Minor Thoughts from me to you

This is very interesting.

And on Wednesday in Washington DC, Soon-Shiong and his L.A.-based NantHealth will unveil a joint venture with Verizon, Intel, Blue Shield of California and others to create a nationwide system for doctors to share DNA and other data on cancer patients. It will enable doctors to do genetic analysis of a patient's tumor in less than a minute -- a job that now can take from eight to 10 weeks.

"This is something the federal government should have done, but we waited and waited for them," Soon-Shiong told Reuters in an interview.

"It's unconscionable that cancer patients get the wrong diagnosis 30 percent of the time and that it takes so long to treat them with appropriate drugs for their cancer."

Soon-Shiong emigrated to the United States more than three decades ago with his wife Michele Chan, an actress who had a starring role in 80's show "Danger Bay" that aired on CBS and the Disney Channel and guest roles on " MacGyver." Since then, he has methodically climbed the ladder of success by adroitly mixing science and business.

He created drugs to fight diabetes and breast cancer and then sold the companies that produced them for a combined $8.6 billion.

In the four years since selling those companies, he quietly spent more than $400 million of his own money to build a national fiber optic network that would link cancer clinics throughout the country -- the groundwork for the health superhighway.

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Personalized medicine is the future. It is where the science is going. It is where the technology is going. It is where doctors and patients will want to go.  Yet unfortunately for many of us, this is not where the Obama administration wants to go.

John Goodman gives several examples of how personalized medicine has saved lives and improved health. This truly is exciting, cutting edge stuff. But it's not where the government wants to steer the healthcare industry.

ObamaCare's premise rests on the idea that everyone can be given the exact same treatments and medicine can be standardized in order to cut costs. So, it has no provisions for personalized medicine.

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This is a super cool piece of technology.

The instrument uses a near-infrared light that penetrates just below the skin and reflects off blood vessels. VeinViewer senses hemoglobin, the oxygen-carrying component in blood, which an onboard computer uses to distinguish veins from arteries. It then projects an image of veins on the skin surface in a green light.

It's especially useful on dark-skinned patients, whose blue veins aren't readily visible, and overweight patients, whose veins tend to be deeper. It also highlights the tiny veins of infants.

"It's a great tool to reduce a baby's stress," Ginny Johnson, director of women's services at North Hills, said as she demonstrated the instrument on 1-day-old Zoey White. Helped by a little rubbing of her wrist, VeinViewer traced Zoey's threadlike veins as she awoke from a nap.

It costs $17,000 but the patient satisfaction with these things has to be off the charts. If I was spending my own money on healthcare, this would definitely be something that I'd be looking for in the hospital or doctor's office.

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In a small clean room tucked into the back of San Diego–based startup Organovo, Chirag Khatiwala is building a thin layer of human skeletal muscle. He inserts a cartridge of specially prepared muscle cells into a 3-D printer, which then deposits them in uniform, closely spaced lines in a petri dish. This arrangement allows the cells to grow and interact until they form working muscle tissue that is nearly indistinguishable from something removed from a human subject.

The technology could fill a critical need. Many potential drugs that seem promising when tested in cell cultures or animals fail in clinical trials because cultures and animals are very different from human tissue. Because Organovo's product is so similar to human tissue, it could help researchers identify drugs that will fail long before they reach clinical trials, potentially saving drug companies billions of dollars. So far, Organovo has built tissue of several types, including cardiac muscle, lung, and blood vessels.

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John Goodman returns to a theme of his blog: third-party payment really screws up the healthcare "market". In no sense is the American healthcare system a functioning market. Or, if it is, patients are certainly not true participants in the market.

Of all the people in the health care system, none is more central than the physician. Fundamental reform that lowers costs, raises quality and improves access to care is almost inconceivable without physicians leading and directing the changes. Yet of all the actors in modern health care, none are more trapped than our nation’s doctors. Let’s consider just a few of the ways your doctor is constrained, unlike any other professional you deal with.

No telephone.

No E-mail

Lack of Electronic Medical Records

Inadequate Advice About Drugs and Other Therapies.

Inadequate Patient Education.

What is the common denominator for all of these problems? Unlike other professionals, doctors are not free to repackage and reprice their services in customer pleasing ways. The way their services are packaged is dictated by third-party-payer bureaucracies. The prices they are paid are similarly dictated. Doctors are the least free of any professional we deal with. Yet these un-free actors are directing one-fifth of all consumer spending!

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John Goodman starts to explain one of the the major problems with American healthcare.

Every lawyer, every accountant, every architect, every engineer — indeed, every professional in every other field — is able to do something doctors cannot do. They can repackage and reprice their services. If demand changes or if they discover a way of meeting their clients’ needs more efficiently, they are free to offer a different bundle of services for a different price. Doctors, by contrast, are trapped.

