Sicko

[Sicko movie link]

First, however irrelevant it might be, I want to mention that I love the song at the end of the movie "Don't Be Shy" by Cat Stevens. I think one of the reasons it's there is Eddie Veder covered it during the "Vote for Change Tour" back in 2004. Great cover.

Second, and to begin the main point, Michael Moore fairly makes the argument that the health care system in the U.S. really does not seem good enough for a great many people and there are probably many tragic stories illustrating this. I think this is probably the extent of the valid points he makes in the movie.

Before going any further, I want to go around record as saying I would *love* to have excellent access to health care for myself, everyone I know, and everyone I don't know in the hopes that we could maybe all get along better if we just had the care we needed. The problem is, it's just not really clear that this is currently possible, or what actions might take us further from or closer to this dream. Legislation is costly, changes dramatically after it is introduced, and can arguably produce a result that is the opposite of what was hoped for. The Wright brothers accomplished flight on their own, despite the fact that government had invested resources in a failed attempt to do so. More relevant, although the human genome was mapped through a cooperative public effort, it had stiff competition from the private sector.

But getting back to the movie:

HMOs: a common complaint about health care is that HMOs barely work and are costly behemoths. However, as Moore himself correctly points out, HMOs arguably owe much of their existence to legislation signed in the 1970s that incentivized their creation and existence. Although I have no first-hand account of the movement leading up to the legislation, I'm fairly certain it was presented by members of Congress, the President, and many others as a way to improve health care. This is an excellent example of why one might consider exercising skepticism when presented with legislative ideas that "sound good" without good empirical evidence of their likelihood of success.

Social Programs: Surprisingly, Michael Moore points to the "free" library system, "free" education system, and the "cheap" post office. I don't think I really have to say anything more except maybe that yes, even libraries are cutting back on services and turning away patrons because cities just can't handle the expenses.

For-profit insurance companies: another complaint about those pesky insurance companies is that their CEOs suck up all the money in their compensation along with the shareholder and retained profits. However, one would really need to find out how much of the CEO compensation is in the form of exercised stock options versus an actual cash payout, and one would need to consider how much profit is retained by the company in comparison to what they charge consumers, etc. I don't have any figures but as an example, if a company has 20 million enrollees and has $10 billion in profit at the end of the year, the most they could ever possibly give back to enrollees is $500 each! But profit has to go to shareholders and towards company growth so that they don't go out of business.

Medical Reviewers: Sadly, there are probably unethical people in all professions. Medical reviewers are probably no exception. As for the argument that everything should be covered and nobody should ever be denied any coverage, it would be a *really* good idea to have a firm idea of the numbers before attempting anything like that. Also, keep in mind, we already have EMTALA (Emergency Medical Treatment and Active Labor Act) which essentially means that anyone who shows up at an emergency room at almost any hospital must be screened and stabilized without consideration of medical coverage or financial resources. Also, by law, no physician may terminate treatment of a patient for financial reasons without giving adequate notice for the patient to seek care elsewhere.

Lobbying: Yes, it seems horribly unfair but it is everywhere. The "big pharma" argument is really just an argument against lobbying.

Canada: Moore presents some interesting anecdotes but nothing more.

Life Expectancy: If life expectancy is lower in the U.S. it could be for almost any number of reasons: Violence, pollution, dangerous roads, and sedintary lifestyle just to name a few. It's possible that health care is not the cause.

London: Again, nice anecdotes but nothing more.

France: Wow, yes, having someone from the government come to do your laundry after you have a baby does sound really good. It sounds good. But you can't look at these things in a vacuum. You need to consider the effect that having so many programs has on the country. For me, it is intuitively inefficient to have a government program for doing your laundry. The more inefficiency a society has, the more problems it has. -- I also found it interesting that the man who had chemotherapy for his cancer was able to get a doctor's note to get a 3 month paid leave from work which he used, in his words, "...to soak up the sun..." (the irony being that he was paid to go soak up sun after being treated for cancer).

How would *I* "fix" health care?: I think I will write another post on that after we see what happens with this $1 trillion dollar Bill. I can tell you one thing though, if I wanted to bring down the amount being spent on health care I would probably not go out and spend more on it - and certainly not $1 trillion. That is more than a whopping twice the amount of our budget deficit for 2008! I'm pretty sure that would qualify as spending more on health care, not spending less.

Movies, movies, movies

Food, Inc. was just released and I have yet to see the movie. I have seen a couple of previews and noticed a couple of interesting tidbits as well as some concepts that reminded me of some other movies I've recently watched. I suppose I'll have to see the actual movie before commenting but I am certainly able to seize the moment to discuss some other movies that came to mind.

