How the Media Covers Health Care

Reprinted from the Health Beat blog by Maggie Mahar

Sometimes health care reporters remind me of the financial journalists who helped hype the bull market of the 1980s and 1990s. I began my career as a journalist at Money magazine, and I remember sitting in an editorial meeting where we talked about an upcoming cover story: “The Ten Best Mutual Funds NOW.” One intrepid reporter asked: “What if there aren’t ten great mutual funds that you really should invest in right now?”

“Let the fact-checker worry about that,” someone else quipped, referring to the person who would be double-checking the details of the story just before it went to press. Almost everyone sitting around the table laughed.

And Money was generally a pretty responsible magazine that tried to warn investors against the risks of the market. Still, “good news” cover stories sold magazines—just as “breakthrough” medical stories on the local evening news keep viewers from changing the channel.

Gary Schwitzer, an associate professor in the School of Journalism and Mass Communication at the University of Minnesota, recently published a provocative piece about how the media covers health care in the American Editor. Schwitzer begins his piece by asking his reader to “Imagine a reporter filing a story from the Detroit Auto Show. She writes about one car maker’s hot new model as if it is the best thing since the ’57 Corvette. But in the excitement over the chrome and style, she doesn’t mention the cost of the new model, doesn’t compare it with other manufacturers’ offerings in the same class, and doesn’t mention anything about performance (fuel efficiency, handling, braking, safety issues, etc.)

“An editor would certainly raise questions about this kind of puffery.

“But over on the health care beat,” Schwitzer observes, “the majority of stories on new products, procedures, treatments and tests are published without including comparable information. Claims that would never be accepted unchallenged from a politician are accepted unquestioningly from physicians and researchers and company spokespersons.”

Schwitzer, who publishes HealthNewsReview.org, a website that grades health care news stories for accuracy, balance, and completeness, has evidence to back up his claim. Below I’ve re-posted some of his data on some 400 stories from almost 60 major news organizations (available at his website) to demonstrate how many health care stories “provide a kid-in-the-candy-store portrayal of the health care system that leaves readers with the impression that most products or procedures in health care are amazing, harmless and without a price tag”:

Percentage satisfactory for 10 criteria for 400 stories:

Did the story adequately discuss costs? 22%
Did the story quantify the potential benefits? 27%
Did the story quantify the potential harms? 32%
Did the story evaluate the quality of the evidence? 33%
Did the story compare the new idea with existing alternatives? 37%
Did the story have more than one source and look for potential conflicts of interest in sources? 55%
Did the story appear to rely on a news release? 63%
Did the story establish the availability of the test or treatment? 68%
Did the story commit “disease-mongering” – exaggerating the condition or medicalizing a normal state of health? 70%
Did the story establish the true novelty of the idea? 86%

Why aren’t journalists more skeptical when reporting on medical news? Because so many Americans want to believe that there is a cure for everything—and that every new drug, device, or surgical procedure that comes down the pike must be the product of sound scientific evidence. Otherwise, why would doctors recommend it? (Does anyone remember when half of the nation’s children had their tonsils removed?)

Dartmouth’s Dr. Jack Wennberg, who has spent nearly three decades researching waste in our medical system, calls this the theory of “Manifest Efficacy: everything we do is effective. And it’s not just doctors--patients want to believe in manifest efficacy, Wennberg adds, because “it places medicine closer to a religion than a science.”

Nevertheless, in recent years, medical reporting in some publications has become increasingly sophisticated. Take a look at Schwitzer’s personal website, Schwitzer health news blog, and you’ll find him spotlighting stories like these:

---CANCER RISK FROM OVERUSE OF CT SCANS

The Wall Street Journal reports on an article in this week's New England Journal of Medicine…
"Doctors are ordering too many unnecessary diagnostic CT scans, exposing their patients to potentially dangerous levels of radiation that could increase their risk of cancer, according to Columbia University researchers . . .

--DEBATE OVER VALUE AND MARKETING OF FERTILITY THERAPIES
The Wall Street Journal reports on questions being raised about genetic screening, egg freezing and other high-tech fertility therapies. Excerpt: "As medical science continues to churn out ever-more-sophisticated methods to treat infertility -- from egg freezing to genetic screening of embryos -- desperate would-be parents rush to embrace the latest techniques. But some fertility experts worry that procedures of limited benefit are unfairly raising patients' hopes.

--TROUBLING PATTERN OF BEHAVIOR BY PHARMACEUTICAL EXECUTIVES"

The Wall Street Journal reports:

"Over a period of several years, drug maker GlaxoSmithKline PLC was so concerned about a prominent physician's negative views of its diabetes drug that it engaged in a concerted effort to intimidate him and stifle his opinion, a report by the U.S. Senate Finance Committee found..."

What’s impressive is that the Wall Street Journal has been particularly brave about exposing what’s going on in our for-profit health care industry. One might expect a financial paper to praise health care companies that are making a killing—but instead, its reporters have honed in on how sometimes, the health care industry’s most touted products may be killing us.

For the Journal understands—perhaps better than other papers—that the health care industry’s for-profit corporations have one goal: to boost earnings. These companies don’t want to hurt their customers, and they certainly don’t want to wind up in court. But making sure that Americans receive the best care possible at the lowest possible price is not their job. That’s why somebody needs to be looking over their shoulder and asking questions. Ideally, that somebody would be the FDA. But if that isn’t happening, skeptical journalists can help. I just hope that new ownership won’t affect how The Wall Street Journal covers medical news.

Health Wonk Review

Want to find the best health care commentary on the web? A good place to start is the bi-weekly Health Wonk Review. This week, the review was written by Health Care Renewal, a fine website that focuses a lot of its attention on conflicts of interest in medicine. I'll be posting the link to the latest Health Wonk Review every two weeks. Check it out!

Did Bush Administration Muzzle FDA?

Near the end of his recap of the recently enacted Food and Drug Administration reform law, former deputy commissioner for policy William Schultz claims in today's New England Journal of Medicine that the Bush administration "blocked agency officials from . . . providing timely 'technical' assistance to ensure that legislation would be drafted to meet congressional goals."

Is this true? While it is perfectly logical that the FDA did not publicly support changes in the law -- I believe federal employees are prohibited from lobbying Congress -- it is crucial that they be allowed to advise Hill staff drafting proposed changes so Congress can work its will, or, conversely, insure that it doesn't inadvertently damage the ability of the agency to do its job. If someone stopped them from doing this during the yearlong debate over FDA reform, it should be exposed and condemned.

Annals of Rising Health Care Costs

Smokers' Screen

Earlier this month, the House of Representatives unanimously passed a resolution asking Medicare and the Veterans Administration to pay for expensive lung cancer screening tests using CT scans. Local hospitals near my home are already jumping on the bandwagon. I suspect that if you check your local hospitals, you’ll find that they are championing the tests, too.

The images invoked in the advertising by these entrepreneurial hospitals is enticing, especially if you are among the 45 million Americans who smoke or the millions more who are routinely exposed to second-hand smoke. Over 160,000 Americans die each year from lung cancer, making it the leading cancer killer by far. Moreover, it’s an odds-on death sentence. Only 15 percent of people diagnosed with lung cancer live five or more years, one-quarter the rate of other leading cancers. And only one in ten lives for a decade after diagnosis. If you only catch it early, the hospital websites suggest, it should increase your chances of survival because you’re catching the cancer when it is “most treatable.”

