Category Archives: Uncategorized

The Seattle PI may have stopped it’s print edition but it’s still online. Today it reports on the continued increase in health insurance rates in Washington State.

What’s going on is the continued waste and mismanagement in a non-systematic health care scheme (I can’t bring myself to call it a system). We’re so inefficient that even what was once the world’s wealthiest economy can’t afford it. Maybe we’ll see some change?

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Ewe Reinhardt’s Economix blog today looks at pricing human life and the choices we face.

“All modern health systems now offer some medical interventions associated with very high costs per QALY. These procedures present two morally vexing questions:”

“1. Is there a maximum price per quality-adjusted life year (or life-month or life-day) beyond which society will not buy additional QALYs from the health system – certainly not out of collective insurance funds, be they public or private? Or is the sky really the limit in health care, as it is not in any other economic sector? “ “

2. If there is a maximum price, should it be the same for all members of society – rich or poor, prominent or not – or should there be different maximum prices for different socioeconomic classes? For example, should QALYs be rationed by market price and the individual’s ability to pay, as it would be in a free-market economy?”

Medicynical note: The point of Reinhardt’s blog is how much are we willing to pay. In the article there is a curve showing a QALY supply curve. On it there are points representing the effect of drugs costing $100,000/year on survival.

I’m not sure that any $100,000/year and more drug represents a cost effective intervention. Aren’t single drugs priced at more than the median and average income in our country by definition, cost-inefficient? And beyond most individual’s, and insurer’s ability to pay?

Abuse of the patent privilege is a real problem. Companies take the patent as a right to price medical advances higher if they treat life-threatening problems.

How did we let this happen?

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Over the years I’ve encountered many medical missionaries in third world situations. None impressed me more than those associated with Catholic institutions abroad. In my experience these providers were devoted first to providing assistance and secondarily to influencing religious beliefs–in contrast to many other missionary groups. Most are pragmatic and effective.

In regard to the HIV epidemic in Africa, the Pope however, doesn’t appear to support this health-first attitude. His religious doctrine based pronouncement today en-route to Cameroons stated:

“you can’t resolve it with the distribution of condoms.” He said that “on the contrary it increases the problem.”

“The Vatican encourages sexual abstinence to fight the spread of disease.”

It would be wonderful if abstinence worked. It’s simple, cheap and if used would be effective in preventing HIV. For those at risk, however, abstinence doesn’t fully meet their needs. They are for the most part sexually active, in many instances at an early age. With the prevalence of the disease in double digits in many areas of these countries, condoms become a reasonable way to decrease the risk of infection, and yes they do work.

Consider “discordant” couples. One person has HIV infection and the other does not. Is abstinence a realistic choice?

“The study, whose results were presented at the 15th conference on retroviruses and opportunistic infections in Boston, Massachusetts, found that of 36,000 couples tested, 96 percent of those in sexually active discordant relationships (where only one partner is HIV positive) reported not using condoms during their last sexual encounter.”

“The people we studied were in stable relationships – usually man and wife – and thus they did not feel the need to use condoms,” said Dr Elioda Tumwesigye, the lead researcher. “Even after testing, many continued to practice unprotected sex, saying that discordance was fate or that one partner must be immune.”

Condoms are an important part of the prevention strategy. It’s tragic that the Pope’s doctrinaire pronouncements may kill some people.

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This article from the BBC may somewhat overstate the case but exercise, diet and weight control are not only good for your mental health but for your physical health.

“about a third of the 12 most common cancers in high-income countries and about a quarter in lower income countries could be prevented through diet, exercise and weight control.”

Estimated percentage of cancers that could be prevented

	US	UK	Brazil	China
Mouth, pharynx & larynx	63	67	63	44
Oesophagus	69	75	60	44
Lung	36	33	36	38
Stomach	47	45	41	33
Pancreas	39	41	34	14
Gallbladder	21	16	10	6
Bowel	45	43	37	17
Liver	15	17	6	6
Breast	38	42	28	20
Endometrium (womb)	70	56	52	34
Prostate	11	20	n/a	n/a
Kidney	24	19	13	8
12 cancers combined	34	39	30	27
All cancers	24	26	19	20
World Cancer Research Fund

Medicynical note: No prospective study of this is possible and no one knows how early one must start behaving to have a salutary effect on cancer prevention or life expectancy. One can take solace in the fact that following the recommendations should make you feel good, even if it may not have the ultimate beneficial effect.

