Tuesday, April 27, 2010

Robert Collison, RIP. And the Deficit Commission Comes to Life.

Back in December, Serious Medicine Strategy took admiring note of an extraordinary medical operation that took place in New York City earlier that month. A team of surgeons led by Dr. Jean Emonds andDr. Tamoaki Kato performed a 43-hour ex vivo operation on Robert Collison, a Wisconsin man suffering from advanced and rampant cancer. In the ex vivo procedure, Collison's organs were removed, the cancer cut away, and then the organs were put back into Collison's body.

Now, sadly, five months later, Collison has died, as reported by The New York Times' Denise Grady, who has been following this case closely.

For his part, Dr. Emond, one of the team leaders at NewYork-Presbyterian/Columbia University Medical Center, said that the procedure would continue:

Dr. Emond said he expected the team in New York to continue performing ex vivo operations, even though health care “bean counters will be appalled at our profligate ways.” New York-Presbyterian/Columbia is a teaching and research hospital, he said, and part of its mission is to be innovative.

He said ex vivo surgery was still in its early days, and the team hoped to improve it to help patients like Mr. Collison.

“We’re not the kind of people who would stop,” Dr. Emond said.

And the truth, of course, is that everything is expensive and difficult at first. It only gets easier, and better, and cheaper, with practice.

But here's a prediction, the "bean counters" that Dr. Emond warns about will descend on this case, citing the expense--nearly $300,000, according to the Times--as an instance to be made into an example. This case could become a rallying cry for deficit cutters. Unfortunately, those deficit cutters don't see that a) such medical heroism is popular, and b) such medical heroism is also the beginning of a new industry.

As it happens, Tuesday. April 27 is also the day that the deficit commission holds its first formal meeting in Washington. There will be much talk about Medicare spending as the biggest driver of entitlement spending, which, of course, it is. And there will be much talk about restraining the growth of Medicare. But there will be little practical effect, because all the approaches being talked about--deep cuts, in some form or fashion--are deeply unpopular. One of the deficit commission co-chairs, former Sen. Alan Simpson, calls it a "suicide mission." In so saying, Simpson helps to cement his reputation for both candor and courage, but we might note that what's really needed is vision and effectiveness. That is, in the long run it doesn't do much good to simply describe a problem--what matters is fixing the problem.

What might be popular is a larger look at Medicare spending, in which ways to make people healthier are explored. Good health is cheaper than bad health. To cite an obvious example, vaccines are cheaper than the disease, outpatient procedures are cheaper than inpatient procedures, and pills are ultimately cheaper than just about anything else. But getting to the point where life-saving and life-enhancing procedures are possible is a great challenge. As with good writing, it takes a lot of work to make it look easy.

And there's even a place for ex vivo surgery in that future Medicare plan. Because while ex vivo might seem expensive, there are plenty of people who would happily pay the $300,000 for the operation--or a lot more than that. And over time, not only would lives be saved, but a new economic engine for New York City and other medical hubs would develop.

Sunday, April 25, 2010

"Faltering Cancer Trials" -- A Challenge to the Obama Administration

The New York Times publishes a tough editorial this morning, under the headline, "Faltering Cancer Trials," concerning the sorry state of the National Cancer Institute--and casting further light on the Obama administration's efforts in the healthcare field.

In a nutshell, it seems as through the Obamans have been so focused on expanding the size of government that they have lost sight of the effectiveness of government. A big but incompetent government is what Americans have come to expect, but they don't like it. And they certainly don't want more of it. As the Times puts it:

The nation’s most important system for judging the clinical effectiveness of cancer treatments is approaching “a state of crisis.” That is the disturbing verdict of experts assembled by the National Academy of Sciences to review the performance of clinical trials sponsored by the National Cancer Institute.

"A state of crisis." Hmm. For a disease, cancer, which is the second-leading cause of death in the US">claiming more than half a million lives every year. And a cost of more than $100 billion a year in direct outlays, to say nothing of indirect costs, including lost work and productivity.

And yet, as the Times details, the National Cancer Institute seems to be in chaos:

The most shocking deficiency highlighted by the report, issued by the academy’s Institute of Medicine, is that about 40 percent of all advanced clinical trials sponsored by the Cancer Institute are never completed. That is an incredible waste of effort and money, and a huge obstacle at a time when researchers are developing promising new therapies that must be rigorously tested.

