CDC Zombie Apocalypse

by: Joshua McKellar - May 19th, 2011   Filed under: healthcare 39 Comments

The Centers for Disease Control and Prevention (CDC) has released what appears to be the most important public health guide of their existence. You can find it on the cdc.gov website here.

Their list of how to be prepared is lacking several important items. I have been zombie-like during 90% of my public health classes, especially the ones in the morning, so I probably know best how to be prepared for a zombie apocalypse.

I truly question whether the CDC is currently run by zombies and this “announcement” has the aim of reducing the likelihood that we will be prepared for them. Notably missing are items that can be used for defense. The CDC would not write an article on a potential avian flu epidemic without noting that killing influenza through the use of hand sanitizer is probably your best defense. However, they don’t state anywhere in their zombie apocalypse article that we should have baseball bats ready. They avoid the issue of homemade bombs and other devices that can be used to fight off zombies. Notice that they don’t tell you anywhere how to get rid of zombies.

Also, they suspiciously include a suggestion to have predetermined meeting places with family members. They include this photo:

with the caption “You should pick two meeting places, one close to your home and one farther away.” Yeah, if they really are zombies they would want to get us outside in open places. Not subtle enough, zombie epidemiologists!

Also suspicious is this picture:

How did they find a zombie to photograph, unless they ARE ZOMBIES?!?!?

Okay, furthermore, you will notice that you can translate this page into several languages: Chinese, French, German, Spanish, or Filipino. Do you notice what language is missing? CANADIAN! Perhaps that is because all Canadians already are zombies! So, now we know that the CDC is run by Canadian Zombies.

And then there is the conclusion to their article:

If zombies did start roaming the streets, CDC would conduct an investigation much like any other disease outbreak. CDC would provide technical assistance to cities, states, or international partners dealing with a zombie infestation. This assistance might include consultation, lab testing and analysis, patient management and care, tracking of contacts, and infection control.

So, if zombies do attack, do not worry, because the CDC will rescue you! Furthermore, the author states that he will be “volunteering the young, nameless disease detectives for field work.” He slipped up! We all know that zombies have no names. He just verified that the CDC employs those with no names, AKA zombies.

Now, what are we going to do about this? I believe this is a call to arms. We need to root out these CDC zombies wherever they are and make the world a safer place.

WSJ on HAART

by: Joshua McKellar - May 12th, 2011   Filed under: healthcare 26 Comments

I just saw this on the WSJ front page.

Link.

First, this is essentially what my thesis is about. If everyone with HIV takes antiretroviral therapy (ART), their infectiousness is reduced to the point that HIV can be eradicated. Second, this is old news. Why is the media several years, perhaps a decade behind scientific findings. I often read reports on various news sites about “new research findings”. The new research findings are, in reality, old research findings. Yes, scientists investigate questions over and over again. However, with respect to highly active antiretroviral therapy (HAART), nobody in infectious disease research did not know about this. This is just one more study finding the same thing as before. I believe the Rakai study in Uganda came out nearly a decade ago (and Uganda is recently in the news for their proposals regarding homosexuals, look it up). Before that it was well known that ART reduced mother to child transmissions by 50%.

More importantly, these findings are nuanced. What are the benefits, besides reduced transmission, to the patients if they begin HAART at CD4 cell counts less than 350 cells/microliter? Also, as he highlighted in the video, will these findings increase risky sexual behavior among those with HIV? He should not have given any cause to the idea that those on HAART can forgo other protection. That is absolutely antithetical to the interests of public health. The fact that he left that possibility open is dangerous, and likely to cause people to die.

Most importantly: popular media is not a reliable source of health or scientific information. This is where blogs have really increased the ability of consumers to understand new research. I bet if you search for any subject under google’s blog search function, you will find some interesting blog that is much more up to date than the mainstream news organizations.

Sorrell v. IMS Health inc.

by: Joshua McKellar - April 27th, 2011   Filed under: healthcare 48 Comments

The Supreme Court held oral arguments yesterday on Sorrell v. IMS Health Inc.

Background Information:

Pharmaceutical companies are a pet topic of mine. Unchecked greed found in pharmaceutical profits permeates nearly all of modern medicine. But I also realize that pharmaceutical development has also saved countless lives over the past hundred years.

Drug reps underly, previously known as “detail men”, underly much of a pharmaceutical company’s sales pitch. These ubiquitous salesmen and saleswomen serve doctor’s whims, lavishing gifts and influence over doctor’s prescription pads. Over the past ten years the influence drug reps hold has diminished, while direct-to-consumer (DTC) advertising became legal and has increased.

