Friday, August 10, 2007
The theory goes like this: By practicing preventive medicine, doctors can keep many people from getting sick in the first place. Those who do end up with a chronic illness will be closely tracked so that fewer of them develop complications. These steps will result in less illness, which in turn will require less health care. With the savings, the country can then lower its medical bills or provide health insurance for the 40-odd million people who lack it — or maybe even both. . . .
The would-be reformers have hit on something important here. The current health care system doesn’t pay hospitals, doctors and nurses to keep people healthy; it pays for tests, surgeries and drugs. So Americans often get expensive invasive care of dubious medical benefit while missing out on sensible basic care. Millions of other people go without any care for chronic illnesses like heart disease and diabetes. If Medicare and private insurers paid for more preventive care, Americans would be healthier than they are today and live longer. . . .
No one really knows whether preventive medicine will save money in the long run, let alone free up the billions of dollars a year needed to help pay for universal health insurance. In fact, studies have shown that preventive care — be it cancer screening, smoking cessation or plain old checkups — usually ends up costing money. It makes people healthier, but it’s not free. . . .
This is a tough idea to swallow because better health really does seem as if it should lead to lower medical bills. Indeed, if it were somehow possible to wave a wand and turn people into thin nonsmokers who remembered to take their statins, this country’s health care expenses would fall.
But any effort to promote health has its own costs. Doctors and nurses need to spend time with patients to persuade them to change their behavior. (Ever tried to get someone to stop smoking or drinking?) For a new program to work, it has to reach people who are not being helped by whatever exists now — and who thus will be among the most difficult and expensive patients to treat. The program would also have to treat a whole lot of people who never would have gotten sick. . . .
The actual savings are also not as large as might at first seem. Even if you don’t develop diabetes, your lifetime medical costs won’t drop to zero. You might live longer and better and yet still ultimately run up almost as big a lifetime medical bill, because you’ll eventually have other problems. That would be an undeniably better outcome, but it wouldn’t produce a financial windfall for society.
Mr. Klein notes, in response, "This is all true. To be sure, in a perfect world, I could probably dream up a set of policy initiatives that, if broadly implemented and competently carried out, could reduce health spending off the bat. But the world continually disappoints with its stubborn lack of perfection. Instead, the more achievable goal is to move towards a universal system that's more cost-effective, which is, in fact, very much the same thing as saving money, and towards an integrated system that readies the ground for tougher cost control mechanisms down the road."
Firedoglake has an interesting post on some of the recent efforts to limit gifts to doctors by drug companies. The blog notes, however, that nothing was said about the practice of data mining or prescription tracking by pharmaceutical companies.
I have a doctor friend who writes a lot of prescriptions for Pfizer drugs. Pfizer knows that because they track it, and the perks they offer are based on that knowledge. They aren’t just throwing out bones randomly to doctors because they have nice offices, there’s a very specific perks-for-scripts relationship at work. My friend is hired with some frequency to give “lectures” to, say, five doctor colleagues (at several thousand dollars a pop) on behalf of the pharmaceutical company and their particular drug. Even my friend acknowledges that it’s quite the racket.
There are many other ways to get money into the pockets of reliably prolific prescription writers, but the fact is that at present every time a doctor puts pen to paper he/she knows that the pharmaceutical company is watching. Without that kind of Big Brother awareness, doctors might be more cognizant of their patients’ needs first and less likely to be influenced by self-interest. Cutting the supply line of information is a critical first step.
Thursday, August 9, 2007
BBCNews reports on an article in the August Issue of Annals of Plastic Surgery concerning research linking breast enhancement surgery and suicide. The Times article states,
Women who receive implants for breast enhancement are three times more likely to commit suicide, according to a new report that offered a sobering view of an increasingly popular surgery. Deaths related to mental disorders, including alcohol or drug dependence, also were three times higher among women who had the cosmetic procedure, researchers said. . . .
