Tuesday, August 31, 2010

Looking Again at the Anglican Health Network

Once again the Council of Anglican Provinces in Africa (CAPA) has met.  There have been the predictable comments rejecting the Episcopal Church.  However, during the buildup to the conference many comments were repeated about Uganda specifically not accepting financial assistance from the Episcopal Church or sources within the Episcopal Church – even as some were noting support for the conference from Trinity Episcopal Church, Wall Street.  Logistical support form Trinity notwithstanding, it was because of decisions like Uganda’s that caused me concern about loss of support for joint ministries.

Which brings me to the Anglican Health Network.

It’s been a while since I mentioned the Anglican Health Network here “at the Bedside,” as it were.  In that time, a lot has happened, and it’s worth sharing.  Here are some highlights you can find at the Network’s web site:

  • There’s the Health Microinsurance Project, now being piloted in Dar es Salaam, Tanzania, and in Karakonam, India.  The idea is to apply the same principles to health insurance that have been so effective and so important in providing microcredit, small business loans in developing countries.  The Network has brought together individuals and dioceses that can provide some seed money, but the intent is that this will become self-sustaining.  It will allow thousands to take advantage of medical care that is already around them but beyond their financial reach.  In fact, the India project has already registered 25,000 members.
  • You can access the Newsletters of the Anglican Health Network.  This summer’s Newsletter has articles on malaria, with a sidebar on the Nets for Life Program; on health issues at the G20 Summit; and health ministries in Haiti.
  • There are links to Anglican and Episcopal hospitals and health ministries around the Communion.
  • There’s even a blog with periodic posts by Paul Holley, Coordinator of the Network.

The Network grew from ideas shared at the first International Episcopal/Anglican Healthcare Ministries Conference in Houston, Texas, in January, 2009.  Individuals and institutions in the Episcopal Church are involved, and have been involved from the beginning.  However, the Network has taken off with some important programs.  We have a lot more going on in health ministries in the Anglican Communion than most of us know.  The Anglican Health Network web site is a good place to start learning about it.

Monday, August 23, 2010

Up Again at Episcopal Cafe

My newest piece for the Episcopal Cafe has been posted.  It's a reaction to "the new Carnegies."  It's a reflection both current and historical, I think; so take a look, and let me know what you think (there or here).

I'm raising a question: what ever became of investing in human resources - a question that goes way beyond simply adding jobs and employing people.  Investing in human resources involves good public education (K through whenever); good public health (because all our health is public); and, an economic that, while not preventing some of the rich from getting richer, at least strives to prevent the poor from becoming poorer.  Sure, there are good employers that do invest in their people; but really investing in human resources as a society will take a whole lot more than that.

Friday, August 20, 2010

For the Public Good - Before the Bugs Win

We've been talking a long time about antibiotics.  We've talked about overuse because of an expectation that the doctor will "do something," especially for children.  We've talked about drug-resistant strains of disease-causing bacteria.  We've talked about patients not completing an antibiotic prescription, allowing resistant bacteria to survive and multiply.  We've talked about those drug-resistant bacteria moving from the hospital into the community.  We've talked about antibiotics in agriculture, and how they might affect us as they end up in the food supply.  We've even talked about, or at least heard about, antibiotics ending up in the water supply, both from agriculture and from "old" pills flushed down the sink.

We've also talked about what to do when they begin to fail.  Note that I said "when," not if.  We know that, in the face of the trends above, our antibiotics will become less and less effective until, at least for some uses, they cease to work at all.  In fact, it's already happening.

A recent article in the Chicago Tribune highlights that failure, it's high cost, and key difficulties in addressing the problem.  The article focuses especially on the tension between the FDA and the pharmceutical companies.

The article focuses on one specific issue in the development of antibiotics: how, or really, against what standard should they be tested.  Is it enough for the new antibiotic to be roughly as good as an existing antibiotic for the same disease?  After all, “roughly as good” may well mean “not quite as good,” but without enough data to be certain – certain whether it’s as good, and if not quite as good, by how much.

