Category Archives: Health Economics

Malaria: Artemisinin, Antimalarial with a political agenda

Fascinating story of the development of artemisinin, a antimalarial developed in China during the Vietnam era. 

Artemisinin’s discovery is being talked about as a candidate for a Nobel Prize in Medicine. Millions of American taxpayer dollars are spent on it for Africa every year.

But few people realize that in one of the paradoxes of history, the drug was discovered thanks to Mao Zedong, who was acting to help the North Vietnamese in their jungle war against the Americans. Or that it languished for 30 years thanks to China’s isolation and the indifference of Western donors, health agencies and drug companies.

Medicynical Note:  Perversely, the delay in development and distribution prevented it’s wide use, and perhaps the development of resistance.  It remains an effective agent.

Health Care Spending Slows (McKinsey)—It’s Economic Rationing?

McKinsey group believes the slowdown in the growth of health care spending is complicated but at least in part driven  by “value” seeking consumers .  They note that consumers are paying a larger proportion of their health care expenses and that makes them more conscious of cost.

Remember we are talking about  a decrease in the rate of increase, not an actual decrease in the amount spent. In fact, our spending per-capita still far exceeds what one would expect even given our wealth when compared with other countries around the world.  This is evidence of an inefficient non-competitive approach. 

The historic slowdown in spending growth was caused by the convergence of a number of factors, including changes in benefit design, structural shifts within specific segments of the health economy, and a recession from which the U.S. economy has been slow to recover. Changes in coverage patterns and the decline in the share of the population with private insurance during the recession have also played an important role. Between 2007 and 2009, the number of people with employer-sponsored or private individual insurance fell by nearly 10 million. In 2009, the share of Americans with private insurance slipped to 64.5 percent – the lowest in 20 years of census records – while the share receiving public assistance and the percent uninsured both reached record highs. 

Despite the “slowdown”  our costs/capita for health care remain by far the highest in world.  For example hospital costs, even with the decreased “utilization:”

costhospitalization

 Medicynical Note:  Mckinsey may view this decreased rate of increase as a search for value in health care, which is laudable. 

However, searching for value when it’s driven by lack of insurance, substandard coverage and poverty  easily morphs into inadequate access, delays, and substandard health care (economic rationing).

No New Polio Cases: India

This report of no new polio cases in India validates (no thinking person really needed further validation) the use of vaccines in serious life-threatening diseases. 

The world of polio as it appeared in 2011:  Countries in black still reporting cases, except perhaps India!

image

Source:  Kaiser Family Foundation

Medicynical Note:  In the early part of my medical career I observed the WHO’s vaccination strategy in Africa.  Small pox was eliminated as an active disease threat.  I didn’t expect another such advance in my lifetime. 

Millions of people have benefitted. 

PIP Implants: Regulating Safety, the role of FDA

We’ve commented previously on the need for regulation.  In health care this is particularly the case because of the consequences.

The recent and ongoing breast implant problems from Poly Implant Prosthese (PIP) devices could well have been a major issue in the U.S. but for the FDA taking seriously it’s mandate to assess the safety of medical devices.

The now-defunct PIP was recently found to have sold implants made with industrial-grade silicone to some 300,000 women worldwide, sparking a global health scare. France’s government instructed 30,000 French women to have their implants replaced due to a high rupture rate, and the country’s health minister has called for Mas to answer for the actions of a “shady business.”

In the United States, where the FDA had banned all silicone implants from 1992-2006, PIP sold a line of saline-filled implants starting in 1996. The business accounted for up to 40 percent of its revenue, according to company securities filings. McGhan’s MediCor signed on to distribute the products in 1999, but a year later the Food and Drug Administration (FDA) conducted a new review of the devices and decided there wasn’t enough data to show they were safe.

The agency then sent an inspector to PIP’s plant in France, who found multiple violations of accepted manufacturing practices and determined the products to be “adulterated,” Reuters has reported.

Medicynical Note:  Read the entire article to get a sense of the aggressive marketing of these devices.  When money is involved people do funny things. 

Health Care Cost’s Moderating? Good News?

