* * * * *
1. Featured Article: Paternalism Costs Lives By HENRY I. MILLER, WSJ,
Decisions about drug safety
and efficacy are far from easy. Tysabri, a multiple sclerosis (MS) drug that
was voluntarily withdrawn from the market last year after the appearance of a
previously unknown side effect, illustrates some of the conundrums.
In advance of the
publication of three critical new studies on Tysabri in this week's issue of
the New England Journal of Medicine, a major news organization recently asked
me, as a physician and former FDA official, whether I knew of examples of
prescription drugs that have "efficacy but [also] serious safety
issues." That is, I responded, the rule rather
than the exception.
Obvious examples include the
antimetabolites used for traditional chemotherapy. Because these drugs are no
more than poisons administered in a way intended to be more toxic to cancer
cells than normal ones, it is not surprising that their side effects are often
serious and even life-threatening. When I was a medical resident three decades
ago, hospital gallows humor included referring to BCNU, an experimental cancer
drug, as "Be seein' you." Approved in 1977, it is still widely used.
A more recent example is
aldesleukin, a drug that has offered new hope to victims of kidney cancer and
malignant melanoma. It is highly effective in a small proportion of patients
but exhibits significant toxicity. The patient information booklet warns that
those taking the drug "frequently experience serious, life-threatening or
fatal adverse events," including dangerously low blood pressure and
reduced organ perfusion, impaired function of infection-fighting white blood
cells, disseminated infection and autoimmune disease.
Antibiotics are another
class of wonder drugs that sometimes manifest significant toxicity.
Chloramphenicol, a drug that is effective against a wide spectrum of bacterial
infections, causes rare cases of fatal aplastic anemia, so it is used only
sparingly. The potent antibiotic gentamicin is often lifesaving but can cause
damage to the kidneys, nerves and ears. And significant numbers of patients are
allergic to other important antibiotics, including the penicillins and
cephalosporins.
But let us return to
Tysabri, only the sixth medication approved -- and the first in several years
-- for the treatment of MS, a common and debilitating autoimmune disease that
affects the central nervous system. The impressive results of the drug's
testing in clinical trials -- the frequency of clinical relapses reduced by
more than half -- induced the FDA to grant accelerated approval in 2004. By the
time that several thousand patients were being treated with Tysabri, however,
three had contracted progressive multifocal leukoencephalopathy (PML), a rare
neurological disorder caused by a virus. (Because the drug suppresses certain
components of the immune response, regulators, clinicians and the product's
developers had from the beginning been sensitive to the possibility of
infections as a side effect.) Immediately -- some would say prematurely -- the
manufacturers of the drug voluntarily halted production and distribution and
withdrew Tysabri from the market. MS patients and many neurologists were
bitterly disappointed.
The three clinical studies
reported this week in the New England Journal of Medicine bolster our
confidence about the safety and efficacy of Tysabri. In a study of almost a
thousand patients that compared Tysabri to placebo, the drug cut the rate of
clinical relapses by 68% (to 0.24 from 0.75), reduced by 83% the number of new
or expanding brain lesions found on MRI, and slowed the clinical progression of
disease. (The other currently used drugs for MS lower the occurrence of acute
relapses by roughly one-third.) Similar results were obtained in a second trial
which compared two-drug therapy with Tysabri plus interferon beta-1a to the
interferon alone. . . .
The "safety" of a
drug is a relative thing. Safety and efficacy, the two criteria required for
marketing approval of a drug, are inextricably linked. The judgments of
regulators (and practicing physicians) require a global and often difficult
calculation of risk and benefit, including consideration of
what alternative therapies are available. For a given drug, we are
willing to tolerate greater uncertainty and more severe side effects for a
potential cure for pancreatic cancer or AIDS, for example, than for a new drug
that treats heartburn. When FDA grants marketing approval, the drug is deemed
to be sufficiently safe and effective to be used for the conditions on the
label.
In light of the
just-published data -- to which the FDA should have had access months ago -- it
is clear that this drug belongs back on the market, probably with new warnings
about PML in the labeling.
The notion that the FDA
should "err on the side of safety" sounds like a tautology but is an
affront to patients with incurable or poorly treatable diseases: For them,
there is no safety in the status quo, and we only damage them further with
paternalistic public policy that prevents individuals from exercising their own
judgment about risks and benefits. If the FDA must err, it should be on the
side of patients' freedom to choose.
Mr. Miller, a physician and
fellow at the Hoover Institution, headed the FDA's Office of Biotechnology from
1989 to 1993.
To read Dr Miller's entire
article, please go to http://online.wsj.com/article_print/SB114125841380186971.html.
