Friday, July 20, 2018

OP-ED

OP-ED

Will Cancer Drugs Ever Be As Affordable As Retrovirals in Low and Middle Income Countries?

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In 2014, the majority of international health aid was dedicated to HIV. So, one might reasonably assume that this is the largest health problem facing the world. Yet, HIV only constitutes 4% of the global burden of disease. In 2014, noncommunicable diseases (NCDs) made up 50% of the entire disease burden, but only received 2% of all global health funds.

The disease burden of NCDs is fast outpacing that of infectious diseases. Despite this, the proportion of global health financing dedicated to combatting NCDs has remained constant over the past 15 years at 1 to 2%.

Currently, 32.6 million individuals are living with cancer (diagnosed in the last five years). In 1970, 15% of new cases were in low- and middle-income countries. In 2008, 56% were in low- and middle-income countries. By 2030, this proportion is expected to be 70%. So, not only is the burden of NCDs rising globally, but it is also beginning to disproportionately affect countries with the least resources to deal with them.

But, if NCDs have been steadily increasing in low- and middle-income countries, why has global action not followed suit?

A Public-Private Partnership to Fix Health Care

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The Administration proposal that would enable small employers to band together to purchase health insurance by forming Association Health Plans has several good features. Large companies do pay about 15% less, apples-to-apples, for health insurance than small businesses because they negotiate lower administrative fees, get larger discounts on health care prices and avoid premium taxes and risk charges by self-insuring. Allowing small business to replicate what boils down to volume discounts also appeals politically to many as a market-based alternative to government intervention. Reliance on Association Health Plans could result in substantial volume discounts, but, in the end, would be like paying $10 for a tube of toothpaste that retails for $100, a big discount and a rip-off price.

Even though the largest companies get very deep discounts, there is substantial research showing that their net costs are much higher than everywhere else because we in the United States pay higher prices for health care goods and services. One need to look no further than the benchmark large corporate purchasers who continue to pay about 40% or 50% more than Medicare for the same health care to see how excessive health care prices for private payers are. And this disparity is likely to get worse. While hospitals gobble up other hospitals and doctors’ practices and gain near monopoly market power to raise prices, employers of all sizes remain highly fragmented and, as a result, impotent price negotiators.

A better approach to health care cost containment than Association Health Plans hides in full view.

Splitting hairs with Hypertension

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Intrigued by many things in my first few days in the U.S., what perplexed me the most was that there seemed to be a DaVita Dialysis wherever I went; in malls, in the mainstreet of West Philadelphia, near high rises and near lower rises. I felt that I was being ominously followed by nephrologists. How on earth could providers of renal replacement therapy have a similar spatial distribution as McDonalds?

After reading Friedrich Hayek’s essay, Use of Knowledge in Society, I realized why. In stead of building a multiplex for dialysis, which has shops selling pulmonary edema-inducing fried chicken, DaVita set shop where people lived or hung out. It wasn’t a terribly clever business plan but its genius was its simplicity, its humility. If the mountain will not come to Muhammed, Muhammed must go to the mountain. DaVita went to the masses.

The link between Hayek’s wisdom and DaVita’s business plan may seem tenuous. But Hayek has been misunderstood, particularly in healthcare. Many a times and oft in the policy world Hayek has been rated about money and usances. This is because of a misperception that Hayek was all about profit and loss, which are anathema to healthcare. Hayek’s message was simple: local knowledge can’t be aggregated. From this premise sprouts others – dispersed agents in certain times and places possess fragments of knowledge which don’t come easily to central planners.

For Hayek, socialism and capitalism weren’t moral but epistemic issues. Socialism would fail because of a coordination problem – markets would succeed because they could use price signals to coordinate. Healthcare doesn’t use price signals to coordinate, not explicitly, at least. Nor does it capitalize on dispersed agents – on local knowledge. Hayek, a supporter of universal healthcare, didn’t specifically discuss healthcare in his essays. Nonetheless, it would be a useful intellectual exercise to speculate how Hayek might have applied his wisdom to modern healthcare.

What does local knowledge in healthcare even mean? Stated in a rather unlettered way, it is the provision of healthcare locally. AEDs are no good if they aren’t located where people congregate. The value of local presence of medical facilities, particularly in poor neighborhoods, is hardly rocket science. Just as great cities grew near rivers, great hospitals germinated in poor neighborhoods. But, with growing centralization of healthcare, with hospitals becoming multiplexes, futuristic cities with a distinct architectural phenotype, different from the neighborhoods they serve, the value of decentralization can be missed.

What Parents of Athletes Should Know About Injuries and Abuse

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I’m not a parent. But I was once a gymnast. Now I teach at a medical school. As far as my own injuries, I consider myself lucky; I can walk through airport security without setting off any metal detectors. But I certainly have had my fair share of visits to the emergency department, the orthopedist, the chiropractor, and the physical therapist – as an adult and as a child, at times without a parent present.

