Minor Thoughts from me to you

Should (a) the "Cadillac tax" on employer-sponsored plans not be implemented as scheduled in 2018, and should (b) half of the Medicare savings provisions be repealed or otherwise not implemented the law will increase the deficit by up to $500 billion in its second decade.

That doesn't look good. Raise your hands if you think the government will really implement the "Cadillac tax", given that it would apply mostly to union benefits. And raise your hand if you think that the government will really crack down on Medicare, when old people are the most reliable voters in existence.

Anyone?

∞

Richard Posner on the problems that come with increased tests for preventative medicine. Are we going too far?

The tendency has been to move the goalposts: to screen for lesser and lesser abnormalities, even though the lesser the abnormality the lesser the expected disease cost to the patient and so the less likely the screening and follow-up treatment are to provide net benefits. Moreover, mild abnormalities are far more common than severe ones, so that moving the goalposts greatly increases the number of persons who have to be screened. When the threshold for excessive cholesterol was lowered from 240 to 200, the number of Americans with excessive cholesterol increased by almost 43 million and all of them are recommended to take drugs to reduce their cholesterol, even though the benefits for persons who are not at high risk of heart disease for other reasons are highly uncertain—yet many of these persons are taking the drugs along with persons who can anticipate a significant benefit. The increased prevalence of screening and preventive treatment has increased the health awareness of Americans and by doing so has increased the innate anxiety that people feel about sickness and mortality.

∞

Division of labor, specialization, and mass production. The result: complex heart surgeries for $1,800 and the head doctor wants to bring the price down to just $800. Now that's healthcare reform.

∞

Megan McArdle talks about what health insurance might look like under the Obamacare health care exchanges. First, she quotes Aaron Carroll.

My conversations lead me to believe that many people are expecting that the plans offered in the exchanges will be Medicare-like in many ways. I feel like many people think they will have choice of doctor, choice of hospital, and the ability to dictate care. I'm not seeing how insurance companies will be able to offer such products at prices people can afford. As I talk to more and more people in the insurance industry, my thoughts seem confirmed.

Why does Aaron believe that?

For instance, we just told millions of people that they can go to the exchanges in 2014 and buy insurance. There won't be any lifetime or annual limits. There won't be denials for pre-existing conditions. There won't be any surcharges for having such conditions. And it's going to be "reasonably" priced.

I asked what insurance companies might offer under those conditions. After all, if it were really that easy to offer comprehensive insurance at a real discount, someone would already do it.

McArdle believes these exchanges will look pretty horrible by the time they actually roll around in 2014.

What people are expecting seems to be a very expensive form of insurance (no gatekeepers or restrictions) on the cheap. What they're going to get is cheap insurance that they will be forced to buy. Moreover, a significant number of workers are going to be dropped from their employer plans and dumped on the exchanges. An even more significant number of workers are going to be shunted onto Medicaid (as I understand it, if you're eligible for Medicaid under the new rules, you have to go into Medicaid, even if you want to buy insurance through the exchanges instead).

Medicaid is even more terrible than whatever stripped down products end up being offered on the exchanges, especially since providers hate taking it. There's been some attempt to alleviate this problem with a temporary boost to Medicaid reimbursement rates, but this will expire, leaving Medicaid patients with the same problem they have now in most states: a small number of providers willing to accept its paltry reimbursements. With millions of new Medicaid patients on the rolls, this problem is going to get worse.

Obamacare delenda est. Because what you get with Obamacare probably isn't going to be anything that you'll actually like.

John Goodman looks at whether or not Obamacare will save lives. He starts out by defining the problem.

Being uninsured is like being unemployed. It happens to lots of people for short periods of time. Of all the people who are uninsured at a point in time, more than half will obtain insurance within 12 months and 90% will be insured within two years. So if you want to argue that being eligible for Medicaid is better than being uninsured for most people you have to have a theory that says that extending Medicaid to the temporarily uninsured saves lives.

It gets worse. Since Medicaid eligibility is conditional on income, people become eligible and ineligible as their incomes rise and fall. So like uninsurance, Medicaid eligibility also is a condition that affects a lot of people for short periods of time.

So now you need a theory that says that temporary enrollment in Medicaid for the otherwise temporarily uninsured adds to life expectancy. I know of no studies that test this proposition.

