Minimal number of approved drugs; fewer approved each year

Some numbers that I heard at Harvard Medical School:

  • About 1500 compounds that are currently approved as patented or generic drugs.
  • About 500 in clinical trials.
  • About 10 approved every year and declining.

Declining? With half of the new glass towers in Boston and Cambridge packed with biologists and chemists? “It’s getting tougher to approve new drugs because they have to be safe, be effective, and be somehow better for an average population of patients than current drugs,” said my source. “Don’t get me started on the FDA. These criteria are probably too strict. A compound that has bad side effects for one person might affect another person very differently. So it would be good to have more options, especially for those with unusual genetics.”

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Men are not bigger than women; richer Americans are not thinner

Playing around with R (bleah) and NHANES data (a comprehensive survey of American health and socioeconomic situation; see also this exploration tool at Harvard Medical School), I got a few surprises…

American women actually have a slightly higher average BMI than men. Muscles are supposedly heavier than fat and men are supposedly more muscular, right? This theory is not supported by data. Given two random adults of the same height, the woman will actually be heavier.

One of our fellow residents (might not be a citizen) rang up a BMI of 120(!). Plenty of company in the 50-60 range…

There is almost no correlation between income and BMI. However, the correlation is in an unexpected direction. An increase in income of 6X seems to result in an increase in BMI of about 1. The rich are not thinner. (NHANES may not be a good sample for the truly rich).

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Mediocre U.S. average income makes it tough to reduce health care spending?

One thing that I learned during a month at Harvard Medical School is that health care spending is inversely correlated with income. The poorer people are, in other words, the more they cost for an insurance company (or the “plan sponsor”, such as an employer, behind the insurance company).

In some cases, of course the causation may go in the other direction, i.e., a person who has a chronic health problem can’t work as hard or as effectively and therefore earns less. But the consensus within the public health and insurance industry seems to be “lower income, therefore higher cost.”

Singapore is notable for low health care spending as a percentage of GDP (only 4.5 percent; compare to 18 percent for the U.S.) while simultaneously enjoying better outcomes, e.g., longer life expectancy. How much of that, though, could be attributed to Singapore simply having a higher-income population? The CIA shows that per-capita GDP, adjusted for purchasing power, in Singapore is $93,900 per person, 58 percent higher than the $59,500 for the U.S. (Singapore and the U.S. are close to each other in rankings of countries by income equality/inequality, so the median incomes should be similarly related).

Plainly this cannot explain most of our off-the-charts spending on health care. Canada and the big European countries spend much less, as a percentage of GDP, despite having lower per-capita income. But if we assume constant waste due to our more-or-less constant system design (fee-for-service, half government, patient doesn’t pay directly), the stagnant U.S. median income (FRED data) could perhaps explain some of why it is so tough for us to achieve incremental improvements.

The “U.S. population” is a moving target, especially due to immigration. Immigrants have a lower income than native-born Americans (see data below), but they also change the median age of the population, which is a big determinant of health care costs (older people are more expensive): “Without immigration since 1965, the U.S. today would have a median age of 41, not 38.” (Pew). Our incompetence at delivering health care may be masked to some extent by immigration, which has reduced median age. Also complicating matters is that immigrants may be less likely than average to have some chronic medical issues. A morbidly obese person, for example, might have trouble making it over the border.

Related:

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American health insurance fine print: wait one extra day for surgery after an accident and price goes up dramatically

Here’s a fun story on the health insurance system that America’s most brilliant technocrats have created…

Woman falls on Christmas (Tuesday) morning and breaks her collarbone. Blue Cross pays 100 percent of the cost of emergency care following an accident. $0 deductible. ED doc says will likely heal on its own. First available consult with an orthopedic specialist is Thursday morning. After a bit of deliberation, it is decided that surgery to insert a plate may be helpful. This will cost the insurer $30,942 ($35,080 “rack rate”). Had it been completed within 72 hours of the emergency visit, it would have been covered completely. Due in part to the holiday and a question about whether the break could heal adequately on its own, the surgery was not done until the following Monday, outside of the 72-hour window (one business day beyond, or maybe not even that if we subtract out Christmas).

Although the procedure is exactly the same, now the insurance customer must pay 15 percent of the total: nearly $5,000!

So the insurance company that you might think would want to encourage patients to step back and consider whether an offered intervention is useful instead gives them a huge financial incentive to sign up for whatever physicians put on the menu during the first 72 hours!

(The good news is that any customer who memorizes the 165-page 2018 benefits document would be well aware of this 72-hour cliff (don’t forget to read the 176-page PDF for 2019, though!).)

