Ezra Klein

It's true that the flu is, as of now, not especially deadly. Survival rates are quite high. That's a very good thing. And there's some evidence that this flu will prove mild. Possibly even more mild than a bad flu season. But it's not the end of the story. Influenzas mutate. The question is whether it mutates out of existence or towards lethality. "Towards lethality" becomes more likely if more people catch the flu and thus more mutations emerge. So being aggressive in stopping the spread of the largely non-lethal variant is important if we want to avert the development of a more lethal strain. It's not about stopping this flu. It's about stopping what this flu can become.

But if the flu isn't currently very lethal, it does appear to be extremely infectious. The reason is simple enough: It's a new strain of flu that human beings don't have resistance against. Not only can it spread very quickly, it is spreading very quickly. We've hit five on the World Health Organization's flu threat level. It only goes up to six. Six denotes a pandemic: The flu has spread to two or more WHO regions. And most experts expect we'll be there in days.

It's true that people shouldn't panic in the sense of stockpiling ammunition and duct taping windows. But this is a situation in which a short-term overreaction might be the best strategy. That would mean that people really curtail the sort of activities that abet the spread of infection: They cancel non-essential travel, bike rather than take the subway, wash their hands obsessively, etc. It's not crazy stuff. And unlike in financial crises or recessions, where cutting spending worsens the downturn, the sensible actions for fearful individuals will actually improve the probable outcomes.

But the fact of it is, if the response works, we'll never know if we overreacted. If the one person who would have been host to the wrong mutation doesn't get the flu, it will have been a successful effort. But there's no way to track that. And there will be costs: The global economy will further suffer. But not as much as it will if we get this wrong.

Posted by Ezra Klein at 1:30 PM | Permalink | Comments (17)

Catchy title, huh? I'm at Union Station this morning for the release of the Robert Woods Johnson Foundation's megareport on improving health, as opposed to simply improving the health care system. I'd like to tell you that I'll parlay the presentations into some incredibly incisive blog posts, but the fact is that I forgot my power cord at home and my battery works for about 45 minutes before demanding a break. Must be a union battery (I kid!).

So we'll see how the blogging goes. The full report, however, can be downloaded here. Word on the street is that it includes charts.

Posted by Ezra Klein at 9:47 AM | Permalink | Comments (5)

Tom Laskawy points us to a nice op-ed in the San Francisco Chronicle arguing that the government is pretty much killing people by allowing industry lobbyists to writes nutritional guidelines. T. Colin Campbell, a biochemist at Cornell University, and Caldwell B. Esselstyn Jr., a surgeon, write:

Right now, the U.S. government's most widely publicized dietary recommendations are deadly. The Food and Nutrition Board's 2002 report says that to reduce degenerative diseases like heart disease and cancer, we can consume up to 35 percent of our calories as fat, up to 35 percent of our calories as protein and up to 25 percent of calories as added sugars.

Here is a daily diet that meets those nutrition guidelines: Breakfast: 1 cup Fruit Loops; 1 cup skim milk; 1 package M&M milk chocolate candies; fiber and vitamin supplements. Lunch: Grilled cheddar cheeseburger. Dinner: 3 slices pepperoni pizza, with a 16-ounce soda and 1 serving Archway sugar cookies.

This helps explain why 12-year-old schoolchildren develop thickening of their carotid arteries to the brain, and 80 percent of 20-year-old soldiers, dying in combat, are found to have coronary artery heart disease.

The authors offer three recommendations going forward: First, "no scientist with financial ties to the food and drug industries should chair - or choose the members of - panels that set dietary guidelines." That seems pretty basic.

Second, "President Obama should establish a new institute at the National Institutes of Health dedicated exclusively to exploring the link between diet, health and disease. Today, there are 27 institutes and centers at the National Institutes of Health, but none devoted to nutrition, despite the great public interest in the subject." That, again, makes perfect sense.

Third, "Congress should require that medical schools - as a condition of receiving federal grants - offer residency programs on dietary approaches to preventing and treating disease." I'm not against more of a preventive focus in medical schools, but it's just not the case that Americans eat poorly because their doctors don't know much about diet. Still, the first two recommendations are wise, and this stuff is going to be important. Health spending has to come down,and if that's to happen, we're going to have to start buying more of the cheap stuff that makes us healthy so we can spend less on the expensive stuff we need when we're sick.

Posted by Ezra Klein at 2:34 PM | Permalink | Comments (27)

The fight over comparative effectiveness research is really a fight over who controls information. Right now, the pharmaceutical industry pays for most of the research and funds the most effective research distribution service (this service, incidentally, comes in the form of leggy former-cheerleaders and Miss America contestants, like the rep pictured at right). That's good for the pharmaceutical industry, which can emphasize the research aligns best with their business strategy.

The threat of comparative effectiveness review is that Pharma loses control of the information. An alternative information pipeline opens up. This one, to use Kevin's evocative sentence, would be "untainted by the influence of drug companies and device manufacturers." (It also won't be delivered by former cheerleaders.) The sudden controversy over the comparative effectiveness money in the stimulus was a well-orchestrated backlash funded by the pharmaceutical industry. As one plugged in consultant told me today, "I've never seen anything like the pharmaceutical industry's mobilization over the language in the House bill."

But don't begrudge Pharma its efforts. As Kevin says, "their motives in attempting to quash comparative effectiveness research could not be more obvious." The current regime is good for profits. And protecting profits is Pharma's job. But it's not good for the public. And protecting the public welfare is the government's job.

Posted by Ezra Klein at 11:33 AM | Permalink | Comments (18)

In Defense of Food

We turn for salvation to the health care industry. Medicine is learning how to keep alive the people whom the Western diet is making sick. Doctors have gotten really good at keeping people with heart disease alive, and now they're hard at work on obesity and diabetes. Much more so than the human body, capitalism is marvelously adaptive, able to turn the problems it creates into new business opportunities: Diet pills, heart bypass operations, insulin pumps, bariatric surgery. But though fast food may be good business for the health are industry, the cost to society -- an estimated $250 billion a year in diet-related health care costs and rising rapidly -- cannot be sustained indefinitely. An American born in 2000 has a 1 in 3 chance of developing diabetes in his lifetime; the risk is even greater for a Hispanic American or an African American. A diagnosis of diabetes subtract roughly twelve years from one's life and living with the condition incurs medical costs of $13,000 a year (compared with $2,500 for someone without diabetes).

This is a global pandemic in the making, but a most unusual one, because it involves no virus or bacteria, no microbe of any kind -- just a way of eating. It remains to be seen whether we'll respond by changing our diet or our culture and economy. Although an estimated 80 percent of cases of type 2 diabetes could be prevented by a change of diet and exercise, it looks like the smart money is instead on the creation of a vast new diabetes industry. The mainstream media is full of advertisements for new gadgets and drugs for diabetics, and the health industry is gearing up to meet the surging demand for heart bypass operations (80 percent of diabetics will suffer from heart disease), dialysis, and kidney transplantation. At the supermarket checkout you can thumb copies of a new lifestyle magazine, Diabetic Living. Diabetes is well on its way to becoming normalized in the West -- recognized as a whole new demographic and so a major marketing opportunity.

I'd just add a question: How many discrete interest groups would save money from a sweeping policy initiative aimed at reducing chronic disease through nutrition, exercise, and other low-cost lifestyle changes? How many discrete interest groups would make money from a sweeping policy initiative aimed at increasing the number of insured Americans able to purchase cutting edge medical care in response to the onset of chronic disease?

Posted by Ezra Klein at 2:48 PM | Permalink | Comments (47)

A team of researchers from Brigham Young and Harvard University just completed a landmark survey with a fairly intuitive finding: Clean air makes you live longer. In the case of urban residents, cleaner air -- the product of both technological advances and, yes, government regulation -- has added more than five months to average life expectancy in recent years. That's huge. In fact, it's hard to think of a recent medical intervention of comparable efficacy.

But you can think of other regulatory interventions of comparable efficacy: Ripping lead out of walls, for instance. Taxing cigarettes certainly qualifies. Conversely, the proliferation of cheap sweeteners has done more to harm the nation's health than Vioxx could ever dream of.

One of the problems with the health care debate in this country is that it's called "the health care debate." But it's not. It's the "health spending" debate. It's an economic issue. Successful health reform would do less to reduce illness than to reduce medical bankruptcy. Which is why it would be nice to cleave the debate in two. Continue health spending reform. That's urgent. Without it our national finances go the way of Citibank's balance sheet. But also have a health policy.

There's much the government could do to make people healthier: To help them live longer, more active, more able lives. Harold Pollack has some ideas for how to do it the stimulus. Health Affairs has some ideas for how to do it outside of health policy. Phil Longman had a nice article on this topic back in 2004. Matthew Yglesias has a nice graph breaking down the determinants of health:

Part of the reason our health care is so expensive is that we tend to think health is the sort of thing that happens inside a doctor's office. But it's not. It happens when you breathe the air outside, when you decide whether to walk or drive, when you figure out how many friends you have, when you choose what to eat for dinner. What happens in the hospital is not health care, it's disease response. It's what happens when something has gone wrong in the other spheres of your life that make up your health. And the cheapest health reform of all would be the one that keeps us out of the health care system entirely.

Posted by Ezra Klein at 12:32 PM | Permalink | Comments (11)

Here's the operative sentence: "a year after surgical teams at eight hospitals adopted a 19-item checklist, the average patient death rate fell more than 40 percent and the rate of complications fell by about a third, the researchers reported."

Hospitals are dangerous. Surgery is dangerous. Modern medicine saves many more people than it kills, but it kills many more people than you'd think. The Institute of Medicine estimates that 100,000 Americans die every year from medical errors. That's 35 9/11s every year. There's much talk over the flood of medical malpractice lawsuits but rather less about the flood of medical malpractice. But it is a crisis, and unlike the legal proceedings, thousands die from it.

It's also needless. The results of the checklist (pictured above -- click for full-size) are encouraging, but also startling. 19 questions -- questions as simple as whether the patient's identity confirmed been confirmed and his surgery site marked -- dropped the death rate by 40 percent and the complication rate by a third. That means not only that more people lived, but there was less need for follow-up care, for rehabilitation, for corrective surgeries. It's possible that some of that improvement came because the surgery teams knew they were being studied but that simply underscores the point: More attentiveness means fewer deaths.

One of the secrets of health reform is that there's substantial opportunity within the system to make it cheaper while making it better. Instead, the discussion proceeds as if we were facing a tradeoff in which every dollar saved is a dollar of health lost. We're not. A system where all the records are written on paper and tucked in manila envelopes, where surgical deaths drop by 40 percent with the addition of a 19-item questionnaire, where prescriptions are scrawled on scraps of notepad, and where there's little in the way of independent evidence demonstrating cost-effectiveness is not a system that lacks for expensive inefficiencies.

