Saturday, January 18, 2020

Waste not, want not

The October 7, 2019, New York Times headlined “The Huge Waste in the U.S. Health System,” referencing a study published in JAMA, the Journal of the American Medical Association. The article went on to say that the estimated waste is at least $760 billion per year. “That’s comparable to government spending on Medicare and exceeds national military spending, as well as total primary and secondary education spending.” None of this should have come as a surprise to readers of my book Prescription for Bankruptcy, nor was it really “news.” Back in 2012, both another paper in JAMA and a report from the National Research Council estimated waste in the system at 30-35% of total spending.

Why is waste so prevalent? There are many sources. The biggest one, and the one that should most concern patients, is “low value care:” care that offers little or no benefit or even harm but which costs patients and their insurers money. This ranges from antibiotics for viral illness that will not improve the infection but may cause side-effects to back surgery for non-specific low back pain that may leave patients worse.

Using branded medicine when generics are available is obvious waste. There is enormous waste in testing and medical services. Not only are U.S. prices for most services dramatically higher than those in other countries, but prices for the same service vary widely within the U.S. If the same imaging study can cost $1200 in one location and $4000 in another in the same geographic area, is not the $2800 pure waste?

Studies at major medical centers have shown that a very large percentage of the tests ordered are clearly unnecessary: tests repeated for no reason or tests done so soon after another that they are unlikely to be different. A study of eye surgery showed that huge volumes of medications were discarded because they came in amounts much greater than normally used. Surgical “kits” used by different surgeons for the same operation can vary 4-fold in cost with no obvious difference in performance. Patients having cataract surgery are routinely required to have “pre-op clearance” with a physical exam and ECG even though the national organization of ophthalmologists has said this is not needed.

Tests that were not needed in the first place often show some minor abnormality, which leads to a “cascade” of further tests and rarely benefit the patient subjected to this testing.

Probably the largest source of waste is the huge administrative overhead embedded in the U.S. healthcare system. Fully 25% of “healthcare” spending goes to the direct cost of private health insurers and to the cost to physicians and hospitals of billing and meeting various “mandates” that the insurers place on them. An argument for a single payer system is that it could cut payments to physicians by 10% and at the same time cut their costs by at least that amount by reducing the administrative burden, leaving them financially whole.

With a system that is so expensive, why has there not been some movement to cut waste? A large factor is the lack of interest by those who would have to move the needle. Why should a hospital cut the cost of their surgical kits when they can simply pass the cost on to the insurers?

Another, and perhaps the major factor, is that one person’s wasteful spending is another person’s income. Only under huge pressure from the public and the government are we going to see change. I am not holding my breath.

Prescription for Bankruptcy. Buy the book on Amazon

Tuesday, January 7, 2020

Dying to be beautiful

Personal care products (nail polish, polish removal, hair products, skin creams, etc.) are found in every American home, and most are perfectly safe if used as intended. There are, however, situations in which these can be dangerous and even deadly.

The most obvious concern is accidental use by small children. An article published on-line in Clinical Pediatrics estimated that between 2002 and 2016, almost 65,000 children under 5 were treated in US emergency departments for poisoning by cosmetics. Toddlers are naturally curious, and as soon as they begin to walk begin to investigate their world, often by putting what they find in their mouths. Products that are perfectly safe when applied to the hair or nails may be dangerous when swallowed. By far the most common cosmetic-associated injuries were poisonings, and this was particularly common in children under 2. About 20% were burns or other contact injuries, and often involved the eyes. It does not help that many of these products are brightly colored and attractively packaged. What entices adults to pick them out on crowded shelves also attracts the attention of exploring toddlers.

Another issue is endocrine-disrupting chemicals, particularly parabens and phthalates that are commonly used as preservatives in cosmetics (and other household products). Researchers found that when women used these extensively during pregnancy, their daughters had significantly earlier onset of puberty. This can be psychologically difficult for the girls and has also be linked to higher risk of breast cancer.

Least common but truly deadly is the finding that many skin-lightening creams bought from other countries or over the Internet are contaminated by mercury. Inorganic mercury IS effective at lightening skin and a widely used contaminant. A California woman was recently hospitalized with severe neurologic damage that was found to be due to mercury poisoning. A cream she bought from friends was imported from Mexico and found to contain high levels of organic mercury, even more dangerous than the inorganic kind.

