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PHYSICIANS/PHARMA/TECH: A take on the news, sort of

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Things we already knew:

Doctors are poor at judging their own abilities. It’s a bit like everyone says they’re a good driver, but that 75% of drivers are terrible.

Merck earnestly believes that it was as pure as the driven snow over Vioxx and never knew that it was dangerous until it took it off the market(who knew about Dodgeball, eh — let alone what Kaiser knew several months earlier).

Little girls don’t really cry tears of stone

Things that I don’t think we did know

Online PHR use is up to 7% by July. Which is about 6% higher than they said it was 2 years ago.

According to the survey, commissioned by UnitedHealth Group and conducted by Harris Interactive ® , only 7 percent of U.S. adults use online personal health records and 35 percent of people surveyed were not even aware this resource technology exists.

PHARMA: Probably another false start from the DEA

The black stone that resides in the chest of DEA administrator Karen Tandy in the place where the rest of us have a heart must have some gravel chipping off today. The DEA allegedly has revised its rules on prescribing pain-killers:

Yesterday, DEA Administrator Karen Tandy said the agency had been wrong in limiting the multiple prescriptions and had made the tough decision to reverse course. She said the DEA received more than 600 comments from doctors, patients and others about its policies on narcotic pain killers, many of them strongly opposed to the agency’s position on limiting refills.

But basically this is a tiny move—allowing multiple prescription refills for those in chronic pain, but only by doctors who the DEA considers not to be in violation of their unwritten laws. After all, 2 years ago—right in the middle of William Hurwitz’s trial when his defense was about to introduce them—they introduced some similar guidelines they’d worked on with pain specialists for two years. So what happened then?  Well given the choice of allowing rational behavior, even according to guidelines they developed and allegedly agreed with, and putting a doctor treating the chronically ill in jail. Guess which one they took?

The agency briefly posted the guidelines on its Web site in 2004 but then pulled them down and disavowed them.

Siobhan Reynolds from PRN is rightly, rightly suspicious

But Siobhan Reynolds, who created the Pain Relief Network several years ago to help defend pain doctors who she said were being unfairly arrested and prosecuted, disagreed and said the new DEA policy has changed little. "Ms. Tandy states here, as she has on many occasions, that doctors need not fear criminal prosecution as long as they practice medicine in conformity with what these drug cops think is ‘appropriate,’ " Reynolds said. "If that isn’t a threat, it will certainly pass for one within the thoroughly intimidated medical community.”

The story is that chronic pain is massively under-treated in this country, and opiates are the most effective way of dealing with that pain. Yet as I pointed out over at Spot-on the mad Calvinists who run our criminal justice system care not a whit. 

POLICY: Becker-Posner miss the point

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And in, I hope, the last comment on the Cutler piece, two venerable Univ of Chicago economists debate it on their blog, the Becker-Posner Blog

Posner ascribes the problem of the high cost of adding a year of life to an elderly person to the desire of people near the end of life to spend whatever it takes to stay alive. Other than that’s not how people at the end of their life usually feel, the problem with these rational analyses is that they don’t understand how health care works. Decisions about end of life care are not made by patients–they are made by doctors and health care organizations. Wennberg’s work clearly shows that. The enormous practice variation in end of life care is a factor of cultural variation amongst physicians not one of patient choice—the patient don’t know about it. And it applies whatever the insurance status of the individual because it’s ingrained in local medical cultures.Other countries have got their physicians somehow to accept that (for instance) heart surgery or kidney dialysis on a 95 year old with a life expectancy of 6 months is not good medical practice. Here we routinely do it (as in Posner’s father’s case).Stopping that absurdity is the solution to our health care crisis as that’s where the vast majority of the unnecessary spending is. But to do that we have to change medical culture, and rather more difficultly, health care system incomes!

TECH/POLICY: A prime example of how health care works, sort of.

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The continuing fuss about the Cutler article rumbles on. Here’s the Scientific American article that I’m quoted in. You’ll note that I may seem a little extreme (“rubbish”) but I was interviewed before I’d seen the article (or even knew that it was coming out!) and the reporter told me that the number for a year of life was between $100,000 and $200,000. But the question is still “worth it compared to spending the money on what else?”

Meanwhile the answer from David Henderson at Hoover (the guy I challenged on the local NPR call in show —on the MP3, my piece is cut out totally! The response is at 44.14) remains “we’ve picked the low hanging fruit, so it will be more expensive to move the needle as the years go by.” I wasn’t given the chance to say a) the industry has co-opted the government so it’s not like there’s a real “choice” in how we spend the money, and b) perhaps we’d get better value for money picking low hanging fruit in some other area of our society. In other words there are diminishing marginal returns from the flat of the curve medicine—so perhaps we should think of spending the money elsewhere? Meanwhile a few others have picked up on that. In the Huffington Post, Merrill Goonzer (yes that’s really a name!) from the Center for Science in the Public Interest points out the other part of the problem—“we may be paying for an Aston Martin but we’re getting a Ford”.

And when the status quo proponents say “costs are going up in other countries too” you can note that in 1970, health care costs in Canada and the US were the same as a share of GDP—and they’re not now! And in the 1990s both Japan and Canada reduced health care costs as a share of GDP. So societies can make choices about this, even if ours politically won’t. In fact in the last decade the Brits made a conscious choice to increase the amount of money they spend on health care—with some interesting consequences.

Of course the whole thing is totally bogus, as no one thinks of these things other than as ex-post facto justifications, and pretty weak ones at that. There’s a perfect example in the NY Times this morning. It says that Cardiologists Question the Risks in Using Drug-Coated Stents, a story that’s been reported on for a while, and includes a new Swiss study that says that only one in three cases is the use of the drug eluting stent correctly indicated.

Of course three years ago a Stanford health services research group suggested that stents as a whole weren’t worth it on a cost-benefit level, and got totally ignored other than on this blog! So there’s a chance (and it’s a slight chance) that medical counter indications might, just might, slow the spread of a technology that is basically unproven. There’s no chance that saying it’s not cost-effective will slow it at all.

Which kind of proves that arguing about the Cutler article is a waste of time!

HEALTH PLANS/POLICY: A health plan CEO who genuinely believes in universal coverage

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Health Plan CEO Georganne Chapin believes managed care can evolve with universal coverage! I thought her money quote was pretty amusing.

So then, if Americans are interested in universal coverage, the industry supports it, and the money is already in the system, when will it happen? “In 1996, I said it would come in 10 years,” Chapin says. “We still have four more months.”

Of course she runs a non-profit Medicaid HMO, so her attitudes may not represent those of a typical AHIP member CEO!

POLICY: Starring on NPR

Not quite, but the local NPR station had a show on poverty, the middle class et al, and the TCS/Hoover /ExxonMobil representative David Henderson came out with the standard crap line about how we were getting more for our health care dollars. Given the recent Cutler piece I just had to pick up the phone and tell him that we weren’t. Unfortunately they cut me off before I had a chance to respond to his "well you go after the hanging fruit first so it’s bound to get more expensive" argument. He failed to note that there’s a point at which you stop going after the fruit well out of your reach, but that we live in a society in which the government has abdicated its fruit grabbing responsibility  and has a allowed a system in which we bow down to the orchard owners and the companies who make ladders.

Meanwhile, his argument in favor of greater income inequality (which is what I originally called the show about) is that we have fluid classes so you’re not surveying the same people all the time…..sadly they’re not as fluid as they are in those stagnant European nations. But it sounds like Henderson got himself in the right class, and I guess it’s just tough luck on those who got themselves in the wrong one.

I’ll get the audio link up when it’s available….

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