Category: Health

Bad Pharma, 2024 edition

by philg

Ten years ago… Book review: Bad Pharma:

Drugs are tested by the people who manufacture them, in poorly designed trials, on hopelessly small numbers of weird, unrepresentative patients, and analysed using techniques which are flawed by design, in such a way that they exaggerate the benefits of treatments. Unsurprisingly, these trials tend to produce results that favour the manufacturer. When trials throw up results that companies don’t like, they are perfectly entitled to hide them from doctors and patients, so we only ever see a distorted picture of any drug’s true effects. Regulators see most of the trial data, but only from early on in a drug’s life, and even then they don’t give this data to doctors or patients, or even to other parts of government. This distorted evidence is then communicated and applied in a distorted fashion. In their forty years of practice after leaving medical school, doctors hear about what works through ad hoc oral traditions, from sales reps, colleagues or journals. But those colleagues can be in the pay of drug companies – often undisclosed – and the journals are too. And so are the patient groups. And finally, academic papers, which everyone thinks of as objective, are often covertly planned and written by people who work directly for the companies, without disclosure. Sometimes whole academic journals are even owned outright by one drug company. Aside from all this, for several of the most important and enduring problems in medicine, we have no idea what the best treatment is, because it’s not in anyone’s financial interest to conduct any trials at all.

The book notes that the British government refuses to pay more for a new drug than the value added by that drug in terms of quality adjusted life years compared to cheap generics or other existing treatments. In the U.S., by contrast, the government and private insurers pay whatever the pharma company asks or, perhaps, a discount off whatever the pharma company asks.

Our ruling elites (I hesitate to say “the Biden administration” because it is unclear what role Joe Biden has been playing) have been touting a recent scheme to pay a little less for some drugs. This scheme is analyzed by Professor Vinay Prasad in “Price negotiation does not save money when keep you paying for drugs that don’t work”:

The Biden Administration saves 6 billion and then loses tens of billions with bad drug policy

They lowered the price of a drug that has no good evidence it is better than older drugs. Consider Entresto (above). Entresto— sacubitril valsartan 160mg BID— beat enalapril 10 mg BID in PARADIGM. Since then it failed in post MI and in HFpEF. It’s one the few drugs that ‘works’ in HFrEF but not post-MI. The dose tested in Paradigm was the MAXIMAL Entresto dose with a dizzying dose of ARB. But few people get this dose in real life. There is NO EVIDENCE that the prescribed doses in the US in 2024 (lower than maximal dose) are better than ace-s, which are dirt cheap.

You can lower the price of drugs, but you lose when you spend billions on covid drugs that have no evidence of efficacy. In recent years the Biden administration approved COVID boosters for toddlers, and spent 10 billion on Paxlovid. There is no evidence either of these interventions work in the current climate. So congrats on your 6 billion in savings, too bad we blew 10 billion on unproven products. (Net impact -4 billion dollars)

For every drug you negotiate prices on, the FDA is approving at least 5x as many new drugs based on poor evidence.

Summary: some things never change!

(The relative cost efficiency of the British health care system combined with the descent into Third World status for Britain is kind of confusing. The U.S. plainly wastes at least 10 percent of GDP via health care (closer to 15 percent if we compare to Singapore). How is it that we’re still so much more prosperous than the UK and most European nations?)

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The $27,321 MRI

by philg

How do Americans go bankrupt after seeking health care?

A friend’s child had some back pain after a fall. A hospital billed $27,321.50 for an MRI (it says “4 services” below, but it was really just one encounter with the MRI machine; some different body parts and contrast). That’s what an uninsured person (“a mark”) would have been chased for, eventually into bankruptcy if necessary. What’s the real price of this service? I.e., what does the hospital actually expect to get paid from a typical patient (insured either privately, via Medicaid, or via Medicare)? About $1,287:

(And, of course, the results were inconclusive, so the value of the $27,321 MRI was $0.)

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Book recommendation: Cook County ICU

by philg

A well-done Audible recorded book and, probably, a good book in print/Kindle form: Cook County ICU. A few things that I learned from it…

The modern insurance/Medicare/Medicaid system requires that hospitals seeking to get revenue give each patient a concrete diagnosis prior to hospital admission. This results in inferior care because the doctors treating the patient become anchored to the initial diagnosis, which is often merely a guess.