These large, government-sponsored studies are supposed to be the gold standard — and very different from the narrow, occasionally biased studies sponsored by manufacturers seeking approval of a new drug.

The government-sponsored trials can be invaluable in comparing one therapy against another (manufacturers rarely want to put their products up against a competitor’s), combinations of therapies, or therapies for rare diseases with little commercial potential.

So it is especially worrying to hear the experts say that the system — run by the Cancer Institute at the National Institutes of Health — is so mired in cumbersome procedures that it needs to be completely overhauled.

The Cancer Institute funds clinical trials primarily through 10 “cooperative groups” of experts. They generate ideas for testing new therapies and conduct the trials through networks of cancer centers and community oncology practices. More than 25,000 patients, 3,100 institutions and 14,000 investigators participate each year.

Yet a series of reviews in recent years found that the testing operation is mired in bureaucracy and poorly coordinated. A typical trial must navigate past dozens of overlapping reviews by different boards and agencies that must approve the original concept for the trial and then the protocol that will govern how it is conducted before the investigators can start enrolling any patients.

The average time between developing the concept for a study and getting it started is about 2.5 years. The longer a study takes to get started, the more likely it is to become scientifically out of date, and the less likely it is that doctors or patients will want to participate.

Other factors, including failure to pay investigators and their institutions the full costs of a trial, can also impede enrollment. And if not enough patients are enrolled, the study lacks the statistical power to generate meaningful results and cannot be completed.

The Institute of Medicine panel, headed by John Mendelsohn, president of the M.D. Anderson Cancer Center in Houston, offered a range of suggestions for improving the prospects for success.

It called for reducing and consolidating the number of cooperative groups, committees and reviews; increasing the money to support the trials; increasing the academic rewards to encourage researchers to run clinical trials; setting strict deadlines for each step in the process; and prioritizing the studies most likely to be successful. All that should be done even if money has to be transferred from other research activities.

The need for improvement looms especially large now that the Obama administration is pouring substantial sums into “comparative effectiveness research.” That is essential to helping doctors determine which treatments work well and which do not — and holding down the cost of medical care.

Yes, it will be interesting to see what the Obama administration proposes to do about this issue. Speeches and rhetoric will not do.

So will the President call a top-level meeting to consider management reforms at the National Cancer Institute? Will he take time away from his other pending priorities, such as financial reform, "cap and trade," and "comprehensive" immigration reform to focus on improving the administration of vital health programs? Or will he be content to let the same bureaucracy that allowed the problem to get worse to work on it--read: worsen it--further?

It is also interesting that this cancer crisis seems to have grown worse during the year that the Obama administration fought so diligently to give the government still more power over healthcare. But a focus on "quantity"--that is, the size of government--seems to be a different thing than a focus on "quality"--the effectiveness of government. But perhaps the Obama administration does not agree.

Friday, April 23, 2010

Polio Makes a Comeback

Robert A. Guth, writing in The Wall Street Journal, reminds us that the ultimate issue in health is combating the diseases that jeopardize our health. So if, as Guth reports, polio is making a grim comeback, mostly in Africa, then the imperative is to keep polio from making that comeback. Financing of health insurance is secondary to financing of cures.

The Gates Foundation--that's Bill Gates, pictured above--has spent $700 million trying to eradicate polio from Africa, but the disease recently popped up in Tajikistan, and is still present in many countries around the world. For most Americans, fortunately, polio is a distant memory--or no memory at all. Thanks to the efforts of Dr. Jonas Salk and many others, a polio vaccine was introduced in 1955.

But the news from Africa and elsewhere is a grim reminder: The struggle against all the great epidemiological killers of the past is never truly over. As the Journal's Guth records, there's an ongoing policy debate between "vertical" and "horizontal" approaches to health. The "vertical" approach focuses on the disease, while the "horizontal" approach focuses on social conditions, including fighting illiteracy and poverty. It's possible to make a strong argument for both approaches, of course, and the Gates Foundation appears to be embracing both approaches.

But if polio, the virus, returns to America, Americans will quickly be reminded of the wisdom of the polio-fighters of decades past. Salk & Co. didn't fight poverty, they fought polio. And they succeeded against polio. In the scheme of things, their victory was relatively quick and decisive. By contrast, the fight against poverty has been, shall we say, a lot more complicated.

Yet today we can assert that those threatened by polio are more needful of ex ante vaccines, than they are needeful of ex post facto financing of their care--their wheelchairs, their iron lungs.