He then points out that, even if this is true, it's the exact opposite of what Obamacare does. Obamacare uses tax data (that can be up to two years out of date) to decide whether or not you can purchase health insurance on an exchange or whether you have to go on Medicare.

So what kind of reform would you want if you believe that temporary uninsurance is bad for health and continuous insurance is good? Obviously, you wouldn't want to enroll people in a plan where eligibility changes every time family income bobs up and down. You would instead want to encourage plans that cover people for long periods of time. The help (subsidy) you make available can bob up and down as income changes -- but enrollment shouldn't follow the same rollercoaster. The subsidy may be income dependent, but enrollment should not be.

Ideal health insurance actually would not include Medicaid at all. It would involve people enrolling in private plans that are portable, and travel with them from job to job. And this result is consistent with other research. For although there is some argument about how much difference health insurance makes, almost every study finds that private insurance is better than Medicaid.

Obamacare delenda est. Because it really is a bad way to solve the problem of health insurance.

James Byrne wrote about new developments in cancer treatment for Scientific American. Researchers are looking at ways to use bacteria to kill cancerous tumours, without making you sick the way chemotherapy and radiation do.

The usefulness of bacteria is limited to certain types of cancer as the requirement for this therapy to be useful is tumours large enough to be dead in the middle.

...

Large tumours with dead or necrotic nodes (necrosis can develop as one large deposit or multiple small foci in the centre of the tumourous tissue) are very common and in many cases act as a marker of the primary tumour where metastases are observed. This makes them very interesting target locations for therapeutics even though direct treatment of the necrosis itself has not been shown to aid recovery.

The current limitations with traditional treatments are reasonable well known and this stems largely from the nature if these therapies. Chemotherapy and radiotherapy are designed to kill all fast growing cells including cancerous cells but other cells grow quickly too leading to hair loss, depletion of the immune system, fatigue and fertility problems. It's the inability to target the therapy that results in much tissue damage associated with treatment. So naturally its been suggested that if a there were a way to target chemo- or radio- therapy these treatments would sho significantly less toxicity. But how do you target tumours alone?

It is here that bacteria can prove their worth. Bacterial species such as Clostridia, Listeria monocytogenes and Salmonella cannot grow well or in some cases at all in the presence of oxygen and so find it very difficult to grow in most locations of the body unless its necrotic.

...

Despite the positive activity observed over the last 20 years in particular a purely bacterial therapy for cancer treatment will not be the full answer to cancer. The real promise lies in combination therapies that place bacterial approaches alongside traditional approaches.

Under extensive research now is the possibility of altering Clostridial species the express pro-drug converting enzymes such as Cytosine Deaminase (CD) or Thymidine Kinase (TK). CD converts the non-toxic 5-Flurocytosine into the cytotoxic 5-Flurouracil and TK phosphorylates the non-toxic Ganciclovir converting it into the active toxic compound. Ordinarily chemotherapeutic agents are administered intravenously and allowed to spread throughout the entire body before eliciting their effects on the quickly reproducing cells of the body. By including the pro-drug converting enzymes within the Clostridia the non-toxic pro-drug can be administered in higher concentrations, as the toxic form will only be present where the bacteria are expressing the enzymes required for its conversion.

I'll freely admit that I only understand about 50% of this article. Here's what it sounds like to me. Bacteria grow best in the dead cancer cells. Researchers will put chemotherapy drugs inside of the bacteria. The bacteria will travel through the body, looking for the dead cancer cells where they can grow and survive. Once the bacteria start reproducing, they'll release the chemotherapy drugs, which will attack the living cancer cells. Between the bacteria attacking the dead cells and the chemotherapy attacking the living cancer cells (and only cancer cells), the combination drug will knock out the tumour without knocking out the rest of your body.

I think the whole article is definitely worth a read through. (If nothing else, you can check my understanding of it.) This is the kind of medical research that really excites me. I really hope researchers are successful in targeting cancers this way.

Obamacare delenda est

John Goodman recommends A Radically Different Approach to Health Insurance:

Middle-class families need health insurance to protect themselves from the financial devastation of a catastrophic illness. But many (arguably, almost all) of the most serious defects of the health care system are created by third-party payment of medical bills.

After 5 years of supporting the billing departments of different healthcare organizations (and using my own healthcare), I've come to agree. Increasingly, I want the choice to spend my own healthcare dollars with the doctor of my choice, for the services of my choice, without having to get approval from an insurance company first.