Never agree to be a consultant to Hollywood. The author accepts a request to work as a medical advisor for The Fugitive (Harrison Ford plays a vascular surgeon) and puts in a huge number of hours on the project. Money is never discussed. He eventually gets a check for $1,100 (in pre-Biden money) for his work on a film that earned almost $370 million (pre-Biden dollars) at the box office.

From the author’s point of view, there were huge advances in medical technology over his 40 years of practice. The electronic medical record wasn’t one of them, however. It has delivered few benefits, in his view. The practice of having a physician look at a screen and type at a keyboard while interviewing a patient is particularly harmful.

Being sued for divorce is a common way to transition out of the middle class and into the free clinic where the author worked after retiring from the big hospital.

HIPAA is ridiculous, making it easy for insurers, hackers, and the government to get your medical information, but not you or your family members.

Cold is far more deadly to humans than heat. Although we are assured by Science that a warmer climate will result in near-term extinction of humanity, in Chicago it is the cold winter that kills people, not the hot summer.

Not every anecdote is equally rewarding, of course, but there are a lot of great ones!

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Gerald Ford and the Swine flu panic of 1976

by philg

An Ordinary Man: The Surprising Life and Historic Presidency of Gerald R. Ford reminds us of the 1976 panic regarding a respiratory virus: a strain of influenza called “swine flu”. This was the genesis of the modern muscular CDC. Congress appropriated $500 million in pre-Carter/pre-Biden dollars. The CDC said that every American should get vaccinated (Republican Ford publicly accepted the sacrament; Democrat Jimmy Carter refused it). The vaccine was rushed to the market, greatly enriching four pharma companies who also were indemnified from any liability. This indemnification turned out to be useful. The vaccine was at least 10X more likely to cause Guillain-Barré Syndrome (paralysis) than it was to protect the injected person from death due to influenza (contemporary CDC page on the subject).

Abram Saperstein, who changed his name to Albert Sabin, was recruited to sell the idea of universal vaccination. Sabin was famous at the time for having created the oral polio vaccine. After a few months, however, Sabin concluded that the rushed-to-market swine flu vaccine was more likely to harm than help and that a 1918-style epidemic was unlikely.

Speaking of Jimmy Carter, the book notes that his campaign promises were similar to Javier “Chainsaw” Milei’s in Argentina. Candidate Carter promised to reduce the number of federal agencies from 1,900 to 200, for example. What did President Carter deliver? A brand new Cabinet-level Department of Education that kicked off decades of tuition inflation at American colleges and universities via subsidized student loans and grants.

Personal health anecdote: Following the example of Jimmy Carter, the greatest president in our nation’s history, I ignored CVS’s constant reminders of flu vaccine availability. In early January, embedded in Boston with the nation’s smartest and most assiduous mask and vaccine Karens, I got a truly horrible cough/flu. I cursed myself for ignoring CDC advice. After limping home on JetBlue (I actually wore a mask in hopes of protecting fellow passengers!) I went to a German-trained physician here in Palm Beach County and tested negative for both COVID and influenza.

Related:

  • “The Effect of Influenza Vaccination for the Elderly on Hospitalization and Mortality” (Anderson, et al. 2020; Annals of Internal Medicine): “Turning 65 [the age at which people in the UK become eligible for flu vaccines from the NHS] was associated with a statistically and clinically significant increase in rate of seasonal influenza vaccination. However, no evidence indicated that vaccination reduced hospitalizations or mortality among elderly persons” (in other words, the flu shot might help some people avoid a brief illness, but it doesn’t reduce the chance of being killed by the flu)
  • “Carter’s Flu‐Shot Plan For the Ill and Elderly Termed Short of Goal” (NYT, 1979): [the CDC director] also defended the program against criticism by Dr. Albert B. Sabin, who developed the oral vaccine for polio. Dr. Sabin, who is associated with the Medical University of South Carolina, said that he did not believe that the influenza vaccine would help many people because new virus strains kept cropping up. and required changes in immunization formulas. He said that vaccines containing major new strains became available only after the new strains already had their major impact.
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Socialists run out of other people’s hospital beds in Massachusetts

by philg

“The problem with socialism is that you eventually run out of other people’s money,” said Margaret Thatcher. She didn’t count on the U.S. Congress and Federal Reserve being willing to print however much was deemed necessary to achieve the ruling party’s goals.

One thing that the technocrats couldn’t print, however, is hospital beds. With just a trickle of undocumented immigrants over the past couple of years (compared to the flood that Texas has received), it seems that Massachusetts is running out of health care system capacity.

