CodeBlueBlog

WE NEED HIGHER DRUG PRICES

You must learn about Monoclonal Antibodies (MAbs).

These new miracle drugs are synthetically manufactured antibodies (like those produced by your own immune system to fight foreign invaders), targeted to one specific site on a cell found to be important in a disease process.

In the past few years we have seen the introduction of MAbs like Kineret, Remicade, and Enbrel to treat rheumatoid arthritis (RA); Erbitux and Avastin for Colon Cancer; and, Rituxan for nonHodgkin’s lymphoma (NHL).

Compared to earlier drug regimens, these MAb therapies are a miracle. RA has been slowed or stopped in its tracks for millions of sufferers. Unresponsive colon cancer has been put into remission for many patients previously considered incurable; and, many NHL patients-- historically those lymphoma cases with a worse prognosis – are now living longer and are even disease free.

In treatment, millions of these safe, nontoxic, easy-to-administer targeted antibodies are injected into a patient, producing mass extermination of the destructive, disease-causing cells.

In cancer, MAbs replace or decrease the need for classic chemotherapy drugs that are basically poisons administered to patients in an attempt to kill cancer cells faster than they kill the patient (not always successfully).

In inflammatory diseases these antibodies deactivate specific components of the inflammatory cascade, thus blunting the damage done by inflammatory cells.

MAbs are very target-specific. So you need to develop many, maybe hundreds, of these drugs to fight individual components of different diseases. We will eventually need several, if not many, MAbs for each disease.

Most research oncologists believe that the final corner in cancer treatment has been turned and that we are on the verge of curing many cancers (listen to this NPR audio link) by developing MORE MAbs.

MAb drugs are being developed in the United States. Why is that? Because price controls on the pharmaceutical industry in other countries (LIKE CANADA) is killing R&D and driving drug development research into the ground.

Since 1990, the U.S. has become the largest drug R&D spender (24 billion Euros to 17 billion in all of Europe); and U.S. companies now sell the majority of the most used pharmaceuticals (33 out of 50, in 1998).

These figures are somewhat deceiving because many European pharmaceutical firms have actually been chased from their homelands, by price controls, taking up residence in the U.S. (e.g. Glaxo and Novartis), where it is still profitable to produce important medications that make a HUGE difference in EVERYONE'S life.

We are on the brink of a new era of disease control and eradication using MAbs. It is also an era when we are most upset about the costs of pharmaceuticals. Politicians, vying for an issue that they feel the general public cannot grasp, except for sound-bites, are beating the drums against drug companies, using foreign price control schemes as an example of how the U.S. citizens are getting ripped off.

Don’t believe it on face value. Learn about MAb's. If you do, you'll want more MAbs developed and brought to market. Thousands more. No matter WHAT the cost. You'll agree with me:

We need HIGHER drug prices.

EXPATIATIONS

Bradford DeLong, Professor of Economics at The University of California at Berkeley, discusses the CodeBlueBlog on his website, a site I recommend, and I responded to his column with the following letter in the "comments" section following his piece "A Health Care Weblog":

I was there in the early '90's when the market did what markets do, i.e., jumped ahead of Hillary (whose intentions were outlined early in the presidency) and anticipated drastic reimbursement reductions, or worse. This was exacerbated by the word out of Washington (and Jackson Hole -- lead by Uwe Rhinehardt) that "managed competition" effected through HMO's would be the predominant reimbursement strategy (read mandated). If you look back you will see that HMO enrollment expanded dramatically, and private insurers began cycling their prices higher and stratifying their policies to make HMO-like options the most appealing financially. This phenomenon is verified by the meteoric rise in the market capitalizations of HMO’s during this period. Once begun, this process has continued, as it would, until its maximum economic benefit began to be eroded by competition and negative market and provider/patient feedback. Notice there are select markets allowed to operate openly, in some ways, within the current health care system; but, each market has its own set of rules which is one reason why the health care market, as a whole, is so inefficient.