* * * * *
2. ![[Graphic]](April1106_files/image001.gif)
In the News: In New Health Plan, Patients Pay Their Share -- Or Else By SARAH RUBENSTEIN
WSJ,
Health insurers are starting
to look to patients' credit cards -- and paychecks -- to ensure hospitals and
doctors don't get stiffed.
As health plans impose
higher deductibles, co-pays and premiums, many patients are becoming slower to
pay their portion of hospital and doctor bills, driving up providers'
collection costs and bad-debt accounts. A major insurer, UnitedHealth Group
Inc., is set to offer an automatic-payment program that would give providers a
strong measure of assurance that patients will pay -- because if they don't,
UnitedHealth will get the money, with interest, out of their paychecks.
The pilot program, which
UnitedHealth is set to launch in
UnitedHealth, based in
Tenet spokesman Harry
Anderson says while collecting from the uninsured remains a bigger problem,
slow payments from the insured are a growing concern. "The higher the
amount owed by the patient, the worse the problem is," he says.
Under the new program,
dubbed "OnePay," UnitedHealth will pay a patient's portion directly
to a provider as soon as it processes an insurance claim. Then, it will collect
from the patient, with payment due in 20 days. If patients can't pay 100% of
their portion right away, UnitedHealth will act as a creditor, steadily
receiving payments, plus interest, deducted from the patient's paychecks until
the bill is paid in full.
![[Graph]](April1106_files/image002.gif)
UnitedHealth says it will
charge interest at the prime rate -- currently 7.5% -- not the double-digit
rates many credit cards apply. It says employees, and medical providers, enroll
in the program on a voluntary basis.
What's in it for employees?
Convenience is a major attraction for health-care consumers overwhelmed by the
paperwork and the technicalities of health-care and hospital billing, the
insurer says. In focus groups, lower-income consumers said availability of low
interest rates and a structured payment plan was appealing, UnitedHealth says.
Plus, UnitedHealth says enrolled patients would feel the discounts from
participating providers.
Telecommunications company AT&T Inc. may be among the early
employers to sign up for OnePay. An AT&T spokesman says the company has
told UnitedHealth it has "an interest in looking at" the program.
Tenet, in addition to participating as a provider, says it will participate as
an employer, offering OnePay to its employees in
In 2002, UnitedHealth
chartered its own bank, Exante, which will serve as lender for employers
participating in OnePay, in effect extending lines of credit for employees to
pay health-care expenses. UnitedHealth moved into the banking business as the
Bush administration began promoting health-savings accounts, which banks have
started offering as a way for people enrolled in high-deductible plans to save
pretax dollars to cover future out-of-pocket medical expenses.
Many providers are taking
steps to collect from patients with high deductibles. Deductibles are "a
great sticker shock and cultural shock" for patients, says Nathan Beraha,
a
Gail Shearer, director of
health-policy analysis at Consumers Union, says automatic-payment programs
"can offer some convenience to consumers." But the programs can pose
a problem, she adds, "if [patients] are concerned
that because of their health status they may not be able to monitor the bills
as carefully as they'd like."
To read the entire article,
please go to http://online.wsj.com/article/SB114221304342196190.html?mod=todays_us_marketplace.
Write to Sarah Rubenstein at sarah.rubenstein@wsj.com.1
* * * * *
3. International Medicine: Where in the World Is Ladrillera? By Herbert Brosbe, MD
In
I
am awake. Something awful is happening. I wait, trying to understand. The room
is pitch black. I can hear the gentle breathing of my
wife next to me. So what is wrong?
The pain begins again. I break into a sweat. Someone has stuffed a football
into my stomach and is slowly turning it sideways. I check my watch.
I quietly roll out of bed and grab my flashlight. The heavy wooden door creaks
as I leave our bedroom. The moon illuminates the cement stairs as I descend to
the courtyard. My movement doesn't seem to make the pain worse. Good, not an
acute abdomen.
I turn on the bathroom light, a single bulb hanging from a wire. The air is
bitterly cold. It's July, the middle of winter down here. As usual, there is no
running water and won't be until early morning. I try to make myself throw up
as another spasm of pain hits. No luck. I'm really not good at this. I sit on
the toilet, which has no toilet seat. A land of limited
luxuries. Defeated, I retire to the kitchen next door. All the rooms
here open onto the courtyard. I am in my heavy winter coat, with a watch cap
on, rocking back and forth. I try to pretend the pain is just a dream. I have
caught one of those ugly parasites.