The U.S. leads the world in health care spending per-capita.  We spend over 2.5 trillion dollars a year (over 8,000/person) on medical expenses but still have 50 million people lacking health insurance and assured access to care—I don’t count “free” ER access as assured care.  This is one and a half to two times the expenditures of other industrialized countries.

We’ve an approach to health care that’s become unaffordable to most people.  Our country leads the world in bankruptcy due to medical expenses.  To tell the truth such a category is unheard of in other industrialized countries. 

One can cautiously take the recent news that health expenses are “only” increasing at the rate of inflation as progress in gaining control over these expenditures:

Still, the increases for 2010 and 2009 were the lowest measured in 51 years. And health care as a share of the economy leveled off at 17.9 percent, the first time in a decade there’s been no growth.

But:

The main reason for the slowdown was that Americans were more frugal in their use of health care, from postponing elective surgery to using generic drugs and thinking twice about that late-night visit to the emergency room.

Medicynical Note:  After increasing at multiples of inflation for years, health care spending seems to have finally become unaffordable, thanks to increasing  deductibles, co-pays, inadequate coverage  and lack of coverage for over 50 million citizens. 

In these hard economic times we’ve proven that rationing by ability to pay works.  It’s however a blunt instrument.  People lacking resources cut back on care, whether it’s really needed or not.  We may lose a few but then we’re saving money.

Progress?  No.  Rational?  No.

Medical Expense Related Bankruptcy—We Lead the World

Our non-system of health care causes many distortions.   Health care costs in the U.S. are the highest in the world, almost double that of other industrialized nations.

Because of escalating costs, lack of job provided coverage, and pre-existing illness over 50 million of our citizens have no health insurance.   Limits in insurance coverage, high deductibles and co-pays make health care increasingly unaffordable.

These costs have driven individuals and families to bankruptcy in increasing numbers as noted in this article which documented that 62% of those going bankrupt in 2007  were driven to it by health bills.

The author’s abstract notes:

Using a conservative definition, 62.1% of all bankruptcies in 2007 were medical; 92% of these medical debtors had medical debts over $5000, or 10% of pretax family income. The rest met criteria for medical bankruptcy because they had lost significant income due to illness or mortgaged a home to pay medical bills. Most medical debtors were well educated, owned homes, and had middle-class occupations. Three quarters had health insurance. Using identical definitions in 2001 and 2007, the share of bankruptcies attributable to medical problems rose by 49.6%. In logistic regression analysis controlling for demographic factors, the odds that a bankruptcy had a medical cause was 2.38-fold higher in 2007 than in 2001.

In 1981 only 8% of bankruptcies were related to medical expenses.   With the current lack of wage growth, the decreasing proportion of people with insurance and the exploding health care costs over the past 10 years (well over 100%) the findings in the article are not surprising. 

For 92% of the medically bankrupt, high medical bills directly contributed to their bankruptcy. Many families with continuous coverage found themselves under-insured, responsible for thousands of dollars in out-of-pocket costs. Others had private coverage but lost it when they became too sick to work.  Nationally, a quarter of firms cancel coverage immediately when an employee suffers a disabling illness; another quarter do so within a year.  Income loss due to illness also was common, but nearly always coupled with high medical bills.

And the U.S. is exceptional:

Medical impoverishment, although common in poor nations,  is almost unheard of in wealthy countries other than the US.  Most provide a stronger safety net of disability income support. All have some form of national health insurance.

Medicynical Note: It’s bad enough that we have adopted an approach that does not have universal coverage and  that our health care costs are rising at an unsustainable rate and that our health insurance provides inadequate coverage. 

It is absolutely obscene however, that when a person gets sick and can’t work, his insurance can be cancelled or made unaffordable by raising the rate.  This is further aggravated by allowing insurers to then deny new coverage because of pre-existing illness.

American health care is set up to provide security and protection to everyone involved except the patient.  Quite an accomplishment if you ask me.

The U.S. is the Least effective, Most Expensive Health-Care Non-System (Industrialized Nations)

Healthcarespending USvswld

Doubleclick to enlarge

From:  Schmid, Tufts University Evidence Based Medicine Lecture: http://andrewgelman.com/wp-content/uploads/2011/12/SchmidJSM2011.pdf

Medicynical Note:  Something’s wrong here.