And that’s precisely what a major study that appeared in the New England Journal of Medicine last fall claimed to show. Researchers associated with New York Presbyterian Hospital-Weill Medical College, who’ve been working with financial support from General Electric, Kodak and assorted foundations for decades to offer experimental CT scans to screen for lung cancer, totaled up the results from over 31,000 tests and follow-up treatments in asymptomatic smokers. They found that their screening program raised the 10-year survival rate among those in the group who were identified with cancer to a stunning 88 percent. “Annual spiral CT screening can detect lung cancer that is curable,” they concluded in the nation’s most prestigious peer-reviewed journal.

The media had a field day. Stories touting the new technology appeared in seven of the nation’s ten largest papers, including front page coverage in the New York Times. Four of the five major television networks devoted their precious on-air minutes to this latest medical breakthrough. A patient advocacy group called the Lung Cancer Alliance, which lobbied for the resolution, launched a national advertising campaign featuring legendary quarterback Troy Aikman throwing, not a Hail Mary pass, but a pitch for widespread lung cancer screening. Trial lawyers have brought a number of suits seeking to force the tobacco industry to pay for the pricey procedures.

The campaign suffered a minor setback in March when a government-funded study in the Journal of the American Medical Association appeared to throw cold water on the earlier NEJM study. It claimed screening failed to save lives. But it received much less prominent coverage. The main difference between the two studies, according to stories in the New York Times (pg. 18) and USA Today (pg. 7D), was whether survival time after diagnosis mattered as much as mortality, for which the earlier study provided no evidence.

Does screening actually save any lives? We won’t know the answer to that question until the results of a controlled clinical trial sponsored by the National Institutes of Health, which involves 50,000 smokers given either routine CT scans or usual medical care, are in. That won’t be for another three years at least.

In the meantime, VA-backed researchers led by Gilbert Welch, Steven Woloshin and Lisa Schwartz at the Dartmouth Medical School are fighting an uphill struggle to educate medical professionals and reporters about the flaws in the original study. I say uphill because their new report, which appeared in this week’s Archives of Internal Medicine, received nary a word of coverage in the nation’s press – at least not yet.

Survival, their common sense report points out, is always prolonged by early detection. And the only way to determine if screening works is through a randomized trial. Here’s their explanation for why the composite results of the screening tests conducted by the New York Presbyterian researchers are essentially meaningless.

First, there is lead-time bias, “a mathematical certainty associated with any successful effort to detect disease early.” Whether people live or die, if the screening works, they’ll know about it sooner.

Then there’s overdiagnosis bias, caused by “screen-detected abnormalities that meet the pathologic definition of lung cancer but will never progress to cause symptoms.” Imagine two groups of 100,000 smokers over age 60 who are followed for ten years. One group is screened with CT scans every year. The other group isn’t. Each group has 1,000 patients who get lung cancer, 900 of whom die by the end of the decade. But the screened group identifies 5,000 people with lung cancer, what the Dartmouth researchers call “pseudodisease.”

“Although this concept may seem implausible to physicians, basic scientists have begun to uncover biological mechanisms that halt the progression of cancer,” they write. Tests are also wrong, generating what are in essence false positives.

In our example, that’s 4,000 people who automatically live the full ten years. So what are our comparative survival rates? In the group without CT scans, 1,000 contracted lung cancer, 900 died and 100 survived, a 10 percent survival rate. In the CT scanned group, 5,000 people contracted (or were identified as having contracted) lung cancer, 900 died and 4,100 survived, an 82 percent survival rate. Voila! A miracle wrought by screening.

Is this a plausible explanation for the New York Presbyterian study? The Dartmouth researchers offered one more scary piece of evidence, this time from Japan, where researchers used CT screens in more than 5,000 people, about evenly divided between smokers and non-smokers. They found almost ten times as much lung cancer as had been found in the same population when they were given chest X-rays, and, more significantly, they found just as much lung cancer in non-smokers as in smokers! “The Japanese data provide powerful evidence that overdiagnosis can be a substantial problem with spiral CT screening,” they conclude.

The Dartmouth researchers spend the rest of their paper pointing out the harms associated with overdiagnosis: the increased biopsies, the dangerous surgical procedures for the mostly elderly population with lung cancer (the death rate during lung cancer operations is 3.6 percent to 6.1 percent for people over 65), and the unnecessary grief associated with false diagnoses.

They conclude with a stern admonition to the New York radiologists, whose financial support from GE and Kodak was buried in a long list of credits, for using a mountain of individual case data to conclude that CT screening can detect cancer that is curable. “While technically true, the conclusion failed to highlight two fundamental unresolved questions: Would screening ‘cure’ the 160,000 cancers that people die from now? Or would it ‘cure’ cancers that never needed to be cured?”

For that answer, we’ll have to wait for the results of the scientifically-controlled, government-funded study.

WARF Learns! Will Stem Cells?

The Wisconsin Alumni Research Foundation will patent researcher James Thomson's new method of deriving stem cells from non-embryonic sources that was announced last week. But an official from the University of Wisconsin tech transfer office told the New York Times yesterday that it will look the other way and not charge non-profit researchers who use the new technology.

“They can do it in their own lab,” said Carl E. Gulbrandsen, the managing director of WARF. “They don’t have to tell me about it, and I don’t really have to know.”

The University of Wisconsin's technology transfer arm came under a firestorm of criticism when it began charging non-profit researchers $5,000 for access to the cell lines derived using Thomson's original embryonic method. Their value was greatly enhanced when President Bush restricted federal funding for embryonic stem cell research to previously derived lines like those owned by WARF. The university clearly didn't want a repeat of that episode.

We now have a natural experiment proving that the brain cells of technology transfer offices can be transformed into neurons capable of intelligent responses. It remains to be seen if researchers can do the same thing with skin-derived stem cells.

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.

Happy Thanksgiving to All!

The Social Security Non-Crisis

Is there a Social Security crisis? Smart, progressive economists like New York Times columnist Paul Krugman and Dean Baker of the Center for Economic Policy and Research say no. The inside-the-beltway conventional wisdom, represented today by this Washington Post column attacking Krugman by Ruth Marcus, says yes. Who's right?

I'm definitely in the former camp. Here's why.

Since 1983, when the Greenspan commission under (Saint) President Reagan raised the Social Security payroll tax and postponed the retirement for aging baby boomers like me (I can't get full benefits until I'm 66 3/4 in, gulp, less than 10 years), the Social Security system has been running huge surpluses. All of that money has been spent by our government in lieu of raising other taxes. Indeed, under President George W. Bush (future generations, get out your groggers, like Jews do on Purim to drown out memories of Haman), the government gave it away to the rich.

The government then took IOUs and stuck them in the Social Security fund. Beginning around 2017 (and in recent years, that date has been receding), the Social Security fund will have to begin redeeming those IOUs to make all its scheduled payments to a growing number of retirees (yup, you can do the math; that is exactly when I am due to retire). The Social Security fund won't run out of those IOUs until, at last estimate, 2041.

So, if nothing is changed, what will happen after 2017? In addition to financing its routine expenditures without relying on excess Social Security taxes, the government is going to have to begin paying off its Social Security debt. That will require either a) raising non-Social Security taxes (the payroll tax will then all have to go to retirees); or b) selling bonds in the open market, and substituting IOUs to foreigners and rich U.S. investors for IOUs to America's senior citizens. Or a combination of the two.

It could also look at areas of the budget where it could save money. Take the war in Iraq, for instance. There's a couple hundred billion a year that could be socked away for retiring Social Security debt. Or the annual maintenance of the nuclear arms arsenal, whose size, in the absence of the former Soviet threat, only serves to destabilize global politics. Add a few tens of billions there. Or the huge waste in the Homeland Security department, that gives billions of dollars in contracts for electronic eavesdropping but can't seem to find the money or will to require chemical facilities to harden themselves.

