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Ewe Reinhardt’s “blog” at NY Times has a series on costs. The U.S. healthcare non system’s costs are significantly higher than other industrialized countries. This is graphically indicated in the blog with a graph showing the relationship of expenditure/capita to GDP/person in various countries. We are at $6700/person/year and way off the curve.

Reinhart believes the U.S. costs are higher because of the following:

“1. higher prices for the same health care goods and services than are paid in other countries for the same goods and services;” Medicynic: We don’t negotiate and allow patent holders to charge whatever they wish for their advances. Patent reform should be part of the mix of healthcare reform.

“2. significantly higher administrative overhead costs than are incurred in other countries with simpler health-insurance systems;” Medicynic: It’s estimated to be 31% of health care costs. 33% to 100% higher than other industrialized countries.

“3. more widespread use of high-cost, high-tech equipment and procedures than are used in other countries;” Medicynic: “Build/buy it and they will come.” Organizations that make an investment in equipment want it used and will “encourage” providers to do so. Often the new approaches offer limited or no improvement over the older technology.

“4. higher treatment costs triggered by our uniquely American tort laws, which in the context of medicine can lead to “defensive medicine” – that is, the application of tests and procedures mainly as a defense against possible malpractice litigation, rather than as a clinical imperative.” Medicynic; You need to look beyond the actual litigation and settlements. Defensive medicine is a major cost center in our non-system.

We need reform but unless the system aggressively attacks our cost issues we will be simply shuffling cards.

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It’s enough to make a medicynic’s day. JAMA reports this week that Vitamin C and E are ineffective in preventing cardiovascular disease.

“A total of 14,641 male physicians who were 50 or older at enrollment took either 500 milligrams of vitamin C and a placebo, 400 International Units (IU) of vitamin E and a placebo, both vitamins, or two placebos every other day for an average of eight years.”

“During this time there were 1,245 confirmed major cardiovascular events among the study participants.”

“Neither vitamin, nor the combination of the two, was found to have a significant impact on the risk for heart attack, stroke , or other cardiovascular events.”

I don’t know what’s more pathetic, this child killing people or the police reaction.

Having weapons in homes is dangerous enough. But not keeping them secure is rediculous.

But according to reports there are fears that the new administration may limit access to semi-automatic assault rifles (including the AK47, UZI and the AR-15 described below), which apparently every self-respecting sportsman desires. These weapons are appropriate for nothing sporting and one can only conjecture why the pro-life gun lobby would promote and protect this weapon’s sales and distribution?

From Wikipedia:

“AR-15 (for Armalite model 15, often mistaken for Automatic Rifle or Assault Rifle) is the common name for the widely-owned semi-automatic rifle patterned after the fully automatic M16 and M4 carbine assault rifles, which are currently in use by the United States military. AR-15 was the original name for what became the militarily designated M16, the assault rifle first used by the U.S. in the Vietnam War. The name AR-15 is now used almost exclusively to refer to the semi-automatic (commercially available) civilian version(s) of the M16 and M4 assault rifles.”

Article in today’s Times about author Carolyn Chute.

“The Chute home does have an industrial-size copying machine, however, and nearby she keeps her AK-47 rifle, which she likes because it has a gas piston that dampens recoil. “It’s very gentle, very soft,” she said.”

The author is also a member of the 2nd Maine Militia

“The 2nd Maine Militia, or Your Wicked Good Militia, as it’s sometimes known, is progun, against corporate lobbying and campaign contributions, and opposed to tax subsidies for big business. The group has been known to meet in a hired hall, but more often it assembles in the woods behind the Chutes’ home, where the members shoot at cans and other targets, talk about what’s wrong with the world and dine on potluck.”

Ahh life in these United States…….

An exconvict murdered a 12 year old who was out trick or treating. He used an AK47, which appears to be one of the the weapons of choice here in the U.S.  See this for more.   What’s wrong with us?

This article from Reuters puts out system in perspective:

“Americans are the least satisfied with their health care system, while the Dutch system is rated the best, according to new research.

Polls about health care in 10 developed countries by Harris Interactive revealed a range of opinions about what works and what doesn’t.

In the United States a third of Americans believe their system needs to be completely overhauled, while a further 50 percent feel that fundamental changes need to be made.

“Given that all countries other than the U.S. have universal health care systems in place, this may invite questions on why the U.S. remains the only wealthy, industrialized country without such a system,” Harris president George Terhanian told Reuters.”

“The U.S. model, widely criticized on its combination of private insurance and publicly-funded programs, spends more on health care than any other nation worldwide but ranks low on overall quality of care, according to the World Health Organization (WHO).”

The health plans offered by Obama and McCain do not answer the questions raised by this polling.  Neither mandate universal health coverage nor attack the lack of value in health care in the U.S.  Our costs are double those elsewhere and our outcomes worse.  Is this the American way?

McCain’s so called plan actually does away with the employer mandate so fewer people will likely be insured.  His tax rebate scheme will not cover insurance costs and further his plan allow insurers to deny insurance to the sick and other high risk groups.  He would, hard as it is to believe, make things worse than they are.

Obama’s plan is better but still allows the waste and duplication of multiple insurers administrative costs–which amount to about 30% of health care spending.  Medicare spend under 10% on administration.

Nice feature on NPR regarding the United Kingdom’s approach to expensive medications. There are trade-offs–toxicity, expenses, limited efficacy.

You don’t find such openness in the U.S. where unrealistic expectations, incomplete information, irrational use of funds and conflicts of interest drive utilization.

I came across a letter in the June 26th N.Y. Review of Books from Gayle Greene regarding a dispute in the 50’s and 60’s about the safety of x-raying pregnant mothers. Today a defense of this practice would be viewed as ludicrous but read the letter, and also the book The Woman Who Knew Too Much: Alice Stewart and the Secrets of Radiation to learn more.