I truly believe that the lack of competition in our current healthcare system is what's killing American healthcare. And we won't see true competition until we stop relying on someone else to pay our healthcare bills. Sadly, Obamacare will only make this problem worse.

Do read John Goodman's recommendation. He describes how you could pay for healthcare yourself without bankrupting yourself.

Obamacare delenda est

This morning I saw a new Facebook poll: "Is Health Care a Human Right?". I voted no.

Do you have a right to health care? Yes. And no. My answer ultimately depends on what you mean by a "right" to health care.

Rights come in two varieties: negative and positive. A negative right can be thought of as the right to be left alone. It's the right to do something without the fear that someone else will restrain you. A positive right can be thought of as the right to be served. While a negative right requires only that someone leave you in peace, a positive right requires that someone actively do something for you.

I believe you have the right to work with the doctor of your choice -- whether or not that doctor has been credentialed by a government.

I believe you have the right to take the drugs of your choice -- whether or not those drugs have been approved by a government panel of experts. I believe you have the right to take experimental cancer drugs, especially as a last ditch attempt to save your life. I believe you have the right to take marijuana to treat pain, to build appetite, and to relax.

I believe you have the right to buy insurance from any company, located in any state, covering any combination of conditions. I belive you shouldn't be limited to only the health insurance that covers a government approved list of condition from a government approved list of companies.

I believe in a strong negative right to health care. That's something that doesn't really exist in America today. Right now, you are not free to receive health care from anyone you trust, you are not free to take the drugs of your choice, and you are not free to buy whatever health care you desire. I am in favor of more freedom in health care. I believe you have a right to consume health care as you see fit, even if the majority of people around you disagree with your decisions. That's freedom.

I don't believe you have a right to force someone else to pay for treatment, medications, or medical supplies. I don't believe you have a right to force a doctor to work with you. It's one thing if you and the doctor can come to a mutual agreement regarding pay and hours of availability. It's something else entirely to require a doctor to treat you at a price of your choosing (not his) and at a time of your choosing (not his). I don't believe you have a positive right to health care.

To be blunt, I don't believe you have a right to turn doctors into slaves (by requiring them to treat for free or at a steep discount) or a right to turn your fellow citizens into slaves (by requiring them to work in order to pay the bills for your health care).

The current discussion of health care rights revolves almost entirely around positive rights -- getting someone else to pay for our health care. It includes an "exchange" that would strictly limit the options available. It includes subsidies forcibly taken from some people through taxes and used to pay for someone else's health care.

It includes a requirement for insurance companies to charge everyone the same price for health care. This practice, known as community rating, allows sicker people to pay less than the cost of their care and requires healthier people to pay more. In effect, community rating is a subsidy to the sick courtesy of the healthy. Community rated health care is a very bad deal for young, healthy individuals. So the current discussion revolves around a health care mandate. Most of the plans under consideration would require young people to purchase something that's a bad deal. They would be required to do this solely to provide a good deal to sick people and the elderly.

Claiming a positive right to health care is nothing more nor less than the claiming the right to enslave your fellow man. I don't believe you have that right.

Here's Warren Meyer, talking about the different types of rationing.

So here is what it boils down to: For every product or service purchase, someone makes a price-value trade-off to determine if that product or service should be purchased for a given price in that particular instance.

One option for making this decision is to have the person who actually will consume the product or service — and whose money will also be used to complete the transaction — make this price-value tradeoff.

... A second way to do this would be to have someone who has you specifically in mind make the price value tradeoffs for you. This might be like your wife volunteering to go out to buy you some new underwear.

... So a third model, and almost certainly the worst in terms of individual satisfaction, is to have a third party make price-value tradeoffs for me only with some notion of average preferences for average people, or worse, with an incentive system that has absolutely nothing to do with my satisfaction at all. This is clearly the case for the government, and is probably the case for many private insurers today[.]

When it comes to your health care choices, who do you want making your decisions? I definitely want to make my own decisions and I think most Americans would agree with me. But the reforms that are on the table would cement the status-quo. The status-quo overwhelmingly encourages us to pre-purchase our health care through expensive health "insurance" policies. Then a bureaucracy will take a look at our care and decide what to reimburse and what to deny. That's true whether you're on an HMO plan, a PPO plan, or a government (Medicare / Medicaid) plan.

Isn't it time that we had real reform? Isn't it time that we put patients back in charge of their own health care decisions?

