nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Wednesday, March 31, 2010

Medical Quote Of The Day

In memory of former attitudes toward tobacco:

"I have made it a rule never to smoke more than one cigar at a time....As an example to others, and not that I care for moderation myself, it has always my rule never to smoke when asleep, and never to refrain when awake."
--Mark Twain [1835-1910]

Will A Ban On Menthol In Cigarettes Improve Tobacco Cessation?

FDA panel considers evidence for claims that menthol encourages addiction in teens and minorities.

The Washington Post (Mar 31) just published a fairly balanced article (for a newspaper) on the issues involved in tobacco additives that potentially encourage smoking.

It was shocking to me that one in four smokers prefer menthol brands, and that menthol cigarettes account for about a third of the US market.  I smoked for almost 30 years and couldn't stand the menthol taste.  Allegedly, people like menthol because it "reduces the harshness of the tobacco taste."

Further, middle schoolers who smoke  prefer menthol almost 2 to 1.  And, 3 out of 4 African-Americans use menthol brands.  That's huge.

Although the surveys suggest that it's the taste that drives the choice to menthol, that's difficult to tease out from the original motivation to smoke.  At these levels, and among the adolescent population, "group-think" and acceptance probably play a role, too.

In any case, it's interesting to learn that Congress banned tobacco companies from adding other flavorings (such as candy, cloves, and chocolate) last year--but specifically excluded menthol.

There's no controversy over whether menthol cigarettes are more harmful--they aren't.  The allegation of harmful impact centers around how they influence behavior in promoting the smoking habit:  that is, they make it easier for beginners to persist, until they can't stop.

But compare this initiative to a similar one in obesity.  Obesity, due to eating unhealthy, high-calorie foods, is arguably just as unsafe (as a habit) as smoking cigarettes.  I've never seen a risk comparison between the high blood pressure, diabetes, heart problems and cancer atributed to obesity, versus the lung and cancer problems associated with smoking.  Both create chronic, expensive health problems, shorten life, and are potentially fatal.

So, suppose a fast food company comes out with a new Fat-burger, containing an additive that adds no harm in itself, but makes its taste more desirable for over-eaters than the original Fat-burger.  Also, no change in calories or other risk.  Would we write a law that says the restaurant can't increase the taste desirability of their food?

Maybe there's a perception that over-eating is less of a health threat, or economic burden to society, than cigarettes.  But I'm not sure that's factual. 

Would we cross a line legislating food taste?  When I buy a Fat-burger, I'm doing it because I'm fed up with all that healthy, veggie, fiber, low-calorie stuff at home. 

Is there anything different with menthol and cigarettes?  People know they're engaging in bad health decisions. 

And, I'm not sure that  un-mentholated cigarettes would have made a difference in getting me started on cigarettes.  (BTW, been smoke free for 15 years)

Food for thought (pun intended).


Poison Pill Of The Day: HC Premiums To Increase For Young Adults

Poison Pill #8:  The health care reform law limits age differences in premiums, so young healthy adults will pay about $500 a year more.

Rand Health, a division of the non-partisan Rand Corporation, performed an analysis of the new law's effect on re-distributing premium costs, as reported by the Associated Press (Mar 29).

Actuarial data shows that insurance companies charge older policyholders 5-6 times what they charge to young adults.  This actually underestimates the difference between what a young person consumes, and what a senior citizen needs, in annual outlays for medical care.  Figures I've heard are in the "10-20 times a younger person's cost" range.

There's an old saying that "90% of a person's lifetime healthcare cost is incurred in the last year of life."  That's the period when more complex and expensive care is provided in order to postpone the decline in health.

These are just "facts of life."  Enter the US Congress, who limited the ratio between what an older person pays to what a young adult pays to 3:1 in the health care reform law.  That shifts a big load of senior health care onto the young healthy population.  The only reason the annual increase is only $500:  there are many more young people than old people.  Imagine what a single 28 year old would have to pay to make up the difference for a single 70 year old.

Since it appears that there are ways for people to game the system and not pay for insurance mandated by the law, there won't be enough money coming in to pay for everybody.  Apparently the IRS is going to enforce the requirement, but only to the extent of what you report on your tax return.  If you buy insurance just before tax time, then you file as having complied with the law.  More on this subject at a later date.

If not addressed, cost is going to undo all the good things about health care reform.

Tuesday, March 30, 2010

Medical Quote Of The Day

"Scientists have found the gene for shyness. They would have found it years ago, but it was hiding behind a couple of other genes. "
--Comedian and actor, Jonathan Katz [1946- ]

Can My Genes Be Patented?

No, says a federal judge in New York.  Genes are a "product of nature."

This ruling is a big deal.  The average person reading this would probably think...duh.

But the company who patented the genes argued that they developed a proprietary process to isolate and purify the genes in question.  Second, the genes in question aren't normal ones:  they are the familial genes that place women at increased risk for breast cancer:  BRCA1 and BRCA2.  Third, the US Patent Office has issued patents already for about 20% of the human genome.