I strongly object to the unfair, contextually predatory characterization of me as having ill will towards “freeloaders” (foreigners, illegal aliens, migrant workers et al) of which I am accused. Here is what I wrote in my CodeBlueBlog concerning the ER waiting room:

If you walk through the waiting room, where patients sit for 5 and 6 hours to see a doctor for these mundane ailments, you’ll see a population predominantly composed of the young, the poor, immigrants, illegal aliens, migrant workers, and a smattering of the middle class. Although this population is disparate, it has a common bond drawing it the ER at all hours, for any physical complaint: no health care insurance.

My adumbration of the typical emergency room population was based on two data sets. First, the CBO report of 1/24/2004 that characterizes the uninsured population as: 39% under the age of 24; 51% as other than white, non-Hispanic; 91% without a college degree; and, by the way, 86% with health status ranging from good to excellent.

Second, my own 24/7/365 experience and observations of over 15 years servicing a community hospital ER that logs 100,000 visits a year. My assessment that migrant workers and illegal aliens are also heavily weighted in the ER population is certainly skewed by my geographical location in South Florida; however, the CBO and all other federal reporting groups on health care admit freely that they have no way to accurately gauge the number of these visits themselves, due to the vagaries of locating and studying this transient and sometimes elusive population.

One of my Blog objectives is to illustrate where health care dollars go. The Emergency Medical Treatment and Labor Act (EMTLA) of 1986 that obligates emergency rooms to assess and treat every person who walks through the doors is an example of the unanticipated consequences principle, and, without passing judgment on the populations affected, it needs to be addressed in any serious discussion of health care spending.

In my practice I, as with most other physicians I know, have yearly written off 40% of anticipated collections (without a tax deduction) for those who cannot – for whatever reason – afford the bill. This will surely evoke the perfunctory snide replies about “rich doctors,” but it is a fact, and it represents only a part of the countless hours every good physician I know spends in labor, efforts, and liability risk taking care of all comers.

Responding ahead to those who will snipe, let me say that if you look at the network of federal and state regulations governing physicians and the manner of reimbursement (fixed and regulated basically by the federal government’s Medicare scale), we are de facto public utilities. With that in mind, try asking Adephia or ConEd to write off the portion of your bill you cannot afford to pay. You’ll soon be using a flashlight to watch history unfold through your living room window.

Hillary Has No Clothes

In case you missed it, Hillary Clinton had a front page story in The New York Times Sunday Magazine, April 18, 2004, titled "Now Can We Talk About Health Care?"

There's a lot to say about the article. Almost too much. It's hard to know where to begin. With the title? As if she were right all along and ahead of her time in 1994 and it's just taken us laggards 10 years to catch up to her? Should I address the threadbare arguments and long disproved statistics? The Magaziner/Clinton arrogance in imagining they could fabricate a secret comprehensive top-down reform that would completely change the U.S. health care system which represents 14% of the economy?

While chewing over where to begin, I had the sudden sensation that something was stuck between my teeth. A persistent sinewy remnant refused maceration until suddenly I spit it out. AHA! I recognize this! The repetitive arguments. The communalistic rhetoric. The sloppy lacing together of disparate strains of logic. The medical non sequiturs. I know where this comes from!

And then I had it. That old feeling of insight and revelation. I had a Clinton moment only now with Hillary: SHE'S JIVING US! Covering up for her intellectual inadequacies with tautology and rhetoric and busted nuance. And why?

Because Hillary is underpowered. Low voltage. She's a lead battery in a Nickel Cadmium world. Hillary doesn't quite understand the health care system and has no real life experience in the field to compensate. She's an empty policy vessel rattling in the vacant room of her arrogance. But more importantly:

Hillary is not a capable enough intellect for this anointed task.

Rereading Hillary's Times cover story, I realized the truth of this insight. Her intelligence, blown out of proportion by an adoring press, has never been questioned; but, if you look closely, her logic and ideas and conclusions come together more like a college Sociology project than an executive policy proposal.

