Replies to post #75844 on Biotech Values

[iwfal]

1) We pay more for our medical services. But though the pharma industry is important, the real action is in wages. Our medical personnel cost vastly more than their counterparts abroad in almost every category.

2) We consume more services. Americans get shiny new facilities--my British colleagues once derisively commented that American hospitals are "like hotels". American hospitals don't have open wards for almost anyone. They staff at very high levels. Doctors conduct an inordinate amount of tests. We use an expensive machine rather than watchful waiting. And often, those expensive machines catch conditions that never would have turned into anything, which we then treat. Natasha Richardson probably would have lived if she'd had an accident here, because doctors would have done a cat scan, and there would have been a Medevac helicopter available. That's tens, maybe hundreds of thousands of dollars to save a single life.

3) There are inefficiencies. I don't mean "compared to other systems"--every system has some screwed-up illogicality that costs it money and makes patients worse off. But compared to what we could have. For example, Medicare pays for procedures, not wellness, which means that there's a chronic undersupply of geriatricians, because the specialty isn't particularly well paid even though the nation's largest healthcare provider is specifically designed for old people. This is madness. But every real-world system that has attempted to pay physicians for wellness has ended up giving up in disgust.

First time I've seen #1 published anywhere. I am not sure why it is so hard to acknowledge.

[drbio45]

Why Does US Healthcare Cost So Much?

because we allow a company like Alexion charge 450k a year for a drug that cost the company less than 20 million to develop.

because cancer drugs cost 50 to 100k a year to increase lifespan by weeks, and most of the time increases toxicity.

that is why

[DewDiligence]

Some Countries Do Get Healthcare Right

[This article is from today’s Boston Globe; the countries alluded to in the title are France and the Netherlands. #msg-36993611 makes a good companion piece.]

http://www.boston.com/bostonglobe/ideas/articles/2009/07/05/healthy_examples_plenty_of_countries_get_healthcare_right

›By Jonathan Cohn
July 5, 2009

“I don’t want America to begin rationing care to their citizens in the way these other countries do.”

That was Arizona Senator Jon Kyl, speaking last month about healthcare reform. But it could have been virtually any other Republican, not to mention any number of sympathetic interest groups, because that’s the party line for many who oppose healthcare reform. If President Obama and his supporters get their way, this argument goes, healthcare in America will start to look like healthcare overseas. Yes, maybe everybody will have insurance. But people will have to wait in long lines. And when they are done waiting in line, the care won’t be very good.

Typically the people making these arguments are basing their analysis on one of two countries, Canada and England, where such descriptions hold at least some truth. Although the people in both countries receive pretty good healthcare - their citizens do better than Americans in many important respects - they are also subjected to longer waits for specialty care and tighter limits on some advanced treatments.

But no serious politician is talking about recreating either the British or the Canadian system here. The British have truly “socialized medicine,” in which the government directly employs most doctors. The Canadians have one of the world’s most centralized “single-payer” systems, in which the government insures everybody directly and private insurance has virtually no role. A better understanding for how universal healthcare might work in America would come from other countries - countries whose insurance architecture and medical cultures more closely resemble the framework we’d likely create here.

Last year, I had the opportunity to spend time researching two of these countries: France and the Netherlands. Neither country gets the attention that Canada and England do. That might be because English isn’t their language. Or it might be because they don’t fit the negative stereotypes of life in countries where government is more directly involved in medical care.

Over the course of a month, I spoke to just about everybody I could find who might know something about these healthcare systems: Elected officials, industry leaders, scholars - plus, of course, doctors and patients. And sure enough, I heard some complaints. Dutch doctors, for example, thought they had too much paperwork. French public health experts thought patients with chronic disease weren’t getting the kind of sustained, coordinated medical care that they needed.

