So What do the Candidates Think?

Now here is a challenge: Talk about health care and get people excited to read it while at the same time weaving politics into the mix. I have been meaning to discuss the upcoming presidential elections with regards to the two candidates and their positions and for some reason the excitement level just wasn’t there. I would start the article and then scrap it because even I was falling asleep and if the author falls asleep during an article what chance does the reader have? I mean just the title “health care politics” dredges up thoughts of long boring meetings and lectures you never wanted to hear. But maybe we can make it fun so lets give it a go. Unless you have no political interest at all I imagine you know by now that we are finally down to two candidates running for office since the primary season is over. (I should hasten to add that I frankly want the whole lot of them gone so I am voting third party this year just to stage my own little protest so in actuality there are still more than two candidates.) For purposes of this little blog we will discuss the main two positions, which shouldn’t take long. Yes I am qualified to do this because I have actually read the plans that each of the senators has on their individual websites so you should be thanking me for the work I have slaved over for you. I didn’t simply take the summaries put out by the media so you should be proud of me. Just because I had a beer to help me through does not diminish the significance of what I have done. So let’s start with Senator Obama and his plan. I can sum it up real quick by telling you that he is going to mandate coverage to all and in so doing he will lower the cost of health care. If people can’t afford the insanely expensive cost of health insurance then taxpayers will pay for it – hardly a cost saving method there. Kudos to Obama for finally getting the uninsured covered but what makes the Obama campaign think that will lower the cost of health care? He explains it in many ways but to summarize his plan it only increases the oversight (ie-bureaucracy) and will do nothing to actually decrease the cost of health care. Just saying it will does not make it so. Health care is the poster child of unintended consequences and when you cover everybody it is historically accurate to say that will increase the prices that doctors, hospitals and drug companies charge. Where is the cost savings in that? So Obama’s plan is bad but not near as bad as McCains. The only thing even remotely unique or different about McCain’s plan is that he says he will allow health care to be bought across state lines and that can hardly be considered thinking outside the box. In a sector of the economy that will ultimately bankrupt this country unless changes are made, McCain essentially says “hey, working good from where I sit so let’s keep it the same”. At the risk of sounding like a long-suffering nanny, that is a “poor choice”. Lets be blunt. The only fact on the health care dilemma that all parties agree on is that health care is too expensive. In other words it costs too much and that means sticker shock when you go to the hospital, doctor or pharmacy. Since we all agree that health care costs too much then I propose that unless a policy helps to bring down the cost of health care……don’t do it! Increasing oversight in health care and subsidizing outrageous insurance bills (Obama) or attempting to convince us that keeping things the same (McCain) in an unsustainable health care system are what I consider outrageously ignorant solutions and are nowhere near the vast changes we need to implement. That, my friends, is one of many reasons why I will be voting third party this year.

Stop the Insanity!