Add to this the fact that we have the lowest tax rate in the industrialized world -- taking about 16 percent of gross domestic product while most of the countries of western Europe and Japan -- whose currencies by the way are soaring against our beleaguered dollar -- are five or six percentage points higher (when you take out the differentials for national payments that are picked up by state and local taxes here). The bottom line is that being a "responsible adult," to use Marcus' phrase, means admitting the crisis the U.S. faces isn't in Social Security, it's in government finance, which has been handled in the most irresponsible fashion by a succession of Republican presidents going back to (Saint) Ronald Reagan.

For proof of that, you need only consult these two charts, which document the spectacular rise of debt both in absolute terms and as a proportion of GDP under this president (and Reagan). The only time in the past 30 years when government finances have been handled responsibly was under Bill Clinton.

Source: Boeing engineer Steve McGourty's website.

First Circulation, Then the Ads

The downward spiral of print continues. Two weeks ago, the nation's papers reported a sharp downturn in circulation. Advertises are paying attention. From Dow Jones wires:

Advertising dollars spent on U.S. newspapers and their Web sites declined 7.4% in the third quarter to $11 billion, a further sign of a deteriorating trend in print publishing, the Newspaper Association of America said.

Spending for print ads in newspapers fell 9% from a year earlier to $10.1 billion, more than offsetting a 21% gain in dollars spent on Internet-based ads, the trade organization said. Online advertising now accounts for 7.1% of newspaper ad spending, up from 5.4% a year earlier.

Richardson Champions Medicare Buy-in

There's not a lot of difference between the various Democrats running for president when it comes to reforming the health care insurance system. But New Mexico Governor Bill Richard, speaking at a Kaiser Family Foundation-sponsored forum yesterday, put several issues near the top of his agenda that I found particularly appealing.

First, he offered to expand Medicare to include anyone between 55 and 64 who wants or need to buy into the seniors' system early because they've either lost a job or their employers do not provide health coverage. This is simple, easy to do, relatively cheap compared to other forms of insuring these aging baby boomers, and, most importantly from the taxpayers' perspective, allows people to obtain preventive care in the decade when many chronic conditions of old age develop. This might raise Medicare's costs in the short run, but any form of universal coverage would. The only question is who will get to collect and then disburse the money.

"Getting those people to buy into the Medicare plan instead of private markets will reduce costs by 25 percent," Richardson said. "If those individuals 55 and over can get access to Medicare coverage, they can get access to cancer screening early, like cervical cancer screening, when women are at an age when they're starting to have those problems. I believe it will improve the overall quality of Americans getting health care."

But won't that send the sickest to Medicare?

"What's wrong with that?" he responded. "There's 14 million human beings excluded because of pre-existing conditions or they have minimal coverage. It's the right thing to do if we're going to have universal coverage."

But then he stumbled when the follow-up question focused on the "long-term budget crisis" that threatens to "swamp Medicare and Medicaid." The buy-in would only make it worse, his questioner claimed.

This question comes up repeatedly and the Democratic candidates have an easier answer than the hemming and hawing about making those public sector systems more efficient.

First, if they stay in the private system, then private insurance costs go up. Somebody's costs have to go up if we're going to have universal coverage.

Can private insurers (and the employers who pay that tab) afford to continue covering the sickest Americans (the 30 percent of the public that consumes 75 percent of all health care)? The fact is that the larger, long-term budget crisis isn't in the public sector programs -- it's in the private insurance market. According to the CBO report, private insurance costs over the next 30 years are projected to rise at a faster rate than Medicare and Medicaid. Holding down health care costs is a society-wide problem -- not just one for the public sector. Premiums in the private market are slated to soar; millions more Americans will lose their health coverage because their employers simply won't be able to afford it.

When will some candidates start talking about the crisis facing the private health care insurance market when reporters raise Republican-inspired questions about a "crisis" facing Medicare?

Insurers Nix Public Option

A new industry-funded study on the Democrats' universal health care plans shows all but Dennis Kucinich's single-payer plan will be a boon to the health insurance industry, which will get tens of millions of new customers pouring $100 billion in new revenue into the system, the Wall Street Journal reports this morning.

But the "biggest risk," according to the study, is that some of the plans call for a public sector alternative for the uninsured that will compete with private plans. This is "disturbing" to insurance companies because it will create a competitive "government-run plan" (read non-profit) that offers price competition.

But the story takes a curious turn. It assumes this option will be separate from Medicare, creating an entirely new bureaucracy to make payment decisions.

That's not the way it has to work. Why not offer an expanded Medicare as the public sector option? Any employers who don't want to buy insurance for their employees can simply make a payment to Medicare to get coverage. and the existing bureaucracy can include their workers in the system. Or individual can buy in. As a start, the Medicare option could be offered to people who are 55 and over but have lost their jobs, the ranks of whom will probably grow substantially in the next economic downturn. Let's not forget that among all health plans, Medicare gets the highest customer satisfaction ratings.

This study signals that the public sector option for the uninsured contained in many of the Democratic universal health care plans will draw fierce opposition from the insurance industry, whose Harry and Loise ads helped sink the 1993-94 reform effort. It also threatens to split the progressive coalition backing health care form into two camps: those that are desperate to insure the uninsured at any price, consider cost a secondary issue, and don't want to alienate insurers; and those that understand that the long-term sustainability of both private and public systems requires reining in rising costs, and that requires an active public sector to keep prices in check while maintaining high standards.

Main Cats Fully Engaged

Remember the cat fight over the role of racial politics in the rise of the GOP that I predicted a week ago after a column by David Brooks? The main cats are now fully engaged. Lou Cannon, Ronald Reagan's sympathetic biographer, offered an apologetic op-ed in yesterday's New York Times. The great communicator was a nice guy, and even quit the country club that discriminated against blacks! Reagan’s defenders protest furiously that he wasn’t personally bigoted. "So what?" rejoins Paul Krugman in this morning's paper. "We’re talking about his political strategy. His personal beliefs are irrelevant."

Meow.

The Case Against Higher Co-Pays and Deductibles

Having thought about the recent Congressional Budget Office report on health care costs for 24 hours, I now have an explanation for its mysterious -- and accurate -- claim that health care co-pays by individuals have fallen as a share of health care spending over the past 30 years.

Is that anyone's experience that you know? Most of us, especially if we have a significant health event, pay much larger co-pays and higher deductibles than we did 10 or 20 years ago. How can individual payments as a share of total health care spending have fallen to 13 percent in 2005 (about 2 percent of gross domestic product) from 33 percent in 1975 (also about 2 percent of GDP, suggesting the individual spending as a percent of income has not risen)?

That answer, as it turns out, is simple math. Health care consumption is highly concentrated. About 75 percent of health care costs are consumed by the 90 million Americans (about 30 percent of the population) with chronic disease. That means 70 percent of the 2 percent of GDP out of pocket is picked up by 30 percent of the population. Thus you could say (via back-of-the-envelope math) that the 30 percent of the population with significant health care costs saw their co-pays rise at about two to two-and-a-half times the rate of inflation -- just like the rest of the health care system.

That's painful for them as individuals. Meanwhile, the rest of health care spending, which has been rising at two-to-three times the rate of inflation for most of the past 30 years, is spread across everyone who pays an insurance bill, which is Medicare, Medicaid, the VA, and other public payers for about half the total health care tab and employers who provide health insurance for the other half. So people who worry about how the taxpayers will be able to afford to pay for government health care programs worry about rising health care costs, and employers worry about rising health care costs, and on a good day, insurance companies worry about rising health care costs, but most Americans, except those who are sick, do not.