Gets stickier, doesn't it?  Throw in the ever-interested ACLU, who argued that granting patents for genes allows the company (Myriad Genetics) "a monopoly on genetic testing for these risk factors" that could keep commercial costs very high for years.

Let's break this down.

1.  My genes.  Do I own them?
2.  The process for producing the genes.  Does the company own that, and is it separate from owning the genes they produce?
3.  Does it make a difference if the genes are present in only some people, and are faulty, disease-producing genes?
4.  Is the gene (BRCA) a "product" of nature or a "defect" in nature's work? 
5.  Did the company "create" something new by producing pure genes that are not otherwise available?
6.  Is there something wrong with having sole right to profit from a biochemical product that happens to be a gene that only you could produce?
7.  A gene is an just an organic chemical.  Does it have special status by virtue of the genetic code it contains?  Olive oil is an organic chemical, too.

You can see there are a lot questions to answer.  Put on your thinking caps:  I'm interested in your comments on items in the list.  My personal opinion is settled on only the first two:

Yes, I own my genes.  I don't want somebody marketing my genetic makeup (one of me is enough).
Yes, a company should own the process they develop, but what that process makes is not necessarily the company's  (If a company finds a new way to make gasoline, they can't patent gasoline).

By the way, the US Patent Office was sued as a part of this case.  The judge dropped them from the suit.

Lastly, just for fun, consider this:  I make a "gene" from pieces of other genes.  It doesn't exist in nature--as far as we know--but it could.  And my research shows that if it appears in a person it would cause a disease, maybe.  Can I patent that?

We Are All Doomed To Infection Due To Climate Change

Hypothesis:  Every event on the planet is due to climate change.

An opinion piece appeared in the highly respected New England Journal of Medicine on "Global Climate Change and Infectious Diseases." (Mar 25).

The article describes how higher heat and moisture can increase the activity of insect vectors of human disease, how flooding can cause outbreaks, how drought can (under conditions of poor sanitation) lead to cholera epidemics.  In fact, any change can increase infectious disease.

It's a laundry list of environmental impacts on infectious disease.

None of which is new.

The link to climate change comes from accepting verbatim the conclusions of the Intergovernmental Panel on Climate Change, whose report has come under severe criticism for overstating models and accepting uncritically the claims of advocacy groups.

Over the last winter and into the spring we have seen ridiculous claims for or against the influence of climate change:  too much rain--climate change; too much snow--climate change; coldest winter in a decade--climate change; too little snow--climate change.  The ice pack is melting, the ice pack is growing.  No, it's melting here, but growing there.  ET CETERA.

All of which has to do with weather, and not climate.

The author of the New England Journal piece accepts uncrticially that droughts, floods, heat, and cold are due to climate change, rather than changing patterns of weather.  All of these effects on infectious disease have been with us for millenia.

To top it off, I heard a news story yesterday that some scientists believe that the Biblical plagues were due to climate changeGreat.

I propose that climate change causes warts, increases toe jam, and promotes the heartbreak of psoriasis.

Send me your personal testimony about how climate change has altered your medical status.  I'm collecting them for my Fads and Fallacies book.

There.  I got it off my chest.  I promise my next post will be on something important.


What's Your Take On BPA In Bottles And Cans? A Health Risk?

There are a number of studies showing "effects" but an unclear causal link to "harm."

For those who think BPA is some kind of federal agency or medical test, the letters stand for Bisphenol-A.  BPA has been used in the making of containers for many decades.  It hardens plastics and seals internal surfaces of cans.  Outside of the food and beverage industry it's used in all kinds of products, like sunglasses.

No one has ever suggested that using BPA for non-food uses is harmful.  However, for some experts there is evidence (1) that it increases the risk of cancer and developmental problems in rodents, (2) suggestions that it may be a risk to development in infants, and (3) that most adults have detectable amounts of BPA in the urine.

A word of caution:  many animal studies never translate into risk to humans.  Some do; it's a good way to approach a potential problem...initially.

There is speculation and some evidence that heat and heating food-containers in microwaves (it may just be heat, not microwaves themselves causing the concern)  raise the exposure to BPA by increasing the release of BPA into the contents.

On top of all this squishy language (suggestions, detectable, concern), the federal agencies have issued opinions that don't seem to jive.  Some health officials have said there is no proven harm, the FDA agreed in a report in 2008 that there was no proven harm to humans, but has since decided to re-study the issue, and the National Toxicology Program has opined that there is concern for risk.  The question of regulating BPA quickly became political:  two states banned the use in infant food and beverage containers, Canada has issued more sweeping restrictions, and federal agencies and advocacy groups have produced guidelines for the public to reduce their exposure.

As usual, we are SOTD (Scaring Ourselves To Death) in advance of reliable information on the subject.  Maybe this product does increase risk, but your risk of a thousand other things is almost immeasurably higher (like smoking, and driving).   And, don't expect the advocacy groups to do a study on how many deaths BPA has prevented by giving us non-reuseable containers that reduce the spread of contamination and disease.