During the next few days, I learn the lessons of dysentery. This version is
much different from the "tourista" I have weathered in other
countries. I learn that putting anything in your mouth will be met with
horrible pain, followed shortly by violent emptying of whatever your bowels can
produce: mucus, blood, bits of tissue, stool. I lose all desire to eat or
drink. I need more than an hour to force a cup of tea down so I can take my
Flagyl. I now know why children refuse to drink and dysentery kills so many
worldwide. How did I get myself into this?
I have always nurtured the idea of practicing international
medicine. In medical school, I spent a wonderful three months in the jungles of
Somehow that dream was compromised away during my subsequent career, but I
recently decided to revive it. At first, I couldn't find a volunteer opportunity
that didn't demand at least two months or high fees to participate. Then my
daughter suggested visiting www.idealist.org where I found a posting for Mosoq Ayllu, an
organization run by a husband-and-wife team of social workers, Patti and Juan
Jose. They have adopted Ladrillera, a poor community on the outskirts of
Huancayo, a city in the
I
was excited to begin my medical duties. At first, I worked in boys' orphanages
in Huancayo. They had an epidemic of mumps, a disease for which Peruvians do
not immunize. I also saw Hepatitis A and sundry common ailments. Then I was
brought to the community clinic in Ladrillera.
I don't think Patti and Juan Jose had any intention of shocking me. It's just a
cultural thing. When I hear the word clinic I think, you know, clinic,
as in a building equipped with medical personnel and supplies. The clinic at
Ladrillera was an adobe brick room. Patti and Juan Jose were proud that it had
a cement floor because the other homes and buildings in Ladrillera had dirt
floors. It had a tarp for a roof and clear plastic taped over an opening for a
window. No door. No electricity. No running water. A desk (doctors in
A long line was waiting outside when I arrived in the morning. Patti and Juan
Jose had posted flyers saying that a doctor was coming. It was like a scene out
of National Geographic. A line of people waiting for the American doctor
to heal them. I was scared senseless. . . .
I
was so grateful when the patient was easy. Parasites. Pneumonia. But there were
few easy cases. One woman had waited 17 days for a doctor to take something out
of her eye. When I gently tried to open her eyelid, a pocket of pus poured out.
I was horrified. I could not identify any normal structures, just macerated
tissue and pus. I explained that my pills weren't able to cure her. She needed
to go to the hospital.
As I was later to learn, poor people in
Among the many memorable patients that first day were people
with cataracts so thick their pupils were white glass. They asked for something
to restore their sight. I explained that I had no medicine for cataracts. They
would have to go to
A
young man comes in and wants pills for his arms. He has been building bricks
since he was eight. Both hands and forearms are swollen. There are barely any
creases left. He has blatant neuropathy and constant pain in his fingers,
wrists, and elbows. How do you explain repetitive-use injuries and prescribe
rest, physical therapy, and vocational rehab? I give him steroids and ibuprofen
and explain that his work causes the problem. He knows that. He must work. Period. He too is grateful for the medicine.
Within a short time, I have learned what to do. No one wants to wait hours in
the cold for the doctor to tell them that nothing can be done. I am ashamed of
myself. In some way I am practicing "poor quality" medicine, but
these people are so grateful to have someone lay their hands on them, to give
them anything to help them continue.
I dispense vitamins, Flagyl, ibuprofen, ranitidine. I begin telling patients to
take una de gato, one of the local herbs used by native healers. I tell them
how to massage and stretch. I ask them if they can afford to boil water and
apply hot cloths to their aching necks, shoulders, and backs. They are all so
grateful. They clasp my hands tightly and say thank you, over and over again.
At the end of the day, I am physically and emotionally exhausted. I ache from
head to foot. I have not eaten for fear of picking up a parasite. I have drunk
bottled water. The interpreter turns the last of the line away, saying come
back tomorrow. The doctor will be here again tomorrow. There is no angry
response. They will come back tomorrow.
After a few days, my shame mounts. But this time it is
different. I am ashamed because I do not want to be here. I want a hot shower.
I want hot food. I want heat in my home. I want my own comfortable bed. I want
my life back. . . .
When
we return to
I wish every American could spend a day or two in Ladrillera. Perhaps it would
strengthen our vision of how people should live. I will volunteer again. The
next time I will go with a medical team and be part of a mobile clinic. I
believe that kind of professional and emotional support will work for me. A
younger doctor, one more resolved and more resilient, would be most welcome in
Ladrillera.
Where in the world is Ladrillera? It is here, in
Dr. Brosbe, a
* * * * *
4.
Medicare: Republican HillaryCare: The Medicare Drug Benefit's Prescription for
Perverse Incentives by John R. Graham, Pacific Research Institute.