Every poll conducted by activist groups pushing for universal health care coverage has shown that most Americans do not respond to political messages about holding down costs, but do respond to messages that the uninsured ought to be covered. The latter is obvious. If you lose your job, you lose your insurance in this society, and people want to protect themselves against that possibility.

But why don't they see that rising costs is threatening everyone's access to insurance? Two out of three Americans are healthy. They do not experience the rising co-pays and deductibles.

That's why strategies that rely on further increases in co-pays and deductibles to hold down costs are misguided. It assumes the 30 percent of the population with chronic disease has an option. Tell that to a 55-year-old former smoker with emphysema, the 20 million Americans with diabetes or the tens of millions of Americans with cardiovascular disease of one sort or another.

The only ones with options are the ones who need care before they get chronic disease: the pre-diabetic, the hypertensive, and smokers. Preventive interventions like smoking cessation programs; diabetic counseling; screening for hypertension; offering low-cost drugs and programs to prevent chronic kidney disease and cardiovascular complications are precisely the kinds of programs low-and-moderate income people will forgo (and they're the ones who suffer disproportionately from these conditions) if you increase their out-of-pocket costs.

Moreover, under the private insurance system, the only way to get insurers to provide this kind of coverage is to require it through a regulation, since the payoff in reduced health care costs is in the future, while the costs are now. Why should an insurance company pay for a prevention program for someone in their 50s who is on the road to heart disease when it is probably going to be Medicare that picks up the cost of that person when they actually get the disease?

The other argument used to support higher co-pays and deductibles is that it will make people confront their doctors about the true usefulness of expensive procedures. Perhaps. But unless we reform the fee-for-service system, doctors have an equally large if not greater incentive to argue forcibly in favor of "you'd better get that test young man." How well positioned are individual patients (I prefer that word to consumers) to argue with the opinion of their doctor? So those with money will pay the higher tab because they can afford it, while the poor and near-poor will forgo treatment because they can't.

That's rationing by income, not by medical usefulness or need. Any health care plan that raises co-pays and deductibles as a key part of its strategy to hold down costs is doomed to failure. It won't significantly hold down costs, and to the extent it does, it will make our already second-rate health care outcomes worse.

"Europe may not be a bad thing"

The frustration with access to care in the U.S. has forced health insurance to the top of the domestic policy agenda for next year's presidential campaign. Today's Wall Street Journal has a front page story documenting one family's struggle to obtain help for a rare, inherited disease that affects the tissues that hold joints together. The story concludes with the 52-year-old woman contemplating moving to Belgium, where she would not only have access to one of the world's leading researchers, but would get her care paid for without hassles from insurance companies. The husband is given the last word:

Mr. Calder, whose father was a doctor and mother was a nurse, grew up believing the U.S. health-care system was the best in the world. But he says his wife's struggle has eroded that faith. "I've actually turned around to where I'm thinking, 'Yeah, Europe may not be a bad thing.'

In last night's Democratic debate, the leading candidates attacked each other for minor differences in each other's health care plans, all of which save one rely on extending private insurance to cover the uninsured. None of those plans will end the problems of people like Mrs. Calder. Only Dennis Kucinich backs a European-style single-payer system, where the extraordinary costs of treating rare diseases can (not necessarily will, since a government-run plan can decide to be just as stingy as a private insurer) get spread across the entire population.

They're Cloning Monkey Cells, But . . .

Setback for Stem Cell Hype in NJ

Today's frontpage news focuses attention on the latest advance in embryonic stem cell research: the successful development of cloned embryonic stem cells from monkeys. But is the bloom off the rose on these breathless takes on a technology that is still years away from usefulness in humans?

. . . Most analyses in the media assert that it was rejected for fiscal, not moral, reasons. Though the evidence remains inconclusive, if this is true, it is noteworthy.

Unlike those of California and Missouri, the New Jersey ballot question originated in the state Legislature and consequently mobilized less on-the-ground support. For example, the website of the state's Citizens Coalition for Cures barely mentions the ballot question.

Furthermore, the public debate - both pro and con - focused much more on the economics than in the previous debates. The state debt, which now stands at $33.5 billion, has been a top issue in recent years. Plus New Jersey is already in the stem cell business. The legislature has already allocated $150 million to construct stem cell research facilities, and allocated another $10 million for research grants.

What's more, New Jersey voters have been historically friendly to ballot initiatives. This one, and one other on the same ballot, became the first to fail in seventeen years. That other was an anti-tax measure, which also would have increased the public debt.

Finally, polls have indicated that state residents support a woman's right to terminate a pregnancy by a 2 to 1 margin. Thus, factors other than the moral status of the embryo must have greatly contributed to the 53% vote against Public Question 2.

Three years ago, in California, the economic cost of the $3 billion Proposition 71 was merely a minor part of the public debate, overshadowed by the promises from the state's top researchers of treatments and the now-prerequisite images of hopeful children in wheelchairs. Missouri's ballot initiative of last year didn't set aside any public funds; it merely enshrined the legality of the work in the state constitution. Despite the efforts of the advocates there to shift debate to purported economic benefits, the issue remained a moral one to most voters, particularly opponents. Missouri's Amendment 2 barely succeeded only after an enormously expensive campaign by its supporters. Also that year, congressional candidates who were vocally supportive of embryonic stem cell research did not fare particularly better than Democrats as a whole. Perhaps the sheen and hype of imminent cures is beginning to wear off of embryonic stem cell research.

A Few Thoughts on the New CBO Health Care Report

The Congressional Budget Office yesterday officially released its new report on the "Long-Term Outlook for Health Care Spending". Its bottom line is that left unchecked, the pace at which health care spending exceeds economic growth will, over the next 75 years, make the health sector nearly half our economy. Medicare and Medicaid alone will consume 20 percent of GDP, making those two programs alone as large as our entire federal budget is now.

To paraphrase Richard Nixon's economic adviser Herbert Stein (father of economic pundit Ben Stein): "Things that can't be sustained won't be."

Peter Orszag made much the same point yesterday at a New America Foundation forum where he discussed the report. Washington think tanks have devoted far too much attention to the Social Security problem, he said, and far too little to the health care problem. He promised a number of new reports as early as December for legislators on Capitol Hill wrestling with how to rein in runaway health care costs.

A couple of his arguments are worth highlighting, one that precisely identifies the nature of the problem and one that misses the point.

First, he presented a chart that compared three of the top hospitals in the U.S. in terms of health care outcomes: UCLA, Massachusetts General and the Mayo Clinic in Rochester, Minnesota. I'll only deal with the numbers from UCLA and Mayo because they are the outliers. UCLA spends twice as much as Mayo for each Medicare beneficiary in the last six months of life. Why? Even when the health of the patients is held constant, UCLA put its patients in the hospital for 19 days on average over those six months compared to 12 days at Mayo. Physician visits were similarly skewed: 52 in Los Angeles versus 24 in Minnesota.

"We have been largely misdiagnosing the problem," Orszag said. "In the media the health care problem has been described as the aging of the Baby Boomers. While that's a factor, it's not the major factor. It's the variation in costs around the country that don't correspond to outcomes. If anything, the higher spending states have worse outcomes than the lower spending states."

Nearly a third of health care spending could be eliminated without jeopardizing health, he said, an echo of the core claim in Shannon Brownlee's new book, "Overtreated."

But in his talk, Orszag also emphasized the role that "declining" out-of-pocket spending has had on rising health care costs. He used the statistic that those costs went from a third of health care spending in 1975 to just 13 percent today. On the surface, that seems to be a strong argument for raising co-pays or moving to a system of making consumers pick up first-dollar coverage for health as a way of reining in unnecessary spending. Make patients cost-sensitive, the argument goes, and let the market work its magic.