But in the course of a few dozen lengthy interviews, not once did I encounter an interview subject who wanted to trade places with an American. And it was easy enough to see why. People in these countries were getting precisely what most Americans say they want: Timely, quality care. Physicians felt free to practice medicine the way they wanted; companies got to concentrate on their lines of business, rather than develop expertise in managing health benefits. But, in contrast with the US, everybody had insurance. The papers weren’t filled with stories of people going bankrupt or skipping medical care because they couldn’t afford to pay their bills. And they did all this while paying substantially less, overall, than we do.

The Dutch and the French organize their healthcare differently. In the Netherlands, people buy health insurance from competing private carriers; in France, people get basic insurance from nonprofit sickness funds that effectively operate as extensions of the state, then have the option to purchase supplemental insurance on their own. (It’s as if everybody is enrolled in Medicare.) But in both countries virtually all people have insurance that covers virtually all legitimate medical services. In both countries, the government is heavily involved in regulating prices and setting national budgets. And, in both countries, people pay for health insurance through a combination of private payments and what are, by American standards, substantial taxes.

You could be forgiven for assuming, as Kyl and his allies suggest, that so much government control leads to Soviet-style rationing, with people waiting in long lines and clawing their way through mind-numbing bureaucracies every time they have a sore throat. But, in general, both the Dutch and French appear to have easy access to basic medical care - easier access, in fact, than is the American norm.

In both the Netherlands and France, most people have long-standing relationships with their primary care doctors. And when they need to see these doctors, they do so without delay or hassle. In a 2008 survey of adults with chronic disease conducted by the Commonwealth Fund - a foundation which financed my own research abroad – 60 percent of Dutch patients and 42 percent of French patients could get same-day appointments. The figure in the US was just 26 percent.

The contrast with after-hours care is even more striking. If you live in either Amsterdam or Paris, and get sick after your family physician has gone home, a phone call will typically get you an immediate medical consultation - or even, if necessary, a house call. And if you need the sort of attention available only at a formal medical facility, you can get that, too - without the long waits typical in US emergency rooms.

This is particularly true in the Netherlands, thanks to a nationwide network of urgent care centers the government and medical societies have put in place. Not only do these centers provide easily accessible care for people who use them; they leave hospital emergency rooms free to concentrate on the truly serious cases. Tellingly, a Dutch physician I met complained to me that waiting times in her emergency room had been getting “too long” lately. “Too long,” she went on to tell me, meant two or three hours. When I told her about documented cases of people waiting a day, or even days, for treatment in some American emergency rooms, she thought I was joking. (In a 2007 Commonwealth Fund survey, just 9 percent of Dutch patients reported waiting more than two hours for care in an ER, compared to 31 percent of Americans.)

Dutch and French patients do wait longer than Americans for specialty care; around a quarter of respondents to the Commonwealth Fund survey reported waiting more than two months to see a specialist, compared to virtually no Americans. But Dutch and French patients were far less likely to avoid seeing a specialist altogether - or forgoing other sorts of medical care - because they couldn’t afford it. And there’s precious little evidence that the waits for specialty care led to less effective care.

On the contrary, the data suggests that while American healthcare is particularly good at treating some diseases, it’s not as good at treating others. (In some studies, the US did pretty well on cardiovascular care, not so well on diabetes, for example.) Overall, the US actually fares poorly on measures like “potential years of lives lost” - statistics compiled by specialists in an effort to measure how well healthcare systems perform. In a 2003 ranking of 20 advanced countries, the US finished 16th when it came to “mortality amenable to healthcare,” another statistic that strives to capture the impact of a health system. The Dutch were 11th and the French were fifth. These statistics are necessarily crude; diet, culture, and many other factors inevitably affect the results. But, taken together, they make it awfully hard to argue that care in these countries is somehow inferior. If anything, the opposite would seem to be true.