Posted by Ezra Klein at 9:02 AM | Permalink | Comments (25)

No one wants to be against "innovation." The word is practically a synonym for "awesome." And who wants to be anti-awesome? But the problem with our health care system is that far too little effort is expended making sure the innovation is good innovation. Take the case of Claritin, the wonder anti-allergy drug. In 2001, loratidine, Claritin's active ingredient, went off patent. Generic producers streamed into the market. Many more people could access Claritin, or at least the compounds that made Claritin powerful. Right on schedule, Schering, Claritin's producer, emerged with Clarinex. Now the active ingredient was desloratadine, and it was said to be effective, for longer. There was little evidence of that. But it was eligible for patent protection, and Schering spent billions of dollars convincing doctors to prescribe it, and so they made profits and health care became a bit more expensive. That was bad, or at least useless and costly, "innovation." On the other side, there's much good innovation. And there should be some status quo bias in favor of protecting a system that does produce important advances.

The problem is, we actually do need to strike a balance. In health care, unlike in other industries, almost anything that is approved is prescribed and paid for. By all of us. bad innovation imposes public costs. Pharmaceutical companies are incredibly sophisticated at generating their own demand. So what to do? My preference, at least in the short-term, would be an alternative track for drug development based around prizes, not patents. This would not replace the current patent system, but compete with it. Nobel prize winning economist Joe Stiglitz advocates this idea ("The fundamental problem with the patent system is simple: it is based on restricting the use of knowledge"), and Senator Bernie Sanders has turned it into legislation. It could do much to ease the most perverse incentives of the private sector -- the need to induce demand and wall off research -- while preserving the incentives for innovation. It could be funded by the public sector but the decision makers -- those competing for the prize -- would remain private. It might not solve our problems, but it could help. It's worth trying.

Posted by Ezra Klein at 2:36 PM | Permalink | Comments (13)

In 2002, four intrepid researchers filed a Freedom of Information Act. But they weren't looking for information on Guantanamo or revelations from Cheney's lair. All they wanted was the FDA's drug analysis data. Taxpayer funded research. They got it. The studies examined were conducted between 1987 and 1999 andcovered Prozac, Paxil, Zoloft, Celexa, Serzone, and Effexor. They found, on average, that placebos were 80 percent as effective as the drugs.

Put aside the surprising results: Why didn't the public know about these studies? Why wasn't the medical community informed? The answer, as Marcia Angell argues in an important New York Review of Books article, is that our system of clinical evaluation is so riddled with conflicts of interests that "it is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines."

The causal line is simple: This country's pharmaceutical system puts the cost of conducting research onto the drug companies. The fox is given the contract to provide security at the henhouse. Forcing pharmaceutical companies to fund the research also gives them control over much of the research. A review of seventy-four clinical trials of antidepressants found that thirty-seven of thirty-eight positive studies were published. Of the thirty-six negative studies, thirty-three were either not published or published in a form that implied a positive outcome. That is to say, in a form that lied. To a doctor reading the published literature, 94% of the trials conducted were positive. In reality, 51% were positive. And these are not exceptions to a rule of transparency. In the medical research and evaluation industry, dual loyalties are common:

In a survey of two hundred expert panels that issued practice guidelines, one third of the panel members acknowledged that they had some financial interest in the drugs they considered. In 2004, after the National Cholesterol Education Program called for sharply lowering the desired levels of "bad" cholesterol, it was revealed that eight of nine members of the panel writing the recommendations had financial ties to the makers of cholesterol-lowering drugs. Of the 170 contributors to the most recent edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), ninety-five had financial ties to drug companies, including all of the contributors to the sections on mood disorders and schizophrenia. Perhaps most important, many members of the standing committees of experts that advise the FDA on drug approvals also have financial ties to the pharmaceutical industry.

Charles Nemeroff, as you might imagine, remains at Emory University. And why not? "A recent survey found that about two thirds of academic medical centers hold equity interest in companies that sponsor research within the same institution. A study of medical school department chairs found that two thirds received departmental income from drug companies and three fifths received personal income." Nemeroff's behavior is par for the course.

Defenders of the system will point out that this doesn't mean the resulting recommendations are wrong. Maybe so. But they are not credible. And you need a credible system. There's a lot of talk about evidence-based medicine, but evidence-based medicine only matters insofar as the evidence is complete and unbiased. Right now, it isn't. As Angell concludes, this isn't a job for disclosure. Admitting conflicts of interest is not the same as eliminating them. But this is a job for policy. If the pharmaceutical companies will not fund research, then someone else must. Dean Baker has some useful thoughts on that score.

Image used under a CC license from I Y E R S.

Posted by Ezra Klein at 1:47 AM | Permalink | Comments (35)

The primary care blogosphere is rightfully pissed at an op-ed by Dr. Jonathan Glauser, an emergency physician and MBA, that takes the form of an angry screed against the primary care profession. "If ever there was a group that has failed in providing care, it is our primary care system," he says. "To fund such a venture for groups that are singularly inept at performing anything of value to society is pure folly and a waste of precious health care dollars."

Data is not the plural of anecdote, and anecdote is the only data Glauser offers. Dr. Rob, Bob Doherty, and even fellow emergency physician Shadowfax pull out the long knives and the longer studies. But the dispute is more than a simple rant. Primary care doctors are asking for massive subsidies right now. The ACP wants a 10 percent boost in Medicare payments. Kevin MD will see their 10 percent, and raises them to 20 percent.

The problem they're responding to is real. We're about to face an epic shortage of primary care doctors -- we're talking 44,000 or 45,000 too few docs -- which will ensure massive disruption for patients. The problems for primary care are basic: Fewer graduates, more patients. As I understand the issue, there are two problems here. The first is lifestyle. Primary care doctors have too many patients, too little time, too much paperwork, too much administrative hassles, too little satisfaction. The other is money. Primary care doctors make far less than specialists, even though they go through a similarly expensive and rigorous training process. It's no surprise, then, that most doctors opt to become specialists, where they have better incomes and more control over their lifestyle. The famous stat here is that the highest MCAT scores are now to be found among dermatologists. Great money, nice lifestyle.

The money fix being proposed comes on the payment side. How can we make it lucrative enough to be a primary care doctor? The answer is increase the pay of primary care doctors. And there's an argument for this: More primary doctors would probably make the system cheaper, even at higher reimbursement rates. Specialist medicine is expensive. But you could also examine the problem on the training side: How can we make it cheaper to become a primary care doctor?

Continue reading "THE PRIMARY CARE CRISIS." »

Posted by Ezra Klein at 11:31 AM | Permalink | Comments (45)

Currently, doctors write your prescription on a pad of paper. They write it in a quick scrawl, to be interpreted by a tired pharmacist. Fairly frequently, some link in this structure breaks down and you get the wrong medication. Sometimes that's fine, sometimes it makes you sick, sometimes it kills you. More than 1.5 million Americans are injured a year due to these errors. All this, in the age of computers and e-mail. In order to get doctors to move away from Bic pens and towards Gmail, Medicare is having to offer bonuses for electronic prescriptions, and many doctors still don't want to comply. It's insane.

Posted by Ezra Klein at 12:31 PM | Permalink | Comments (22)

The study cost $130,000,000 and included 42,000 patients. It compared the effectiveness of four types of blood pressure drugs: a calcium channel blocker, an alpha blocker, an ACE inhibitor, and a simple diuretic. The diuretic performed best. It was the sort of finding worthy of celebration. Health costs are too high, and rising too quick. Our flabby society gets bad readings when it straps on the blood pressure cuff, and soon enough we'll all be on these drugs. And here were study results saying that the diuretic, a generic drug which sells for pennies, outperformed its pricey, patented competitors. So what happened? Not a whole lot. The Times tells the story, and even includes a graph:

Diuretics sales jumped, but only by a few percentage points. "[They] should have more than doubled," says Curt Furberg, who chaired the study. And in a world where doctors prescribe medications based on a simple reading of the latest evidence, maybe they would have doubled. But we don't live in that world. We live in a world where pharmaceutical companies have big budgets and sophisticated public relations teams. Pfizer, for instance, put up $40 million to ensure that their Cardura, their alpha blocker, was included in the study. That proved a mistake. Patients on Cardura were more than twice as likely to require hospitalization for heart failure.

So what did Pfizer do? Spin! "Rather than warn doctors that Cardura might not be suited for hypertension," reports The New York Times, "Pfizer circulated a memo to its sales representatives suggesting scripted responses they could use to reassure doctors that Cardura was safe, according to documents released from a patients’ lawsuit against the company." Another e-mail from the same document dump shows Pfizer's PR people congratulating each other over diverting a group of European physicians away from a cardiology conference and onto a sightseeing trip on the day when these results were being presented.

Then came the methodological challenges, some cynical, some legitimate. The pharmaceutical companies pounced eagerly atop these arguments. At a shareholder meeting, Pfizer's chief executive called the results "extremely positive." In what can only be described as wry understatement, he said, "it will be our job to explain that to the medical community.” Pfizer began taking out full-page ads in medical journals touting their performance in the mega-study. The ads didn't mention the superiority of the diuretics, nor the increase in heart failure when using the other drugs. And on, and on.

The basic reality was this: The pharmaceutical companies had a skilled team and a lot of money promoting their drugs. No one was promoting the generic diuretics. Folks looking to things like comparative effectiveness review to save the health care system should take the story seriously. Evidence is only effective if physicians use it. And right now, they have no real reason to use it. Even in a system this expensive, there's no internal incentives to aggressively cut costs. Maybe it's time there were. If doctors were paid by capitation -- if they got a fixed amount of money per patient, and they kept whatever they didn't use, as happens in England -- it's hard to imagine they wouldn't have been more interested in these study results.

Posted by Ezra Klein at 9:05 AM | Permalink | Comments (29)

Browsing GraphJam yesterday, I noticed this neat little chart:

Ah, would that it were true. Sadly, a study published in the Annals of Internal Medicine found that "overall adherence to hand hygiene guidelines was 57%. Factors associated with poor adherence included having busy workloads, performing activities with high risks for cross-transmission, and being in technical specialties (such as surgery and anesthesiology)." In other words, about six-in-ten doctors wash their hands as often as they should. And being a surgeon actually lowers your likelihood of being a conscientious germophobe.

Because of this, government guidelines now cut against hand washing (pdf). That ritual takes up to a full minute, and in busy units, study after study shows that doctors will skip it as they rush to fit in their full load of patients. Those minutes add up. The government now recommends alcohol-based hand purifiers. You clip the vial to belt and use it as you walk from bed to bed. This may all sound a bit silly, but "the CDC estimates this saves an hour in an eight-hour intensive care shift."