… Medicare has a list of some 7,500 separate tasks it pays physicians to perform. For each task there is a price that varies according to location and other factors. Of the 800,000 practicing physicians in this country, not all are in Medicare and no doctor is going to perform every task on Medicare’s list.

Yet Medicare is potentially setting about 6 billion prices across the country at any one time.

Is there any chance that Medicare can get all those prices right? Not likely.

… In addition, Medicare has strict rules about how tasks can be combined. For example, “special needs” patients typically have five or more comorbidities — a fancy way of saying that a lot of things are going wrong at once. These patients are costing Medicare about $60,000 a year and they consume a large share of Medicare’s entire budget. Ideally, when one of these patients sees a doctor, the doctor will deal with all five problems sequentially. That would economize on the patient’s time and ensure that the treatment regime for each malady is integrated and consistent with all the others.

Under Medicare’s payment system, however, a specialist can only bill Medicare the full fee for treating one of the five conditions during a single visit. If she treats the other four, she can only bill half price for those services. It’s even worse for primary care physicians. They cannot bill anything for treating the additional four conditions.

Since doctors don’t like to work for free or see their income cut in half, most have a one-visit-one-morbidity-treatment policy. Patients with five morbidities are asked to schedule additional visits for the remaining four problems with the same doctor or with other doctors. The type of medicine that would be best for the patient and that would probably save the taxpayers money in the long run is the type of medicine that is penalized under Medicare’s payment system.

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How safe and effective is a hospital? It depends and we may not even be using the right metric.

Hospitals, health insurers and patients often rely on patient death rates in hospitals to compare hospital quality. Now a new study by researchers at Yale School of Medicine questions the accuracy of that widely used approach and supports measuring patient deaths over a period of 30 days from admission even after they have left the hospital.

Published in the Jan. 3 issue of Annals of Internal Medicine, the study has wide implications as quality measures take on more importance in the healthcare system, notes Elizabeth Drye, M.D., a research scientist at Yale School of Medicine’s Center for Outcomes Research and Evaluation, who led the research. The study compared two widely used approaches to assessing hospital quality. One approach uses mortality rates of patients who die during their initial hospitalization, and the other uses rates of patients who die within 30 days, whether or not they have been discharged.

Just to be clear, the standard metric is based on patients who died while they were actually in the hospital.

Drye and colleagues focused on mortality rates for patients with heart attack, heart failure, and pneumonia. For these conditions, one-third to one-half of deaths within 30 days occur after the patient leaves the hospital, but this proportion often varies by hospital.

“We were concerned that only counting deaths during the initial hospitalization can be misleading,” said Drye. “Because some hospitals keep their patients for less time than others due to patient transfers to other facilities or because they send patients home more quickly.”

Drye and her colleagues found that quality at many U.S. hospitals looked quite different using the two different accounting methods. The team also found that measures looking only at deaths in the hospital favor hospitals that keep their patients for a shorter length of time.

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I want to like this article, I really do. After all, I support Dr. Potts's main goal: making birth control pills available over-the-counter, without a prescription. It's a good goal. But he's dead wrong on one issue.

So why isn't the pill sold next to aspirin in every pharmacy or gas station? Commercial greed and a strong patriarchal streak in American politics.

Prescription medicines bring higher profits than over-the-counter drugs. As a doctor, I would recommend my loved ones use a low-dose generic pill whose safety has been well documented over a generation of use. A good generic manufacturer can make a packet of pills for under 20 cents, and they could be sold for $8 a month or less and still make a profit.

Sooner or later, one generic manufacturer will break ranks and ask the FDA to let the pill be sold without a prescription. Let's hope it's sooner.

Uhm, no. The pill is already available in multiple generic forms. Walmart and Target pharmacies both already sell it for about $9 / month. Dr. Potts is conflating two different things: prescription vs OTC and name-brand vs generic. Many generic drugs are still prescription only and many name-brand drugs are already OTC.

Drug companies make a large chunk of their profits by having a patent on a drug. Once that patent expires, any generic manufacturer can make and sell their own versions. But that doesn't automatically make the drug available over-the-counter. It just gives your doctor multiple options, at multiple price points, of what to prescribe for you.

No, the pill is still prescription only because the FDA is one of the most paranoid and risk averse Federal agencies. The pill won't be available OTC until there is enough public pressure to make it OTC or until Congress or the President forces them to make it OTC. Given that various governments are busy cracking down on Sudafed and taking it from OTC to prescription only, I'm not holding my breath for a happy ending for the pill.

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John Goodman, making sense on health insurance and third-party payment.

The fact is that health insurance is complicated because health care is complicated. Congress may think it can wave a magic wand and declare that it should be simple, but that is like passing a law that declares ice should not be so damned cold.