My take-homes?
1. If you have toddlers or small children at home, treat cosmetics the way you should treat medicines: keep them out of sight and out of reach, preferably in locked cabinets.
2. If you are pregnant, try to avoid skin products containing parabens or phthalates; these should be easily identified by reading the label.
3. Do not use any skin-lightening product from any but a reputable local store. Clearly do not use any imported products, and I would not use any bought over the Internet based on recent revelations about how poorly Amazon vets some of its third-party sellers.

Prescription for Bankruptcy. Buy the book on Amazon

Tuesday, December 31, 2019

Why combination pills?

Almost half of the drugs marketed today are fixed combinations of two (or rarely more) drugs that are also available separately. In a very few cases, the use of such fixed-dose combination products makes sense. Examples would be many birth control pills, the urinary infection drug trimethoprim-sulfa (sold as Bactrim or Septra) or the Parkinson’s drug carbidopa-levoda. Here the two drugs help each other and work better together than does either alone.

Many more combinations are no better than using the two products separately but offer some convenience and so improve compliance – it is always easier to take one pill than two. The medical problem with many combination pills is that the doses of the two ingredients cannot be adjusted separately, and it is only by coincidence that the amounts in the pill might be correct for any given person. In the World Health Organization’s list of 240 “essential” drugs, only seven are fixed-combination products.

A major societal problem with many combination pills is the absurd over-pricing attached to the product. One horrific example is Vivimo, marketed for pain (and really being pushed hard to doctors as an alternative to narcotics). What is Vivimo? It has the anti-inflammatory drug naproxen (Aleve and others) packaged with esomeprazole (Nexium and others). The logic is simple. Naproxen, like all “non-steroidal anti-inflammatories (NSAIDs)” (ibuprofen, aspirin and numerous prescription products), can irritate the stomach. For long-term users of these products, or for people with prior stomach bleeding who still might benefit from their use, doctors may prescribe an acid-suppressor along with the NSAID. You can buy 60 tablets of naproxen, a month’s supply, for about $35, and for about the same amount get a month’s worth of an acid suppressor like esomeprazole. So, $60-65/month for the same ingredients as are in Vivimo. Vivimo was first marketed by Astra Zeneca. Horizon Pharmaceutical bought rights to the product in 2013, when it cost $57 for a month’s supply and immediately raised the price to $400. Nine price hikes later, it now lists for $1241 for a month! Why, you may ask, would anyone use this? Since Horizon is very skilled at gouging, as are most pharmaceutical companies, they use coupons to lower the out-of-pocket cost to consumers – but not to their insurance companies, which then just jack up premiums to cover the cost.

Another similar example is Zegerid, which combines the acid-suppressor omeprazole (Prilosec and others) with sodium bicarbonate (yes, baking soda) and sells this frankly silly product at a list price of $14,213 for a 90-day supply! Again, coupons lower the out-of-pocket cost to the consumer, but the cost to society and indirectly to the consumer are very high.

A group of Harvard researchers looked at Medicare spending in 2016 and found that Medicare spent $925 million more for combination drugs than would have been spent on the products bought separately. While this is a small fraction of the enormous waste in our bloated healthcare system, it should be one of the easiest to fix. Just say no to fixed combinations in most situations.

Prescription for Bankruptcy. Buy the book on Amazon

Sunday, December 22, 2019

Green - the color of relief

This post was originally going to be about the waste in the U.S. health care system, but it is Christmas and Hanukah, and who wants a downer story at the holiday season?

Serendipitously I came across a “do you believe it?” story that was much more fun to write. Several research groups, notably at the University of Arizona and Harvard, have found that exposure to green light can relieve pain. The Harvard group found that while most migraine sufferers cannot tolerate light (the medical term for this is photophobia), green light is much less annoying than other colors, and may even relieve the headaches. The group at Arizona found 2-3 years ago that rats exposed to green light were much better able to tolerate heat on their paws than rats exposed to other light or left in the dark. It has also been found that people who are surrounded by greenery are healthier than others. I assumed this reflected a generally healthier environment and lifestyle, but who knows. There is some experimental data suggesting that green stimulates the body’s own (“endogenous”) opioid system.

Dr. Mohab Ibrahim, the lead researcher at U Arizona has recently done a small study with 25 chronic migraine sufferers who had numerous headaches that interfered with their quality of life. They spent two hours daily in a dark room exposed to green lights, and all had major improvement in the frequency and severity of their migraines. Some got relief within a few days of starting while in others it took weeks. All had their usual headache pattern return when the light treatment was stopped.

