A brief article in yesterday's New York Times notes that California, by having among the highest tobacco taxes around, and by spending significantly on tobacco education and counter-marketing, has the lowest adult smoking rate of any state except Utah, and has seen rats of lung cancer decrease at a rate three times as fast as the rest of the country. All told, the state calculates that it has saved $86 billion in health care costs. (I can't find the actual report, so I would discount this somewhat). There's more detail at this blog, and here's a link to a press release from September.
This is a fascinating video from the BBC with a statistician showing increasing wealth and life expectancy by country from 1810 to 2009. The visualization is excellent - and the impact of the WWII and the swine flu epidemic is impressive. More impressive (and not commented upon) is the fall in life expectancy in China associated with the Great Leap Forward in the late 1950s.
What does this have to do with health care costs? The places where health care is most expensive just so happen to be those with the highest GDP -and in general they have the longest life expectancy. Increasing wealth is enormously important to improved health - all the more reason we should manage our economies for robust growth. When health care costs end up being so high that they are a major impediment to growth, that can actually lower health!
That’s how much a Czech physician makes each month, NPR reported this weekend.
The series starts in
The final installment is a visit to
Extranormal produces great 'homemade' videos. Some of the pronunciation of medical terms is rough (asystole = the heart has stopped for my nonmedical readers. Temperature of 29= 84 degrees F, and normal pH is 7.4)
By the way, a nicely paired set of articles by perceptive NY Times journalists today and tomorrow.
Today, David Leonhardt reminds us that this quote
“We are against forcing all citizens, regardless of need, into a compulsory government program,” said one prominent critic of the new health care law. It is socialized medicine, he argued. If it stands, he said, “one of these days, you and I are going to spend our sunset years telling our children, and our children’s children, what it once was like in America when men were free.”
is from Ronald Reagan talking about Medicare in the 1960s. He goes on to discuss the tension between Americans who believe in individual responsibility (the laissez fair conservatives) and those who believe in a minimum standard of living (progressives.) Both traditions have played a role in America's success; the tension remains
Tomorrow, Matt Bai reminds us that Social Security started collecting premiums in 1935 but didn't pay out pensions until 1941 - and was under siege for decades until it became a critical part of our social fabric (and until most families were getting some benefit from the program). He suggests that the final analysis of the Affordable Care Act can't be written for a generation.
A few articles worth bookmarking:
The initial study showing that this medicine appeared to be 'trouble' was a metaanalysis published in 2007, and accompanied by an FDA "black box" warning. The good news is that this new information and warning was associated with an impressive ~45% drop-off in drug utilization. We often worry about the slow pace of incorporation into practice of new information. In this instance the communication around the dangers of rosiglitazone looks like a big success.
Here's a worry though. Look at the geographic variation of use of this drug from 2005 to 2010.
This is another illustration of the Dartmouth Atlas contention. Variations in overall cost usually don't purchase better quality - and sometimes purchase higher risk.
Click to enlarge image
Click to enlarge image
Amidst the riches of our system, we continue to make large investments in high technology high margin medicine to rescue the sickest of newborns. But we can't figure out how to pay for the continuing care to be sure that the 'graduates' of the high-tech NICU get the ongoing care they need.
However, almost half of all Medicare beneficiaries have income at or below 200% of the federal poverty level. Therefore, increasing out of pocket costs substantially would be likely to price many elderly Medicare recipients out of health care.
- Establish high risk pools for those who are difficult to insure, and fund this with $25 billion.
The funding is small, and there is a promise to cap their premiums at 50% more than regular premiums, which would be actuarially expensive.
- Extend HIPAA so that employees would be protected from exclusions of preexisting illness even if they did not exhaust their COBRA coverage
- Eliminate annual or lifetime maximum
- Prohibit recissions (where an insurance company withdraws coverage that has already been in force and paid for because of an often-minor error in the original application.)
- Fund $50b for a state innovation fund
- Establish state health plan “finders,” a marketplace for health plans, as opposed to exchanges, where consumers can purchase health plans
- Administrative simplification
- Allow small businesses to band together as “association health plans.”
- Cover dependents on their parents’ plan until age 25 (instead of the 26 in Affordable Care Act)
- Eliminate legal barriers to auto-enrollment, or “opt out” insurance, where employees will be enrolled unless they refuse.
- Allow interstate sale of insurance
- Make health care savings accounts more attractive, through tax credits and by allowing their use to purchase high deductible health plans (HDHPs), to fund some past expenses, and by requiring greater HDHP-HSA coordination
- Malpractice reform, including caps on noneconomic damages ($250,000), proportional damages (meaning that the party with deep pockets or generous insurance would only pay her share of damages), and limits on attorney billing.
- Eliminate comparative effectiveness research. The cost of this research is small, and it could help us figure out what health care is most valuable.
- Allow higher discounts for wellness. This effectively allows higher penalties for those who do not have healthy lifestyles.
- Increased funding for antifraud efforts, as well as better subrogation to recover claims from other responsible parties and tracking banned providers across state lines.
- Prohibitions on taxpayer funding for abortions and protections for health care professionals who don’t want to participate in certain procedures, such as pharmacists who believe the “morning after pill” is equivalent to abortion and therefore immoral.
- FDA approval for biosimilars. This is similar to the Affordable Care Act
The Washington Post has a thoughtful article this morning about a new prostate cancer vaccine, Provenge. The vaccine must be individualized for each patient, and the price has been set at $93,000 per person (each receives just a single dose). Average life expectancy increase using Provenge is 4 months.
This is great news. Individualized medicine is here! The promise recounted in Jerry Groopman's Dr Fair's Tumor (1998, New Yorker) is finally available for the masses. This drug will be very desirable for people with terminal metastatic prostate cancer, their families, and their providers. It's also good news for those of us who will get other cancers - where this type of technology could be life-saving or life-prolonging.
The good news, of course, carries a steep price tag. The increased life expectancy means that Provenge will cost substantially over $300,000 per quality adjusted life year. ($93K *3, and assume that for someone with terminal prostate cancer, each surviving month will be at least slightly discounted because of suffering or disability associated with the cancer). That's far more than we usually spend -and a price point that could leave us unable to invest in other health care initiatives with as much or more promise. Even this steep price tag can be good for those with cancer, though. Such a high price encourages more investment in future biologics to treat cancer.
Most prostate cancer is in those over 65, so Medicare's payment approach for Provenge will determine whether this drug is used commonly, or whether it is available to only the superrich. Medicare has established a national coverage analysis for this product, and will have a public hearing later this month. If Medicare makes a national coverage determination, it will be binding on all Medicare intermediaries across the country.
This is a good example of a "quadrant four" decision. It's much like Folotyn, another recent cancer therapy priced similarly.
The WSJ did a bit of data diving, and discovered that a single