Public health, American-style: Donuts at the vaccine clinic

Public Health 101: When confronted with a virus that attacks the obese and unfit, lock people next to their refrigerators for a year.

Public Health 102: When the local government runs a COVID vaccine clinic, make sure that it is amply supplied with donuts.

From a town-run COVID-19 vaccine clinic in the Boston suburbs:

Readers might reasonably ask how many of these health-enhancing items I consumed personally. Answer: zero. I was merely there as driver for a 92-year-old and therefore did not feel that I had earned one. Separately, what’s the process for becoming a volunteer driver in our all-white all-heterosexual town? Look for the rainbow flag and “Black History Month” stickers to find the “Council on Aging” door. Knock and receive a Criminal Offender Record Information (CORI) form to fill out and also a form in which one must supply one’s pronouns and gender ID.

The vaccination process itself was efficient. We arrived at 11:55 am for a noon appointment and were fully checked out by 12:25 pm. My old-but-fit neighbor noted that she hated wearing a mask, but otherwise was happy with her experience.

Readers: Who has vaccination stories to share?

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Should a rich person on Medicare buy supplemental insurance?

A friend is turning 65. If he can easily afford the co-pays (20 percent for most things), does it make sense for him to buy insurance to supplement Medicare?

From a reasonably wealthy consumer’s point of view, the main advantage of health insurance in the U.S. is that the insurance company will defend against the providers’ attempts to steal via fake rates. See America’s Efficient Health Care System: my $15 bill for a checkup (2010), in which the doctor charges a fictitious $510 fee for a checkup that is actually valued at $83 (the insurance company’s “negotiated rate”). If you don’t have insurance, you will be attacked by the health care industry with rates that are 5-10X higher than what 95% of patients are paying. No other part of the U.S. economy works like this and I am not even sure how it is legal. The fictitious prices aren’t quoted to the patient in advance. How can it be legal to hit someone with a bill for 5-10X the real price after the visit? If you take your car in for dealer service and the dealer can’t reach you to get authorization for replacing the bald tires, the dealer can’t charge you $5,000 for a set of tires that 95 percent of the dealer’s customers are paying $500 for, right?

[Related question: Why is the uninsured rate only $510 for an $83 service? Why isn’t it $5,100, for example? The insurance company will still pay $83 and the uninsured can be pursued for $5,100. There isn’t a better rational basis for $510 versus $5,100 or vice versa.]

So… if this guy and his wife will be on Medicare, which is doing the negotiation dance with providers, if he doesn’t buy supplemental coverage is there any circumstance in which he’ll be exposed to this kind of systemic crime by the U.S. health care industry? Or will Medicare always negotiate a normal rate for him even if he ultimately has to pay whatever Medicare has negotiated? (In the latter case, it doesn’t make sense for him to buy insurance because he doesn’t need the insurance part of the insurance.) Is there any convenience benefit to having supplemental insurance, e.g., one doesn’t get annoyed via mail with $10 or $15 hardcopy bills?

A couple of Medicare beneficiaries and their pup, enjoying a misty day at the beach in Hilton Head, South Carolina (January 2021):

And the South Carolina license plate motto (“While I Breathe, I Hope”), perfect for the Age of COVID-19:

Also of interest from Hilton Head…

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Why you can’t get vaccinated by your local dentist

A dentist friend (yes, even dentists need friends!) looked into becoming a COVID-19 vaccination center. She’s amply qualified to inject people (“so is a janitor,” says a med school professor friend). She earns her high income by serving a low-income high-risk population so it would make perfect sense for the parents of her patients to come in and get stuck.

What’s stopping her? “It costs $12,000 for the fridge and I don’t think I’d be able to get reimbursed for giving shots. I’m set up to bill for dental services and being able to bill for medical is a whole different procedure.”

(How is it possible to prosper when the patients are poor? Medicaid doesn’t pay quite as much as private dental insurance for any given procedure, but it is common for children on Medicaid to need $10,000+ in dental surgery due to candy+lack of brushing. An upper middle class child might yield a slightly higher payment for a cleaning, but that is the only revenue that can be obtained from treating the upper middle class child.)

Marketing to MassHealth (Medicaid) customers in Worcester, Maskachusetts, a city whose entire economy consists of mining poor people (medical, dental, criminal prosecution and divorce/custody/child support litigation in a magnificent brand new courthouse).

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Is it ethical for a physician to vaccinate a healthy 20-year-old against COVID-19?

