Giving in On Health Care Reform?

On Monday President Obama took a significant step back on his health care reform bill. President Obama said that he is willing to amend the law to allow individual states to  opt out of the most critical aspect of the law: the insurance mandate. Under this amendment, states would have the option of not mandating health insurance for all citizens, as long as it could create some other viable option for coverage. In order to be approved for this waiver, the state must meet two requirements:

  1) The state must create another plan that will cover as many citizens as the original health care bill would.
  2) This alternative plan cannot further increase the federal deficit.

If this amendment is passed, states that earn a waiver will still be given the same money by the government to support their new plan.

Although the original law allowed for waivers to be applied for in 2017, Obama's offer to move this date up to 2014 is a significant step back for health care reform. The most important aspect of the bill is being diluted.

Should states be allowed to opt out of this insurance mandate or was the original health care law the best idea? Is this a political move to curb skepticism of the health care reform bill?

The Tradeoff: Medical Technology v. Personalized Care

In my last post I mentioned medical technology as a fiercely growing area that contributes to overall health care spending. In this post I wanted to look at the pros and cons of evolving medical technology (specifically electronic medical records). On one hand, this technology can make doctors extremely efficient, allow them to share patient data and save money by moving away from paper records; On the other hand the technology itself is expensive to implement, difficult to learn and can take away the "personal" feeling most doctors have with patients.

I have two articles that serve as a good contrast and explore this issue thoroughly. The first is an op-ed piece by Doctor Abraham Verghese about his personal experience with advancing medical technology. Doctor Verghese admits that on occasions he gets so caught up in technology, that it seems there is a "digital patient" and a real patient. He explains that advancing technology is starting to take away from the personal aspect of medicine. The second article is a piece by Steve Lohr about the pros and cons of implementing electronic medical records. 

Both articles, although written differently, give a great picture of the trade offs that come with medical technology. As a patient, which kind of medical experience would you prefer? A highly computerized visit that relies on technology for a diagnosis or a more personal visit that relies on doctor-patient interaction and intuition?

Healthcare Spending & End of Life Care

In August, 60 Minutes did a segment on end of life care and how much it costs the U.S. health care system each year. Although the video is from August, the issue it covers is still relevant today. This is a huge issue that comes with a gigantic moral debate attached to it.



The segment presents some staggering stats:

• U.S. spends 55 billion dollars a year  on hospital bills in the last 2 months of patients lives. This 55 billion  trumps both the annual budget for The Department of Homeland Security and The Department of Education. It is estimated that 20-30 percent of these procedures have no meaningful impact on the patient.
• One day in an Intensive Care Unit (ICU) costs over 10,000 dollars. 18-20 percent of Americans spend their last days in an ICU
• While a majority of Americans prefer to die at home, 75 percent die in hospitals & nursing homes.
• The government or private insurance pays for 85 percent of these medical costs

What are the underlying issues?

1. Medical technology has become so good that if patients want to, they can be kept alive much longer with advanced procedures and machines. The problem is, this is very expensive.
2. The U.S. health care system is built so that supply drives demand. This means that doctors are in control of the kind of medical care you demand because they suggest it. If the doctor suggests a certain treatment chances are you will demand that treatment. Doctors get paid by the patients they see and the tests & procedures they do so their incentive is to provide as much care as possible. This is also expensive.
3. Patients often never even see the medical bills they rack up because the government & insurance pays them. If they aren't paying nobody really cares how much these procedures cost.

It was amazing to hear the word "bankruptcy" brought up several times throughout the video. But that's how big of an issue this is; it can eventually bankrupt the United States. The problem is the huge moral debate. We can't just stop caring for people when they begin to die but at the same time a huge amount of money is being spent on this. Is there a moral middle ground or a way around this issue? Should end of life care be rationed or capped at a certain amount? It's a really hard debate to have.

Lower Healthcare Spending with...A Checklist?

Health care spending is out of control for a number of reasons: the health insurance system, U.S. lifestyle, lack of preventive care, prescription drug costs, administrative costs etc. A cure-all solution for health care spending is near impossible. Atul Gawande has a solution that can make a difference and it doesn't involve a controversial bill or fancy new medial technology. It's as common as something you and I use every day: A Checklist.



