Category: Health

Health Care Spending Increases Faster than Inflation, But Slower than Previous Year

HealthCareSpendingGraph.gif   Source of graph:  online version of NYT article cited below.

 

WASHINGTON, Jan. 8 — Spending on health care in the United States increased in 2005 at the slowest pace in six years, mostly because of much slower growth in spending on prescription drugs, the government reported Monday.

It was the third consecutive year of slower growth in the nation’s medical bills. Total health spending reached nearly $2 trillion in 2005, growing only a bit faster than the economy as a whole, officials said.

But with new medical technology becoming available every month and with a generation of baby boomers approaching old age, federal officials made no bold claims about having tamed health costs.

“It is unclear whether this phenomenon is temporary or indicative of a longer-term trend,” said Aaron C. Catlin, the principal author of the government’s annual report on health spending, published in the journal Health Affairs.

 

For the full story, see: 

ROBERT PEAR. "In ’05, Medical Bills Grew At Slowest Pace in 6 Years."  The New York Times  (Tues., January 9, 2007):  A13.

 

The Mere Threat of “Hillary-Care” Reduced Investment in Drug R&D


TaurelSidneyCEOEliLilly.jpg   CEO of drug company Eli Lilly.  Source of image:  online version of WSJ artcle cited below.

 

NEW YORK — Is the future of your health riding on what happens in Washington?  Sidney Taurel thinks it might be.  The Eli Lilly CEO ticks off a list of former "death sentences" being cured or turned into chronic conditions — "AIDS, leukemia, Hodgkins, hopefully solid tumors within the next few years.  The potential for medical research is unlimited.  We just need to make sure we don’t interdict it by the wrong policies."

And what might those "wrong policies" be?  Anything, it would appear, that reduces the financial incentives for drug companies to invest in research and development.  Mr. Taurel points without hesitation to the mere threat of HillaryCare in the early 1990s as an episode that reduced investment in R&D, as drug makers, including his own, redirected money toward the purchase of pharmacy benefit management companies.  As another example, he offers the anti-drug industry crusade of Sen. Estes Kefauver in the late 1950s and early ’60s:

"At that point companies started to diversify.  We bought Elizabeth Arden, we went into animal health and agricultural chemical products, later on in medical instruments and so forth.  All other companies did similar things.  And for a while after that we saw fewer new products.  When this threat subsided the companies focused again on R&D and we saw a golden era in the ’80s and ’90s with a lot of new products and breakthroughs."

 

For the full interview, see:

ROBERT L. POLLOCK.  "THE WEEKEND INTERVIEW with Sidney Taurel; Of Politics and Pills."  The Wall Street Journal  (Sat., December 2, 2006):  A8. 


Hugely Wasteful Health-Care Spending

CureBK.jpg   Source of book image:  http://www.encounterbooks.com/books/cure/

 

Milton Friedman is gone now, but the new book reviewed below, includes a forward written by him.  Friedman can be praised for many reasons; a minor one is that he was tireless and generous in offering praise and support for others who were seeking to better understand free markets. 

 

About 10 years ago, I broke my leg playing basketball.  After I came out of surgery, with a cast stretching from my ankle to the top of my leg, an orderly asked me whether I had ever used crutches before.  I hadn’t, so he showed me what to do, swinging through them from one end of the room to the other.  The whole lesson lasted about 90 seconds.  When I got my hospital bill, I saw that I had been charged $150 for "gait training on crutches."  I did what all insured Americans do:  I forwarded the bill to my insurance company.  Why should I care?  I wasn’t paying for it.

One of the problems with American health care, as David Gratzer notes in "The Cure," is precisely a payment system that takes the patient out of the equation.  In the early 1960s, the average American paid out of pocket one of every two dollars that he spent on health care; today the figure is one dollar in seven.  The inevitable effect is hugely wasteful spending (and inflated hospital bills like mine).  In fact, per-patient costs have gone up almost exactly in inverse proportion to the share of spending borne by the consumer.