It's great that Great Britain has high quality health care available to everyone, courtesy of the British government. Expectant mothers are especially appreciative. After all, without the NHS, some of them would have never known that it's possible to give birth outside of a delivery room.

Thousands of women are having to give birth outside maternity wards because of a lack of midwives and hospital beds.

The lives of mothers and babies are being put at risk as births in locations ranging from lifts to toilets - even a caravan - went up 15 per cent last year to almost 4,000.

Health chiefs admit a lack of maternity beds is partly to blame for the crisis, with hundreds of women in labour being turned away from hospitals because they are full.

Latest figures show that over the past two years there were at least:

• 63 births in ambulances and 608 in transit to hospitals;
• 117 births in A&E; departments, four in minor injury units and two in medical assessment areas;
• 115 births on other hospital wards and 36 in other unspecified areas including corridors;
• 399 in parts of maternity units other than labour beds, including postnatal and antenatal wards and reception areas.

Additionally, overstretched maternity units shut their doors to any more women in labour on 553 occasions last year.

I'm so glad that the British don't leave their health care up to a greedy, heartless private sector motivated only by profits. Imagine what might happen if they did!

The National Center for Policy Analysis published a press release from the HealthPlanWire today, showing the grow in private insurance world wide.

HPW follows health insurance markets globally, and is projecting that total covered lives will exceed one billion by 2012. Single-payer systems are declining world-wide because they are primarily based in countries which have static or declining populations, while private insurance is growing rapidly in countries with the fastest population growth.

Most of this is coming from developing countries which are for the first time ever building out a health financing system, choosing to encourage private health insurance over single-payer on five continents. Examples include China, Columbia, South Africa, Mexico, India, Australia and most of eastern Europe. Most of these countries considered and rejected a single-payer system in favor of a private insurance system, and more than a dozen more are following suit in the same regions.

Private insurance is the chosen system for several reasons. In developing countries in eastern Europe there is a strong aversion to the former Soviet-style model, and western European global insurers like Allianz and Vienna Insurance Group have actually acquired the entire single payer system from the government and turned it private.

Cool.

I should know by now that whenever I try to explain something John Stossel has already explained it better. First, he delivers a great quote about why competition keeps prices low.

In a free market, a business that is complacent about costs learns that its prices are too high when it sees lower-cost competitors winning over its customers.

I posted yesterday about why "exchanges" are worse than free markets. Stossel takes that on too and does a far better job than I did.

... Competition is not a bunch of companies offering the same products and services in the same way. That sterile notion of competition assumes we already know all that there is to know.

But consumers often don't know what they want until it's offered, and their preferences and requirements change. Businesses don't know exactly what consumers want or the most efficient way to produce it until they are in the thick of the competitive hustle and bustle.

Nobel laureate F.A. Hayek taught that competition is a "discovery procedure." In other words, the "data" of supply and demand emerge only through the market process. We need open-ended competition not merely to see which rival is better, but to learn things we didn't know before and aren't likely to learn any other way.

"Competition is valuable only because, and so far as, its results are unpredictable and on the whole different from those which anyone has, or could have, deliberately aimed at," Hayek wrote.

The health care bills are perfect examples. If competition is a discovery process, the congressional bills would impose the opposite of competition. They would forbid real choice.

In place of the variety of products that competition would generate, we would be forced "choose" among virtually identical insurance plans. Government would define these plans down to the last detail. Every one would have at least the same "basic" coverage, including physical exams, maternity benefits, well-baby care, alcoholism treatment, and mental-health services. Consumers could not buy a cheap, high-deductible catastrophic policy. Every insurance company would have to use an identical government-designed pricing structure. Prices would be the same for sick and healthy.

In today's New York Times, David Leonhardt talks about the problem of health care choice. Specifically, the fact that most people don't have any choice. He starts out making a lot of sense.

Health insurers often act like monopolies -- like a cable company or the Department of Motor Vehicles -- because they resemble monopolies. Consumers, instead of being able to choose freely among insurers, are restricted to the plans their employer offers. So insurers are spared the rigors of true competition, and they end up with high costs and spotty service.

But then, discussing the Wyden-Bennett bill, he makes less sense.

In the simplest version, families would receive a voucher worth as much as their employer spends on their health insurance. They would then buy an insurance plan on an "exchange" where insurers would compete for their business. The government would regulate this exchange. Insurers would be required to offer basic benefits, and insurers that attracted a sicker group of patients would be subsidized by those that attracted a healthier group.