We don't want to go back to those bad old days.

"Health Overhaul To Increase Nation's Tab"

"Health Overhaul To Increase Nation's Tab" --that's the headline from the Associated Press' Ricardo Alonso-Zaldivar detailing a study from the Department of Health and Human Services that shows that Obamacare will raise costs while hurting Medicare. How could a program do both--raise costs and cut services? Simple: The bill adds as many as 34 new million people to the rolls, while transferring money from existing Medicare programs. Here's an excerpt of the AP story:

The analysis also found that the law falls short of the president's twin goal of controlling runaway costs, raising projected spending by about 1 percent over 10 years. That increase could get bigger, however, since the report also warned that Medicare cuts in the law may be unrealistic and unsustainable, forcing lawmakers to roll them back.

The mixed verdict for Obama's signature issue is the first comprehensive look by neutral experts.

In particular, the warnings about Medicare could become a major political liability for Democratic lawmakers in the midterm elections. The report projected that Medicare cuts could drive about 15 percent of hospitals and other institutional providers into the red, "possibly jeopardizing access" to care for seniors.

The Obama administration, of course, sought to distance these findings by their own HHS staffers, but just as obviously, the talk about controlling costs--however sincere it might have been from some Obamacare advocates--was ultimately a sucker's game.

But as with Charlie Brown and the football, some folks never seem to figure out that they are getting snookered.

Wednesday, April 21, 2010

Prosecutions Are Not A Strategy For Improving Health and Medicine

The New York Times’ Barry Meier raises many interesting--and disturbing--questions about the future of medical liability. That is to say, Meier, without saying it, Meier takes up the issue of medical progress, and whether or not we will have medical progress. The unspoken issue: While we should all oppose corporate malfeasance, we should also be fearful of the medical stasis that might result from a paralyzing of the system by which medical progress is made. To put it bluntly, medical stasis means that we die before our time. Medical stasis is a greater threat than corporate malfeasance.

The headline for the Times story reads, “When Heart Devices Fail, Who Should Be Blamed?” Focusing on a case in which the Guidant Corporation sold defective heart defibrillators, leading to at least six deaths, Meier details a debate in legal and governmental circles: Are fines--to say nothing of liability lawsuits, which can run into the billions--a sufficient punishment or deterrent for bad corporate behavior, or should authorities pursue criminal prosecutions as well?

In recent years, Meier notes, the Justice Department has imposed heavy fines on drug and device makers, and yet corporate executives have only rarely faced criminal charges. Yet this situation might change: “Officials of the Food and Drug Administration say that the Obama administration intends to push for more prosecutions of corporate officials, a move that is likely to please patient advocates but also to touch off intense debate.” In other words, criminal charges--and perhaps prison sentences--might in store.

Yet debates over civil vs. criminal liability aren't just legal and governmental issues. They are also medical issues. The legal and the governmental are connected to the medical. So those tinkering with the legal and the governmental need to be mindful of the medical, because the medical affects all of us.

Meanwhile, as the Times notes, Boston Scientific, which now owns Guidant, is looking at a $296 million fine, unless, of course, in the glare of publicity, such as this Times story, the legal rememdy is made harsher toward the company, and the Justice Department escalates to criminal charges.

But we might ask: Where's that $296 million going to go? The answer, of course, is that in federal cases, the money goes into the Treasury general fund. So what we are seeing, then, is the transfer of $296 million out of capital available for healthcare, over to the national fisc. That might be good news for bailout recipients, or other federal dependents; it might even be good news for budget balancers, those eternal optimists. But it is not good news for healthcare. Because not only is that $296 million gone out of the pocket of Boston Scientific, but the general signal has been sent--there are easier ways to make money than medical equipment. Allocation of risk-capital is always a pivotal issue in any industry. However, for obvious reasons, there’s a greater public interest in the allocation of capital to healthcare than to most other sectors.

And so, mindful of the year-long debate over Obamacare, we might pause to ask: Is it possible that the Obama administration is seeking to shrink the healthcare sector in the name of “bending the cost curve”? That is, by pushing capital out of the healthcare sector, is it trying to lower the share of our economy dedicated to healthcare? If the federal government says that spending 17 percent of GDP on healthcare is too much, then the reductions must start somewhere--and every $296 million helps.

So the average American, too, is a stakeholder in the discussion of medical priorities--or should be. After all, heart disease is the leading cause of death in the United States; nearly half a million Americans die every year.

