Stan Nowak is President and CEO of Silverlink which does automated phone calls on behalf of health plans. It’s a lot more complex and much more interesting than you might think, and it really is closing the loop for those health care consumers who don’t use the web. Plus Stan is an interesting and fun guy, even though he had to suffer through that awful Cambridge, Mass based business school!
Listen to the podcast. The transcript will be up in a few days.
Nothing really new here, but a nice piece from Lisa Girion in the LA Times about how because of the haste of insurers to avoid association groups and insure the young healthies, said groups are going into death spirals. And of course being kicked out by their plans if they can possibly figure out a reason in the fine print to do so. Today’s bete noir is Blue Shield of California which is kicking out the Association of Realtors on a technicality, but they’re obviously all at it.
Which of course means that if you’re in one of those association groups and yours get terminated and you’re sick, you’re screwed. I thank my lucky stars that when this happened to me, I was able to fool one plan into thinking that I’m healthy enough to be worth having. So far, one year later I have no claims, so they’re up!
My father would rolling in his grave if he wasn’t still alive. I, yup the guy who voted for Thatcher twice, have been given a column on the venerable web site of The Guardian–the paper of the wet liberal lefty chattering classes in the UK. I’m up explaining the Democratic Presidential candidate’s health plans or lack of them.
This past week saw the first debate among the Democratic candidates
for president about what has become the most important domestic issue
in American politics: the country’s failed healthcare system.
To serious students of policy, America’s healthcare is the most obvious
feature of its society and economy that needs correction. However, to
serious students of American politics, reforms to the
healthcare system are the most difficult problems. Case in point: the
Democrats lost control of Congress in 1994 in large part because of
opposition to the Clinton healthcare plan.The problem is that healthcare system reform will necessitate
controlling the system’s huge and growing costs – currently 17% of GDP
in the US against less than 10% in most of Europe. But those reforms
will need to cover the 45 million people who now lack insurance, as
well as reassure middle America that they will keep their coverage, and
not upset upper-income Americans and the senior lobby who are generally
happy with their doctors. And of course then there is the problem of
dealing with a powerful $2,000bn industry which has little interest in
seeing its bumper profits diverted.
Note: I put this up late last night–but it’s such a huge story (and as one emailer says, can you think of a recent study that so blatantly points out all the flaws in the health care industry better than this?) that I’ve moved it to the top today
Man. This is no fun for Boston Scientific and the rest. Most angioplasties unneeded, study finds. This is even worse than was thought. Non-emergency angioplasties with stents are not even any good at reducing chest pain (angina) compared to drugs over 5 years:
The stunning results found that angioplasty did not save lives or prevent heart attacks in non-emergency heart patients. An even bigger surprise: Angioplasty gave only slight and temporary relief from chest pain, the main reason it is done. "By five years, there was really no significant difference" in symptoms, said Dr. William Boden of Buffalo General Hospital in New York. "Few would have expected such results."
<SNIP>
About 1.2 million angioplasties are done in the United States each year. Through a blood vessel in the groin, doctors snake a tube to a blocked heart artery. A tiny balloon is inflated to flatten the clog and a mesh scaffold stent is usually placed. The procedure already has lost some popularity because of emerging evidence that popular drug-coated stents can raise the risk of blood clots months later. The new study shifts the argument from which type of stent to use to whether to do the procedure at all. It involved 2,287 patients throughout the U.S. and Canada who had substantial blockages, typically in two arteries, but were medically stable. They had an average of 10 chest pain episodes a week — moderately severe. About 40 percent had a prior heart attack.
Live by the stent and potentially die by it. BSX was down around 6% at the close. And it would be un-THCB like to say “I told you so”, but I told you so.
UPDATE: Meanwhile, all the analysts MarketWatch polled don’t think that this study will make any difference, even though BSX barely got a dead-cat bounce today after its mauling yesterday. And then, well you knew this was coming….here’s what The Industry Veteran thinks about my pussyfooting around the issue:
The NEJM study on stents versus medical therapy, publicized this week in connection with the American College of Cardiology meeting, is not really “worse than what we thought” in terms of what it reveals about the larger health care system. It demonstrates exactly what we thought and what I’ve made explicit on this site several times. Ed Silverman over at Pharmalot nails it squarely when he writes that a large segment of cardiologists feel threatened by the study’s results because there are financial incentives for them to insert stents. In other words, the big problems facing health care will not be adequately addressed by digitalizing medical records, adopting treatment algorithms or any other technical tweaks. As long as the public remains hostage to obsessively greedy manufacturers, equally greedy physicians and third-party payers that are capital aggregators, we will continue to pay more than the rest of the world for our health care and, for the population as a whole, derive fewer benefits. Too many middlemen are allowed to extract too much economic rent from the health care system.