The immediate advantage would be that people could choose a plan that fit their own preferences, rather than having to accept a plan chosen by human resources. You would be able to carry your plan from one job to the next -- or hold onto it if you found yourself unemployed. You would never have to switch doctors because your employer switched insurance plans.

The problem with this idea is that it really doesn't offer much choice. Insurance companies are still protected from competition by the friendly confines of a government controlled "exchange". True choice would consist of an open market place where any entrepreneur can offer any product to any interested consumer. The success or failure of the product would depend on one all important criteria: whether or not consumers saw any value in it. Insurers would no longer be able to foist their plans on consumers who don't want them. And entrepreneurs would be free to introduce radical, new products that threaten the current insurance companies.

That kind of free choice wouldn't exist under an insurance "exchange". Each new product would have to be carefully weighed and analyzed by government bureaucrats. Nothing new would be approved unless they determined that it was worthwhile and useful. Existing insurance companies would have a hand in writing the regulations and only products that conform to the current status-quo would be allowed in. Anything that threatens that status-quo would be barred from the "exchange" and never offered to consumers. The end result would be akin to Ford's infamous statement that consumers could buy any color car they wanted -- as long as it was black.

Instead of fostering innovation and creativity in health care, the Wyden-Bennett bill would take the current "insurance" industry and lock it in cement. Consumers would continue to be forced to buy health insurance not health care and bureaucrats would continue to dicatate how, when, and where their health care dollars can be spent.

All of this makes me happy to hear that Wyden-Bennett doesn't have much support in the Senate.

Any bureaucracy -- public or private -- is going to make pointless decisions and complicate your life. This applies to health "insurance" as much as it applies to anything else. It's easy to find stories of people who were heartlessly treated by their health bureaucracy. In Britain, the bureaucracy is the government run NHS. In America, it's often a private company. But the end result is often the same.

John Goodman points to a recent story and then offers an alternative.

Is there a better way? Yes. It's called casualty insurance -- similar to the kind of insurance most people have on their homes and automobiles. In the case of a catastrophic illness, the insurer makes a lump sum available -- ideally enough to cover all reasonable care. But when there are differences of opinion, patients can add their own funds to the insurer's payment and buy any type of care from any provider. For Medicaid, additional funds could be provided by private charity (which is what is happening anyway for Dr. Pollard's patients).

This is not a small change from the current system. It is a huge change. It would lead to a real market for catastrophic care in which patients and their families become real, empowered buyers. Providers would compete for patients based on price and, therefore, on quality. Doctors would be free to act as the agents of their patients rather than agents of third-party-payer bureaucracies.

Why would you want to hand control over your health care over to a bureaucracy? And why would you believe that a government bureaucracy would run more smoothly -- and treat you more fairly -- than a private bureaucracy?

Health care will be rationed. The only question is "who will do the rationing?". Will you make the decisions or will someone else? Megan McArdle illustrates this with a great quote.

Fears of "death panels" are way overblown. Fears of "Are second knee replacements worth it?" panels are not.

This morning, the Wall Street Journal reported on another one of the goodies that's buried in the House healthcare "reform" bill. If the bill passes, the IRS will fine you for any mistakes you make on your tax returns.

Under current law, taxpayers who lose an argument with the IRS can generally avoid penalties by showing they tried in good faith to comply with the tax law. In a broad range of circumstances, the health-care bill would change the law to impose strict liability penalties for income-tax underpayments, meaning that taxpayers will no longer have the luxury of making an honest mistake. The ability of even the IRS to waive penalties in sympathetic cases would be sharply curtailed.

Recent experience shows that Congress needs to be careful about imposing no-fault penalties. In 2004, Congress adopted very large automatic penalties for failures of taxpayers to attach a tax-shelter reporting form to their tax returns. While penalties make sense where a taxpayer deliberately fails to file a return, the approach here was too unforgiving.

The normal ability of the IRS to waive penalties was taken away. Predictably, the result was some taxpayers getting hit with penalties they didn't deserve.

Last June, the Small Business Council of America sent some compelling tales of woe to Congress, including one in which a 72-year-old owner of a coin operated car wash set up retirement plans for his seven employees and got socked for his good deed with a $900,000 penalty for not reporting the plans properly. The company and its owner are now headed for bankruptcy. In another case, a penalty of $100,000 each was imposed on the six minor children of an owner of a small business in Utah for not filing the right tax forms.