“‘Capacity disaster’: Mass. General Hospital says it needs more beds to combat ‘unprecedented crisis’” (Boston News 25):

Massachusetts General Hospital in Boston announced Friday that it has been dealing with an ongoing “capacity disaster” and that it’s in desperate need of more beds to help combat the “unprecedented crisis.”

The hospital has been operating every day for the past 16 months in “Code Help” or “Capacity Disaster” status, despite the worst days of the COVID-19 pandemic being a thing of the past, a spokesperson for the medical center said.

According to the hospital, “Code Help” occurs when inpatient beds and monitored hallway stretchers are full, and “Capacity Disaster” is triggered when the emergency department is full, all hallway stretchers are being used, and there are more than 45 inpatients boarding in the emergency department awaiting a hospital bed.

What do the technocrats have to say about this kind of situation? It can all be fixed with a technocratic solution. “How to keep people out of the emergency room; Help for immigrants in arranging primary care visits leads to substantial drop in ER visits and costs, a new study shows.” (MIT News, 9/23/2023):

“This program is fairly low-touch and minimalist, yet it had a meaningful effect,” says MIT economist Jonathan Gruber, co-author of a new paper detailing the study’s results.

Separately, as the authors note in the paper, extending formal health insurance to undocumented immigrants “remains politically untenable” for the most part. On the other hand, jurisdictions might examine if other approaches increase care while, in this case, lowering emergency room traffic.

“There’s this tendency with health care to think that if you give people health insurance, you’re done,” Gruber says. “This study is saying the right system combines insurance as financial protection with other kinds of [tools].” He adds: “There is just huge potential to use data and science to get people to where they need to be in terms of getting the most efficient care.”

With data and science, all problems can be solved!

From the hospital itself…

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Sterile gloves are as effective as masks

by philg

2015, Journal of the Royal Society of Medicine, “Unmasking the surgeons: the evidence base behind the use of facemasks in surgery”:

overall there is a lack of substantial evidence to support claims that facemasks protect either patient or surgeon from infectious contamination

2023, Injury, “Risk of wound infection with use of sterile versus clean gloves in wound repair at the Emergency Department: A systematic review and meta-analysis”:

No evidence of additional protection against wound infections with the use of sterile gloves for wound repair in the ED compared to clean gloves was found.

Let’s ask Dr. ChatGPT:

Speaking of wounds, we can remember as we light the kinara this evening, for the second night of Kwanzaa the likely headwounds of the women who were hit on their heads with toasters by Professor Dr. Dr. Maulana Karenga, Ph.D., Ph.D., the creator of the holiday.

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Randomized controlled trial of therapy for teenagers

by philg

“These Teens Got Therapy. Then They Got Worse.” (Atlantic, by Olga Khazan; paywalled, but readable in the Google cache):

Researchers in Australia assigned more than 1,000 young teenagers to one of two classes: either a typical middle-school health class or one that taught a version of a mental-health treatment called dialectical behavior therapy, or DBT. After eight weeks, the researchers planned to measure whether the DBT teens’ mental health had improved.

The therapy was based on strong science: DBT incorporates some classic techniques from therapy, such as cognitive reappraisal, or reframing negative events in a more positive way, and it also includes more avant-garde techniques such as mindfulness, the practice of being in the present moment. Both techniques have been proven to alleviate psychological struggles.

The author and editors forgot to capitalize “Science”!

This special DBT-for-teens program also covered a range of both mental-health coping strategies and life skills—which are, again, correlated with health and happiness. One week, students were instructed to pay attention to things they wouldn’t typically notice, such as a sunset. Another, they were told to sleep more, eat right, and exercise. They were taught to accept unpleasant things they couldn’t change, and also how to distract themselves from negative emotions and ask for things they need. “We really tried to put the focus on, how can you apply some of this stuff to things that are happening in your everyday lives already?” Lauren Harvey, a psychologist at the University of Sydney and the lead author of the study, told me.

But what happened was not what Harvey and her co-authors predicted. The therapy seemed to make the kids worse. Immediately after the intervention, the therapy group had worse relationships with their parents and increases in depression and anxiety. They were also less emotionally regulated and had less awareness of their emotions, and they reported a lower quality of life, compared with the control group.

Most of these negative effects dissipated after a few months, but six months later, the therapy group was still reporting poorer relationships with their parents.

Last year, a study of thousands of British kids who were put through a mindfulness program found that, in the end, they had the same depression and well-being outcomes as the control group. A cognitive-behavioral-therapy program for teens had similarly disappointing results—it proved no better than regular classwork.

