Category Archives: Ethics

Washington Post’s Sunday edition had an opinion piece on our health care system. Nicely done as far as it goes.

The Post’s myths, with medicynical comments:

1. “America Has the best Health Care in the World”–

” We rank near the bottom of countries in the Organization for Economic Cooperation and Development , just ahead of Cuba and way behind Japan, France, Italy, Sweden and Canada, countries whose governments (gasp!) pay for the lion’s share of health care.”

Medicynic: This appears to be an accepted truth, except perhaps for the very wealthy, for whom cost and access are not issues.

2. “Someone else is paying for your health insurance”

“Rising health-care costs are partly to blame for stagnant wages. Over the past five years, health insurance premiums have risen 5.5 times faster on average than inflation, 2.3 times faster than business income and four times faster than worker’s earnings.”

Medicynic: This also seems to be understood. What’s missing is the fact that we all are paying one way or another for those who are uninsured and need care.

Also, as we move away from employer based coverage to a more rationale arrangement the question whether the money used to pay for insurance is employee salary or employer profit will need to be settled–watch this issue carefully.

3. “We could save a lot if we could cut the administrative waste of private insurance”

“For one thing, some administrative costs are not only necessary but beneficial. Following heart-attack or cancer patients to see which interventions work best is an administrative cost, but it’s also invaluable if you want to improve care. Tracking the rate of heart attacks from drugs such as Avandia is key to ensuring safe pharmaceuticals.”

“Let’s just say that we could wave a magic wand and cut private insurers’ overhead by half, to what the Canadian government spends on administering its health-care system — 15 percent. How much would we save?”

Medicynic: The authors include monitoring for toxicity and evaluating a drug’s or procedure’s effectiveness as administrative costs and as noted above seem to posit that private insurers routinely do such work. Others count this a drug or procedure development expenses and while administrative are not what insurers do or what they count as an insurer’s administrative cost.

However, even with these non-typical costs included as administrative expenses, they believe that as much as 125 billion dollars can be saved–not chump change. Medicynic thinks the numbers are conservative as most other countries spend far less than the 15% suggested overhead. Medicare for example spends less than 10% on such expenses.

4. Health Care reform is going to cost a bundle

“Even moderate reform of the delivery system would improve care and save money. The Lewin Group’s analysis shows that a bill proposed by Sen. Ron Wyden , an Oregon Democrat, calling for a more comprehensive overhaul of the health-care system than either McCain ‘s plan or Obama ‘s could actually insure everyone and save $1.4 trillion over 10 years. More reform is cheaper.”

Medicynic: Health care reform will be costly but probably no more than our current system that excludes 50 million people. Omitted in the article’s analysis is the major problem of conflicts of interest in the system, and the need to control the costs of developing new technology. See this for more on cost saving strategies for health reform.

5. Americans are not ready for a major overhaul of the health-care system

“A recent study published in the New England Journal of Medicine found that only 7 percent of Americans rate our health-care system excellent. Nearly 40 percent consider it poor. A whopping 70 percent believe it needs major changes, if not a complete overhaul.”

Medicynic: Medical expenses are one of the major causes of bankruptcy in our country. The system is toxic and and people are dying from their lack of reliable affordable access to care. It’s time to heal ourselves.

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The report that Dr. Frederick Goodwin has received financial support (money) from a drug company for touting their products is not shocking or for that matter the most onerous of conflicts of interest in our health care system. Consider practitioner’s tendency to do procedures for which they benefit financially; insurers declining to cover services thereby increasing profits; deceptive advertising that doesn’t fully reveal the risks benefits and costs of a product; technological innovators (drug companies included) who tout marginal advances and then charge a fortune for them.

In regard to Dr. Goodwin, we’re not talking small amounts of money. He is reported to have received $329,000 for promoting the drug Lamictal and probably more for his “other” valuable services. The article also noted that “Dr. Charles B. Nemeroff of Emory University, an influential psychiatric researcher, earned more than $2.8 million in consulting arrangements with drug makers from 2000 to 2007, failed to report at least $1.2 million of that income to his university and violated federal research rules.” Guess who pays?

Using the analogy of our current financial mess, we have a bubble in health care caused by the deregulation. Each player in the health care system is corrupted (i.e.has a major conflict of interest). Deceptive practices promote ridiculously priced products, often with marginal efficacy, that the health care non system cannot afford. These conflicts of interest drive utilization and inefficiency without significantly improving outcomes. Pricing of products and services have increased exponentially while health care statistics, compared to other industrialized countries, are mediocre. The goal of the health care industrial complex appears to be to assure profit, not wide access to quality affordable health care.

In summary, the industry has lost interest in prudent management, value and efficiency in order to increase short term profits. Sound familiar?

We need more than disclosure of conflicts of interest to correct the system.

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For years we’ve been hearing of the “benefits” of such interventions as homeopathy, mega-vitamin therapy, coffee enemas, detoxification, cranial sacral therapy, weekly chiropractic therapy and a multitude of other alternative remedies.  People swear they help and spend billions.   Yet there is precious little evidence that show’s benefit such as decreased chronic illnesses or improved longevity.

So it’s not surprising that a study of routine medical practices reveals that doctors candidly believe some of the practices no better than placebo.  I used to tell patients with colds that without treatment it would take seven long days for the problem to resolve.  With antibiotics it would take just one week–yet that is what they wanted.  I was told that if I didn’t treat them they’d find someone else to do so and a number of patients did so.

It’s as simple as that, people believe an intervention anyone, even lacking in evidence, is better for them than none.  How else to explain the “efficacy” of homeopathic remedies which contain no active ingredient and is diluted to the the point of having no medicinal value.  Yet patients swear by it because they think they are being treated and they do get better.  It should be pointed out that the great majority of what a family doc sees each day would also better, just as quickly and completely, without any intervention.  Patients seek  reassurance but also in many cases insist on something being “done.”

That’s the essence of placebos and as long as patients want to believe it works it will in most instances–just a week rather than 7 long days.

But it is a costly game.