The AVASTIN Spin Machine: Costs $100,000, little proof of survival benefit, But……..

It’s remarkable how drug companies spin the limited proven benefits of their new drugs.   This in the LA Times:

Avastin can stabilize tumors in ovarian cancer, studies find

Two independent groups working with advanced-stage cases say the drug extended the period before the disease worsened by more than 3.5 months.

At this point there is little data indicating that people with ovarian cancer treated with Avastin (bevacizumab) live longer. 

Medicynical Note:  In the past the end points for a cancer treatment advance was actual proof of shrinkage of tumor masses and a significant survival benefit.  In recent years companies have tried to sell “delay in progression” as proof of benefit.  Often as not however, this “delay”, when found, is not repeatable on follow-up trials and/or there was no observed survival benefit.    That was the case when the FDA deauthorized this same drug’s use in breast cancer because the short delay in progression was not replicated and did not increase breast cancer patients’ length of life.

The problems with Avastin are it’s outrageous price, in the range of $100,000/year and the apparent fact that it is only marginally effective.  This type drug is marketed to desperate patients with life threatening illness and priced way out of proportion to it’s benefit, or even development costs.  It is a fact that most of the early development costs came not from drug companies but rather from taxpayers in the form of research grants.

At a cost to consumers and insurers of nearly $100,000/year, more than practically any other consumer purchase, and just a few months delay in progression–Would you buy a $100,000 car that lasted 3.5 months?–it’s hard to be enthusiastic .

Less Regulation? Ask Women with Poly Implant Prosthese (PIP) Breast Implants

Since 2000 there has been a warning about Poly Implant Prosthese (PIP) breast implants.  The FDA refused to approve their use in the U.S. because of concerns that they might rupture.  Meanwhile, until recently these fragile bags of silicone have been implanted in thousands of women in Europe, and elsewhere.  They were cheaper than other brands. 

But now:

The recall was expanded to PIP implants exported to Italy, Australia, and Great Britain. It is initially estimated 35,000 to 45,000 women worldwide are affected, but the British Association of Aesthetic Plastic Surgeons estimated 50,000 British women have the implants.

AFSSAPS, the health regulatory agency of France, discovered an unauthorized type of silicone gel being used in the pre-filled implants. Following the recall, the French court ordered the company to shut down entirely for the manufacturing of fraudulent implants.

Medicynical Note:  We have a “movement” in the U.S. that believes less regulation will lead to a thriving economy.  This despite evidence,  from the thalidomide problem in medicine and the S and L fiasco in the 80’s, the Enron disaster, and most recently the world wide banking crisis, that less regulation  can lead to abuses and disaster. 

In the case cited today, the FDA saved tens of thousands of U.S.  citizens from the problems of a substandard breast implant device.  In medicine as in other fields where profit overrules reason, regulation is essential.

Bevacizumab: No Survival Benefit for $100,000

How much is a 2 month progression delay, with no survival benefit, worth?

Another study of bevacizumab (Avastin) in Metastatic Breast Cancer :

Median PFS increased from 5.1 to 7.2 months (stratified hazard ratio for PFS (Progression Free Survival), 0.78; 95% CI, 0.64 to 0.93; P 􏰁 .0072). The 10% improvement in ORR (Objective Response Rate) between the placebo- and bevacizumab-containing arms (39.5% v 29.6%; P: .0193), although not statistically significant, was consistent with previous trials. There was no statistically significant difference in overall survival.

As noted in the discussion the improvement in ORR is not statistically significant and there is no improvement in survival. This, in a drug, with costs in the $5000- $10,000/month range.

Medicynical Note: The FDA has removed the breast cancer indication for this drug because of lack of objective efficacy. This study confirms their decision.

Medicare, however, as I understand it, continues to pay for it. The big question is why we should have public funds, or pooled insurance money, used to pay for an exceptionally expensive drug that has no survival benefit? In the end we all pay.

It’s no wonder that health care is bankrupting individuals and our non-system of health care.