Remember the lady 10-20 years ago who created a diet fad around the idea that diets don't work and she would always yell out "stop the insanity!" to the point of driving you insane? If I remember right, Susan Powter was her name. Well, I want to start yelling that at the health care industry for some of their useless studies because it seems like every week I see another study that comes out that makes you say in a very mature manner "well, duhhhh.....I could have told you that myself and saved you a couple million dollars".
Last week I heard of a study that related the increased risk of stroke in women to the fact that they visit the salon more and tilt back their head a lot thus increasing the pressure to their carotid arteries which induces damaged plaque to break off and travel into the brain which creates a stroke. Thats a little bit like performing a study on drivers that found that unsafe drivers were the ones who had peanut butter for breakfast because their tongue was stuck to the roof of their mouth and they were searching for gum so they ran into a telephone pole. To sum it up: Subjective, Stupid and pure conjecture. In no way can that be proven and even if it were then what do you propose as the solution? Having women wear neck braces at the salon so as to protect their carotid arteries. Wouldn't that create even more deaths from choking? It seems we have a dilemma.
In my particlar specialty there was once a study done that measured toenail growth (I kid you not) in the summer as compared to the winter to determine the specific time of year when toenails grow the fastest. I would like to see the conversation that led to that study......Ok maybe I wouldn't. I can't even imagine how bored you would have to be at work one day to decide "wow, I really have no idea whether toenails grow faster in July or December and I have no idea how I have run my practice to this point without that information!". So you launch the life saving study for which society will forever be indebted to you.
This week's choice of stupid study though is not quite so obvious but dumb nevertheless. A study published in the journal Neurology found a link between belly fat in your 40's and dementia in your 80s. Dementia for those of you who may have "forgotten" is the condition where you lose short term memory and eventually fade into more permanent memory loss which is a very frightening idea for all of us. Well this does seem like a reasonable study though because we all want to know how to avoid dementia so that we don't forget how (to avoid it that is). The problem is applicability (ie-what do we do about it?) and the definition of belly fat. See, as a bit of perspective our current view of fat is that it only takes second place to terrorism in public safety and pure evil....Ok fine I am sure cigarettes are in there somewhere near the top as well. So this study decided that people who store fat in their abdomen (and for the record everyone does even if they are skinny) had a higher risk of developing dementia. In other words, we all have a higher risk of developing dementia while we are alive. I guess we could have saved a lot of money on that one and just come out and said "as long as you are alive and not dying of starvation you are at risk of dementia and dying". That would have summed it up just fine but then it wouldn't accomplish the agenda some people seem to have of saving us from ourselves. I don't know about you but I can't wait for the study that comes our to determine whether we are more at risk for death the longer we live. Now that would be some useful information.

Ahhhh, Pharmucopia at Last!

When former Colorado governor Dick Lamm joked in his recent book (A Brave New World of Healthcare) that by 2066 we will spend 100% of our GDP on Healthcare I began to wonder what that world would look like. Would we take pills for food? Will we all have a permanent IV implant that would constantly feed and nourish our every need through a venous portal? What about work? I guess we would all work for a health care company or not at all and as a doctor I guess my future would be pretty secure. Maybe vaccines would take care of everything since we seem to be vaccinating all sorts of ailments from polio to the common cold. Whatever the future looks like in this scenario I was fairly sure I didn't want to be a part of it. Until recently that is.

A new report came out this week on a recent study of our water supply that shows all sorts of drugs floating around in our water from antipsychotics to sex hormones. A virtual pharmucopia. This started to bring the picture into a little more clarity and it really doesn't sound so bad now. Pharmaceutical companies obviously know what is best for us and they have been told incessantly how difficult it is to swallow their horse pills so they are coming up with the perfect solution. Put the pills in the water supply. I knew I had felt better lately and in my naivete I had given the credit to my wife who had recently placed me on a vitamin drink. How simple of me. Clearly the pills in the water supply are taking care of my every need from constipation to diarrhea and everything in between. The antibiotics keep me healthy from infection. The antidepressants keep me happy. There are even anti-convulsants in there in case my brain should decide to give me a seizure. These brilliant pharmaceutical phriends have thought of everything! And I had the audacity to doubt them. I want to take this opportunity to apologize to all pharmaceutical companies and reps who come into my office because clearly they they do know what is best for me and my patients. I don't even dread the future any more and I think a world of all health care is starting to look pretty good......in fact I am starting to get sleepy. In the end it is nice to know that when our politicians say they want "universal health care" that the drug comanies take them literally. Cradle to grave baby. Your wish is their command.

I hate to say I told you so but....

It seems to me that a pattern is developing here. We cover things (like medications, etc.), drug companies raise their prices and costs escalate. Pretty simple formula. If you are a drug company and someone else is paying for a patients drugs (like an insurance company or Medicare) then you could raise your prices without anyone getting too upset. In fact, it is pretty logical to think that you could raise your prices much easier in that scenario than if someone was paying for your product directly. Am I missing something here?