Key
Points:
1. The
complexity and confusion of the Medicare Part D drug benefit, where the media
focuses its attention, is actually a relatively insignificant part of the
problem posed by the new entitlement, which accelerates a vicious circle of bad
incentives for politicians, citizens, and providers.
2. The
Medicare drug benefit will make the
3. Americans
are receiving mixed signals from the government: on the one hand, it gives us
control of more of our health dollars while we are working and privately
insured (through tools like Health Savings Accounts); but on the other hand it
tells us that we are "entitled," out of the blue, to prescription
drugs and other health goods and services almost for free when we retire and go
on Medicare. This creates negative incentives for privately insured patients
under 65 years old, increasing the likelihood that Health Savings Accounts
(HSAs) will become simply retirement savings accounts for well off Americans.
4. Insurers
do not have good incentives to spend the appropriate amount of money on
prescription drugs. Instead, Medicare establishes a "silo" approach
that forces insurers to consider only one area of health spending, to patients'
detriment.
5. Drug
makers are losing the incentive to offer their own discount programs to
low-income seniors, now that the government has taken them over.
The
"bidding" element of the drug benefit is its sole positive attribute,
and it should be extended throughout Medicare as an interim reform. However,
executing this will require extraordinary political will, which is extremely
unlikely in the current climate of public opinion.
A
Serious Strategic Error
President Bush is doing an outstanding job developing patient-friendly
solutions in the private health insurance market, by focusing on getting health
care dollars out of the hands of the government and into the hands of the
patients who need them, primarily via Health Savings Accounts (HSAs). If the
Congress gets on board with the President's proposals to expand HSAs, 2006 will
be the year that Americans will be able to engage these powerful tools to take
control of their health care, as I discussed last month.1 Ironically,
the legislation that introduced HSAs, commonly known as the Medicare
Modernization Act of 2003 (MMA), also introduced a seriously flawed new
entitlement into Medicare: the now infamous Part D drug benefit. . .
Despite
the media flurry, and the pain of the affected patients, these are transitory,
"frictional" challenges that will be sorted out sooner rather than
later. The real problems with Medicare Part D will become apparent after it has
reached equilibrium, with all interested parties relatively content. That's
when the new entitlement's perverse incentives will really take hold, becoming
deeply entrenched and extremely difficult for advocates of consumer-directed
health care to dislodge.
It
is important to remember the trajectory of this program: the politicians set up
a brand new entitlement, which few seniors needed, outsourced it to the private
sector, and then claimed to have injected "free market" incentives
into Medicare, without compelling change in traditional Medicare
Describing
the drug benefit as "free market" is like nationalizing interstate
bus service, outsourcing the operations to Greyhound, and claiming that you are
on the way to privatizing Amtrak!
To read John R.Graham's entire report, please go to www.pacificresearch.org/pub/hpp/2006/hpp_02-06.html.
Government
is not the solution to our problems, government is the problem.
- Ronald Reagan
* * * * *
5. Medical Gluttony: I Don't Care What It Costs, but
Saving 50˘ Is Extremely Important to Me
A patient came to the window unannounced saying he
wanted a new prescription in lieu of the one we gave him last week. With the
new Medicare Drug Plan, he needed a 90-day supply and to have it filled
elsewhere. This would save him 50 cents on each prescription. I believe he had
four.
I looked him straight in the eye as I handed him the
rewritten prescription, which I did outside of an office appointment making the
next patient wait an extra five minutes, to see if there was any recognition or
understanding of the costs involved. He said to my inquiring look, "A guy
has to save fifty cents when he can."
It's on these days that makes a physician want to give
up helping patients and rather just let the government take over - denying one
form of health care today, delaying another operation tomorrow, postponing all
necessary health care for six months due to budgetary reasons - as occurs in
the National Health Service or Canadian Medicare. But we have to understand the
self-centeredness of humankind and comply with our patient's requests, even if
they don't understand our hesitation or we never get a thank you.
On the same day, a private patient
who is a member of a large Integrative Health Plan came in for a complete
pulmonary examination for his yearly second opinion. He handed my receptionist
a signed, blank check made out to me. He told her to fill in the amount
"when the doctor is done doing everything he thinks I need." After
updating his medical and pulmonary information for the year, doing a chest
x-ray and a pulmonary function test, my receptionist filled in the amount and
gave him a copy of the check, the consultation and the PFT report for his
personal physician.
After we thanked him, we
mentioned the aforementioned incident. Being a retired businessman, he told us
what he would have told that patient.