Posted by Ezra Klein at 11:29 AM | Permalink | Comments (2)

Now Leavitt has responded on his blog, saying that the issue at hand is not the definition of abortion, but the efforts of medical specialty groups to deny a physician's right to refuse to perform abortion. That, says Leavitt, is what the possible regulation is meant to address. "It contained words that lead some to conclude my intent is to deal with the subject of contraceptives, somehow defining them as abortion," he writes. "Not true." In a subsequent post, he says "This is not a discussion about the rights of a woman to get an abortion. The courts have long ago identified that right and continue to define its limits. This regulation would not be aimed at changing or redefining any of that. This is about the right of a doctor to not participate if he or she chooses for reasons they consider a matter of conscience."

The draft language of that regulation is extremely clear. Though the regulation itself may be focused on issues of "conscience," were it to be implemented, it would create precedent for conflating abortion and certain forms of contraception. This would not change Roe, but it would be meaningful, as Leavitt knows, for reasons of Health and Human Services funding. Indeed, in the letter that kicked this whole thing off, Leavitt warns that federal funds could be "jeopardized" if the American College of Obstetricians and Gynecologists doesn't change its position on whether OB/GYNs can decide to neither perform nor refer for abortions. Leavitt's blog posts are interesting, but they're dancing around the language of the regulation and refusing to address the critic's central point of concern. Happily, this is a blog, and you can leave Leavitt comments, and having been on a blog panel with him last week, I can say, with some certainty, that he actually reads a lot of them (and, admirably, has responded to this issue twice already, even if he's not been fully forthcoming). So ask him to clarify, why don'cha?

Posted by Ezra Klein at 9:58 AM | Permalink | Comments (19)

Over at the Motherblog, Dana makes a great catch showing the ways in which reducing the profit motive in health care also reduces overtreatments, overspending, and poor health. The issue is in vitro fertilization, a method of artificial embryo implantation of giving sterile couples a chance at parenthood. In vitro doctors have a tough tradeoff to make: When you transfer more embryos, there's a higher likelihood of implantation, and thus, success. But the more embryos, the higher the likelihood of multiple implantations, with the attendant health risks (far higher rates of prematurity, lung impairments, cerebral palsy, and infant death).

The American Society for Reproductive Medicine has released guidelines on how many embryos to implant at a time, but lots of clinics ignore the rules. As Peggy Orenstein explains, "What if a couple has only enough money for one round of treatment and wants to be sure — really, really sure — that it works? Or a clinic’s success rates, which are posted on the Web site of the Centers for Disease Control, begin to founder and need a boost to stay competitive? Such pressures may contribute to the high rate of I.V.F. multiples produced in this country. Only 1 percent to 2 percent of naturally conceived children are twins. Among I.V.F. babies, it’s 32 percent."

In Europe, where universal health care covers the cost of in vitro treatments, the rate of multiples born from IVF is a mere 5 percent -- a huge difference. As Dana writes, "because Europeans know they will be covered if they seek a second or third implantation procedure, they don't take the risk of implanting 5 or 6 fertilized eggs during one procedure." Under the European system, the medical concerns take primacy, while the economic issues fade into the background. It's an example where the European model is not only cheaper (treating cerebral palsy is a helluva lot more expensive than paying for a few more IVF procedures), but also results in better care, period.

Posted by Ezra Klein at 1:44 PM | Permalink | Comments (13)

Matt reprints the famous Dartmouth Atlas graph showing there's no relationship between the amount of money Medicare spends on treatments and the quality of care they get for those dollars:

"Long story short," he writes, "substantial progress on the health care costs problem will probably require the crushing of the doctor's lobby." That is, in part, true. Doctors make money from prescribing treatments. If, as in England, they made money by not prescribing treatments (i.e, through capitation pay, where they're paid X amount per patient, rather than per treatment), they would prescribe more carefully. You could even set up those salaries such that doctors made approximately what they do now (so they don't rebel), but they kept more of it as profit if they didn't spend so much on treatments. Over time, that would radically slow the growth in health spending. So too would increasing the supply of doctors and increasing the responsibilities of nurse practitioners, both of which the doctor's guilds oppose.

But there's more than just guild greed at work. Methods of rationing, like capitation, are a hard sell to voters who want to believe they'll get not only every treatment they could plausibly benefit from, but quite a few they couldn't plausibly benefit from. In general, patients have a Samuel Gompers attitude towards medical treatment: They want more. Doctors don't make much money when they prescribe unnecessary antibiotics for colds. They do it because patients want antibiotics -- they feel better knowing something has been done. And doctors want them to feel better. And since neither the doctor nor the patient pays much per marginal unit of care, their incentive is to leave the encounter feeling good, not save money. So paitients ask and doctors prescribe. More expensively, doctors help families pursue heroic measures for their dying relatives even as they know they won't do much good. This isn't a guild protecting itself so much as human nature pointing in a possibly harmful, and definitely pricey, direction. Doctors take an oath to heal, they don't take an oath to cut health spending.

Continue reading "WHY DOCTORS OVERPRESCRIBE." »

Posted by Ezra Klein at 12:56 PM | Permalink | Comments (72)

I spent some time last night tooling around on Google Health, the omnipresent search engine's latest attempt to colonize my world. G-Health lets you create a total medical profile: Personal characteristics, conditions, doctors, test results, medications, immunizations, and on, and on, and on. They warn you of worrying drug interactions and even let you import your health records from providers. Google promises that third-party applications are being developed, and users will eventually be able to choose from a rich variety of services that let you do everything from refill prescriptions to schedule appointments. All in all, it's an impressive interface.

Here's the problem: My health records are in a manila envelope, in a wall-sized file cabinet, somewhere on K and 21st Street (and we're not even getting into the thick document stored in some basement in California). Paper is not interoperable with Google. Now, I could begin inputting my health records by hand, and because I'm a nerd, I might do that. But most won't. So until the provider community decides to step up and commit to one (or even a couple) standard electronic health record platforms, G-Health won't be much more than a curiosity.

But down the road, when electronic health records are either required by the government or demanded by the market, G-Health will be a fascinating system. For one thing, it's completely portable and user-controlled. Aetna's CEO is bragging about his superior system, but given that that system is controlled by Aetna and I'm not, it's of little use to me. G-Health, by contrast, can be used by anyone, and thus has much more potential to become the standard than do proprietary systems.

There are, of course, questions of privacy. And those questions need to be balanced by the utility of actually having and analyzing good data that could improve care quality. If Google gets all this information, then squirrels it away, it's robbed of its potential to improve care. But if they have some system for coding it anonymously in ways that researchers can nevertheless use, they risk bad press (here, incidentally, is the privacy policy). Which is why G-Health is probably a stopgap solution that will help individuals better control their records. The actual health system won't move into the electronic age till the government sets standards and creates funding to help it do so.

Posted by Ezra Klein at 10:18 AM | Permalink | Comments (16)

"Only in December did the U.S. Department of Agriculture modify the Women, Infants and Children nutrition program to assist low-income families in buying fresh fruits and produce," reports The Washington Post in their feature on obesity. "The addition was blocked for a decade by politics and by industry sectors worried that WIC's food packages would contain less milk, eggs and cheese."

The WIC is a federal program that "provides Federal grants to States for supplemental foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and non-breastfeeding postpartum women, and to infants and children up to age five who are found to be at nutritional risk." In other words, it's a health program for expectant mothers and young families. And for decades, the program was blocked from encouraging families to buy fruits and produce and instead used to push saturated fat, cholesterol, and more cholesterol milk, eggs, and cheese. Charming.

Folks talk a fair amount about the obesity crisis, but here's the number that sticks in my head: 27 percent. Between 1987 and 2001, health spending rose by about $1,110. And 27 percent of that increase was directly attributable to the rise in obesity. Not, mind you, total obesity. Simply the rise in obesity. Now multiply 300,000,000 by $301. That tremendous number? That's how much we, as a country, paid to offset the health costs of rising obesity in fiscal year 2001. Worried about obesity yet?

Obviously, obesity isn't something the government can reverse by fiat. But nor need public policy be arrayed so as to intensify the epidemic. Schools raise money through vending machines and exclusive deals with snack food companies. Corn production is subsidized to such an absurd degree that industry had to figure out a way to make it not-corn, so they could use it more, and so we got high fructose corn syrup and the heavily processed, nutritionally inadequate, dead cheap foods it tends to sweeten. In 2005, Congress passed a $286 billion highway bill -- an enormous subsidy meant to make the country more drivable. No equivalent sum was spent to make our communities more walkable. In essence, we're paying to make our country fatter, then paying even more to keep our alive as the health costs of obesity come due. It's insane.

Picture used under a Creative Commons license from Flickr user Stan.

Posted by Ezra Klein at 10:02 AM | Permalink | Comments (16)

Johann Hari has a fascinating article on his use of Provigil, a drug that basically makes you smarter:

A few clicks on-line and I found I could order it from a foreign pharmacy, just £30 for a month’s supply. I called a friend who is a GP, and told her what I was thinking of. She’d heard of people using the drug, and went away and looked up the details. “I think it’s a stupid thing to do, because you shouldn’t ever take drugs you don’t need,” she said when she called back. “Do I think it’ll seriously harm you? No, I don’t. But you’d be much better off taking a long holiday than narcolepsy pills.” Then she warned me: “There is one known side-effect.” Oh, damn I thought. A downside. “It often causes people to lose weight.” Are you mad? You become cleverer and thinner? I whipped out my Visa card immediately.

A week later, the little white pills arrived in the post. I sat down and took one 200mg tablet with a glass of water. It didn’t seem odd: for years, I took an anti-depressant. Then I pottered about the flat for an hour, listening to music and tidying up, before sitting down on the settee. I picked up a book about quantum physics and super-string theory I have been meaning to read for ages, for a column I’m thinking of writing. It had been hanging over me, daring me to read it. Five hours later, I realised I had hit the last page. I looked up. It was getting dark outside. I was hungry. I hadn’t noticed anything, except the words I was reading, and they came in cool, clear passages; I didn’t stop or stumble once.

(via Kevin)

Posted by Ezra Klein at 3:58 PM | Permalink | Comments (36)

One of the problems in health care is a simple shortage of primary care doctors willing to work in underserved or poor areas. In response to this, people like me often suggest inducements like loan forgiveness programs that might help folks rationalize choosing a post medical school career path that doesn't make them very rich. Turns out Massachusetts just tried a repayment program that knocked out about 60 percent of medical student loans for doctors willing to serve in Eastern Massachusetts' community health centers. The program more than doubled recruitment success. Imagine what full repayment could do.

