Category Archives: Uncategorized

This is one of the risks of a market driven health care system and is one side of the health care equation.  It mirrors the holistic crowd’s approach to staying “healthy” by taking pills, enemas, aromas, massages, adjustments and detoxification regimens. 

More “interventions” mean more treatment and more money into the system. 

The problem is that while some of this may feel good, they don’t produce a measurable health benefit beyond that of a placebo.  I used to tell my patients that if you do everything that is recommended you may not live any longer, but it will seem that way.

Using a blog to cite a blog is not my usual practice but look at this .

“In all cases, the companies spent more on marketing and administration than they did on research. In all but two cases profit exceeded research and development expenses.” Note also that all companies but one reported profits in the 15-30% of revenue (presumably), an almost unprecedented level. The outlier reported profits of 13.5%, so don’t feel too bad for them.

Big PHARMA’s shibbolith, that pricing is necessary to sustain development, falls apart with the data about actual costs of development and their costs of administration and marketing.

Sadly, PHARMA is pricing itself out of the market. The costs/year of many new cancer drugs exceed the median and average incomes in our country. In most instances the new drug’s efficacy is marginal and the benefit to the patient, if any, is measured in a few months additional survival. In a few cases the drugs are revolutionary (Gleevac) and those who cannot afford them simply spend down their savings, go on medicaid and you and I pay for them, or die.

So why are new drugs so expensive? Is this a bubble (irrational pricing that is not sustainable?). You might want to review some of medicynic’s earlier posting on pricing, patents, and profits.

Two weeks ago our local paper neglected to report on the loss, in Iraq, of 14 of our military over one weekend.  Not even a brief note documenting the number.  Is it insensitivity from the continual bad news there?  Is it our collective guilt and denial because we bought into the flawed rational for a pre-emptive war–Colin Powell among others shamed himself? 

We seem to look elsewhere for bad news that somehow is less challenging.  So we find our news reports innundated with the unfortunate tragedy of a family lost in the snow, or the three climbers who for whatever reason were climbing Mt. Hood in the dead of winter, and so on.  

Our president tells us that he is aware of the deaths and suffering going on over there.  Yet we have little idea what’s really happening to Iraqis or for that matter to our own troops.  This article in the New England Journal of Medicine tells a small part of the tale. 

Last night on the Colbert Report, Deepak Chopra was asked whether he was a prophet. Deepak then spelled it p-r-o-f-i-t. That notion sums up the state of American medicine. Everything is touted as a major advance, whether it is a treatment heart disease, cancer or hot flashes. Too often however, the supposed benefit turns out to be an illusion, or to be overstated,  and —as noted on our masthead skim milk often masquerades as cream.  It’s hard to escape the notion that monetary gain has something to do with the claim.

Some recent news items illustrate this

1. Black cohosh and soy—For years our naturopathic and health food friends have touted this as a treatment for hot flashes. The only problem is that when tested in an objective manner, (noted here also) in controlled randomized studies there is no evidence of benefit over a placebo.

2. Vitamin E: This has been promoted for what ails you. All manner of pills and capsules have been marketed catering to the hopes of consumers that this will give them long life and ward off a variety of problems.  Most recently there was a report on vitamin E’s inability to improve cognitive dysfunction (prevent Alzheimers disease). Other uses recently  questioned include the prevention of heart disease and cancer. Vitamin E does not appear to be effective in any of these indications.

3. Prostate cancer treatment: There was a widely reported non randomized study in JAMA (also noted here) last week. The headlines claimed a major advantage for patients aggressively treated for prostate cancer versus those who were simply observed (wait and watch)–i.e. fewer in the treatment group died.  The study seems to prove an advantage for aggressive treatment. However, what was not emphasized in the news reports was that those who died most often died of other illnesses—not prostate cancer. Just 8% of treated patiennts who died actually died of prostate cancer while only 6.8% of those not treated died of the disease.

Huh? fewer patients died of prostate cancer in the non treated group? What’s going on here? The problem with this study is that patients with significant illnesses besides their prostate cancer were not treated for prostate cancer because of their limited life expectancy from other illnesses. Thus what was reported as an advance in treatment, fewer people dying if they are treated, would seem to be the result of patient selection.

This study was widely publicized but is unfortunately flawed.  It gives cover to those who want to aggressively treat every patient with prostate cancer.  Patients live longer with treatment, right?  Wrong!!  The flaws are too evident and call into question the conclusions.