The current modus operandi for marketing by drug reps is to target the doctors that write the most scripts for your drug. Information technology provides one of the most powerful tools in drug reps’ arsenals. Market research firms collect data on hospital and doctor’s prescribing patterns and sell their information to pharmaceutical companies. The American Medical Association (AMA) is compliant in this practice, licensing physician information they collect in their Physician Masterfile to market research firms. The information the AMA provides includes non-member physicians.

The information provided to market research firms allows drug reps to become more efficient in targeting their practices. Gifts are better targeted, and notes on individual physicians are extremely elaborate. Also, pharmaceutical companies are better able to track how well their drug reps are performing, fire the underperforms or reward the over-performers.

Many research institutions and hospitals have attempted to stem the lucrative practice of the unwritten and unsaid quid pro quo rule governing drug rep-doctor relationships. Rules dictate the maximum gifts allowed and some academic journals require disclosure of payments made. Still, the drug reps continue to proliferate. Fueled by high prices charged for pharmaceuticals and the information provided by market research firms, nearly all new drugs are overprescribed. Massachusettes had a law in 2008 that forbid certain gifts and required other payments to be reported to a public database. That law was repealed yesterday, mainly by Republicans but also some Democrats, in favor of economic stimulus.

That brings us to the current Supreme Court case.

Vermont attempted to curb the power of drug reps. They restricted pharmaceutical marketers’ use of prescription records. The law in Vermont restricts access to nonpublic prescription drug records and forces an opt-in policy for prescribers to be included in the records. Uses besides marketing are allowed, such as ones by law enforcement, journalists, and insurance companies. IMS Health Inc. is arguing that the First Amendment prohibits a law that disallows pharmaceutical companies to use the data for marketing purposes. Data is de-identified, of course. Maine and New Hamshire have similar laws that have been upheld by a federal appeals court.

The New England Journal of Medicine, the AARP, several dozen state attorney generals, privacy groups, and the federal government have filed briefs in support of Vermont’s law. Briefs against the law come from the National Association of Chain Drugstores, the Association of National Advertisers, and several news organizations, or basically anyone who profits from SCOTUS striking the law down.

After oral arguments, it is apparent that the Justices view the case as a expression of corporate free speech. As Scalia said, “Let’s not quibble over what the purpose is.” He pointed out that the law’s purpose is to prevent drug reps from selling their products to physicians. He is correct. Kennedy stated that the state is “regulating speech.” He is also right. Roberts stated, “To use a pejorative word, the state is censoring what they can hear to make sure they don’t have full information.” Ginsburg said that the state “is interested in promoting the sale of generic drugs and correspondingly to reduce the sale of brand-name drugs.” She pointed out that the goal is tantamount to the opposite of the First Amendment. Kagan suggested “a bar on selling [the] information to anyone”, which in my opinion goes further away from Constitutionality and borders on insanity.

You probably remember Citizens United v. FEC, where SCOTUS struck down a law regulating corporation’s and union’s political speech. The Justices are raising the same concerns in Sorrell v. IMS Health Inc. and will likely follow a similar pattern of voting.

Pharmaceutical companies spent $6.3 billion on marketing drugs to doctors in 2009. An academic study found that the return on investment for each dollar spend on marketing drugs produced after 1997 to physicians is $10.29 [1]. That is absolutely incredible return on investment. Pharmaceutical companies argue that they do this to find physicians with patients that they may be able to most help.

I concede that if the issue is truly free speech, the Justices are on the right track. In fact, I don’t even want to try to argue that repeal is unwarranted. However, the pharmaceutical industry has the entire medical profession by the balls. The profligate nature of the industry has made a lot of people extremely rich, largely at the expense of patient care. Still, I have no doubt that Vermont can find a solution that does not restrict free speech.

I wrote a very reactionary piece a few days ago about the importance of patients as consumers underlying patient-driven care. Really, Krugman and others are part right. Often the consumption of health care occurs under quite extraordinary circumstances. Patients, or consumers as I prefer to call them, have to be vigilant before they need healthcare to insure that they receive the best quality care possible. Kruman’s ideal of a special doctor-patient relationship just isn’t feasible when there are pecuniary incentives for doctors to act as imperfect agents. Still, there are many many excellent physicians out there. It is just hard to find them.

I think that a major part of the problem is lack of organizations providing accountability data on perfidious healthcare workers or organizations. The absence of this data is largely due to the lobbying efforts of major medical and pharmaceutical associations. Still, obscurantism is not the entire issue. Consumers just tend to not care. With many pharmaceutical companies facing the expiration of key patent protections, we can expect the marketing campaigns for their less-than-effective drugs to increase substantially.