Or, do you test that it’s at least as good and perhaps better than an antibiotic currently in use?  The two ways to accomplish that would be a double blinded comparison study, or a double blinded placebo control study.  The blinding (“double blinded” means neither doctor or patient knows which pill the patient receives) would mean that the results would be dependable.  These would set higher standards that would prove (or disprove) clear effectiveness and even superiority. 

There are, of course, two issues with the more rigorous testing.  The first is that , even testing with sinus infections and other non-life-threatening bacterial infections, how many patients would consent to a comparison trial, much less a placebo controlled trial?  The second is, of course, that the more rigorous testing takes more time and costs more money.

We need to take seriously the second issue.  According to the article, “Drug companies are abandoning the antibacterial business, citing high development costs, low return on investment and, increasingly, a nearly decade-long stalemate with the Food and Drug Administration over how to bring new antibiotics to market.”  While the article is focused on the issue of the FDA approval process, development costs and low return are significant challenges.  This is part of the challenge of for-profit health care – and pharmaceutical companies are certainly for-profit health care.  I’ve commented before that the drug companies are especially interested in medicines for chronic diseases.  Patients take such drugs regularly for years, providing a steady revenue stream.  Antibiotics aren’t quite as low return as vaccines, that, if things go right, are taken only once or a few times in a lifetime.  However, they aren’t like the chronic meds.  The patient will take them for a ten days, or a week, or less.  Indeed, in some infections the patient still receives the drug just once, as many of us received one injection of penicillin (my memory is of one painful injection, but I was small) for strep throat.

At the same time, the development costs are as high as with any other medication.  The axiom is that “The first pill costs a million dollars.  Every pill after that costs 35 cents.”  (And that axiom has been around for a while; a million dollars is, by today’s standards, blessedly cheap.)

Still, I find myself wondering if there isn’t reason to temper the requirement for profit, especially for antibiotics.  You see, pharmaceutical companies spend their time and money on applied research.  That is, they put most of their efforts into taking the research of others, and developing specific applications.  Certainly, they do some basic research – gathering new knowledge without a specific application in mind – but most basic research is done in academic and clinical settings.  Basic research is, for example, the Ph.D. candidate wandering through the jungle collecting plant samples, analyzing back in the lab the proteins and chemicals they produce, and testing what effects those proteins and chemicals might have.  Applied research is taking one of those chemicals because of an effect it has shown, developing that into a specific drug, and completing the tests that show whether it’s safe and effective.

The thing is that, while pharmaceutical companies do pay a lot to complete the applied research, they don’t pay nearly as much for the basic research they base the applied research on.  Instead, we pay a lot for it.  That is, much of it is paid for with tax revenues and fees paid to government and distributed through such agencies as the National Institutes of Health.  Much of it is also paid for with charitable contributions, whether large contributions from private foundations or smaller, individual contributions to the latest telethon.  The research is available to the pharmaceutical companies because it’s publicly available, published in peer-reviewed journals.  Sometimes it makes it possible for researchers to start their own companies, taking their own basic research and developing the applications. 

My question is what the for-profit pharmaceutical companies owe to the larger society in compensation for the basic research that they don’t pay for.  Oh, they certainly do pay taxes and contribute to charities; but, then, so do we, and I bet they don’t pay anywhere near the percentages of their income that most of us do.  On top of that, while they take some clear risks in applied research, they don’t have nearly the risk that we do paying for basic research.  Sure, some applications don’t work out, but they don’t make the effort without some likelihood of success.  Basic research, on the other hand, is knowledge for its own sake, whether there’s money in it or not.  So, arguably it’s mostly risk.  That is, while a plant sample or a new animal may produce lots of chemicals, there’s no reason to expect that any one of them, or even most of them, will be useful, or, at any rate, more useful than chemicals already identified. 

So, might we expect pharmaceutical companies to take on less profitable pursuits like antibiotics as public goods, doing so as compensation for the basic research that they didn’t pay for, but without which they wouldn’t have any products?  Somehow, I don’t expect it.  However, I think it’s a question worth asking.

Saturday, August 14, 2010

A Chance to See Both Sides

One of the statements I’ve heard about the Affordable Health Act (our new health care law) is that it is “an experiment.”  For supporters, that’s because it’s how we begin to discover how to meet the goal, in this case, access for all to affordable health care.  For critics, it’s that’s because we can’t know ahead of time how well it will work, with the implication that in fact it won’t.

