The answer, is of course, no-one. And this interesting web site Factcheck.org, a non-partisan organization like the Center for Public Integrity hated equally by everyone, has an article about Bush’s use of Mark McLellan’s research which said that some 8-10% of HC costs were caused by defensive medicine,. It says something I didn’t know which is that the CBO looked into the research and couldn’t duplicate it. But that’s not the real issue. The real question is when those "defensive" tests and procedures were ordered, did the doctors and providers get paid? The answer is of course yes. Which means that getting rid of defensive medicine will mean reducing providers incomes. Is that what the AMA really wants?
Above the Fold
PHARMA: More on the state of pharma marketing, by The Industry Veteran
Yesterday I had a long post which touched on the malevolence of some pharma marketing, the alleged incompetence (or at least unoriginality) of other pharma marketing, and the possibility that efficiency in sales will be improved by better user of CRM and business intelligence. In theory that greater efficiency will in turn lead to sales force manpower reductions, cost-cutting and improved margins even as the overall pricing strategy of big pharma comes under more pressure. Needless to say The Industry Veteran is not swayed by the arguments presented….
I don’t believe that substantial reductions to salesforce sizes will appreciably reduce the unconscionable prices of drugs. Several sources are prompting greater scrutiny of promotions to physicians and the federal government is set to play a somewhat larger role in prescription drug benefits. Both trends mean that Big Pharma is begrudgingly accepting a wee bit of pricing constraint in return for more customers and the resulting cost-benefit of ever more sales people has approached its limit. Remember, the arms race in salesforce sizes really started in earnest during the mid-1990s. That’s when Pfizer showed the industry that two or three babes in short skirts, bending into the trunks of their cars to retrieve samples, can outsell one Health Science Associate or Medical Science Liaison with a Pharm.D. Prior to that time, when the salesforces were considerably smaller, Big Pharma had the highest ratios of earnings-to-equity, earnings-to-sales and earnings-to-assets of any industry in existence. Once again, deciding on what is to be done involves fundamentally changing the system.I understand and sympathize with the frustrations Brian Towell expresses as a marketing communications supplier. Big Pharma’s state of the art in marketing and marketing-support services remains decades behind consumer packaged goods and many other industries. Memo to Brian: get over it, understand that it’s intentionally that way, then either accept it or get into something else.Contrary to what some people believe (including my friend who teaches marketing and sends me daily missives of Big Pharma’s outrages that include the subject line, "new stupidity"), the Hank McKinnell’s and his malevolent cohorts are not dumb. Their economic model of patent protection, a gatekeeper system, long product development durations and the rest work for them. They don’t have to be nimble because they can’t sweeten the cola on Saturday and get it onto store shelves the following Thursday. They don’t have to target ever changing, ever more complex consumer segments (left-handed, unmarried women with small breasts who disdain mass merchandisers and prefer vegetables in aspic) because the universe of their US market consists of a share of 600,000 doc-whores. Big Pharma doesn’t need to spend $2 million for 30-second Superbowl ads in outmoded media such as network television to reach the lower-middle class. (TCHB editors note: But they do!) Nor do they need to send people into bars or use communication techniques that Brian may consider innovative to reach Gen Y’ers. Frankly, I’m happy that Big Pharma is stodgy in this area and I’d prefer to see a rollback of the 1997 legislation that expanded DTC promotions so that Pharma promotions become even stodgier. Brian, go peddle your promotions for discretionary bullshit to other industries. Healthcare is too important for asshole ad men.
POLICY: Toto, we’re back in Kansas and it’s 1991 again.
Back in 1991 in a very, very brief moment of (reflected) non-stardom, which I rediscovered on an old photocopy when I was unpacking some boxes during my recent move, my name (and those of my co-authors on a piece about Japanese health care) was in an article about other countries health care systems on the front of The New York Times. At that time the health care debate was about to warm up, and the NYT was trying to educate the public–or at least the small fraction of it that reads or cares about the "paper of record"–about a few basic facts.
Those included the fact that the amount spent on healthcare as a share of GDP vastly exceeded that of other industrialized countries, that American outcomes in terms of infant mortality rates and life expectancy were only in the middle of the pack, and that some 14% of the population had no health insurance–a situation unique to the US. A series of articles about other health care systems (Canada, Germany and Japan’s among them) hinted at the fact that there may be alternative models that we possibly should just consider here. And additionally another article showed that you could, if you wanted to, cover all Americans without spending more on health care–(another article in which I glommed onto the much superior intellects of Evans, Barer and Morrison).