I wish I had more time to study the pharmaceutical industry. They most definitely do not operate in a free-market environment. They obtain substantial profits through their patent protections. Any research on the pharmaceutical industry underscores how useless the FDA is in  However, I fail to see how a different system would work better. Francis Collins, the NIH director and a personal hero of mine, called on the NIH to engage in substantially increased drug research development. Maybe that is a step in the right direction, I really do not know. Pharmaceutical companies make me question my assumption that all policy is bad policy.

 

 

Note: You might be interested to know that Vermont is one step closer to instituting a single-payer system in their state. Their state senate voted in favor of the law yesterday.

[1] Milton Liebman, “The Right Media Mix is the Key to Maximizing ROI,” Medical Marketing & Media 36 (2001): 92-95.

Disclosure: I hold and have held investments in several pharmaceutical research and development companies.

 

Patients as Consumers

by: Joshua McKellar - April 22nd, 2011   Filed under: economics, healthcare 23 Comments

In his latest article, Paul Krugman (yes, another Krugman post) bemoans the use of the word “consumer” apropos “patients” or those in a doctor-patient relationship. His quote:

“The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car — and their only complaint is that it isn’t commercial enough.”

This was brought to my attention by the venerable Don Boudreaux in a post on CafeHayek. Okay, full disclosure: I have consumed healthcare in the past! I would bet that you have too, since you were most likely born at some point, typically a year before your first birthday.

First, if Krugman had even bothered to glance at literature or that bastion of conservative propaganda, Wikipedia, he would realize that the purpose of referencing patients as consumers is to give them empowerment. In reference to his article, Krugman referenced Kenneth Arrow’s important article on the economics of healthcare. In that article, Arrow demonstrated, rather persuasively, why healthcare cannot be treated as a market. Still, it would have benefited Krugman well to have used all six of his brain cells to think about the term “consumer”.

The term “consumer” was first used widely by those treating and undergoing treatment for mental health issues. I believe the use was piloted by those subscribing towards a recovery model of mental health care where the belief is that those in need of medical care understand best what they need. This was in the wake of terrible monstrosities within public mental health institutions (think of any movie that shows a mental health institution). If you realize the type of system that the term “consumer” birthed from, you would find the idea that patients are not consumers to be heinous.

Referring to “patients” as “consumers” provided them with empowerment. If Krugman was familiar with mental health issues (as he must be, c’mon), he would realize that one of the biggest factors leading to success is outlook. The term “consumer” provides one with an understanding that he or she is in charge of their own care and reduces the stigma that attends mental health care.

Furthermore, the term “consumer” moved over into the realm of daily medical care with the advent of patient-centered care and now patient-driven care. The term “consumer” was not made up to force healthcare into a market schemata, rather, it was aimed at improving the quality of the healthcare system. While Krugman points to Arrow as demonstrating why patients and doctors need to have a special relationship, I could point to Wennberg as showing that physicians often over-prescribe. Also, I could as easily point to the Institute of Medicine’s report that medical errors cause 44,000-98,000 deaths each year in the United States. The word “consumer” helps place destiny in the hands of the patient, and it helps them understand that they can work towards bettering their care.

Up until Krugman’s article, I thought that empowering patients to choose what is best for them was a good idea subscribed to by nearly everyone. Now I understand how dangerous this is for those on Krugman’s side of the aisle (I’m not speaking politically but, well, sanity-wise). Frankly, I agree with a lot of what Krugman is saying. We can’t continue to spend as much as we are on healthcare (especially Medicare). In my words, this is one way of stating that we have scarce resources. Krugman understands this, after all, it is why he wrote this article. The federal government only has a certain number of dollars. The question quickly becomes: How do we allocate these scarce resources?

Krugman is dead wrong that Medicare provides a “blank check” to doctors. In fact, they have numerous cost-control measures already in place. They don’t cover all procedures. A senior citizen on Medicare still has substantial cash outflows when they go to the doctor’s office or undergo a procedure.

Krugman would suggest that we have a government authority that decides what is paid for and what is not (by the government, we can spend our own money on other things). He suggests that this will make medical care less about the money. Dr. Krugman, this would make it even more about the money. With a new focus on comparative effectiveness and cost-effectiveness research, doctors would only be allowed to use the methods deemed “cost-effective” by the advisory panel. Each dollar put into the system would only allow purchase of specific procedures. Notice that we are still talking about dollars, but according to Krugman we cannot talk about “consumers”. This would be similar to purchasing a gift card to Best Buy, but worse. You can only spend your money on electronics, even if you are starving. It is worse because you could sell your gift card, but you can’t sell your Medicare benefits.