Though the study did not look at the reasons behind the suicides, senior author Joseph McLaughlin, a professor of medicine at the Vanderbilt University School of Medicine, said he believed that many had psychological problems before getting implants and that their conditions did not improve afterward.
Previous studies have shown that as many as 15% of plastic surgery patients have body dysmorphic disorder, a condition marked by severe distress over minor physical flaws. People with the disorder have a higher rate of suicidal thoughts and rarely improve after surgery. . . .
Controversy has long dogged the surgery. Last year, the Food and Drug Administration lifted a 14-year ban on silicone-filled implants after finding little evidence they were unsafe. But the agency required manufacturers to run 10-year studies of 10,000 women each to look for long-term consequences, including possible suicides.
The latest study analyzed data from 3,527 Swedish women who got implants between 1965 and 1993. Breast cancer patients who received reconstructive implants were not included. Scientists tracked the women for as long as 29 years after their implant surgeries and found the suicide risk increased over time. There was no higher risk in the first 10 years afterward, they said, but the risk was 4.5 times higher after 10 to 19 years and six times higher after 20 years.
David B. Sarwer, a University of Pennsylvania psychologist who wrote a commentary accompanying the report, said the results suggested that women experienced psychological improvement after surgery, but that it was not sustained. Researchers said the results may have limited applicability to women today because breast augmentation is more acceptable than it was 40 years ago.
McLaughlin said the study underscored the need for the psychological screening of women seeking breast enhancement. Allergan Inc. of Irvine, manufacturer of Inamed brand implants, "is a big advocate" of counseling beforehand, spokeswoman Caroline VanHove said. She said women should have realistic ideas of how the procedure would change their lives.
Thanks to Ann at Feministing for the link. Here are some further thoughts from Ann on the article,
Realizing this, some plastic surgeons are calling for more pre-augmentation mental-health screenings. (My question: Would they really tell a woman with severe depression that she couldn't have D-cups? Maybe. Maybe not.) Other surgeons don't seem concerned, saying that, because the research was conducted between 1965 and 1993, the situation today is much brighter for the silicone-boobed:
Researchers said the results may have limited applicability to women today because breast augmentation is more acceptable than it was 40 years ago.
Do they actually mean to suggest that the women in the study were suicidal because, in previous decades, society was not accepting of their silicone-enhanced breasts? I'd argue that today there is even more social pressure to look perfect than there was 40 years ago. And as plastic surgery becomes more socially acceptable, women with mental-health issues (and problems like body-dysmorphic disorder) may be under even more pressure to get breast augmentations. Therefore this problem is not going away.
Thanks to Feministing for the link.
Wednesday, August 8, 2007
Salon.com has an article by Andrew O'Hehir discussing a recent book, "Passions and Tempers" by Noga Arikha, historian, on what hasn't changed in medicine over the years. Mr. O'Hehir writes,
What if a physician from, say, the late Roman Empire were transported to the 21st century and asked to treat patients? Historian Noga Arikha performs this thought experiment in her new book, "Passions and Tempers: A History of the Humours."
Most obviously, he -- and he'd definitely be a he -- would be clueless about modern medical technology. He wouldn't know how to take your blood pressure, and he'd never have heard of viruses or bacteria. Cancer, to him, would be a constellation and a sign of the zodiac (as well as the word for "crab"). For certain ailments he might want to bleed you, and you'd be right in suspecting that was a bad idea. If you complained of a cold or a fever, on the other hand, he might define your illness in unfamiliar terms but he'd also be full of suggestions for herbs, poultices and potions, some of them no worse than those developed by the last 2,000 years of medical science.
This Roman doctor would probably subscribe to the humoral theory of human physiology, meaning that he believes physical and mental health are governed by the relative balance and temperature of four "humors" or fluids that flow through the human body: blood, choler (yellow bile), melancholy (black bile) and phlegm. This theory is completely discredited today, and for good reason: Those humors either do not exist or do not do what the ancients thought they did.