Dr. Gratzer cites a remarkable Rand Corp. study that tracked health-care spending by 2,000 families over eight years.  The families who got free health care spent 40% more than the families with cost-sharing arrangements.  And yet the health outcomes for the two groups were the same.  The lesson:  Market-based health insurance systems, such as health savings accounts, cut out inefficiencies and lower costs without compromising quality.

. . .

. . . :   America is clearly at a crossroads in medical care.  Within the next decade we will get either some version of Hillary-care or more free-market medicine, starting with universally available health savings accounts.  Let’s hope that our nation’s policy makers read "The Cure" before they decide.  They will learn that the government route flattens costs only by holding back the pace of technology, artificially controlling its price and rationing its use.  That is not a prescription for better health.

 

For the full review, see: 

STEPHEN MOORE.  "BOOKS; The Market and Its Medicine."  The Wall Street Journal  (Tues.,  By  December 5, 2006; Page D6. 

 

The reference to the book under review, is: 

Dr. David Gratzer.  The Cure: How Capitalism Can Save American Health Care.  Encounter Books, 2006.  (233 pages, $25.94)

 

Standard Heart Therapies Do Little to Fight “Vulnerable” Plaque

Most people have of a clear image of how atherosclerosis, popularly known as hardening of the arteries, causes a heart attack — fatty deposits called plaque build up in a coronary artery until the day the blood flow that sustains the heart is blocked.

If only they were right.  In reality, severe coronary artery blockages almost always cause chest pain known as angina and other symptoms as they form.  But among those who suffer heart attacks, half of the men and two-thirds of the women report never experiencing a warning symptom.  And autopsies of such victims frequently show blood clots jammed into arteries that have been only modestly narrowed.

Standard atherosclerosis therapies include bypass surgery to route blood around blockages, angioplasty and stenting to clear blockages from inside the artery, and drugs like statins that reduce cholesterol levels to slow the formation of plaque.  But they have not been enough to prevent 200,000 to 500,000 American deaths annually from what doctors refer to as coronary artery disease.

As a result, many researchers have turned their attention from atherosclerosis in general to the tendency of some patients to develop a form of plaque prone to inflammation and rupture, which can spill a stew of cells into the bloodstream that can incite rapid clotting.  Such plaques have been called ”vulnerable” plaque. 

 

For the full story, see:

BARNABY J. FEDER.  "In Quest to Improve Heart Therapies, Plaque Gets a Fresh Look."  The New York Times  (Mon., November 27, 2006):  C1 & C3.

 

Doctors Earn More When They Rush Colonoscopies

ColonoscopyGraph.gif   Source of graph:  online version of the NYT article cited below.

 

For years, patients and many doctors assumed that a colonoscopy was a colonoscopy.  Patients who had one seldom questioned how well it was done.  The expectation was that the doctor conducting the exam would find and cut out any polyps, which are the source of most colon cancer.

But a new study, published today in The New England Journal of Medicine, provides a graphic illustration of how wrong that assumption can be, gastroenterologists say.  The study, of 12 highly experienced board-certified gastroenterologists in private practice, found some were 10 times better than others at finding adenomas, the polyps that can turn into cancer.

One factor distinguishing the physicians who found many adenomas from those who found few was the amount of time spent examining the colon, according to the study, in which the gastroenterologists kept track of the time for each exam and how many polyps they found.

They discovered that those who slowed down and took their time found more polyps.

. . .

The Rockford study was preceded by other signs that colonoscopies are by no means foolproof.   But as problems have been pointed out, they have all too often been met with disbelief among doctors, Dr. Rex said.

The first indication that colonoscopies were not as effective as widely believed came with two studies, one in 1991 and a larger one, in 1997, in which patients had two colonoscopies on the same day.  Those studies showed that doctors were missing 15 to 27 percent of adenomas, including 6 percent of large adenomas.