Krugman’s declaration that we are not “consumers” of healthcare is true. We aren’t. We consume insurance. The RAND Health Insurance Experiment (HIE, the most expensive empirical study of all time) demonstrated that by forcing “patients” to have monetary considerations, with regards to their medical decisions, will reduce utilization. The purchase of insurance creates moral hazard that drives up utilization (and perhaps unnecessary utilization).

That gift card analogy is why the Ryan plan (health care vouchers) is so desirable. Realistically, few sane insurance companies today would insure the elderly at a price considered reasonable, ceteris paribus. Hence, a voucher to provide a subsidy for medical care. If someone wishes to spend their money on something else, why shouldn’t they be allowed to?

Krugman states that the US has the most “consumer-driven” healthcare system in the world, thus consumer-driven care has failed. I contend that this is not a linear relationship. For someone who is in a field that despises OLS regression, I would have thought that Krugman would have realized this.

If the US had completely consumer-driven care (except for a few things like vaccines) it would work. The conglomeration of federal programs, private insurance, and a few private payments make the system worse than if we all just paid for our own care. Krugman lacks the ability to forsee how this would change healthcare, as does everyone. Who can imagine the types of insurance companies that may arise out of a different system. I contend that it would force transparent and lower prices. Why doesn’t Krugman look to other reasons for our high prices (and costs) in the US healthcare system?

Krugman ends his article with a diatribe against society viewing healthcare as a financial transaction. He contends that this demonstrates there is something terribly wrong with the values of society. First, I would point out that Krugman does not deny that someone has to make these decisions, whether at the personal or at the federal level. His whole article is inconsistent. Second, I would point out that most of the issues we have in the medical care sector arise out of regulation from those that believe we can build a better system. Third, I would assert that the idea that others know better than I do what is best for me is truly the worse value to have.

Healthcare in Cuba

by: Joshua McKellar - April 19th, 2011   Filed under: economics, healthcare 306 Comments

Tyler brought up an interesting question in this post on healthcare in Cuba. I think that the US has a lot to learn from comparative healthcare systems. So what can we learn from Cuba?

First, a look at per capita healthcare spending:

Data Source: World Health Organization 2006

From that, you can see that the US spends a lot on healthcare, while Cuba spends relatively little. The US spends around 16% of GDP on healthcare while Cuba spends 7.3% of their GDP on healthcare (as of 2008). In 2006, the US spent $6,714 per person while Cuba spent $363 per person. Why do we spend 18.5 times that of Cuba, when by most aggregate measures of health, we are not better off? Cubans have a life expectancy of 77.7 while United States citizens have a life expectancy of 78.37, barely more.

Cuban healthcare is free and universal for all Cuban citizens, and they place a lot of emphasis on primary care. Cuba has no private hospitals or clinics. They have more doctors per person than the US (627 per 100,000, compared to 225 per 100,000 in the US as of 2005).

The question quickly becomes, What inputs affect healthcare?

How do we prolong the average length of life? The simplest way to do this is to reduce infant mortality. “Healthcare” dollars spent on the elderly have the potential to extend average length of life a few years, while dollars spent on a neonate can extend their life twenty times as long. So, how does the US compare in infant mortality?

Data from: The CIA World Factbook 2011 estimates

You can see that the US has an infant mortality of about 6.06/1000 live births while Cuba has an infant mortality of 4.9/1000 live births. But this doesn’t tell the whole story. Cuba is very good at doing other things, as well.

Cuba has the highest treatment and control of hypertension in the world. They have free medical education for Cuban students as well as students from Africa and Latin America. They have a national biomedical internet. They have one of the world’s lowest national rates of AIDS1. They have a tuberculosis case detection rate of 98.2%, compared to the US’ rate of 85.1%. Their HbV three-dose vaccination rate is 99%, compared to the US’ 92%. Their adult literacy rate is 99.8%, the same as the US. They have a higher percentage of children enrolled in primary school than the US. They eradicated polio in 1962, diptheria in 1979, measles in 1993, and rubella and mumps in 1995. They had approximately 20,000 medical tourists in 2006. In 1988, the World Health Organization (WHO) gave Fidel Castro the Health for All award, for achieving the WHO goals for developing countries to achieve by 2000. How can they be so good at providing healthcare for so much less than the US?

What impacts healthcare expenditures?