Since sitting in a room looking at green light two hours a day is hardly convenient, alternatives are being studied. One (totally uncontrolled) study has found that wearing green-tinted eyeglasses has a beneficial effect on relieving chronic pain. While I am a great skeptic when it comes to “alternative therapy,” using green to help relieve pain appeals to me. It is cheap, it is totally safe, and it has just enough data behind it to be plausible.

Try it – you just may like it. Happy holidays.

Prescription for Bankruptcy. Buy the book on Amazon

Monday, December 9, 2019

What's the truth about vaccination?

A headline I should never have had to see: “Worldwide measles deaths surge, reversing years of progress.” This was ABC News on December 5, quoting a report from the World Health Organization that over 140,000 people died in 2018 from measles, most children under 5. The same week, officials in Samoa asked the public to hang red flags outside their homes if they had an unvaccinated family member living there – reminiscent of a public health measure dating back to the Middle Ages, when homes and businesses affected by the black plague were marked.

Vaccination against infectious diseases is one of the great triumphs of medicine. It can be dated back to 1796 when William Jenner, an English country doctor did his now-famous experiment. Country wisdom and his own observations found that milkmaids who suffered from cowpox, a disease that caused blistering on cows’ udders and which caused a mild illness in humans, never developed smallpox. Smallpox was a very serious illness: 30% of those infected died, and many of the survivors were left blind or disfigured. Jenner inserted pus from a cowpox pustule into a cut in eight-year-old James Phipps’ arm and later inoculated James with smallpox and the boy did not get ill. He repeated this with other children, including his own 11-month-old son, with the same results. Vaccination against smallpox was rapidly taken up across Europe.

Vaccines are now available to prevent many once-deadly diseases, including polio, diphtheria, measles, tetanus, yellow fever, typhus and hepatitis. Over the past two decades, with the memory of these diseases fading from our daily consciousness, we have seen the growth of the “anti-vaccine” movement that threatens to undo much of this life-saving progress.

There has always been objection to vaccination. After Jenner’s vaccination became widely adopted, many opponents claimed it was repulsive and ungodly to inoculate someone with material from diseased animals. The widespread awareness of such dread diseases as smallpox overcame these objections, as the vaccine clearly worked, and everyone knew friends, relatives and neighbors who had died. When I was a child, polio was still a dread disease, and the public welcomed first Salk’s and then Sabin’s vaccines. By the late 20th Century, memory of most dreaded childhood diseases had faded, leading people to underestimate the severity of the harms that vaccines prevent.

Much of the current “anti-vax” movement can be traced to a paper by Andrew Wakefield in The Lancet, a British medical journal, in 1998. He and 12 coauthors claimed to have investigated a “consecutive series” of 12 children referred to the Royal Free Hospital with chronic enterocolitis and developmental disorders, including autism, which they linked to MMR vaccination. The General Medical Council of Britain found that the children were carefully selected and that the study was funded by lawyers representing parents suing vaccine manufacturers. In 2010, the editors of The Lancet retracted the paper, apologizing for published a clearly flawed paper, but the damage had been done.

Autism is a serious life-long developmental disorder, whose cause remains unknown. It has a strong genetic component, and even though it may not manifest until early childhood, researchers feel the underlying pathology is present at birth. Parents want an answer, and vaccines provide an easy answer. Multiple studies have been done that strongly repudiate any link between MMR vaccination and autism. Three large studies, in Denmark, the U.S. and Britain have found less autism among vaccinated children than those not vaccinated.

Just as the proliferation of clearly biased news presentations have left all-too-many of us in our own silos politically, those who oppose vaccination can find all the support they want in chat groups and Facebook, science be damned. The problem with letting parents decide is that it is not only their children who are harmed, but the general public. Just as courts have decided that parents cannot let their own beliefs allow them to refuse life-saving medical treatments for their children, parental objections should not allow them to refuse vaccination for their children. A small number of children with immune deficiencies are at risk from vaccines and should be exempt. They will be safe if the large majority of healthy children receive the vaccines, as this makes epidemics very unlikely. Parents who refuse are not “bad” people, but they are seriously misinformed, and should not be allowed to harm others if their minds are closed to evidence.