And both are right, at least to some extent.  This is an experiment, at least to the extent that we haven’t really pursued a goal we’ve been talking about for generations.  It’s also an experiment in that we can’t know all the consequences, including that we can’t know how close this will get us to our goal.  One the other hand, many of us think it can work, and once again doing nothing certainly can’t.

Well, now we’re not the only ones experimenting.  Several weeks ago it was announced that the new administration in the United Kingdom had decided to make some changes to the National Health Service in England (services in other parts of the UK are separate and will not be affected).  They published a white paper describing the goals of the changes.  These included allowing more control over health care decisions to patients and to general practice physicians, with less control by bureaucrats.  Goals also included focusing on procedures that work, and no longer supporting those that don’t – much like our new health care law’s efforts at measuring effectiveness.

Over all, these goals seem quite ambitious.  At the same time, while goals are interesting, so are the measures taken to meet them.  Now we know a bit more about that.  The first step appears to be to privatize in whole or in part NHS Professionals Ltd, a subsidiary of the National Health System that provides employees for NHS hospitals and practices.  It functions largely as a temp agency within the National Health Service.  While what steps can be taken isn’t clear, the point will be to begin a decentralization of NHS structures and creation of opportunities for for-profit companies to provide services to NHS institutions.

Now, just as President Obama has insisted that, while our Government is more involved in overseeing health care, it remains primarily a private-practice, market oriented industry, so the British Government says that, even with decentralization and some private participation, it remains committed to the National Health Service as a service of the government.  That makes this all the more interesting.  As we experiment with more government involvement in our health care, they are experimenting with more market involvement in their health service.

While a great deal of attention is being paid to the fall’s Congressional elections, the new health care law is safe at least until our next presidential election (and longer if President Obama is reelected).  At the same time, there won’t be a new Parliamentary election in the UK for a while.  That gives us some time to see how this unfolds.  While we’re discovering what it means for us to have more government involvement in health care, they’ll be discovering what it means for them to have less.  I think there will be something to learn in both processes.  If we’re wise, I think we’ll pay attention to both.

Sunday, August 08, 2010

A Bit of Good News About Medicare - and "Obamacare"

So, since the passage of our new national health care law, consequences and projections of consequences are coming out a little at a time.  Most have had to do with who would get more coverage and how, and what the costs would be for various groups.

Friday we had a report of a somewhat different consequence, one that many of us will appreciate.  According to the 2010 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds – that is, Medicare –

The financial status of the HI trust fund is substantially improved by the lower expenditures and additional tax revenues instituted by the Affordable Care Act. These changes are estimated to postpone the exhaustion of HI trust fund assets from 2017 under the prior law to 2029 under current law and to 2028 under the alternative scenario.

I’m old enough to have some expectations of signing up for Medicare – not next week or next year, but in the plans.  I’m also young enough to expect to need it for some time, or at least to hope to need it for some time.  That additional 12 years is a happy thought.  No, it’s not enough – I certainly hope it won’t be enough for me! – but it’s more time, and it’s more time to make further necessary improvements.

Well, that’s certainly god news – but, it’s a good news/bad news sort of situation.  The same report says

The SMI trust fund is adequately financed over the next 10 years and beyond because premium and general revenue income for Parts B and D are reset each year to match expected costs. However, further Congressional overrides of scheduled physician fee reductions, together with an existing “hold-harmless” provision restricting premium increases for most beneficiaries, could jeopardize Part B and require unusual measures to avoid asset depletion. In particular, without legislation, Part B premiums payable in 2011 and 2012 by new enrollees, high-income enrollees, and State Medicaid programs (on behalf of low-income enrollees) will probably have to be raised significantly above normal requirements to offset the loss of revenues caused by the hold-harmless provision, raising serious equity issues.

