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Tag: International

Interview: TR Reid on healthcare reform around the world

TR Reid is a former foreign correspondent with the Washington Post. He spent two years (partly funded by the Kaiser Family Foundation) looking at health care systems across the world and has been featured heavily in many media venues lately asking the simple question, if everywhere else can cover everyone at half the cost, how do they do it?  I had a great and not too long interview with him last week.

His book is called The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care and here's an interview he did as part of Frontline's Sick Around The World.

Funnily enough I'm posting this from Barcelona, Spain where hopefully I won't have to use the healthcare system unless I get carried away with the late night Sangria…

Health Panels are a NICE Way of Improving Care and Controlling Costs

By ADRIAN BAKER

One of the proposals for health care reform is to have a panel of medical experts oversee Medicare, in order to improve quality and reduce cost. Butfalse accusations permeating the debate have scared people into thinking that would mean a government bureaucrat deciding what treatments you should or shouldn’t have, and would ultimately deny your grandma her vital drugs. Like any debate involving the future, fear of the unknown is going to be used by those who want to maintain the status quo for their own self interest. But health panels are not unknown. They have been used in Britain for ten years, and have proven to work.

Health panels are a simple enough idea: experts look at the evidence out there and make sure it’s the best that is available. They then make recommendations based on analysing hundreds of studies and consulting numerous stakeholders. The recommendations suggest the best form of treatment and care for a particular condition, or advise on areas your doctor may be unsure about.Continue reading…

Donald Light sticks it to PhRMA and Tauzin, again

Over the years PhRMA must be getting pretty sick of Univ of Medicine and Denistry of New Jersey Professor Donald Light. He’s made a cottage industry of pissing on the commonly-trumpeted propaganda that only American drug research is effective, and that high prices for drugs in the US cross-subsidize lower prices elsewhere in the world. And in Health Affairs this week he does it again. Essentially Light shows that the added R&D spent in the US compared to Europe doesn’t give much bang for the buck, and that not many breakthrough drugs have been created anyway—something that PhRMA knows all to well as it looks at its shrinking pipelines.

In global NCEs, European research productivity was about the same as U.S. productivity in the first period but increased by 30 percent in the second period (1993-2003), while U.S. research productivity declined 26 percent (Exhibit 3). In first-in-class drugs, European relative innovativeness moved from well behind the United States in the first period to well ahead in the second. These are the most commercially and therapeutically important types of new chemical entities.

Now personally I think that, in an era in which all drug research is pretty much international, the basic premise of the argument about which system does more effective drug research is pretty silly. But of course it’s a one-two punch. And the upper-cut that would leave pharma staggering if it didn’t have control of the microphone is this quote from Light:

Congressional leaders and others concerned about high prices of new patented drugs will be heartened by this analysis, because lower European prices seem to be no deterrent to strong research productivity.20 A previous analysis using industry-based data showed that pharmaceutical companies recover all costs and make a good profit at European prices.21 Europeans are not “free riders” on American patients–another myth promoted by industry that assumes that countries are separate R&D/market silos that should each pay for themselves.

Given that Billy Tauzin at PhRMA has already cut a deal with the Obama Administration (albeit one that seems to be unofficially official), none of this matters very much. But it’s good to see that it might just be possible to reduce the very high margins earned by big Pharma without necessarily ending scientific advancement as we know it.

Sunday reading-Jon Cohn on French & Dutch health care

Jon Cohn has a long article in the Boston Globe about how the French and Dutch get health care about right at half the American cost with none of that unpleasant Canadian or Britishness that FoxNews loves to complain about. Given that (if we get reform even vaguely right) we’ll look more like Holland or Germany that Canada, it's your essential Sunday reading.

Of course Jon is slightly too nice as ever. One minor point about access to specialty care—it may take longer there than here, slightly. But in the same Commonwealth study Cohn quotes, waiting times for elective surgery were shorter in Germany than they are in the US. And of course no one there gets bankrupted by the cost of medical care.

As Medical Tourism Grows, Hold On We’re In For a Wild Ride

Until now, medical tourism has been a curiosity, iconic “Wow, Look How Flat the World Is Becoming,” fodder for stories on 60 Minutes. But as health insurers and employers get into the act, get ready for some Battles Royale.

Of course, it was only a matter of time. With surgeries costing tens of thousands of dollars less in India and Thailand than in Indiana and Tucson, and with companies ranging from GM to Citigroup desperately trying to shave health care costs to fend off bankruptcy, you knew it wouldn’t be long before insurers or employers began offering incentives – or forcing – patients to have their surgery overseas.

Starting this month, some employers working with WellPoint, the nation’s largest health insurer, will begin offering their employees substantial discounts if they choose to have their surgery in India. The Indian hospitals are accredited by Joint Commission International (JCI), the arm of the Joint Commission that’s in the business of blessing foreign hospitals. If they are like most of the foreign hospitals catering to international tourists, chances are that the quality of care is more-than-acceptable and the quality of service would make the concierge at the Ritz jealous.

The press release trumpeting WellPoint’s arrangement oozes with PC spin:

Members will now have more choices regarding where to receive care and a greater involvement in the care they receive.