We heard so many powerful statements from young women at Larry Nassar’s sentencing hearings. As I read and listened to these women confront their abuser, I was empowered by statements like those of Kyle Stevens, who said: “…little girls don’t stay little forever. They grow into strong women that return to destroy your world.”

But I wondered if parents of male athletes were paying as much attention to the Nassar story as were the parents of young girls. Now that the first male gymnast has come forward to accuse Nassar of sexual abuse perhaps they will.

As a health educator-turned-bioethicist who studies physician sexual abuse of patients, I have some practical advice for parents.

The Intractable Debate over Guns

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When Russian forces stormed the school held hostage by Chechen terrorists, over 300 people died. The Beslan school siege wasn’t the worst terrorist attack arithmetically – the fatalities were only a tenth of September 11th. What made the school siege particularly gruesome was that many who died, and died in the most gruesome manner, were children.

There’s something particularly distressing about kids being massacred, which can’t be quantified mathematically. You either get that point or you don’t. And the famed Chechen rebel, Shamil Basayev, got it. Issuing a statement after the attack Basayev claimed responsibility for the siege but called the deaths a “tragedy.” He did not think that the Russians would storm the school. Basayev expressed regret saying that he was “not delighted by what happened there.” Basayev was not known for contrition but death of children doesn’t look good even for someone whose modus operandi was in killing as many as possible.

There’s a code even amongst terrorists – you don’t slaughter children – it’s ok flying planes into big towers but not ok deliberately killing children. Of course, neither is ok but the point is that even the most immoral of our species have a moral code. Strict utilitarians won’t understand this moral code. Strict utilitarians, or rational amoralists, accord significance by multiplying the number of life years lost by the number died, and whether a death from medical error or of a child burnt in a school siege, the conversion factor is the same. Thus, for rational amoralists sentimentality specifically over children dying, such as in Parkland, Florida, in so far as this sentimentality affects policy, must be justified scientifically.

The debate over gun control is paralyzed by unsentimental utilitarianism but with an ironic twist – it is the conservatives, known to eschew utilitarianism, who seek refuge in it. After every mass killing, I receive three lines of reasoning from conservatives opposed to gun control: a) If you restrict guns there’ll be a net increase in crimes and deaths, b) there’s no evidence restricting access to guns will reduce mass shootings, and c) people will still get guns if they really wish to. This type of reasoning comes from the same people who oppose population health, and who deeply oppose the sacrifice of individuals for the greater good, i.e. oppose utilitarianism.

The UPMC-Highmark Brawl Spills Into Philadelphia’s Backyard

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The UPMC/Highmark rivalry continues to open new fronts in Pennsylvania. Highmark’s response to UPMC is differentiated in two ways: first, Highmark is using a coalition-building strategy and, second, it is controlling its exposure to big in-patient assets; in contrast, UPMC is building an integrated, single-brand system and happily taking over hospitals (and building more) along the way. When UPMC and Highmark make major investments in a region, local systems will be caught in the capex arms and feel the pressure to affiliate. Credibly threatening to respond in kind may defuse the arms race. But unaffiliated systems may struggle to find partners willing to bankroll a battle with both Highmark and UPMC, leaving no option for unaligned systems than to pick sides. Philadelphia systems – so far largely neutral to Highmark vs. UPMC – should be able to stay neutral as the fight develops in their western backyard. If the battle moves into northeastern Pennsylvania or jumps into south Jersey, however, the Philadelphia systems will have to develop a response.

The competitive rivalry between Highmark and UPMC is truly epic. Long ago – when Highmark largely focused on insurance and UPMC largely focused on care delivery — they were good partners in the Pittsburgh market. But as each has become more vertically integrated – with Highmark acquiring the West Penn Allegheny system and UPMC’s health plan buisness growing – they have since become bitter rivals. The competition has expanded out of Western Pennsylvania and into the rest of the state. 

No Surprise, Life Expectancy Declined Again

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Newborns born in 29 other countries of the world have life expectancies exceeding 80 years; yet, an infant born in the US in 2016 is expected to live only 78.6 years according to recently released statistics. While death rates fell for 7 of the 10 biggest killers, such as cancer and heart disease, they climbed for the under-65 crowd. The irrefutable culprit is the unrelenting opioid epidemic.

Last year life expectancy declined for the first time since 1993. The last two-year decline was in 1962 and 1963, more than a half-century ago. I predicted (accurately) it would decline again this year unless there was a dramatic change in the primary care physician workforce. We are dying at a younger age today than two years ago– two months earlier to be exact. It might not sound monumental, but life expectancy is the king of noteworthy health statistics, making it quite significant in the grand scheme.