Well, surprise, surprise, 13 years later all those facts are still true. We have made some progress in improving overall health, we are spending a boat load more money (roughly double in nominal dollar terms, from about $800bn to $1.6 trillion), and there has been a little more research suggesting that in some specific health areas we are in fact doing a little better. But overall, despite a bunch of industry propaganda, we’re spending a lot more on what can be claimed is more or less a luxury good, and we’re still doing that equally inefficiently as we were 15 years ago.
And as in 1991, the New York Times has published an article explaining that all those problems are still here. We have made some improvements in some areas, the Commonwealth Fund and Harris have discovered that there are some areas where the US does alot better than other countries (and worse in some other areas), and we are of course spending more while covering a lower percentage of its population with insurance. The reason that we spend more is mostly because of higher unit prices, rather than more services. While this may be news to NY Times readers, it’s not to either Health Affairs readers who know about the "It’s the Prices" article from Anderson, Rheinhardt et al, or to Americans who understand that drug prices are a whole lot higher here than elsewhere. It’s also true that prices in hospital and physician services are higher here. For example when I was researching the comparison between Stanford and Tokyo hospitals back in 1990-1, it was apparent that after everything worked out, prices were about double here. In another example I had an office visit and a blood test in new Zealand in early 1993 and exactly the same visit and blood test here 7 months later. The total in New Zealand was about $65 US. In San Francisco, even with the PPO discount, the total was over $200. Funnily enough real incomes of physicians in New Zealand have gone down by about 20% over the last 20 years. Here their experience has been the opposite.
But so what? We’ve known about these disparities for at least 15 years. We’ve known about the problems of uninsurance in the US for over 90. The reasons that the system hasn’t changed are wrapped up in American domestic politics, and will stay wrapped up in American domestic politics. Those politics may change over the next few years–and I think they will change and that universal health security will be a bigger issue in 4-8 years–but no one will care about these international comparisons when that time comes around.
PHARMA: Even the The New York Times has noticed that pharma has PR problems
In an article picking up on the Harris data TCHB shared with its stellar, avid readers (that’s you BTW) last week, the NY Times this morning places Pfizer’s decision to give cheap drugs to the uninsured next to the polling data about pharma’s unpopularity next to several examples of egregious price rises. They also quote extensively Roy Vagelos, scientist CEO of Merck in its 80s and 90s heyday, as basically saying that the industry has blown it.
It’s well worth reading the article because it shows that the mainstreaming of the anti-pharma opinion will have a political impact on the industry, and by extension on the election. (Need I remind you again that the two states with the oldest populations are Florida and Pennsylvania, both extremely close at the moment).
However, the Times lumps several reasons together as to why pharma is so profitable in the US:
The pharmaceutical industry earns nearly two-thirds of its profits in the United States since drug prices in the rest of the industrialized world are largely government controlled. Those profits rely almost entirely on laws that protect the industry from cheap imports, delay home-grown knockoffs, give away government medical discoveries, allow steep tax breaks for research expenditures and forbid government officials from demanding discounts while requiring them to buy certain drugs.
It is not the case that each of these "privileges" has equal weighting for the industry. The fact is that allowing personal imports would not have that big an impact on the overall market. Allowing Medicare to bargain as aggressively as say the VA (or worse, the Spanish or Australian governments) would bring what are called "price controls" by Americans talking about the EU or "discounts" by PBMs to a large section of the market.
That would certainly have a big impact on the industry’s margins. But the pharma industry can take note that, under a similar environment of strict price controls from Medicare and Medicaid, its colleagues on the inpatient, outpatient and ambulatory care side have seen their share of the overall economy grow dramatically in the past 40 years. So, if forced to, pharma companies could manage the potential change in their environment. As a potentially relevant example which also works under monopsony purchasing, the defense industry seems to struggle by OK.
Not that the industry would want to go there, and it will continue to do what it can to fight what is increasingly looking like a rearguard action. Of course in a rearguard action a strategic retreat can often work wonders. I stick by my guns and think that big pharma, looking out strictly for its own self-interest, should cave on the Canadian imports but try to continue to muddy the waters on discounts and price controls. After all 15 years of allegedly aggressive discount seeking by the PBMs hasn’t exactly reminded observers of the way Wal-mart treats its suppliers!
