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PHARMA/POLICY: Another Canadian import to cause trouble?

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As you know I (along with a couple of other medical bloggers) have long been opposed to the War on drugs and the ridiculous ban on marijuana.  Marijuana has obvious medical uses, particularly as an anti-nausea and anti-neuralgia agent. Many other wonders are claimed for it as an anti-cancer agent, etc.  These may or may not be true but as clinical trials are not allowed we can’t tell for sure, and it doesn’t seem any less effective than many of the equally ineffective chemo regimens that are used in oncology–if a patient tells you that he’s alive because of marijuana, who are we to take it away from them? I of course think that marijuana should be legal, fully regulated (and taxed) like any other herbal supplement or alcohol. 

However because of its obsession with promoting arrests, prisons and the black market, the US government has been blind to all the news on medical marijuana as it’s just too inconvenient to note that a supposedly evil drug with no medical value is actually therapeutically useful. Well now the Canadians have gone further than allowing patients to use their own marijuana, they’ve actually approved a medicine that is liquid marijuana. I’ll let the MPP take it from here, but suffice to say if the drug warriors cared a fig for reason, they’d be tying themselves in logical knots over this one.

The Canadian government has just delivered a body blow to the U.S. government’s irrational prohibition against the medical use of marijuana. Today, Canada approved the prescription sale of a natural marijuana extract — for all practical purposes, liquid marijuana — to treat pain and other symptoms caused by multiple sclerosis.

In short, the Canadian government has just certified that virtually everything our own government has been telling us about marijuana is wrong. Sativex, produced by GW Pharmaceuticals in Britain, is literally liquid marijuana. It is nothing like Marinol, the synthetic THC pill old in the U.S. and sometimes falsely touted as an adequate substitute for marijuana. Rather, Sativex is a whole-plant extract, containing the wide variety of naturally occurring compounds called cannabinoids that are unique to marijuana. It also contains trace elements of other compounds in the plant, which scientists believecontribute to its therapeutic value.

Sativex is to marijuana as a cup of coffee is to coffee beans. If Sativex is safe and effective, marijuana is safe and effective. And Sativex is safe and effective. Studies have shown significant effect against pain and other symptoms caused by multiple sclerosis and other debilitating conditions, and over 600 patient-years of research have established a remarkable record of safety.

Sativex should certainly be approved in the U.S., but the process may take years — if it is allowed to happen at all, given our federal government’s reflexive hostility to the medical use of marijuana. And more importantly, now that we know beyond doubt that marijuana is a safe, effective medicine, how long will our government continue to arrest patients who use it?

Visit http://www.mpp.org/sativex.html to learn more about the issues associated with Sativex. Please visit http://www.mpp.org/donate2088 to give MPP the money we need to continue lobbying to end our government’s war on medical marijuana users.

POLICY: Unrealistic, unfair mercatilism in health care.

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I like Don Johnson’s blog Businessword but sadly when you really push him, as I’ve done in his comments over the last couple of years, he either won’t answer or his answers reveal a political philosophy that is downright mean. So in his criticism of Krugman’s analysis on his blog and in comments at THCB here, Don essentially says that if you’re poor or sick in America, well that’s just tough titties. And, as a by product, it’s OK for the insurance market to screw over those who really need individual insurance because, well, because it’s a "market". Same way it’s OK for Enron to defraud the California rate payer, or same way it’s OK for Healthsouth to defraud its shareholders. After all they’re operating in "markets" too.  But Don misses the wider point. Because of the way the US system is set up  — because we’re a richer country than any in Europe, and because the majority of people can afford to pay way too much for our health care —  we systematically overpay for things that no rational market would value. That does not help our economy, it hurts it as most health care spending is non-productive to the overall economy.

The other point that pro-unrestrained booty capitalists in health care, or those Krugman was criticizing, go on about is the huge waiting lists in Canada and the UK.  Well as I mentioned in the UK the wealthy can trade up with their own money while the less well-off get a decent standard of care. Meanwhile single payer advocate Don McCanne found this just excellent chart from Stats  Canada which shows that median waiting times for non-emergency surgeries in Canada  are just over 4 weeks! I’m more than prepared to wait 4 weeks for non-emergency surgery if it means that poor people wont be crushed by their medical bills and can get access to basic health care. (For far more details on this see my "Oh Canada" piece).  And anyone who doesn’t think that’s a fair equation is just mean in my viewpoint. Not to mention that such a system would cost me as a tax payer and a premium payer less money! Money I could spend on other, more productive things, like Frappuchinos.

POLICY: Ezra Klein on Health Care in France

Ezra Klein is a nauseatingly over-achieving student at UCLA who, at an age when I was trying to pick sufficient 10p pieces out of the gutter to buy myself a half of ale at the college bar (and usually end up back in the gutter), has a successful blog and is on the way to becoming a writing star of the liberal ilk. Ezra’s blog goes all over the map in a fascinating way.  This week he’s featuring a whole series on health care systems in other countries.  Dangerous work, Ezra — that’s where I started.  The first one is about Health Care in France and it’s really good.