Just try to harvest some policy meat off this bone she throws us:

Twenty-first-century problems, like genetic mapping, an aging population and globalization, are combining with old problems like skyrocketing costs and skyrocketing numbers of uninsured, to overwhelm the 20th-century system we have inherited.

And here is a lesson in alliteration producing conclusions, for all you aspiring science writers:

As a whole, our ailing health care system is plagued with underuse, overuse and misuse. In a fundamental way, we pay far more for less than citizens in other advanced economies get.

Hillary also has ideas about the etiology and pathophysiology of diseases -- which she is not afraid to blurt out without preface or footnote; then, satisfied with her comprehensive grasp of the processes she goes on to offer a solution and a plan. All in one sentence!

If asthma and other pulmonary disorders are the main drivers of increased health spending, that argues strongly that we should rethink how social and environmental factors impact our collective health.

Oh, and in case we forgot, Hillary has a recurring theme, to be applied like a chiropractic adjustment to the manifold ills she intends to master and reform:

It will, as I have been known to say, take the whole village to finance an affordable and accountable health system.

Oh yeah, right. I almost forgot. It takes a village. HOW COULD WE HAVE BEEN SO STUPID?

No more. There is a LOT more of this, but, it's just too easy. Especially now that I know the answer is a riddle wrapped in an enigma: Hillary is the little kid in the back of the class with a finger up her nose.

Don't take my word for it though. There are other better-known, more influential people who are in on this dirty little secret. Like J. Bradford DeLong, professor of economics at Berkeley and a veteran of the Clinton administration. Delong was on Hillary’s health care reform taskforce in 1993-94. Here's what he had to say to the National Review:

“My two cents' worth--and I think it is the two cents' worth of everybody who worked for the Clinton Administration health care reform effort of 1993-1994--is that Hillary Rodham Clinton needs to be kept very far away from the White House for the rest of her life. Heading up health-care reform was the only major administrative job she has ever tried to do. And she was a complete flop at it. She had neither the grasp of policy substance, the managerial skills, nor the political smarts to do the job she was then given. And she wasn't smart enough to realize that she was in over her head and had to get out of the Health Care Czar role quickly."

REPAIR YOUR AORTA IN EUROPE?

Europeans...need minimally invasive repair of your abdominal aortic aneurysm (AAA)? ...don't hold your breath

From the Heritage Foundation:

A recent study shows that while over 50 percent of patients in the United States receive the latest, most effective pharmaceuticals for arthritis, they are available to only 15 percent of patients in Germany and the United Kingdom. The same trend is revealed with regard to cardiovascular medicine. In Italy and Belgium, the threshold condition for receiving the most innovative and effective therapy is having a cholesterol level of about 290 as well as proof of a family history of heart trouble, even though established medical opinion holds that a cholesterol level of 190 is the appropriate threshold for treatment.

New medications are a critical component of health care, yet patients in many European Union countries have to wait years before they become available. In most European countries, pharmaceutical companies must not only get approval from the national departments of health, but must also obtain pricing and reimbursement approvals before they can introduce a new drug into the market. Because this can result in delays averaging 18 months, many breakthrough medications are simply unavailable for extended periods of time. A study conducted by Europe Economics revealed that, from 1995 to 1997, more than half of the new medications surveyed were unavailable through pharmacies in Portugal, Italy, and Greece. More than one-third were unavailable in Belgium, France, and the Netherlands.

The delays serve an economic purpose: Because the new products are more expensive than the old ones, by delaying access to the new drugs, the governments save money. Though European politicians try to save money by cutting services across the health care sector, pharmaceuticals are frequently targeted because cutting drug expenditures is relatively easy.

REPAIRING YOUR AORTA WITHOUT SURGERY

There is no crisis in health care. There is an ongoing crisis in cost and delivery of medical services.

The aorta is the body's main arterial trunk. It traces a path from your heart upwards to the upper chest (= thoracic aorta), then it curves backwards and dips down to descend through the back of your chest, passing through the diaphragm, into the abdomen (= abdominal aorta). Once in the abdomen, the aorta passes to the level of your pelvis (just below umbilicus) breaking into two main trunks, the iliac arteries. These arteries then go on--one to each leg-- to supply blood to your legs.