Critics of health reform frequently point to cancer as proof that American healthcare really is superior. And, it’s true, the US has, overall, the world’s highest five-year survival rate for cancer. But that’s partly a product of the unparalleled amount of government-funded research in the US - something healthcare reform would not diminish. Besides, it’s not as if the gap is as large or meaningful as reform critics frequently suggest. France (like a few other European countries) has survival rates that are generally close and, for some cancers, higher. Much of the remaining difference reflects differences in treatment patterns that have nothing to do with insurance arrangements and everything to do with idiosyncratic medical cultures. This is particularly true of prostate cancer, where a staggeringly high survival rate in the US seems to be largely a product of aggressive US treatment - treatment that physicians in other countries, and increasingly many specialists here, consider unnecessary and sometimes harmful.

None of this is to say that either the Dutch or French systems are perfect. Far from it. In both countries, healthcare costs are rising faster than either the public - or the country’s business interests - would like. And each country has undertaken reforms in an effort to address these problems. The French have started to introduce some of the managed care techniques familiar to Americans, like charging patients extra if they see specialists without a referral, while developing more evidence-based treatment guidelines in the hope that it will reduce the use of unnecessary but expensive treatments. The Dutch overhauled their insurance arrangements a few years ago, to introduce more market competition and reward healthcare providers - that is, doctors and hospitals - who get good results.

But cost is the one area in which France and the Netherlands are a lot like Canada and England: They all devote significantly less of their economy to healthcare than we do. The French spend around 11 percent of their gross domestic product on healthcare, the Dutch around 10. In the US, we spend around 16 percent [#msg-27114485, #msg-36993611]. And, unlike in the US, the burden for paying this is distributed across society - to both individuals and businesses - in an even, predictable way.

Of course, reforming health insurance in the US isn’t going to turn this country into France or the Netherlands overnight, any more than it would turn the US into Britain and Canada. The truth is that the changes now under consideration in Washington are relatively modest, by international standards. But insofar as countries abroad give us an idea of what could happen, eventually, if we change our health insurance arrangements, the experience of people in Amsterdam and Paris surely matters as much as - if not more than - those in Montreal and London. In those countries, government intervention has created a health system in which people seem to have the best of all worlds: convenience, quality, and affordability. There’s no reason to think the same thing couldn’t happen here.‹

[DewDiligence]

Trimming Healthcare Costs Without Reforming the System

[Business Week muses on the startling results of the “real world” Kaiser Permanente study of reported today. The drug regimen in question consists of three generics: lovastatin, lisinopril, and aspirin. Inasmuch as simvastatin (Zocor) is now available as a generic and is more efficacious than lovastatin, the discussion below could be applied to a cocktail of simvastatin, lisinopril, and aspirin.]

http://www.businessweek.com/bwdaily/dnflash/content/oct2009/db2009101_015899.htm

›A Kaiser Permanente study shows patients can ward off heart attacks and slash medical expenses with a simple generic drug regimen

By John Carey
October 1, 2009

In the heated debate over health-care reform, one inconvenient fact is often ignored. There's little evidence to support the use of many of today's routine treatments and procedures. By some estimates, the portion of medicine that has been proven truly effective is still in the range of 25%. That means billions of dollars are being spent on care that may not be effective. And there's even a raging debate over whether the country should do "comparative effectiveness" research to try to figure out what does really work.

That's the bad news. The good news is that these woes mean there is enormous room for improvement, if doctors can understand how to care for people more effectively. The latest proof of the gains that are possible comes from a study published Oct. 1 in The American Journal of Managed Care by researchers from Kaiser Permanente.

In the study, patients with diabetes or heart disease were given a simple, low-cost regimen of aspirin, a generic cholesterol-lowering drug, and a blood-pressure drug. Compared with similar patients not taking the combination, these patients had 60%-80% fewer heart attacks and strokes in a two-year period. [Moreover, most patients did not take the proscribed regimen 100% of the time, according to prescription records; had they done so, the % reductions in MI and stoke would presumably have been even better.] Plus, the approach saved hundreds of dollars per patient. "This is an example of an opportunity that has been sitting there for more than a decade," says Dr. David Eddy, founder and chief medical officer emeritus of Archimedes Inc., a private health-care research firm whose work paved the way for the study. "It shows how we can be smarter at determining the right treatments and find clever, simple ways of delivering those treatments."