What a contrast of events
occurring the same morning - one patient who understands the value of medical
care and another who has no concept of what a professional five-minute
interruption is worth. He refuses to recognize the overhead cost of those five
minutes or the value or his time to drive to the office, paying $2.50 a gallon
to save fifty cents.
When an entitlement is
essentially free, the only future that those who think they're entitled can see
is more gouging of the taxpayer's dollar, not realizing they too are taxpayers.
* * * * *
6. Medical Myths: If We Had a Surgeon As President, We
Could Solve the Health Care Problem
Some think that a doctor in
politics knows the answer not only to health care issues, but other issues as
well. That may not be the case. DANIEL HENNINGER, in a recent column about
immigration and law, states: "Respect for the law" is part of the
American bedrock. As Alexis de Tocqueville rightly said, each voter indirectly
contributes to the making of our laws, and "however irksome an enactment
may be, the citizen of the
Another 19th-century
Frenchman close to the hearts of American conservatives is Frederic Bastiat,
who had a further thought: "The surest way to have the laws respected is
to make them respectable." Is our immigration law "respectable"?
Need you ask?
It's not a coincidence that
the first push-back Immigration Act emerged in the Roaring Twenties, another
period of abrupt social disruption and anxiety with heavy immigrant inflows
from southern
To read the entire
Henninger's WonderLand column, please go to (subscription required) http://online.wsj.com/article_print/SB114376883496913068.html
TRUTH: We Would Experience a Real Crisis If a Surgeon Occupied the White House
* * * * *
7. Overheard in the Medical Staff Lounge: If I Had Wings,
I Could Have Flown Home to
Mrs. Ackford, who had very high cholesterol, tried a
low-fat diet but was unable to reduce her cholesterol on a six-month recheck. She was placed on one of the statin drugs. She
stated she had been on one of them previously and it had created some bowel
problems. She called back a week later indicating that this one also caused
bowel problems. What problems? It created a large amount of gas (known as
flatus for the medically sophisticated).
She stated that she tried to take it at night, but it
was good that she was widowed because if she were sleeping with a gentleman,
he'd divorce her. She tried to take it in the morning and by midmorning,
she had to cancel all get-to-gethers with her friends for fear of alienating
them. She claimed that if she had wings, she's sure she could have flown to
What's a Proper English Lady to Do?
I Wish I Still Had My
Invalid Wife to Care for
About three years ago, Mr. Jack, during his annual
pulmonary review, testing, and plan for the next year of his medical life,
began to shed tears. He said his wife was getting more demented and physically
incapacitated from the stroke she had sustained. Even in retirement, he had
great difficulty managing his own home because she had become a 24-hour-a-day
responsibility. He no longer felt safe to leave her just to do some grocery
shopping or run brief errands. In trying to obtain help, he finally decided a
nursing facility was more affordable than in-home care. He looked up at me
through his tear-stained eyes as said, "Do you think God will forgive me
for neglecting to care for my wife to the end?"
He made six-hour visits to the nursing home every day
and took her home on Friday night so they could spend the weekend together in
the home they had shared for more than forty years. He said, "I just
wanted her close to me where I had always seen her all those years. That way I
can also hold her next to me for three nights a week before I take her back on
Monday." It's just the closeness that I cherish. He continued, "You
know, doctor, last weekend as I was holding her close to me, she said, 'Jack, I
have this wonderful feeling in my pelvis like I had when we were young. Do you
suppose you could make love to me again?'"
Mr Jack said that he'd not been able to provide any
marital relations to her since his prostate surgery ten years ago. In those
days they didn't have potency drugs. He said he'd heard an advertisement for
Levitra, the wonder drug. "You suppose I could try that?" I did give
him a prescription.
This year he announced that his wife died two months
ago. "I wish she was still here for me to care for. I'd love to care for
her another six years. I'm sorry I ever shirked my spousal responsibilities to
care for her and placed her in a nursing facility. I wish she were still in my
arms every day, even though she may not have recognized me towards the
end. She was such a wonderful wife,
mother, homemaker, and companion. I miss her so."
When voices from so many fronts judge some stages of
human life as having no value, that euthanasia is the kindest thing to do for
people with lives not worth living, much like Hitler of yesteryear, it's good
to see such lives having value to those with whom they were shared.
* * * * *
8. Voices of Medicine: The Price of Automotive Love
by Lauren Bower, MD
Editorial:
Sonoma Sonoma County
Careening
down the roadway at
A week later, at a crawl in rush-hour traffic, I whine, "I could walk
faster than this" - until I find that the real victim, a teenager still
clutching her cell phone, has been taken by ambulance to the nearest trauma
center.