 

Contrast this with the Bush AIDS program’s use of the same drugs, but branded, costing hundreds of dollars per year. People die while our government and big Pharma play games.

Reading about Prime Minister Sharon recalls to me similar death watches for Franco and Tito. I believe Chevy Chase spoofed the situation in a “news” report on Saturday Night Live reporting that President Franco after a long drawn out illness was still alive.

An advance directive is the proper way to manage end of life situations. It helps your family and physicians make the right decision.

Continuing with the theme of being rich doesn’t mean you have good care here is another aspect of the problem. In 1980 the recently deposed Shah of Iran arrived in Panama after being expelled from the U.S. Our government was concerned about the safety of U.S. hostages there and asked the Shah to leave and Panama was chosen as his destination.

The Shah had a lymphoma that was progressing and Panama was felt to have good medical facilities that could easily deal with it. Indeed the Panamanian physicians were quite excellent–mostly U.S. trained and board certified, many from the most prestigious programs in the states. The Shah however was not satisfied and arranged for Michael De Bakey, a well known heart surgeon, to come and perform a splenectomy–a relatively simple surgical procedure. Unfortunately, because of the Shah’s medical team’s precipitous dismissal of local physicians and facilities as inadequate, no Panamanian facility would agree to allow the procedure to be done. The U.S. facility in Panama, Gorgas Hospital, was suggested as being appropriate by the Shah’s team but because of the political environment at the time they were advised to go elsewhere. The Shah went to Egypt had the splenectomy and died shortly thereafter.

There is no moral to these stories but simply an observation that wealth and power does not guarantee proper treatment and may in reality get in the way.

It can’t be any clearer than this.

“When I’m with a patient, my job is to be a patient advocate, not to try to save society money on chemotherapy,” said Dr. Barbara L. McAneny, the chief executive of New Mexico Oncology/Hematology Consultants, in Albuquerque.

The quote was in reference to a new drug, Abraxane developed by Abraxis. The manufacturer”s spokeman “Dr. Michael Hawkins made a remarkable observation about how the company’s $4,200-a-dose drug compared with $150 generic paclitaxel.”

“Dr. Hawkins said the F.D.A. should approve Abraxane in early-stage patients without a clinical trial because such testing would probably not prove that his company’s drug was different than the conventional treatment. “These are just two forms of paclitaxel,” he said.” Yet one costs $4200/dose the other $150.

Our non system of health care is fatally flawed by the lack of a mechanism of cost containment. All levels of the system have conflicts of interest that interfere with unbiased cost effectiveness evaluations. The above article notes that patients with insurance have few incentives to be cost conscious. As also noted, physicians many with inherent financial conflicts of interest, do not accept responsibility for more rational choices. Manufacturers obviously aren’t interested in controlling costs of health care–their fiduciary responsibility is to maximize profits. Insurers have tried but their focus has become guarding their own profits and passing through costs. Government’s interest in cost containment has been nullified by the contributions of special interest lobbies.

So who cares about costs?

Back from vacation.

There have been a number of articles recently about the inadequacy of the U.S. health care establishment. All agree that whatever it is that we have (I hesitate to call it a system) doesn’t work. An article by Paul Krugman and Robin Wells, “The Health Care Crisis and What to Do With it” elicited a particularly insightful response. Written by Arnold Relman, a former editor of the New England Journal of Medicine, the letter notes why the task is so difficult.

“The “monetarization” of health care (a term used by the late Eli Ginzberg) changed it from a largely not-for-profit, community-oriented social system into an industry, and this has affected the behavior of all providers—hospitals, doctors, and others.

Investor-owned businesses constantly seek to expand their revenues. Yes, expensive new technology and new procedures, more specialists, and an aging population are all part of the problem. But much of the impetus to expand the use of health resources surely comes from the fact that there is a lot of money to be made and the expectations of investors and physicians are high.

Krugman and Wells are right that we will have to reform the delivery system as well as the insurance system and that powerful vested economic interests will have to be confronted. They should understand, however, that private insurance companies and the pharmaceutical industry are not the only vested interests who will resist. All those investors who have an equity interest in a vast variety of for-profit health care businesses and all those medical specialists whose high income depends on the fee-for-service reimbursement of expensive technology and complex procedures will also have to become convinced that change is necessary before we can make it to the promised land.”

The Times notes “Evolutionary biology has vanished from the list of acceptable fields of study for recipients of a federal education grant for low-income college students.” Is this a form of reverse evolution?