For those of us who didn't know (including me), it seems that Medicare is made up of two trust funds, one of which is about hospital expenses (Medicare Part A) and the other about other medical expenses (Medicare Part B).  While the first (Part A trust fund) is in better shape because of the new law, the second (Part B trust fund) isn’t really helped.  Moreover, while it’s still good for at least a decade, largely because premium fees will go up, two things prevent it improving.  One is acts of Congress that have prevented scheduled reductions of reimbursement to doctors, acts which now seem to have become annual events.  The second is this “hold-harmless” provision.  “Hold-harmless” is a common enough concept in contract law, on which I am not an expert.  However, in this case it’s a provision that has to do with Part B benefits.  If one’s premiums go up in a given year faster than benefits, the result is a net loss in benefits (the patient ends up paying more in premiums, but not getting more in benefits).  Under the Medicare “hold-harmless” provision, benefits can’t be reduced even when premiums rise faster.  So, the increases don’t result in as much new revenue as they might. 

So, there’s some good news, something we haven’t heard for a while about Medicare funding.  There’s also a reminder that we still have work to do.  For example, reducing reimbursement to doctors doesn’t seem all that good an idea.  We’ve had many reports in recent years about doctors who feel they can’t take any new Medicare patients – or perhaps any Medicare patients at all – because reimbursement, already poor, is supposed to go down even further.  And between the doctors lobbying to prevent the reductions, and American seniors lobbying to feel secure about their doctors, the reductions aren’t nearly as politically palatable as the annual votes in Congress to stave them off.  But, the guidelines for the reductions and the scheduled dates are matters of law, and so only changes in the law can actually address the problem.  The same is true of raising the age of eligibility, or adjusting premiums and/or benefits according to income, or other adjustments that would redefine premiums and benefits in ways that would secure Medicare beyond current projections.  We’ve known for a long time that real Medicare reform, reform that would take us beyond annual adjustments and Congressional tweaking, will involve extension revision of the entire framework of Medicare.

Still, I’m glad of this good news, and I’m glad it’s a consequence of the Affordable Care Act.  There are so many claims out there about its shortcomings, that I’m glad when we can identify clear benefits.  The Affordable Care Act is, really, just a start.  There is much more to be done to secure health care for all residents of the United States.  That “much more” also includes the changes we need to secure Medicare.  We’re far from done; but we’re close than we’ve ever been before: we’ve made a start.

Tuesday, August 03, 2010

Making the Shots Even Longer

I know that I was distracted through most of July working on my peer review materials. However, that didn’t mean I wasn’t paying attention. So, I when last week I was listening to All Things Considered on NPR, a story on vaccines caught my attention.

The story, reported by Kelly Weiss, was about physicians, both pediatricians and family practitioners, who were struggling with whether and when to provide some of those vaccines that we feel are a part of childhood. While we’ve heard a lot in the past few years about parents (and a rare few doctors) having anxieties about ingredients in vaccines, and about associations of vaccines with long term consequences such as autism, that wasn’t the problem. Instead, the problem was expenses related to the vaccines themselves. The physician interviewed spoke of paying for vaccines almost twice what insurance companies would reimburse. As a result, she spoke of delaying vaccines for children, or, for some children, of foregoing vaccines entirely. Even as she was being interviewed for the story, she was conscious of the outbreak of whooping cough not far from her in the Los Angeles area, and of the risks faced by any patients she hadn’t vaccinated.

In her story, Weiss interviewed Dr. Gary Freed, and cited his work. He and colleagues published the article, “Primary Care Physician Perspectives on Reimbursement for Childhood Immunizations,” available on line in the journal Pediatrics (in its first publication here, and in a “supplemented” version here – but, I can’t spot the difference). They surveyed 1280 pediatricians and family practitioners, and had a 65% response rate. They asked questions about the purchasing of certain vaccines for children, about reimbursement for providing them, and about whether the physicians had delayed or had stopped providing the vaccines, and whether they had considered no longer providing any vaccines. They also asked whether the respondents were directly involved with decisions about purchasing and distributing vaccines so as to distinguish the responses of those “directly” involved from those “indirectly” involved.

The responses were very interesting. Almost half (49%) said they had delayed purchasing a new vaccine for financial reasons. Those “directly involved” were more likely to report this than those “indirectly involved.” 58% “disagreed” or “strongly disagreed” that reimbursement was adequate for the purchase of vaccines, and 51% “disagreed” or “strongly disagreed” that reimbursement was adequate for the administration of vaccines. 65% “agreed” or “strongly agreed” that they would not provide a vaccine if the cost were more than the reimbursement. When asked whether respondents or their practices had considered no longer providing vaccines to privately insured patients, 66% responded “never;” which means, of course, that 34% had at least considered it.