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Elon Musk provides inspiration for the damaged

by philg

One defining principle of our age is that a damaged human is an economically useless human. Parents weren’t nice to you? You can be mean to others for the next 75 years. Back pain at age 50 when working for the government? Retire on disability (see “A Disability Epidemic Among a Railroad’s Retirees” (NYT): “Virtually every career employee [at the government-owned Long Island Rail Road] — as many as 97 percent in one recent year — applies for and gets disability payments soon after retirement. … The L.I.R.R.’s disability rate suggests it is one of the nation’s most dangerous places to work. Yet in four of the last five years, the railroad has won national awards for improving worker safety.”) Back pain at age 50 when scraping by on minimum wage? Segue to SSDI and Medicaid-funded opioids.

Elon Musk (the book) is a good inspiration to power through the pain, both emotional and physical. Tending to confirm The Son Also Rises: economics history with everyday applications, his mom’s mom was divorced and Elon’s mom was divorced and Elon himself is now thrice-divorced. Elon’s mom could be brutally frank and Elon’s dad was just plain brutal, as was life growing up in South Africa.

His most searing experiences came at school. For a long time, he was the youngest and smallest student in his class. He had trouble picking up social cues. Empathy did not come naturally, and he had neither the desire nor the instinct to be ingratiating. As a result, he was regularly picked on by bullies, who would come up and punch him in the face. “If you have never been punched in the nose, you have no idea how it affects you the rest of your life,” he says. At assembly one morning, a student who was horsing around with a gang of friends bumped into him. Elon pushed him back. Words were exchanged. The boy and his friends hunted Elon down at recess and found him eating a sandwich. They came up from behind, kicked him in the head, and pushed him down a set of concrete steps. “They sat on him and just kept beating the shit out of him and kicking him in the head,” says Kimbal, who had been sitting with him. “When they got finished, I couldn’t even recognize his face. It was such a swollen ball of flesh that you could barely see his eyes.” He was taken to the hospital and was out of school for a week. Decades later, he was still getting corrective surgery to try to fix the tissues inside his nose. But those scars were minor compared to the emotional ones inflicted by his father, Errol Musk, an engineer, rogue, and charismatic fantasist who to this day bedevils Elon. After the school fight, Errol sided with the kid who pummeled Elon’s face. “The boy had just lost his father to suicide, and Elon had called him stupid,” Errol says. “Elon had this tendency to call people stupid. How could I possibly blame that child?”

When Elon finally came home from the hospital, his father berated him. “I had to stand for an hour as he yelled at me and called me an idiot and told me that I was just worthless,” Elon recalls. Kimbal, who had to watch the tirade, says it was the worst memory of his life. “My father just lost it, went ballistic, as he often did. He had zero compassion.” Both Elon and Kimbal, who no longer speak to their father, say his claim that Elon provoked the attack is unhinged and that the perpetrator ended up being sent to juvenile prison for it.

How about back pain, the standard American initiative-killer?

For his forty-second birthday, in June 2013, Talulah [Riley; photo below] rented an ersatz castle in Tarrytown, New York, just north of New York City, and invited forty friends. The theme this time was Japanese steampunk, and Musk and the other men were dressed as samurai warriors. There was a performance of Gilbert and Sullivan’s The Mikado, which had been rewritten slightly to feature Musk as the Japanese emperor, and a demonstration by a knife-thrower. Musk, never one to avoid risks, even needless ones, put a pink balloon just underneath his groin for the knife-thrower to target while blindfolded. The culmination was a demonstration of Sumo wrestling. At the end, the group’s 350-pound champion invited Musk into the ring. “I went full strength at him to try a judo throw, because I thought he was trying to take it easy on me,” Musk says. “I decided to see if I could throw this guy, and I did. But I also blew out a disc at the base of my neck.” Ever since, Musk has suffered severe bouts of back and neck pain; he would end up having three operations to try to repair his C5-C6 intervertebral disc. During meetings at the Tesla or SpaceX factories, he would sometimes lie flat on the floor with an ice pack at the base of his neck.

(I didn’t understand the appeal of SSDI and opioids until, at around age 50, I decided to repeatedly throw a friend’s 7-year-old onto a couch. This required a twisting motion and, the next morning, I could barely move.)

Elon Musk worked like a demon for years after this injury (I think that we can be confident that the surgeries did not render him “good as new”) and also after the malaria+Stanford misdiagnosis that nearly killed him (see previous post).