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The biggest complicating factor is third-party payment. It is incredibly complicated to pay someone else’s bills — for anything. How would you like to be responsible for paying my grocery bills? Or my clothing bills? Or my transportation bills? How would you write the contract for any of that?

It is far easier to make a sum of money available to me and let me go get my own services and pay the bills myself. Now that would be an easy-to-understand contract! It would be one sentence — “Here’s $XXX. Go get your own services.”

If Congress wants health care financing to be “easy to understand,” it should remove the third-party from the mix.

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John Goodman explores some of the characteristics of complex systems and applies them to healthcare.

• Complex systems can never be accurately modeled
• There is no reliable model of the health care sector
• Complex systems have unintended consequences
• Implications of unintended consequences.

The key take away is that it's impossible to centrally plan a complex system and that trying to do so is generally counterproductive.

Why are unintended consequences so important? Because in trying to solve one problem we can create other problems. Also in trying to solve problems, we can end up making them worse. ObamaCare has three principal goals: control costs, raise quality and increase access to care. Yet there is no model which allows us to predict that any of the three objectives will be even partially achieved. In fact, readers of this blog know that we expect all three problems to get worse.

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Virginia Traweek asks why nurses can't do some of the work that doctors currently do. They're qualified and they're willing. It would alleviate some of the shortage of primary care doctors. So, aside from protecting doctors' paychecks, why shouldn't we allow nurses to do more?

Ms. Traweek focuses on Texas's ridiculously restrictive regulations but it's a question that other States should examine as well.

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The U.S. Centers for Disease Control and Prevention estimates that nearly 1% of children across the country have some form of autism — 20 times the prevailing figure in the 1980s. The increase has stirred fears of an epidemic and mobilized researchers to figure out what causes the brain disorder and why it appears to be affecting so many more children. Two decades into the boom, however, the balance of evidence suggests that it is more a surge in diagnosis than in disease.

via Instapundit

There's a lot of quotable stuff in this article. Do, please, read the whole thing. I do think that a lot of the increase in "autism" is really an increase of paranoid parents not of disabled children.

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Over at HISTalk, Doctor Sam Bierstock gives a fascinating (and somewhat disgusting) history of how our presidents died in office.

Over the next two months, Garfield was subjected to repeated probing of the wound with unsterile fingers and instruments, non-aseptic incisions to drain abscesses, and other invasive procedures in an effort to locate the bullet, which was, in fact, located harmlessly in fatty tissue behind the pancreas. Eventually, the original three-inch deep wound was converted to a twenty-inch long contaminated, purulent gash stretching from the president’s ribs to his groin.

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Her mother couldn’t remember the names of close relatives or what day it was. She thought she was going to work or needed to go downtown, which she never did. And she was often agitated.

A workup at a memory clinic resulted in a diagnosis of early Alzheimer’s disease, and Ms. Katz was prescribed Aricept, which Ms. Atkins said seemed to make matters worse. But the clinic also tested Ms. Katz’s blood level of vitamin B12. It was well below normal, and her doctor thought that could be contributing to her symptoms.

Weekly B12 injections were begun. “Soon afterward, she became less agitated, less confused and her memory was much better,” said Ms. Atkins. “I felt I had my mother back, and she feels a lot better, too.”

Now 87, Ms. Katz still lives alone in Manhattan and feels well enough to refuse outside assistance.

Still, her daughter wondered, “Why aren’t B12 levels checked routinely, particularly in older people?” . . . A severe B12 deficiency results in anemia, which can be picked up by an ordinary blood test. But the less dramatic symptoms of a B12 deficiency may include muscle weakness, fatigue, shakiness, unsteady gait, incontinence, low blood pressure, depression and other mood disorders, and cognitive problems like poor memory.

Have you had your vitamin levels checked recently? (Or the levels of your loved ones?)

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I love this story. I’ve wanted to do this after sitting and waiting in a clinic waiting room but I’ve never actually had the guts. Maybe next time I will.

Elaine Farstad got antsy as she waited for her doctor, who was late for her scheduled appointment. Then she got downright impatient. Then, as nearly two hours passed, she got mad. Then she came up with an idea.

"I decided to bill the doctor," she says. "If you waste my time, you've bought my time." When Farstad returned home, she figured out her hourly wage working as an IT specialist at Boeing in Everett, Washington. She doubled it for the two hours she'd spent in the waiting room, and mailed the invoice to her doctor.

"It's ludicrous -- why would I wait for free?" says Farstad, who is now an engineering graduate student at North Carolina State University. "Like we all learned in kindergarten, it's about respecting each other."

In years gone by, doctors would likely have scoffed at the suggestion they reimburse patients for time spent waiting. But Farstad's doctor sent her a check for $100, the full amount she requested, and some tardy doctors tell CNN they give patients money (or a gift) before the patient even asks.

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Do you want to live for a long time, in decent health? If the rate of innovation in medical science doesn’t slow down, you just may be able to.