Posted by Ezra Klein at 11:28 AM | Permalink | Comments (20)

I don't really know what it says that the Association of Medical Colleges actually had to release a report concluding "offers of free food, gifts, travel and ghost-writing services by drug and medical device companies should be spurned by doctors, staff and students in medical colleges to avoid conflicts of interest." Wouldn't a big sign with the word "BRIBES" crossed out basically serve the same purpose?

The report also recommends that "visits to physicians by pharmaceutical representatives occur only by appointment or at the doctor's invitation, and that the visitors be restricted to non-patient areas." Reminds me that last time I went to the dermatologist, he asked if I minded if a pharmaceutical representative sat in on our appointment. I told him I did, and felt like I'd made a faux pas. Charming. And mine wasn't even a former cheerleader.

Posted by Ezra Klein at 11:01 AM | Permalink | Comments (9)

The The New York Times has an interesting piece this morning on "Tiered" pricing for pharmaceutical drugs. "Tiers" are, in essence, the practice of covering different pharmaceuticals at different rates. So a generic statin might be covered at 100 percent (Tier One) and you don't pay a penny to take it while an experimental cancer drug might force you to lay down thousands of dollars. The article focuses on Tier Four, where patients are paying a huge amount in order to access certain high cost drugs. The problem is that the article never tells us how Tier Four is decided.

The article vaguely implies that Tier Four is simply composed of costly drugs that insurers are dumping on patients. My understanding of the situation is that Tier Four is actually composed of largely experimental and unproven treatments that don't seem to offer benefits in line with their cost. If it's the former, then this really is, as the article seems to suggest, a cruel and crazed practice. If it's the latter, then it's exactly what we need to be doing. And the question isn't academic: Tiering drugs have actually brought pharmaceutical costs way down in recent years, and can be a step towards the sort of smart cost sharing that liberals should embrace. The problem comes if the Tiering is being done without evidence, as a pure money-saving, rather than value-driven, effort. That's the salient question here. Sadly, the Times doesn't really address it.

Posted by Ezra Klein at 11:11 AM | Permalink | Comments (29)

Much is made of the remarkable research and development conducted by pharmaceutical companies. Too much, in fact. But whether you believe that their labs are thrumming with activity or that their job is merely to patent and profit from discoveries made with taxpayer dollars in the public sector, the current situation remains a problem: The drug pipeline has dried up. The new products aren't coming. Don't believe me? Ask The Wall Street Journal. Or, better yet, ask Merrill Goozner, who's running an important series of posts on the apparent slowdown of innovation in pharmaceutical sector. His first post explained just how bad things have gotten. Today's entry focused on the perverse financial incentives (and the horribly misguided patent system) which encourage the development of me-too drugs, discourage attention to rarer diseases, and impede the transformation of research into product. Both are well worth a read.

Posted by Ezra Klein at 9:10 AM | Permalink | Comments (17)

Shannon Brownlee explains the differences between managed care and (real) HMOs/group practices, and tries to rescue the shattered reputation of the latter:

The reason group practices and HMOs haven't flourished is that the market isn't set up to pay them. There isn't an insurer in this country, including Medicare, which consistently pays doctors and hospitals for the quality of care they provide. They pay for quantity. They pay for the volume of individual services provided, not for the value of those services to the patient. As Michael Hillman of the Marshfield Clinic (a group practice in Marshfield, Wisconsin) recently put it, our current payment system "is like buying a car based on how many parts it has and how long it takes to make it, without considering how well it runs.'' So even though HMOs and group practices have in effect built the equivalent of a better car, the market doesn't give a rip.

Patients don't care either, partly because they are insulated from the cost of medicine, so they have little stake in getting good value for their dollar. But they also have a bias against HMOs and group practices because the American Medical Association has spent the last century telling them that HMOs and group practices offer inferior care. The AMA's rallying cry has been the almighty "doctor-patient relationship." This might sound like a motto based on the needs of patients, but what it has meant in practice is the AMA has trumpeted the rights of individual doctors in private practice to treat patients as they see fit, without interference from the government or their peers, and more importantly, to charge whatever price the market will bear. According to the AMA anything that resembles organized medicine, including group practices and Medicare, is a Commie plot to saddle us with socialized medicine -- and constrain physician incomes.

Doesn't ring true? Think about this: HMOs came into being largely in order to better coordinate care. Much like the VA, they bring together doctors who're jointly tasked with individual patients, who share notes and generally work as a team. That's part of how they keep costs down. Now, all of you, just about, are in the Big Insurance version of the HMO: Managed care. How coordinated does your care feel?

Posted by Ezra Klein at 10:50 AM | Permalink | Comments (14)

New York Magazine has a terrifically interesting article on sleep research, and the overwhelming scientific consensus that even moderate reductions in shut-eye can do serious damage to our mental speed. In one study, "the University of Pennsylvania’s David Dinges did an experiment shortening adults’ sleep to six hours a night. After two weeks, they reported they were doing okay. Yet on a battery of tests, they proved to be just as impaired as someone who has stayed awake for 24 hours straight." Yikes. In another, we learn that "Sleep deprivation hits the hippocampus harder than the amygdala. The result is that sleep-deprived people fail to recall pleasant memories yet recall gloomy memories just fine. In one experiment...sleep-deprived college students tried to memorize a list of words. They could remember 81 percent of the words with a negative connotation, like cancer. But they could remember only 41 percent of the words with a positive or neutral connotation, like sunshine or basket."

We also get some data on the commonly heard, and totally accurate, complaint that schools start too early. "in Edina, Minnesota, an affluent suburb of Minneapolis...the high school start time was changed from 7:25 a.m. to 8:30. The results were startling. In the year preceding the time change, math and verbal SAT scores for the top 10 percent of Edina’s students averaged 1288. A year later, the top 10 percent averaged 1500, an increase that couldn’t be attributed to any other variable." And yes, as anyone who's ever stayed up all night and felt voraciously hungry in the morning knows, sleep deprivation stimulates your appetite, and makes you fat. "Three foreign studies showed strikingly similar results. One analyzed Japanese elementary students, one Canadian kindergarten boys, and one young boys in Australia. They all showed that kids who get less than eight hours of sleep have about a 300 percent higher rate of obesity than those who get a full ten hours of sleep....In Houston public schools, according to a University of Texas at Houston study, adolescents’ odds of obesity went up 80 percent for each hour of lost sleep. "

The risk of reading this article is that you'll do what I did this morning, which is wake up tired, tell yourself that your place of employment wouldn't want you functioning at 60% capacity, nor becoming really fat, and go back to sleep. A little sleep research is a dangerous thing, particularly at 7 in the morning.

Posted by Ezra Klein at 9:50 AM | Permalink | Comments (14)

As per usual, Robin Hanson's claims that we should cut the provision of medicine in half are, shall we say, a bit strong, but it is true that we've got enormous amounts of waste, and it's undoubtedly true that we should vastly enhance the amount of money we spend studying the effectiveness of treatments.

David Cutler's riposte, by contrast, seems quite on-point. Policy should focus on separating good care from bad care. There's no reason to go at this with a meat cleaver (unless you're Robin Hanson, and have made a career out of, um, "viewquakes," which sort of require you to make Shocking! Claims!) Also, if you are going to cut care, you'll want to do it on the supply side (i.e, with trained professionals helping decide where to slash spending), because all the available evidence shows that patients do not, themselves, know which care to cut, and when faced with higher medical bills, will just cut care indiscriminately.

Lastly, Hanson mentions that medicine is often used to "show that we care," which does not actually increase anyone's health. But medicine is also used to comfort. Take a patient with heart palpitations. Odds are they're just benign skipped beats. A doctor may even know those odds. But when your heart jumps, it's scary. So the doctor runs the set of tests that distinguish them from deadly arrhythmias. These tests are, in Hanson's telling, wasted medicine, as they do nothing to improve biological function and are very costly. But the assurances they offer do much to improve quality of life, which is, along with extending the length of life, rather the point of medicine.

There will always be some level of "wasted" medicine that isn't, at the moment of prescription, sure to be waste (i.e, a diagnostic that could find a deadly disease, but doesn't), and some amount of medicine that's used to calm fearful patients. Neither of those show up on yearly physicals, but nor are they necessarily wasted dollars if your metric is improving patients' quality of life.

Posted by Ezra Klein at 11:47 AM | Permalink | Comments (22)

David Leonhardt has a smart column on health care spending today, in which he takes on the idea that preventive care will actually save us money:

The actual savings are also not as large as might at first seem. Even if you don’t develop diabetes, your lifetime medical costs won’t drop to zero. You might live longer and better and yet still ultimately run up almost as big a lifetime medical bill, because you’ll eventually have other problems. That would be an undeniably better outcome, but it wouldn’t produce a financial windfall for society.[...]

Intermountain Healthcare, a network of hospitals in Utah and Idaho that has saved money in recent years by reducing hospital infections and drug errors. Intermountain hospitals have also largely stopped inducing child labor for the sake of doctors’ or parents’ convenience. The hospital induces birth only for medical reasons — and the number of babies that spend time in the neonatal intensive care unit has fallen.

It’s this last example that holds the real key to cutting medical costs. I realize many people will react to the notion that preventive care usually costs money by saying, “So what? We should do it anyway.” And we should.

But by describing it as an easy win-win solution, the presidential candidates are gliding over an important part of the issue. Preventive care saves real money only when it replaces existing care that is expensive and doesn’t do much, if any, good. There are plenty of examples of such care — from induced labor to many lumbar surgeries and cardiac stent procedures.

The problem is that the people getting this care typically don’t consider it wasteful. We all like to believe that other people are the ones getting the unnecessary care. We, on the other hand, are probably not getting enough treatment.

This is all true. To be sure, in a perfect world, I could probably dream up a set of policy initiatives that, if broadly implemented and competently carried out, could reduce health spending off the bat. But the world continually disappoints with its stubborn lack of perfection. Instead, the more achievable goal is to move towards a universal system that's more cost-effective, which is, in fact, very much the same thing as saving money, and towards an integrated system that readies the ground for tougher cost control mechanisms down the road.

Posted by Ezra Klein at 8:24 AM | Permalink | Comments (25)

In answer to last week's study suggesting that initial installations of electronic health records aren't proving as effective as hoped, Overheard in Providence offers up a corrective to the doubters, and looks into a future filled with health information technology and the many fruits of its abundance:

If EMRs [electronic medical records] become widespread, they open the door to a huge new area of medical research. Computer-aided diagnosis is going to get a lot better if millions of anonymized medical records become available. A few years ago I went to a talk by MIT professor Peter Szolovits. He was able to use a computer to diagnose certain heart conditions from audio recordings better than most doctors. EMRs would greatly facilitate the development of automated screening procedures. More importantly, when new procedures are developed, they could be applied retroactively to data collected years earlier, even when a patient stops seeing a doctor. There’s absolutely no way to do this now.

