The latest edition of the Health Wonk Review is available at Joe Paduda’s Managed Care Matters.
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Fentora Deaths
In “The killer drug,” Joe Paduda of Managed Care Matters discusses how four deaths caused by the off-label use of Fentora have had Fentora-manufacturer Cephalon in crisis control. Mr. Paduda claims that Cephalon is known for aggressive marketing to physicians regarding the of off-label uses of their pharmaceuticals.
Why would Nigerians boycott a polio vaccine?
It seems like Africans don’t know what’s best for them. They fear that the vaccine would make them infertile. Shouldn’t they trust Western medicine more than their local health treatments?
If past experience is a guide, probably not.
The Washington Times (“Nigerians suing Pfizer…“) and AllAfrica.com (“…Pfizer…“) report on the 1996 tragedy in Kano, Nigeria. In 1996 there was a Meningitis outbreak in the northern-Nigerian city of Kano.
“The firm, it is alleged, broke all the rules of ethical conduct to rush its doctors and a controversial new and unapproved antibiotic, Trovan, into a rural and crisis-torn area to try the product in a way which was forbidden under international rules.”
Now Pfizer is being sued in four different court cases related to the 11 deaths and 189 injuries cause by Trovan. The case has seriously hurt the reputation of Western medicine in Nigeria and may be the reason locals were hesitant to receive the polio vaccine.
Ahmad Nadabo offers a level-headed argument on the Kano case. He claims that if Pfizer misbehaved, then the myth of the evil first world corporation manipulating third world countries (e.g.: The Constant Gardener) would be fulfilled. Further:
“It is possible that Pfizer did everything that the prosecution alleges. It is possible that everyone lied their heads off and was complicit in an illegal and immoral drugs trial. The medical authorities in Nigeria may have conspired with Pfizer’s employees and stooges to pull off the multinational’s scheme. It is possible because anything is possible. It is also likely that Pfizer did not rush to the outbreak solely because it believed its drug could help the victims. It is very likely that Pfizer also believed that this was an entirely valid and safe trial and that it operated in good faith. It may yet be widely accepted that undertaking it helped children suffer less.
All that can get thrashed out in open court. But we need to remember this. Big firms are not on the whole wicked or even especially devious. We need them and we need to remember that they are not aliens, villains or even strangers. They are seldom heroic philanthropists and we are fools if we expect them to be. So as Pfizer’s behaviour comes under magnifying glass, let’s remember to be fair as well as vigorous in our scrutiny.
Sean Carroll, a physicist at California Institute of Technology, has some interesting comments regarding how economists use the utility function in a post titled “So what have you been maximizing lately?“Â For instance, here are his musings on ‘rational choice’:
If the job of science is to describe what happens in the world, then there is an empirical question about what function people go around maximizing, and figuring out that function is the beginning and end of our job. Slipping words like ârationalâ? in there creates an impression, intentional or not, that maximizing utility is what we should be doing â a prescriptive claim rather than a descriptive one.
There is an interesting article from Sunday’s N. Y. Times magazine (“…what makes us healthy?“) about the problems in epidemiology of using non-randomized data to draw conclusions. For instance, there is much uncertainty as to whether hormone-replacement-therapy increases, decreases or has no effect on the probability a woman will have heart disease.
The article talks about a few important biases which occur when researchers analyze observational data:
- Healthy user bias. People who faithfully take recommended pharmaceuticals, are more likely to take better care of themselves (i.e.: eat a healthier diet, exercise more, go to doctor for regular check-ups). Thus, researchers may erroneously conclude that a people who take a certain drug become healthier, when in fact it is really the case that healthy people are the ones who are using the drug.
- Compliance bias. People who comply with the doctors orders may also be different than those who do not comply. The author cite a Coronary Drug Project study which found that “…faithfully taking the placebo cuts the death rate by a factor of two.”
- Prescriber Effect. A physician may prescribe statins to a healthy patient in order to lower their cholesterol. On the other hand, “a physician is not going to take somebody either dying of metastatic cancer or in a persistent vegetative state or with end-stage neurologic disease and say, ‘Let’s get that cholesterol down, Mrs. Jones.’ The consequence of that, multiplied over tens of thousands of physicians, is that many people who end up on statins are a lot healthier than the people to whom these doctors do not give statins.”
There are also some interesting comments on Seth’s blog.
Recently I came across two Washington Monthly articles in their Health Care Issue which are both very interesting.
The first (“Newtered“) by Shannon Brownlee talks of the lack of evidenced based medicine in the U.S. In the mid-1990s, the Agency for Health Care Policy and Research (AHCPR) panel concluded that there was little evidence to support surgery as a first-line treatment for low back pain; non-surgical treatments should be tried first. The back surgeons, understandably, were upset by this finding and decided to start lobbying Congress. What happened next?
