Medicynic

Ten issues that can go away with Health Reform:

1. The approximately 47,000,000 uninsured: Virtually all will have access to coverage with incentives for provider efficiency and the most cost efficient interventions.

2. The profit squeeze on employers who provide health insurance to employees: It’s estimated that U.S. car makers have had expenses of over $1500/car related to health care coverage for employees. A national system, delinked from employer based insurance, allows employers to compete on the same basis as those in other industrialized countries.

3. Our disgraceful system of health care for GI’s and their families: Incorporating the VA and military health care systems is into a National Health Insurance program provides more and better options for care. These would be community based and thus provide more convenient access.

4. The administrative duplication and fraudulent behavior of multiple insurance providers, each with their own administrative overhead and fiduciary responsibility to generate profits: It’s estimated that we spend 30% of our expenditures for health on administration ($1059/capita in U.S. vs $307/capita in Canada). That could easily be halved or more with a national health program.

5. The conflict of interest between insurers, providers and patients.

6. The crisis in emergency rooms: With insurance people will have a place, other than ER’s, to go with non-emergent medical issues Our republican friends cite ER access as health insurance for all but guess who ultimately pays. ER care is the most inefficient expensive care imaginable. Is this the republican way?

7. The dance of the veils billing system: There is no set price for services. Those with leverage, i.e. large insurers, are given large discounts while the individual pays the full amount. If everyone has insurance there will be a consistent negotiated price.

8. Big PHARMA’s free ride: We pay more for medications than any other industrialized country. PHARMA’s mantra that they need profits to encourage creativity is bogus when one considers they spend more on promotion and advertising than research. In a national insurance scheme drug price negotiation will be the rule–as it is in the rest of the industrialized world. (see more below)

9. Bankruptcy due to enormous medical bills

10. Our mediocre health care outcomes: We spend more per capita than anyone, yet our outcomes (longevity, infant mortality etc) are in the middle of the pack. We do better with diagnosed disease but not significantly better than other industrialized countries paying half of what we do. With universal access we can expect this to change.

Medicynical Note: None of this will be automatic and actually having an efficient functioning system of care will require much due diligence and negotiation.

What won’t change is physician unhappiness with reimbursements and the continuing issues with intellectual property rights. No where in the world are physicians as well paid as here. We’ve made the profession entrepreneurial and money driven and in the current non-system reward procedures rather than primary care. It can be anticipated that a national health insurance scheme will want to flatten the disparities and redistribute, somewhat, the fees. One would hope this would guarantee all physicians reasonable reimbursement for their time and expenses. However, meeting the expectations of the profession will be almost impossible–as it is now.

We do need some type of protection for innovators in our system. We should not however delude ourselves that this is a “free market”. Patent protection creates monopoly and in health care that has resulted in a life threatening market distortion that we can no longer afford. We need to somehow require patent holders to price their products responsibly and to be efficient in their product development and marketing. Once again meeting the expectations of the industry and their stockholders will be almost impossible–as it is now.

But in both cases the status quo is not working.

Marcia Angell former editor of the NEJM (New England Journal of Medicine) and thoughtful author on the health care mess has concerns about the house bill and several suggestions.

Her concerns are that the bill will do little to control excess spending and while “budget neutral” will:

• “throw more money into a dysfunctional and unsustainable system, with only a few improvements at the edges, and it augments the central role of the investor-owned insurance industry. The danger is that as costs continue to rise and coverage becomes less comprehensive, people will conclude that we’ve tried health reform and it didn’t work. But the real problem will be that we didn’t really try it. I would rather see us do nothing now, and have a better chance of trying again later and then doing it right.”

She suggests:

• “Drop the Medicare eligibility age from 65 to 55. This should be an expansion of traditional Medicare, not a new program. Gradually, over several years, drop the age decade by decade, until everyone is covered by Medicare.”
  
• “Increase Medicare fees for primary care doctors and reduce them for procedure-oriented specialists.”
  
• “Medicare should monitor doctors’ practice patterns for evidence of excess, and gradually reduce fees of doctors who habitually order significantly more tests and procedures than the average for the specialty.”
  
• “Provide generous subsidies to medical students entering primary care, with higher subsidies for those who practice in underserved areas of the country for at least two years.”
  
• “Repeal the provision of the Medicare drug benefit that prohibits Medicare from negotiating with drug companies for lower prices.”
  

Medicynical Note: Read the article for more detail.

To these suggestions Medicynic would add that we should also reform our patent system to reward responsible pricing of new advances and penalize companies that gouge.

After 20 years on the market and tens of billions of dollar/year spent on erythropoietin-stimulating agents (ESA’s) a large study in the Journal of the National Cancer Institute (Dec 2,2009) will report:

• “These agents were approved to reduce the risk of blood transfusions by 50 percent,” Hershman said. “There was absolutely no difference in the transfusion rate over the 10-year period from when these drugs hit the market,” she said. “The majority of patients are getting these drugs and receiving transfusions.” (emphasis Medicynic)
• “The researchers found that 14.3 percent of patients receiving ESAs developed thromboembolism (deep vein thrombosis or pulmonary embolism) compared with 9.8 percent of those who did not receive an ESA.”
• “ESAs stimulate red blood cell production and are intended to reduce the number of blood transfusions needed during chemotherapy. However, the rate of blood transfusions remained the same for both groups (22 percent). Survival in both groups was also similar, the researchers noted.”

Medicynical Note: These drugs (ESA’s) did not decrease the need for transfusion, did not improve outcomes, increase complications and cost us tens of billions of dollars/year.

When EPO came onto the market oncologists were skeptical of the benefit and were very slow in their acceptance of the drug. The manufacturers mounted an unprecedented, at the time, direct to consumer campaign focusing on fatigue and chemotherapy. It was remarkably successful in getting physicians to use their agent.

Can you guess why the U.S. is number 1 in health care expenditures, by a wide margin?