Then, in the last few years, two studies of so-called virtual colonoscopies, which use a CT scan to view the colon, found that the rate of overlooked adenomas in traditional colonoscopies was even higher.  Patients in those studies had traditional and virtual colonoscopy on the same day.   Traditional colonoscopies missed 12 to 17 percent of the large adenomas detected in the virtual colonoscopies.  But many doctors dismissed those findings, saying — if they believed them at all — that they applied to other doctors, not to themselves, Dr. Rex said.

Dr. Schoen, for one, said he was a believer.  The conclusions of the adenoma detection studies were reinforced, he said, by studies finding that colonoscopies missed not just polyps but actual cancers.

That finding emerged from studies testing ideas about how to prevent polyps, like taking beta carotene or calcium pills or sticking to a low fat, high-fiber diet.

The patients in all the studies had at least one adenoma detected on colonoscopy but did not have cancer.  They developed cancer in the next few years, however, at the same rate as would be expected in the general population without screening.

. . .

The study by the group in Rockford suggests a way to improve colonoscopy:  by slowing down.  “If you rush things, you miss things,” Dr. Schoen said.

That happens in part because reimbursement rates for colonoscopies have fallen in recent years, and some doctors are doing the exams faster than ever, Dr. Schoen and others say.

“I have heard of people who do it in 30 seconds,” Dr. Schoen said.  “Whoosh, and it’s out.”

 

For the full story, see: 

GINA KOLATA.  "Study Questions Colonoscopy Effectiveness."  The New York Times  (Thurs., December 14, 2006):  A23.

 

 

Feynman: Nothing in Biology Requires Us to Die

   Source of book image: http://stochastix.wordpress.com/files/2006/08/the-pleasure-of-finding-things-out.gif

 

(p. 100)  It is one of the most remarkable things that in all of the biological sciences there is no clue as to the necessity of death.  If you say we want to make perpetual motion, we have discovered enough laws as we studied physics to see that it is either absolutely impossible or else the laws are wrong.  But there is nothing in biology yet found that indicates the inevitability of death.  This suggests to me that it is not at all inevitable, and that it is only a matter of time before the biologists discover what it is that is causing us the trouble and that that terrible universal disease or temporariness of the human’s body will be cured.   

 

Source: 

Feynman, Richard P.  The Pleasure of Finding Things Out: The Best Short Works of Richard P. Feynman.  New York:  Perseus Books, 1999.

 

Incentives Influence Doctors’ Choice of Prostate Therapy


(p. A1)  The nearly 240,000 men in the United States who will learn they have prostate cancer this year have one more thing to worry about:  Are their doctors making treatment decisions on the basis of money as much as medicine?

Among several widely used treatments for prostate cancer, one stands out for its profit potential.  The approach, a radiation therapy known as I.M.R.T., can mean reimbursement of $47,000 or more a patient.

That is many times the fees that urologists make on other accepted treatments for the disease, which include surgery and radioactive seed implants.  And it may help explain why urologists have started buying multimillion-dollar I.M.R.T. equipment and software, and why many more are investigating it as a way to increase their incomes.

. . .

(p. C7)  The one certainty about I.M.R.T. is that for doctors who own the technology, it can be much more lucrative than alternative treatments.  Medicare and other insurers typically pay urologists only $2,000 or less for performing surgery to remove the prostate or for implanting radioactive seeds.  The insurers say the much higher I.M.R.T. payments, which in some cases exceed $50,000, are based on the technology’s cost.  

 

For the full story, see: 

STEPHANIE SAUL.  "Profit and Questions as Doctors Offer Prostate Cancer Therapy."  The New York Times  (Fri., December 1, 2006):  A1 & C7.


Ignoring the Elephant in the Stent Hearing Room

Stent.jpg   A stent.  Source of photo:  online version of the 3/27/07 NYT article cited below.