Remember all the flap about Alar, the preservative that was used to spray on fruit so its shelf life was extended?  I can still see actress Meryl Streep 25 years ago, at a protest event, agonizing on the shame of it all:  "These are your children!"   The lifetime risk of Alar was eventually pinned down to about one in a million, and experiments that showed a measurable risk had to drink the equivalent of 5,000 gallons of apple juice a year.  How realistic is that?  In any case, Alar was banned.

As with all hazards, it's important to wait for the causative data to surface.  We ain't there yet.  If we start reacting to undefined threats, the fear never stops and we are SOTD.  In the meantime, how about concentrating on those things we know are a high risk to people (like drugs, alcohol, tobacco, auto accidents).  A one percent reduction in harm in these areas would save more people than 10,000 years of BPA exposure would cause harm to.

I welcome any further references to data on BPA (not anecdotes, or statements from activist groups).

To MSM, Citicizing Health Care Reform Is Always Racism

Every day there are articles that call HC reform critics racist.

To reiterate, there are great things in the health care reform law:  no denial, no caps, pre-existing coverage.

But, there's a ton of stuff that just creates an inefficient, costly bureaucracy--and controls our options for health care--that needs to be fixed.  If not fixed, the system is unsustainable.

But, in answer to the racist accusation, I'm pinning this sign (virtually) to myself:


Monday, March 29, 2010

UPDATE to Poison Pill #4: Congress Calls Businesses On The Carpet

Congress has "invited" CEO's of large corporations to testify, submit all accounts, emails after claiming a huge loss due to ObamaCare.

We all know what that means:  get ready to be whacked for communicating the financial loss, caused by elimination of the retiree drug loss deduction, to investors.

I was once "invited" to testify before Congress on the antrhrax vaccine.  I asked the Pentagon to RSVP my regrets.

They said, "you don't understand."

In any case, it was unpleasant:  members walked in and out, delivered prepared diatribes, and left.  The rest was stupid questions from people who knew nothing of biological science.

Medical Quote Of The Day

"Quacks are the greatest liars in the world except their patients."

--Benjamin Franklin [1706-1790]

Another Bizarre Supplement Fad: Milk Thistle Caps For A Healthy Liver

Another supplement sold in health food stores shown to be effective only in emptying your wallet.

Scientific jargon warning:  Silymarin is one of the flavonolignans found in the Milk Thistle plant (Sylibum marianum).

Got that?

This chemical has been shown to have antiviral activity when used against viruses in a lab, and appears to have some beneficial effect when administered intravenously for Hepatitis C in people.

So, naturally (pun intended), this was something the supplement industry could really make a bundle at.  Since there are no laws to regulate supplements, anybody can produce them, and claim anything about them.

We now have Milk Thistle Extract capsules, at ~$10 for 100 [175mg of extract containing ~140mg silymarin].

This study was just published in the Journal of Clinical Pharmacology (Apr, 2010), showing no improvement in measures of liver function when taking up to 10 times the recommended oral dose.  Investigators were unable to show significant blood levels even at these excessive doses.

For Onion Peelers:
Four cohorts of 8 patients with well-compensated, chronic noncirrhotic hepatitis C who failed interferon-based therapy were randomized 3:1 to silymarin or placebo. Oral doses of 140, 280, 560, or 700 mg silymarin were administered every 8 hours for 7 days.  No meaningful reductions in abnormal liver enzymes, or in viral numbers, ("titers") were obtained.

We are Born Free and Live Free in this country.  You can spend your money any way you want.  Here's another wacky way to exercise your freedom.


How Often Does A Malpractice Award Indicate Actual Medical Negligence?

Not many cases that result in malpractice awards are substantiated by outside experts

You will frequently hear the argument (mostly from trial lawyers and the political Left) that tort reform drastically cuts the financial compensation to victims of medical negligence.

As I've said before, the awards don't really go to the victims;  studies vary but I've seen everything from 15% to 45% of the award actually ending up in the victims hands.  The lawyers make more than the people whose situation we are trying to compensate.

That being said, most of us know that frivolous lawsuits are common.  In my day, it was an every day occurrence that an insurance company would settle a claim, right or wrong, if it was relatively small (say $100,000.00) because it cost more to fight it and win in court.  Doctors hated that they caved in like that.  but it was easy money for the lawyers.

But, all this is irrelevant to tort reform.  Malpractice cases award two types of claim:  an economic award and a punitive award.  The economic award is based on a formula:  if the person would have earned X during the remainder of an average life span, then the award is calculated from that and other economic impacts.  Tort reform doesn't have any affect on this award.

The other award, the "punitive" award, is given to punish doctors or companies for doing something that the plaintiffs lawyer has successfully portrayed as shockingly bad.  It's unlimited, in theory.  In practice, it's where the big awards come from...and where the lawyers get their big fees.  One way to do tort reform is to cap the punitve amount: in Texas, it's $750,000.00

So, you could have a $3M economic award and a $10M punitive award without reform, for a total of $13M.  With tort reform the limit would be $3.75M.  Not bad.