The average American might therefore be justified in intervening in this legal-governmental debate, to ask a purely medical question: What's the best way, amidst this legal and political wrangling, to advance the science of medicine? More to the point, what’s the best way to advance the cause of helping people to live longer and better in the face of heart disease?

If the Obama administration decides to target medical executives for criminal prosecution, does that make it more likely, or less likely, that medical companies will stay in the field, to say nothing of going into the field? If, as they say, that things you tax you get less of--and what's the corollary for things you seek to imprison? Or does the Obama administration have some other plan for improving healthcare--that none of us know about?

Here at Serious Medicine Strategy, we hold no brief for Boston Scientific.

But lack of financial interest is not the same as policy disinterest. We are intensely interested in the process by which defibrillators and other devices are made, improved, and then further improved. And we feel the same way about drugs and other kinds of treatments.

We wonder, therefore, if we have lost sight of the real goal here, which is to make Americans healthier. If Americans are made healthier by piling on civil and criminal liabilities--chasing bad actors out of the system--then that's one thing. But if not, if we are simply shrinking the healthcare sector as punishment for bad decisions--that’s a much different thing. If Obama administration prosecutions are the beginning of something better, great. But if they are an end in themselves, then it’s not so clear that we, and our health, are better off.

Perhaps we should step back and take another look at how this system works. Right now, we have the equivalent of a machine for churning out legal and political judgments, not medical-scientific advances. We know how to make trial lawyers rich, and we know how to build big bureaucracies. But do we know how to move medical science forward?

What's the best strategic approach to advancing medical devices, and making them better? Maybe Boston Scientific is a part of the solution, maybe it isn't. But if Boston Scientific is not part of the solution, let's figure out, quick, what should be part of the solution. Let's not crush one company in the medical equipment space--and send a potentially scary signal to others in that space--and think that we have made any progress toward improving our prospects against heart disease. If not Boston Scientific, then who?

To answer these questions in a systematic way, we need a strategy--a Serious Medicine Strategy. Trial-lawyerism is not a strategy for improving healthcare. Neither is Naderism. Nor revenge. Even justice, desirable as that might be for other reasons, is not a strategy for improving healthcare. If somebody at Boston Scientific goes to jail, that jailing will not cure a single diseased heart.

What will cure a diseased heart is medical research. And medical research must be encouraged, not frightened away. If people need to go to jail, then they need to go to jail. But let’s not call that a healthcare policy. It’s no kind of strategy for improving the health of Americans.

Tuesday, April 20, 2010

Was Obamacare An Exercise in Vindicating Big Government? If So...

Interesting catch by David Paul Kuhn, writing in RealClearPolitics.com.

The PBS documentary "Obama's Deal" has a revealing moment. White House communications director Dan Pfeiffer is discussing how the president decided to focus on healthcare.

Pfeiffer: We were sitting in the Oval Office, and we were sort of having a debate around health care at one point, and the president said, "It's about health care, but it's not really about health care. It's also about proving whether we can still solve big problems in this country." And this was going to be the test case for that.

An interesting quote to dwell on, from Barack Obama: "It's about health care, but it's not really about health care. It's also about proving whether we can still solve big problems in this country." Kuhn's point is that Obama & Co. badly misread the temper of the times. Maybe that's why Republicans seem destined to win back the House, at minimum.

Friday, April 16, 2010

How long a wait for healthcare in the UK? How long a wait in the US in the years ahead?

Tom Shales, TV critic for the Washington Post, reviews the British prime ministerial debate last night and catches this item:

And if Americans have had presidential debates for 50 years, the British have had -- and been complaining about --"the National Health" since 1948. Questions about the National Health Service contained details that could well give the jitters to Americans already worried about recently approved health-care reform. Brown vowed that henceforth, all necessary operations would be performed within 18 weeks of diagnosis, which didn't sound very speedy and made one wonder how long the wait is now.

Good point! 18 weeks is the goal? What is it now? And what if they don't reach that goal?

And so, we might wonder, what does this mean sort of stultification portend for the US, now that we are moving down the same bureaucratic path?

Monday, April 12, 2010

"Wireless health care: When your carpet calls your doctor"

"Wireless health care: When your carpet calls your doctor. The coming convergence of wireless communications, social networking and medicine will transform health care"--that's a headline in The Economist. The article starts witha question about the iPad:

Is it possible that amid all the hoopla about Apple’s iPad, one potential use has been overlooked? Larry Nathanson, head of emergency-medicine “informatics” at one of Harvard Medical School’s hospitals, has experimented with using the device in the casualty ward. He writes that “initial tests with our clinical applications went amazingly well…the EKGs look better onscreen than on paper. It was great having all of the clinical information right at the bedside to discuss with the patient.”