Doctors take the Hippocratic Oath, in which they promise, depending on the version, to “do no harm”, do what will benefit their patients, and avoid “overtreatment.”

Suppose that a healthy slender 20-year-old calls up to a doctor’s office and says “By governor’s order, I am not allowed to leave my house unless you stick me with a COVID-19 vaccine.” Is it ethical for the doc to vaccinate him/her/zir/them?

A healthy slender 20-year-old is more likely to be killed in a car accident driving to/from the doctor’s office than he/she/ze/they is to be killed by COVID-19. Can the doctor ethically and consistently with the Hippocratic Oath intervene in this person’s body? Even if we had years of data proving these brand-new vaccines safe, they are unnecessary for a 20-year-old with no health conditions that would render him/her/zir/them vulnerable to COVID-19. A doctor isn’t supposed to do unnecessary things to patients.

How about the argument that sticking Patient A with a vaccine with help Patients B, C, D, and E? That’s a fine public health argument, and maybe a technician working for the state could do it, but it doesn’t seem consistent with the physician’s oath.

I asked a medical school professor friend for his thoughts on this. He couldn’t think of any other situation in which doctors apply procedures to patients for whom there is no medical benefit with the justification that others will benefit. He did not believe that vaccinating the young/healthy against COVID-19 was consistent with the Hippocratic Oath.

Readers: Are we breaking new ethical ground here? Is there an ethical problem? (If the answer is that there isn’t an ethical problem, can we start harvesting organs out of young people in order to keep old people alive? Common sense organ control tells us that young people don’t need two kidneys and a full-size liver, right?)

Ethical question #2: Is it ethical to throw out vaccine doses because you’re too lazy to post on Facebook or Twitter or call a few friends? From “CEO of Health Center Explains Why COVID Vaccine Doses Had to Be Thrown Out” (NBC Boston):

The CEO of the Brockton [Maskachusetts] Neighborhood Health Center says doses of the COVID-19 vaccine were thrown away on Christmas Eve while they were vaccinating health care workers, due to some of those workers not showing up for their inoculations.

“Since the vial is only good for six hours after we start using it, there was no way we could put it in your fridge like we do the other vaccines and just use it in the morning,” Joss said. “There was just no way to salvage the remaining doses.”

“For our staff, that vaccine is just like gold. They’re protecting it like nothing else,” said Joss. “And yet, I think, at the same time, just by the fragility of the vaccine, I think it’s probably, it’s probably going to happen here and there.”

It’s like gold, but sometimes we need to throw gold away because it is too tough to find additional humans in thinly settled eastern Maskachusetts (Brockton itself has a population of roughly 100,000 and a continuously raging coronaplague among its low-skill immigrants). (Of course, in New York “providers who knowingly administer the vaccine to individuals outside of the state’s prioritization protocols may face penalties up to $1 million, as well as revocation of all state licenses” by governor’s order, but our governor hasn’t issued any new orders since #59 on December 22 (the “emergency” declared nearly a year ago continues, but we’ve had no new orders for two weeks).)

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Travel to get an adenovirus-based COVID-19 vaccine?

One of my instrument flying students recently traveled back to his native Russia and got the Sputnik V vaccine (his wife had it too and the result was two days of fever for her, no significant negative effect for him). Although the U.S.-approved Pfizer-BioNTech and Moderna vaccines are supposedly quite effective, they’re also brand new technology that has never previously been tried in humans (see, from 2018 Nature, “mRNA vaccines — a new era in vaccinology”).

What about the idea of traveling to a country where a vaccine based on more conventional adenovirus technology is available? In addition to the Russian vaccine, the Oxford/AstraZeneca product meets this definition (explanation of function in NYT).

Why not take a trip to a Mexican beach resort, for example, and pay a private clinic for a dose of the AstraZeneca product? (produced and/or packaged in Mexico) Then go back a month or two later for some more poolside margaritas, a stop at a UNESCO World Heritage site, and the second dose?

(Why not get one of these vaccines here in the U.S.? The FDA might not approve it before 100 percent of Americans are infected (roughly half are already if we use the 8X multiplier that the CDC suggests). Even if the FDA does approve it, the centrally planned distribution strategy might make a adenovirus-based vaccine impossible to obtain as a practical matter.)

Readers: Which would you rather have? A leading-edge mRNA vaccine or a slightly-more-conventional adenovirus vaccine? (or no vaccine at all?)