Super Size Me - I didn't care for this movie because I found it to be misleading and unscientific. It has been a while since I've watched it but as I recall, among the many problems with the movie was the fact that the man at the center of the movie didn't analyze the fact that he had been on some type of vitamin and was probably eating vegetarian food prepared by his partner for most of his meals and then suddenly switched to the unthinkable habit of eating until nausea or vomiting for almost every meal and suddenly not getting any exercise. Couldn't his problems have been from this rapid shift? And what empirical evidence is there to suggest that eating McDonald's even once a day would yield any of the effects that he incurred using his methods?

The Future of Food - I enjoyed this movie because of its discussion of biotechnology and related legal concepts, issues, and problems. It tackles matters and uses facts not really discussed anywhere else nowadays in popular media such as questions of whether governing officials are too closely tied to private industry to be trusted with protecting our health in a high-tech world.

Bitter Harvest - If for no other reason I have to admit that I enjoyed watching this simply because it stars Ron Howard (a.k.a. Richie Cunningham) in a very early 1980s movie. More than that though, the movie is based on an actual event that left millions of people in the country with traces of a fire-retardant chemical in their bodies permanently after the chemical found its way into the dairy supply. I would have to assume there are still millions of people to this day with the chemical present. The movie also addresses the problems that can occur when we empower regulatory agencies to decide what is in our best interests.

King Corn - A pretty good documentary which brought to light some interesting (and highly relevant) facts about corn production in the U.S. One of these first things I remember about this movie is that it did a good job of mentioning some of the potentially big problems that can result subsidizing an industry. (I'd mention General Motors but this blog is supposed to be related to health.)

Sicko - This is extremely relevant right now considering Obama's push for health care reform. I have much to say about this topic. I think it is best saved for what may be my next post. As for the movie - I found it full of anecdotes and fairly devoid of good empirical data.

Tricorder Beta?

I humbly confess that I used to watch Star Trek "Next Gen". The tricorder was an instrument that a fan of nearly any Star Trek series is likely familiar with. The device was capable of measuring all kinds of things including vital signs and unhealthy air. The latter came to mind when I read an interesting article about the possible future of cell phones as "scientific devices".

It's not that cell phones are expected to literally sense air composition. Rather, with GPS the cell phones could easily tap into data on a large-scale basis. This got me to thinking though, if Google can drive a van down every street in every major city and snap panoramic pictures, who is to say that there won't some day be devices installed every few streets in cities that measure the air quality and report it in real time right to your cell phone? How about UV?

I do not at all claim to have any information supporting the notion that would even be market demand for such a concept. Rather, it's just interesting to imagine.

As a side note, this also reminded of another sci-fi movie: Gattaca - in that authorities carry small measuring devices that use biometrics which I presume are linked via satellite to a database that yields real-time information about the individuals in front of them. Unless, of course, the individual does what Ethan Hawke did in that movie. What's that? You haven't seen it? You might be surprised what is on the internet nowadays...

Glowing Puppies, Monkies, and Babies (and Mice with "Human Ears")

When I read the headlines about glowing green monkeys I immediately recalled other recent news articles about glowing red puppies. There is, of course, a key difference between the two developments.  While the glowing dog story involved gene-splicing, it did not involve a key aspect of the marmoset gene-splicing.  With the marmosets, after the gene-splicing was complete the "recipients" reproduced and actually passed on the new DNA sequence.  This is being considered a significant milestone and rightfully so.  The implications for research and medicine are tremendous (researching treatments for human diseases is just one benefit) and the ethical implications are possibly broader - especially when you wonder how far away human gene-splicing is and the potential effects on future generations.  It is important to keep in mind how quickly science is moving along.  It's moving even more quickly than I thought.  I mistakenly thought back to what I thought was another example of genetic manipulation around 12 years ago.

The mouse with the human ear, however, really had to do with cow cartilage being placed under the skin of a mouse, and not genetic manipulation as such.  More closely related to the marmosets is the story of baby Jessica.

Also just a little over decade ago, scientists successfully selected a gender of a human baby named Jessica.  Some raised concerns over the future of so-called "designer babies."  Even that technique however, was really a technique using selection during artificial insemination.

The marmoset gene-splicing is a completely different twist and, as its terminology suggests, really does involve splicing in DNA from a different species - in this case a jellyfish - and from now on babies of those marmosets can inherit the DNA the same way they can inherit marmoset DNA! 

Okay, so how DID health care become so expensive?

I am happy to see that a leading publication such as Reuters has mentioned a rarely-discussed turning point in the cost of health care.  The article discusses the effects of folks being "tied" to their employee health plans.  The turning point I mention is that during World War II the federal government instituted a cap on wages which meant that employers could not pay more than a predetermined amount (I think this was done in an attempt to stifle inflation and was possibly considered by some as a way to support high production of war time industry).  When employers wanted to attract workers and couldn't do so by raising wages, they came up with the idea of offering health insurance which was not considered "wage" and was therefore permissible.

