December 04, 2007
Kids, Food, Junk
Not to get too nanny state on you all, but why shouldn't the "federal Congress" be able to pass laws mandating healthy foods in public school cafeterias and snack machines? When children are at school, the school is, according to the Courts, in loco parentis -- put simply, functioning in the place of the parent. Providing healthful foods, rather than utter junk, would seem an appropriate use of that power. Providing junk, particularly when deals are made with soda and candy companies, would be quite the opposite.
I realize this sort of thing gets libertarian hackles up, but I'm genuinely curious as to why. The Congress is simply deciding what can be sold at public schools, not what can be consumed on the grounds. Someone, somehow, is going to do the choosing as to what is stocked in cafeterias, and this legislation simply ensures that nutritional concerns will help govern that choice. If parents want to pack ding-dongs into their kid's lunches, they still can. But if they don't, they can rest easy knowing that their kids' purchasing choices are overwhelmingly healthy. It seems win-win, unless you've got stock in ding-dongs. Or really like this video:
October 26, 2007
Health Wonkery Watch
Shannon Brownlee explains the differences between managed care and (real) HMOs/group practices, and tries to rescue the shattered reputation of the latter:
The reason group practices and HMOs haven't flourished is that the market isn't set up to pay them. There isn't an insurer in this country, including Medicare, which consistently pays doctors and hospitals for the quality of care they provide. They pay for quantity. They pay for the volume of individual services provided, not for the value of those services to the patient. As Michael Hillman of the Marshfield Clinic (a group practice in Marshfield, Wisconsin) recently put it, our current payment system "is like buying a car based on how many parts it has and how long it takes to make it, without considering how well it runs.'' So even though HMOs and group practices have in effect built the equivalent of a better car, the market doesn't give a rip.
Patients don't care either, partly because they are insulated from the cost of medicine, so they have little stake in getting good value for their dollar. But they also have a bias against HMOs and group practices because the American Medical Association has spent the last century telling them that HMOs and group practices offer inferior care. The AMA's rallying cry has been the almighty "doctor-patient relationship." This might sound like a motto based on the needs of patients, but what it has meant in practice is the AMA has trumpeted the rights of individual doctors in private practice to treat patients as they see fit, without interference from the government or their peers, and more importantly, to charge whatever price the market will bear. According to the AMA anything that resembles organized medicine, including group practices and Medicare, is a Commie plot to saddle us with socialized medicine -- and constrain physician incomes.
Doesn't ring true? Think about this: HMOs came into being largely in order to better coordinate care. Much like the VA, they bring together doctors who're jointly tasked with individual patients, who share notes and generally work as a team. That's part of how they keep costs down. Now, all of you, just about, are in the Big Insurance version of the HMO: Managed care. How coordinated does your care feel?
October 16, 2007
In Praise of Slumber
New York Magazine has a terrifically interesting article on sleep research, and the overwhelming scientific consensus that even moderate reductions in shut-eye can do serious damage to our mental speed. In one study, "the University of Pennsylvania’s David Dinges did an experiment shortening adults’ sleep to six hours a night. After two weeks, they reported they were doing okay. Yet on a battery of tests, they proved to be just as impaired as someone who has stayed awake for 24 hours straight." Yikes. In another, we learn that "Sleep deprivation hits the hippocampus harder than the amygdala. The result is that sleep-deprived people fail to recall pleasant memories yet recall gloomy memories just fine. In one experiment...sleep-deprived college students tried to memorize a list of words. They could remember 81 percent of the words with a negative connotation, like cancer. But they could remember only 41 percent of the words with a positive or neutral connotation, like sunshine or basket."
We also get some data on the commonly heard, and totally accurate, complaint that schools start too early. "in Edina, Minnesota, an affluent suburb of Minneapolis...the high school start time was changed from 7:25 a.m. to 8:30. The results were startling. In the year preceding the time change, math and verbal SAT scores for the top 10 percent of Edina’s students averaged 1288. A year later, the top 10 percent averaged 1500, an increase that couldn’t be attributed to any other variable." And yes, as anyone who's ever stayed up all night and felt voraciously hungry in the morning knows, sleep deprivation stimulates your appetite, and makes you fat. "Three foreign studies showed strikingly similar results. One analyzed Japanese elementary students, one Canadian kindergarten boys, and one young boys in Australia. They all showed that kids who get less than eight hours of sleep have about a 300 percent higher rate of obesity than those who get a full ten hours of sleep....In Houston public schools, according to a University of Texas at Houston study, adolescents’ odds of obesity went up 80 percent for each hour of lost sleep. "
The risk of reading this article is that you'll do what I did this morning, which is wake up tired, tell yourself that your place of employment wouldn't want you functioning at 60% capacity, nor becoming really fat, and go back to sleep. A little sleep research is a dangerous thing, particularly at 7 in the morning.