Wrong. First, when out-of-pocket costs were a third of health care spending, health care only consumed six percent of gross domestic product. That meant individuals were paying about two percentage points of GDP for health care out of their own pockets. Today, health consumes 16 percent of GDP. Multiply that by the 13 percent picked up by consumers and you still get two percent picked up out-of-pocket.

In other words, average folks whose income has only kept pace with inflation over the the past 30 years are paying on average the same portion of their incomes for health as they always have. And, given the rising number of people who are uninsured, a majority of Americans are probably paying more out of pocket for health today or are going without.

More significantly, raising co-pays or making consumers pick up first dollar coverage is a terrible way to control costs. The first thing to get eliminated will be preventive care, a prescription for increasing long-term health care costs. It also won't rein in the most expensive parts of the system because the decisions to operate or order pricey imaging tests are controlled by physicians and are largely picked up by insurers. Or, if the expensive co-pays on those expensive operations and imaging tests force lower income Americans to forgo that care, it will take the nation farther down the road toward a two-tier society where health care will be rationed by price sensitivity, not need.

With this new report, Orszag and the CBO add their voices to the call for a new agency to conduct comparative effectiveness research and analysis to inform payment decisions. He said that payment policies must be aligned with this new information as it is generated.

But he also recognized that it will take many years to put this new infrastructure in place. So what will get done in the short run? I would hate to see the impartial CBO adding its voice to the simplistic notion, favored by economists who don't have a lot of knowledge about public health, that making consumers have "more skin in the game" is a fruitful way to slow the long-term growth rate of health care costs.

$1-Per-Gallon Gas Tax?

It would only be a start on coming up with a decent energy policy.

My wife drives a Prius. I'm still driving a 14-year-old clunker with 140,000 miles on it because I want my next car to be a plug-in (a friend told me over the weekend that all-electric vehicles now being sold in India using power generated by coal would, in a U.S. context, give off the carbon equivalent of 350 miles per gallon).

The politics of oil in the wake of 9/11 are discussed in today's Tom Friedman column in the New York Times. He renews his call for a dollar-a-gallon gas tax.

Readers know I focus mostly on health care issues, and a part of me is pleased that it has risen to the top concern of the American people as the next presidential election approaches. But the truth is that we can bumble along for a few more years yet with our failing health care delivery system.

Our failing energy policies, on the other hand, are threatening to drive us into new wars in the very near term, and totally ignore the long-term threat posed by global warming. When historians look back at the failed Bush presidency, they will surely note his energy policy -- not health care -- as his single greatest domestic failure.

Amgen Sued Over Marketing Scheme

In its latest quarterly report to the Securities and Exchange Commission, Amgen revealed that it has received subpoenas from U.S. attorneys in New York and Washington State, and has been sued by a union health fund over an alleged illegal marketing scheme. According to this Associated Press article, the lawsuit says Amgen engaged in an “anticompetitive tying arrangement and pricing scheme” involving the sale of Neupogen and Neulasta, used against the side effects of chemotherapy, and Aranesp, an anemia drug.

The details of the alleged illegal bundling scheme were contained in GoozNews posts here and here.

Meanwhile, the Wall Street Journal (subscription required, although not for long) this morning documents Amgen's extensive lobbying efforts to roll back the Center for Medicare and Medicaid Services cancer drugs payment policy, which will limit excessive use of Aranesp and Johnson & Johnson's Procrit because they have been shown to be unsafe at the higher doses needed to raise red blood cell counts to the near normal range.

TNR Takes on Medical Innovation

Jon Cohn, whose new book "Sick" is the best primer on the flaws of our health insurance system and the need for universal health care, has a major article in the latest New Republic that takes on what has always the opposition's best argument against change: do anything that limits prices or cuts out wasteful spending and you'll choke off medical innovation. It's a must read, and not just because he mentions my book.

I found his lead anecdote about the discovery of deep brain stimulation to treat Parkinson's disease, which his colleague Michael Kinsley suffers from, was illustrative of everything I tried to show in my book: 1) innovation is the product of science, not money; 2) it often involves serendipity, which can't be bought; and 3) a tremendous amount of what passes for innovation is waste, pure and simple.

Cohn argues that universal health care, which to be affordable will have to limit wasteful spending, will not choke off innovation (or lead to long lines for care). Done right, a universal system can eliminate waste while leaving the real sources of medical progress -- public sector science and the dedicated medical scientists' eternal quest to improve the human condition -- intact.

Eyes on Prizes

It's always hard to know what to make of the endless talkfests on global health that take place in Geneva. Last week, a subcommittee of the World Health Organization discussed ways of increasing the amount of research and development that goes toward cures for the neglected diseases of the developing world: tuberculosis, malaria, leishmaniasis, Chagas disease and the like.

News accounts Saturday suggested that these "talks" are progressing slowly, although the indefatiguable Jamie Love of Knowledge Ecology International was characteristically upbeat in this Reuters reports. The Intellectual Property Watch newsletter is also keeping close tabs on the talks, which will resume next spring.

Knowledge Ecology, Doctors Without Borders and a feisty coalition of non-governmental groups (NGOs) are pushing the WHO to endorse a prize system for developing new drugs. Under a prize system, donor countries and health care payers could put up large one-time payments for any major breakthrough against a neglected disease. By making the reward for industry (or non-profit) R&D a one-time payment, rather than the ongoing surtax of high prices on the price of the drugs or vaccines, the IP could be transferred by the prizemaker (and therefore new owner) to generic manufacturers, who would then provide the technology to poor countries on much cheaper cost-plus basis.

Relying on the WHO to experiment with such a system will take forever since the glacial pace of the talks is directly related to the fierce opposition of the global pharmaceutical industry. That's why anyone interested in this approach should pay close attention to the machinations of the X Prize Foundation, launched a few years ago by Internet billionaires like Larry Page, a co-founder of Google, Inc.

Most of the news from that group was generated when it offered prizes for commercial space travel and the 100-miles-per-gallon car. But last month, with the encouragement of the Clinton Foundation, they ponied up $300 million in prize money for innovations in public health and education.

They promised a first round of targets (presumably with the prize dollar amounts attached) next spring. Following this story -- what they deem prize-worthy, who goes after it, and whether the goals are achieved -- should provide an early test of the viability of using a prize system to encourage medical innovation.

Note to Readers

I added a blogroll to my website this week (see the left hand column) and am considering adding advertising. As many readers of GoozNews know, I spent many years in the news business. For me, it wasn't just a career choice. I am and continue to be a fervent believer in the role that independent news gathering plays in our society. It is crucial to any well-functioning democracy, and I cannot help but think that the decline of the quality of the mainstream press in recent years is in part responsible for the sorry state of our political and economic affairs.

The media's poor performance on issues ranging from Monica-gate to the War in Iraq can't be blamed entirely on its declining economic fortunes. But it sure didn't help. As newsroom budgets shrank, the longer-term, investigative projects that reporters like me used to specialize in were the first to go. Entire walks of life went uncovered, or became just one of three or four beats on beleaguered reporters' plates. Reporters without time or resources to follow a story become easy marks for spinmeisters and propagandists, and far too many fell into the trap of simply regurgitating without evaluation what they were told.

Will the press snap back with a change in administration? The inescapable fact is that the economic model that historically provided employment for the vast majority of reporters is this country is collapsing. Readers are migrating to free websites on the Internet (see this post from last week) in ever greater numbers, yet the jobs are not following them there.

Here's some job statistics I looked up this morning that you may find interesting:

A decade ago, newspapers employed 420,000 people. Today, that's down to 344,000, which includes a loss of 15,000 jobs in the past year alone.