This was a turning point because it marked the large scale shift towards a society with a third-party payer for health care.  Today, in fact, the majority of people with health coverage are covered by an employer-provided plan.  Under the "old system" well before World War II folks usually paid for physician and hospital services out-of-pocket.  This meant that they had a great deal of incentive to reduce their use of services.  This low-demand situation was necessarily met with lower prices by physicians and hospitals who had to attract consumers.

The big change came on a large scale during World War II when the third party payer system began en masse and lifted the burden on the consumer.  The patient could then obtain more services which in turn enabled physicians, hospitals, and the like to both perform those services and gradually raise prices knowing that they would get paid by the third party.

This is just a simple explanation of the beginnings of the third-party payer system and, as such, yields the opportunity for many future posts discussing the costs of health care today.

Standard and Poor's UK Rating (yes, it's relevant)

Whenever people talk about the state of health care it is highly likely that cost and financing will be discussed.  Whether you believe it or not a discussion of economics - even global economics - is relevant to the cost of health care.

According to Bloomberg, Standard and Poor's has indicated a negative outlook for U.K.'s credit rating.  Historically, U.K., United States, and other leading nations have held AAA credit ratings which is the highest possible rating.  The announcement of Standard and Poor's outlook is of particular interest to me because I remember that several months ago, U.K.'s central bank lowered its target interest rate to the lowest since the 1600s.  Its near-zero rate raised the issue of what would happen if it didn't work (the U.S. near-zero rate raises the same question).  The connection between the target inerest rate and the credit rating is this: governments acheive their target interest rates by buying their own bonds (in the U.S. the Federal Reserve Bank purchases Treasuries on the open market as well as directly from the Treasury).  Two observations can be made from this process: 1) The government is borrowing more money (A LOT more during this crisis) 2) This process can also be thought of as "printing money" - that is, the money the Treasury borrows didn't really exist before it sold bonds (and paid them off).  When you print money, you inflate the money supply, which causes devaluation pressure, and possibly lowers your credit rating.

The relevance for medicine is that in the U.S. government spends (depending on the year) close to half of all money spent on health care.  One might be tempted to think devaluation of the dollar won't really affect health care so much then because government won't be willing to pay dollars to compensate for the fact that the dollar is worth less, and then people working in health care will just have to take what the government gives them.  Actually, they won't.  If people working in health care get paid less and less because of a devalued dollar, they will find other places to work where the pay can better help them survive.  One can imagine what would happen to the state of health care then.

On the other hand, if health care spending becomes more federal and the government just prints more and more money to put into health care and other sectors the cycle continues until the government can't print money fast enough to keep up (I suppose eventually people would just value the dollar so much less than say, a Canadian dollar, that people would tend to work in fields where they can get paid in Canadian dollars.)  In that case, for the most part the U.S. government would no longer be able to finance health care as we know it - instead it would be financing a backwards and possibly unsafe health care system where only a fortunate few will have anything resembling reasonable access to the decreasing numbers of physicians and facilities.  If you don't "believe in inflation" and its ill effects consider the extreme example of Zimbabwe which was recently calculated at a 231 million percent inflation rate.  I don't think we'll see that rate any time soon but inflation doesn't have to get to that point before most of us suffer its effects.

So what's the solution?  It depends on who you are, and it depends what kind of time frame you're talking about.  If you're at a good job with good coverage you might not need a solution right now.  If you don't have coverage you might try to find a way to get covered and stay covered by a government program (although if you're an "average" adult male you might find this is impossible).  If you are interested in medicine as an innovator, researcher, or developer - the world needs you - we need you to find a way to do an "end-run" around the system - kind of like the way fax and e-mail did an end-run around the post office.

Iressa (by AstraZeneca) - A Good Example of PGx

A new trend in medicine goes by several names: Personalized Medicine, Pharmacogenomics, Pharmacogenetics, and more. The names are often given similar yet different meanings depending on who you ask. It is probably most accurate to say that the broad concept of Personalized Medicine includes several concepts - among them Pharmacogenomics appears to be the largest and most significant

Pharmacogenomics combines the words pharmaceuticals and genomics to describe medicine based on the link between genetic patterns and the way an individual will metabolize types of drugs, as well as to precise types of diseases. I recall reading that there are now thought to be 5 different types of asthma with genetic markers for each. New developments in this field are made frequently.

Lung cancer patients, who might receive a prescription for standard chemotherapy drugs or an alternative drug, can be tested for a mutation of gene EGFr to determine whether they should be presribed Iressa or receive standard chemotherapy if they do not have the mutation. This and similar recent research was recently reported on by Marilyn Chase for Bloomberg.