As the ACC meeting in New Orleans winds down, I’m reminded of a conversation I had at a previous meeting with a cardiologist from Westchester County, New York. American society, in his considered opinion, must guarantee practitioners who choose to start in his field a minimum yearly salary of $250,000 in return for their willingness to “give up the decade of their twenties.” Until then I still held the naive notion that while nationally acclaimed investigators working in academic medicine are exalted whores and crooks, the garden variety specialists in solo offices maintain genuine concerns for their patients as they work to obtain a secure but not unconscionable livelihood. In a pig’s eye!! Specialty practice in the United States today attracts people with the souls of Tony Soprano or “Chainsaw” Al Dunlop and it refines their predatory instincts through an arduous indoctrination process. Debating whether they or the pharma and stent companies do more to corrupt the system remains pointless, similar to arguing whether local politicians or the road contractors who bribe them are worse crooks.
While I’ve been focusing on pricking egos in the HBS common room, Greg Pawelski has been keeping vigil on our friends over in the wonderful world of chemo. The main recent development is the FDA issuing a warning about overuse of the anti-anemia drugs Eopgen, Arenesp and Procrit. Amgen (which makes the first two and JVs the latter) is running into problems because of this. Greg believes that things may be worse than that. He wrote to me saying:
Superficially, it sounds like a great expose—greedy clinics/doctors trying to make money by pushing drugs. The New York Times article states that the drugs, given by injection, have been heavily advertised, and there is evidence that they have been overused, in part because oncologists can make money by using more of the drug. That’s not really a new revelation. We’ve been down that road before without much done to change it. According to Dr. John Glaspy, director of UCLA’s Outpatient Oncology Clinic, one complicating factor, experts say, is that oncologists make significant revenue buying cancer drugs from manufacturers and charging patients a higher price for receiving the drugs in their offices. That profit motive could influence some doctors’ decisions. However, patients with anemia, which can cause sluggishness in its early stages and can be fatal in advanced phases, can get blood transfusions, typically every few weeks, instead of using EPO.
Could it be that increased numbers of red cells deliver more oxygen to the tumor cells and thereby increase their activity across the board, including with respect to invasion, proliferation, and metastasis? On one hand they’re developing drugs to halt and reverse angiogenesis while on the other hand they’re helping the tumor to obtain more oxygen with existing vasculature. And nobody in charge foresaw that? Amazing how they can apply differing standards for proof or benefit when profit is involved.
Whether or not there’s any truth in that it’s clear that bigger guns than Greg’s are being aimed at the issue. And one such gun belongs to United Healthcare which has found some pretty disquieting things about the use of some big time biotech drugs including Epogen and Herceptin among its cancer patients. Lee Newcomer, United’s ex-Senior Medical Director (but still an employee) told a meeting last week:
In reviewing records of patients who were prescribed the drug erythropoietin — an expensive agent that boosts blood supply in patients with anemia — <snip> 44 percent of those patients had blood work-ups that would indicate they were not anemic. Last year at the NCCN meeting, Newcomer also cited the use of the new breast cancer drug tratuzumab, sold as Herceptin, which has been found to be helpful in a group of women with breast cancer that overexpresses a certain gene known as HER2. The drug is ineffective in women with normal levels of HER2, yet Newcomer said about 12 percent of drug orders — which costs thousands of dollars per treatment — were for women who tested negative for HER2 overexpression.
So right there, real questions abut the inappropriate overuse of the two most popular biotech drugs. But that’s not all. What about overuse of other drugs that may also be innapropriate, but that we’re not so sure about?
Newcomer also said that, when he scrutinized prescribing habits for treatment of patients with pancreatic cancer, "we had doctors writing prescriptions for 188 different combinations of treatments, yet we know that there are only two drugs that have any activity against that disease."
<snip>
Newcomer said that one of the newest biological targeted agents, bevacizumab, sold under the trade name Avastin, which is rapidly being included in numerous drug cocktails because it has been shown to extend survival in diseases such as colon cancer, can cost as much as $47,000 a year for one person. "But that doesn’t explain its true cost," Newcomer said. "We know that Avastin improves outcomes in about 20 percent of patients, but we have no idea which cancer patients will benefit from a course of treatment." According to his calculation, it costs $354,000 per year of life extended with Avastin.
And of course, there’s a message in all this for Pharma and the Oncology-Industrial Complex.
Newcomer and other panelists said that unless the prices of the drugs are controlled, a major backlash against the pharmaceutical industry is brewing.
There’s a new blog about HL7. If you don’t know what it is, then it’s probably not for you. But if you do, then take a look.
Things Halvorson said….
In his remarks to (video, no transcript yet) The Commonwealth Club as interviewed by Chris Rauber, who was being rather too nice—although that’s mostly the fault of the stupid written Q&A format the Commonwealth Club uses (You’d think that something vaguely modeled on the UK system would grok the concept of a follow-up question), KP CEO George Halvorson said a few interesting things:
“One of the things we need in American health care is an extremely high level of transparency” (more on that later George!)