Back to the original question.  A study was done some years ago (Annals of Internal Medicine):  a panel of internal medicine specialists (internists) were give a stack of case records, under conditions of anonymity.  They were given  no knowledge of the case, the patient, or the hospitals or doctors involved; all this information had been removed.  They were asked to determine whether, in their expert  medical negligence occurred:  yes or no.

Half the cases had gone to trial for malpractice and a jury had awarded damages.  The other half were control cases matched for disease, patient characteristics etc.

Guess what percentage of the malpractice award cases were validated by the objective experts:  10%.

That doesn't give me much confidence that our judicial system works very well.  Don't get me wrong; we need a system that is fair to victims, but doesn't drive up the cost of medical care  (MY MAIN POINT).

I vote for arbitration panels, with trials as a backup if an agreement can't be reached.  I also support punitve award caps--they are mostly egregious and unrelated to the damages.


Poison Pill Of The Day: HC Reform Law Directs Useless Calorie Labeling

Posion Pill #7:  The health care reform law requires restaurant chains with 20 or more locations to include calorie labeling in menus and billboards--a strategy for obesity which lacks proof.

Actually, I've written before on calorie-labeling.  A study of the New York City ordinance which directs a similar labeling requirement failed to show any change in calorie consumption.

There may be a way to educate people about their dietary and nutritional requirements that will result in a reduction in obesity, but we haven't found the right formula yet.  Putting a regulatory requirement on a type of restaurant is premature.

This requirement is so counter-intuitive that it exempts vending machines from the labeling requirement.  I guess the message is that a Double Whopper is bad, but Snickers are OK.

These regulations will cost businesses money, but have yet to show they will have any effect on obesity.

Besides I don't go to a restaurant to count calories.  I go to pork out.

Doc D

Sunday, March 28, 2010

Tanning Beds And Risk Of Skin Cancer

This post is timely because the FDA is considering further restrictions on tanning bed use, possibly an age limitation that would ban those under 18 years old from using tanning beds.

The Tanning Salon industry is disputing the link between exposure and cancer later in life.

Doesn't this sound a lot like what the tobacco companies said decades ago?

Admittedly there's not a lot of data to show a direct link between tanning bed use (specifically) and skin cancer.  And, tanning beds tend to use the UVA, an ultraviolet light that is less prone to causing skin damage and cancer.  However, in 2003 the World Health Organization put out a report that the tanning industry was resorting to UV lamps with increasing amounts of the more dangerous UVB, in order give customers a speedier tan.

Another bit of suggestive evidence is dermatologists reporting that they are seeing younger patients with skin cancer, in their 20's and 30's.  Surveys show that teenage girls are common users.

But, since we do know that UV is related to skin cancer, and increased exposure raises the risk of skin cancer, I don't need a lot of evidence to confirm that the UV from tanning beds contributes to the overall UV exposure risk.

Besides, I think it's unlikely we will get directly causal evidence of the increased risk:  you would have to have a control group that had no sun exposure, only tanning bed exposure.  How likely is that?

The bottom line:  we engage in risky behavior every day.  It's probably a lot more risky to drive a car than to risk cancer from a tanning salon.  However, for the intended result--a temporarily more attractive appearance--some people may want to give it some thought.  And, the more UV exposure, the earlier in life skin damage appears.  Not a good trade-off in my opinion.

Medical Quote Of The Day

William Osler was a doctor, originally from Canada, who along with three colleagues formed the world famous Johns Hopkins Hospital in Baltimore.  An advocate of hands-on patient experience, backed up by laboratory science--which became the standard for training doctors in this country--he is the most famous Western physician of the 20th century.

He was known and loved by students for his philosphical reflections on the medical arts.

Here are three of my favorites.

--The young physician starts life with 20 drugs for each disease, and the old physician ends life with one drug for 20 diseases.
--One of the first duties of the physician is to educate the masses not to take medicine.
--It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.
--Sir William Osler [1849-1919]


Poison Pill Of The Day: Law Does Not Prohibit Rationing.

Poison Pill #6:  Section on coverage does not exclude cost considerations.

Boring and nearly incomprehensible quotations below are taken from Section 1302(b)(4)  of the new health care law (formerly "the Senate bill").  See page 107 and following.

The Secretary of Health and Human Services shall

"not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life;"
"take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups;"
"ensure that health benefits established as essential not be subject to denial to individuals against their wishes on the basis of the individuals’ age or expected length of life or of the individuals’ present or predicted disability, degree of medical dependency, or quality of life;"

That is, no discrimination, and no denial based on group, and ensure coverage of diverse needs--that's good.  As you can see, the law is explicit about many things above on gender, age, disability, etc.

Note that none of this prohibits the Secretary from making decisions (regarding coverage or needs) on the basis of cost.