Broadcasting employed 314,000 people in 1997 and employs 337,000 today. But the number of jobs in television and radio is still below its 2001 peak of 345,000.

And the Internet? In 1997 there were just 22,000 jobs in that sector, according to the Bureau of Labor Statistics. Now there are 45,000 jobs. That doubling is good news, but it still makes up for just one in three jobs lost in the newspaper industry, despite the huge profits and stock valuations of aggregators like Google and Yahoo.

As many of you know, for many years I have supplemented my regular jobs as a professor of journalism and, more recently, at the Center for Science in the Public Interest by doing freelance writing, some of which later (when contractual obligations allowed) appeared here. But that kind of work, like full-time work in the field, is getting harder to find. And what is available pays less than before as publishers pare their freelance budgets and/or take advantage of a desperate workforce.

In one sense, I am part of the problem. I don't want to break my arm patting myself on the back, but I like to think that the quality of the writing on this blog and, more importantly, its analysis offers real value to readers. Indeed, I have been pleasantly surprised to watch readership grow month after month almost without fail since I began a few years ago. This site now gets about 15,000 different individuals visiting each month, many of them multiple times. While that's nothing compared to major blogs that cover politics or culture, it is quite respectable for an independent site that focuses largely on health care.

But this is part of the problem. Newspapers, news magazines, and other general circulation periodicals were the aggregators of old. A million circulation newspaper was in reality a composite of audiences: a third of readers liked the news section, a third liked sports, there were sub-audiences for cultural coverage, business, health, and features. Now those sub-audiences have fragmented. They can create a home page or RSS feed that brings in a dozen sites that reflect their interests. Yet none of these aggregators hire journalists -- at least not yet.

Which brings me to a decision point. Unlike many of my competitors with health care-oriented blogs, I do not work for a think tank, work fulltime for a media outlet, or run a consulting business. I will always want to freelance for some publications. But allowing advertising on this site will enable me to devote more of my freelance time and energy to reporting pieces that will appear exclusively on this website. I'm leaning in that direction. What do you think?

The Lives of Others -- a must-see this holiday season

The Washington Post reported details yesterday about the Bush administration's massive domestic telephone/internet/email monitoring project. The surveillance is being carried out by the National Security Administration (NSA).

The report was based on the Congressional testimony of a phone company whistleblower, recently retired, who had seen a diagram showing how data was being routed to a "secret room" in an AT&T building in San Francisco:

"That was my 'aha!' moment," he said. "They're sending the entire Internet to the secret room." The diagram showed splitters, glass prisms that split signals from each network into two identical copies. One fed into the secret room, the other proceeded to its destination, he said.

"This splitter was sweeping up everything, vacuum-cleaner-style," he said. "The NSA is getting everything. These are major pipes that carry not just AT&T's customers but everybody's."

After reading that story, you might consider renting this movie over the holiday season. It should help get you in the mood for next year's election campaigns:

Cat Fight

This could be fun. David Brooks, the New York Times' in-house conservative columnist, this morning launched a frontal attack on the paper's in-house liberal columnist Paul Krugman. Brooks accuses anyone who points out that Saint Ronald Reagan kicked off his 1980 presidential campaign with an overtly racial appeal to southern voters of propagating a calumny.

The essence of Brooks' argument is that the man who made his first mark in politics by attacking welfare queens and Berkeley demonstrators should be excused for highlighting "states rights" in that opening speech outside Philadelphia, Mississippi, a few miles from where three civil rights workers had been slain. Why? Because a weekly earlier he showed up at Vernon Jordan's bedside and offered the inner city tax breaks for breakfast.

I recently read Krugman's "The Conscience of a Liberal." A major theme of his book is that the politics of race, and the South's wholesale defection to the Republican Party in the wake of the Civil Rights era, is the real cause of the nation's rightward drift in recent decades. It provided the plutocrats who control the Republican party with the political cover needed to impose their unfair economic agenda.

Krugman repeatedly says that in writing the book, he was forced to confront his own bias as a professional economist that economic events and evolution drive political change. In that standard view, rapid technological change and the evolution of a high tech society raised the rewards to education and skill, thus creating a more unequal society in terms of income and wealth. In Krugman's new view, the growing inequality that has characterized American life over the past three decades is the product of political decisions to change tax law, regulations and to eviscerate social programs, changes that were enabled by the southern strategy political realignment initiated by Nixon and achieved under Reagan.

Brooks never mentions Krugman in his column. It will be interesting to see if Krugman rises to the bait and answers his critic -- without naming names, of course.

CBO for Effectiveness Analysis, Not Much Else

This morning's New England Journal of Medicine contains the second installment of the Congressional Budget Office's views on health care cost containment. Sad to report, there's not much new or far-reaching in its recommendations.

The good news is that CBO chief Peter Orszag and and senior analyst Philip Ellis join the ranks of policy wonks promoting the use of comparative effectiveness research to inform payment decisions. As I've said many times before in this space, it was the number one reform in my book (published in early 2004), just as it is the top or one of the top reforms in nearly everyone's book on a health care subject. With CBO joining the chorus, it should make the creation of such an agency, which would generate studies evaluating competing medical approaches, one of the highest priorities of a new Congress after the 2008 election.

As I continued reading the piece, my heart soared since their second point gets to the heart of one of the biggest problems with our health care system: the fact that doctors are paid on a fee-for-service basis. Doctors are still on the piece work system, which nearly every manufacturing industry except clothing sweatshops abandoned long ago because of its deleterious effects on quality. Fee-for-service "encourages providers to deliver a given service efficiently but also creates an incentive to supply additional or more expensive services -- as long as the payment exceeds the costs," they note.

In a medical context, efficiency means running patients through a mill, seeing them for ten minutes, and making snap judgments. That may be a good way to sew buttons, but hardly guarantees the delivery of quality care, not to mention avoiding medical error. And if the snap judgment is to send the patient off for the expensive test or procedure to avoid error (and innoculate oneself from a costly malpractice lawsuit), why worry since it's the insurer's money, which means it's everyone's money, which means it's noone's money.

Patients have no incentive to say no because they only pay a small portion of the price. And if the system forces them to pay more through higher co-pays or individual accounts for first-dollar coverage, they have no way of discriminating between what's really necessary and what is purely superfluous.

Insurers, the writers note, do not have information about what treatments work best for which patients. Therefore, they can't make blanket decisions about reimbursement. If they do, they're sure to be lambasted for denying someone who needs the expensive test or procedure the care they need. And the nation's biggest insurer, Medicare, doesn't even have clear legal authority to take costs into account, so it is paralyzed in trying to impose cost effectiveness analysis on its payment decisions.

So what's the answer? According to the CBO authors, more of the same. Do the comparative effectiveness analysis. Allow insurers, including Medicare, to use it to inform reimbursement decisions. Make patients pay more. (Parenthetically, they throw cold water on disease management programs that give more power and money to primary care physicians, suggesting that pilot projects using such approaches "may improve quality of care but do not substantially reduce costs.")

What was notable in the analysis was what was not said. Nowhere do they even discuss the idea that the fee-for-service system should be scrapped entirely. The nation's best health care systems -- Kaiser Permanente among private health maintenance organizations, the Veterans Administration among public agencies, for instance -- rely on organizational structures where physicians are employees and their incomes are not directly correlated with the number of procedures they conduct. Arnold Relman, the long-time editor of the NEJM, has issued a clarion call for reorganizing medicine along such lines in his book, "A Second Opinion," which is available from Public Affairs Press.

But taking on the power of the American Medical Association and the myriad specialty societies that dominate organized medicine remains the bridge-too-far in the health care reform debate. And, sadly, it is subject-non-grata for the CBO.

