptional. 

It IS The Money, Stupid (Gilead– Solvaldi, Harvoni and Hepatitis C)

Make no mistake for the pharmaceutical industry, it’s the money that counts.   Gilead is now marketing two drugs for hepatitis C costing in the range of $80-100,000 for the pills alone.  That is over $1000/pill.

In the 90’s the drug companies discovered that people with serious life-threatening illness would pay anything for a “treatment” even if it was minimally effective.  They would pay more if the drug actually worked.

For years Pharma’s problem was that people with cancers were not so numerous as those with high cholesterol or high blood pressure  or even diabetes.  As such it was less rewarding to develop new drugs for these patients.  That limitation however became less of a problem  as the price of the drug increased to tens of thousands of dollars/year for the drug alone–and insurers paid.

Now Gilead appears to have hit the trifecta.  First they have a drug that appears to work in a majority of those afflicted.  Second they are charging $90,000/head for the treatment, and third there are millions of people afflicted.  What could be better?

Medicynical note:  The cost of this drug puts to rest once and for all the notion that drug companies have any interest in the well-being of their patients.  It IS the money.  There is little doubt that charging half or a quarter of their asking price would reward the company handsomely for their investment in this drug and provide stockholders a generous return.  BUT as is the case in our drug industry, why charge less when you can get away with more.  After all the disease is often fatal, insurers will pay and patients are desperate.  It’s perfect.

And the price is only about twice the median income (including physicians fees and lab expenses for a year) of people in the U.S.  Affordable, no.  But who really cares?

 

Ebola and CDC

The CDC’s Mission Statement:

CDC works 24/7 to protect America from health, safety and security threats, both foreign and in the U.S. Whether diseases start at home or abroad, are chronic or acute, curable or preventable, human error or deliberate attack, CDC fights disease and supports communities and citizens to do the same.

CDC increases the health security of our nation. As the nation’s health protection agency, CDC saves lives and protects people from health threats. To accomplish our mission, CDC conducts critical science and provides health information that protects our nation against expensive and dangerous health threats, and responds when these arise.

And in it’s wisdom congress (largely through republican efforts) has decreased the agency’s budget 10% since 2010.

2010: $6.467 billion
2011: $5.737 billion
2012: $5.732 billion
2013: $5.721 billion
2013 (after sequestration took effect): $5.432 billion
2014: $5.882 billion

Medicynic Note:  It’s a little like cutting taxes during a war (of course only madmen do that).

The Cleopatra Study (Her 2 Positive Metastatic Breast Cancer) Unprecedented Survival, Unaffordable pricing

What happens when there is promising technology for severe illness that is unaffordable? I’m guessing we’ll find out if the results of the Cleopatra study are applied to clinical practice.

The study noted:

Final results from the CLEOPATRA study show that the combination of 2 targeted agents, trastuzumab (Herceptin, Roche/Genentech) and pertuzumab (Perjeta, Roche/Genentech), significantly prolonged survival in HER2-positive metastatic breast cancer, compared with trastuzumab alone. The targeted agents were added to chemotherapy with docetaxel.

Patients treated with the combination plus chemotherapy lived 15.7 months longer than those who received trastuzumab and chemotherapy (median overall survival, 56.5 vs. 40.8 months; hazard ratio [HR], 0.68; P = .0002).

But there is a catch

An added concern is the high cost of dual HER2 inhibition at a time when oncologists are under pressure to contain costs. According to the New York Times, Genentech is putting the wholesale cost of pertuzumab at $5,900/month, which added to the typical $4,500/month costs of trastuzumab, would drive the cost of 18 months of treatment to $187,000.

And this pricing does not include  physician fees, imaging expenses, the cost of the additional chemotherapy (taxanes), laboratory and so on.

Medicynical Note:  The pricing for the two HER 2 blockers used in the Cleopatra study is three time the median income of families in the U.S.   Adding insult to injury, after this huge expenditure the patient is not cured.

The question is who will be able to pay for these drugs?  How will such care be funded by insurers?  And shouldn’t we be able to develop advanced approaches at more reasonable costs? 

As it is the U.S. pays more for everything in healthcare than other places in the world.  We are literally bankrupting ourselves individually and collectively.  There’s something terribly wrong in a health care “system” whose primary goal is revenue generation. 

It’s the Money Stupid! (Or Doctors play the lottery)

Medicine over the years has become increasingly entrepreneurial and money driven.  Health care, efficiency and value have become secondary aims  being overshadowed by the quest for money.   In health care, the product you are buying is not usually discretionary, predatory billing is common and an uninformed naive patient can literally lose his shirt.  These patients experiences while extreme are not unique.

Before his three-hour neck surgery for herniated disks in December, Peter Drier, 37, signed a pile of consent forms. A bank technology manager who had researched his insurance coverage, Mr. Drier was prepared when the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan, $4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he knew would accept a fraction of that fee.

and

Patricia Kaufman’s bills after a recent back operation at a Long Island hospital were rife with such charges, said her husband, Alan, who spent days sorting them out. Two plastic surgeons billed more than $250,000 to sew up the incision, a task done by a resident during previous operations for Ms. Kaufman’s chronic neurological condition.

Read the article for more details.

Medicynical Note:  Medicine is simply following the lead of a deregulated culture that seems to believe that anything  goes and that in time the problem will sort itself out.  In health care that policy has left a trail of people who are “uninsurable”, neglected medical problems, medically related bankruptcies (we lead the world), exploding  costs and a non-sytem of  care whose primary focus is generating revenue. Some drug costs have increased 1000 percent in the past 30-40 years…has your salary kept up? 

The Affordable Care Act is already helping but we should not underestimate the reactionary forces that believe the money driven non-system is the “best in the world.”