Healthcare in the U.S.: It’s really about the money

In our third-world like health care non-system bribes and kickbacks are a normal way of doing business.  We’ve previously commented on generous gifts and salaries given providers to use a drug company’s product, this week it’s pharmacists.

The U.S. government sued Novartis Pharmaceuticals Corp. Tuesday, claiming it gave kickbacks to pharmacies to switch kidney transplant patients from competitors’ drugs to its own.

And

The government said Novartis offered one pharmacist in Los Angeles a “bonus” rebate amounting to several hundred thousand dollars to induce the pharmacist to “shoulder the burden” of switching 700 to 1,000 transplant patients to Myfortic.

Medicynical Note:  Unbelievable but true.

What’s doubly distressing is that this is not unique or unprecedented behavior by these companies which formerly called themselves “ethical.  When money is involved apparently another form of ethics emerge, i.e. greed—and it’s not good…. for patients or health care or costs.

Accountable Care: Brakes in the System?

In this blog we’ve talked about health care costs ad-nauseum and how our non-system has the highest costs in the world, in part, because everyone sees a benefit to themselves by doing more and spending more.

Patients believe that they need to do everything to maximize their care, no matter the cost or efficacy of the intervention.     Moreover most believe they are entitled to do everything and have someone else (insurance/Medicare/the VA whatever) pay for it.  Providers and hospitals figured out a long time ago that doing more means more income.  Insurers learned that they could simply pass through the costs without affecting their 20% or share of premiums–check out insurance executives salaries.  Suppliers understand that there is no real price competition in health care and if they charge more, someone will pay.

Adding insult to injury Congress in it’s infinite (well lobbied and paid for) wisdom protects manufacturers and suppliers by not allowing the largest purchaser of health care in the country (Medicare) to bargain on price.

So it’s encouraging to find a model that puts in place a braking system  to slow expenditures.

For most health care providers, that would be cause for alarm. But not for Advocate Health Care, based in Oak Brook, Ill., a pioneer in an approach known as “accountable care” that offers financial incentives for doctors and hospitals to cut costs rather than funnel patients through an ever-greater volume of costly medical services. Under the agreement, hospital admissions are down 6 percent. Days spent in the hospital are down nearly 9 percent. The average length of a stay has declined, and many other measures show doctors providing less care, too.

And

Under Advocate’s deal with Blue Cross Blue Shield, certain patients are assigned to the accountable care framework — about 380,000 — and their health costs are projected. If Advocate achieves savings below that amount while meeting explicit quality targets, it splits the money with the insurer. If not, its revenue is at risk.

Read the article for more.

Medicynical Note:  It will be fascinating to see whether this “innovation” is effective, and if patients and the other players in the health care game allow it to work.  Previously you will recall, a very similar system of cost containment ran into patient and industry opposition in the 90’s. 

Just so you know I am covered by a HMO/medicare advantage program and like it.

More on Health Care Costs: The LA Experience

This, from the April 18 LA Times, describes the rather complicated dance some insurers go through before approving a procedure, and why we pay so much for care, even if we carry insurance.

Ted Kamp wanted to make sure his daughter received the medical treatment she needed. That was his first priority.

nHis second was making sure his insurance would cover things and that he’d pay a fair price for any procedures.

The fact that this proved so difficult highlights one of the crazier aspects of the U.S. healthcare system: the inability of patients to know how much their treatment really costs.

Cigna’s  preapproval procedure required an evaluation of the indication for the MRI by  a third party contractor.  In this case the insurer paid nothing for the procedure as the family had not yet paid their $5000/year deductible.  When approved, the patient was expected to accept whatever was charged by the “approved” provider, and not afforded the opportunity to shop for the best price. 

The price paid was several times the cost of other providers in the area and  multiples (my estimate) of the amount charged if the insurer was paying the bill directly—this patient has a $5000 deductible and the bill came to $4700. 

Medicynical Note:  We have the most expensive health care costs in the world, no one else is even close.  

Insurers get the best prices for care through their negotiating leverage.  The uninsured, or in this case those still paying off their deductible are charged more, multiple of the insurance payment.   This is a system designed to assure profits not quality affordable care. 

Prostate Cancer Radiation: Proton beam costs twice as much, twice as good? NO

A recent retrospective study looked at outcomes in prostate cancer treated with Proton radiotherapy (PRT)  vs intensity-modulated radiotherapy (IMRT).

And the results:

We identified 27,647 men; 553 (2%) received PRT and 27,094 (98%) received IMRT. Patients receiving PRT were younger, healthier, and from more affluent areas than patients receiving IMRT. Median Medicare reimbursement was $32,428 for PRT and $18,575 for IMRT. Although PRT was associated with a statistically significant reduction in genitourinary toxicity at 6 months compared with IMRT (5.9% vs 9.5%; odds ratio [OR] = 0.60, 95% confidence interval [CI] = 0.38 to 0.96, P = .03), at 12 months post-treatment there was no difference in genitourinary toxicity (18.8% vs 17.5%; OR = 1.08, 95% CI = 0.76 to 1.54, P = .66). There was no statistically significant difference in gastrointestinal or other toxicity at 6 months or 12 months post-treatment.

Medicynical Note:  There is a build it and they will come mentality in medicine that applies to new approaches that are costly and have little benefit.  In this case Proton Beam radiotherapy has a word of mouth that it is less “toxic”,  fostered in part by institutions that invested in this prohibitively expensive equipment. 

It appears, however, that the benefits of this modality are overstated, as often is the case with medical “advances,” and that the nearly 100% additional expense of proton beam treatment  is not justified in prostate cancer.