In 2005, Congress and the Bush Administration created Medicare "part D" which was a reasonable idea given the fact that medication costs were soaring and threatening to bankrupt many of the elderly. The problem at the time was that the law specifically forbids Medicare from negotiating in bulk with pharmaceutical companies thus limiting the overall negotiating pressure that Medicare could exert on prices. So guess what happens. In 2007 brand name drugs (non-generic medications) rose 2.5 times the rate of inflation and (here is the real shocker) there was an overall 7.4% increase in the wholesale price of brand name medications in 2007 compared with a still significant but smaller raise of 5.3 to 6.6% in the four years prior to Medicare part D implementation. In plain English that means that every year drug companies raise their prices an outrageous amount but since part D started this has allowed them to raise their prices more. Medicare is paying for them (except that in reality seniors still have to foot a large portion of the bill-and even more as price increases are implemented) so now the price increases go largely unnoticed. Now the cycle that I raised above becomes clear and you have to ask yourself a fundamental question, "who really benefits here?". I think that answer is fairly obvious but in case I confused you with this blog (since it is 2 am) let me just assure you there is only one winner in this scenario and that is the drug companies.

Prior to the Medicare bill being passed, the Bush administration formally estimated the 10 year cost for the bill to be somewhere around $350 billion. After the bill was passed, the Bush administration admitted the cost of the bill was miscalculated and would cost somewhere in the neighborhood of $750 billion which appears to be a fairly significant miscalculation but I am sure I am too critical. At the time I said I would bet a nickle that the cost would run over $1 trillion for the 10 year period and even though I do not want to be right in this prediction it looks like I probably will be. Oddly enough, it appears that patterns do repeat themselves and I now know what my parents meant when they said that "those who don't learn from mistakes are doomed to repeat them". When are we going to learn that covering things without regard to how much they cost will ultimately bankrupt us in the process.

Health Insurance Lottery

In a never ending stream of information that is proof that health care is too expensive for the average citizen, my home state of Oregon has now established a lottery for health care that gives the lucky recipient a chance to avoid bankruptcy by attaining coverage that they otherwise have no chance to afford. This is a sad day when we reach a point where getting health coverage is equivalent to winning millions. In a day and age when health costs demand "your money or your life!" it is no wonder that getting health care coverage would be the prize of a lottery system.
An interesting statement has come out of this. According to Barney Speight (director, Oregon Health Plan Fund) the state of Oregon has a comparable number of uninsured right now as they had in the late eighties when the last effort to "fix" heatlh care was implemented. This is an absolute confirmation that we cannot fix this problem unless we do something to address the underlying cost issues because even if states could cover their uninsured patients somehow the problem would still return 20 years later in a much worse scenario because health care costs continue to eat into our overall GDP. I know that is a bit technical but this is why we say the health care crisis is about "cost not coverage".
Good for Oregon for thinking outside the box (as they have on many past issues) but if you ask me this is a pathetic statement on the sustainability of health care costs bound to bankrupt us all eventually.

I really couldn't make this stuff up!

I blogged a few weeks ago about the current flu vaccine being only 40% effective (see "does preventive care really lower cost?"). The vaccine is a guess at what flu virus will be prevalent this year and it turns out that the current one missed by a long shot. In yet another example of how the cure for bad health care is more, there is news out today that a federal advisory panel in Atlanta has voted to extend the flu vaccine to all children except those under the age of six months. For once, I am at a loss for words. I mean this is wrong on so many levels but lets just start with the science. Since when is 40% effectiveness satisfactory enough that all children will be required to get the vaccine? Are we going to just ignore that part. They will try to claim that this year is an aberration but let me assure you it is not. The failure rate on the flu vaccine is high year in and year out.
Next, what about the parents. Many parents are paranoid of vaccines and believe firmly that vaccines cause autism. While there is no solid evidence for this I have spoken to more than a few parents who are sure beyond a shadow of a doubt that a vaccine created autism in their child and given the state of our health care system I am inclined to believe them more than some quasi-scientific study. So now we are going to force parents to accept a vaccine they are frightened might cause some untoward outcome in their children for a vaccine that historically is woefully effective. Good choice.
Finally, lest I forget to talk about cost, this is as good an example as any why our health care costs are out of control. We are going to administer a costly vaccine to an unsuspecting public in the name of lowering costs. In other words, theoretically if we administer a vaccine it should lower the number of people accessing the health care system for a serious complication. Good idea except that in practice this vaccine is largely ineffective and from this years numbers it would appear will not do much good. So in practice it wont work like the theory states. What if in fact it does cause other complications? In that case a costly vaccine is ineffective and adds to the overall costs by causing other complications.
Oh well, why ask all these questions. I am sure that administering a vaccine will be useful. After all, doing something is better than doing nothing. Right?