Maybe all of this damage will eventually catch up with him, but until then I think we can all look to Elon as inspiration to stop making excuses!

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Missing teeth will be the hallmark indicator of working class chumps?

by philg

I’ve now reached the age where I can spend 110 percent of my time maintaining my disintegrating body and material possessions (where the house is Exhibit A!). As part of this effort, I’ve had two dental crowns for summer 2023 as well as an old filling that needed to be replaced. I found a Tufts-trained dentist down here who is a refugee from the Maskachusetts lockdowns. She has the CEREC machine for milling same-day crowns:

What does this cost? If you’re a working class chump with less spending power than someone on welfare… more than $2,200 per crown. What if you’re a laptop class member with dental insurance? The “negotiated rate” scam in dentistry is not quite as absurd as in medicine, but the total revenue for the dentist then becomes $1,200 and the patient must pay $500. In other words, those with substantially greater financial resources pay less. What about those who have chosen to refrain from work? If they’re back in my dentist’s old neighborhood around Boston… crowns are free through MassHealth (Medicaid). What about in New York? As of 2023, the 5 million New Yorkers receiving taxpayer-funded health insurance get free crowns, implants, root canals, etc. (NYT)

Whom does that leave to go down the cheaper road of extraction? The working class chumps who fund Medicaid via their tax payments and who therefore can’t pay the $2,200 per crown retail price. These will be the Americans with missing teeth.

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Is immigration killing native-born Americans via overcrowding in health care?

by philg

A friend’s daughter in NYC is soon to turn a disposable fetus into a precious baby. This transformation will cost her $5,000 out of pocket. She couldn’t find an ob-gyn in Manhattan without agreeing to the “concierge” plan and says that this is the direction of primary care in the city. In Maskachusetts it was difficult to find a primary care physician who was taking new patients and waiting times to see specialists were generally measured in months if not seasons. Florida is, if anything, even more stressed. Americans fleeing lockdowns have been disproportionately not doctors. A doctor who wanted to escape Andrew Cuomo would have had to get licensed in Florida, which is a complex process, and then build a practice here. Compare to a laptop-based worker who could pick up and move over a weekend.

Can waiting a few months to see a doctor result in death? Yes, concludes “Delayed Access to Health Care and Mortality” (2007):

Veterans who visited a VA medical center with facility-level wait times of 31 days or more had significantly higher odds of mortality (odds ratio = 1.21,p = 0.027) compared with veterans who visited a VA medical center with facility-level wait times of < 31 days.

“The U.S. Has Fewer Physicians and Hospital Beds Per Capita Than Italy and Other Countries Overwhelmed by COVID-19” (KFF, 2020) includes a chart with 2017 data:

Our World in Data shows that there was an upward trend from 1960 to 2004, as the U.S. became wealthier and medicine more advanced, but now we’re in a downward trend as our population expands via low-skill immigration.

Maybe the shortage of docs can be addressed via using non-doctors to do what doctors in Switzerland, Germany, and Sweden do? The trade union for docs says this doesn’t work… “3-year study of NPs in the ED: Worse outcomes, higher costs” (AMA):

Nurse practitioners (NPs) delivering emergency care without physician supervision or collaboration in the Veterans Health Administration (VHA) increase lengths of stay by 11% and raise 30-day preventable hospitalizations by 20% compared with emergency physicians, says a working paper published by the National Bureau of Economic Research.

Overall, the study shows that NPs increase the cost of ED care by 7%, or about $66 per patient. Increasing the number of NPs on duty to decrease wait times raised total health care spending by 15%, or $238 per case—not including the cost of additional NP salaries. In all, assigning 25% of emergency cases to NPs results in net costs of $74 million annually for the VHA.

They don’t bother to try to figure out whether the patients lived or died or what quality of life they might have experienced, but it seems safe to say that “preventable hospitalizations” are not beneficial.

Rich people can buy their way out of waiting to see primary care docs and, perhaps, a handful of specialists who are affiliated (or bribed?) by a concierge practice. A 50ish friend in Boston pays $8,000/year for this. But even the rich may experience a long wait if they need to see a specialist outside of their concierge network.

There have been some recent articles decrying a decline in U.S. life expectancy (example from the public health folks at Harvard, taking a rare break from their mask and COVID-19 vaccine advocacy). But none mention population growth combined with relative stagnation in the number of physicians.

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