I think I'll call Congresswoman Baldwin's office. I'm very curious to know if she supports this measure; if so, why; or, if not, what she's going to do about it.

Over at Reason Magazine, Steve Chapman tackles infant mortality. He says the high U.S. rate is the result of American lifestyles, not of American health care.

No one denies the problem. Our infant mortality rate is double that of Japan or Sweden. But we live different lives, on average, than people in those places. We suffer more obesity (about 10 times as much as the Japanese), and we have more births to teenagers (seven times more than the Swedes). Nearly 40 percent of American babies are born to unwed mothers.

Factors like these are linked to low birth weight in babies, which is a dangerous thing. In a 2007 study for the National Bureau of Economic Research, economists June O'Neill and Dave O'Neill noted that "a multitude of behaviors unrelated to the health care system such as substance abuse, smoking and obesity" are connected "to the low birth weight and preterm births that underlie the infant death syndrome."

Nicholas Eberstadt, a scholar at the American Enterprise Institute in Washington, also attributes the gap largely to conduct. Comparing white Americans to Norwegians in his 1995 book, The Tyranny of Numbers, Eberstadt concluded that "white America's higher rates of infant mortality are explained not by poverty (as conventionally construed) or by medical care but rather by the habits, actions, and indeed lifestyles of a critical portion of its parents." Whites are not unique in those types of behavior.

African-American babies are far more likely to die than white ones, which is often taken as evidence that poverty and lack of health insurance are to blame. That's entirely plausible until you notice another racial/ethnic gap: Hispanics of Mexican or Central or South American ancestry not only do consistently better than blacks on infant mortality, they do better than whites. Social disadvantage doesn't explain very much.

Last week I said that "my health insurance reform plan would involve shifting healthcare spending from large premiums and all-inclusive health "insurance" plans to small premiums and plans that only offer catastrophic insurance coverage. Patients would have more money left in their pocket, to allow them to pay more money out of pocket".

Two days ago, while driving to work, I saw a gentlemen standing by the side of the road holding a sign. It proclaimed "Doctors support affordable healthcare for all". Great! I'm glad to hear it. We need more people on board with affordable healthcare.

But affordable healthcare isn't always what you think it is. Paradoxically, charging people more -- paid directly, out of their own pocket -- can actually lead to people paying less. And this isn't just pie-in-the-sky ivory tower theory. The savings effects of higher out of pocket costs are real.

The paper contends that, contrary to recently recommended policy changes by the Centers for Medicare and Medicaid Services that exclude incentives through copay or co-insurance for chronically ill beneficiaries and high-value medications that target chronic conditions, the effectiveness of such incentives in driving business-based results is documented: At Caterpillar, for example, generic statins for cholesterol management were moved to a $0 co-pay; brand-name statins, to $35 per month or no benefit paid, depending on the dose. The plan, which covers 90,000 people, saw increased medication compliance, contributing to a $750,000 per month savings to the company and $175,000 savings per month to employees.

"These barriers to the implementation of incentives actually reduce their impact and have the potential to reduce any measurable progress," the report says of the CMS recommendations.

At Caterpillar, patients were given a financial incentive: the cheaper drugs cost them less and the expensive drugs cost them more. Normally, these price differences are hidden behind a one-size fits all copay which is supported by the monthly premiums. Normally, the cost of individual healthcare treatments is obfuscated by the overcall cast of the healthcare "plan".

Caterpillar brought some of those costs out into the light -- and reduced them. Obama and the Democrats have been discussing healthcare "reform" for the pat several months. They're desperately looking for a way to "bend the cost curve" and hold down the cost of healthcare. I think Caterpillar found a way. It's simple: charge patients more and they'll pay less.

I hope everyone who supports "affordable healthcare for all" will support my plan.

The pharmacy profession likes to think of itself as an indispensable part of the healthcare landscape. The APhA (American Pharmacists Association) says that pharmacists are "essential in patient care for optimal medication use". That implies that pharmacists spend a lot of time educating patients about their drugs and advising doctors on the best drugs to use.