 

(p. C1)  See, there was an elephant in the hearing room last week that went almost entirely ignored.  One study after another has found that whether or not a stent is coated, angioplasty — the process of opening up an artery before a stent is inserted — and stenting do not actually reduce the risk of heart attack or extend life span for most patients.

“There’s a much more liberal use of angioplasty and stenting than there needs to be,” Dr. Eric J. Topol, a member of the panel, told me last week.

Dr. Calvin L. Weisberger, the top cardiologist at Kaiser Permanente, said, “A large pool of angioplasties and bypass surgeries are being done without scientific evidence.”

. . .

Angioplasty dates back to the 1970s, and stents became a part of the process in the 1990s.  Doctors have assumed, sensibly enough, that blocked arteries caused heart attacks by preventing blood from reaching the heart.  Opening those ar-(p. C14)teries would keep the blood flowing.

But when researchers tried to prove the theory, they kept coming up empty.  The reason seems to be that heart attacks aren’t generally caused by a big buildup of plaque that blocks an artery.  They occur instead when a small piece of plaque bursts, causing a cascade that can suddenly clog an open artery.  The best way to reduce the risk of that is through cholesterol-lowering drugs, diet and exercise, rather than by opening up a couple of clogged arteries.

Yet stent use keeps growing.  “Cardiologists just believe that if you open up a blockage, you’re going to help someone,” said Dr. Judith S. Hochman, director of the cardiovascular clinical research center at New York University.  “And they make money from these procedures.”

Ah, yes — money.  Medicare typically pays $12,000 to $15,000 for a coated stent procedure, according to Thomas Gunderson of Piper Jaffray.  Angioplasty and stenting have accounted for almost 10 percent of the increase in Medicare spending since the mid-1990s, Jonathan S. Skinner, a Dartmouth economist, estimates.

 

For the full commentary, see: 

DAVID LEONHARDT.  "ECONOMIX; What Money Doesn’t Buy in Health Care."  The New York Times  (Weds., December 13, 2006 ):  C1 & C14.

 

Added on 3/22/08: For a later, related story, see: 

BARNABY J. FEDER.  "In Trial, Drugs Equal Benefits of Artery Stents."  The New York Times  (Tues., March 27, 2007):  A1 & A13.

 

Your Tax Dollars at Work: Government Protecting Us from Bling-Bling

DentalGrill.jpg  A dental grill, one form of the hip-hop jewelry sometimes called "bling-bling."  Source of image:  http://www.thesmokinggun.com/archive/0410062teeth1.html

 

If all you want for Christmas is to gild your front teeth, you may have to buy the bling-bling somewhere other than the Gold Plaza II kiosk at Crossroads Mall.

That’s because an employee of that shop, Bhavin Dalal, faces a felony charge of practicing dentistry without a license.  He’s accused of helping customers fit their teeth for glittering mouthpieces known as grills.

It’s the first such case in Nebraska involving the hot hip-hop fashion accessory.  And Dalal and his attorney, James Martin Davis, plan to fight it tooth and nail.

Dalal entered a not guilty plea Friday in Douglas County Court.  Davis blasted the Nebraska Health and Human Services System for its investigation of Dalal and the charge that resulted.

"It’s overzealousness on the part of a bunch of bureaucrats" who don’t want people to wear grills, Davis said.

 

For the full story, see:

CHRISTOPHER BURBACH.  "Dental Grill Seller Feels State Law’s Bite."  Omaha World-Herald  (Saturday, December 2, 2006):  1A & 2A. 

(Note:  the slightly different online title for the article is:  "State puts bite on grill seller")

 

 

Distinguished Physician: “I Hate Hospitals”

Dr. James Armitage is a leading lymphoma physician.  His honesty in the passage below, is refreshing.  But instead of it being viewed as a personality quirk of the physician, it should be viewed as one more reason to reform how our medical system is organized.

 

"I hate hospitals. I like working in them; I just don’t like being a patient."