EMRs would also be a huge boon to public health research. Researchers could be given access to a huge data base of anonymous medical records, all in a standard format. It would be trivial to check if two conditions are correlated, or if one disease occurs more often in some segment of the population. The amount of data would be so large, a doctor could even search for records similar to their patent, and use those records as a guide for what health problems to watch for.

Finally EMRs make much better use of healthcare we already provide. If you go in for surgery, all sorts of equipment is used to monitor your well-being. This data should be recorded and reviewed by a doctor who isn’t busy cutting you open. If you go in for a 3D bodyscan, even more data is collected. The scan could easily be reviewed by experts in other parts of the country, provided they have access to your EMR.

I tend to plug EMRs in terms of their immediate and obvious benefits: Reduction in paper, reduction in cost, reduction in lost records, simple programs that prescription errors, etc. But this is all correct, too. The widespread implementation of EHRs could trigger enormous change in the way medicine is practiced, and could accelerate many, many types of research. The downside here is that there are obvious and clear privacy concerns, but as genetic risk profiling inches ever closer to reality, these are issues we're going to have to deal with one way or the other.

Posted by Ezra Klein at 11:46 AM | Permalink | Comments (28)

I often plug the possibilities of electronic medical records to vastly increase care quality while reducing costs, as they have in the Veteran's Administration System. But I'd be remiss not to point to this recent study showing that, in private practices, using electronic health records resulted in merely minor improvements in only two of the 17 tested metrics. And on one metric, the prescription of statins, they actually worsened physician performance. I don't have full access to the study and so can't tell you what hypotheses the researchers attached to their results, but the data is interesting on its own.

Posted by Ezra Klein at 1:27 PM | Permalink | Comments (32)

A new study finds that older, cheaper diabetes drugs control blood sugar as well, with somewhat less harmful side effects, than newer, more expensive ones. In a sane health care system, this would mean a rush to prescribe these older agents, or at least to gather more data on the subject. In our health care system, where doctors take tens of thousands from pharmaceutical companies and patients are bombarded with advertising to make them think they want, or know they want, certain drugs, the more expensive, no more effective, compounds will almost certainly remain atop the market. There's simply no incentive for doctors to switch over, but plenty of incentive for them to prescribe the more costly drugs.

And if that doesn't work, maybe the drug industry will just take a page from their playbook for the epileptic drugs that are about to lose patent and go generic, and try and get state legislatures to pass laws making it illegal for pharmacists to switch patients over to cheaper, perfectly effective generic alternatives. Illegal. But that's no surprise: Pharma spent $44 million on statehouse lobbying in 2005 and 2006 -- and they weren't just buying good times. Hell, in this case, they donated tons of money to the Epilepsy Foundation and did the lobbying under their auspices.

But look, Andrew Sullivan tells me the pharmaceutical industry is great, and way better than in Europe, so I'm sure this is all some sort of big misunderstanding. If they don't keep patients from switching to generics, after all, how will they fund R&D!?

Posted by Ezra Klein at 10:25 AM | Permalink | Comments (44)

I'm not entirely sure there are words to describe how bizarre it is to watch Andrew Sullivan rely entirely on research from the pharmaceutical industry's web site to make his case for why drug companies should get to charge anything they want. I mean, really, we're going to need a new term. Gullimarkable?

In any case, Sullivan's case is a mess even if you excuse his sources. He gets really excited about a 1994 European Commission report saying "Europe as a whole is lagging behind in its ability to generate, organise, and sustain innovation processes that are increasingly expensive and organisationally complex." The quote from the report then ends, and we have to rely on Pharma's interpretation of how it relates to drug research on the continent.

If Sullivan weren't just parachuting into the issue with a copy of Free to Choose and a tone of extreme indignation, he'd know that a similar study was released last year showing problems in the American pharmaceutical market -- notably, a precipitous drop in new drug development from the pharmaceutical industry.

A report by the General Accounting Office concludes that current patent law discourages drug companies from developing new drugs by allowing them to make excessive profits through minor changes to existing pharmaceuticals. While pharmaceutical research and development expenses have increased by 147% since 1993, applications for approval of "new molecular entity" (NME) drugs, or drugs which differ significantly from others already on the market, have risen only 7%. According to the report, the majority of newly developed medicines are so-called "me-too" drugs, which are substantially similar to existing drugs, are less risky than NMEs drugs to develop, and which "offer little in the way of therapeutic breakthroughs."

Entirely 68 percent -- two-thirds -- of the industry's new drug applications are for knock-off, me-too drugs. The incentives for copying tried-and-true products are far, far too high. So it turns out profit -- generated here by patents -- can actually harm drug development! Am I blowing your mind yet?

Continue reading "Things You Won't Learn From Industry Propaganda" »

Posted by Ezra Klein at 3:52 PM | Permalink | Comments (92)

[litbrit wonders why this isn't front-page news...yet.]

I've been following the pet food poisoning story for a while, and with the advent of last week's revelation that not only wheat gluten, but also corn gluten and rice protein concentrate--all imported from China, all used in pet food, animal feed, and human food--had tested positive for melamine and may have been introduced into the human food supply, I knew it was only a matter of time before this happened: melamine has indeed been detected in the feed and body fluids of pigs meant for human consumption, and California authorities have issued both a quarantine and an advisory to not consume pork from at least one farm (along with weak assurances that eating pork tainted with the industrial chemical poses only "minimal" health risks); others may follow, since the tainted feed was also shipped to New York.

A hazardous chemical believed to have killed scores of pets nationwide has been found in California and New York hog farms, raising concerns for the first time that it could have been consumed by humans.

[.....]

California authorities have quarantined American Hog Farm, in Ceres  south of Sacramento, after melamine was detected in a least seven urine samples and three samples of the animal's food, news report said.

California officials and are trying to trace what happened to slaughtered animals.

Continue reading "Melamine Found In California Pork; FDA Launches Criminal Investigation" »

Posted by at 11:09 AM | Permalink | Comments (27)

Great post by Cactus on the medical innovation issue:

most of the folks on the right who make this point will point with pride at the American military-industrial complex (to use Ike's term). They will note that American military equipment is often the best there is...

Anyway... why is it that a monopsony buyer of military equipment, a buyer that puts its suppliers on a cost-plus arrangement most of the time, hasn't managed to kill off innovation in military equipment but a monopsony buyer of health care would strangle all medical advance forever more?

Not clear. To be sure, the spending bloat in the armed forces is undeniable, so it's not a perfect model given the emphasis reformers like myself place on cost controls. But nor is it clear that much of the R&D is productive, rather than profitable. Genuine advances in care technology would find a huge market under a nationalized system, and could be ushered in and tested through high-end private (supplemental) insurance. It's possible, though, that the very minor tweaks that allow Claritin to be renamed Clarinex and kept on patent won't prove a profitable R&D outlet anymore, and we'll all cry many a tear for the loss.

Meanwhile, the public sector already does an enormous amount of the innovative work anyway, and if it is indeed true that a restructured system would harm PhRMA's business model, we could easily move towards pumping more money into public research and creating, as Joseph Stiglitz has suggested, a prize structure, rather than patent structure, for medical research. It would probably be far more efficient, with far fewer perverse incentives.

Lastly, many of these medical innovation conversations take place on the cutting edge of care. That's how we're trained to think about all this. But the greatest gains in health aren't likely to come from that end. They'll come from better preventative services, electronic records and treatments systems like the VA's ViSTA program, wider access to basic care, and more testing and attention given to what care actually works. We currently spend an awful lot on treatments that do awfully little, and we'd do much more to improve health were we as intent on making sure every heart attack patient was given an aspirin when he reached the hospital as we are on getting them a bypass procedure. Our current system, sadly, doesn't have the financial incentives in place to emphasize such low-cost, high-value, treatments. Nevertheless, their implementation would do a lot more for health than the average innovation.

Posted by Ezra Klein at 3:02 PM | Permalink | Comments (9)

On the sharp decline in NIH funding, a reader explains:

I'll interject a perspective from a longtime researcher who has funded his research primarily via NIH. The problem with the 15% per year during Clinton to the near zero today under Bush is not that we or anyone else expects 15% per year increases. Rather, the very sharp pull back in funding creates a funding whiplash because grants that are funded in 2007 for example, typically run for 3-5 years. Thus, each awarded grant encumbers a proportion of future money. Money for new grants each year come essentially from grants that have run out and from budget increases. New grants are critical to young researchers. The current situation is one of the worst case senarios for how you fund research. That is, fund lots of new grants (during the 15% increases), and now essentially freeze the budget. In previous years, if your grant was scored in the top 20% of all grants, you were likely to get funded. These days, the lack on funding increases means that the pool of money for new grants is such that you must score near the upper 10% for many of the institutes (e.g., National Institute of Mental Health grants have flirted with an 8% payline).[...]

Researchers understand that funding is in the mix of priorities along with everything else, we're not looking for more 15% increases. But, the damage of the current situation is real. I have seen laboratories severely curtail their work, and the researchers go from writing 2 or 3 grants per year to 6-7 per year. This isn't productive, it generates alot of work for everyone, and draws us out of the laboratory where we would normally be doing much more productive work.

Posted by Ezra Klein at 8:50 AM | Permalink | Comments (10)

This is crazy:

Representatives from a consortium of major medical and scientific institutions testified at a Senate Appropriations Committee hearing on Monday that a lack of funding for grants at NIH has stymied scientific research, the Washington Times reports. In previous years, the federal health agency's budget typically increased by 15%. It grew by 2.5% in 2004, 2% in 2005 and one-tenth of 1% last year, for a total budget of $28.3 billion. The fiscal 2007 budget has yet to be released, but an increase of eight-tenths of 1% is projected for 2008, according to NIH figures. The researchers testified that NIH's recent funding levels have caused about eight out of 10 research grant applications to go unfunded and researchers to spend more time applying for grants than studying treatments for diseases.

I don't even know what to say. The NIH is, by all accounts, a remarkably successful government institution, and the research it funds has a proven track record of advancing science, spurring new treatments, and saving lives. And that doesn't even address the economic benefits of supercharging America's pharmaceuticals and biotechnology industries. But we're now slowing it's growth down to less than one percent...and for what? The war in Iraq? Deficit reduction?

Let's just be clear on this. Democrats, you listen up too. You do not reduce the deficit by defunding innovative research in growth industries. That's shooting yourself in the in the hip to spite your wallet.

Posted by Ezra Klein at 5:07 PM | Permalink | Comments (34)

New research suggests it might:

[Neuroscientist Charles Hillman] rounded up 259 Illinois third and fifth graders, measured their body-mass index and put them through classic PE routines: the "sit-and-reach," a brisk run and timed push-ups and sit-ups. Then he checked their physical abilities against their math and reading scores on a statewide standardized test. Sure enough, on the whole, the kids with the fittest bodies were the ones with the fittest brains, even when factors such as socioeconomic status were taken into account.

