New Therapies: And Their Costs

Again the brother of the former White House Chief of Staff writes on health care and how it should be rationed, in his opinion. The discussion this time is on proton beam treatment of prostate cancer. He has a point worth considering but presents a conundrum as well.

In the NY Times he states:

The most promising option is a new approach called dynamic pricing. Medicare would pay more for proton beam therapy, but only for diseases that are proven to be treated more effectively by the therapy than by other forms of radiation. For cancers like prostate, it would pay only what it pays for the cheaper alternatives. But if studies were done showing that proton beam therapy was better than other treatments, the payment would go up. If no studies were done, or the new evidence demonstrated no advantages, then coverage would continue, but at the lower reimbursement.

 Now this is a somewhat rational approach. Namely a new therapy comes along and it is expensive yet unproven clinically. However clinical tests to "prove" its effectiveness would require many years and many patients, depending on the desired end point. For example if death is the end point then one may have to test for say 10 years or more and then look at survival, especially when looking at prostate cancer.

This proposal may hit a brick wall when we start to look at many of the new genetically developed pharmaceuticals treating cancers. These have passed clinical three phase trials where efficacy has been proven but their costs are often monumental and the effectiveness may prolong life but a small amount. Thus will he then deal with these as the Brits, namely the QALY approach, and pay on some similar pari passu basis?

As they say, paraphrasing, the cost we will always have with us. 

Obesity, Fat, Taste and Missing the Point

The Scientist had an article on fat, taste, an why we are seeing more obesity. Now one must always remember two things:

Input-Output = Net Accumulation

and

3500 cal = 1 pound

These are constants of nature. Eat too much and you get fat. Will power exists, especially in humans, delayed gratification has been around for years, forgoing the candy bar has been a cornerstone of good health, at least until now. Finding some exogenous factor other than ourselves to blame for the problem has become the status quo. It is the environment, genes, a disease, whatever. It never is our own weakness.

The Scientist states:

People the world over are getting fatter. Today more than one-third of adults in the United States are obese, and the rates in other industrialized countries are catching up. Obesity is no longer considered a condition particular to affluent societies—it has now spread to developing nations such as China and India, resulting in a global health crisis. According to the World Health Organization, 500 million adults worldwide are now obese, and this number is expected to climb well into the foreseeable future. Obesity is so problematic because it poses serious threats to personal health and well-being. Obese people are at an increased risk of chronic and potentially debilitating diseases such as cardiovascular disease and stroke, certain forms of cancer, type 2 diabetes, osteoarthritis, and asthma, among others. And the impact of obesity on an individual’s work and family life can be far-reaching, affecting a person’s employability, work productivity, and ability to pursue interests and activities of daily life.

All true, but, they continue:

A great deal of progress has been made in identifying the genes that may contribute to obesity. According to recent estimates, 135 different candidate genes have been linked with obesity and the eating patterns associated with it. Except for a handful of single-gene mutations that produce extreme obesity, the common, everyday form that we typically encounter on a city street probably reflects very modest contributions from each of a large number of individual genes.

 It is NOT the genes fault. It is lack of will power period. Blame not the gene, blame the person. The gene approach is another excuse generating solution which results in more medication for a problem which really does not exist. They are just fat, so stop eating. A human can survive 90 days with water and no food, just burning their stores. So as a New Year's resolution, shut the mouth now.

Health Care and Comics

Perhaps this tells more than was intended. Gruber from MIT has published a comic book explaining the new health care law of which he was allegedly a part of as advisor to the current administration. It may very well be the first hardcover $30.00 comic book ever.

The praise comes from the as expected corners of progressives and left wing elements from Massachusetts.

For a Bill exceeding several thousand pages being reduced to a comic book one wonders what has happened. After all we were told that one had to pass it to see what was in it, and alas it is a comic book after all.

I wonder if the rest of the MIT campus is doing the same, I retire and we get this, pity.

Ethics and the Practice of Medicine

In an editorial by Ezekiel Emanuel, the, in my opinion, erstwhile proponent of medical care limiting and rationing, in the Annals of Internal Medicine the author states regarding the recently released Ethics Manual for the members of American College of Physicians (ACP):

But then the ACP Committee elaborates a very significant obligation: 

Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely. . . . 

Most physicians were inculcated that ideal physicians are thorough, comprehensive, and exhaustive in their workups and treatments—and ignore costs in the process. Here is an authoritative medical body using such words as “efficient” and “parsimonious”—and without “qualifications”—to describe the ideal physician’s practices. And to be sure it is not missed, this statement is placed in a “call-out” box. This is truly remarkable.

The issue here is the use of parsimony. Now one can interpret that in many ways. For example for lower back pain an MRI may not be the first step in determining the problem. Fifty years ago there was no MRI and the physician used their knowledge of anatomy to isolate the problem and recommend a course of treatment. And of course all too often an MRI finds what may require additional investigation which in turn is oftentimes costly and of no benefit. Parsimony in treatment may mean focus, focus, focus, but it could in the author's words mean cheap, cheap, cheap.

This may be the next step in the current health care debate.

Guest Blogger

Braeden Bottner has been a guest blogger today.

Observations on Income

The above is a plot of per capita income by state, including DC. Talk of income disparity, look at DC, it is well above $70,000 per capita making it over $200,000 per HH! The now infamous 1%. Now one wonders why DC is worth this when at the bottom is Mississippi at $30,000 and near the bottom the next door state of West Virginia.

The above is the annualized rate of change averaged over ten years. Note again DC is well above 9% pa! Michigan is below 3%. The rate of income gap change with those growth rates is fantastic. Again the creation of the 1%.

Finally a year by year snapshot of the change, and again DC comes out ahead. Is there something wrong with this picture.