QUALITY: The nursing shortage, with UPDATE from The Industry Veteran
Yesterday I ended a piece on medical safety with a reference to a well known British agony auntie advice columnist who will not go into hospital unless she’s at the point of death, primarily because of the lack of training (and lack of professionalism) of the staff she saw in her last visit where she contracted a severe nosocomial infection. One issue that she included was the relative lack of RNs who were involved in patient contact.
Another issue, detailed well in this article from March 2004, has been the impact on patient safety of overwork for nurses. The story cites a malpractice case where 2 nurses had over 40 patients to look after, and at least one terrible diagnosis fell through the cracks to terrible effect for that patient’s future. Consequently several states, notably California, have mandated nurse to patient ratios (usually 1 to 6), and the initial news seems to be that it is improving patient care. However, a new article by the Univ of Pennsylvania team (lead author is Ann Rogers, but nursing staffing guru Linda Aitken is a co-author) suggests that increased work weeks, increased shift lengths and unexpected but forced overtime is also bad for patient care and increases error rates. As the article is behind Health Affairs’ fire wall, I’ve quoted a chunk of their findings and recommendations:
"Our analysis showed that work duration, overtime, and number of hours worked per week had significant effects on errors. The likelihood of making an error increased with longer work hours and was three times higher when nurses worked shifts lasting of 12.5 hours or more (odds ratio =3.29, p =.001). Working overtime increased the odds of making at least one error, regardless of how long the shift was originally scheduled (OR = 2.06, p = .0005). Our data also suggest that there is a trend for increasing risks when nurses work overtime after longer shifts (OR = 1.34, 1.53, and 3.26 for scheduled eight-hour, eight-to-twelve-hour, and twelve-hour shifts, respectively), with the risks being significantly elevated for overtime following a twelve-hour shift (p = .005). Although the effects of working prolonged shifts were clearly associated with errors, there was no interaction between scheduled shift duration and overtime (p = .17). Finally, working more than forty hours per week and more than fifty hours per week significantly increased the risk of making an error. Results were somewhat similar for near errors."
The article concludes with a recommendation, which is similar to that made by the IOM last year:
"Hospital staff nurses’ long hours may have adverse effects on patient care; we found that both errors and near errors are more likely to occur when hospital staff nurses work twelve or more hours. Because more than three-fourths of the shifts scheduled for twelve hours exceeded that time frame, routine use of twelve-hour shifts should be curtailed, and overtime–especially that associated with twelve-hour shifts–should be eliminated".
But there is a huge YABBUT behind all these numbers, and that YABBUT is the severe shortage of nurses (and allied staff) in the US.
The average age of a working RN is 43 and by 2010 it will be pushing 50. Admission to nursing schools is slightly up but the number of individuals sitting for the nursing exam is flat, and far too few new nurses are coming into the workforce. Increased demand based on the aging of the population (the 85+ group is doubling between 2000 and 2010, and of course the baby boomers start turning 65 in 2010) means additional demand for health care services. More, sicker patients plus fewer nurses to care for them means this problem will get worse, so the likelihood is more rather than fewer medical errors in the future. This is all well captured in the 2002 JCAHO report, Health care at the Crossroads.
126,000 nursing positions are currently unfilled in hospitals across the country. Some estimates are that by 2020, there will be at least 400,000 fewer nurses available to provide care than will be needed. Turnover rates are at about 20% a year, and it costs nearly an annual salary to replace a nurse.
This is probably the biggest single problem facing hospitals today. So in the words of Valdimir Ilyitch, What is to be done? There seem to be two main strategies. The first is to buy in talent from abroad. This has worked relatively well for physicians–roughly 20% of new residents each year are foreign medical graduates (who tend to stay here). This may not exactly be good news for other countries, many of whom already have bigger nursing shortages than the US. For instance the Pasadena Star-News reports on importing nurses from Mexico, while nurses are being recruited from the Philippines, China and India. While this is all at some cost to the medical care of the people in those countries, as an immigrant myself I would never blame any individual for coming to the US to try to do better for themselves than they can at home. And of course the money sent home to their families often means that one nurse is supporting many people.
The second solution is to replace (the lack of) nurses with technology. Much of the recent hospital investment in IT is moving towards attempting to change the process of a nurse’s workflow. Too much time is spent recording patient information and fetching supplies, rather than directly delivering patient care. If IT systems can directly capture information from medical devices (i.e. blood pressure, pulse, etc) then nurses could spend less time recording that in the chart. If robots can bring supplies direct to the bedside then nurses won’t need to go fetch them and could stay with their patients. Even something as simple as the soon-to-be ubiquitous Vocera "no-hands" communications badge can save nurses’ time from answering the phones and returning pages.