There's an old saying in government work that "an action not prohibited is an action allowed."  So, the door is open to exclude coverage that exceeds the revenue alloted for care; i.e. rationing.

Concerningly, the same section does require the Secretary to make

"an assessment of the potential of additional or expanded benefits to increase costs and the interactions between the addition or expansion of benefits and reductions in existing benefits to meet actuarial limitations described in paragraph (2);"

The law puts great resonsibility and power in the hands of the Secretary of Health and Human Services (HHS).  While searching for signs of how cost and coverage would be related, I came across hundreds of statements that she will "decide" this, "determine" that, "include or exclude" whatever, and "report" all kinds of things.  Note that the Secretary of HHS is a political appointee of the President.

For a lesson in how government funding of healthcare can go wrong financially, see the article in the Telegraph (Mar 26) on the desperate measures under consideration in Great Britain.


Saturday, March 27, 2010

Medical Quote Of The Day


"The least questioned assumptions are often the most questionable."
--Paul Broca [1824-1880]

Doc D

Why Doctors Practice Defensive Medicine

Almost half of all doctors get sued for malpractice.  Which do you consider more likely:  half of the doctors are bad doctors or there are a significant number of good doctors who get sued?

[To be fair, it may be that good doctors can make a bad decision, or that a "bad result" is sometimes considered  "bad medical care."]

Just from watching the process of medical litigation (and participating in peer-review) over the past few decades, my view is that about one-half to two-thirds of allegations of medical negligence are frivolous.

Doctors are motivated to defend against frivolous lawsuits, but why should they fear them if they did no harm?

I hear this from people sometimes:  "right or wrong, you make a good living, you can afford it" and "you would stand up for yourself if you didn't do anything wrong."  This makes some of my colleagues cynical.  They think patients like them only when they're sick and need help; at all other times, they resent needing doctors, and particularly dislike doctors when they have to pay the bill.

But back to what I hear people say.  I'm not sure that anywhere in the job description does it say doctors should expect cross-examination as a consequence of caring for patients.  If you've ever watched a trial, it's pretty typical for the plaintiffs lawyer to accuse you of every vile thing they can think of, in order to influence the jury.  It's pretty unpleasant.

Juries are swayed by lawyers implying that a test was not done, needed or not.

By the fact that there IS a test that sometimes is done in some cases, many people see it as negligent that it wasn't done in this case.  This makes it very hard to defend not doing a test:  if a treatment had a bad result, and you didn't do some test, then it may be that the test would have avoided the bad result.  It's not a logical train of thought, but humans have a hard time not buying into it--particularly when faced with someone who has undergone suffering or loss.

If doctors do all the defensive medicine they can, does it keep them out of the courtroom?

The evidence is mixed on this.  Even the worst ambulance-chaser will think twice before suing:  he/she may be unlikely to win for a patient if they can't find a test that wasn't done.  So, yes, it works--somewhat.

BUT, studies show that there is a single most common cause for malpractice lawsuits:  poor communication.

For the record, a couple of patients were really ticked off at me when I was tired and snotty, back in my early days.  So I learned the lesson of Communication early.  And, for the record, I have never been sued in 35 years.

Next posting on this:  The relationship between medical lawsuits and medical negligence.

Stuporked: Pro-Life Flippers Submit $5B In Earmarks After Vote

Thanks to Hot Air for the term, and to the Sunlight Foundation for the report.

Not letting a day go by, Rep Bart Stupak and his caucus of pro-life Congress members, who were critical to passing the unpopular health care reform bill, submit a package to the House leadership for $4.7 billion in earmarks for their districts.  Recall that Stupak, et al held out until the controversial Executive Order deal was struck... a deal hated by both pro-life and pro-choice.  Their flip-flop brought the vote total to just 3 over what was required for passage.

This is all a bizarre coincidence, because they could have put in for these earmarks at any time of the year, it just so happened to be now (what's the emoticon for sarcasm?).

Get ready to fund two new wings of the Great Lakes Historical Shipwreck Museum.  This will be of some comfort to the millions without a job.

Thanks, also, to CM Bart Stupak for his expansion of the English language.  We already have "Stupaked"  (meaning "betrayed" or "stabbed in the back").  Now we have a new verb.

How much more will Congress Stupork me?


Health Care Reform - Poison Pill Of The Day

Poison Pill #5  - Beginning a new series

I may be off on the number, but I'm starting to track them. 

Don't get me wrong, there are great results in the health care reform law:  no caps, portability, pre-existing illness coverage, and the like.  Unfortunately, there's another 2500 pages of stuff.

Since nobody read the bill, we're learning of defects every day.  Will they get fixed? 

So, rather than continuing to extoll the good aspects, about which there's nothing more to say, I'll concentrate on the problems created by writing a huge law, drafted by Congressional staff who are mostly poli sci majors or long-term politico's (with no deep understanding of the system), under circumstances of haste, special deals, etc.