Cuban doctors are paid substantially less than doctors in the US. A typical doctor in Cuba earned $15-20 in the 1990s, while a typical doctor in the US probably earned around $150,000. Cuban doctor’s medical education was completely subsidized as well. This has the ability to dramatically reduce healthcare expenditures.

But Cuba also has the ability to allocate more doctors to primary care than specialities. Since they control the entire system, they have an incredibly integrated system, where you have a family doctor that acts as a gatekeeper. Their system is vertically integrated. One of the major problems with the US healthcare is lack of integration. This likely leads to increased costs with multiple tests and reduced quality of care. They don’t have an American Medical Association or Congress requiring the number of doctors be held low to provide opportunities for rent-seeking behavior.

Cuban medical facilities are much older than facilities in the US. Their labor costs are also much less than ours. While hospitals here have an incentive to update their facilities and provide the latest technologies, hospitals in Cuba do not face competition, thus there is no Nash equilibrium or medical arms race. Consumers in the US often believe that the newest technology is best, but often it isn’t. Much of our new medical technology does little to improve health, and Cuba resists spending on newer technology. This brings up the next point.

Cuba spends dramatically less on research and development than the US does. This is also true of every other nation. Take the example of pharmaceuticals. Drugs are discovered for the US market. Other countries tell pharmaceutical companies how much they are willing to pay, and the companies agree. They agree because the marginal cost of producing another pill is near zero, and thus any price above the marginal costs can contribute to their fixed costs and profit. If the US was to demand lower prices it would be interesting to watch how this transformed the pharmaceutical industry (which is already hurting, check out p/e of bigPharma).

Most people have very little comprehension of what will improve their health. In the US, they rely on their agent, a doctor, to tell them what is best. Even so, with insurance and governmental programs, such as Medicare and Medicaid, reducing individual’s exposure to the cost of their consumption, there is substantial moral hazard in consuming healthcare. While Cuban’s don’t have the ability to earn a lot of money and spend it on their own health, if they wanted to, we do. When you have more income, you are more likely to want to spend it on improving your health, even if the probability that something will improve your health is lower.

There is no easy way to quantify how much US healthcare expenditures contribute to quality of life. We have the ability to receive many elective procedures that don’t necessarily improve our health, as defined by broad measures like length of life. Here is a graph of quality of life scores and life expectancy.

Data Source: Here

If you read the linked paper, you will discover that the quality of life scores are non-linear. However, it is extremely difficult to find a quality of life measurement for Cuba. Any measurements I found were similar: Cuban’s have dramatically lower quality of life than those in the US. If I had extended the graph out, you would discover that quality of life does seem to decrease with decreasing length of life. Anyways, all I wanted to point out was that having excellent healthcare does not mean you have excellent quality of life.

I think that looking at healthcare in Cuba should make on realize a few things. The first is that healthcare does not mean health. The US spends a lot on healthcare, but we don’t reap the benefits in terms of health. The second is the need for integration2. I believe integration will improve healthcare far more than increased spending. This is a way that we can add value without spending a lot more. The third is that we have no way of knowing that allocating even 7.3% of GDP in Cuba to healthcare is appropriate. Their healthcare system came at the expense of something else. Resources are scarce. While most will say that improving healthcare is important, perhaps Cubans would rather enjoy US cinema, and spend more money on it. Perhaps they would rather enjoy quality food.  They lack many of the choices that we enjoy any and every day.

The fourth realization is that often the best ways to improve health involve those that can least afford them as well as externalities. How much better off would we be if we had broad TB and HIV testing and treatment? Fighting infectious disease often involves vaccines that have externalities. Cuba does a much better job at prevention because they can tell their citizens what to do. We cannot force everyone in the US to be vaccinated, even though we all would be better off. We cannot force doctors to enter primary care. We must discuss how to achieve goals of disease eradication in light of privacy and personal rights.

Politicians chose recently to reduce federal spending on important programs for those that need them most, rather than reduce spending on Medicare, those that need the dollars the least. We must choose to cut spending, but not all spending cuts are equal. We should begin by cutting what doesn’t provide much benefit. We should finish by cutting everything and dissolving government, but that is a conversation for another day.

 

1 In the 1980s, Cuba had mandatory testing for HIV and quarantined anyone who was HIV positive. This was discontinued in the 1990s. Now they manufacture their own generic antiretroviral medications, allowing them to provide them at substantially lower costs than other developed nations. Highly active antiretroviral therapy (HAART) has the ability to reduce transmission risk. All pregnant women are tested, and those positive are given HAART, substantially reducing mother-to-child transmission.

2 A major reason why we lack integration as well as competition is the AMA. For more, read this link on why they prevent transparent pricing or sharing of medical records.