The thoracic portion of the aorta has its own set of problems -- like the dissecting aneurysm that killed John Ritter -- which I will discuss another time.

The abdominal aorta can age, gaining calcium in its wall and expanding abnormally. If this part of the aorta becomes larger than 3.5 cm diameter, it is then called an abdominal aortic aneurysm (abbreviated:AAA--See illustration above). In general, this phenomenon begins to become a problem in your seventies. Smoking, diabetes, and high blood pressure are the major culprits.

These aneurysms can progress and grow slowly. After they reach 5cm or so, you are in danger of dying suddenly from a burst aorta (= rupture of an abdominal aortic aneurysm). Obviously, if the aorta bursts it will not take long to pump your entire blood supply into your abdominal compartment.

In the past IF detected, these aneurysms needed an open surgical repair. This operation has a relatively high mortality rate. After all, the aorta is deep in you abdominal compartment and is already fragile. One can die from the length and difficult machinations of the surgery; or, one can die if the aneurysm breaks open during surgery.

There has been, for the past 4 or 5 years, an FDA-approved, minimally invasive way to repair AAA's, once detected.

The aneurysms are detected by an abdominal ultrasound, and everyone over 70 should be screened with this procedure -- sooner if you smoke, have high blood pressure or diabetes, or you are a first-order relation to someone who had an AAA.

Once detected, the aneurysm can most often be repaired using a stent graft. This procedure is done without general anesthesia, in the radiology department, usually by an "interventional radiologist," and/or a vascular surgeon.

The procedure involves placement of a needle into the pulsing blood vessel of your groin followed by passage of a thin plastic tube (a catheter) carrying a Chinese finger trap-like metallic stent.

The stent is deployed across the aneurysm by inflating an underlying balloon.

You may spend two or three nights in the hospital, but, overall, this represents a remarkable and well-proven alternative to surgery.

Recent articles confirm the utility of this procedure.

Oh, by the way, you will have a REAL hard time getting a screening ultrasound OR a stent graft repair in Canada.

CRISIS? WHAT CRISIS?

There is no crisis in health care. There is an ongoing crisis is cost and delivery of medical services.

Unfortunately, the misapplication of this "crisis" buzzword is a method of camouflage and enables the liberals to push their agenda for national health insurance -- which will severely affect health care itself by destroying initiative, vitiating quality, and undermining research.

As part of the proof of this thesis, I will post medical innovations and the newest in medical research -- most of which becomes immediately and diffusely available throughout the U.S. for you -- the patient.

So this site will also be a place to go to get a look at what we've got -- and what you might need...soon. Let's hope it is still there for you when YOU are one of the 3-5% of the population who, at any given time, needs the best, available anywhere, fast.

OH SURE, UNINSURED

Health Care Crisis activists like to point to the "41 million" uninsured people out there as a proof to their case. Turns out that half that number of people are only temporarily uninsured, and get insurance inside a year. That's what the CBO shows in the accompanying chart (click to enlarge).

Tendentious statistics litter the health care crisis debate.

EMERGENCY

If you have worked in a hospital, as I have, over the past 15-20 years, you have noticed a striking increase in emergency room visits.

And we aren't talking about people with crushed bones and severed limbs. No. If your emergency room is anything like mine, it is filled to bursting, 24 hours a day with patients complaining of runny noses, stomach cramps, headaches, bruises, nearsightedness...the quotidian medical affairs that at one time were attended to by the family doctor.

If you walk through the waiting room, where patients sit for 5 and 6 hours to see a doctor for these mundane ailments, you'll see a population predominently composed of the young, the poor, immigrants, illegal aliens, migrant workers, and a smattering of the middle class.

Although this population is disparate, it has a common bond drawing it to the ER at all hours, for any physical complaint: no health care insurance.