Related:

  • “A $20,243 bike crash: Zuckerberg hospital’s aggressive tactics leave patients with big bills” (Vox), in which the government-run hospital tries to get $24,074 for a $3,831 (market price) visit because “the hospital’s focus is on serving those with public health coverage — even if that means offsetting those costs with high bills for the privately insured. … ‘Our mission is to serve people who are underserved because of their financial needs.'” (the woman involved in the bike accident never had a choice to go to a hospital that was in-network for her Blue Cross)
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Healthy cannabis becomes poisonous marijuana at an elementary school

“At least a dozen elementary students exposed to marijuana gummies, police say; mom arrested” (CNN, 2019):

More than a dozen students at an elementary school in Cleveland were admitted to the hospital after being exposed to gummy candy that police say contained marijuana.

Fifteen children, ages 5 to 9, were tested for drugs and released from Rainbow Babies & Children’s Hospital at University Hospitals Ahuja Medical Center, said Katelyn McCarthy, a media relations strategist at the hospital.
She said that a couple of the children complained of stomachaches.
The police report noted that one of the children tested positive for a mind-altering chemical found in marijuana called tetrahydrocannabinol, also known as THC.

“When young children consume them, they can result in severe symptoms, including dizziness, excessive sleepiness and, in rare circumstances, impair their breathing,” [the toxicologist] said.

It’s key to safely store marijuana products far from where children can see them, said Dr. Suzan Mazor, director of toxicology for Seattle Children’s Hospital and a toxicology consultant for the Washington Poison Center, who was not involved in the Cleveland case.

Also, “make sure to have the poison center phone number on hand for caretakers, grandparents: 1-800-222-1222,” said Mazor, who is also an associate professor of pediatrics and emergency medicine at the University of Washington School of Medicine.

Previously in CNN:

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The next book… Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Killing Ourselves to Live Longer

I’ve started reading Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Killing Ourselves to Live Longer by Barbara Ehrenreich. She’s an interesting writer. Years ago she pointed out that Playboy magazine was promoting what was at the time an essentially gay lifestyle: life in the city, avoid marriage, swap out sex partners on a regular basis, be able to spend one’s entire income, appreciate art, food, wine, etc. Therefore they needed to have pictures of naked women to remind readers that this wasn’t a lifestyle reserved for homosexual men.

Her latest book is timely for those of us who are closing on Medicare eligibility and/or who have aging parents. She’s unimpressed with the bargain that Americans have struck with the health care industry, i.e., hand over 18 percent of earnings for a marginal net improvement in health over the most basis system and for, arguably, worse health than what is achieved in countries such as Singapore (4.5 percent of GDP devoted to health). [See my health care reform article from 2009, in which I ask “Who Voted to Spend All of Our Money on Health Care?” and point out that we could have a mostly paid-for life if we didn’t shovel most of our cash to the medical industry.]

From the author’s intro:

Most of my educated, middle-class friends had begun to double down on their health-related efforts at the onset of middle age, if not earlier. They undertook exercise or yoga regimens; they filled their calendars with upcoming medical tests and exams; they boasted about their “good” and “bad” cholesterol counts, their heart rates and blood pressure. Mostly they understood the task of aging to be self-denial, especially in the realm of diet, where one medical fad, one study or another, condemned fat and meat, carbs, gluten, dairy, or all animal-derived products. In the health-conscious mind-set that has prevailed among the world’s affluent people for about four decades now, health is indistinguishable from virtue,

I had a different reaction to aging: I gradually came to realize that I was old enough to die, … If we go by newspaper obituaries, however, we notice that there is an age at which death no longer requires much explanation.

Once I realized I was old enough to die, I decided that I was also old enough not to incur any more suffering, annoyance, or boredom in the pursuit of a longer life. I eat well, meaning I choose foods that taste good and that will stave off hunger for as long as possible, like protein, fiber, and fats. I exercise— not because it will make me live longer but because it feels good when I do. As for medical care: I will seek help for an urgent problem, but I am no longer interested in looking for problems that remain undetectable to me.

As it is now, preventive medicine often extends to the end of life: Seventy-five-year-olds are encouraged to undergo mammography; people already in the grip of one terminal disease may be subjected to screenings for others. 4 At a medical meeting, someone reported that a hundred-year-old woman had just had her first mammogram, causing the audience to break into a “loud cheer.”  One reason for the compulsive urge to test and screen and monitor is profit, and this is especially true in the United States, with its heavily private and often for-profit health system. How is a doctor— or hospital or drug company— to make money from essentially healthy patients? By subjecting them to tests and examinations that, in sufficient quantity, are bound to detect something wrong or at least worthy of follow-up.