But talk to a retail pharmacist about her job sometime. Listen closely to what she does most often. You'll find that she's basically a human vending machine. When she's not grabbing drugs off of a shelf and putting them in a bag for patients, she's probably swiping an insurance card and figuring out how much they owe. Occasionally, she'll get to answer questions about how the drug works and how it interactions with other medicines, but that's comparatively rare.

Enter the pharmacy vending machine.

Integrity Urgent Care, 4323 Integrity Center Point, in northeast Colorado Springs, recently installed a machine stocked with dozens of common prescriptions -- antibiotics, painkillers, asthma inhalers and oral steroids. It dispenses patients' medications like a bag of potato chips or package of Skittles, and it is the first such machine in Colorado, according to the Minneapolis-based manufacturer, InstyMeds.

The process works like this: The doctor or physician's assistant submits the prescription electronically to the machine and gives the patient a code. The patient types in the code and a birthdate and receives the medicine after the bar code is triple checked.

A phone on the machine connects the user directly to a pharmacist 24/7 if the customer has questions or concerns.

If you're job is to perform the function of a vending machine, you probably won't be too happy that an actual vending machine is being used. Enter, the APhA spokesperson:

Kristen Binaso, a New Jersey pharmacist and spokesperson for the American Pharmacists Association, said people need quick access to their medications, but she said people should understand that a drug is not a package of Ritz crackers. Even certain common drugs can increase sensitivity to the sun, react negatively to alcohol, cause diarrhea, or interact with vitamins, herbs and over-the-counter drugs.

Her statement ignores something: the FDA mandates that all drugs come extensively labeled with warnings about every possible danger or complication. So, it sounds like a vending machine can replace much of what a retail pharmacist does on a regular basis.

And, this is a good thing. I wish that more pharmacists would recognize this. There is a very limited future in taking an average prescription, putting the pills in a bottle in a bag, reading the list of drug warnings, and taking payment.

The future of pharmacy is in the work that machines can't (yet) do: helping a patient recognize what the "blue pill", "red pill", "square yellow pill", and "round yellow pill" actually are. Helping that patient understand what each drug is supposed to, how it should make them feel better, what to be aware of when it it's not working, knowing which side effect goes with which drug(s), etc. Pharmacists have a great future in helping patients know whether their particular cocktail is safe or whether there's a potentially deadly interaction between multiple drugs.

But all of that counseling work can't be done well in today's retail setting. Today's retail setting is focused around volume, not around thorough counseling sessions. And that's not going to change until retail pharmacists are willing to allow vending machines to take over the tedious, rote work of actually dispensing pills.

On a closing note: what does it mean when people talk about a shortage of pharmacists? Are they referring to a shortage of dispensers? Well, technology can help with that? Or are they referring to a shortage of counselors? Technology can help with that too. By freeing pharmacists from the drudgery of being a vending machine, technology will create more pharmacist hours to be used for counseling. It will be as though thousands more pharmacy graduates entered the market, ready to help.

Thank you InstyMeds. You're helping to take us forward to the future.

Mr. HIStalk recently did a great interview with Dr. Jordan Shlain, founder of Current Health. It was a fantastic read. Here's a sample:

I want to give you a softball question here, because I've seen your answer elsewhere, but I think it bears repeating. What's wrong with the average patient-physician-insurance company relationship that's common today?

All the incentives are all wrong. The insurance companies have an incentive to not pay the doc because its more money to them.

The fundamental problem is the patient walks into a doctor's office, kind of with someone else's credit card, and says, "I want this, this, and this". They're not paying for it. They are not accountable for it. "I want an MRI, doctor. I want a fancy blood test. I want all these things, but I don't want to pay for it. I want somebody else to pay for it."

So the fundamental problem right now is that there's no price transparency, so nobody knows what anything costs, really, number one. Number two is there's no accountability on the patient's part to bear some of the cost of what they either consume or use. I fundamentally believe that insurance, as a construct and a principal, is a financial instrument. It's not a healthcare instrument. Health insurance is no different than car insurance or life insurance. You put money in, and if something really bad happens to your car, your house, or your life, there's money on the other side of that.

Health insurance was never intended for, if you look at the old model, a sprained ankle or an eye exam or a physical exam or for minor surgery. You paid that by yourself, and if you hit your $5,000 or $10,000 deductible, you were covered. Therefore, car and home and health insurance should be and is personal bankruptcy protection. That's what's it's supposed to be. It's to protect you in the case of unforeseen catastrophic loss. ...

Go and read the full thing. You'll learn a lot.