If Aubrey de Grey's predictions are right, the first person who will live to see their 150th birthday has already been born. And the first person to live for 1,000 years could be less than 20 years younger.

A biomedical gerontologist and chief scientist of a foundation dedicated to longevity research, de Grey reckons that within his own lifetime doctors could have all the tools they need to "cure" aging -- banishing diseases that come with it and extending life indefinitely.

"I'd say we have a 50/50 chance of bringing aging under what I'd call a decisive level of medical control within the next 25 years or so," de Grey said in an interview before delivering a lecture at Britain's Royal Institution academy of science.

"And what I mean by decisive is the same sort of medical control that we have over most infectious diseases today."

De Grey sees a time when people will go to their doctors for regular "maintenance," which by then will include gene therapies, stem cell therapies, immune stimulation and a range of other advanced medical techniques to keep them in good shape.

These two charts are very scary. "The first shows the rise of antibiotic resistance in various common infections. The second shows the decline in the approval of new antibiotics."

These are not two trends you want to see moving in opposite directions.

There are a lot of reasons for the decline of new antibiotics--the market incentives are hopelessly misaligned, we've already picked a lot of the low-hanging fruit, and we're using way more antibiotics than we should in both humans and in animals. But anything we do to reduce overusage actually makes the problem of new antibiotic development worse, because it reduces the potential profit. At any rate, there's no clear way to solve this terrible divergence.

I've been talking about this problem for a while, but I've mostly thought about things like the ear infections that would have left me deaf before the advent of penicillin, or people dying in childbirth. I didn't start to understand the radical implications that antibiotic resistance has for health care practice until I read the absolutely gripping Rising Plague, by an infectious disease specialist who points out just how much of modern medicine is dependent on being able to control bacterial infection.

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Infectious mortality will go up, reducing our costs for longer, more expensive diseases--and making people less willing to undergo marginal surgeries.

On the other hand, when the first-line antibiotics fail, the second line means admitting people to the hospital for intravenous antibiotics. This is obviously much more expensive than giving them a pill, even if we make all the doctors take pay cuts and use the awesome monopsony power of the federal government to buy all our antibiotics at a discount. We might be able to worry less about those huge health care costs in 2060--but we might need to worry a lot more about our health care costs in the next twenty or thirty years.

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Of course, the most worrying thing is not the effect on the budget. It's the effect on the people. A world without antibiotics is a world of vast suffering and early death.

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Congratulations, you're Medicaid eligible! You now have health insurance. What's that? You actually wanted health care? Oh, well, that's something different. Why didn't you say so?

Children with Medicaid are far more likely than those with private insurance to be turned away by medical specialists or be made to wait more than a month for an appointment, even for serious medical problems, a new study finds.

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The study used a “secret shopper” technique in which researchers posed as the parent of a sick or injured child and called 273 specialty practices in Cook County, Ill., to schedule appointments. The callers, working from January to May 2010, described problems that were urgent but not emergencies, like diabetes, seizures, uncontrolled asthma, a broken bone or severe depression. If they were asked, they said that primary care doctors or emergency departments had referred them.

Sixty-six percent of those who mentioned Medicaid-CHIP (Children’s Health Insurance Program) were denied appointments, compared with 11 percent who said they had private insurance, according to an article being published Thursday in The New England Journal of Medicine.

In 89 clinics that accepted both kinds of patients, the waiting time for callers who said they had Medicaid was an average of 22 days longer.

Health insurance isn't the same thing as health care. Not by a long shot. By focusing the national debate on who has health insurance we're missing the far bigger problem of who actually has access to care. That's what we should be focused on instead of obsessing over how many people are subscribers to a particular type of insurance product.

Georgia Governor Nathan Deal recently signed a bill that removed state regulations that prevented small business owners from buying out of state insurance. Giving business owners more choices will do a lot to provide healthcare competition and help to bring down prices. More states should pass legislation like this and Georgia should open this up to all state residents, not just small business owners.

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Brown was living in Berlin, Germany back in 2007, dealing with HIV and leukemia, when scientists there gave him a bone marrow stem cell transplant that had astounding results.

“I quit taking my HIV medication the day that I got the transplant and haven’t had to take any since,” said Brown, who has been dubbed “The Berlin Patient” by the medical community.

... Both doctors stressed that Brown’s radical procedure may not be applicable to many other people with HIV, because of the difficulty in doing stem cell transplants, and finding the right donor.

“You don’t want to go out and get a bone marrow transplant because transplants themselves carry a real risk of mortality,” Volberding said.

He explained that scientists also still have many unanswered questions involving the success of Brown’s treatment.

“One element of his treatment, and we don’t know which, allowed apparently the virus to be purged from his body,” he observed. “So it’s going to be an interesting, I think productive area to study.”

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