And then come more answers:

Dr Nathanson’s enthusiasm hints at the potential of wireless gadgets to improve health care, and to ensure more personalised treatment in particular. Pundits have long predicted that advances in genetics will usher in a golden age of individually tailored therapies. But in fact it is much lower-tech wireless devices and internet-based health software that are precipitating the mass customisation of health care, and creating entirely new business models in the process.

Wireless health is “becoming omnipresent” in hospitals, according to Kalorama Information, a market-research firm; it estimates that the market for such devices and services in America alone will grow from $2.7 billion in 2007 to $9.6 billion in 2012. Don Jones of Qualcomm, a maker of networking technology, argues that the trend speeds diagnosis and treatment, and saves doctors’ and nurses’ time. GE, an industrial giant, and Sprint, an American mobile operator, have joined forces to offer hospitals such services. GE’s Carescape software allows the secure monitoring of patients’ health via mobile phones, as does rival software from Airstrip.

Yes, indeed, there is much potential in all these systems. But the key word in the previous sentence is "systems," as in plural. Eventually, someone is going to have to figure out how to turn myriad systems into one system, so that it runs as seamlessly as the old Bell System did in its heyday. In the 90s, Microsoft dreamed of MSFT on every computer, in the 00s, it was Google as everyone's search engine. We don't yet know who or what will provide the same integration for health.

Sunday, April 11, 2010

The War of All Against All in Healthcare--And A Better Approach. Leadership Needed!

If we fear Dr. Big Brother, and we should, we should also fear medical chaos. That is, it's perfectly possible to spend trillions of dollars every year on healthcare, and yet get disappointing results, if the money is spent by individuals and groups working at cross-purposes to each other. That is, if the trial lawyers wake up every day looking for people to sue, and if the regulators live in fear of investigators and scrutinizers to the point that they are paralyzed into inaction, and if doctors and hospitals fight the government when they aren't fighting each other, and if patients' groups are upset with everybody who might be slowing down a cure, even as limited-government activists seek to repeal much or all of the whole system, then it's easy to see that we are financing conflict, even chaos, not constructive medical effort.

Some would say, of course, that such struggling between interest groups is simply freedom in action, in a pluralistic and diverse country. Indeed, they might say that such struggling is the essence of our Madisonian system--checks and balances writ large.

And yet for all the importance we should attach to freedom, we should also remember the importance of consensus, teamwork, and common purpose. Otherwise we risk decay and decline amidst chronic squabbling. And the extreme version such squabbling and feuding is what Thomas Hobbes warned about four centuries ago--"the war of all against all." The illustration above is not meant to be taken literally, it's simply meant to evoke the idea that if we spend our time feuding, big missions, such as improving the health of the commonweal, will be left undone. Fighting may satisfy certain primal impulses, but fighting should not be an end in itself.

So how to get things done? Thus we come to the importance of leadership. If we can agree on certain goals, then we should figure out how to achieve those goals. Here at Serious Medicine Strategy, we have argued that curing big-killer diseases ought to be a goal that Americans can rally around. And we will need leaders to articulate those goals, and guide us toward achieving them.

In the meantime, we all might consider other ideas, too, about using healthcare as a platform for creating more jobs and growth. That's what the Japanese are doing, according to a report on the Nippon Keidanren in Japan Today:

The Japan Business Federation, the country’s most influential business lobby, is considering proposing that the government include health-related businesses as a key field for the creation of new demand under the nation’s growth strategy . . . the federation plans to call for extending remote medical care using the Internet and satellite connections as well as implementing joint development of drugs with Asian countries.

Japan, of course, is in something of an economic and political eclipse. Major Japanese companies, such as Toyota and Sony, have had serious problems, as has the country as a whole over the last 20 years. However, Japan should never be underestimated, and the power of the "Japan Inc." idea should not be underestimated. It worked before, it could work again--in more countries than Japan.

Dr. Big Brother? Who Will Guard the Guardians? Who Will Mediate the Medicators?