Well, what could possibly be controversial about that?!

I’ve written two articles for the New England Journal of Medicine about international teleradiology and other digitally-facilitated outsourcing (here and here), another burgeoning piece of our newly flattened world. That phenomenon is far from fantasy: thousands of patients in American ERs will have their x-rays read tonight by physicians sitting in India, Zurich, Tel Aviv, and Sydney. But because this happens behind our professional curtain, the debate over tele-whatever has largely been Inside Baseball (Is the quality adequate?

Do the non-U.S. docs need American malpractice coverage? Can the foreign docs bill Medicare? [Answers to date: 1) Seems reasonable, a few anecdotal glitches, but no good studies; 2) At this point, yes; 3) Presently, no – the local docs bill Medicare for their “final read” in the morning and they or their hospitals compensate the foreign docs]). It’s all been back office and arcane enough that it hasn’t been terribly controversial.

While medical tourism seems poised to be more controversial, its limited niche thus far has attenuated the arguments. To date, most participants have been un- or under-insured people trying to control their out-of-pocket costs for elective surgeries that require large cash payments, such as plastic surgeries and elective hip replacements. So most surgeries have involved private arrangements between patients and international providers, sometimes facilitated by intermediaries that have sprouted up like weeds. (Since nobody needs a travel agent anymore to book a vacation to Paris, up pops a new tourism niche. Capitalism’s resiliency never ceases to amaze.)

As I said, as long as these were private choices, the potential reach of medical tourism was muted, as was the controversy. But every healthcare insurer and large employer is now actively scrutinizing the concept, and many find it quite appealing. Of course, sensitive to the politics, it is unlikely that any of them will flat-out force their customers/employees to travel to Thailand or Singapore. The pressure will be more subtle: with savings of tens-of-thousands of dollars per case at stake, there is enough money around to waive patient co-pays, give insurance discounts to employers, and cover travel expenses – including in-flight drinks and headphones – and still come out way ahead. As Brian Lindsay wrote in a terrific piece in Fast Company last March,

“They [patients] don’t – and we don’t – want to be in a situation where an insurer says, ‘You have to go,’ ” says Victor Lazzaro, CEO of the [medical tourism] packager BridgeHealth International and a former executive at Prudential… One solution is to be up front with patients about the true cost of their treatment and offer to share the savings with them. In light of what it costs for a fresh set of knees in the States – $45,000 and up for the uninsured – and the huge discounts overseas, it’s conceivable that patients might come out ahead if they let a Thai doctor install them. Of course, just because insurers won’t use a stick doesn’t necessarily mean the dangling carrot couldn’t be considered coercion in its own right.

The wars will be fascinating and the battles lines will be fluid and a bit unpredictable. Consider unions, for example. On the one hand, the cost savings for companies that insure their workers may help preserve union jobs or allow for cost savings to be passed on in the form of higher salaries or richer benefits. On the other hand, as local hospitals are hurt, unionized service and nursing jobs may take a hit. So should unions be for medical tourism or against it? Who knows?

But one set of losers seems clearer: domestic providers, particularly cardiac, plastic, and orthopedic surgeons. Again, from the Fast Company article,

In one fell swoop, [the surgeons] devolve from the rock stars of the OR to glorified mechanics, and they’d really only have themselves to blame. Overseas patients routinely return home raving about the personal attention shown by their Thai or Indian surgeons. Even before arriving, patients can trade phone calls and emails with doctors. (Nothing punctures the myth of American medical invincibility quite like the experience of having a doctor who actually speaks to you.)

I participated in a panel on medical tourism at last October’s American College of Surgeons meeting, and many of the docs in the audience were pissed. Using those computerized audience response gizmos, the surgeons in attendance were asked: If a patient returned from surgery abroad with a complication and came to see you, would you agree to care for the patient? A clear majority answered “No.” (Had there been a choice called “Hell, No!” I’d wager that it would have been the winner). Surely Hippocrates would be turning over in his grave, but I’m guessing that Hippocrates didn’t have to pay $100K/year in malpractice premiums or watch his 8 years of residency training become devalued by foreign competition.

How will all of this play out? It seems likely that medical tourism will continue to grow, as will the number of concerned responses from domestic providers (mostly guild behavior and protectionism clothed in the garb of patient safety and quality). I’m sympathetic to my colleagues’ reactions, but look, the status quo isn’t acceptable: We’re spending $2 trillion dollars per year on healthcare and still have nearly 50 million uninsured people, 100,000 yearly deaths from medical mistakes, huge and clinically indefensible variations in care, and outcome and performance measures that are as likely to be sources of shame as pride. If flattening our world improves value (quality divided by cost), either through the new internationalized care or by goosing our own system into action (the now-familiar disruptive innovation), that’s got to be a good thing.