WHO Considers Patent Pooling, Prizes

Knowledge Ecology International, the U.S.-based non-profit, has pushed a proposal for pooling patents and awarding prizes for developing drugs for neglected diseases onto the World Health Organization agenda. A WHO committee is meeting in Geneva this week to consider that proposal along with other approaches to this thorny problem, according to yesterday's Financial Times (registration required).

The WHO mainstream is leaning towards "cheaper distribution of medicines through measures including more support for generic companies, compulsory licences under World Trade Organisation rules, and transparent, consistent and lower prices for drugs," the FT reports.

A few thoughts: It's important in this debate to disentangle the issues of access to existing drugs and development of new drugs. HIV/AIDS medicine, for instance, has a well-developed market in the advanced industrial nations, and results in billions of dollars of sales. This is adequate to incentivize continued drug company investment in newer medicines, to tackle drug resistant strains of the disease, for instance. Therefore, companies can afford to sell the drugs to the poor countries at the marginal cost of production. It will have no impact on their willingness to invest in research and development.

But the search for a new drug for a disease for which there is no cure, or for which there is no first world market is very different. Here, there are two choices: either you incentivize the private sector to throw significant resources at the problem. Or, you can rely on the non-profit model.

The American Society of Tropical Medicine and Hygiene annual meeting now underway in Philadelphia is filled with sessions about non-profits developing new and better drugs and vaccines for malaria, African sleeping sickness, and river blindness. Many private firms are collaborating with the non-profits like Medicines for Malaria Venture, One World Health and the DNDi (Drugs for Neglected Diseases Initiative, a project of Doctors Without Borders). But, in a new wrinkle, many of these for profit firms are small start-ups like Scynesix of Research Triangle Park, NC, which was started by idealistic refugees from large pharmaceutical firms who devote substantial resources to the neglected disease arena while simultaneously serving as a contract house for Big Pharma's R&D department. In taking money to do research from groups like DNDi (which gets most of its own money from the Bill and Melinda Gates Foundation), these firms agree to turn over the intellectual property they develop at no or extremely low cost to generic manufacturers for eventual production, should the research efforts prove successful.

Prizes and patent pooling are great ideas. But, as things stand now, they are of greater relevance to creating a model for developing affordable medicine in the advanced industrial world than they are to incentivizing drug development for neglected diseases. To the extent that drugs for the diseases of the global poor already exist and are patent protected, strong laws protecting country rights to compulsory licensing ought to be sufficient to ensure that those drugs are offered at affordable prices in the developing world.

On the neglected disease R&D side, the deep pockets of Bill Gates and Warren Buffett have changed the equation. A large amount of money is flowing into neglected disease R&D. Could there be more? Of course. But as I listened to the arguments between sessions (I could only attend for one day, alas), I was pleasantly surprised to hear that the strongest disagreements among scientists came over what targets to pursue, not where to deploy scarce resources.

Newspaper Circulation in Freefall

While a few newspapers bucked the trend, the downward spiral in newspaper readership continues unabated. This chart in today's New York Times says it all.

A few thoughts: The Wall Street Journal not only lost circulation, but more than half its circulation is now online and those paid subscribers (it's the only newspaper that makes readers buy its content on the web) are included in its total. So most Journal readers now are like me: they read it every day, but they read it only online.

The Los Angeles Times seems to have stopped its slide momentarily. That must be heartening to Jim O'Shea, its new editor, whom I once worked for. I congratuate him, and if it is anything other than blind luck, he ought to share his secrets with the world. Ditto for USA Today (How much of this circulation is real anyway? I'm at a hotel this morning, so I guess I'm included in the totals.).

As readers gravitate to the web, advertising in this medium is just a fraction of the lost advertising at the print editions. And as long as that's the case, the financial support for independent journalism will continue to erode. One of the major issues confronting our democracy in the next few years will be whether an independent, neutral source of news is worth having; and if it is, who will finance it.

Orthopedic Surgeons’ Buck-raking Exposed

Nearly 50 orthopedic surgeons, many affiliated with the nation’s top teaching hospitals, each earned over $1 million a year in consulting contracts and royalties from the five companies that make artificial knees and hips. The payment disclosures were posted on the companies’ websites last week as part of a $311 million anti-kickback settlement between four of the firms and the U.S. attorney for northern New Jersey. The complaint had accused the companies of using consulting contracts as an illegal kickback scheme to get surgeons to use a particular company’s artificial joints.

The top two earners were Thomas Thornhill, chair of the orthopedics department Harvard-affiliated Brigham and Women’s Hospital in Boston, and Robert Scott, also at Brigham and Women’s, who each collected $6.7 million in the first ten months of 2007 from DuPuy Orthopaedics, a unit of Johnson & Johnson. In a statement released Friday, the two men claimed the money came consulting fees and from patent royalties on an artificial knee licensed to J&J in 1986 and an artificial hip licensed to J&J in 1991. They said in a prepared statement that they collected no royalties on DuPuy products used at their hospital, and all the consulting fees were donated to charity.

Norman Scott of the Insall Scott Kelly Institute for Orthopaedics and Sports Medicine in Manhattan collected $5.5 million in payments so far in 2007 or about $25,000 a day from Zimmer Inc. The institute’s website claims an affiliation with the Albert Einstein School of Medicine, but the Yeshiva University affiliate says Scott’s appointment ended in 2005. A secretary at the institute refused to comment or put a call through to Scott. Richard H. Rothman of the Rothman Institute, the former chairman of the orthopedics department at the Thomas Jefferson Medical School in Philadelphia, received $2.4 million in 2007 or about $12,000 a day from Stryker, a division of Howmedica Osteonics Corp. A spokesman for the institute, contacted Sunday, refused to comment.

With seniors accounting for nearly 70 percent of the knee and hip replacement market, Medicare spent $16 billion on the procedures last year. A typical knee replacement costs $33,000, according to Medicare records. A spokesman for Christopher J. Christie, the U.S. attorney in Newark, said the investigation into the alleged kickback scheme is ongoing.

The preceding first appeared in Integrity in Science Watch, a publication of the Center for Science in the Public Interest.

Columnists Miss Chance to Educate on PSA Testing

Paul Krugman's column in today's New York Times and Eugene Robinson's column in the Washington Post justifiably attack Rudy Giuliani's misuse of prostate cancer stats, all but accusing him of lying. Krugman begs political reporters to make the Republicans' false attacks on Democratic health care plans as "socialized medicine" as big an issue as Clinton's laugh or Edwards' hair.

That's fine as far as it goes.

But here's his paragraph debunking the claim that the U.S. has much better prostate cancer survival rates than Great Britain:

You see, the actual survival rate in Britain is 74.4 percent. That still looks a bit lower than the U.S. rate (82 percent), but the difference turns out to be mainly a statistical illusion. The details are technical, but the bottom line is that a man’s chance of dying from prostate cancer is about the same in Britain as it is in America.

How hard would it have been in a column of 650 words to use 50 of those words to explain that thousands of American men are incorrectly diagnosed with prostate cancer each year. The prostate specific antigen (PSA) test has a very high false positive rate, identifying "tumors" that will never threaten patients' lives or well-being. Moreover, to "survive" that non-cancer, they are subjected to needless treatments -- costly operations, drugs, and/or radiation -- that leaves many of them impotent and incontinent.

Robinson misses this entirely. After attacking Giuliani for misrepresenting the statistics, he concludes that he prefers the American system of massive screening because "if I'm going to be hit by a freight train, I want to see it coming."

Americans need to hear the message that many aspects of our vaunted "best health care system in the world" are wasteful when not downright harmful. And for men over a certain age -- about 70 -- they would be better off if they adopted a "watchful waiting" strategy if diagnosed with prostate cancer rather than letting their specialist docs operate, chemically castrate or radiate.

