Medicynic

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?

This little gem from the Roanoke Times explains our situation better and more clearly.

Our health care establishment gives higher priority to the quest for profit than the care of patients. Consider this from the Times about one of the leading Roman Catholic hospital systems in our country.

Companies, even non-profits, don’t seem able to resist the urge to maximize revenue. This is a recipe for disaster in health care where patients, not profits should come first. Consider also that Big Pharma charges confiscatory prices for their medications, some amazingly mediocre, and has one of the largest profit margins in American industry. They can’t help themselves, they have a government sanctioned monopoly and it is your money or your life.

What a sad excuse for a health care establishment–it’s not a system.

No other place on earth would consider this.

“The White House says the changes are needed to ensure the “fiscal integrity” of Medicaid and to curb “excessive payments” to health care providers.

These are the same guys whose fiscal policies have led to unprecedented tax cuts for the wealthy; a federal deficit of hundreds of billions of dollars; a war that our children and grandchildren will pay for without a reasonable entrance or exit strategy.

The best they can do is cut support for a health care program for the poorest and neediest. Quite a commentary on our culture, or lack thereof.

The August 10, 2006 New England Journal of Medicine’s lead article, High Dose Atorvastatin after Stroke or Transient Ischemic Attack reports the results of the Stroke Reduction by Aggressive reduction in Cholesterol Levels (SPARCL) trial. The study is sponsored by the drug manufacturer (Pfizer) and all of the authors are Pfizer employees, consultants and grant recipients.

The study found “The atorvastatin group had 218 ischemic strokes and 55 hemorrhagic strokes, whereas the placebo group had 274 ischemic strokes and 33 hemorrhagic strokes. The five-year absolute reduction in the risk of major cardiovascular events was 3.5 percent (hazard ratio, 0.80; 95 percent confidence interval, 0.69 to 0.92; P=0.002). The overall mortality rate was similar, with 216 deaths in the atorvastatin group and 211 deaths in the placebo group (P=0.98), as were the rates of serious adverse events.

Elevated liver enzyme values were more common in patients taking atorvastatin.”

It was also reported ” A total of 136 patients in the placebo group and 154 patients in the atorvastatin group died from causes other than stroke before they could have a nonfatal stroke.” And “On the basis of our data, 46 patients (95 percent confidence interval, 24 to 243) would need to be treated for five years to prevent one stroke, 29 patients (95 percent confidence interval, 18 to 75) to prevent one major cardiovascular event, and 32 patients (95 percent confidence interval, 22 to 59) to avoid one revascularization procedure.”

What is not reported is an estimate of the cost of preventing one stroke using high dose atorvastatin (Lipitor). Medicynic’s estimate is as follows: Additional expenses for the use of the drug in post stroke patients include the drug ($1200/year), additional laboratory costs (liver function tests 2 times a year $150), 1 additional physician visit because of the medication ($75) giving a total of $1425/year/patient for this intervention.

Figuring, as the article suggests, that 46 patients need to be treated for five years to prevent one stroke the cost to prevent one stroke ($1425X46X5) is $327,750 to prevent one stroke. Given the limited benefit of this treatment, no improvement in survival but a small decrease in new strokes, can our system afford such an intervention?

Medicynic realizes this cost estimate is not scientific (i.e. not the actual costs experienced) but rather a seat of the pants estimate based on current costs of care. The estimate is, however, indicative of the price of this intervention. Should the NEJM require all such studies include an accurate cost estimate and include this information in the debate about the intervention’s utility?

According to this article in the Times we must control payments to physicians “because spending on doctor’s services was increasing faster than expected, and faster than the annual goals set by a statutory formula.” The change will result in a saving of 13 Billion dollars over 5 years

Contrast this serious concern about controlling physician costs with the docile acceptance of 10-20% increases in yearly drug expenditures and the utter irresponsibility of a pharmaceutical program (Medicare D) originally estimated to cost 450 billion yearly but actually costing over 550 billion. But of course the poor pharmaceutical companies must not be subject to competition or negotiation because we wouldn’t want to stifle their profits, whoops I mean creativity.

It’s fascinating that we can rationally talk about this. Overseas there is greater variation in quality but with due dilligence, skilled and competent physicians and facilities can be identified. However, people with the greatest problems particularly those needing continuing care have the fewest options…and highest expenses. Outsourcing is not a cure for the sickness in our health care system.