Nonetheless, the nursing shortage is a real challenge for American healthcare (I’m not so convinced about the "physician shortage" by the way!). And it’s a challenge that has a serious negative impact on the quality of care being delivered. However, I have some confidence that in 10 years time, the use of technology will improve the job of the nurse which will eventually cause more Americans to choose nursing as a career, and finding it a rewarding one psychically as well as financially. I hope I’m right, otherwise it will be grim to be old and sick in 20 years time if you can’t afford your own private nurse.
UPDATE: My cautious optimism that IT would help guide us out of the nursing shortage mess did not sit well with The Industry Veteran, who leaves his lair of pharma exclusivity to talk about nursing. But don’t worry, he stays in character with his remarks about doctors! So in an attempt to keep my email box from overflowing with his MD admirers, I’ve hidden his comments in this update!
As far as the nursing shortage, so what else is new? My memory of this subject goes back to the 1950s, and even then, the lack of good nurses was considered a major obstacle to quality care in hospitals. Nurses’ hours are too long, performance suffers, enrollment in nursing programs fails to keep pace, yaddada, yaddada. I must say, Matthew, I don’t share your optimism that more IT will substantially improve the situation. More IT can help, but so can good shoes, meditation, chair massages and a hundred other measures. To extend your analogy, when Comrade Vladimir asked how we might transform the plaintive cry, "What am I to do," into the search for concerted action ("What is to be done?"), he specifically disdained tinkering around the edges and adopting increments that perpetuate the alienating system.Hospitals have always appeared to me as the most caste-ridden social organizations in the country. At the top sits a small group of physicians and senior administrators who earn large incomes and receive extraordinary deference. Everyone else works undesirable hours under problematic conditions, receiving mediocre compensation for jobs that require high skills and induce substantial stress. Want to get more and better nurses, lab techs, radiology techs and the rest? Well if your universal panacea is IT, my universal villains are the f
PHARMA: More on big pharma’s marketing and sales strategies
And in continuing rumblings from the pharma marketing corruption story THCB reported on a week or so back — Schering was mailing physicians checks to get them to prescribe their drug — a couple more missives have crossed my desk. They concern how pharma companies market both in terms of how they deal with physicians, and in terms of how they choose their sales force and marketing strategies. It appears that there is room for major change in the latter. And as I mentioned in passing in a previous article about margins in the drug business, this whole sales and marketing arena is ripe for cost reduction and efficiency enhancement.
The first piece was sent to THCB is from Random Contributor who writes in a somewhat scurrilous vein:
In short, pharma companies bribe physicians because it works, physicians expect it, and it doesn’t take much imagination. In a world in which there are many clinically similar drugs packed into each of a few high-return clinical categories – and a bunch of drug companies whose future rests on their performance in those clinical categories – docs can safely make prescribing decisions on things other than clinical performance. Prescribing Zocor instead of Lipitor won’t kill a patient,but it could enrich the doctor prescribing it…
It’s hard to argue that drugs aren’t "overpriced" if payoffs are built into their pricing schema. So how much would this drug cost if you didn’t pay docs millions to prescribe it?
As a quick aside, I was talking to my uncle (72 years old) who lives in Florida. His doc (internal med) recently gave up hospital privileges and malpractice insurance, but continues to practice primary care. He told me that his doc "plans to make up the difference through seeing more patients and prescribing more drugs." Don (my uncle) listed several of the drugs that he is taking (Plavix, Provachol, etc.) and I noticed that they were primarily from BMS… I wonder if there is a connection (or if his BMS rep is just really hot)?
While the Contributor is probably overstating the case–after all physicians don’t actually make money from prescribing drugs (unless they’re oncologists or in Japan), but it’s no secret that some doctors and some reps have particularly close relationships and that much pharma detailing is made very effective by leaning on those personal relationships. Meanwhile, the whole concept that pharma does it one way because it always has is also probably true. That’s partly why detailing and professional marketing only works effectively on less than half of physicians. The rest of all the reps in the sharp suits/push-up bras hanging out in the waiting room to get 30 seconds with the doctor is mostly waste motion.
But that might all be changing. Pfizer, which won the pharma arms race of the 1990s by building up its sales force when others were cutting back and trying to ingratiate themselves with managed care companies, or buying PBMs, is now looking to cut its global sales force, use CRM software to more accurately support its physician "customers" and eliminate the "significant number of calls where product market messages are not delivered and where theres little to no value to the physician." In other words the Bludgeon needs to be replaced by the Rapier.