Two thousand years ago, the Roman poet Juvenal asked, Quis custodiet ipsos custodes? That is, "Who will guard the guardians?" Juvenal was referring to personal morality, but the question, more broadly, concerns any sort of concentrated power: What restraints on power? What checks and balances?

Such questions are always timely, in all manner of public and private settings, but two recent news items, concerning the interplay of state power and medicine, remind us all about what ordinary people fear about national health insurance. Most people want medical help from the government, but they also fear medical intervention, especially in personal and private matters.

Both news items are from the UK, reported by The Times of London, and both reveal different aspects of what people fear when they think of the medicine as a part of a vast bureaucratic complex.

The first story, written by Kate Youde, reports on how Britons discovered that the government had been removing body parts from deceased patients without permission:

Bereaved U.K. families will be told that the organ donor records of 800,000 people were wrongly recorded, leading to organs being removed from some loved ones without consent.

As Youde further reports:

The error came to light last year when NHS Blood and Transplant, which runs the organ register, wrote to new donors outlining details of the consent they had given. Respondents complained the information was incorrect.

The NHS corrected 400,000 of the false records but 400,000 people will soon be told the details held about them may be wrong and be asked to provide consent again.

That's going to be a lot of tumult--400,000 Britons being asked, again, about deeply personal choices for themselves and loved ones. Organ donation is an important issue, and there is much to be said for encouraging people to donate organs. But if the government, or anyone else, tramples on people's feelings of privacy and dignity, well, the people will trample right back.

The second story, reported by Chris Hastings and Maurice Chittenden, concerns politicking by the incumbent Labour government, which seems to have gained access to lists of cancer survivors, so that it can send them a postcard telling them that their cancer treatment would be at risk if the Tories take power in the May 6 elections. Labour has sent out 250,000 "cancer cards" so far--not all of them to cancer survivors, some merely to those who have been screened in the past few years--and has plans to send out a total of 4.5 million cards, targeted to various issues and concerns.

Now how, exactly, did the Labour Party know who in the UK had cancer? Labour says that it got the list from a private database company, not from government sources. For their part, the Tories are not convinced that Labour is telling the truth.

Of course, many people seem to be disturbed by the mailers themselves--that is, the Labour government politicizing personal medical information, from wherever it might have been derived. On the other hand, some would say that the politicization bridge was crossed more than six decades ago, when the National Health Service was created. At that point, it became inevitable, and necessary, that politics would enter into just about every healthcare decision. And in 2010, this mailer is just another expression of such politicization.

Finally, we must also note that the Tories are not enemies of the NHS. As a Tory spokesman said in response to the mailer: "We are going to increase the NHS budget in real terms and cut bureaucracy and waste, we will have the capacity to ensure that cancer patients are seen sooner than they are at the moment and to meet the quality standards that they expect.”

So Labour and the Tories are now arguing over who will do more for cancer patients--that's politics. But still, there's something a little bit creepy about politicians knowing so much about you.

And now, of course, those issues are going to come to the US, in an ever more forceful way. as Americans wrangle over Obamacare in 2010 and probably every election thereafter. It must be noted, of course, that the government has always been involved, to at least some extent, in health matters--the Public Health Service, for example, was founded in 1798. And now, in the 21st century, very few American politicians will say that they don't want the government involved in healthcare. They will say, we want reform, we want to protect privacy, we want a better medical strategy, but few this side of Ron Paul will say that the government out to just exit the field. So the prognosis is: More politics.

And so the eternal question, "who will guard the guardians?" needs to be updated. Today, we might ask: Who will mediate the medicators?

Sunday, April 4, 2010

Palliative Care For You, Serious Medicine For Me

Did you hear the one about the "palliative care" doctor who wanted more than palliative care for herself? She preached palliative care to others, but when she herself was confronted with a serious illness, she wanted nothing but the best care--no matter what the cost. It's not really a joke, of course, and it's not a funny story. But it is a revealing story.

It's the story of the late Dr. Desiree Pardi, who died of cancer last September, at the age of 41, as chronicled by Anemona Hartocollis, writing in Sunday's New York Times. Dr. Pardi was diagnosed with breast cancer a decade ago, and was saved by Serious Medicine. Whereupon she decided to specialize in "palliative care," described by Hartocollis as the "gentle gospel" of accepting mortality without engaging in heroic measures, all the while focusing on avoiding pain and getting one's affairs in order, in anticipation of death.

For decades, now, that's been a popular approach to sickness and death--at least for others.