But for domestic providers, it might not feel so good. Yes, foreign competition led the Big Three automakers to build better and more efficient cars – but they answered their wake-up call too late to save their hides. The risks to domestic healthcare are not as monumental as those playing out in Detroit (it is one heck of a lot easier to buy a Camry at San Francisco Toyota than to get a CABG in Bangkok, and every now and then a Bangkok airport shutdown or a Mumbai terrorist attack will make some Americans hesitate before getting on that plane). And there are hundreds of issues still to be worked out: can patients sue for medical malpractice, how do you ensure continuity of care for patients receiving care both domestically and internationally, will medical tourism compromise local care for Thais and Indians, will middlemen start siphoning off too much of the savings or acting unethically, and much more.

But in the end, the Flattening of Healthcare is inevitable. And, while it will be controversial, it may also represent the kind of shakeup our system requires if it is ever to deliver the value Americans need and deserve.

So hold on tight. We’re in for a wild ride.

Global 2.0: A lesson from Indian pharmacies

MedPlus Pharmacies is arguably one of India’s fastest growing health companies. Since its launch in 2006, the retail pharmacy chain has opened 500 stores in several Indian cities and serves roughly 25,000 customers daily.

MedplusIn a space no larger than a walk-in closet tucked into neighborhoods, local MedPlus pharmacists dispense low-cost but guaranteed high quality medications and track customer orders with a sophisticated electronic record system.

In many respects, the MedPlus business model could not be more different than that of U.S. retail pharmacy chains. I spoke recently with Apu Gupta, MedPlus COO, who explained to me that the business’ success is rooted in its uniquely Indian model developed by founder and CEO Dr. Madhukar Gangadi while he was a student at Penn’s Wharton School of Business.

MedPlus’ business model would likely not work outside India, and the Walgreens or CVS model would likely not work in India, Gupta said. This got me to thinking about a term I first heard last spring: Global 2.0.

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NICE job. Cost-effectiveness in the UK

Yesterday I went to a high powered lunch put on by HealthTech, with a high powered crowd attending (including the head of the California Dept of Managed Health Care, lots of Kaiser Permanente people, Arnie Milstein from Mercer, et al).

The speaker was Andrew Dillon, the head of the National Institute for Clinical Excellence (NICE), the UK’s technology assessment agency. But unlike the late and somewhat lamented Congressional OTA that the Republicans killed in 1995, NICE has teeth. NICE is only well known in the US as being the agency that stops new wonderful treatments getting to blighted Brits who are instead left to die in the streets.

The way this works, as Dillon explained to the somewhat incredulous head of the California Dept of Managed Healthcare (and I paraphrase) was that if NICE says something’s off limits (such as a new drug) a doctor won’t prescribe it. And if they did, the pharmacy wouldn’t fill it. And if they tried to, well they wouldn’t find it because the hospital wouldn’t have bought it. Such power! And I’m sure the envy of the many regulators and payers in the room.

However, Dillon explained that contrary to popular belief there isn’t a straight cut off point for approving new technologies.

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Commonwealth puts the boot in, again

Veteran THCB readers shouldn’t need too much reminding about this, so I’ll spare you the blow by blow documented here over the years. Here’s the bottom line. Any time you do a trans-national study on health care, you find that the U.S. spends way too much and gets way too little in terms of quality and outcomes.

In doing these studies the Commonwealth Fund has become the bete noir of the political right.

Why? Well it starts with data first and then draws conclusions, rather than the opposite approach followed by most on the right. And whatever way you look at the data they’ve produced over the years, it’s clear that things aren’t going well.

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Dispatch from India: Private sector responding to new health care consumers

Editor’s note: The current issue of Health Affairs released next week
focuses on health care in India and China.

As with most parameters within the Indian economy these days, the health care industry is huge but that doesn’t tell you much.

The fact is that health care in India is a broken system whose fault lines are fast being papered over by the rapidity of change, influx of big capital, drive of entrepreneurship and the relative ease of staking positions and targeting opportunity in an economy on fire. Combine that with the government’s involuntary relinquishing of idealistic heights due to resource constraints and its abysmal record and you get an industry that is overwhelmingly in the hands of the private sector. Maybe the private sector can redeem the industry after six decades with little to show by the government.

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Drug advertisements annoying and possibly misleading

Sean Neill is a South African-born, British-trained anesthesiologist, who
recently relocated to Midwestern USA. He blogs regularly at OnMedica about his cross-cultural experience, frequently
pointing out oddities of American health care. 

Watching television in America takes some getting used to. Apart from the accent, it is strange to hear companies marketing drugs directly to the consumer. Not only do they sell their own brand, but they actively name and shame their competitors’ products. During a commercial break there may be two different brands of antihistamine telling you how bad the other is.

Direct-to-consumer advertising (DTCA) is the promotion of prescription drugs through newspaper, magazine, television and internet marketing. Although the drug industry is mounting major campaigns to have DTCA allowed in Europe and Canada, the only two developed countries where it is currently legal are the U.S. and New Zealand.

Studies have shown that increases in DTCA have contributed to overall
increases in spending on both the advertised drug itself and on other
drugs that treat the same conditions. For example, one study of 64
drugs found a median increase in sales of $2.20 for every $1 spent on
DTCA. It has been reported that 10 of the leading 12 brand-name drugs
with DTCA campaigns have sales in excess of $1 billion annually.

Continue reading…

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