Weekend Reading

I engaged in an annual family ritual over the weekend. We (there's three of us) returned to the Big Apple for a holiday weekend of (off-Broadway) theater, which included a pleasant Upper West Side brunch leisurely reading the New York Times. Daniel Carlat's mea culpa in the magazine about his life as a drug rep for Wyeth pharmaceuticals caught my eye. Much has been written about the role of "detailing" in inflating the cost of drugs, pushing unnecessary brand medications over generics and the quasi- to illegal off-label marketing. But insider confessions are rare so this relatively short article is definitely worth reading.

Less enlightening was the lead editorial on "The High Cost of Health Care, which in touching on every issue in the health care debate managed to avoid all the crucial questions.

Take the single issue of drugs, which it handled in a paragraph. It called for Medicare negotiating lower prices and allowing imports, but "the prospect for big savings is dubious." Over in the magazine, Dr. Carlat reports how he was able to pick up an extra $30,000 a year on top of his $140,000 salary by pushing a drug that was not more effective against depression for most patients but had worse side effects. The problem isn't just price.

When I walk into a Circuit City and see the same flat screen TV I bought a year ago on sale for $2,000 less than what I paid for mine, the problem is price. If I walked into that Circuit City to buy a television for $3000 that has a comparable product on sale elsewhere in the store for one-third the price, and the one I'm buying is going to blow every circuit breaker in the house, and the salesman doesn't let me know those facts, I have a much more significant problem.

Yet in its list of "reforms" for the drug sector, the editorialists couldn't find time to call for curbs on physician marketing or direct-to-consumer advertising by drug companies. Add these unnecessary marketing costs to the unwise prescribing they provoke and the drug companies have inflated the nation's total drug tab by 20 to 30 percent. Saving 20 percent of $250 billion is $50 billion a year or about half of what it would take to insure the uninsured. To paraphrase the late great Senator from Illinois, Everett Dirksen, a billion here, a billion there, after a while, we're talking real money.

The rest of the editorial was equally dismissive of more far-reaching reforms in other aspects of modern medicine. Comparative effectiveness studies "could take a decade, or several" to have an effect. Not really. There's plenty of information out there now. The question is whether there is going to be an agency in the government that pulls it together, and then whether insurers (like Medicare) have the gumption to use payment policy to enforce its conclusions.

The editorial starts out by genuflecting in the direction of the Dartmouth studies that have shown the wide disparities in costs around the country with no difference in outcomes. If physicians use what is known to deliver superior outcomes, they could pare 20 to 30 percent off the health care bill. Alas, this is not about changing "long-ingrained practices" of the medical profession. This is about using less doctors, less procedures, and fewer hospital beds.

Unfortunately, the editorialists did not want to challenge the "provider" community. "With doctors dreadfully unhappy under the heavy hand of insurers, it would seem shortsighted to make them even unhappier by cutting their compensation to levels paid in other countries." I'm confused. How are you going to get rid of the 20 to 30 percent of health care expenditures that are superfluous if you don't cut physician incomes (and that of others in the "provider" community)?

The editorialists forgot the old saw that one person's waste is another person's paycheck. They were right to say that there is no silver bullet for holding down health care costs. But it's no help when those with the bully pulpit refuse to engage in the crucial battles while aiming their guns in the wrong direction.

Posted by gooznews at November 26, 2007 08:53 AM