And yet when the crunch comes, such palliative care seems not be popular with the palliators. They themselves are regarded, by themselves to be different, more deserving of care. But let the Times tell the story:

In 2008, while on vacation in Boston, she went to an emergency room with a fever. The next day, as the doctors began to understand the extent of her underlying cancer, “they asked me if I wanted palliative care to come and see me.”

She angrily refused. She had been telling other people to let go. But faced with that thought herself, at the age of 40, she wanted to fight on.

While she and her colleagues had been trained to talk about accepting death, and making it as comfortable as possible, she wanted to try treatments even if they were painful and offered only a 2 percent chance of survival. When the usual cycles of chemotherapy failed to slow the cancer, she found a doctor who would bombard her with more. She force-fed herself through a catheter and drank heavy milkshakes to keep up her weight.

So Dr. Pardi fought the good fight, for her own life, all the way to the end. It's a shame that she died so young, and a reminder that there are still victories to be won against cancer and other premature killers.

But we are also reminded that pretty much everybody thinks as Dr. Pardi did--we all want to live. Others, too, in the forefront of the "good death" movement have made similar choices, including Peter Singer, the Princeton University professor,who chose to finance long-term care for his mother, even as she declined from Alzheimer's. It's fine that Singer wants to help his mother, but he shouldn't then be able to deprive of us of the opportunity to help our mothers.

As for the cost of such Serious Medicine, as argued here at length, Serious Medicine that really works becomes Routine Medicine, and then it becomes cheap--indeed, Serious Medicine-turned-into-Routine Medicine is the beginning of a new health industry.

The point is, most of us want to fight for our lives, and for the lives of loved ones. And if we want to, we should all get that chance, to fight to the utmost.

Friday, April 2, 2010

Healthcare Hangover, Part Four: The Silent Majority Has New Tools To Make Noise--and to Make Change. But Both Parties Need to Listen Carefully.

So was Obamacare really a wealth-distribution scheme? As we have seen, here at SMS, the obvious reality that healthcare spending is still going up calls into question whether Obamacare was ever sincerely cost-control effort as its proponents claimed, at least some of the time. Indeed, it now appears all the more likely that cost-control was just "boob bait for the Establishment," to freely adapt the late Daniel Patrick Moynihan's arch line about, certain conservative policies being "boob bait for the bubbas."

The Establishmentarian business community bought into Obamacare, thinking that maybe, this one time, the healthcare cost-cuts would be real. You know, as in the "Peanuts" comic strip: Lucy (the political power structure) would actually hold the cost-control football so that Charlie Brown (the fiscal-hawk Establishment) could kick it through the goalposts of a balanced budget.

But now, the morning after, healthcare costs seem destined to rise, just like always--the "doc fix" is fixed, the culture of medicine is still the same, and the trial lawyers are still impeding everything.

And now that the bill is signed into law, why not admit what the real plan was? What's the harm of a little feel-good credit-taking, basking in the admiration of liberal opinion-makers and history-book writers?

This video, from the Democratic Congressional Campaign Committee, speaks the language of liberal victory lap, not cost control.

So now the message-discipline of austerity is starting to break down. Byron York, writing in The Washington Examiner this morning, pulls together a string of revealing quotes--from Sen. Max Baucus, ex-DNC chair Howard Dean, from New York Times economics writer David Leonhardt--all suggesting, with satisfaction, that a huge income-transfer has been engineered. Of course, these days, big income transfers do not go from the rich to the poor, they go from the middle class to the poor.

That point was made by Lloyd Green, a former Justice Department official in the Bush 41 administration, last summer. Green raised the point in opposition, but OMB Director Peter Orszag and all the other putative curve-benders were so persistent that they, and their arguments prevailed. Or, just as likely, the Establishment, searching for some piece of common ground, was an easy mark for the Orzsagians.

But now, we're starting to see the backlash, not from the Establishment, but from ordinary people. The millionaires and billionaires who fund Establishment deficit-control groups might not be affected, at least in the short run, by the fiascoes of Obamacare, but ordinary people are, and they know it.

And now we are starting to see the power-source behind those polls that show most Americans are not happy with the healthcare bill, or with the people who enacted it. The Silent Majority, to revive a term first used by Richard Nixon in 1969, is getting stirred up. (That's Time magazine's "Man of the Year" cover from 1969 pictured above--the "man" of the year being "Middle Americans."
Even back then, the Silent Majority was a force to be reckoned with--Silent Majority votes gave Nixon one of the biggest landslides in US history in 1972.)