 

Armitage, as quoted in:

MICHAEL KELLY.  "Michael Kelly: Doc lacks patience for being a patient."  Omaha World-Herald  (Thursday November 16, 2006):    1B. 

FDA Hurdles Block Widespread Use of Baby-Saving Drug

(p. A1)  BOSTON — Like thousands of children in the U.S., Maggie Leaver has short bowel syndrome.  These children can’t absorb enough nutrients from food, and some need intravenous feedings to survive.

A baby’s digestive system can adapt over time, but that may take months or years.  Many of these babies can’t wait.  For reasons not fully understood, children put on intravenous nutrition may suffer liver damage.  Some require liver and small bowel transplants, risky procedures that don’t always work.  Others die waiting for a transplant.

In July, in a paper in the scientific journal Pediatrics, researchers at Children’s Hospital Boston reported on a small study that suggested a promising treatment.  They found that by switching from the standard intravenous formula to a different kind — called Omegaven — babies weren’t progressing to liver failure.  Omegaven, used in Europe for adults, isn’t approved in the U.S. and is considered experimental treatment.

"The kids aren’t dying anymore," says Mark Puder, a pediatric surgeon who was lead investigator on the study.  "We think we have a good treatment."

But Dr. Puder’s effort to get Omegaven widely used in babies has put him in an unusual conflict with the German company that developed the drug.  Fresenius Kabi AG, which makes Omegaven, says it isn’t interested in bringing the drug to the U.S. market.  The company says it doesn’t agree that Omegaven is the best drug for these babies and has a new product that it believes is better.

In 28 of 29 babies treated with Omegaven so far at Children’s Hospital, Dr. Puder says they were able to stop further liver damage — and damage that children already incurred seemed to improve.  Some babies who were switched to Omegaven rebounded enough that they were taken off the waiting list for an organ transplant.  At one point, Maggie Leaver’s condition deteriorated so much that her surgeon thought she was going to die.  Now the 18-month-old is thriving at home in Hingham, Mass.

. . .

Mr. Ducker says the company’s new product, called SMOFlipid, "presents a better option for pediatric feeding."  The company believes the new product does contain all the essential fatty acids babies need and can be used on its own.

Fresenius Kabi says it doesn’t want to invest the resources required to test both products for approval by the U.S. Food and Drug Administration.  It hopes to eventually sell the new product in the U.S., Mr. Ducker says, although no timetable has been set and no trials are under way.

. . .

Because Omegaven is considered experimental in the U.S., if hospitals want to try it, they have to ask permission from the FDA for each individual patient.  The FDA has regulations that enable doctors to use experimental drugs in certain (p. A15) emergency situations.

If hospitals obtain the required permissions, they must then find a way to buy the drug on their own, since insurers typically won’t cover Omegaven because it’s experimental.  The cost can run from $50 to $100 a day per patient.  At Children’s Hospital Boston, the surgical department has already spent close to $100,000 to buy Omegaven for babies.

. . .

Dr. Mooney says he wrestled almost from the beginning about whether to put Maggie on Omegaven. He knew about Dr. Puder’s results, which he calls "amazingly great," but the number of children treated was still small.  He worried about adverse effects.  "It is so easy to get caught in the hype of new things," Dr. Mooney says.  Maggie was already fragile.  What if he put her on Omegaven, he says, "and there was a horrible side effect that could tip her over the edge?"

But when standard therapies failed, he felt "there was nothing else to do."  Given that the treatment is experimental, Dr. Mooney says he believes it was right to wait.  But he also feels Omegaven has made a difference.  "Five years ago, every single one of the kids taking Omegaven would be dead by now, Maggie included," he says.

 

For the full story, see:

MARCUS, AMY DOCKSER.  "Different Rx; A Doctor’s Push For Drug Pits Him Against Its Maker; Dr. Puder Thinks Omegaven Is Best Option for Sick Babies; Company Prefers New Product Turnaround for Little Maggie."  Wall Street Journal  (Mon., November 13, 2006):  A1 & A15.