“Any time you get to a pure single payer system you get a health care system that rations <snip> if you want a good look at single payer look at the medical systems in our prisons.” I agree with him in his specifics about transparency and how it would be better to have a system with providers competing properly with better information, but with that type of rhetoric is his next job at NCPA or at PRI? C’mon George! Every health care system rations—something John Goodman is actually right about. The question is, how is it done? Just accusing single payer systems of rationing and actually bringing up the erroneous bogeyman of Canadian patients crossing the border puts Halvorson in a camp of wingnuts with whom he ought not to be associating himself.
And as for that transplant program. “It was an excellent program” but on the administration of the list “we just screwed up.” Methinks that David Merlin, the fired administrator of that program and the source of the LA Times story does not agree. Here’s what he said in response in a letter to the SF Business Times today:
Whistleblower: Kaiser’s kidney ills not tied to CEO’s absenceAs the person who exposed the Kaiser kidney transplant program tragedy to state and federal officials and the media, I¹m certain the majority of Kaiser kidney patients are as insulted as I by George Halvorson¹s attempt to portray KP¹s unwillingness to speak up and/or take responsibility due to his six-week absence. KP¹s transplant program had been in operation over 18 months prior to his hospitalization in April 2006. The massive clinical and administrative failures had been identified by Kaiser senior officials long before this. Around May of 2005, a majority of the 48 northern California Kaiser nephrologists (kidney specialists) called an emergency meeting of senior KP physicians (including Robbie Pearl, M.D., CEO of the 6,000 member TPMG physician group) and demanded the fledgling Kaiser kidney program be shut down due to overwhelming concerns of patient neglect and associated health issues and that all 2000-plus patients be sent back to UCSF and UC-Davis Medical Centers.These problems didn’t suddenly surface at the time Halvorson became ill. His comment that the kidney crisis was kept from him during his six-week recuperation rings hollow and his assertion that United Network for Organ Sharing thought Kaiser was transferring one patient, and not 2,000, is both ridiculous and irrelevant. Kaiser (TPMG) doctors were responsible for the day-to-day care of these patients, not UNOS.Kaiser has attempted to portray their internal problems as administrative issues, but as an experienced health-care administrator who personally witnessed the internal operations, I can tell you with certainty the problems stemmed from clinical issues due to inadequate staffing of properly trained physicians and nurses and the personal in-fighting between Kaiser transplant surgeons and transplant nephrologists.Kaiser violated the covenant of public trust between patients and physicians. Thousands of real people endured unnecessary pain and others suffered unnecessary death. In health care, the unnecessary death of a patient is the strongest indicator of quality of care or in Kaiser’s case, lack of care. It doesn’t get any more clinical than that.David MerlinFormer director, Kaiser Kidney Transplant Program San Francisco
It’s worth saying again that the crux of this whole thing is not only was there a screw-up of huge proportions on the UNOS-Kaiser hand-off, but there is the strong suspicion–highlighted by what Merlin says and intensified by Halvorson boasting about the successful outcomes of the transplants that were done–that the KP surgeons were cherry-picking their cases and leaving the marginal ones on the waiting list (if indeed they ever got onto the "new" waiting list). If the meeting between the nephrologists and the senior Permanente staff Merlin talks about took place, you can bet that that was at least one topic of conversation.
I must admit when I am wrong. My repeated claims that the Massachusetts Health Plan would
be on life support—with a likely ‘pulling of the plug’—by early 2008 have been
proven wrong.It has happened already.
So the WSJ gives another know-nothing big oil-sponsored hack from AEI another forum to use the same tired defense of the US system in the Elizabeth Edwards case. Oh look! Cancer outcomes are worse here than in Europe therefore their health care systems must be worse. With the unspoken implication that if her husband’s plans get enacted she’d be dead.
Just for a minute ignore all the other issues about costs, the 18,000 people whom the IOM says die each year here earlier than they would in those European countries because they’re uninsured, medical bankruptcies up the wazoo, etc, etc, and feast your eyes instead on this little nugget from a much longer article at the Annals of Internal Medicine.
Contrary to popular belief, the health care here isn’t always the best. Many other industrialized countries provide health care that is just as good and sometimes better. For instance, 30-day acute myocardial infarction case-fatality rates are below 7% in Denmark, Iceland, and Switzerland, compared with almost 15% in the United States. Incidence of major amputations among diabetic patients in Finland, Australia, and Canada is less than 10 per 10,000 compared with 56 per 10,000in the United States. And Australia, Canada, England, and New Zealand all have a better 5-year kidney transplantation survival rate than the United States.
There are so many better things to be arguing about.
But if the AEI and the fake free-marketeers want to play that game, why is the American health care system killing people with heart attacks, or chopping the legs off diabetics at more than double the rate of foreigners? Does the AEI really want to go down that path–particularly as there are way more Americans with heart disease and diabetes than with cancer.
Citiria Publishing is looking for a reviewer for a patient self-help book, "Heart Bypass – The Road Map".
Please contact clive ‘at’ citiria.com. If it’s good I’ll print the review here.
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