This is the Poison Pill list so far.  We have (1) Congressional staff exempt from mandate, (2) failure to implement coverage for kids with pre-existing illness, (3) taxpayer bonus to hospitals that are less costly, (4) billions in charges to businesses (Caterpillar, John Deere) from loss of tax deduction for retiree drug benefits--reducing economic growth and new jobs.

#5:  3500 companies who offer retiree drug benefit may be forced to dump their retirees on Medicare.

This is related to Pill #4, but the impact is on the patient, not the company.  The loss of tax deduction for the companies of the over 4 million people covered by employer-supported retiree drug benefits will lead to those companies adopting higher co-pays, deductibles, and order to make up for their tax losses.  In some or all cases the companies may decide that it's cheaper to cancel the coverage and dump the retirees onto the Medicare system.  So much for keeping your health plans, and lowering premiums.

Taxpayers may now pay $1200 instead of $600 for each person receiving drug coverage.

Here's the kicker for us all.  On average, before health care reform, the companies received a $600 tax deduction for providing this coverage.  The companies paid the rest.  With Medicare, the average annual taxpayer bill for covering the benefit is $1200.  We traded a $600 tax revenue loss, for a $1200 taxpayer payment.  Such a deal.  How does anybody benefit from this--except the government; who receives the revenue from the companies-and can spend it as they wish? (I understand that the Rock and Roll Museum may get only $3M in earmarks this year; maybe we can bump them up a few million).

Stay tuned for the next Poison Pill.

Friday, March 26, 2010

Medical Quote Of The Day

Talent is hereditary; it may be the common possession of a whole family (e.g. the Bach family); genius is not transmitted; it is never diffused, but is strictly individual.
--Sex and Character, Otto Weininger [1880-1903]


Worried About Financing College? Ethical Concerns with Selling Your Eggs And Sperm

Tuition on the rise?  So are income opportunities.

A report issued by the Hasting Center shows that advertisements in college newspapers offering to pay students for their oocytes are keyed to desired personal characteristics of the seller.

For the monosyllabic, sterile couples want smart people's eggs.  The Boston Globe (Mar 26) reports an advertisement in the Harvard Crimson for a woman under 29, with GPA over 3.5, and SAT score over 1400.  The compensation?  $35,000.00.

The following graph illustrates the relationship between fee and SAT (Scholastic Aptitude Test)

There's a lot of scatter but the pattern is clear.  I wonder who that person was who got $50K?  (4.0, 1600?)

Given the genetic combinations possible, the likelihood of this being an effective strategy for birthing a genius child is  Most people realize this when they think about it.  I'm sure that the psychology is, "I would feel guilty if my kid turns out dumb, and I didn't get a 'smart' egg."

"You're traveling through another dimension, a dimension not only of sight and sound but of mind...Your next stop, The Twilight Zone."


Why Some Doctors Don't Take Medicaid and Medicare

Factoid:  over half of the cost of medical care is already paid for by the government.  Question: Then who controls the cost?

The administration's effort to blame insurers for high cost has been accompanied by little data.  A review of the net profit margins for different industries throughout the country shows that Health Care Plans rank 87th with a profit margin of 4.4% (see here for the data.).  Doesn't sound like real price gougers does it?  By contrast Cigarettes are #7 (19.2% profit),  and the Beer Industry is #14 (13.8%).

But the hype about the evil scoundrels in the insurance industry isn't really where we need to target our concern over cost.  Nor should it be Drug Manufacturers, who are an astounding #3 in net profit margin (22.2%).  Like several other sectors of the health care system Pharma was bought off by the Obama administration for $80B they agreed to spend to lower drug costs--knowing full well this is a drop in the bucket which they will make back ten-fold, later.

If we can't demonize industries, where do we put the anger?

Again, these sectors are not the problem.  As a doctor who deals with real people's problems I have a different perspective--a personal one.  Back when Medicare was a new law, I was practicing emergency medicine in Houston.  One day I saw an elderly lady who came to the ER in acute heart failure.  It took me about an hour, never leaving the bedside, using digitalis, diuretics, oxygen, bronchodilators, etc, to bring her back from a near-fatal situation.  When I admitted her to a colleague for follow-on treatment, she thanked me.

Medicare paid me $3.00.

Some weeks later I got a hand-written letter from this lady, saying she was appalled by the government's payment and offered to pay me $1.00 a week until the bill was fully paid.  That was too heart-wrenching for me, so I told her that no further payment was due.

For those who think, "well, that was then, when Medicare was new," fast-forward to a couple of months ago.  I have a government-run insurance plan, and was covered for an operation I needed.  The surgery was a success, and I feel fine.  My surgeon is one of only a couple in his specialty in this area, and is a highly-respected, Mayo Clinic-trained professional.  He charged the government $920.00 for my operation; they paid him $226.59.  I don't think that pays even his malpractice premium for one day.