There are even sizable constituencies for discredited tests. When the U.S. Preventive Services Task Force decided to withdraw its recommendation of routine mammograms for women under fifty, even some feminist women’s health organizations, which I had expected to be more critical of conventional medical practices, spoke out in protest. A small band of women, identifying themselves as survivors of breast cancer, demonstrated on a highway outside the task force’s office, as if demanding that their breasts be squeezed. In 2008, the same task force gave PSA testing a grade of “D,” but advocates like Giuliani, who insisted that the test had saved his life, continued to press for it, as do most physicians. Many physicians justify tests of dubious value by the “peace of mind” they supposedly confer— except of course on those who receive false positive results.

Physicians see this all the time— witty people silenced by ventilators, the fastidious rendered incontinent— and some are determined not to let the same thing happen to themselves. They may refuse care, knowing that it is more likely to lead to disability than health, like the orthopedist who upon receiving a diagnosis of pancreatic cancer immediately closed down his practice and went home to die in relative comfort and peace. 9 A few physicians are more decisively proactive, and have themselves tattooed “NO CODE” or “DNR,” meaning “do not resuscitate.” They reject the same drastic end-of-life measures that they routinely inflict on their patients.

Not only do I reject the torment of a medicalized death, but I refuse to accept a medicalized life, and my determination only deepens with age. As the time that remains to me shrinks, each month and day becomes too precious to spend in windowless waiting rooms and under the cold scrutiny of machines. Being old enough to die is an achievement, not a defeat, and the freedom it brings is worth celebrating.

Why is medicine so bad? White males are substantially to blame:

According to critical thinkers like Zola and Illich, one of the functions of medical ritual is social control. Medical encounters occur across what is often a profound gap in social status: Despite the last few decades’ surge in immigrant and female doctors, the physician is likely to be an educated and affluent white male, and the interaction requires the patient to exhibit submissive behavior— to undress, for example, and be open to penetration of his or her bodily cavities. These are the same sorts of procedures that are normally undertaken by the criminal justice system, with its compulsive strip searches, and they are not intended to bolster the recipient’s self-esteem. Whether consciously or not, the physician and patient are enacting a ritual of domination and submission, much like the kowtowing required in the presence of a Chinese emperor.

[Based on my conversations with friends who are non-white non-male physicians and dentists, I’m not sure that the author would be happy with these immigrants or children of immigrants from India and China. Despite their double-victim status (immigrant/person-of-color plus female gender ID), these physicians do not seem to be any more respectful of the American masses than are my white male physician friends. In fact, they often use harsher and more direct language when discussing what they perceive to be the personal failings of their welfare-dependent patients and their less-than-brilliant or less-than-rational patients.]

Ehrenreich points out that it is we who should be calling doctors deficient, not vice versa. The “science is not settled” for a lot of the stuff into which we pour huge amounts of money, time, and suffering:

As for colonoscopies, they may detect potentially cancerous polyps, but they are excessively costly in the United States— up to $ 10,000— and have been found to be no more accurate than much cheaper, noninvasive tests such as examination of the feces for traces of blood.

There is an inherent problem with cancer screening: It has been based on the assumption that a tumor is like a living creature, growing from small to large and, at the same time, from innocent to malignant. Hence the emphasis on “staging” tumors, from zero to four, based on their size and whether there is evidence of any metastasis throughout the body. As it turns out, though, size is not a reliable indicator of the threat level. A small tumor may be highly aggressive, just as a large one may be “indolent,” meaning that a lot of people are being treated for tumors that will likely never pose any problem. One recent study found that almost half the men over sixty-six being treated for prostate cancer are unlikely to live long enough to die from the disease anyway.  They will, however, live long enough to suffer  from the adverse consequences of their treatment.

In 2014, the American College of Physicians announced that standard gyn exams were of no value for asymptomatic adult women and were certainly not worth the “discomfort, anxiety, pain and additional medical costs” they entailed. 16 As for the annual physical exams offered to both sexes, their evidentiary foundations had begun to crumble over forty years ago, to the point where a physician in 2015 could write that they were “basically worthless.” Both types of exams can lead to false positives, followed by unnecessary tests and even surgery, or to a false sense of reassurance, since a condition that was undetectable at the time of the exam could blossom into a potentially fatal cancer within a few months.

As in her previous works, Ehrenreich is good at finding big trends:

It was the existence of widespread health insurance that turned fitness into a moral imperative. Insurance involves risk sharing, with those in need of care being indirectly subsidized by those who are healthier, so that if you are sick, or overweight, or just guilty of insufficient attention to personal wellness, you are a drag on your company, if not your nation. As the famed physician and Rockefeller Foundation president John H. Knowles put it in 1977: “The cost of sloth, gluttony, alcoholic intemperance, reckless driving, sexual frenzy, and smoking is now a national, and not an individual, responsibility.… One man’s freedom in health is another man’s shackle in taxes and insurance premiums.”

I’m hoping that some other folks here will pick up
Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Killing Ourselves to Live Longer  and then we can have a real discussion about it!