Policy: A Break in the Florida HIV case By John Pluenneke

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It sounded a lot like one of those stories from Florida we keep hearing about. A mystery like the chads. Or the anthrax case, which started not far away in Boca Raton.   

Two months ago a worker at the Palm Beach Department of Health (DOH)
accidentally sent out an email containing a list with the names of
6,500 people with HIV/AIDS. Officials thought the problem had been
contained. It turned out it had not. About thirty days after the incident mysterious letters started
appearing at the homes of people named on the list. "Your name appears
on a list of people with HIV/AIDS", the letters began.

Somebody had apparently gotten their hands on the list. That somebody
was using it to target people with HIV/AIDS. The head of the Palm Beach
Health Department called the case "terrorism."  Speculation immediately
focused on the e-mail leak.

Had a copy of the list somehow escaped and found its way into unfriendly hands?  It seemed unlikely we’d ever know exactly what happened. After all, the
anthrax case showed how difficult it is to track down somebody who
wants to go around using the U.S. postal service to mail things to
people.

There has however been a break in the case. Late last week, the Palm Beach Health Department said it has fired an analyst
in its HIV/AIDS program. It also said it had discovered another
security breach. There is suspicion that Dr. Shireesh Patel was the
person responsible for the disappearance of 15 pages of the paper copy of the Palm/Beach HIV/AIDS list. 

According to documents obtained by the Palm Beach Post, the internal
investigation into the matter found that Patel lied to investigators
about the incident. It also found that he asked fellow employees to
help him cover up the mistake. 

There are also new details about the number of letters sent. According
to the report, which was filed by inspectors Jerome Worley and Paladin
Henderson (a solid name for law enforcement, if ever there was one), 36
letters were sent to people with HIV/AIDS in the Palm Beach area.

Case closed?  Perhaps not. The Orlando Sentinel
has a piece which ran over the weekend, which strongly suggests that
things are far from settled.  According to Department spokesman Tim O’Connor the
paper copy of the list could not be the source of the leak because the
missing pages do not include any of the names of patients who received
letters.  Very mysterious. Very mysterious, indeed.

It would be interesting to know what Dr. Patel has to say for himself, wouldn’t it?

POLICY: Krugman on the international health care context

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Paul Krugman has a great column out about the international health care context, called The Medical Money Pit. There’s nothing new or original that THCB readers or Health Affairs readers won’t already know. We spend more and basically get less, but we lead the league in surgeons driving Porsches. But it’s very good that someone is raising this issue outside of pure policy wonk circles. Even Krugman seems stunned that our government spends so much more per head than other governments which cover all their people, and all we get for it is Medicare for seniors and crappy coverage for the very poor. And by the way those numbers don’t count the role of the Feds and states as employers paying for health care coverage for 10 million government workers–if you add that in, the government share of spending is higher (although that math doesn’t really matter as we don’t cover any more people because of which column you put the spending in).

What Krugman doesn’t say is that, in general, government spending in those other countries guarantees a basic level of care for everyone, and that the rich (even in the UK, but not in Canada) can trade up with their own money for a nicer class of waiting room or to jump the line. And they do, and there’s not only nothing wrong with that.  It doesn’t destroy the basic fabric of the social system.  And if we had universal health care here, it would be true here too, and there would be nothing for those in the upper social tiers here to be afraid about.  But you won’t find that rumor getting out when this gets discussed politically.

HEALTH PLANS/POLICY: It will stagger you to find out that health care competition may not result in better quality!

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Now I want you all to sit down comfortably  and drink a glass of water before you read this article.  Says here (in a story cribbed from the academic journal Medical Care) that Health care competition may not result in better quality. The study found that HMOs in places where there was less competition between HMOs did better on HEDIS scores. Oddly those where there was more enrollment in HMOs also did better on HEDIS scores (though not as well on consumer satisfaction).  All suggesting that a single monopoly HMO probably does best of all on quality.  Um, does this sounds like anywhere we know? Well now you’ve all recovered from the shock, let’s review what little that we know on the subject.

a) Competition amongst health plans and HMOs is not about the competition to produce the best quality care. It’s about the competition to insure as many as possible of the people least likely to need it. Harsh but fair words.b) In general health plans have little ability to control what medical providers do, and providers are the ones who do the things that make up HEDIS scores. Consumer satisfaction with health plans has to do with customer service reps, not health care quality which the average consumer wouldn’t recognize even if it showed up as their prom date.c) The more health plans there are in an area the less each plan’s ability to get providers to do anything, as they’ll be responsible for a very small part of the provider’s businessd) As Porter, Enthoven and a host of other bright people have pointed out, competition such as it exists in the US system is in the wrong place (see point a).And e) no one in the real world, where people and employers vote with their money, cares about HEDIS or has even heard of it.

I hope no one working hard in a health plan feels too offended. Sorry for feeling bloody minded tonight, but my next chore is to do my taxes! I’m sure you understand!