Twenty three years ago Medicare paid $1700 for a gall bladder operation.  Today they pay less than $600.00.  Despite the government's control over this, costs continue to climb.  The government's answer is to spend more, institute price controls, and demonize the industry, but keep adding people who provide no revenue for the system--a prescription for failure.

The government drives the high cost of health care

In order to compensate for the government's less-than-break-even reimbursement rates, the industry (hospitals and doctors) charges more to private insurers.  The politicians then point to the commercial insurance market to make their point about high costs--completely disregarding the fact that, at bottom, they are the cause, by setting government payment rates so low.

And just so you don't think this is doctor-whining, you should know that the way the government decides on how much they will pay is to FIRST decide what the real cost is, THEN set their payment at 90% (Medicare) or 80% (Medicaid) of that (approximately).  They know they're undercutting.

In defense, many doctors limit the amount of government care they provide

So, why do doctors limit or deny Medicare and Medicaid patients?  If too many of your patients are government-supported, you don't break even.  This is why only 43% of Texas physicians take Medicare.  The percent who take Medicaid is much lower still, since the Medicaid reiumbursement rate is even lower than Medicare.  It's why one of the Mayo Clinics announced they could no longer accept Medicare patients except for cash.  They announced their losses due to Medicare for 2009 were $840M.

As a practicing physician, I (like most) hate messing with this stuff.  I didn't become a doctor to run a business.  We just want to concentrate on the patient care.  But when your business person comes to you and says the cost of running a practice is increasing by 20% a year and we can't afford to take these patients, many of us reluctantly say, OK--and damn the government for their perfidy.

I expect all this to get worse under Obamacare.  The President touts taking $500B from the Medicare program to fund the new entitlement.  How is that going to be taken out of the Medicare program?  They say it's revenue that corrects "inefficiencies."  To me, that just means "paying even less."  We'll see....

Opinions are entirely my own.

Thursday, March 25, 2010

Medical Quote Of The Day

Life is a hospital in which every patient is possessed by the desire to change his bed.
--Small Poems in Prose, Charles Baudelaire [1821-1867]


Health Care Reform Costs: More Taxpayer Money to Less-Costly Hospitals?

Am I missing the logic here:  we're going to give extra money to hospitals that are less costly?

So a hospital creates efficiencies in cost, lowering the amount of taxpayer payments through Medicaid and Medicare.  We then celebrate "bending the cost curve" downward, by authorizing them additional taxpayer funds in the health care reform bill.

Perversely, this is exactly what happened.  In order to gain the votes necessary to pass the bill that was signed into law this week, Speaker Pelosi had to promise $800 million in additional funding to less-costly hospitals in Iowa, Wisconsin, Oregon, and other states.  Kaiser Health News (Mar 23) calls it a "political dilemma" that legislation designed to lower costs could only be passed with massive cost-increasing political deals.  That's putting it too stinks, and it's stupid.

As one health economist, Stephen Zuckerman (quoted in the Kaiser article), questioned, wouldn't it be a better cost-cutting strategy that "high cost hospitals should be penalized with lower payments."

Posion Pills in the health care reform law

I said previously that we will find many poison pills in this legislation.  Mainstream media and others have reported on the exemption for Congressional staffers, failure to include children in coverage, takeover of college loans (how is that health care related?), the states opt-out option on mandates, businesses dropping health care coverage.  The list is growing every day.


Osteoporosis Drugs And Risk Of Fractures


Osteoporosis drugs are supposed to strengthen bone, not increase risk of fracture, right?

Well, concerns about a set of unusual hip fractures in women taking bisphosphonates for osteoporosis can't be validated...for now.

The study, published online in the New England Journal of Medicine,  lumped together patients (14K) from three studies who were taking Fosamax or Reclast.

Prior to this there have been a number of case studies that suggested long-term use of the drugs could cause two kinds of hip fracture. 

This study found that these fractures were very rare, even in patients on the medicine for 10 years, and couldn't establish a significant link between the drugs and the fractures.

Onion Peelers:  The statistical relative hazard ranged around 1.0, meaning that there was no increased hazard.  But, there was a whopping confidence interval for each drug that ranged from 0.06 to 16,46.  That means that we can say with 95% confidence that the relative hazard was somewhere between 0.06 and 16.46.  That means taking the medicine could be very much less hazardous or very much more hazardous.  Clearly, that doesn't make any sense, and only proves the authors' comment that this study doesn't definitively answer the question.

Bottom line, keep taking your osteoporosis drugs if your doctor recommends them, and stay tuned for further research.


Wednesday, March 24, 2010

Medical Quote of The Day

Doctors' incomes have been falling, on average, for the last 12 years or so, although they still make a good living:  from $150K for a pediatrician to $600K or more for a specialty surgeon.  On average though, they make less than a full professor at Harvard, or a senior Congressional staff member.  Therefore, I was amused to read the following from a previous century:

"My old man used to say that he guessed the percentage of scoundrels was less among doctors than any other class of men, professional or otherwise, in the world...He said his own life had been saved several times by doctors and that he always paid the doctor first and let the other debts incurred during his illness wait.  He said he figured that had the doctor not saved him and put him in action again, the others would never have been paid anyway."
--The Brighter Side, Damon Runyon [1880-1946]


The Eternal Triangle: Women, Exercise, and Weight Gain

Women have to exercise til they drop in order to avoid weight gain?