At the same time, the study also offers a cautionary tale of how hard it is—and how long it can take—to prove that changes in treatment really are effective. This particular story starts way back in the early 1990s, when Eddy began developing a computer simulation he dubbed Archimedes. The idea was to create a SimCity-like world in silicon, where virtual doctors conduct virtual clinical trials on virtual patients.

Modeling a Cholesterol Drug's Benefits

Eddy showed that the predictions of the model almost exactly matched the results from clinical trials. Then it was time to tackle a real-world problem.

At the time, Kaiser was prescribing to its patients what was then a relatively new cholesterol-lowering drug, Mevacor, from Merck (MRK). "We were treating everyone who walked in the door," recalls Dr. James Dudl, diabetes expert at the Kaiser Permanente Care Management Institute. "We thought the drug would do spectacular things."

But maybe not. When Kaiser plugged the data into the Archimedes model, the computer simulation predicted that the net benefit was tiny. "We were treating the wrong population with an expensive drug," says Dudl.

Was there a better approach? Dudl began to think of ways to target high-risk patients, such as those with diabetes and other conditions like hypertension and heart disease. The conventional wisdom was that the best treatment for diabetes was keeping blood-sugar levels consistently low, which would help ward off complications like heart disease. But Dudl wondered what would happen if he flipped that around, aiming treatment at the downstream problems instead of blood sugar. His idea: give patients a trio of generic medicines—aspirin, a cholesterol-lowering statin, and a blood-pressure-lowering ACE inhibitor.

Using Archimedes and thousands of virtual patients, Eddy compared the drug combination to the traditional approach. The model took about a half-hour to simulate a 30-year trial, and the results were startling. Controlling blood sugar accomplished little, but the simple three-drug combination would cut heart attacks and strokes by 71%.

$8 Billion in Potential Cost Savings

At a pivotal meeting of the board of the Care Management Institute in 2003, Eddy presented the results and made an impassioned plea to implement the findings. "I told them, 'This is as good as it gets to improve care and lower costs, which doesn't happen often in medicine,' " Eddy recalls. "'If you don't implement this,' I said, 'you might as well close up shop.' "

Kaiser listened. As reported in the new study, the company prescribed the drug combination to 68,560 Kaiser Permanente members in California with diabetes or heart disease. Researchers followed the fates of those patients for two years and compared them to 101,464 similar patients who didn't take the combination.

The results mirrored Archimedes' prediction almost exactly. Patients who took the drugs some of the time had a 60% reduction in heart attacks and strokes. For those who adhered more closely to the drug regimen, the benefit was an 80% reduction. [The definitions of “some of the time” and “adhered more closely” were extremely conservative; e.g. the latter category required only 50% adherence to the regimen, according to prescription-refill records. Thus, these results probably understate the achievable benefit with full adherence to the regimen.] "We're extremely happy with the results," says Dudl.

Dudl and his fellow researchers didn't do a cost analysis of the program. "Kaiser's motivation was to improve the quality of care and let the cost chips fall where they may," says Eddy. But Eddy wasn't so reticent. By reducing heart attacks and strokes, he calculated, the program saved about $350 per person treated. Multiply that by the number of diabetics in the country (23 million) and the potential for cost savings is huge: $8 billion.

"The general point here is that quantitative thinking is just beginning to enter health care," says Eddy. Imagine, he says, trying to optimize the operations of an airline without having any data on the numbers of passengers, the cost of fuel, and other basic information. The new study shows it's possible to get that key information in health care, and put it to use to both improve quality and cut costs. "This is equivalent to the Wright brothers flight at Kitty Hawk," says Eddy. "It's saying that something can be done."‹