Prescription for Bankruptcy. Buy the book on Amazon

Sunday, December 1, 2019

Death at an early age

There are many ways to gauge the health of a population, whether a nation or some specific portion of it, but the commonest and broadest measure is the average life expectancy: the number of years a child born will live on average. Life expectancy in developed countries has increased for most of the past century, as antibiotics decreased deaths from infectious diseases and better sanitation became universal. US life expectancy began to lag that of most other developed countries in the late 1980s and by 1998 had fallen to a level below the average among OECD (the Organization for Economic Cooperation and Development) countries. Average life expectancy in those countries has continued to increase every year but stopped increasing in the US in 2010 and since 2014 has fallen, even though we pay almost twice as much per capita as do those countries on health care. Why is this?

Death rates among those 65-84, while obviously high (the biggest risk factor for most diseases is old age!), have fallen substantially between 1999 and 2017, while the death rates for those 25-64 reached a low in 2009 and have risen since. The death rates have risen significantly among those 25-44, as deaths from suicide (usually by gun), opioid overdose and alcohol-related liver disease – diseases of despair - have all jumped. Infant mortality rates have fallen slightly in the US over the past 20 years but remain well above those in other developed countries and are improving at a slower rate than theirs.

Differences in life expectancy are clearly related to factors other than health care expenditure. Researchers have shown dramatic differences in life expectancy among people living in zip codes less than 10 miles apart, sharing access to the same hospitals but having very different household incomes. Increased stress, including economic, has been linked to higher heart attack rates. Rising unemployment or under-employment probably explains the much higher suicide and opioid-related death rates in the industrial heartland, Appalachia and northern New England. Maternal death rates are 5-fold higher among African-American women than whites.

The solution to our discouraging health statistics is not more health care spending. Rather it lies in reining in our excessive and wasteful spending and re-directing this money to such areas as vocational education, improving social support, providing better access to healthy foods and increasing minimum wages. A living wage is the best medicine available for most conditions.

Prescription for Bankruptcy. Buy the book on Amazon

Sunday, November 24, 2019

The problem of rural health care

There are many disparities in health care. Black mothers have a much higher rate of maternal death than do white women. All women are less likely to get guideline-advised cardiac care than do men. Among the many such examples, perhaps the hardest disparity to solve is that of the poorer access to health care faced by rural communities. People living in rural counties have higher death rates from cancer and heart disease than their urban counterparts, and there are more deaths from opioid overdose. Rural hospitals are closing every week, leaving their communities with less local access to needed services. Physicians practicing in rural communities are older and are not being replaced as they retire.

To keep small hospitals open, the federal government created the Critical Access Hospital program in 1997 that pays more to small (25 or fewer beds) and isolated (at least 35 miles from another hospital) hospitals. A friend who is an experienced nurse once told me she thought this was akin to the Chrysler bail-out, and these hospitals provided poor care and should be allowed to close. Many studies have documented poorer processes of care at small hospitals compared to larger one. It is certainly true that small rural hospitals do not provide the same level of service as do larger hospitals. They have few specialists and rarely have anything close to a critical care unit for truly sick patients.

I remember well an experience from many years ago. I was “moon-lighting” in the emergency department of a small isolated hospital when a patient came in with an obvious acute appendicitis that looked about to rupture. Unfortunately, the only surgeon on staff was quite inebriated after a night of partying and clearly in no shape to even drive to the hospital, never mind operate. The weather was foul and getting the patient to another hospital was going to be dangerous, so the nursing staff convinced me, a cardiology fellow, to operate. Luckily the OR nurses knew more about the procedure than I did, and I had assisted on a few appendectomies in medical school, so the patient survived, but at a larger hospital this dilemma would never have arisen.

What can be done? Better transportation would help. In truly isolated areas, air ambulances may be needed. Under our current system these are often exorbitantly expensive and a common source of “surprise medical bills” that run into the $10’s of thousands for non-Medicare patients. State governments and/or referral hospitals should establish fairly-priced air ambulance services if they cannot get commercial providers to bring down their prices. More use of tele-medicine would help, both in providing specialty consultation to the small hospitals and in allowing patients to avoid long drives. It has been found that pre-hospital personnel, EMTs and paramedics, can often avoid taking a patient to the hospital if they have telephone back-up at the scene. Consolidation of rural hospitals to provide more of a critical mass of physicians might require longer drive times but would provide better care in return. Medical schools should recruit more students from small communities, as graduates are much more likely to serve their own or similar communities than are students from an urban background, and rural students are now very under-represented among medical students.

In the meantime, if you are contemplating a move to the bucolic countryside after retirement, look carefully at the medical resources that would be available when you need them!

Prescription for Bankruptcy. Buy the book on Amazon