This would be a perfect example for another column that takes on "consumer directed" healthcare. It could start by begging readers to bear with him as he explains the technical reasons why the U.S. prostate cancer survival rate is slightly higher than the British rate, and what that means for American patients.

The columnist could use the "complexity" of this one example to show why forcing "consumers" to understand all this on every medical situation they may face is a completely unrealistic approach to holding down health care costs. What we need is an unbiased comparative effectiveness institute like the one proposed by most Democratic candidates to generate these analyses, and then pay primary care doctors enough money to help their patients understand these choices.

Instead, what we have is fee-for-service medicine where the specialist doctors who operate, chemically castrate and radiate make the big bucks; many men needlessly suffer; and our health care outcomes in terms of survival are no better than Great Britain, where they spend 41 percent of what we do on health.

"Consumer-Driven" Health Care

Over at the Century Foundation's Health Beat blog (highly recommended), guest blogger Niko Karvounis pens a brilliant short essay on the flaws in market-based solutions to health care cost containment. It begins by pointing out that 10 percent of "consumers" account for 70 percent of health care costs. They're the people with chronic diseases like diabetes or heart disease, which disproportionately affect the poor and lower middle class. It concludes:

So long as educational disparities persist, painting patients with the broad brushstrokes of market logic is counter-productive because in reality we don't all have the same capacity to be effective in efforts to manage our own care.

As I said, highly recommended, especially for those looking for ammunition for countering the individual choice-health spending account model.

Aging Boomers Are Not the Problem

Today's New England Journal of Medicine contains the first of two articles from the Congressional Budget Office on what's really behind skyrocketing health care costs. This is an important series because the CBO, now run by Peter Orszag, is usually seen as a source of "facts" in any debate.

So what are the facts, as CBO sees them? First, Social Security has nothing to do with the long-term fiscal crisis facing the nation, as Dean Baker of the Center for Economic Policy and Research has frequently pointed out. Over the next ten years, as the Baby Boom enters retirement, Social Security spending will rise from 4.2 percent of gross domestic product (GDP) to 4.8 percent. That level of increase is clearly manageable.

What's not manageable is the projected increase in spending on Medicare and Medicaid, which now take 4.6 percent of GDP and will go, if left unchecked, to 5.9 percent by 2017, a 30 percent increase in 10 years. Projecting out a bit further, government spending on health would reach 20 percent of GDP by 2050, which as a share of the economy is roughly what goes for ALL government expenditures now. Private sector spending on health, now about half of all expenditures, will rise right along with it.

But the most interesting part of the CBO analysis comes from what they blame. An aging society? Nope. Obesity? Nope. "The bulk of this spending growth appears to result not from increasing disease prevalence but from the development and diffusion of new medical technologies and therapies," they write. Moreover, "many treatments and services are provided to patients who could do just as well with less expensive care. . . substantial evidence exists that more expensive care doesn't always mean higher-quality care. Consequently, embedded in the country's fiscal challenge is the opportunity to reduce costs without impairing overall health outcomes."

There was one other interesting fact in their analysis that signals the CBO may be lining up to support the Republican approach to eliminating this expensive, not-needed care. Republican plans generally call for insurance to cover just catastrophic care while consumers, subsidized if need be, pick up first dollar coverage through tax-advantaged health savings accounts. As I've argued elsewhere, this would be a disaster for our already abysmal record in providing preventive care (which is the first thing people would eliminate in their efforts to save money), and substantially worsen our already lagging health care performance in international comparisons.

The CBO article points out that out-of-pocket expenditures have actually been declining as a share of total health care spending, falling from 33 percent of all health care expenses in 1975 to 15 percent in 2005. It's slated to fall to 13 percent by 2015.

But wait, how can that be? Everyone's co-pays are rising! Yes, but they're not rising as fast as overall health care expenditures, so their share of the total pie is falling. CBO uses this statistical fact as a lead in to describing the famous RAND study from the 1970s and early 1980s, which found that health care outcomes didn't decline when people had to absorb higher costs. It's the main study used to argue that people won't eliminate needed services if they are forced to have more "skin in the game."

Is not having "worse health outcomes" what we aspire to as we move to rein in health care spending? We're already 21st out of 30 OECD nations in longevity, a full four years behind Japan, despite spending 40 percent more on health care than any other industrialized nation. Isn't it about time that we get value for our money? Making people pay for first dollar coverage may succeed in holding down the rate of health care expenditure growth, but it will be at the expense of our already abysmal health care record.

We should be reducing co-pays on preventive services, and looking for creative public health strategies to ensure that individuals and families take advantage of them. Several interventions (like smoking cessation programs and aspirins-to-prevent-heart attacks) save money in the short run. Most, like the right kind of colorectal cancer screening, save money in the long run.

It will be interesting to see what CBO has to say in next week's article when it identifies "specific steps that could be taken to capture" the "potential savings" in health care costs.

Behind the Times Data on Seniors' Health Costs?

The latest issue of the journal Health Affairs contains a study showing that the Medicare beneficiaries are spending more out-of-pocket on health care in 2003 (15.5 percent) than they did in 1997 (11.9 percenet). I hope the full study (which I haven't read yet) points out that 2003 was the year before the new prescription drug benefit kicked in, and, presumably, sharply lowered many seniors' out-of-pocket costs.

Scientist: Glaxo Credit for Malaria Vaccine Misplaced

One of the scientists behind Glaxo's experimental malaria vaccine wrote a comment to my GoozNews post from last month that lauded the company's efforts. I thought it worth highlighting, since it illustrates the theme of my book (that government research is behind most medical advances), and properly chastises me for not doing my homework:

I am disappointed in your assertion that "There's no quarreling with the assertion that this Glaxo effort to develop a much-needed malaria vaccine -- an effort, by the way, that has bedeviled scientists for decades because of the complexity of the parasite -- ought to receive a multi-billion-dollar reward if it succeeds." You seem to think that Glaxo has pulled this out of the thin air after poor bedeviled scientists had failed miserably. Actually work by us bedeviled scientists has been going on for more than 40 years with the support of taxpayer money from the NIH, USAID and Dept. of Defense. The first immunization study was " Nussenzweig, R., J. P. Vanderberg, H. Most and C. Orton. 1967. Protective immunity produced by the injection of X-irradiated sporozoites of Plasmodium berghei. Nature 216: 160-162". I later discovered the antibody (CSP antibody) that led to the identification of the CS protein, which is the very basis of the Glaxo vaccine (Vanderberg, J. P., R. Nussenzweig and H. Most. 1969. Protective immunity produced by the injection of X-irradiated sporozoites of Plasmodium berghei. V. In vitro effects of immune serum on sporozoites. Mil. Med. (Suppl.) 134: 1183-1190.) And I later led the efforts that used malaria sporozoites for the first successful vaccination of a human against malaria (Clyde, D., H. Most, V. McCarthy and J. P. Vanderberg. 1973. Immunization of man against sporozoite-induced falciparum malaria. Am. J. Med. Sci. 266: 169-177.). I am glad that Glaxo is now coming to the aid of us poor bedeviled scientists. There are things in basic research that scientists are able to do and there are vaccine production things that can be done only by a large corporation such as Glaxo. But please give a break to the poor bedeviled scientists (me and many others) who spent their entire professional lives doing the groundwork for a vaccine and then find that you are crediting Glaxo and insulting us. By the way, I believe that it is immoral for scientists who have had their work supported by taxpayers profit personally from a vaccine that they helped to develop but I believe that I am in a minority on this subject.

Dr. Jerome Vanderberg

New York University