Intriguingly, however, our visiting specialist would find the allopathic principle that underlies modern medicine -- the idea of treating through "contraries," or opposites -- completely familiar, since it was humoral medicine, the tradition of Hippocrates and Galen, that first advanced that principle.
Even more intriguingly, some medical concepts that seem relatively new to us would also strike him as normal, like the idea that stress can cause physical ailments, or that mental illness might result from a chemical imbalance in the body. Once he figured out what you meant by "depression," for instance, he'd want to treat it with herbal remedies, probably using plant products still employed for that purpose today.
In short, this Caligulan doctor would possess what we'd now call a holistic conception of the human body and human health, along with an impressive body of empirical knowledge about treatments and cures. He would understand the body as a carefully balanced organism full of invisible essences, and his own role as a cautious recalibrator who intervenes only as necessary to restore that balance. He would know almost nothing, by our standards, about human anatomy, but he'd be a highly cultured fellow who had read more Aristotle than any doctor you're likely to meet today.
The article is an interesting read and the book looks good too.
Tuesday, August 7, 2007
Ezra Klein points out a recent article on the American Prospect website concerning an interview by Roger Bybee, writer and progressive activist, who formerly edited the official labor weekly Racine Labor, with Dr. Steffie Woolhandler, one of the founders of Physicians for a National Health Program, on single-payer health care. Here is a brief portion of the interview:
How do you envision closing the gap between big firms like Wal-Mart making vague commitments to universal healthcare and actual recognition that only a single-payer system can hold down costs, reach all citizens, and provide free choice of doctors?
If companies want to hold down costs, they need to support universal healthcare. Otherwise, it won't solve the problem of healthcare for low-wage workers. The good news is that no one would miss the administrative burden that accounts for such high costs in the
However, we would have to provide retraining and income support to displaced health insurance workers.
Polls of doctors in
(Feb., 2007) and
(2004) both show a remarkable 64 percent favoring a single-payer plan. What accounts for this historic shift in the sentiment of doctors, when you think back to how the American Medical Association successfully mobilized doctors in every community to block Harry Truman's health reform effort? This new polling seems extraordinary; both because doctors' support for single-payer is just slightly below the general public's and because doctors are presumably much more knowledgeable about health systems than the average citizen. How do you see things developing among doctors and the health industry?
The opposition in Truman's era was the medical profession, and the AMA still is opposed even though a high percentage of doctors support a single-payer plan.
But now there are two other powerful forces: the health insurance industry [that emerged since the Truman plan] and the pharmaceutical companies. Under a single-payer plan, the government steps into the pharmaceutical pricing picture with a lot of bargaining power, so both of these forces feel threatened.
It's ironic that hospitals aren't more supportive. The health insurance industry would be put out of business, so it's life or death for them. But hospitals would still be there. Some for-profit hospitals oppose national health insurance, and our plan calls for reconversion to non-profit status. With the non-profit hospitals, I think opposition to single-payer is mostly fear of change. I think that they can live with a single-payer national health insurance plan, so I don't see them as our biggest enemy.
Over at Talking Points Memo Cafe, Representative Steven Kagan (and former physician) provides a summary of his plans for health care reform. He will be writing each day to provide further details about this ideas for change and ways to achieve universal coverage. He writes,
The nation's health care system is in critical condition, and slapping another Band-Aid on it won't help. Believe me, I know. As a physician, I've been healing my patients for 30 years. But I had to run for Congress to begin to make sure they can afford their prescriptions without having to choose between taking their next pill or eating their next meal.
It's time for my fellow members of Congress to stand up to Big Insurance and guarantee universal access to affordable care for every citizen. Here's how:
Openly disclose all prices - so the real price of all health care services and products is always visible and openly disclosed. That way, we'll know the price of a pill before we swallow it.