High health care costs finally explained, exclusively on the Talus post.

Seriously folks, why do we have high health care costs? I am only old enough to remember the 80's so lets start there.
In the 1980s doctors were the culprit. They were paid too highly and unfortunately I had not become one yet. So insurance companies and Medicare started to bring theire costs down by capping what doctors could bill for procedures. This helped in one area of health care but costs still soared through the 90s due to high hospital costs which insurance companies and medicare are still trying to get under control. Then along came the drug companies and they are the experts. They create drugs to save lives and advertise them on TV so we all want them. (That reminds me, drug companies were going to save lives so how come we have all the erectile dysfunction pills and sleeping pills costing the most........do you think they told us they would save lives so we bought into it?) Drugs have become so expensive that Medicare passed "part D" which pays for drugs for seniors - just not the ones in high school, they still have to get them on the black market. So Medicare part D will fix it right? Wrong. The Bush Administration put a clause in the bill that forbids Medicare from negotiating in bulk to lower drug costs. And you cynics out there suggest that corporations are running Congress! They are saving our lives people and I for one don't like your tone!
Two recent articles in the world of health news will explain this further. Experts are befuddled by a recent finding in which strokes in women have soared despite the fact that many women are taking cholesterol lowering medications (called statins). With no better explanation the experts have blamed it on fat people even though the study didn't focus on how fat these people were. They just simply blamed fat (like they do for every other terrorist act) and concluded that people had to lose weight. Back in the olden days -- before any of us were around -- scientists would have actually studied that possibility and if found to be true they would have done two things. 1)Start people on a program to lose weight and 2)told people to quit taking the statins because obviously they are doing no good. And therein lies the exact problem. Statins are a $10 billion drug in the US alone for one single company and that means they are upwards of $30 billion worldwide when all statins are taken into consideration. It makes sense to look at the statins critically and stop using them if they are not helping and then focus on another area. But in the moderna age of health care what happens is that we keep piling on. If the blood pressure pill isn't working then take statins but continue to take the blood pressure pill. If the statins aren't working then your too fat so lose some weight. And, oh yeah, keep taking the blood pressure pills and statins. If Losing weight doesn't work then take a biolongitudinal eradicator pill. By the way, the biolongitudinal eradicator pill hasn't been invented yet and it is a word I made up but I am sure that something like that will be made and this will be the next pill to save us all from death......and dont forget to keep taking the high blood pressure pill, the statin and lose weight too because those will help as well.

Say It Ain't So! Health Spending Set to Rise Dramatically?

Here's a shocker everybody saw coming. A posting in the journal Health Affairs is about to be published proclaiming that health care costs are set to rise dramatically and will reach $4 trillion by 2017 at which time 1 out of every$5 will be spent on health care. We of course know this won't happen because Talus will ride to the rescue, but nonetheless projections are in place. The Associated Press reported this bit of "news" but what was amazing about it were not the projections of outrageous health care spending but rather the cavalier way in which it was reported. The article went on to detail that health care is in fact expensive (No Way!) and it will only get more expensive as the baby boomers retire (Seriously?). Never does the reporter think to stop and ask why. We always thought that science would save our health care woes, better medications, better coverage, etc. By this point in time we were supposed to have our health care costs under control and HMO's were going to fix it all. Instead all we see is reporting that says "well, get used to spending money on health care cause soon you will spend it on nothing else and you'll like it!". President Bush has a novel approach. He is going to limit the amount of Medicare growth by lowering the Medicare growth rate from 7% to 5% by freezing the rate paid to providers. Haven't we tried this before? What makes us think it will be different this time? Ok, here comes the biased part.......How about trying the Talus solution? You can't say that has been tried before.

Does preventive care really lower costs?