The old explanation for the possible linkage between brawn and brains was that a stronger heart could pump more blood, better oxygenating brain cells and keeping jocks sharp. Turn out it's a bit more chemically complex than that:

The process starts in the muscles. Every time a bicep or quad contracts and releases, it sends out chemicals, including a protein called IGF-1 that travels through the bloodstream, across the blood-brain barrier and into the brain itself. There, IGF-1 takes on the role of foreman in the body's neurotransmitter factory. It issues orders to ramp up production of several chemicals, including one called brain-derived neurotrophic factor, or BDNF...It fuels almost all the activities that lead to higher thought.

With regular exercise, the body builds up its levels of BDNF, and the brain's nerve cells start to branch out, join together and communicate with each other in new ways. This is the process that underlies learning: every change in the junctions between brain cells signifies a new fact or skill that's been picked up and stowed away for future use. BDNF makes that process possible. Brains with more of it have a greater capacity for knowledge....In unlucky people with a faulty variant of the gene that makes BDNF, the brain has trouble both creating new memories and calling up old ones.

Exercise, it turns out, builds those cells, and those who make the greatest cardiovascular gains in studies also build the most neural capacity. The growth tends to happen in the sectors of the brain governing memory, and thus retards the earliest cognitive declines of aging. Sadly, though, this appears to be limited to cardiovascular fitness. Weight-lifting, stretching, and toning does little to nothing for the brain, unless by "brain" you mean "how cut your abs are."

Posted by Ezra Klein at 10:54 AM | Permalink | Comments (16)

One real failure in the discussion over health policy is that it takes place largely among educated elites. So while I may not think patients have the training and judgment to always assume a leading role in their health decisions and others do, we're too often thinking of folks basically like us. Here's who we're not thinking about:

In a 2004 report, the Institute of Medicine defined health literacy as the ability to obtain and understand basic health information and services needed to make informed decisions. Low health literacy, the institute noted, affects an estimated 90 million Americans, who struggle to understand what a doctor has told them or to comply with treatment recommendations as essential as taking the proper dose of medication. A 1999 report by the American Medical Association found that consent forms and other medical forms are typically written at the graduate school level, although the average American adult reads at the eighth-grade level.[...]

A comprehensive national assessment of adult literacy conducted in 2003 by the U.S. Department of Education found that 43 percent of adults have basic or below-basic reading skills -- they read at roughly a fifth-grade level or lower -- and 5 percent are not literate in English, in some cases because it is not their first language.

So forget, for a moment, whether individuals have the interest or time to take charge of their treatment regimens. If 43 percent of Americans are reading at a fifth-grade level of lower, how many even have the capability? And how much damage will be done -- as in the article's example of a women who sought to save face and accidentally consented to a hysterectomy -- if we don't take these educational inequities seriously?

Posted by Ezra Klein at 2:33 PM | Permalink | Comments (37)

[litbrit speaking]

According to the United States Department of Veterans' Affairs--as its information page reads this morning, at least--Post Traumatic Stress Disorder (PTSD) is defined as:

An anxiety disorder   that can occur following the experience or witnessing of a   traumatic event. A traumatic event is a life-threatening   event such as military combat, natural disasters, terrorist   incidents, serious accidents, or physical or sexual assault in   adult or childhood. Most survivors of trauma return to   normal given a little time. However, some people will have stress reactions that do not go away on their own, or may even   get worse over time.

Insofar as the government asserts, some   60% of men and 50% of women (overall, both military and civilian) experience a traumatic event at some point in their   lives.  Assuming, of course, that all traumatic events are reported or somehow noted--which of course they aren't--one can still be forgiven for being alarmed that such a staggeringly high number of human beings are at risk for developing PTSD.  And of course, many human beings do heal on their own, handling trauma in ways that don't threaten the safety and well-being of themselves and those around them; they work through the shock, terror, grief, flashbacks, and sense of needing to be on guard at all times, and with time and support, they return to a point where they can sleep a reasonably normal length of time without waking from re-enactment nightmares or go to a noisy, crowded place without feeling overcome by irrational waves of fear or violent urges.

For far too many who've witnessed war's indescribable tragedies firsthand, though, the notion of healing is itself a phantom concept, a dream.  From The Real Cost Of War (currently at Playboy Online):

Continue reading "PTSD: Treating The Numbers, Not The Soldiers" »

Posted by at 1:09 PM | Permalink | Comments (17)

It might be argued that, at this point in history, we should simply accept that fast food is our food culture. Over time, people will get used to eating this way and our health will improve. But for natural selection to help populations adapt to the Western diet, we’d have to be prepared to let those whom it sickens die. That’s not what we’re doing. Rather, we’re turning to the health-care industry to help us “adapt.” Medicine is learning how to keep alive the people whom the Western diet is making sick. It’s gotten good at extending the lives of people with heart disease, and now it’s working on obesity and diabetes. Capitalism is itself marvelously adaptive, able to turn the problems it creates into lucrative business opportunities: diet pills, heart-bypass operations, insulin pumps, bariatric surgery.

There's similar chapter in The Omnivore's Dilemma about our treatment of cows. The short version of this is that we've taken an animal accustomed to feeding on forage and forced it to digest grain. Corn, after all, is cheaper, more plentiful, more engineerable, less land-intensive, and more subsidized than grass. But cows haven't evolved to eat corn. And so we drug 'em.

Bloat is perhaps the most serious thing that can go wrong with a ruminant on corn. The fermentation in the rumen produces copious amounts of gas, which is normally expelled by belching during rumination. But when the diet contains too much starch and too little roughage, rumination all but stops, and a layer of foamy slime forms in the rumen that can trap the gas. The rumen inflates like a balloon until it presses against the animal's lungs. Unless action is taken quickly to relieve the pressure, the animal suffocates.

A concentrated diet of corn can also give a cow acidosis. Unlike our own highly acidic stomachs, the normal pH of a rumen is neutral. Corn renders it acidic, causing a form a bovine heartburn...Acidotic animals go off their feed, pant and salivate excessively, paw and scratch their bellies, and eat dirt. The condition can lead to diarrhea, ulcers, bloat, rumentitis, liver disease, and a general weakening of the immune system that leaves the animal vulnerable to the full panoply of feedlot disease[...]

Cattle rarely live on feedlots for more than 150 days...Over time, the acids eat away at the rumen wallo, allowing bacteria to enter the animal's bloodstream. These microbes wind up in the liver, where they form abscesses and impair the liver's function. Between 15 and 30 percent of feedlot cows are found at slaughter to have abscessed livers...in some pens, the figure runs as high as 70 percent.

What keeps a feedlot animal healthy -- or healthy enough -- are antibiotics. Rumensen buffers acidity in the rumen, helping to prevent bloat and acidosis, and Tylosin, a form of erythromycin, lowers the incidence of liver infection. Most of the antibiotics sold in America today end up in animal feed...public health advocates don't object to treating the animals with antibiotics; they just don't want to see the drugs lose their effectiveness because factory farms are feeding them to healthy animals to promote growth. But the use of antibiotics in the feedlot confounds this distinction. Here the drugs are plainly being used to treat sick animals, yet the animals probably wouldn't be sick if not for the diet of grain we feed them.

When I first came across that passage, I was suitably shocked and outraged, and in fact stopped eating meat for a few months (a practice I've since been unable to maintain). It didn't occur to me that this strategy of using powerful drugs as health maintenance devices in service of an unhealthy but cheaper diet is precisely what we're all doing with Lipitor, and Tums, and all the rest.

Posted by Ezra Klein at 10:01 AM | Permalink | Comments (29)

Joe Paduda spanks the Manhattan Institute:

Conservative think-tank Manhattan Institute is the source of these statistics, which are based on their analysis of the financial impact on big pharma if CMS adopts the VA's pricing. The analysis is based on a faulty premise, uses a flat-out wrong methodology, and produces results that are, in a word, hysterical.

MI's lead expert, economist Benjamin Zycher, claims that drug companies would lose the incentive to do research if the Feds based their prices on the VA, and investment in new drug research and development would (therefore) decline by approximately $10 billion per year. In turn, this would mean about 10 fewer drugs per year.

In all of his research efforts, Zycher evidently did not bother to look at pharma investment in Europe, where countries negotiate for drugs directly with manufacturers (like the VA does, and restrict the formularies to boot). As a result their costs for brand drugs are about 60% of US costs. One would think that European pharma companies would therefore spend less on R&D. And one would be wrong; there's more investment by European companies, not less.

Posted by Ezra Klein at 10:24 AM | Permalink | Comments (31)

The New Republic has a fantastic article attacking the obesity myth. Paul Campos, the author, calmly and methodically details the misuse and misinterpretation of epidemiological studies to show that, contrary to what's often reported, being overweight (particularly according to the deeply flawed Body Mass Index) is possibly healthy, and the most important predictor in any case is cardiovascular fitness -- weight is merely a crude stand-in. But mistaking correlation for causation when it comes to fat is but half the story. The hysteria's intensity owes much more to our cultural repulsion towards flab and the massive industry that has arisen to combat it:

Americans think being fat is disgusting. That psychological truth creates an enormous incentive to give our disgust a respectable motivation. In other words, being fat must be terrible for one's health, because if it isn't that means our increasing hatred of fat represents a social, psychological, and moral problem rather than a medical one.

The convergence of economic interest and psychological motivation helps ensure that, for example, when former Surgeon General Koop raised more than $2 million from diet-industry heavyweights Weight Watchers and Jenny Craig for his Shape Up America foundation, he remained largely immune to the charge that he was exploiting a national neurosis for financial gain. After all, "everyone knows" that fat is a major health risk, so why should we find it disturbing to discover such close links between prominent former public health officials and the dietary-pharmaceutical complex?

The issue isn't fat, but fitness. Problem is, though we all "know" a sedentary lifestyle and junk food diet are unhealthy, we spend our time combatting what we perceive as the aesthetic end point of such habits, not the root causes. And then, through diet pills, eating disorders, and neuroses, we try to slim down without shaping up.

So what should we do about fat in the United States? The short answer is: nothing. The longer answer is that we should refocus our attention from people's waistlines to their levels of activity. Americans have become far too sedentary. It sometimes seems that much of American life is organized around the principle that people should be able to go through an average day without ever actually using their legs. We do eat too much junk that isn't good for us because it's quick and cheap and easier than taking the time and money to prepare food that is both nutritious and satisfies our cravings.