September 12, 2007
Too Much Medicine?
As per usual, Robin Hanson's claims that we should cut the provision of medicine in half are, shall we say, a bit strong, but it is true that we've got enormous amounts of waste, and it's undoubtedly true that we should vastly enhance the amount of money we spend studying the effectiveness of treatments.
David Cutler's riposte, by contrast, seems quite on-point. Policy should focus on separating good care from bad care. There's no reason to go at this with a meat cleaver (unless you're Robin Hanson, and have made a career out of, um, "viewquakes," which sort of require you to make Shocking! Claims!) Also, if you are going to cut care, you'll want to do it on the supply side (i.e, with trained professionals helping decide where to slash spending), because all the available evidence shows that patients do not, themselves, know which care to cut, and when faced with higher medical bills, will just cut care indiscriminately.
Lastly, Hanson mentions that medicine is often used to "show that we care," which does not actually increase anyone's health. But medicine is also used to comfort. Take a patient with heart palpitations. Odds are they're just benign skipped beats. A doctor may even know those odds. But when your heart jumps, it's scary. So the doctor runs the set of tests that distinguish them from deadly arrhythmias. These tests are, in Hanson's telling, wasted medicine, as they do nothing to improve biological function and are very costly. But the assurances they offer do much to improve quality of life, which is, along with extending the length of life, rather the point of medicine.
There will always be some level of "wasted" medicine that isn't, at the moment of prescription, sure to be waste (i.e, a diagnostic that could find a deadly disease, but doesn't), and some amount of medicine that's used to calm fearful patients. Neither of those show up on yearly physicals, but nor are they necessarily wasted dollars if your metric is improving patients' quality of life.
August 08, 2007
A Free, Preventive Lunch
David Leonhardt has a smart column on health care spending today, in which he takes on the idea that preventive care will actually save us money:
The actual savings are also not as large as might at first seem. Even if you don’t develop diabetes, your lifetime medical costs won’t drop to zero. You might live longer and better and yet still ultimately run up almost as big a lifetime medical bill, because you’ll eventually have other problems. That would be an undeniably better outcome, but it wouldn’t produce a financial windfall for society.[...]
Intermountain Healthcare, a network of hospitals in Utah and Idaho that has saved money in recent years by reducing hospital infections and drug errors. Intermountain hospitals have also largely stopped inducing child labor for the sake of doctors’ or parents’ convenience. The hospital induces birth only for medical reasons — and the number of babies that spend time in the neonatal intensive care unit has fallen.
It’s this last example that holds the real key to cutting medical costs. I realize many people will react to the notion that preventive care usually costs money by saying, “So what? We should do it anyway.” And we should.
But by describing it as an easy win-win solution, the presidential candidates are gliding over an important part of the issue. Preventive care saves real money only when it replaces existing care that is expensive and doesn’t do much, if any, good. There are plenty of examples of such care — from induced labor to many lumbar surgeries and cardiac stent procedures.
The problem is that the people getting this care typically don’t consider it wasteful. We all like to believe that other people are the ones getting the unnecessary care. We, on the other hand, are probably not getting enough treatment.
This is all true. To be sure, in a perfect world, I could probably dream up a set of policy initiatives that, if broadly implemented and competently carried out, could reduce health spending off the bat. But the world continually disappoints with its stubborn lack of perfection. Instead, the more achievable goal is to move towards a universal system that's more cost-effective, which is, in fact, very much the same thing as saving money, and towards an integrated system that readies the ground for tougher cost control mechanisms down the road.
July 20, 2007
Electronic Medical Records Will Clean Your House
In answer to last week's study suggesting that initial installations of electronic health records aren't proving as effective as hoped, Overheard in Providence offers up a corrective to the doubters, and looks into a future filled with health information technology and the many fruits of its abundance:
If EMRs [electronic medical records] become widespread, they open the door to a huge new area of medical research. Computer-aided diagnosis is going to get a lot better if millions of anonymized medical records become available. A few years ago I went to a talk by MIT professor Peter Szolovits. He was able to use a computer to diagnose certain heart conditions from audio recordings better than most doctors. EMRs would greatly facilitate the development of automated screening procedures. More importantly, when new procedures are developed, they could be applied retroactively to data collected years earlier, even when a patient stops seeing a doctor. There’s absolutely no way to do this now.