It shoul
d be noted that the outcome benefit is not dependent on use of supplements, omega 3 oils, and other unproven remedies.

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Another child murderer. An instant of misjudgment and this youngster took the life of his father’s pregnant fiance, ruined his own life and that of his father.

Is this what the founders had in mine with the second amendment? Guns are too prevalent. We need some regulation here too.

Addendum: 2/26 Adding insult to the injury of our ridiculous gun laws, is how we imprison child killers. Imagine having this problem in the first place. We facilitate murder by having guns so available and their use so commonplace.

“Pennsylvania has charged Jordan with two counts of first-degree murder in the February 20 shooting, and placed the fifth grader behind bars. Jordan’s new home is the Lawrence County jail’s 8-by-10 suicide-watch cell.”

“Should Brown receive the maximum penalty, he would join a select fraternity, one that includes Eric Smith, who killed a 4-year-old friend when he was 13, and is now serving a sentence of 9-years-to-life in upstate New York. And Joshua Phillips, sentenced to life without parole at the age of 14 for killing his 8-year-old neighbor in 1998. Phillips began serving his sentence when he was 15 in the prison’s “general population,” sharing an open dorm with dozens of adult men”

Medicynical Note: This says more about our culture and values than the excessive verbiage and pontification of the right.

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It’s alway puzzled me that taking innumerable vitamins, of dubious utility and origin, appealed to the “natural healthy food” crowd. These supplements are pushed, presumably for a fee, by various “experts” who are anything but expert–such as Kathie Gifford, various athletic types, Suzanne Somers and all manner of fading B-list celebrities. These people, and they include health gurus such as Andrew Weil, are willing to sell you their own brand supplements at a substantial profit to themselves.

Proponents of health lifestyles and “organic foods,” don’t hesitate literally ingest handfuls of these remedies and vitamins of uncertain origin and dubious efficacy. They take them to “stay healthy” while berating our health care system, ironically, for prescribing too many pills.

The use of vitamins to prevent disease is a little like the man from Sri Lanka I once met in Pennsylvania wearing flower in his vest. When asked why? He replied “it keeps the elephants away.” When I told him there were none here, he nodded and said, “see it works.” When he returns to Sri Lanka it won’t continue to work.

The best way to stay healthy is to eat well, exercise and not use tobacco products. There is little evidence that indiscriminate use of vitamins do much of anything. To true believer of vitamin use, however, vitamins appear work for most of their lives (most of us are healthy for most of our lives) and then they don’t.

In fact virtually all of these “health store” remedies are unproven and in many instances have been proven harmful to the health. Yet billions of dollars are wasted on them each year.

The FDA has been reviewing over the counter “natural” diet pills and found that they contain dangerous ingredients and may do significant harm to harm.

“And StarCaps are not the only culprits. In a continuing investigation that has prompted consumer warnings and recalls by some distributors, the F.D.A. has determined that dozens of weight-loss supplements, most of them imported from China, contain hidden and potentially harmful drugs.”

“Doctors said undeclared drugs could cause problems on their own, like elevated blood pressure or seizures, could have toxic interactions with other medications and could make it difficult for physicians to diagnose patients.”

How do such products get on the market? In the 90’s when the use of over the counter (OTC) agents was accelerating, Orin Hatch of Utah, the home of many of the supplement companies, sponsored and got passed through the republican congress the Dietary Supplement Health Education Act of 1994 (DSHEA)–Clinton signed the bill. Before DSHEA manufacturers of OTC remedies had to prove to the FDA that their supplement was safe. The idea that they might have to prove that the remedy did anything was never a part of the FDA review process.

After the act was passed, the FDA, already short staffed and underfunded, had to discover and prove that a “dietary supplement” was unsafe before they could stop its sale. What followed was feeding frenzy of marketing of agents for such indications as “heart health”, “prostate health,” “male enhancement,” and all manner of vague indications. Just as a stopped clock is right two times a day there are occasional useful supplements. Unfortunately,however, most are useless and some as noted above cause significant problems.