From the NY Review of Books:

“I interviewed Doll while writing about Stewart, the physician and epidemiologist who discovered that the practice of X-raying pregnant women, which was common in the Forties and Fifties, doubled the chance of a childhood cancer. Doll and Stewart moved in the same Oxbridge circles, sat on the same committees and editorial boards. Both started out as physicians, then moved into epidemiology after the war, each making major discoveries in the Fifties that helped shape epidemiology so it came to include cancer as well as infectious diseases. But after Stewart went public with the dangers of radiation, she plummeted to obscurity, while Doll, credited with discovering the link between lung cancer and smoking, rocketed to fame and a knighthood.”

“Immediately after Stewart published her findings, Doll launched a study to prove her wrong. For nearly two decades, he succeeded in keeping her findings from being accepted, thereby allowing fetal X-raying to continue”

“After his death it came out that Doll was receiving payment from Monsanto (quite a lot) all the while he was doing the studies that cleared vinyl chloride of an association with liver cancer. I’d have thought that would have laid to rest this overblown veneration. But no, Horton defends him, suggesting that he may simply have been “naive.” I can tell you, whatever else he was, he was not naive.”

Not much has changed as indicated in today’s (June 8,2008) NY Times report on professors of pediatrics receiving unreported income from drug companies.

“In 2000, for instance, Dr. Biederman received a grant from the National Institutes of Health to study in children Strattera, an Eli Lilly drug for attention deficit disorder. Dr. Biederman reported to Harvard that he received less than $10,000 from Lilly that year, but the company told Mr. Grassley that it paid Dr. Biederman more than $14,000 in 2000, Mr. Grassley’s letter stated.”

“At the time, Harvard forbade professors from conducting clinical trials if they received payments over $10,000 from the company whose product was being studied, and federal rules required such conflicts to be managed.”

This is the tip of the iceberg of unreported relationships between physicians, researchers, and institutions and the medical industrial complex.

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Medicare drug costs, deductibles (read that as the infamous doughnut holes) are increasing at multiples of the inflation rate and the insurance for Medicare part D are increasing at multiples of the inflation rate.

In the political campaign we talk of strategies to provide universal health care but have heard few if any suggestions to control costs. We continue to pay whatever the providers charge (providers=practitioners, institutions, insurers, equipment manufacturers and pharmaceutical manufacturers). Where cost containment implemented it is almost always at the patient/practitioner/institution level.

That’s not bad but it has proven ineffective. We continue to have hospitals with wide variability of costs between one location and another; physicians overusing technology–doing tests and providing treatments that do not change decisions or outcomes; and pharmaceuticals that alone cost more than the average and mean incomes/year of individuals.

This is a system from hell and unless we are willing to attack costs beyond cutting provider reimbursement we will continue to pay twice what the rest of the world pay for care and continue to have mediocre results.

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The zoledronic acid (Zolmeta) study reported:

“The women were premenopausal and were receiving hormone therapy – either tamoxifen or anastrozole – to prevent recurrence of their tumors. Half the women also received Zometa.”

It should be emphasized that this study was in pre-menopausal women. The results do not necessarily apply to older women–in whom 75% of breast cancers occur.

The ASCO abstract of the study stated:

“With median follow-up of 60 mo (March 31, 2008), 137 (7.6%) DFS events and 42 (2.3%) deaths have occurred. There was no significant difference in DFS between patients who received TAM alone vs ANA alone (HR = 1.10 [95% CI = 0.79, 1.54]; P = 0.59). However, endocrine therapy plus ZOL significantly reduced the risk of DFS events by 36% “

Lets look at that 36% figure. The difference (reported in news articles) between the the two groups was that 9% of those receiving hormone therapy alone recurred while 6% recurred when zoledronic acid was added. This is in absolute numbers a 3% difference between treated and untreated–and could be due to a small difference in disease severity between the groups or actual benefit from the drug. In any case the people promoting this study at some point decided that a 3% benefit doesn’t sound impressive enough so the investigators call it a 35% reduction of risk (9% to 6%). While technically right in their claim, it, in reality, is just a 3% absolute decrease in recurrence in the study group.

Looked at another way 91% of those treated with hormone blockers and 94% of those with the added zoledronic acid were disease free at the end of the study–even less impressive.

As a matter of fact after 5 years one cannot be sure whether patients will recur later and even out the recurrence rate. The delay in recurrence is a real benefit particularly if it is associated with a survival benefit–which has not yet been proven with this drug. So more time will need to pass to fully understand the benefits of this intervention.

In media reports there were no analyses of cost implications of the use of this drug.

The cost of zoledronic acid is about $2000/year, not a huge number but consider, in order to get the 3% improvement, you need to treat all the patients diagnosed with breast cancer receiving hormonal blocker adjuvant therapy. That means the costs for zoledronic acid in 100 cases will be $200,000 or about $66,000 for each of the 3 patients in 100 who benefit from the drug treatment.

For the health care system (and the pharmaceutical manufacturer) the financial aspects may be profound–particularly if the results are extended to post menopausal patients. There are about 185,000 new cases of breast cancer/year. If you figure that 100,000 patients require adjuvant therapy (therapy to prevent recurrence after surgery) that means a cost to the system of $200 million dollars/year to delay recurrence (some of these may be cures) in 3000 women. These costs are in addition to the cost of surgery, physicians, hormone blocker costs etc.

More study necessary? Of course. Cost effective? It’s anybody’s guess. Shouldn’t cost data be a part of the analysis of new interventions? I can’t think of a reason to not have such analysis.

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