In the video above, Atul Gawande, a surgeon at Bringham & Women's Hospital, explains his idea for a 19 point hospital checklist. His checklist is something surgeons, doctors and nurses can use to prevent mistakes, infections and deaths during hospital stays. His checklist was initially tested in 8 hospital worldwide. In these 8 hospitals there was a 1/3 reduction in infections and deaths during surgery. A hospital in Michigan implemented the checklist and saw a 2/3 reduction of infections, saved 1,500 lives and over 200 million dollars.

This checklist is being used in less than 1/4 of U.S. hospitals. Imagine if this was required by all hospitals? Hospital infections are negative externalities that cost the health care system a ton of money. A low cost solution like Atul's could save a lot of lives and money.

Are there other simple fixes like Atul Gawande's checklist that can contribute to lower health care spending? Can an idea as simple as a checklist really save lives and money?

Another Point for Healthcare Reform

The New York Times reported on Tuesday that Judge Gladys Kessler of the Federal District Court for the District of Columbia became the 3rd federal judge to  uphold the health care reform bill. As detailed in one of my earlier posts the health care bill is currently working its way through a series of appeals in the U.S. court system.

Judge Kessler's decision on Tuesday makes the "score" of these appeals 3-2 in favor of upholding the health care reform. The most controversial part of the bill is the provision that would require American's to purchase some form of health insurance by 2014. The two judges that have ruled against the bill cited that this provision forces citizens to participate in commerce. In other words, it's causing them to "act" when they don't necessarily want to act. However, Judge Kessler determined that deciding not to purchase something as important as health care is an "act" on it's own.

Is a law too powerful if it is requiring America to purchase health insurance? Do you think this bill will ultimately be ruled unconstitutional if it rises to the Supreme Court?

FDA User Fees For Generic Drugs: Show us the Money

Dr. Margaret Hamburg, commissioner of the F.D.A., asked for new legislation on Friday that would require makers of generic drugs to pay the F.D.A. a "user fee." Each generic drug company would pay the F.D.A. a fee to expedite their approval process.

This is not necessarily a new idea; major pharmaceutical companies pay fees each year to speed up the approval process of their major drugs. Dr. Hamburg justified her call to action by explaining that the F.D.A. has many inspections and approvals to make and that user fees would allow the FDA to better serve the public.

Some criticize this idea because they feel it creates a conflict of interest between generic companies and the government.

Do you think the process of "user fees" is unfair? Does it promote a conflict of interest?

Sanofi Acquisition of Genzyme

Earlier this month French pharmaceutical giant Sanofi Aventis acquired locally based Genzyme Corp. This article from The Wall Street Journal has all the details of the major biotech acquisition.

Acquisitions happen all of the time in pharmaceuticals and biotech. Why is Sanofi's acquisition of Genzyme worth talking more about?

1) It positions an otherwise French based company in the east coast hub of biotech in the U.S. : Cambridge. This greatly improves Sanofi's position as they will have their hand on the pulse of the U.S. biotech industry. They will be more able to communicate and collaborate with U.S. based researchers.

2) The acquisition gives Sanofi a biotech arm. Genzyme specializes in biological drugs and enzymes that treat very rare diseases like Gaucher's Disease and Fabry Disease. Sanofi now has a position in the orphan drug market (drugs with very low patient populations).

3) Genzyme will keep its name and identity as a producer of orphan drugs. It will operate as a separate unit of Sanofi and will retain all current employees.

This acquisition was a major deal and one that has been looming for several months. Sanofi looks to be positioning itself to compete with other major U.S. drug companies. Looking at the terms of the deal and the benefits: Do you think Sanofi made a wise choice in acquiring Genzyme?

Insurance on the open market? Good Luck.

The New York Times recently posted an op-ed article about the difficulty of purchasing health insurance in the individual market. If you have the time to read the whole story, I highly recommend it. It shows just how hard it is to purchase health insurance if you aren't receiving it from your employer. The family in the story is not poor, unemployed or in bad health. Yet the U.S. health insurance system is so twisted, that this family was denied coverage several times before finally attaining it.

Although frightening, the story shows what life is like for those who do not obtain employee based health insurance. This family had the means to fully pay for insurance and still could not get accepted. Imagine what life is like for those in poorer health who cannot afford insurance.