The FDA has a list of potentially harmful dietary agents on their site.

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Patient Autonomy taken to a ridiculous level.

“The births were a hot topic of conversation Friday, with many people incredulous that a woman with six children would try to have more — and that a doctor would help her do so. Several doctors said it is not their role to dictate family size.”

“Nadya Suleman and her other six children, who range from age 2 to 7, live with her parents in Whittier, a Los Angeles suburb.”

“Angela Suleman said all the children are from the same sperm donor, but she did not identify him. She said that her daughter is divorced, but that the ex-husband is not the father.”

“Friends and family said Suleman worked as a psychiatric technician until she was injured on the job several years ago. Then she began having children and enrolled in college, earning a bachelor’s degree in child and adolescent development and returning to pursue a master’s in counseling before dropping out last year.”

Guess who is going to pay?

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Part of the ethical basis of our health care system is that patients have autonomy.

“The right of patients to make decisions about their medical care without their health care provider trying to influence the decision. Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient.”

Ideally, physicians provide information, explain alternatives, options and implications but the patient makes the decision. However, despite this, patients often make bad decisions. For example, patients with terminal illness with little or no chance of response or recovery may decide on the most aggressive, toxic, and costly treatment option. As a result, he/she may have more problems in their last days and the expenses for care in the last six months of life may exceed the all the expenditures for health care in that person’s life.

The physician’s influence should not be discounted. Most doctor’s explanations and recommendations are in the best interest of patients. However, physicians because of the nature of fee for service can have conflicts of interest that influence their behavior. The more they do, the more they make. Other factors such as the physician’s research interest, or financial interest in laboratory or imaging facilities may also affect decisions.

Pharmaceutical companies and other providers of health care technology influence patient decisions through promotional activities. Drug companies spend more on advertising than on research. Physicians are barraged with advertisements, “educational” opportunities and company propaganda. Lay people are deluged with media advertisements touting the benefits, with scant disclosure of toxicity and cost, of new drugs and technological advances. In many instances the new products are no better than older more cost effective agents. All of this is about influencing patient autonomy.

The cost of patient decisions is buffered by our system of insurance. With an insurance based system after paying the insurance premium someone else pays. Costs are under-represented in the care decisions. The patient wants to live a full and healthy life. The physician runs a business and like all businesses it has to generate enough money to pay expenses and salaries. Suppliers of services and health technology have the fiduciary responsibility to make a profit. Insurers, in addition to paying for care of their beneficiaries, also want to make money for their stockholders. Nowhere in our system is an objective balance to the universal incentive to spend more.

Our republican friends want a system that places greater financial responsibility on the patient. That would certainly increase patient concern about costs. But it would also eliminate most people from the health care system because the price for care would exceed the ability to pay. This creates the ethical dilemma of people with diseases who are unable to afford health care. Are we as a country willing to allow these sick people to die because of lack of access? At this point only very wealthy very insensitive people seem to favor this solution.

The question then is how to raise the level of cost consciousness in an insurance based system. A system that maintains the concept of patient autonomy but also provides efficient affordable services. The answer is not simple and will be part of the challenge that faces Secretary Daschle and the Obama administration.

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In the U.S. you might get shot if your family talks during a movie.

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The NY Times notes that many journal articles are written by professional medical writers rather than medical investigators.

The article states:

“Wyeth, the pharmaceutical company, paid ghostwriters to produce medical journal articles favorable to its hormone replacement therapy Prempro, according to Congressional letters seeking more information about the company’s involvement in medical ghostwriting. At least one article was published even after a federal study found the drug raised the risk of breast cancer.”

Senator Grassley, in the article, notes:

“Any attempt to manipulate the scientific literature, that can in turn mislead doctors to prescribe drugs that may not work and/or cause harm to their patients, is very troubling,”

From a medicynical perspective there appears little or no difference between an article written by a professional writer hired by a drug company and an article written by a medical investigator who is on the payroll (grants and/or salary) of the drug company. Both have the potential to be corrupted by the conflict of interest.

The problem is money. The issue is the potentially corrupting influence of pharmaceutical companies on the conclusions and recommendations of medical journal articles.

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