While the researchers did ask about discontinuing vaccines, they felt all of the results spoke of issues in adequately protecting their patients and the public. They wrote:

Discontinuation of immunization services should not be the only end point of concern. Almost half of the physicians in this study had delayed purchase of a recommended vaccine due only to financial concerns. Al- though the length of the delay was not specified, this implies that at least some children either did not receive recommended vaccines, and therefore remained at risk for vaccine preventable diseases, or that they may have been referred to the public health system for vaccination.

Now, before we get all high and mighty about greedy physicians only in it for the money, there are several things we need to remember. First and foremost, in our market-oriented health care system, most physicians are really small-business persons. That’s what a private practice office is, really. Yes, the physician wants to make enough money for themselves and their families (and fewer and fewer of them are getting rich in their practice) and to be reimbursed adequately for their training and levels of responsibility. However, they also have employees to pay and provide benefits for. They have to pay rent on space, and to pay the utilities. They have to provide equipment and supplies, and to replace them as they’re used up (and while a doctor may or may not want to be “not for profit,” you know the companies they by from are as profit-centered as one can imagine). They also have other expenses, such as their malpractice insurance and, for many of them, student loans.

Remember, too, that those expenses can be expected to rise gradually from year to year. We expect a certain amount of “growth” in our economy, and that “growth” translates into higher prices. And even the “not for profit” have to keep up, or cease to offer services. As many have noted before, “No margin, no mission.”

There is, of course, an important moral issue. As I have discussed, all health is public. That is, each of us is affected as an individual by the health of others and by the health of the community as a whole. The current outbreak of whooping cough is a good example. Whooping cough or pertussis is a serious disease, dangerous both for children and adults. We have thought it controlled, but that was precisely because almost every child has been vaccinated. The small number of children who didn't get vaccinated because they couldn't medically were still somewhat protected by the "group immunity;" that is, if almost everybody was immune, there would be almost noone from whom to catch it.

But that has changed in the past decade. Sure, it's still the case that the great majority of kids get their vaccinations. However, the number of kids who don't has been creeping up. Some of that is anxious and misinformed parents. Some of that is our current recession, with people losing employer-based health insurance and/or having less money for health care (or anything else). Some of that is new immigrants, both documented and undocumented, who don't know or are afraid to use the resources available.

And some, it appears, may be the net costs (vaccine cost minus reimbursement by insurance and/or patient) to private practice physicians. None of the other three issues are new, although they all appear to have grown recently. This last feels new, or relatively new, to me. We have enough trouble addressing the first three problems, and I don't think we need a new one.

There are some states that address this differently. In “universal purchase” states, certain vaccines are purchased by the state at a price negotiated by the Centers for Disease Control, and then distributed to both public and private providers. They then provide them to patients at little or no cost. Providers can also purchase vaccines from manufacturers if they would prefer, and charge for them as seems appropriate. (Note that Freed et al did not include in their survey pool physicians in “universal purchase” states.)

There are also issues simply about how much vaccines cost. Unlike medications for chronic disease and health maintenance, vaccines aren’t that profitable. After all, if they work, each dose is given once. A drug for cholesterol or for blood pressure is taken every day, perhaps for a lifetime. So, for the pharmaceutical company those drugs for ongoing use are a lot more profitable. Since pharmaceutical companies are certainly for-profit, they tend to focus their research and development on the drugs that will make the most money. That’s not to say that they’re not interested in the public good. However, their profit, and not the public good, is the measure of their value and success.

Perhaps it’s best to come back to what I said above: that this is simply another issue in providing childhood vaccines that protect our children – and, really, all of us. We need, really, to be addressing all of them. However, among the four I mentioned (and there is at least one other, that of adequate access to providers in general, which is most acute in our most urban and our most rural areas), this is the one we haven’t noticed. Like the others, we need to work on the problem; and like any other problem, we can’t work on it until we’ve noticed it’s there.