The Emergency Medical Treatment and Labor Act of 1986 (EMTLA) prohibits hospitals from turning away patients who arrive with a complaint. Originally intended to prevent patient "dumping" (where a private hospital buys a taxi ride to a public hospital for an uninsured patient), the omnipresence of liability lawyers has forced expansion of the Act's intent to cover everyone (including noncitizens and illegal aliens) who walks through the door, no matter what the complaint.

Because people know a good thing when they see it, smart consumers who are pinched for cash drop their health insurance because now they are covered. Covered for cuts and scrapes, for pregnancy, for cancer -- you name it. It can be a $15.00 problem or a million dollar problem.

In addition, foreigners, illegal aliens and migrant workers pass the word around their community and in their home countries: free care in the U.S. at the hospitals. All you have to do is wait in the ER! I have seen many patients who fly to Florida from the Carribean and walk into the ER to get an obstetrical ultrasound, or be casted, or just for a check-up. A flight from the Dominican Republic is cheap compared to an MRI of the brain to follow-up a lesion.

So when politicians claim that there is a HEALTH CARE CRISIS, and then adduce the growing number of uninsured as proof of this crisis -- toss it right back at 'em. Ask them to show you a graph showing the percentage of uninsured per year before 1986, and after 1986. Ask them about EMTLA.

The cost of all this free care? $22 billion last year, and going nowhere but up.

MAMMACTIVISTS KILLING THE MAMMOGRAM

There is a reality radiologists have faced for several years: Mammography, performed and interpreted by experts, can not survive. It is a technology besieged by conglomerate forces that will drive it into extinction, with many other important procedures and technologies to follow. Radiologists see four major reasons for this destructive phenomenon: HMO’s, government regulations, special interest groups ( THE MAMMACTIVISTS) and trial lawyers.

President Clinton’s overblown health care crisis and ill-conceived reform project of the early ‘90’s catalyzed the conversion of fee-based private health insurance into the HMO chimera we now face. Positioned as middlemen – with profits their sole motivation-- HMO’s are driving down reimbursements to the point where it is no longer economically possible for reputable physicians to do mammography and balance the books.

MAMMACTIVISTS -- special interest groups fanatically focused on breast cancer -- have railroaded thousands of pages of Federal regulations and compliance requisites through Congress affecting every aspect of mammography. These disease-specific laws are enforced by regular inspections and audits; this, despite the fact that mammography is one of the most straightforward procedures in radiology and is little more complex than a chest X-ray. No such regulations exist for neurosurgery, heart transplant, treatment of pediatric malignancy, or any other medical procedure. These laws have increased operating costs of women’s centers significantly, yet neither the HMO’s nor the government recognizes this exigency with increased compensation. Micromanaging individual diseases with laws leads, at best, to inefficiency and inflated costs.

A mammogram is an inherently limited study with relatively low sensitivity and specificity. Unfortunately, the public does not understand these limitations because the exam has been oversold as a diagnostic modality (We are told this is for the public’s “own good”). As a result, people have a difficult time understanding why breast abnormalities are “missed” or “misinterpreted” during routine mammography. Personal injury lawyers ruthlessly take advantage of this dilemma by scavenging mammograms involved in breast cancer cases. They prey on this ignorance by holding radiologists to impossible standards bolstered with retrospective analyses of mammograms done by venal physicians in their stable of “experts”. As a result, mammography is the single highest liability risk for radiologists (and the second highest risk in all of medicine). For a $15 reading fee, radiologists can face multi-million dollar lawsuits.

In their practices, the few radiologists left who interpret mammograms are seriously considering abandoning the procedure. Some argue that radiologists have an ethical obligation to do the procedure. This may be so, but radiologists cannot be the sole bearers of this obligation. If the businessmen, the politicians, the lobbyists, and the lawyers cannot share in this ethical challenge then radiologists will increasingly refuse to shoulder the burden alone.