The agency’s name soon appeared on a House Budget Committee “hit list” of 140 federal programs targeted for elimination. (The list also included the congressional Office of Technology Assessment, which evaluated the effectiveness of medical technology.) The Republicans saw the AHCPR as a wasteful government agency, and in 1995 the House voted to eliminate its funding, calling it the “Agency for High Cost Publications and Research.” Eventually, the agency was rescued with the help of a handful of Republican supporters in the Senate, but it suffered a 21 percent cut of its already meager $159 million budget.
The article gives another example:
Just this August, the Washington Post reported that the Department of Health and Human Services, under heavy pressure from the infant formula industry, had buried the AHRQ’s comprehensive finding that breast-feeding leads to better health in babies.
What is Ms. Brownlee’s solution? To create a new agency–which she names ACE–which “would fund systematic reviews of the medical literature, as well as clinical trials to test the comparative effectiveness of everything from drugs to treatments.” This agency would have to be independent of political pressure, like the Federal Reserve.
I agree that having government research agencies is important, but we already have the Agency for Healthcare Research and Quality (AHRQ). Insulating any government agency from lobbying or corruption is always difficult and I no sure that making the agency unaccountable to public opinion or politicians is the answer. Is the answer to bad government more government?
The second article (“Best Care Everywhere“) by Phillip Longman argues for a nationalized version of the Veterans Affairs health care system, which he names Vista.
Uniquely among U.S. health care providers, the VA has a near-lifetime relationship with its patients. This, in turn, gives it an institutional interest in preventing its patients from getting sick and in managing their long-term chronic illnesses effectively. If the VA doesn’t get its pre-diabetic patients to eat right, exercise, and control their blood sugar, for example, it’s on the hook down the road for the cost of their dialysis, amputations, blindness, and even possible long-term nursing home costs. Unlike the vast majority of American health care providers, the VA also has no incentive to perform unnecessary surgery or redundant tests. Where other health care providers make money by treating patients, the VA makes money by keeping them well.
The author proposes that an individual health insurance mandate. While ideologically I am not in favor of health insurance mandates, they do make some sense if the uninsured can 1) save money from not purchasing insurance while 2) still receiving free care at non-profit clinics or emergency rooms. Wisely, the author will offer subsidies to low-income individuals so they will be able to purchase insurance. The Vista program will not be the only health care option–private health insurance will still be available–so competition between Vista and the private market should drive down cost and increase quality. Mr. Longman proposes that “…any person in the Vista system who gets a job with health insurance should be allowed to direct his or her company to pay premiums to the Vista system if that person wants to remain in the system.”
One problem with this idea is that the VA current policies are based on serving the patient over their entire lifetime. If the VA was nationalized and people could switch to private health insurance, then the incentives for preventative care would be greatly reduced if there were moderate amounts of turnover. Further, Longman envisions Vista being run by an independent board appointed by the President–similar to the Federal Reserve Board. Yet, would insulating the medical board from public opinion/politics really be the correct thing to do? Having a government or health care system run by partisan politicians may not be optimal, but neither is having a health care system run by technocrats who have no accountability to the public.
I am very amenable to having a basic healthcare package available to all Americans as long as each person has the choice to opt to purchase their own insurance if they please. I also find a health insurance mandate reasonable. We must, however, eliminate poverty traps such as currently exist in Medicaid. If working more and increasing my income by $5000 will cause me to lose my Vista subsidy, the health insurance program will have serious work disincentives. Thus, the health care subsidies must take these issues into account. Vouchers may be a more reasonable solution.
What is your favorite presidential candidate’s solution to the “health care crisis?” The Kaiser Family Foundation has a great resource on its health08.org website. The site offers links to each candidate’s website where they discuss their health care policy. Unfortunately, there is no analysis of the candidates’ plans, but the site is an unbiased source of information.
In a follow-up to my “No hip replacement for you, fatso!” post, the Daily Mail reports that in Britain”Doctors refuse to fix builder’s broken ankle unless he quits smoking.”
John Nuttall, 57, needs surgery to set the ankle which he broke in three places two years ago because it did not mend naturally with a plaster cast. Doctors at the Royal Cornwall Hospital in Truro have refused to operate because they say his heavy smoking would reduce the chance of healing, and there is a risk of complications which could lead to amputation. They have told him they will treat him only if he gives up smoking. But the former builder has been unable to break his habit and is now resigned to coping with the injury as he cannot afford private treatment…
Mr Nuttall states…”I have paid my dues as a taxpayer-and now the NHS won’t treat me.”
Wal-mart recently released the details of its new health plan for 2008 (see company press release or the Houston Chronicle article). Here are some highlights of the plan.