Physicians, like most Americans, have a love-hate relationship with the
automobile. We are hooked on the convenience of going where we want, when we
want. But the freedom the personal vehicle gives us comes with a hefty price. The
articles in this issue of Sonoma Medicine give us a bill of
particulars.
For starters, Beth Dadko, MPH, paints a frightening picture of the
all-too-human perils of teenage driving, the leading cause of death and
hospitalizations for local 15- to 19-year-olds. She offers useful suggestions
for how physicians can help reduce this tragic loss of life and limb. To read
"The Biggest Threat to Teenagers," go to www.scma.org/magazine/scp/wn06/dadko.html.
Next, Dr. Richard Jackson, Monica Rai, and Megha Doshi detail the direct health
care costs of vehicular accidents. They also examine the more common - and much
more insidious - costs to our collective health of the sedentary lifestyle the
automobile promotes. Obesity, hypertension, and depression are all on the rise.
To read "Driving Ourselves Sick," go to www.scma.org/magazine/scp/wn06/jackson_etal.html.
Fortunately, there are alternatives to traffic. Some people have found ways to
integrate regular exercise into their daily routine while avoiding the
twice-daily rush-hour drive. One of them, Dr. Mark Berenson, describes the
perils and pleasures of bicycle commuting. To read "See You In The Bike Lane," go to www.scma.org/magazine/scp/wn06/berenson.html.
Another alternative, explained by Dr. Brien Seeley, is the true-to-life science
fiction of personal air vehicles (PAVs). The idea of a flying machine in every
garage is no longer the exclusive purview of Jetson cartoonists. The first
annual NASA-sponsored competition for PAVs is to be held at the
The concept of "walking districts" is introduced by a local housing
developer, Alan Strachan. This reversal of the American trend to group like
with like - ticky-tacky suburb here, office-building cluster there - seems new
and revolutionary, yet recalls the layout of a medieval European village.
Placing work and living spaces in closer proximity may have social as well as
economic and ecological benefits, yielding a happier, healthier community. To
read "Financial Tools for Inducing Smart Growth," go to www.scma.org/magazine/scp/wn06/strachan.html.
Love it or hate it, the automobile is here to stay. So buckle up, play soothing
tunes to calm your inner road warrior, watch for speeding cyclists passing you
on the right, and dream of
Dr. Bower, a
* * * * *
9. Book Review: Healthy
Competition - What's Holding Back Health Care and How to Free It by Michael
Cannon & Michael D Tanner, Cato Institute, Part III: Chapter 7 – Healthy Choice and
Competition or Controls.
Health care may be the most
intensively regulated sector of the
Regulatory Costs
Christopher Conover of
Conover labels the social
cost of health care regulations "a $169 billion hidden tax" and
offers a number of ways to comprehend its magnitude. Health care regulation
costs Americans more than they spend on gasoline and oil ($165.8 billion in
2002) or on pharmaceuticals ($162.4 billion in 2002). "Spread across all
households, health services regulation cost the average household an estimated
$1,546 in 2002." Over the next 10 years,
health care regulation will cost consumers three times the cost of the new
Medicare prescription drug benefit. Such regulation makes health insurance
unaffordable for an estimated 7.5 million Americans, or one-sixth of those who
are uninsured on any given day. Finally, health care regulation reduces
societal income and with it society's ability to purchase products that protect lives (e.g., safer homes, safer automobiles). Conover estimates that this effect induces an
additional 22,200 deaths per year - 4,000 more deaths than the
The cost of health care
regulation is equal to roughly 10 percent of all
Conover does find that some
regulations are on balance helpful. In
his overall estimate, these net benefits hide part of the cost of the remaining
regulations - those that do more harm than good. Taken by itself, this latter
group imposes net costs of $204.2 billion annually. It also gives policymakers a
good place to begin deregulating
In numerous industries,
deregulation has spurred greater consumer choice and competition, which has led
to increases in quality and productivity, as well as reduced prices. A consumer-directed health
care agenda would deregulate the health care industry to increase competition
and give consumers greater freedom of choice, including the ability to choose
the level of regulatory and legal protection they desire.
Choice and Competition in
Health Insurance
State and federal
governments have enacted layers of regulation that place restrictions on the
pricing, composition, administration, and cancellation of health insurance
policies. Regulations that restrict insurers' ability to offer and price health
insurance according to risk force low-risk customers to subsidize high-risk
customers, and price low-risk and low-income consumers out of the market.