This study in the Journal of the American Medical Association this week (Mar 24/31) is getting a lot of press (WSJ, Mar 24).  My link to the study is for the free abstract only.

What bugs me is the headlines, which say "Women Need 60 Minutes Of Exercise A Day To Not Gain Weight" or some such.  That's not really what the data says.

It does say that "Women successful in maintaining normal weight... averaged approximately 60 minutes a day of moderate-intensity activity."

BUT, and this is a big "but," the only group of women who had a statistically significant association between exercise and less weight gain was that group with a BMI of less than 25.  Recall that BMI is Body Mass Index, which is a calculation of overall body fat based on height and weight.  For instance, if you are 5 feet 6 inches and weigh 160 pounds, you are over the limit (25.9), and not in the group referenced above.  Interested in what your BMI is?  Go here for a quick calculator.

Back to the data to validate this claim.  The study looked at 34K women over the period of 1992-2007.  The study group was a median 54 years old.  All together women gained an average of 2.6 kilos over the course of the study.  The study categorized the women's activity into "less than 7.5 MET hours per week", "7.5 to 21 MET hours per week," and "more than 21 MET hours per week."  A MET (metabolic equivalent) is a measure of exercise:  21.5 MET hours per week  is about 60 minutes of moderate-intensity exercise per day.

Women in the <7.5 category gained 0.12 kilos over 3 yrs.  Women in the 7.5-21 category gained 0.11 kilos over 3 yrs.  Not significantly different.  4540 (13.3%) women with BMI of less than 25 at the start had significantly less weight gain throughout the study.

So, bottom line, the authors conclude that "physical activity was associated with less weight gain only among women whose BMI was lower than 25."  That's a lot different from the headline, because it means if you were skinny before, you're most likely to stay skinny.  Does that sound like an earth-shattering finding?  Conversely if you were heavy before you tend to get heavier.

So, the media is hyping the results...again.  The science is more mundane.

Nothing is changed:  the best prescription is to eat right, exercise, get your rest, and enjoy your life.

Opinions are entirely my own.

Rep Bart Stupak: Damned By Both Sides On Health Reform


On a polarizing issue like abortion it's hard to be hated by both sides--simultaneously.

It's uncommon to be hated by one side one day, then by the other on another day...but, wow!  Both at the same time.  There ought to be an award for that.

Speaking of awards, Rep Stupak was scheduled to receive a "Defender of Life" award from the pro-life group, Susan B. Anthony List Candidate Fund today.  They've withdrawn that award.

On the one hand the pro-choice people see his deal with the President as an impediment to the funding of abortion in the bill (and, yes, it does allow for the use of public funds in the community health exchanges--see my analysis here, in a previous post).

On the other hand, the pro-life people see the Executive Order the President has promised to sign (which he hasn't yet) banning public funding for abortion as a worthless gesture:  the courts have said more than once that previous public law allowing access to abortion will override any executive order--unless Congress specifically prohibits that funding--stating otherwise.  You'd think Stupak would have known this (I'm sure he does).

The situation becomes clearer regarding Rep Stupak's state of mind, when you learn that two days before his decision to reverse course and support the health care reform bill, his state was given an airport grant for $700K by the Obama administration.   Purely a coincidence, of course.

Abortion is strictly an issue of conscience for both sides, right?  But finding yourself to be both anti-pro-life and anti-pro-choice takes a lot of ingenuity.  Way to go...

As a side note, Stupak was a shoe-in for re-election until two days ago, when funding began pouring in for the other candidates for his seat, both Democrat and Republican.  Another coincidence?  Doubtful.

Opinions are entirely my own.

Tuesday, March 23, 2010

Medical Quote of The Day

The surest road to health, say what they will,
Is never to suppose we shall be ill.
Most of those evils we poor mortals know
From doctors and imagination flow.
--Night, Charles Churchill [1731-1764]

Congressional Staff Exempt From Health Care Mandate?

Tempest or Teapot?

In a story on the National Journal Hotline On Call, it appears that there may be a loophole for Congressional staff.  The health care reform bill passed on Sunday says that members and their "office staff" must participate in a government-offered exchange.  This is being interpreted as applying only to personal office staff, and NOT to staff who work for a committee or the leadership.  Does this mean those "non-personal" staff don't have to purchase insurance?

By coincidence these are the people who drafted the bill.

People who think this was deliberate, will argue that it's another example of the poison pills we have yet to uncover in the bill.  I agree that there will be some unpleasant surprises as everybody (including the President and all who voted on the bill) realizes what's in the legislation, but I have my doubts that it's a corrupt plot.  We'll see.

Opinions are entirely my own.


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