POLICY/PHYSICIANS: Beauty Contest

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Modern Physician is running a poll where you can go and vote for the
best looking, err…most powerful physician executive in American
health care.  It’s actually quite a tricky call. For example is Tom Frist from HCA the most powerful doc because he and his family own the biggest hospital chain and have a sibling who runs the Senate? (For that matter why isn’t Bill on the list as overall he’s obviously by the far the most powerful MD in the nation even if it hasn’t got much to do with his increasingly dubious behavior when he claims to be using his medical training). Is Jack Rowe from Aetna or Bill McGuire at United Health the most powerful because everyone at one the biggest insurers has to do what they  say (plus Bill’s probably got the most money!)? But maybe as the doc preaching the word of disease management at the single biggest insurer Sam Nussbaum (Wellpoint) is now the most powerful?

But then again while I don’t think Carolyn Clancy (AHQR) is that powerful, and that’s a bad thing for American health care, Mark McClellan (CMS) has got the biggest stick and seems to be prepared to use it in the interest of promoting "the right things" from Medicare in the years to come.  On the other hand Don Berwick (IHI) or Jack Wennberg (Dartmouth) have probably had more influence in promoting P4P and the quality movement that McClellan’s now espousing than anyone else.  Influence?  For sure. Power?  Well in some ways they wouldn’t have had the time they’ve had to build up their influence if they’d had the power to achieve their goals!

Maybe it’s some new fangled IT whiz who’s got the most power — readers in one poll last year called David Brailer the most powerful man in all of health care — then he didn’t even get $50m from the Congress to fund his office so I’m not convinced that he has any real power.  Maybe Blackford Middleton at Partners is the most powerful, showing that real EMRs can be brought into the ivory tower (Well I met a bunch of his serfs last night and they all seemed real scared of him!!). Molly Coye is great, but for all Healthtech’s influence with the big hospitals her days of real power were back when she struck fear into the heart of Medi-Cal managed care plans (or at least would have done if they’d figured out what she was up to!).

Is Jack Lewin at the CMA (the largest state medical association) the most powerful? Hmm…you don’t hear much about Michael Maves at the AMA either for that matter.

So my vote this year for the first and last time will be for someone who’s not in the mainstream.  David Graham, the FDA gadfly, is pretty much responsible for destroying Vioxx and crippling Merck, and has had a hand in causing problems for the rest of big pharma. I can’t vote for him as he’s not on the list, but Sid Wolfe shares the same views so I can vote for him and call it a team vote. That’s real power even if its effervescent and more destructive than constructive (although something constructive may yet come out of all their work).

But overall this tells me that physicians are just not that powerful in health care as big names. It’s not the star power here that counts. It’s the collective behavior of all the doctors in practice and the power they exert in decisions they make every day that still more than anything else really determines what happens in American health care.

 

POLICY: Uninsured number will rise, but maybe not enough

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In an article in Health Affairs today called It’s The Premiums, Stupid Gilmer and Kronick project the numbers of the uninsured through 2013. Kronick, BTW was a co-author with Alain Enthoven of some of his market-based consumer choice articles, though he seems to have moved leftwards since the early 1990s.   Essentially they forecast that there will be a continued price effect with low and middle-income workers continuing to be squeezed out of insurance as the costs go up.  For the human side of this, take a look at the LA Times article which assessed this phenomenon yesterday. For the numbers, Kronick and Gilmer say:

Based on the
projected growth rates for health spending and personal income, we
estimate that the rate of uninsured non elderly workers will increase by
4.0 percentage points to 27.8 percent in 2013. We estimate that the
uninsurance rate among all nonelderly Americans will increase by 3.3
percentage points to 20.5 percent in 2013. With an expected population
of 271 million people under age sixty-five in 2013, we estimate that
there will be fifty-six million uninsured Americans in this age group,
an increase of thirteen million over the CPS estimate for 2002. Of this
estimated increase, 8.6 million occurs because of the expected increase
in the proportion of the population that is uninsured, and 4.4 million
because of an increase in population size.

The problem is that while there are countless stories of misery behind these numbers, and some real costs to being uninsured in terms of both access to care and worse health status —  not to mention the corresponding increase in people being severely underinsured — this may not be enough to change things.  Vic Fuchs at Stanford always used to say that we needed a national crisis to change the health system.  Adding a couple more million people — and they are poorer, more marginalized people than the typical voter — to the uninsured numbers each year isn’t going to change too much.  If however, things are getting worse, and we see these numbers increase at a faster rate — particularly amongst white middle income males in their 50s (i.e. Republican voters) — then there might be some real change coming up in 4-8 years.  I think that’s an equally plausible scenario, but if Gilmer and Kronick are right, then it’s probably more of the dreary same.

POLICY: The high cost of health care

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I’m giving a talk this morning about consumer health care so not much time for a long post.  Kind of ironic that we’re entering the brave new world of consumer health care at a time when the price of insurance has got so high many people just cannot afford it. The LA Times today has an article called At what cost? which has some horrendous stories of low paid workers having to pay up to a quarter of their income in health insurance premiums. As IFTF/Harris has said for years, the empowered consumer is in general reluctantly empowered, and the basic ethos is pay more, get less.

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