Many health insurance
regulations are meant to correct the unintended consequences of other laws and
regulations. Such regulations include those laws that require employers to
provide health benefits to former employees, as well as those that require
insurers to cover services from providers that may otherwise be excluded from
coverage. In many cases, health care
regulations are an attempt by private interests to seek private gain. For
example, states have enacted an estimated 1,823 separate benefit mandates that
require health insurers to cover particular services, including "acupuncture,
massage therapists and hair prostheses (wigs)." The most vocal proponents of
laws requiring consumers to purchase acupuncture, massage therapy, and
chiropractic coverage are (not surprisingly) acupuncturists, massage
therapists, and chiropractors.
The costs of health
insurance regulation are substantial. Conover finds that some health insurance
regulations yield benefits in excess of their costs. However, the remaining
regulations impose annual costs of $46.6 billion in excess of the benefits they
provide. Grace-Marie Arnett (Turner)
and Melinda Schriver of the Galen Institute found that the 16 states that most
aggressively regulated their health insurance markets in the 1990s saw their
uninsured populations grow eight times faster than other states. The FTC cautions legislators
on the harms of benefit mandates:
Governments should
reconsider whether current mandates
best serve their citizens'
health care needs. When deciding
whether to mandate particular
benefits, governments should
consider that such mandates are
likely to reduce competition,
restrict consumer choice, raise the
cost of health insurance,
and increase the number of
uninsured Americans.
Some states already see the
wisdom of deregulation. After leading the trend toward greater regulation in
the 1990s, officials in
regulation in
Can Competition Improve
Medical Technology Regulation?
The Newtonian principle of gravitation is now more firmly established,
on the basis of reason, than it would be were the government to step in, and to
make it an article of necessary faith. Reason and experiment have been
indulged, and error has fled before them . . .
Subject opinion to coercion: whom will you make your inquisitors? Fallible men; men governed by bad passions,
by private as well as public reasons.
·
Thomas Jefferson, Notes on the State of
To read the rest of Part III, Chapter 7 – Health
Choice and Competition or Controls - please go to the Cato Bookstore: www.catostore.org/index.asp?fa=ProductDetails&method=cats&scid=33&pid=1441272. The price is only $10. At that rate, consider purchasing two or three and
surprise those friends, who don't understand that government involvement in
health care is destroying affordable health care, with a gift that keeps on
giving. There are other excellent recent titles you may want to consider.
For Next month, read Part III: Chapter 8 – Medical
Malpractice Reform
To read some of the other book reviews that are
available, please go to www.delmeyer.net/PhysicianPatientBookshelf.htm.
Cinematic OpEd Review:
"Why We
Fight"
Can
"Why We Fight" exposes
"the demon of error" in our Millitary-Industrial Complex
Warning: movie
spoiler alert. If you have not seen "Why We Fight,"
consider seeing the film before reading further.
[Note:James Murtagh has spent 20 years as an
Intensive Care Unit physician at a major Southeast hospital. ]
-Look upon our
works, yea mighty, and despair. (apologies to Shelly's
Ozymandias)
-It is nowhere written that the American empire goes on forever. (Jared
Diamond)
By now, Americans are no
longer worried about whether the invasion of
Eugene Jarecki's film
"Why We Fight" shows war, especially war fought secretly and deceptively,
since the time of ancients, often destroys both victor and vanquished.
Homer may have been the
first to describe "Blowback," or the unintended consequences of
war. Both Greek and Trojan societies were destroyed in Homer's mother of
all ancient wars. Even victorious king Agamemnon was assassinated on his
return. The conquerer Achilles was left lamenting he would rather be a slave of
a peasant than ruler of the strengthless dead.
It was the end of the golden era
Now,
Today, war aftermath on the homefront brutalizes us, numbs us to loss of
freedom, wiretapping and torture, loss of treasured alliances, loss of
security, and it appears Greek tragedy repeated again.
Sophocles heard the long note of tragedy long ago on the Agean, as ignorant
armies clashed by night.
War has not led to an Open society for either
Can we vow that we will not shed "blood for oil?" Given that our
society is absolutely besotted by the need for oil, is there an alternative?
Eisenhower's farewell address on
In another cycle of Greek tragedy, Herodotus showed free armies of the Greeks
were inspired to fight harder by the corrupt luxury of the Persian despots,
exemplified by the tent of Xerxes.
Now, our elites must ask if Americans will fight to retain the luxuries in the
increasing wealth-stratified Enron nation for the top 1% of the population
which is rapidly becoming an oligarchy.
Oil is running out rapidly, guaranteeing world conflict. Paul Roberts in
"The End of Oil" shows the world has less than 30 years of fuel left.