EMRs would also be a huge boon to public health research. Researchers could be given access to a huge data base of anonymous medical records, all in a standard format. It would be trivial to check if two conditions are correlated, or if one disease occurs more often in some segment of the population. The amount of data would be so large, a doctor could even search for records similar to their patent, and use those records as a guide for what health problems to watch for.
Finally EMRs make much better use of healthcare we already provide. If you go in for surgery, all sorts of equipment is used to monitor your well-being. This data should be recorded and reviewed by a doctor who isn’t busy cutting you open. If you go in for a 3D bodyscan, even more data is collected. The scan could easily be reviewed by experts in other parts of the country, provided they have access to your EMR.
I tend to plug EMRs in terms of their immediate and obvious benefits: Reduction in paper, reduction in cost, reduction in lost records, simple programs that prescription errors, etc. But this is all correct, too. The widespread implementation of EHRs could trigger enormous change in the way medicine is practiced, and could accelerate many, many types of research. The downside here is that there are obvious and clear privacy concerns, but as genetic risk profiling inches ever closer to reality, these are issues we're going to have to deal with one way or the other.
July 17, 2007
Do Electronic Medical Records Help?
I often plug the possibilities of electronic medical records to vastly increase care quality while reducing costs, as they have in the Veteran's Administration System. But I'd be remiss not to point to this recent study showing that, in private practices, using electronic health records resulted in merely minor improvements in only two of the 17 tested metrics. And on one metric, the prescription of statins, they actually worsened physician performance. I don't have full access to the study and so can't tell you what hypotheses the researchers attached to their results, but the data is interesting on its own.
It's Pharma's World, You Just Live In It
A new study finds that older, cheaper diabetes drugs control blood sugar as well, with somewhat less harmful side effects, than newer, more expensive ones. In a sane health care system, this would mean a rush to prescribe these older agents, or at least to gather more data on the subject. In our health care system, where doctors take tens of thousands from pharmaceutical companies and patients are bombarded with advertising to make them think they want, or know they want, certain drugs, the more expensive, no more effective, compounds will almost certainly remain atop the market. There's simply no incentive for doctors to switch over, but plenty of incentive for them to prescribe the more costly drugs.
And if that doesn't work, maybe the drug industry will just take a page from their playbook for the epileptic drugs that are about to lose patent and go generic, and try and get state legislatures to pass laws making it illegal for pharmacists to switch patients over to cheaper, perfectly effective generic alternatives. Illegal. But that's no surprise: Pharma spent $44 million on statehouse lobbying in 2005 and 2006 -- and they weren't just buying good times. Hell, in this case, they donated tons of money to the Epilepsy Foundation and did the lobbying under their auspices.
But look, Andrew Sullivan tells me the pharmaceutical industry is great, and way better than in Europe, so I'm sure this is all some sort of big misunderstanding. If they don't keep patients from switching to generics, after all, how will they fund R&D!?
June 29, 2007
Things You Won't Learn From Industry Propaganda
I'm not entirely sure there are words to describe how bizarre it is to watch Andrew Sullivan rely entirely on research from the pharmaceutical industry's web site to make his case for why drug companies should get to charge anything they want. I mean, really, we're going to need a new term. Gullimarkable?
In any case, Sullivan's case is a mess even if you excuse his sources. He gets really excited about a 1994 European Commission report saying "Europe as a whole is lagging behind in its ability to generate, organise, and sustain innovation processes that are increasingly expensive and organisationally complex." The quote from the report then ends, and we have to rely on Pharma's interpretation of how it relates to drug research on the continent.
If Sullivan weren't just parachuting into the issue with a copy of Free to Choose and a tone of extreme indignation, he'd know that a similar study was released last year showing problems in the American pharmaceutical market -- notably, a precipitous drop in new drug development from the pharmaceutical industry.
A report by the General Accounting Office concludes that current patent law discourages drug companies from developing new drugs by allowing them to make excessive profits through minor changes to existing pharmaceuticals. While pharmaceutical research and development expenses have increased by 147% since 1993, applications for approval of "new molecular entity" (NME) drugs, or drugs which differ significantly from others already on the market, have risen only 7%. According to the report, the majority of newly developed medicines are so-called "me-too" drugs, which are substantially similar to existing drugs, are less risky than NMEs drugs to develop, and which "offer little in the way of therapeutic breakthroughs."