A rational public health policy would emphasize that the keys to good health (at least those that anyone can do anything about--genetic factors remain far more important than anything else) are, in roughly descending order of importance: not to smoke, not to be an alcoholic or drug addict, not to be sedentary, and not to eat a diet packed with junk food. It's true that a more active populace that ate a healthier diet would be somewhat thinner, as would a nation that wasn't dieting obsessively. Even so, there is no reason why there shouldn't be millions of healthy, happy fat people in the United States, as there no doubt would be in a culture that maintained a rational attitude toward the fact that people will always come in all shapes and sizes, whether they live healthy lives or not. In the end, nothing could be easier than to win the war on fat: All we need to do is stop fighting it.

That bit about genetics isn't nearly so certain as Campos suggests, but his general gist is sound. America is an unhealthy society, and that has helped make us a fat one. But from a public health standpoint, the problems are too much time at a desk, too much processed food, too many hours at work, too little walking, and a host of other socio-cultural-political elements that incentivize poor habits, not our waistlines.

Posted by Ezra Klein at 6:24 AM | Permalink | Comments (51)

Just to freak folks out a bit, angioplasties and stents -- two canonical treatments for blocked arteries -- are rapidly being proven worthless. Not totally worthless in every case, but given their frequency, pretty damn worthless. A similar thing, incidentally, is happening to bypass surgeries, which don't exhibit anything near an efficacy justifying their ubiquity.

Libertarian response: If consumers had more "skin in the game" (and by skin we don't mean actual skin, which is already "in the game," but more financial vulnerability), they'd demand more comparative studies and begin weeding out such ineffective treatments.

Paternalistic liberal response: It's been so hard to conduct studies on these treatments precisely because desperate patients adore their promise and doctors know they'd be considered monsters if they put unsuspecting individuals in a "control group" that was denied a treatment that soon proved effective. Patients are terrible at evaluating care -- look at the holistic health industry, and the limitless range of unproven supplements and treatments -- and skin in the game will always be overwhelmed by lives-on-the-line. On the other hand, if doctors lacked their current incentives for providing such intensive medical procedures, we could begin to make a dent.

Bipartisan response: In 100 years, a good half of our medical treatments will look to our descendants like leeches look to us.

Update response: And yes, leeches are back in use in very limited contexts. Much as the research shows angioplasties should be.

Posted by Ezra Klein at 10:29 AM | Permalink | Comments (16)

According to Laurence Wein, pandemic flu will kill us all. And hand-washing ain't gonna stop it. Indeed, researchers have apparently found that aerosol transmission -- where the virus in inhaled -- is dominant in influenza infection. That means hand-washing, which works against contact transmission, won't do much. So what're we going to do? Look ugly:

the single most effective intervention is face protection. And because roughly one-third of influenza transmissions occur before an infected person exhibits symptoms, these precautions should be taken whenever people are in the same room throughout the pandemic period.

There are two kinds of face protection: N95 respirators, as worn by construction workers, for instance, and surgical masks of the sort worn by dental hygienists. (The respirators cost roughly a dollar apiece, the surgical masks 10 cents.) Their efficacy in preventing aerosol transmission depends on three factors: the extent to which the face filter prevents virus particles from passing through, how tightly the device fits and — most important — how long people can be coerced into wearing them.

To our surprise, we found that the filters in surgical masks, although not as good as the filters in N95 respirators, are still quite effective. And although a surgical mask fits much more loosely and allows more leakage, it’s also more comfortable — and therefore likely to be effective because it’s used more. Wearing nylon hosiery over a surgical mask essentially eliminates the face leakage, making this combination a practical, albeit macabre, alternative. The less comfortable N95 respirators would probably result in lower compliance.

So surgical masks fitted with nylon hosiery. Well, at least STD transmission will fall as well.

Posted by Ezra Klein at 1:53 PM | Permalink | Comments (8)

Andrew Sullivan writes:

The next phase in the Medicare prescription drug entitlement is pretty obvious: the law will be changed soon to ensure that the federal government negotiate with drug companies for the price for the drugs. You can see the logic here at the DailyKos. Once you have laid the groundwork for a new entitlement, the full power of the state is involved. Once you have conceded the principle that all seniors should be able to get the latest drugs by borrowing other peole's money, it's weird to put any restrictions on demand - it will soon grow exponentially, and the "donut hole" will surely be removed by a future Congress. So we'll soon shift to a system of fantastically expensive free drugs of all kinds for all seniors and a crippling of the pharmaceutical industry's research and development arm. The trade-off will be complete: a collapse in research in return for free drugs for the most pampered senior generation in history. Those boomers still have clout!

We can only hope!

More seriously, fretting that centralized bargaining authority will "cripple" Big Pharma's R&D arm is silly. If Pharma ceases being in the top three most profitable industries in the country (#1 for over two decades straight!), maybe they can dial back on the advertising and administration spending, which accounts for about 250 percent more of their budget than research and development. Or maybe the government should just step in further, as they already fund 36 percent of all medical research in the country and taxpayer-funded work developed 15 of the 21 most important drugs introduced between 1965 and 1992. Another study, this one from 1990, looked at 32 drugs on the market and concluded 60 percent would've never been developed without public funds.

Yeah, socialism sure is sucky.

Moreover, the whole idea that centralized bargaining destroys the market is self-evidently silly. Ever heard of the military-industrial complex? Who do you think they're negotiating with? The American government. And you don't exactly see companies fleeing that sector. Meanwhile, Pharma sells to Canada (where prices are lower than they'll ever be here) and the VA, which pays between 50 and 80 percent less for its drugs than Medicare. And unless you think Pharma is in the charity business (or don't understand capitalism), they're operating in those markets at some profit, otherwise they would simply sell to America and let Canadians and veterans alike perish till they increased their compensation. The worst that'll happen is Americans will stop subsidizing a massive discount for Canadians, Brits, Germans, and all the rest.

And by the way, in case you're wondering how some of that R&D works, take a look at the cancer drug Taxol. Discovered by the NIH and licensed to Bristol-Meyers-Squibb, Taxol is sold for $20,000, costs $1,000 to produce, and the NIH gets .5 percent of the royalties. Some deal us taxpayers are getting.

Posted by Ezra Klein at 2:14 PM | Permalink | Comments (32) | TrackBacks (4)

By Kate

Always pay your prostitutes. (warning: blood and guts when you click on the photos inside the post)

Posted by at 2:17 PM | Permalink | Comments (6)

One thing I've always wondered about drug legalization plans: how do you deal with new drugs? Is it simply assumed that whatever concoction some teenage chemist cooks up and finds a market for can be quickly absorbed by private producers and put in stores? Does it need to go through FDA testing? If it does so and fails, then does it become illegal, creating the same old problems? Is there a patent process, so we'll have scores of researchers trying to create new substances with trippier highs and more addictive qualities? How does the patent process work -- or are recreational drug compounds placed in the public domain?

I am, generally speaking, a friend of regulated legalization, particularly the sort described in Stamper's op-ed. It does seem to me, though, that there exist a fair number of hurdles that aren't well overcome. With alcohol and tobacco already legal, there's no guarantee that legalizing other drugs will reduce the market for newly-discovered, still-illegal substances that offer new experiences, which might end with us trapped in the same old cycle.

Posted by Ezra Klein at 11:54 AM | Permalink | Comments (26) | TrackBacks (1)

Whether you're comfortable with America's gaping income inequality or not, I think we can all agree that this really shouldn't be happening:

People whose net worth is over $70,000, the median in the United States, are 30 percent less likely than poorer people to feel pain at the end of their lives, a difference that persists even when controlling for age and severity of illness, a new study shows.

The findings, which appear in the August issue of The Journal of Palliative Medicine, used information on more than 2,600 adults over 70 who died from 1993 to 1998. The researchers interviewed proxies, usually surviving spouses, to gather information about pain, depression, delirium and difficulties in breathing or eating at life's end.

Wealth was a strong predictor of how many different types of discomfort an older adult suffered, with those whose net worth was over $70,000 having a 9 percent lower risk of experiencing multiple symptoms.

There's much in life that I think is perfectly justified in being dependent on income. How nice your TV is, or how many square feet are in your home. Whether you drive a Corolla or an Avalon.

But not death. Never death. Working for low wages should not mean more pain, depression, and suffering than working for high wages. It should not mean worse medical care and fewer end-of-life options. Let the rich have vacations and homes and cars and cruises, but only if the poor have dignity and relief. At the end of their lives, we at least owe them that.

Posted by Ezra Klein at 2:45 PM | Permalink | Comments (29)

File under "That's Freaky":

It was a dispute over whether the cortex ever makes any new cells that got Dr. Frisen looking for a new way of figuring out how old human cells really are. Existing techniques depend on tagging DNA with chemicals but are far from perfect. Wondering if some natural tag might already be in place, Dr. Frisen recalled that the nuclear weapons tested above ground until 1963 had injected a pulse of radioactive carbon 14 into the atmosphere.

Breathed in by plants worldwide and eaten by animals and people, the carbon 14 gets incorporated into the DNA of cells each time the cell divides and the DNA is duplicated.

So a variety of nuclear tests 40-some years ago blasted enough radioactive carbon into the atmosphere that we all carry bits of it in our DNA.

It's really a wonder that humanity hasn't destroyed itself yet.

Posted by Ezra Klein at 9:16 PM | Permalink | Comments (10)

For the last few years, there's been a fair amount of talk about the medical power of prayer. A few interesting studies came out saying there might be some positive benefit and the excitement swelled from there, hitting every pulpit and spiritual book in the nation. But this week, a study of cardiology patients pretty well disproved it:

The study of more than 700 heart patients, one of the most ambitious attempts to test the medicinal power of prayer, showed that those who had people praying for them from a distance, and without their knowledge, were no less likely to suffer a major complication, end up back in the hospital or die.

I've never resented the hope that prayer could heal -- that's merely human. But the idea that it could, particularly in the scattershot way the other studies showed, always seemed fairly problematic. So if you pray God makes the ill 5-10% better? And He only does that for some of them? And what of the lonely, who have no one to pray for them? It almost seemed more theologic trouble then it was worth.

Posted by Ezra Klein at 10:58 AM | Permalink | Comments (25) | TrackBacks (1)

With all the hubbub, hullaballoo, a kerfluffle recently generated by unsafe, massively popular meds, a handful of our major pharmaceutical companies have begun posting their full, uncensored trial results on the web. Full transparency, the market calls it. But Merck and Pfizer, citing "competitive pressures", haven't followed suit. As Kate notes, this poses a problem as Merck's Vioxx, more than any other drug, is the one that started this rush to transparency by proving itself unsafe. And those competitive pressures Merck is citing really don't make sense. Indeed, competitive pressure would logically demand that they match their competitor's move towards transparency. At least, that's what it'd demand if doing so wouldn't cause grievous harm to the company. So all this calls into question exactly what Merck's internal trials have been showing. It's not the most reassuring move if you swallow any of Merck's products.