This new way of thinking might even extend to advertising and PR-type promotions. I am on a list-serv from Pharmaceutical Marketing Network, and recently this somewhat bitter screed about the sloth in thinking and consequent incompetence of pharma marketing was posted by Brian Towell from Doghouse, an online marketing agency. I repost it here because although I don’t agree with it all, it certainly puts the marketing strategies of pharma into sharp focus:
The operational procedures of the large drug companies never cease to amaze me, particularly at the level of procurement of medical communications (which includes vanity publishing aka MedEd, Advertising, Branding, Congress & Scientific Meeting Event management, Professional Relations and Public Relations, along with some other City/Stockholder targeted communications that none of us ever see or hear about.) All of these served by agencies with global and/or local expertise, and often with ridiculous levels of duplication, isolation and total lack of connection with the brand.
The procurement process is flawed for all, however you look at it. In America, ‘Global’ means everywhere else, whereas in Europe, ‘Global’ means everywhere, so US sited businesses are strangely infatuated by their own agencies, who are collectively useless at almost everything, but manage to hoodwink their clients into accepting dull and sub-standard creative work because that’s what everyone does in the US. In Europe, despite the rise and rise of the European community, the cultural and regulatory differences that exist on a country to country basis make it impossible to engage at head office level with a Novartis or a Roche on a ‘Global’ basis without some kind of network that allows differing cultures and medical legal systems to be managed profitably, and with due diligence.
Unfortunately, the problems of both major markets (US & Euro) conspire to produce an industry of communications service providers inadequate in creativity and strategic bravado (largely serving tactical briefs) who somehow manage to continue to exist and grow alongside a healthcare industry that is rotten with stagnant process, and trapped by its own strategic immobility.
The world is leaving Big Pharma behind. Agencies need to become smaller, more responsive, and more strategically driven, to help the industries that support them to make more responsive, dynamic choices and decisions, and to to open a portfolio of strategies that provide a meaningful escape route from the conventional, stagnant practice that all involved seek comfort in.
The idea that these companies set up rosters of ‘preferred providers’ is obscene, and simply appalling business. Even the Schering Plough reverse auction idea was only open to their cute list of favorites, who they get along with really well, who never surprise or challenge them, and allow the same stuff to keep rolling along like an endless roll of Magnolia tinted wallpaper. Sameness is a real issue for the industry that needs to be challenged, instead of propagated ad nauseam.
Thought innovators within the industry are now pointing to the reality of a ‘here and now’ strategic inflection point for big Pharma, where yesterday’s choices (strategic traps) and ‘already thought’ behaviors become not just redundant but unsustainable. Whatever the Big Companies continue to do in that vein are simply expressions of improved effectiveness at inefficiency.
It is a self-propagating world of publications and activities that is, under the sharpest magnifying glass, difficult to justify and difficult to benchmark in terms of any contribution to the business. Its poor quality, and it costs. But no-one measures that cost.
Novartis ask questions of providers that they must answer in a 10 slide powerpoint presentation, to get to 2nd base. But they don’t ask the right questions. What can you meaningfully contribute to our business? Show us. 2 questions. Tough call. That’s how it should be. Not a 45 minute display of last year’s work that fits our neat idea of how we have always done things here.
That’s all it should be. Then maybe the people who work in Healthcare Communications Services would wake up to some home truths about what they’re actually doing for their clients, instead of churning out the same ‘already thought’, safe, and largely generic tripe that no other industry would tolerate.
POLICY: Scully guilty, but not legally, with BRIEF UPDATE
In a splitting of hairs in a report from the HHS inspector general, Tom Scully the administrator of CMS when the Medicare bill was passed, was found guilty essentially of lying to Congess. In fact while Scully pressured the main CMS actuary so that he didn’t reveal that the MMA would cost more than $500 billion rather than the $400bn that the Administration told Congress, he didn’t break the law in doing so.
The irony of all this is that despite the huge pressure the Administration and the leadership brought to bear mostly on House conservatives to vote for the bill, its passage has probably been a negative for the Administration, and will probably be a liability come November.
UPDATE: While neither this story nor the related ongoing enquiry into the bribery on the floor of the House while the bill was being voted on, probably won’t make much difference in real life (i.e. the election), The NY Times report on this story has a couple of juicy factoids:
In recent weeks, Mr. Scully has registered as a lobbyist for major drug companies, including Abbott Laboratories and Aventis; for Caremark Rx, a pharmacy benefit manager; and for the American Chiropractic Association and the American College of Gastroenterology, among other clients. All are affected by the new Medicare law, which Mr. Scully helped write.