- Employees now have “50 ways of customizing their health care coverage options…a substantial increase from last year, when most associates had only nine choices.” However, it seems that the employees will not be able to choose different coverage options (i.e.: what medical procedures are covered), but can only alter their insurance on the dimensions of the deductible/health care credit and thus their premium. More choices may be good, but it also may create an adverse selection death spiral in which the more generous plans become more and more expensive in the future.
- All Wal-mart employees will have deductibles (up to $2000 in the case of the cheapest plan), but employees will also receive a health-care credit of $100, $250 or $500. I believe that that the reason for the credit is so that employees don’t forgo, low cost preventative measures (e.g.: regular doctor check-ups, immunizations) simply because they would have to pay out of pocket.
- There is no maximum insurance coverage which is good. Insurance is made alleviate the risk of large-scale medical problems.
- Their plan offers $4 co-pay for over 2,400 covered generic prescriptions.
The Houston Chronicle reports:
As of the start of this year, 47 percent of Wal-Mart’s 1.34 million U.S. employees were enrolled in company coverage, compared with 46 percent a year earlier and 43 percent at the start of 2005.
Wal-Mart has said most of the remainder are insured through other plans, such as a spouse’s or a second job. That justifies its contention that 90 percent of employees have health coverage.
I am not sure whether this 90% figure is reliable. It may count spousal coverage, but may also include those on Medicare or Medicaid, which would mean that John Q. Public would be footing the bill for these employees and Wal-mart should not implicitly take credit for providing insurance to these employees.
Is this good?
Having Wal-mart offer health insurance is not an unequivocal good thing. When Wal-mart offers affordable health insurance plans, that means that Wal-mart will be a more desirable place to work. The supply of individuals willing to work for Wal-mart will increase and thus the wage of Wal-mart employees will decrease. In a reality with sticky wages, wages will likely not decrease, but the rate of increase of future Wal-mart employee wages will be lower than the wages of similarly-skilled employees working at companies without health insurance. Risk loving people will not appreciate that some of their wages are taken to pay for health insurance. Risk averse individuals–which likely represent the majority of Americans–will fully value the increased health benefits and will not mind a slight wage decrease. Further, because of Wal-mart’s buying power, they will receive less expensive, more comprehensive health care costs than they would have on the non-group market.
While a single payer universal health care system will likely increase equality in the U.S., it will also likely lead to gross inefficiencies. For example, see Monday’s USA Today (“Medicaid Drug Rule“). A new rule was enacted which attempts to reduces the amount of fraud in physician prescribed drugs. The law–whose backers claim will save the government $150 million–offers the following solution to the problem of Medicaid patient overuse of prescription drug: tamper-resistant paper.
Yes, the federal government is legislating the type of paper physicians can use to write prescriptions. According to the article, the law
“…requires that all non-electronic prescriptions for Medicaid patients be written on tamper-resistant paper…[doctors, pharmacists and patient advocates] warn that pharmacists could be forced to return Medicaid payments if they fill prescriptions improperly, and patients could be denied medications if the prescriptions aren’t written on tamper-resistant pads.”
This is one way that single payer systems can reduce costs: by making it more and more difficult for patients to actually receive the care they desire.
How do market forces affect the safety of children in hospitals? A paper by Smith, et al. (HSR 2007) looks at data from Florida, New York and Wisconsin and they see if Medicaid market concentration affects quality of care for children aged 0-17. It is important to examine Medicaid’s affect on patient safety since about 40% of all pediatric hospitalizations are charged to Medicaid. Recent developments have lead to a variety of Medicaid programs.
Since the early 1990s, most states, with increasing flexibility granted by the federal government, have transferred Medicaid-eligible children into managed care programs as a way to improve access to preventive services and to reduce health care expenditures. Between 1991 and 2004, the proportion of Medicaid recipients enrolled in managed care plans increased from under 10 to over 60 percent.
Using data from the State Inpatient Databases (SID) and the Healthcare Cost and Utilization Project (HCUP), the authors calculate the Herfindahl-Hirschman index (HHI) for both Medicaid-payer and hospital concentration. The hospital data is adjusted for available technology using the ‘Saidin Index’ and DRG diagnoses are used to adjust for hospital case mix characteristics.
The authors find the following:
At the market level, patients in markets in which Medicaid payers face relatively little competition are more likely to experience a patient safety event (odds ratio [OR]=1.602), while patients in markets in which hospitals face relatively little competition are less likely to experience an adverse event (OR=0.686). At the patient-discharge and hospital levels, Medicaid characteristics are not significantly associated with the incidence of a pediatric patient safety event.
The authors do note, however, that the number of Medicaid markets with high market power is very small and not representative of most Medicaid markets. Thus, these results may not be very generalizable.
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