Entirely 68 percent -- two-thirds -- of the industry's new drug applications are for knock-off, me-too drugs. The incentives for copying tried-and-true products are far, far too high. So it turns out profit -- generated here by patents -- can actually harm drug development! Am I blowing your mind yet?
Here's a bit more: Those molecular advances Sullivan thinks come entirely from the magic of private enterprise? They're socialism in action. One survey found that taxpayer-funded research developed 15 of the 21 most important drugs introduced between 1965 and 1992. And these aren't joke pharmaceuticals:
A study of the 21 drugs introduced between 1965 and 1992 that were considered by experts to have had the highest therapeutic impact on society found that public funding of research was instrumental in the development of 15 of the 21 drugs (71 percent). Three-captopril (Capoten), fluoxetine (Prozac), and acyclovir (Zovirax)-had more than $1 billion in sales in 1994 and 1995. In addition to these drugs, other members of the group of 21 drugs, including AZT, acyclovir, fluconazole (Diflucan), foscarnet (Foscavir), and ketoconazole (Nizoral), had NIH funding and research to help in clinical trials.
Another study, this one from 1990, looked at 32 drugs on the market and concluded 60 percent would've never been developed without public funds. Yet another "traced more than 45,000 references from U.S. patents to the underlying research papers, and tabulated both the institutional and financial origins of the cited science. We found that more than 70 percent of the scientific papers cited on the front pages of U.S. Industry patents came from public science -- science performed at universities, government labs, and other public agencies."
Pharmaceutical companies don't develop all their drugs. They spend a lot of time buying, patenting, and bringing to market advances made in the public sector through NIH grants and university research. If you're curious as to how this works, take a look at the cancer drug Taxol. Discovered by the NIH and licensed to Bristol-Meyers-Squibb, Taxol is sold for $20,000, costs $1,000 to produce, and the NIH gets .5 percent of the royalties. The pharmaceutical industry was damn innovative, to be sure, but not in the development of this drug -- only in the selling of it.
But you won't find that on the pharmaceutical industry's web site.
April 22, 2007
Melamine Found In California Pork; FDA Launches Criminal Investigation
[litbrit wonders why this isn't front-page news...yet.]
I've been following the pet food poisoning story for a while, and with the advent of last week's revelation that not only wheat gluten, but also corn gluten and rice protein concentrate--all imported from China, all used in pet food, animal feed, and human food--had tested positive for melamine and may have been introduced into the human food supply, I knew it was only a matter of time before this happened: melamine has indeed been detected in the feed and body fluids of pigs meant for human consumption, and California authorities have issued both a quarantine and an advisory to not consume pork from at least one farm (along with weak assurances that eating pork tainted with the industrial chemical poses only "minimal" health risks); others may follow, since the tainted feed was also shipped to New York.
A hazardous chemical believed to have killed scores of pets nationwide has been found in California and New York hog farms, raising concerns for the first time that it could have been consumed by humans.
California authorities have quarantined American Hog Farm, in Ceres south of Sacramento, after melamine was detected in a least seven urine samples and three samples of the animal's food, news report said.
California officials and are trying to trace what happened to slaughtered animals.
About 100 pigs were killed on-site and sold privately, Don Agresti, co-owner of the farm, told The Oregonian.
American Hog Farm is a speciality operation in which people actually pick pigs for consumption and have them killed at a special slaughterhouse. The company's license requires that the meat must be stamped "not for resale."
California officials are conducting tests, trying to determine whether there was any melamine in the meat of the animals. They've warned people not to eat any pork purchased from the farm.
Meanwhile, the FDA has opened a criminal investigation into the melamine-tainting disaster (emphasis mine):
The Food and Drug Administration has opened a criminal investigation in the widening pet food contamination scandal, officials said yesterday, as it was confirmed that tainted pork might have made its way onto human dinner plates in California.
Late Thursday, Royal Canin USA became the most recent company to recall pet foods. Some of its brands were contaminated with rice protein concentrate. Its South African subsidiary said contaminated corn gluten had been linked to the deaths of 30 pets there.
Five companies received the contaminated Chinese rice protein concentrate. Three firms have identified themselves by announcing recalls; the other two are not publicly known because the FDA will not name them until the companies say they used contaminants in their products.