Many people are fond of saying that preventive care reduces costs and that if more people sought preventive treatment that costs would go down. Is this true? Intuitively, I doubt it but statistically it is questionable as well. There are many definitions of preventive care and to be fair I believe that some help. Keeping yourself healthy and in shape is preventive care and that helps. Having your eye looked at when you are bleeding out your eyeball is a good idea as well. But what about other things like having a colonoscopy annually, getting vaccinated for every disease known to mankind, having a checkup every 6 months, etc.? Are these good for you and do they lower cost. Well, according to some evidence the answer is no and no.

A large study was recently published on prostate cancer (by Dr. Grace Lu-Yao of Robert Woods Johnson Medical school) in which it was determined that delaying treatment was best in many cases. Some people have whispered about this in the past and the suggestion was that most people would die of natural causes long before prostate cancer would kill them. While this is not entirely true, it does turn out that in this study cited that only 10% of the 9,000 men who chose to delay or skip treatment had died of the cancer 10 years later. The vast majority of these men were still alive without significantly worsening symptoms. In general, more people than this usually die while actually receiving treatment.

While this may sound complicated, it is actually quite simple. Anyone who has received treatment for prostate cancer may in fact not need it and therefore all the treatment such as rectal exams, MRI's, surgeries, radiation , chemotherapy, etc. MAY (and I emphasize MAY) have been wasted. The point is not whether this study is right or wrong but rather that this needs to be looked at in more detail so we can determine when to treat and when not to treat. So why isn't this being done? Simple. No single party in the health care industry has any vested interest in not treating. Patients are scared and want treatment. Doctors would rather treat than not treat since doing something is better than nothing once the word cancer has arisen. Hospitals of course treat when possible for obvious reasons. Drug companies don't create a drug unless it is going to be used. Everyone wants to treat and nobody wants to look at when not to treat. So treatment and intervention continue and in many cases the necessity of such treatment is not considered. Strange, isn't it?

One more thing and I'll let you go. Vaccines. They are great right? It turns out that so far the 2007-2008 vaccine is one of the worst performing vaccines to date. All flu vaccines are basically guesses at what viruses will cause the flus for the upcoming seasons and this is never an exact science and so therefore it doesn't cover 100% of the outbreak. This years vaccine is only 40% effective which is terrrible to say the least.

This is not to cast doubt on all preventive care but it does mean that we should consider the unintended consequences of preventive care that is not helpful. In the overall picture though one thing is for sure, increasing the amount of preventive care in the health care industry will never control costs like many people say it will.

Medicare not the answer?

New government data was reported on by USA Today and others on Thursday(Feb. 14, 2008) that revealed that "senior benefit" costs are up 24% beyond the inflation rate since 2000. Now for those of you who had never heard the term "senior benefit" (like myself) before, it is a measure of all costs the government pays for seniors for health care, nursing home and Social Security combined. The report showed that health care costs were by far the largest part of that 24% increase as Social Security remains fairly stable. This means, as "cost not coverage" has always suggested, that even Medicare couldn't solve the excessive inflation rate in health care.

It is a common misconception amongst Americans that Medicare is the answer to our health care woes. I have stated all along that in fact universal health care in countries such as Germany, Britain, Canada, etc. is not the answer to our health care inflation. These universal payers do not eliminate inflation beyond the CPI, they simply control it better than inflation is controlled in the US. In other words, they are failing too but just failing at a slower rate than the US health care system.

Here is what will happen over the next 10-15 years in the politics of health care (no, I am not consulting a psychic I am just making a prediction). Universal coverage will be implemented within the next two presidential cycles in some form and this form will most likely be mandated coverage that you must buy through your employer or personally. This will be mandated much like auto insurance is right now. Costs will soar as a result and a public outcry will arise the likes of which we have never seen and Congress and the administration will rush to our aid. They will implement "universal Medicare" where the government becomes the single payer and costs will continue to soar. Strict rationing and controls will be placed at that point and this will also not work in the same way that the HMO experiment has failed. So in 20 years or so we will look back at a failed universal health care experiment and where will we go from there?
How can I be so negative as to say that Medicare will not be the answer? Because we have this report from 2008 that is telling us exactly that. Some people say you can't tax your way into prosperity and I am going to modify that to say that you can't universally cover your way out of high health care inflation. Not quite as catchy I guess but maybe someone will quote me on it some day. In the mean time I won't hold my breath.