In the past, epidemics by definition were temporary; the narcotic epidemic will be anything but transient; there is no foreseeable end for the scourge of opioid addiction sweeping the nation. In my humble opinion, the solution to this dilemma is no different than it was last year, we must correct the primary care physician shortage. Time is of the essence. The last three-year decline occurred in 1912- 1914 as a result of the Spanish flu. Unfortunately, life expectancy will continue to decline until the nation makes comprehensive changes.

One in five Americans live in a primary care shortage area; the ratio of the population to primary care providers is greater than 2,000 to 1 (Bodenheimer & Pham, 2010), when it should be closer to 1,000 to 1. I am a third-generation primary care physician, with a unique historical perspective on how medical practice has changed since my grandfather made house calls back in 1940.   My practice is currently located in a shortage area and the difference in volume compared to 16 years ago when I first hung a shingle, is extraordinary. Only 37% of doctors serve in primary care, yet 56% of the office visits are completed by that particular group of physicians (Health Resources and Services Administration, Bureau of Health Professions, 2008.) In my grandfathers’ time, primary care physicians made up 70-80% of the physician workforce.

The Death of Objectivity

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For veterans of the healthcare industry, the current debate over the future of the Affordable Care Act – and proposed changes that would fundamentally alter Medicaid and individual market exchanges – is a frustrating battle of ideologies with the future of healthcare at risk. Our debate over who should be eligible for expanded coverage and how we reform reimbursement is often laced with self-preservation, which in our case means preserving an employer-sponsored system that is riddled with inequities, opacity, dubious middlemen and weak public and private sector fiduciary oversight. Those who provide, pay for and/or consume healthcare are drowning under rising per capita costs while many in the middle of these transactions grow fat.

As brokers, consultants and advisors, we have to face an inconvenient truth: we have presided over and benefited from a system in crisis. Not everyone believes our industry’s purpose is noble or necessary.

Health system stakeholders long to deal direct with employers. Many professional benefits managers hate being on the end of the latest pitch from their advisor  to sell a project or broker to hawk a new product to increase commission income. In the digital age, there is a heavy bias in favor of disintermediation and the elimination of distribution costs that are often not easily rationalized.

How does one grade the contribution of a sentinel? How does a client know whether the advisor who is paid a commission or fee is acting out of self-interest or as a trusted change agent?

How one makes money is as important as how much one makes in certain industries. There are ethical implications to anyone who adds cost to a healthcare system fraught with waste, fraud and abuse. This expense translates into higher cost and erodes the ability for employers and public entities to finance care for those that are often most in need.

In the last two decades, ineffective regulatory and advisory oversight of the financial and healthcare industries has allowed abuses to take place in the form of mergers and protected opacity in pricing.

Trump, Stalin and the Price of Replacing Science with Ideological B.S.

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Donald Trump and many of his closest advisors have been accused of colluding with Russia to win his election as President. We shall see what Robert Mueller and the FBI discover in that regard. But, whatever truth emerges there is no doubt that Trump has ripped a page from a long-dead leader of the Soviet Union, the monster Joseph Stalin, to undercut science in the name of his ideological goals.

Friday the Washington Post reported that a senior leader at the Centers for Disease Control and Prevention was told not to use certain words in documents “related to the budget and supporting materials that are to be given to the CDC’s partners and to Congress”. Policy analysts at the Centers for Disease Control and Prevention in Atlanta the Post said were given a list of forbidden words at a meeting with senior CDC officials. The seven prohibited words are:

  • Vulnerable
  • Entitlement
  • Diversity
  • Transgender
  • Fetus
  • Evidence-based
  • Science-based

What does Trump’s disgraceful censorship of science by banning words known to be useful, valuable, essential and important have to do with Stalin and Russia? Everything.

Stalin like Trump only wanted to hear scientific words when they confirmed his political beliefs. He did not care if by implementing false news he killed millions of his citizens. Trump with his decision to ban scientific terms in public policy that don’t suit his taste is proudly marching in Uncle Joe’s bloody footsteps.

Premium Support: Coming Soon to a Medicare Plan Near You?

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Unnoticed by most of the media, the Congressional Budget Office recently released a report that could profoundly change American seniors’ healthcare coverage.

The report updates a 2013 CBO analysis of the potential impact of switching Medicare to a premium support system. Under such a system private plans would compete with the traditional fee-for-service plan much like today, but with a big difference. Whereas now, for most beneficiaries, Part A is free and Part B requires a modest premium, under premium support the government would pay only up to regional benchmark amounts for Parts A and B together. Seniors choosing a plan (or the FFS option) priced above the benchmark would pay the difference.

The concept isn’t new. Over the past twenty years, various versions have been proposed by bipartisan commissions and—more recently—by Republican budgeters in Congress. What is new is the projected magnitude of the federal budget savings.

Both CBO analyses looked at two options for setting the benchmarks, either as the average of all bids (including the projected FFS cost) for a region, or as the lower of the FFS cost and the second lowest private plan bid. The differences between the projections in the two analyses, four years apart—and the numbers themselves—are huge.