Some major issues this story raises:
1) U.S. reliance on employee sponsored health insurance
2) The difficulty of getting health insurance with "pre-existing conditions"

Is the U.S. relying too much on employee based insurance? Is it fair for people to be denied individual health insurance based on minor procedures and ailments? Should congress really be working to repeal the health care reform bill that protects against all of this? It really is a tough call...so let's get a discussion going. 

Ignorance and Healthcare

The Affordable Care Act (health care reform) has generated an overwhelming amount of controversy. Political insults have been traded all amidst rumors of socialism and "government death panels."

Everyone is a critic. But when we open our mouths to talk about health care reform do we know what we are talking about? It would appear that an alarming amount of people don't. A professor recently passed a report along to me from the Kaiser Family Foundation on America's knowledge of the health care reform bill. The report surveyed a nationally representative sample of 1,207 adults and asked them questions about the elements of the Affordable Care Act. Below I've attached a chart with the results of this study.

Notice the percentage of wrong answers to questions on some very important elements of the act. A staggering 40 percent of people surveyed actually believe the U.S. government has the ability to make end of life decisions for patients. 65 percent wrongfully believe that all U.S. businesses will be required to provide health care insurance to employees. These aren't numbers that can be brushed aside. The Affordable Care Act is one of the most significant pieces of legislation passed in years, and a good portion of the citizens it applies to have no idea what it says. 

 I am of the belief that everyone is entitled to an opinion, as long as its a rational one. Some good questions: Why do you think there is such a disconnect here? Whose job is it to educate the American public on such important legislation? Let's hear it.

Health Care Act in Danger

On Monday January 31, the Affordable Care Act which many know as "the health care reform bill" was ruled unconstitutional for the second time since appeals began.

The controversial bill has now been upheld twice and ruled unconstitutional twice by appeal courts in Virginia, Florida and Michigan. This article by The New York Times explains that Judge Roger Vinson of The Federal District Court in Pensacola Florida labeled the bill unconstitutional on the grounds that it gives congress too much authority over commerce. The Affordable Care Act mandates that Americans must purchase commercial health insurance by 2014 or face penalties. Judge Vinson ruled that it is unconstitutional to force citizens to engage in commerce, saying, “If Congress can penalize a passive individual for failing to engage in commerce, the enumeration of powers in the Constitution would have been in vain."

The fact that Judge Vinson ruled against the bill is not as surprising as how strongly he ruled against it. While the previous rejection of the bill called for changes in parts of the act, Judge Vinson claims that the insurance mandate invalidates the entire bill.  The insurance mandate is so ingrained in the other stipulations of the bill, Judge Vinson feels the entire reform must be ruled unconstitutional.

As the Affordable Care Act winds its way through the appeal system, the existence of the reform remains to be seen. Will parts of the bill be changed or will the entire reform be ruled unconstitutional? Should Congress have the right to mandate the purchase of health insurance? Or is that a decision best left to the free market?

As always, comments are welcome and appreciated. Let's hear it. 

Government Drugs

No one is discovering new drugs and the U.S. government has something to say about it. The New York Times wrote an article in January about the NIH breaking into the business of drug discovery. In October of 2011 the NIH will launch its "National Center for Advancing Translational Sciences."

The center will use screening to find chemicals that act on enzymes to create new drugs and cures. Once these chemicals are discovered, the center will also be responsible for animal testing and clinical trials---all functions usually undertaken by pharmaceutical & biotech companies in the private sector. All of this will happen with an initial investment of one billion dollars.

So why would the NIH start doing something its never done before? Because someone has to do it. The past decade has been marked by minimal drug discovery in the private sector. Add this to the fact that pharmaceutical companies are cutting research and you have a medical community that is desperate for new answers.


 Issues I Foresee:

1) The Learning Curve: The drug discovery process is long and extremely involved. Major pharmaceutical companies have been working on the process for years; they know it. The time from initial discovery to market is often 15-20 years (See Diagram Below). Jumping head first into a process which takes that long could prove frustrating.

2) The Funding: The center is starting out with an initial investment of one billion dollars. A single drug can cost up to a billion dollars to discover. It begs the question: will there be more funding eventually? Because they will need it.

Is drug discovery something the government is obligated to undertake? Will the NIH's attempt at drug discovery flourish or flop with the rest of the pharmaceutical companies? Let's hear what you think.