Mass starvation and cold is coming unless we do something drastic.
Pulitzer Prize-winning author Jared Diamond writes that the world at the end of
oil appears infinitely worse than a nuclear Armageddon, which by comparison
could be quick and merciful. The struggle for life between individual people
and nations as oil dwindles would be slow and horrifying, possibly leading to
grizzly horrors in "societal failure" as cannibalism.
Al Gore demands that humanity "make the effort to save the global
environment the central organizing principle of our civilization."
"Why We Fight" is chock-full impeccable,
staunch conservatives. "The
"When war becomes this profitable, you're going to have more war,"
notes a CIA analyst. But what happens when war is not only profitable, but
deemed essential to the survival of a nation addicted to oil?
I am a lung doctor, and we have a wry saying, "Everyone stops smoking
eventually." Well, eventually everyone will eventually not use oil,
because we are going to run out of it. The question is,
will the end of oil also be the end of society? Will the end of oil be the end
of us, or the beginning of something new?
In a sense, "Why We Fight" is the documentary twin
of George Clooney's "Syriana," which declares that "Corruption?
Corruption is our protection! Corruption keeps us safe and warm! Corruption...
is why we win!"
Other recent films echo this Greek tragedy cycle and link the loss of freedom
and war. "Good Night, Good Luck" is a metaphor for loss of press
freedom since the war unmatched since the days of McCarthy.
The heartbreak of one American father was in the end linked to the heartbreak
of another father in
James
J. Murtagh Jr., MD,
* * * * *
10. Hippocrates & His Kin: Is the Health-Care Customer Always Right?
By Perry Solomon, M.D., WSJ,
In regard to Vernon Smith's
March 8 editorial page commentary "Trust the Customer!1": His suggestion of
"channeling third-party payment allowances through the patients . . . who
are choosing and consuming the service," so that they can control costs,
really does nothing to meet this end. The large insurance groups have already
negotiated discounts with the hospitals and medical- care providers on the
services they provide. A hospital may bill $10,000 for a surgical procedure
that has been pared down to $2,500 by the insurance company. If the patient can
now pay the $2,500 to the hospital, how does this help lower costs? The
discounts that the Amish and Mennonites received in Lancaster County, Pa. (40%
for cash payments) was just an example of being "self-insured" and
negotiating in the same way the insurance companies did.
The notion of the ability of
patients to "make choices" and become "competent" is
slightly simplistic. A patient really has no metric to measure the care he is
receiving. There are basic studies about "quality" and
"outcomes" for hospital care, but these are fraught with danger, as
there are so many variables that enter into these results that they can render
these studies practically meaningless. The same evaluations for physicians are
practically nonexistent and probably will not matter anyway.
Also, patients have
different perspectives of their physicians apart from those that can be
objectively measured. Would they rather receive their medical care from a
sympathetic and kind physician who spends a great deal of time listening to
their complaints but may not be the most stellar physician clinically, or an
arrogant, unemotional one who spends as little time listening as possible but
one who has been rated "the best" by some subjective evaluation?
The comments that
"Service providers are oriented to whoever pays: physicians to the
insurance companies" is absolutely true. But it is usually an orientation
that is acrimonious and adversarial, since these companies want to pay less
than the physician wants to receive. Is this the type of relationship a patient
wants with his doctor by holding his fee over his head in return for treatment?
Right now both parties can "blame" the insurance company and get on
with the doctor-patient relationship, one that should be built on trust and
mutual respect -- not negotiation skills.
Crystallizing
the cause of the uncontrolled rise of health-care costs by Albert Fuchs, M.D.
I am grateful to Mr. Smith
for crystallizing the cause of the uncontrolled rise of health-care costs. When
a service is provided to one party (the patient) but paid largely by another
(the insurance company) there is no incentive to reduce costs. There is also a
second adverse effect to such an arrangement that Mr. Smith did not mention:
There is no incentive to improve quality.
The physicians who allow
insurers to set the price for their services have very little incentive to
delight their patients. They can increase their earnings only by seeing more
patients at the fixed price. It's not surprising that patients increasingly
complain that the amount of time, attention and counseling they receive from
their physician is lacking.
By withdrawing from all
relationships with insurance companies and asking my patients to pay me
directly for my services, I am applying Mr. Smith's advice. Many other doctors
are as well -- we're trusting the customer. When the
patient pays me, he is very attentive to my fees, and I am very motivated to
deliver excellent care.
http://online.wsj.com/article_print/SB114299576974404870.html
* * * * *
11. Restoring Accountability in HealthCare, Government and
Society: