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Archive for the ‘Public Health’ Category

An excellent post from a fantastic blog, Get Rich Slowly:

Beggars are a moral quandary for me. I want to help. In an ideal world, I’d help them all. Or I’d at least help those who are legitimately in trouble. But how can I tell which beggars are truly needy, and which are just going to use the money for booze or pot? Does it matter? And who am I to judge?

It might seem silly to write about this — it’s such a trivial part of personal finance (if a part of it at all) — but I think it presents important moral implications. I know many people are opposed to giving money to beggars ever, and I cannot blame them. I’m always reminded of one of my favorite Bible passages, the parable of the Sheep and the Goats (Matthew 25:31-46), which reads in part:

For I hungered, and ye gave me no meat: I was thirsty, and ye gave me no drink: I was a stranger, and ye took me not in: naked, and ye clothed me not: sick, and in prison, and ye visited me not. Then shall they also answer him, saying, Lord, when saw we thee hungered, or athirst, or a stranger, or naked, or sick, or in prison, and did not minister unto thee? Then shall he answer them, saying, Verily I say unto you, Inasmuch as ye did it not to one of the least of these, ye did it not to me.

The comments I posted in that blog:

The Sheep and Goats parable is troubling. It is easily to justify not giving by making judgments like “they probably use it for drugs,” but I don’t think that is what God intended. The Bible doesn’t tell us to try to figure out the scammers, it just asks us to give what we can. There is an ultimate judge, and I try to trust that the scammers will get what they deserve, and those who are not scammer will find some measure of comfort.

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The New York Times is reporting today about how Medicare changes that were planned are being reversed.  I guess it’s a fancy way of saying that nothing has changed.

The “scale back” (lack of change) was argued as being a good thing.  In particular, the new payment system would have made heavy cuts into the payments for cardiac coronary artery drug-eluting stents, defibrillators, and other “newest technology.”  The New York Times cites a number of analysts:

“The final rule significantly moderates proposed cuts for cardiac procedures,’’ Citigroup said in a note to investors. Lehman Brothers described the final rule as “a win for cardiac and orthopedic device companies, specialty hospitals and general acute care hospitals.’’ The Prudential Equity Group said the final rule, which takes effect on Oct. 1, was “favorable for device manufacturers’’ like Boston Scientific, Medtronic and St. Jude Medical.

The part that concerns me, however, is what follows:

“Under the final rule, hospitals will receive much smaller increases than originally proposed for treating some conditions, like pneumonia and chronic obstructive pulmonary disease.”

The issue I have is with the assumption that the newest technology represent the best of medicine.  As a self-proclaimed gadget geek, this might surprise you, but it is not entirely clear that the latest findings are the best and most accurate.  In particular regarding devices, very few of these have good long term studies showing safety and efficacy.  In fact, by their very nature, because they are new technologies, nobody truly knows what is going to happen 20 years down the road.

Medical devices, unlike other technologies, don’t automatically improve.  Windows XP (no matter how bad) is better than Windows 95, is better than Windows 3.1, but it’s not clear if the new hip device is worth 50% more than the old hip device.  This goes hand-in-hand with the fact that a major reason for rising health care costs in this country for the past 20 years is due to medical technology such as these.

I’m not down on medical devices in general.  The innovation of these companies is commendable.  I just worry that the “new technology” is taking precedence over tried and true technology such as antibiotics.  I worry that innovation is being steered away from less profitable fields like pulmonology and into fields flush with money such as cardiology and orthopedics.  In my hospital, I can already see that the patients who have “high-paying” problems generally get preference, and these payment structures only exaggerate the multiple-tier system.

I suppose these payment systems are examined by people smarter and better informed than me.  I am happy that the health care field is getting money, I just wonder if it is going to the right place, and whether we are creating the proper incentives for innovators within our field.
The complete article, as usual, is below:

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From our friends at the New York Times:

(Given that links sometimes die, i’m posting a copy of the entire article).

p.s. I will vouch for the fact that the slow churned ice cream is excellent.

The article is reproduced below:

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Another article from the New York Times. Many physician joke that the health section is the only medical journal they read. Most of the time, it’s only a joke.

The article discusses a case of a family winning a case against Johnson and Johnson for the tune of $772,500 after the patient had an unexpected death thought to be due to overdose/defect of a duragesic (fentanyl) patch. I’m not sure if the patches were actually defected, and I certainly agree that the death of a such a young woman is indeed tragic. It’s not clear if the jury knew if the defect existed or not as well. It is also not clear if the patient died due to intentional (but misguided) overuse.

My concerns regard the reverberations of this case. According to the article:

“Johnson & Johnson, based in New Brunswick, N.J., added warnings to the patch’s label last July, saying doctors should not prescribe them for patients who cannot tolerate similar drugs or who might be prone to abusing them.The patches, introduced in 1990, release the opiate fentanyl through the skin. Researchers say fentanyl can cause addiction or death in some users.”

Vague terminology like “some” and “might” are entirely unhelpful guidelines.

The medical field tends to undertreat pain, and duragesic patches have done wonders toward relieving pain to thousands if not millions of patients in the US suffering from intractable pain. However, the “guidelines” put out by Johnson and Johnson are just broad statements designed to protect themselves from lawsuits and push the liability onto the physicians that prescribe them. If JNJ seriously thought that fentanyl patches are dangerous to an undefinable segment of the pain-suffering population, perhaps they should pull the product entirely. Of course, they don’t do anything such as that.

This practice is all too common, and physicians have found themselves in a bind as pharmaceuticals create unhelpful guidelines without the best interest of the patient in mind. Many medications are used routinely as “off-label,” and are considered standard of care and best practice. The problem is that a drug only can become FDA approved for that indication if the company applies for it. At times one will find a disconnect where the medical research clearly shows the benefit of the drug and the company simply does not apply to get the medication “officially approved” for that reason.

In the end, it is because of these kinds of lawsuits that JNJ has to charge so much money for their drugs to cover their costs. It is because of these lawsuits that they make statements to push away liability. It is because of these lawsuits that doctors pay high malpractice premiums and eventually leave practice. It is because of these lawsuits that the United States is spending 16% of it’s GDP on healthcare, even as over 40 million people don’t have health insurance.

Time to get off the Saturday morning soapbox….

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The article from the New York Times today reports on how there will be an exemption on the new law that requires documented proof of citizenship on application for Medicaid. The part that really struck me was a section in the middle:

“The new documentation requirement is part of the Deficit Reduction Act, signed by President Bush on Feb. 8. It is meant to stop the “theft of Medicaid benefits by illegal aliens,” in the words of Representative Charlie Norwood, Republican of Georgia, a principal author of the provision.”

The attempt to withhold care to certain populations is rather mind-boggling. The truth is that society pays for the care of these patients, one way or another. Furthermore, study after study shows that paying for whatever outpatient care they need is cost-effective…. you can give a patient 20 expensive medications for months and the cost still would not equal a single night of stay in an intensive care unit (ICU).

If these patients don’t get outpatient care, they clog up the ER. Yes, yes, I know the studies that show that ERs are clogged by non-underserved people as well. Sick people is bad for productivity, bad for the economy, and is a public health hazard. What happens if the government refuses to pay? The hospitals will take the hit at first, and they’ll have to bill those who can pay in order to make ends meet. If they can’t, they will close down, and not provide care to anyone. Eventually, the government will have to bail them out, thus costing more taxpayer money.

The evidence is there. Also see another article regarding a homeless drunk housing project in Seattle. It’s simply cheaper to take care of these people. It is a social good. We don’t have to like them, but we have to realize that by ignoring them and pretending that they don’t exist, we’re costing ourselves a whole lot of money.

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