Further, and correct me if I'm wrong, but couldn't the FDA force this information forward? Or couldn't a congress that doesn't call Big Pharma's pocket "home" legislate that this information needs to be in the public domain? After all, if the Republicans really do want consumer-driven healthcare, consumers will need access to the data and studies that'll allow them to make wise, informed choices. If competitive pressures are keeping those results locked in a silo somewhere, one would think it would behoove legislators to pressure them out into the light and prove that patients can take an active role in their own health.

On another note, speaking of Kate's site, this really was in the top 5 funny things to ever happen to me.

Posted by Ezra Klein at 10:21 AM | Permalink | Comments (9)

Kate catches doctors surrendering to their inner capitalist and accepting the practice of giving project funders -- often pharmaceutical companies -- full control over their research projects. That means control over design, what's studied, how the material is presented...the whole deal. Why is this so attractive in such a service-oriented profession? She explains:

researchers at medical schools are often responsible for coming up with their own project funding after their first couple years on staff. Many will turn to pharmaceutical comapanies and other for-profit entities to foot the bill. This just perpetuates the conflict of interest cycle, from the researcher's petri dish to the doctor's prescription pad -- Big Pharma has their hand in all of it.

So there's a funding gap in research, researchers need funding to do their job, and Big Pharma altruistically steps into the void, with a few little sub-clauses. Another win for the magical market, I guess.

Posted by Ezra Klein at 6:07 PM | Permalink | Comments (6)

Rich Tucker writes about the link between vaccines and autism in children, and subsequently recommends that we slow down the rate of vaccination for young children.

Not being that well versed in the vaccine/autism link, I thought I might have misremembered, but I didn't - the area of conflict is over the use of thimerosal, a mercury-based vaccine preservative. It has little to do with how rapidly the vaccines are administered, but instead whether or not they include a dangerous preservative. If cars get in crashes (to borrow his analogy), you don't ban cars - you make driving safer. Vaccines (presumably) existed without mercury preservatives, and (presumably) can exist without them again - just as the potential to crash your car doesn't require you to ram it into something.

-Jesse Taylor

Posted by at 8:58 PM | Permalink | Comments (16)

In Krugman's otherwise good article on bargaining for pharmaceuticals, he makes a really poor argument on a really important point:

Needless to say, apologists for the law insist that the prohibition on price negotiations had nothing to do with catering to special interests - that it was a matter of principle, of preserving incentives to innovate. How can we refute this defense?

One way is to challenge claims that the pharmaceutical industry needs high prices to innovate. In her book "The Truth About the Drug Companies," Marcia Angell, the former editor in chief of The New England Journal of Medicine, shows convincingly that drug companies spend far more on marketing than they do on research - and that much of the marketing is designed to sell "me, too" drugs, which are no better than the cheaper drugs they replace. It should be possible to pay less for medicine, yet encourage more real innovation.

Sigh.  That's not an important comparison, though.  The drug companies are saying reimportation from Canada will make new, expensive drugs less profitable to produce and thus diminish the incentive to produce them.  Whether or not they break the bank on marketing isn't really an issue here.  Here's what is an issue: drug company R&D is rarely spent on the life-saving, critical medicines that we imagine. 

Much of it goes towards "me-too" drugs, slight variations of popular, existing medications that don't increase their effectiveness at all, but allow drug companies to evade their competitors patents while still using their competitor's latest innovations.  So assume one company brings out a new, powerful, statin drug.  The others will rush it back to the labs, figure out how to change a few molecules in order to call it to evade the patent while retaining the effect, put it in for testing and, so long as it works better than the placebo, the FDA will approve it.  That, of course, is where the marketing comes in.  Since they've all got the same drugs -- and if R&D were truly on such shaky grounds, this would be the problem, not drug reimportation -- they have to use advertising strategies to get a leg up in the market. 

In addition, most of the research is done on the same few ailments, particularly those that offer high profits.  Now, that's often positive -- our society is better off with blood pressure, heart disease, and arthritis medications.  But you're seeing enormous redundancies at work, and it's much to the detriment of rarer, tough illnesses.

Continue reading "Crying Wolf" »

Posted by Ezra Klein at 12:20 PM | Permalink | Comments (14) | TrackBacks (1)

Watching David Brooks and John Tierney both race to write the same column extolling the virtues of obesity and mocking liberals for denying themselves cheeseburgers was pretty funny. Did no one warn David that Tierney got there first? Does David not even read his conservative competitor? Seems that the Times token righties need to coordinate a bit better.

But it was also sad to watch two supposedly powerful conservative minds use some of the most read newspaper real estate in the world to misinform their readers in the exact same way and in service on the exact same agenda. So let's get something straight: the study did not tell you to get fat. It did not tell you to get a little fat. It did not, in fact, tell you to do anything at all. We're dealing with observational data that's widely available and the authors are trying to divine a connection between weight and mortality rates from it. We're also focusing on the rate of death, rather than disability and disease (as the Times article on the study -- though not its op-eds -- notes, the connection between excess weight and diabetes, high blood pressure, and high cholesterol in undeniable). And what, exactly, did the study find?

Well, folks whose BMI rests in the normal category provided a baseline mortality, i.e, their death rate is considered the "normal" death rate. Folks in the overweight, though not obese nor extremely obese categories, die less than their "normal" counterparts. The obese, the severely obese, and the underweight die more than everyone else. Why?

First you've got to look at the basic measure used, the BMI. The central mistake of Tierney and Brooks is believing that the BMI is a body fat test. It's not. Instead, it's a purely mathematical calculation that takes your weight, divides it by your height in inches squared, and then multiplies the product by 703. So to give an example, my weight is 188. I'm about 72 inches tall (calculate yours here). So my BMI is 25.5, a shade into the overweight category (which goes from 25-29). But am I overweight?

Now things get interesting. I've lifted weights regularly since my first year of high school, making me a fair bit stronger than most folks. I also have a body fat scale, a relic from when I lost 50 pounds as a high school sophomore (I was a fat kid). My body fat is regularly around 15-16%, which'd put me in the "fitness" category, a good 10% under obesity and 3% under the beginning of "average". So I'm not overweight given my body's composition, but I am a bit overweight if judged via my height-to-weight ratio. To restate, I'm not overweight, but I am if the BMI is used.

Continue reading "Correlation is Not Causation" »

Posted by Ezra Klein at 2:22 PM | Permalink | Comments (14)

Speaking of alarmism, this Marburg virus sure is scary. Big ups to Angola for doing nothing. Big ups to the tribal chiefs for inciting violence against epidemiologists who are risking their lives to help. Big ups to the radio speeches accusing hospital heads of creating the virus through witchcraft so they can get a promotion. Big ups to tribal superstition and customs which won't allow the sick to be quarantined nor the dead to be isolated. It's much more than tragic to watch such a ravaged country bring so much more pain on itself -- it's just unbelievably sad.

But I'm inspired by the epidemiologists and WHO workers and others who've parachuted into one of the most inhospitable countries and climates earth has to offer in order to confront one of the ugliest, deadliest diseases we've ever seen. That's not just dedication, that's towering courage. They're all heroes. And I sure hope they stop this thing.

Posted by Ezra Klein at 2:05 PM | Permalink | Comments (99)

Brad's point that:

The way things are going, in the future people are going to be choosing to spend X percent of their income on health care. X will get larger and larger over time, by choice. So let's say X is 40 percent. From one standpoint, it really doesn't make a difference whether you pay 40 percent of your income for private health care, or 40 percent of your income in taxes that then go to government-administered health care.

That's a very specific standpoint Brad's using. Because paying for government-provided health care leaves you in an enormous pool that guarantees you access to these procedures, no matter their cost and no matter your income. Private insurance, however, is different. If you want comprehensive health care, you have to buy into (or have your employer buy into) pretty expensive plans. For many, that much income simply cannot be spared and, thus, they simply won't have access to many of those treatments. To even try and get close to the top plans, poorer workers won't be paying out the same percentage of their incomes as richer workers, they'll be spending much, much more. The reason single-payer is worthwhile is precisely because everyone pays out roughly the same percentage of their income (with some income brackets a bit more and some a bit less) and receives comprehensive care in return.

Update -- The more I look at this post, the more I think I have Brad's point wrong. He knows health care way better than I do, and wouldn't have overlooked this. So I suggest reading his post in full, as I'm well open to other interpretations of it.

Posted by Ezra Klein at 3:10 PM | Permalink | Comments (12)

This is the worst news we've had on HIV in a long while:

On Friday, New York City health officials issued this chilling announcement: A man is infected with a form of the AIDS virus that is not only resistant to three of the four classes of anti-HIV drugs, it is apparently so virulent that it causes full-blown AIDS in a matter of weeks rather than the usual decade or more. It will be super-difficult to treat, and it may be a super-fast killer.

New York City Health Commissioner Thomas Frieden first heard of the case on Jan. 22. Tests showed that the man had been infected for only a short time.

Frieden prudently had samples of the mysterious virus assessed by two independent labs. Both labs confirmed that it is resistant to all three of the classes of pill-form HIV drugs and that it attacks its victims with what are called CX4 cellular receptors, which are typically found only in those infected with HIV for a long time and in advanced stages of AIDS.

There is more bad news. The man is the victim of another U.S. epidemic — methamphetamine use. While high and uninhibited, he had sex with more than 100 men over the last two years, often without using a condom. And he recalls little about those encounters — certainly not the partners' names and addresses. There is little hope of tracing the virus, of studying the strain's transmission, of warning the victim's partners or stopping them from having more unprotected sex.

Read the whole thing.

Posted by Ezra Klein at 5:43 AM | Permalink | Comments (28)

Brad Plumer jumps on a hobbyhorse of mine, namely, the need to build more medical schools. There are a mere 125 in the nation, and the competition is so intense that a B here and there disqualifies you. Fast forward a few years and doctors are so overloaded that they make patients wait hours but can only offer them minutes. Residents are in such high demand that they work inhuman shifts and their exhaustion leads to mistakes. Sounds like we need a supply increase.

Further, can anybody explain why the pre-med track makes sense for anyone who wants to be a primary care physician? In that job, which mainly consists of treating basic cases, reassuring harried parents, and referring complex problems, interpersonal abilities are the most important attribute. Yet the training ground is an absurd load of sciences that prizes the workhorses above the socially-adept. Maybe we can create a separate track for those wanting non-surgical, non-specialized, non-research based practices? Maybe we can codify Nurse Practitioners (who I've always found to be excellent, often superior, doctors) into an education path? What say you, world?

Posted by Ezra Klein at 1:00 PM | Permalink | Comments (14)

Be afraid. Be very, very afraid.

Posted by Ezra Klein at 2:15 PM | Permalink | Comments (10)