Tricare: An Expensive Anachronism

Tricare is as dysfunctional as the rest of our non-system of health care.  It’s costly, redundant and driven by the notion that the military types deserve something special in return for their service.  The problem is that life long health care is an expensive gift that simply doesn’t stop giving (or rather taking).  This is a problem: 

Despite dire warnings from three defense secretaries about the uncontrollable cost, Congress has repeatedly rebuffed Pentagon efforts to establish higher out-of-pocket fees and enrollment costs for military family and retiree health care as an initial step in addressing a harsh fiscal reality. The cost of military health care has almost tripled since 2001, from $19 billion to $53 billion in 2012, and stands at 10 percent of the entire defense budget.

Read the rest of the article to understand what’s happened.

Medicynical Note:  The truth is all citizens need affordable access to health care.  Our haphazard piecemeal  approach has resulted in a totally dysfunctional, historically expensive non system that leaves 50 million people without coverage. 

The crisis in health care is self inflicted and solvable (every other industrialized country has a national health plan).  Our excessive costs result from the inordinate influence the health industrial complex has over our legislators controlling any real attempt to assure quality and economy in health care. 

It is ironic that the rather conservative military types strongly oppose a national health care solution, but want just that for themselves. 

What’s Wrong with American Health Care: The Prices, Stupid

Ezra Kline has a post on prices for health services in the U.S. versus other industrialized countries.  His data is taken from a report from the International Federation of Health Plans.  Guess where it is more expensive…it’s not even close!

Medicynical Note:  It’s hard to believe that some die hard reactionaries think this is the best health care “system” in the world. 

Healthcare: It’s About the Money

The Supreme Court is about to review the practice of the “ethical” pharmaceutical industry paying generic manufacturers to keep their product from competing with the branded drug. 

After a long period of exclusivity and monopoly the drug industry wants more.  Rather than price their drugs reasonably the companies push to stifle competition.  The new American way?

The case, Federal Trade Commission v. Actavis, No. 12-416, centers on whether the maker of a brand-name drug can pay a generic-drug company to keep the generic version off the market. Based on antitrust law, the obvious answer would seem to be no, the view voiced by the government and most recently upheld by a federal appeals court.

Medicynical note:  Yet another reason we lead the world in drug and health care costs.  There are a number of drugs available as generics overseas that continue to be sold as branded items here.  Where is the outrage?

America’s Health Care Non-System—A Lottery or Just a Joke

I never ceased to be amazed how dysfunctional and  bad our joke of a health care system is.  This is the tip of the iceberg…..

A few nights a year Tennessee holds a lottery for applications  for help with health care expenses.

State residents who have high medical bills but would not normally qualify for Medicaid, the government health care program for the poor, can call a state phone line and request an application. But the window is tight — the line shuts down after 2,500 calls, typically within an hour — and the demand is so high that it is difficult to get through.

There are other hurdles, too. Applicants have to be elderly, blind, disabled or the “caretaker relative” of a child who qualifies for Medicaid, known here as TennCare. Their medical debt has to be high enough that if they paid it, their income would fall below a certain threshold. Not many people end up qualifying, but that does not stop thousands from trying.

Medicynical Note:  America is unique in so many ways, some however are just plain embarrassing.  

It should be noted that America (the U.S.) is the only industrialized country in the world without a system to provide health care to all it’s citizens. 

Cancer Treatment Centers of America: Billfold Biopsies and Skewed Data

This company has claimed better results from their treatment approach.  If it’s too good to be true, it probably isn’t.

It turns out their approach is to not accept patients unless their insurance is “preferable.”  They minimize Medicare and Medicaid patients in their population—unlike other facilities.  They arbitrarily don’t accept certain patients.  They don’t report on patients who do not receive all their treatment at their facility.  As a result when they report outcomes the results are skewed by small numbers and careful patient selection.  They are under pressure to change as noted in the article.

Hilborn had seen CTCA’s website touting survival rates better than national averages. His call secured Vicky an appointment at the for-profit, privately held company’s Philadelphia affiliate, Eastern Regional Medical Center. There, the oncologist who examined Vicky told the couple he had treated other cases of histiocytic sarcoma, the cancer of immune-system cells that she had.

“He said, ‘We’ll have you back on your feet in no time,'” Keith recalled.

Vicky’s cancer treatment was forestalled by an infection and other complications that kept her at Eastern Regional for three weeks. In July 2009, when she got back home, things changed. Despite Keith’s calls, he said, CTCA did not schedule another appointment. As his wife got sicker, Keith, a former deputy sheriff in western Pennsylvania, was reduced to begging.

Read the article to get the full flavor of this type for profit beast. 

Medicynical Note:  What’s missing is an accounting of cost of treatment at this facility that provides “free transport” and limos to their hospitals.  It’s little wonder that medical care is bankrupting us.  More on this in Brill’s recent Time essay. 

In fact there is no magic in cancer treatment.  The reality, bad cancers that have spread have bad outcomes, with few exceptions.

No this is not the “gospel of hope,” but it is the truth.

Johnson and Johnson ASR Hip: Fails 40% of the time within 5 years

It’s remarkable that so called “ethical” pharmaceutical companies are anything but…..ethical.  Johnson and Johnson and it’s DePuy Orthopedics division appear to have suppressed and/or ignored early information that the devices were faulty and would fail prematurely.

Johnson & Johnson never released those projections for the device, the Articular Surface Replacement, or A.S.R., which the company recalled in mid-2010. But at the same time that the medical products giant was performing that analysis, it was publicly playing down similar findings from a British implant registry about the device’s early failure rate.

The company’s analysis also suggests that the implant is likely to fail prematurely over the next few years in thousands more patients in addition to those who have already had painful and costly procedures to replace it.

Medicynical Note:  As we’ve noted before these companies are not about patient care or good outcomes.  They are about the money.