And Pete Stark gets his snide oar in there.
Representative Pete Stark of California, the senior Democrat on the House Ways and Means Subcommittee on Health, said, "It sounds as though the Bush administration examined itself and found it did nothing wrong."
QUALITY: Hospitals remain dangerous, but talking about the issue makes them safer
I saw Michael Millenson doing Grand Rounds at UCSF last week. Michael, who has been mentioned in THCB a number of times, is a former journalist who has become something of a "bete noir" to organized medicine–or at least would be if they paid him any attention. While the AMA debates not offering care to trial lawyers, Millenson continues to point out the general "Silence" of leading medical organizations on the medical safety issue. The case he discussed at the UCSF Grand Rounds concerned a woman who’d had a double mastectomy for breast cancer that was later found to be a case of wrong identity on the pathology slides. The case was used by trial lawyers responding to Bush’s attacks on them over malpractice caps. Of course the AMA and its political allies have plenty of other human interest stories of counties where there are no obstetricians/brain surgeons/pediatricians because of the cost of malpractice insurance.
However, this fight between the lawyers and the doctors continues to miss the point, which is that we are a long way from achieving widespread use of evidence-based medicine. One little thing that might help is the "signing" of body parts by the surgeon prior to surgery, now as the Washington Post reports it is recommended as standard. I recall that before knee surgery in California at Stanford Hospitals in 1996 I wrote "Not This One" in marker pen on my healthy knee, and that got the admitting nurse very annoyed. At least the medical error debate is now in the open.
What’s not so in the open is the in-hospital infection issue. Millenson suggested last week that a nosocomial infection during on of Cheney’s heart procedures, or (my preference) perhaps during Ashcroft’s recent stay in hospital, would really put that issue on the front burner. (They could of course have a complete and full recovery afterwards!) Maybe not, but he found for me a really vicious example in the UK, where the medical safety debate has been even slower to develop than over here. This one concerns Claire Rayner, who is the British equivalent of Ann Landers. In this interview she hammers on the issue of infections caused by sloppy hygiene in hospitals. Take a read, And before you say it couldn’t happen here, be assured that it is happening here too — unless the IOM is making it all up.
Claire Rayner ascribes the problem to a decrease in standards of nursing care, directly associated with an increase in the number of less-well trained people dealing directly with patients. Interestingly enough Linda Aitken’s academic work has shown that there is a relationship in quality of care and outcomes based on the overall level of nurses’ education in a hospital staff. So Rayner may be on to something there. In any event, the more known about this issue, the better, and whatever Newt Gingrich and anyone named Kennedy say, IT is not a guaranteed standalone fix here. We need a system change.
TECHNOLOGY: Boston Scientific recalls stents
A while back THCB reported that there were some murmurs about problems with Boston Scientific’s Taxus stent. That followed earlier manufacturing problems with J&J’s Cypher stent. Now Boston Scientific has recalled about 200 stents with manufacturing defects.
This is probably a very minor hiccup in what has been a stellarly successful product launch. The Drug Eluting Stent (DES), which is on the way to being a $5bn market, has grown very fast to replace the bare-metal stent as a treatment of choice. This transition has helped over shadow research that showed that bare-metal stents (and the TCPA that accompanies them) were not as effective as by-pass surgery. Of course there are as yet no long term studies of the impact of re-stenosis from the new DES–but cardiologists and their suppliers have carried the day, and the drug-eluting stent (which incidentally is beginning to really negatively impact hospitals’ bottom lines) is the latest and greatest thing to hit interventional cardiology in ages. That’s a typical evolution of medical technology–put into mass use before it’s proved cost-effective compared to other treatment largely on implied promise. That’s the way health care works, and three decades of technology assessment work hasn’t changed it, and isn’t likely to soon. And minor manufacturing quality issues, if handled properly, won’t make any difference to that process.
TECHNOLOGY: Fuel Cells That Keep Going And Going…
A quickie for July 6th. I have been moving house (and office), had limited access to DSL and THCB has suffered a bit. Sorry, but the move is almost done (You must all come and visit!). My backlog is huge and there’s tons of interesting stuff coming!
Robert Mittman wrote about fuel cells last year and Forbes followed up last week. Hopefully PDA Fuel Cells That Keep Going And Going… will mean that we won’t be searching around for that socket in the departure lounge in a hopeless attempt to keep that phone or laptop going all flight.