But today, the Internet has further empowered the Silent Majority--given ordinary people new tools for raising their voices. On the front page of The Washington Post this morning, Anne E. Kornblut reports that the White House is starting to realize that Barack Obama is a political campaign asset in only a dwindling number of states.

Meanwhile, inside the paper, the Post's Perry Bacon Jr. and Sandhya Somashekhar write of one angry voter, whose words contain a big warning to Democrats, and a small warning to Republicans:

"I grew up in the '50s," said Hugh Pearson, 63, a retired builder from Bakersfield, Calif. "That was a wonderful time. Nobody was getting rich, nobody was doing everything big. But it was 'Ozzie and Harriet' days, 'Leave It to Beaver'-type stuff. Now we have all this MTV, expose-yourself stuff, and we have no morality left, not even by the legislators."

As we can see from this quote, Mr. Pearson doesn't appear to be in love with redistributionist and avant-garde ideologies of the left--he just wants people to behave, with a decent respect for patriotic and moral norms. But there's a warning, there, for the right, too: the 1950s were not a libertarian epoch for America. The welfare state of the 50s was smaller, but in addition, it was run by moderates and conservatives, not left-liberals. It was 60s liberalism that voters rejected, beginning with the 1966 midterm elections, which saw among conservative winners that year, the gubernatorial election of Ronald Reagan. And then, as we have seen, Nixon won national election twice.

So the question: Which party will give Mr. Pearson--and all the other Mr. Pearsons across the country--what they want?

And so the question moving forward: repeal or reform?

Thursday, April 1, 2010

Intelligent Health -- And Falling Productivity

Last week the Galen Institute, a DC-based healthcare thinktank, held a conference on Intelligent Health. That is, the use of new technology to personalize, and thus improve, healthcare.

The single most startling revelation, was this chart, above, showing the real crisis of American healthcare. It's from Dr. Arthur Krieg, MD, of Pfizer, and it shows how Pharma spending has soared, while Pharma productivity has fallen. That is, the amount of money spent on R&D by the Pharma companies has more than tripled since 1996, while the number of New Molecular Entities--that is, drugs--approved by the FDA has plummeted from 54 in 1996 to 19 in 2009. So put it another way, expenditures have more than tripled, while output has fallen by two-thirds. That's the real crisis. Insurance that entitles you to go to the doctor matters a lot less than effective treatment once you get to the doctor.

What are the reasons for this falloff in productivity? That's a source of great controversy, and we will take that up in future posts. But all we know, now, is this: If the pipeline of drugs is choked off, our prospects for longer and better life, too, are choked off.

Obamacare is getting it from both sides now

So 65 percent of Americans say that Obamacare expands government too much, according to the latest USA Today/Gallup poll. And 64 percent say that Obamacare costs too much. That's good news for Republicans, many of whom have staked out an outright "repeal" position.

But as a look at the graphic above shows, the picture is a bit more complicated than that. 58 percent of Americans say that the bill does not do enough to curb costs, while 52 percent say that it should have included a public option, and 51 percent say that it doesn't do enough to regulate the insurance companies.

So the picture we see is of a public that is not averse to government activism, but doesn't trust Barack Obama & Co. to administer the program. And so now 50 percent of Americans disapprove of the bill and disapprove of Obama. In the words of USA Today reporter Susan Page:

Half call passage of the bill "a bad thing" and 47% "a good thing." That differs from a one-day USA TODAY poll taken March 22 — a day after the House approved the legislation — in which a 49%-40% plurality called the bill "a good thing."

"Any one-day poll in the immediate aftermath of a major event is likely to be subject not only to sampling error but also to very short-term effects," says political scientist Charles Franklin of the University of Wisconsin-Madison. At the time, "the news cycle was dominated by the positive side of the story, and only a little bit by the Republicans' rebuttal to that."

There was a strong reaction against the tactics Democratic leaders used to pass the bill. A 53% majority call Democratic methods "an abuse of power;" 40% say they are appropriate.

And when asked about incidents of vandalism and threats that followed the bill's passage, Americans are more inclined to blame Democratic political tactics than critics' harsh rhetoric. Forty-nine percent say Democratic tactics are "a major reason" for the incidents, while 46% blame criticism by conservative commentators and 43% the criticism of Republican leaders.

Those last findings are particularly interesting--it seems that people blame the Democrats for divisive tactics, not Republicans.