Unitary Pricing - so we all pay the same price for the same product or service, like ordering from a restaurant menu. Show us your price, and then charge every citizen the same.
Form a single risk pool, made up of all 300 million citizens - with no discrimination against anyone who has a pre-existing condition - to leverage down prices for all of us.
Renew our commitment to care for "The least of these" among us - so all our children can reach their full potential, all our working families have an equal opportunity to be healthy, and all our senior citizens can afford the care they need without having to quietly skip a meal.
And before my Congressional opponents, who support Big Insurance, reach for their partisan talking points about "government run health care," ask them to do what I did--reject their own "government-run" Congressional health package until every citizen they represent has the same health care benefits offered to them. . .
. . . .you can learn more in Clarence Page's column from yesterday's Chicago Tribune.
Monday, August 6, 2007
Slate's William Saletan reports on a new scientific development:
Scientists are developing an "artificial uterus environment." Key ingredient: microchips that "rest on a membrane of cultured uterus cells," whose chemicals help fresh IVF embryos (up to 20 at a time) grow. In mice, the chip is almost as effective as a womb; it'll be tested on human embryos this year. Goals: 1) improve the success rate of IVF. 2) "create a fully automated artificial uterus in which egg and sperm are fed in at one end and an early embryo comes out the other, ready for implanting in a real mother." 3) "growing genetically modified animals, stem cells and cloned embryos." (For Human Nature's take on artificial wombs as organ factories, click here.)
Where do people get these ideas?
McClatchy News reports on the concern many independent pharmacists have concerning the new Medicaid drug reimbursements. It states,
For Mark Williams, it's a simple business proposition: He can't afford to sell medicine for less than what he paid for it. But he says that's what Washington expects him to do, come January. . . .
It's a common warning from the nation's community pharmacists, who have been watching their ranks dwindle in recent years. Now they're looking for help from Congress, fearful that reductions in the amount the federal government reimburses them for Medicaid drugs will drive more of them out of business.
Yet much more than the livelihood of pharmacists is at stake. If the changes proceed, critics warn, tens of thousands of Americans who depend on Medicaid could be denied life-saving drugs or forced to drive long distances to get them. Medicaid is the federal-state program that subsidizes health costs for 53 million low-income people and those with disabilities. . . .
Kody Krien, who runs Krien Pharmacy in St. Francis, Kan., is among those who are ready to stop serving Medicaid patients if necessary. "If they set it below cost, I'll just drop them," he said. "The sad thing is those Medicaid people are going to have to drive 40-50 miles to get medicine. .... And those people, they can't afford to drive anyway. That's why they're on Medicaid."
Faced with growing competition from big chains and mail-order pharmacies, 1,152 independent pharmacies across the United States were sold or closed in 2006, according to statistics gathered by the National Community Pharmacists Association. . . .
The uproar is caused by fallout from the Deficit Reduction Act of 2005, which was passed by Congress and signed into law by President Bush. It forced the Centers for Medicare and Medicaid Services (CMS) to come up with changes in the government's complicated reimbursement formula as a way to save $8.4 billion. . . .
Critics of the new rule say it would reimburse retail pharmacies at an average rate of 36 percent below their costs. That's based on a December report by the Government Accountability Office. The new rule would base reimbursements for more than 500 generic drugs on the average manufacturer price. Currently, they're based on average wholesale prices.
Government officials are defending the new system. "We don't agree with some advocates who claim that the new rule will put pharmacies out of business," said Mary M. Kahn, CMS spokeswoman. She said that states "were greatly overpaying for many drugs, especially generic drugs." And even with the new changes, she said, pharmacy revenues from the Medicaid program will decline by less than 1 percent over the next five years. . . .
For those of you who are wondering about the safety of your state's bridges after the tragic collapse of the Minnesota bridge, MSNBC provides a helpful interactive map with information on the status of the bridges within each state.
Thanks to Americablog for the site.