[A medical school professor friend: “The adenovirus vaccine is more likely to have a known side effect than the mRNA vaccine. The mRNA is much more likely to have an unknown side effect.” Why did he prefer? “I don’t want to feel bad for a day or two and the probability of a significant negative effect from the mRNA vaccine is small, so I’d rather have the mRNA vaccine. In reality, it doesn’t matter because so many Americans will have been immunized by a COVID infection by the time I get my vaccine that my actual protection will come from herd immunity.” He does work in a hospital, but seldom sees patients and therefore is not likely to get a vaccine before March.]

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If COVID-19 vaccines weren’t tested on likely COVID-19 victims, how do we know that they will reduce COVID-19 deaths?

Sweden, in which coronaplague was allowed to rage while the population continued sending children to school, sending adults to work, restaurants, the gym, etc., will have about the same death rate in 2020 as compared to 2010 (stats; be sure to adjust for population growth of 9.5 percent from 9.34 million in 2010 to 10.23 million today). This suggests that most of the people whose deaths were tagged to COVID-19 were, as the Swedish MD/PhDs said, on track to die from some other cause at some point in 2020. In other words, COVID-19 kills humans who are already 98-99 percent dead (watch out, Joe Biden, even if you do have a Dr. in the house).

What we’ve heard so far from the vaccine trials are the following:

  • the vaccines don’t stop people from getting infected or spreading the infection to others
  • the vaccines cut down on symptoms and severity of an infection

So… the vaccines might actually make an epidemic worse, in terms of the percentage of the population infected, because people who are infected won’t feel sick and therefore won’t #StayHomeSaveLives.

Maybe this would be fine if we can be sure that vaccinated people won’t die with a COVID-19 toe tag. But do the clinical trials tell us that? Did they go to nursing homes and find the sickest oldest most machine-dependent humans? Given that nursing homes are completely locked down, even if they had found such trial subjects, what could be learned from folks who, by design, are shielded from all exposure?

Let’s have a look at the Moderna FDA paperwork. Only 3 people in the vaccine group, out of 15,208 total, died during the study (approximately 3 months; see pages 17 and 18), which tells you that Moderna picked a much healthier population with a much longer life expectancy than the kinds of people who have been tagged on death with COVID-19 positive test result. (If we assume that a typical COVID-19-tagged death is among those with a life expectancy of 4 years, we would have expected at least hundreds of deaths during a similar study of vaccination among people who really need the vaccination. Note that the Swedish data suggest that 4 years is an overestimate.)

Table 6 says that 4 percent of the study participants had “two or more high risk conditions” and that 25 percent were over 65 years of age, but here in Maskachusetts before the state pulled the age-related data, the median age of a “COVID-19 death” was 82 and more than 98 percent of those had an “underlying condition.”

It is nice that a healthy out-and-about 66-year-old develops a good immune response from these injections, but does that tell us that an extremely unhealthy 82-year-old with just a year or two of life expectancy will develop a similarly good immune response?

So… is it fair to say that we can hope, but not expect, these vaccines to stop the kinds of “COVID-19 deaths” that have been Americans’ consuming obsession?

(A med school professor friend: “Good question, probably not.”)

Loosely related…

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Our apolitical science-driven physicians

From the New England Journal of Medicine, i.e., the folks whom we can trust to give us science-informed advice on masks and vaccines, untainted by a political point of view… “Failed Assignments — Rethinking Sex Designations on Birth Certificates” (December 17, 2020):

We believe that it is now time to update the practice of designating sex on birth certificates, given the particularly harmful effects of such designations on intersex and transgender people.

Recognizing that the birth certificate has been an evolving document, with revisions reflecting social change, public interest, and privacy requirements, we believe it is time for another update: sex designations should move below the line of demarcation.

Designating sex as male or female on birth certificates suggests that sex is simple and binary when, biologically, it is not. Sex is a function of multiple biologic processes with many resultant combinations. About 1 in 5000 people have intersex variations.

Assigning sex at birth also doesn’t capture the diversity of people’s experiences. About 6 in 1000 people identify as transgender, meaning that their gender identity doesn’t match the sex they were assigned at birth. Others are nonbinary, meaning they don’t exclusively identify as a man or a woman, or gender nonconforming, meaning their behavior or appearance doesn’t align with social expectations for their assigned sex.

Moving sex designations below the line of demarcation wouldn’t imperil programs that support women or gender minorities, it would simply require that programs define sex in ways that are tailored to their goals.

Moving sex designations below the line of demarcation may not solve many of the problems that transgender and intersex people face. Controversies regarding bathrooms, locker rooms, and sports participation will continue, regardless of legal sex designations.