More On Medicare Slotists

Lots of feedback, mostly indicating that people just don't get it...In a nutshell:

POINT ONE: Health care crisis = cost crisis...Medicare is the biggest cost in the system

Currently, there is a severe crisis in health care costs. Drastic, pernicious measures being used right now to reverse this problem include:

-curbing research
-curbing reimbursements to hospitals
-decreasing subspecialty physician positions
-decreaing approval rate of new procedures and diagnostics
-decreasing physician reimbursement
-denying reimbursement for infrequuent or expensive procedures and drugs

Medicare entitlements will cost $3 trillion in the next ten years. The baby boomer generation is predicted to bankrupt the system during that time.

With such a crisis, and such dire predictions, we cannot afford to allow wanton misuse of discretionary income by those receiving federal (taxpayer) entitlement dollars.

POINT TWO: Slot Machines Are Elegant Money Shredders

Like evaluating coin flips, one must look at a statistically significant sample before judging outcome probabilities. Viewed in this way, slots must always produce losses because they are rigged. Legally rigged, with a built-in "hold" for the house. Therefore, no matter what result any one slot-user achieves, when viewed as a whole, slot users are losers. Massive losers.

If you consider the entire population of people who use slot machines as ONE person, then THAT person loses $40 billion every year. That number can never improve. There can never be a year when slotists are in the black. Never.

No matter what the jackpots paid; no matter what any individual wins; the entire mass of people have $40 billion less to spend at the end of the year. And that number will grow as slots continue to proliferate around the country.

A significant percentage of these people -- who are shredding $40 billion a year -- are receiving government entitlements, most onerously, Medicare.

POINT THREE: Slotting is not Gambling

Using slot machines IS NOT gambling. Gambling, by the dictionary, is: To bet on an uncertain outcome, as of a contest.

The outcome, in slots, is fixed by a computer chip. It is not uncertain.

One does not stand in front of the machine, add up the chances of success, weigh this against the predicted failure rate, and then decide to take a fling. There are no calculations to be done. No assessment of the odds. No counting cards. There is no skill. No thinking. ACTUALLY, THERE IS NO RISK because risk is the possibility of suffering harm... and in slots you are guaranteed to suffer harm. There is no risk, only certitude.

POINT FOUR: Medicare Slottists Shred Billions of Dollars Every Year, Instead of Helping Out With Their Health Care Costs. This is wrong and it must be changed

Seniors do not have a right to shred dollars under the morally vapid rationale that shredding dollars represents discretionary expenditure on entertainment.

First, one is morally compelled to refute the notion that shredding taxpayer dollars -- no matter how elegantly--is entertainment.

Second, there is ample precedent for government to influence the behavior and habits of those to whom it extends its largesse, under the threat of loss of the entitlement. Campaigns for integration, DUI laws and anti-smoking laws were all promulgated in this way. In addition:

1. Food stamps cannot be used to purchase liquor or cigarettes

2. Restaurant owners with liquor licenses are leveraged to obey any number of government dictums about how they run their businesses, who they hire, and who they allow into their establishments, under threat of license loss

3. Universities are forced to follow Title IX regulations and affirmative action mandates or risk losing federal subsidies, loans, and grants

4. Even states are muscled to follow federal party line with any number of policies or risk losing federal dollars such as highway construction subsidies

Likewise, the federal government needs to act to negatively influence Medicare Slotists from pursuing this wanton waste of taxpayer money.

Some correspondents suggest to me that Medicare Slotists are literally using their own cash over which we ought not have moral or legal control.

My response is that we must begin to means test Medicare recipients; i.e., ask them to list their assets, and then reduce their Medicare reimbursements according to a formula that indicates what they can reasonably afford out of pocket. MEANWHILE we educate people hard and clear on just what this obsessive behavior of slotting is all about...THEN if Medicare Slotists still want to shred their discretionary dollars, fine.

But not until then.

PROPOSALS:

MEANS-TEST MEDICARE RECIPIENTS

TAX SLOT MACHINES 50% -- DIRECTLY TO MEDICARE

INITIATE CLASS ACTION SUITS AGAINST CASINOS AND GAME MACHINE COMPANIES