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How to avoid opioid addiction

Some things that I learned about opioids from working with billions of insurance claims (teaching SQL at Harvard Medical School) and reading papers by Denis Agniel…

Note: All of this information relates to legally prescribed opioids after surgery (folks who use opioids illegally aren’t likely to ask an insurer to reimburse them!).

Americans are getting more prone to abusing opioids, with rates of abuse rising since 2012.

Doctors are not gate-keepers. They write nearly twice as many opioid prescriptions as patients actually filled.

After reports of opioid addiction, docs started prescribing lower doses around 2014, but they extended the number of pills/days. This increased addiction (34 percent increase in misuse rate per week), as did every refill (71 percent increase per refill). What doctors should be doing is giving high doses for less than two weeks, then telling patients to go cold turkey.

Young men are more likely to abuse opioids after surgery than young women, but rates converge around age 30.

Combining benzodiazepines with opioids puts a person at high risk for addiction.

Main take-away: Try not to take opioids for even one day longer than you need to and definitely don’t go for more than two weeks.

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Some things that I learned about the health insurance business

Some of the stuff that I learned about the health insurance business during a month at Harvard Medical School (earlier this year)…

Forcing people to get a second opinion prior to surgery was a “a stupid idea” and did not change costs or outcomes. [I don’t understand why. “Christopher had 323 doctor visits and 13 major surgeries. Here’s why his mom was arrested” (Fort Worth Star-Telegram) is an unfortunate story about a healthy child enduring a lot of medical torture. Wouldn’t he have had a lot fewer surgeries (maybe none?) if second opinions had been required? The media blames the mom, but could this even have happened in a country where doctors are on fixed salaries rather than being paid fee-for-service? And how much could have happened with a two-opinion system?]

The normal profit margin for health insurance is 1-2 percent (except for ACA/Obamacare, where the expectation is to lose money so it makes sense to withdraw). The Holy Grail for health insurers is to find an unregulated corner of the health care market in which high growth and high profit margins can be obtained.

Customers on the ACA/Obamacare exchanges are much more likely to go to the Emergency Room (“ED”), which represents a disaster for an insurer. (There are some differences in ER/ED usage due to age and gender ID. This article says “about 20 percent of women said they went to the ER, compared with 16 percent of men”. Young people are more likely to go as well, presumably because they can’t be bothered to put down their videogames for the hours of phone calls that it would take to find a non-ER solution.)

Insurance companies have limited outcome/health data. They know if a customer was readmitted to a hospital, but in a world where consumers are chased with surveys they never call up or email members to ask “How is your health?”

Much of “health insurance” is actually “healthcare billing administration.” The headline “health insurer” is not taking any risk. They are just negotiating rates with providers, haggling over bills, etc., on behalf of the real party at risk: your employer. If you’re upset because “the insurance company doesn’t cover X” it is actually your employer who decided that X wouldn’t be covered.

Employers (“plan sponsors”) start out wanting to cover everything. Then they find out what their generosity will cost and change their minds. In-vitro fertilization (IVF) is a good example. The employers are initially thrilled to help add more children to Spaceship Earth. Then they find out that 30% of IVF births are multiple, that the risk of prematurity is higher with multiple births, and that an average triplet birth is a $300,000 event compared to $11,000 when one baby emerges. IVF generates 1.6% of US births, but 16% of all twins and 38% of all triplets.

(Which plan sponsors are so stuffed full of cash that they don’t care about these costs? Universities and the U.S. military’s TRICARE.)

Why are premature babies so expensive? A NICU bed averages $3,000 per day on average (times 3 with triplets!). Advances in technology enable extremely premature infants to survive.

[There are new ethical questions to go with the new tech. For example, it is legal to abort a pregnancy up to 24 weeks of gestation in Massachusetts, but some of these would have been viable babies if born. Massachusetts also says it is legal to abort a child after that if it will harm the mother’s mental health. But what is more harmful to mental health than having a kid around? (see also: abortions sold for cash in Massachusetts)]

Enormous sums could be saved if patients could be moved around a little. There is at least a 2:1 ratio in cost of knee replacements, with the same quality, between higher cost and lower cost geographical areas. IVF is $25,000 in New York City; it is $7,000 in Baltimore (two and half hours away by AMTRAK Acela).

Enormous sums could be saved if patients could be redirected away from hospitals. The inefficiency of hospitals is truly staggering. In what other industry does buying the same service from a bigger enterprise cost 10X as much? Getting a shot or a pill at a hospital could cost 10X what it costs at an urgent care center such as a CVS clinic. But if you go to a big Petsmart you don’t pay 10X for dog grooming compared to what a local one-groomer shop would charge. The insurance companies spend a lot of time thinking about how to keep patients away from the ER/ED, but maybe it would be worth looking at why stepping through the front door of a hospital costs $1,000.

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