Today, the medical community has a duty to ensure that policymakers don’t misinterpret the science regarding sex and that medical evaluations aren’t being misused in legal contexts.

Also, “A Test of Diversity — What USMLE Pass/Fail Scoring Means for Medicine” (June 18, 2020):

The stakes are high for all students taking this first Step examination of the three required for medical licensure. But students from racial and ethnic groups that are underrepresented in medicine experience great angst.

Recently, the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME) decided to change score reporting from a three-digit numerical score for the Step 1 exam (the mean score for first-time takers was 230 in 2018) to a pass-or-fail outcome. … Although the effect on trainees from underrepresented groups remains uncertain, we believe that the change is a critical step toward diversifying the medical profession — particularly the most competitive, and simultaneously least diverse, medical specialties — opening a world of possibilities for physicians and patients alike.

The odds are stacked against students from underrepresented minority groups starting early in their scholastic journeys. Beginning in grade school, they may be subject to teachers’ racial and ethnic biases that can hinder their achievement. Socioeconomic factors such as neighborhood poverty and parental educational attainment may limit their access to high-quality schools, test-preparation resources, and supportive mentorship, widening the achievement chasm.

The medical examination system poses challenges that are especially burdensome to students of color and those with lower socioeconomic status. Step 1, much like the Medical College Admission Test (MCAT), places a financial burden on students that includes the cost of the exam ($645 in 2020) and the study materials required to prepare for it.

As with the MCAT, scores on Step 1 are lower among black, Hispanic, Asian-American, and female students than among their white male counterparts. Although this disparity has multiple causes, historically disadvantageous early education in minority communities probably plays an important role for members of underrepresented minority groups.

… we believe that holistic review will be a tide that raises all ships equitably.

The last sentence is my favorite. There are a limited number of slots for training the most lucrative and cushiest specialties, but everyone will have a better chance of obtaining a slot after this change.

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Experience with One Medical?

As Toucan Sam likes to remind us, Barack Obama said “If you like your doctor, you can keep your doctor,” but our new insurance company apparently did not get the Presidential memo.

It is thus time for me to shop for a new physician. The new insurer assigned me to a doctor, but after a couple of hours on hold with the big clinic where he works, I learned that (a) he isn’t accepting new patients, and (b) he is mostly retired.

One Medical has a couple of offices here in Boston and claims to be patient-centric rather than insurance-company-centric. Does anyone have experience with this concierge-lite primary care system? (it is $200/year, which is a lot better than waiting on hold for hours!)

Update… part of the sign-up form:

(I decided to sign up based on positive reviews from people here and also a friend who drives 30 minutes from the Boston suburbs to continue his treatment at One Medical. As readers can no doubt imagine, it was tough for me to resist entering a long essay into the Gender Information box. And, then, of course, I had to de-subscribe from One Medical after it turned out that they accept Tufts insurance, yes, but not the particular flavor of Tufts “Platinum” that we have.)

Related:

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Is it possible that a COVID-19 vaccine won’t be lucrative?

Just as Big Pharma’s worst enemy in D.C. is on his way out, we have “Pfizer says early analysis shows its Covid-19 vaccine is more than 90% effective”. In a world where a lot of people have no goal other than avoiding COVID-19, will Pfizer shareholders now become infinitely rich?

I’m wondering if there will be so much competition in the coronaplague vaccine market that this ends up being only moderately profitable.

First, maybe it isn’t that difficult to create immunity to coronavirus. Here’s a curve of COVID-19-tagged deaths in Sweden.

After a few months of mixing in schools, workplaces, restaurants, gyms, etc., it would appear that a lot of Swedes became immune (otherwise, how to explain the drop in deaths? The Swedes didn’t change their laws or behavior after mid-March. From the IHME prophets:

If it was that easy for Sweden to build immunity, maybe most of the current vaccine candidates from all around the world will work fairly well (WHO report on 47 currently in clinical trials, which also mentions 155 in preclinical evaluation). Except in the U.S., therefore, competition should work to drive down the price.

Related:

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American health insurance as understood by a licensed health insurance broker

From an email exchange with our aviation insurance broker, regarding why he uses an agent for his own small business’s health insurance plan, rather than going direct to an insurer:

I would say exposure to more markets (United Health is probably going to be more cost effective than Blue Cross) as well as someone to turn to when you have questions about the different options. I have my health insurance brokers license and the intricate differences between plan offerings still confuse me sometimes.

What hope is there for the rest of us?

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