Please go read this, but get a barf bag first. Physicians will remain frustrated with the tort system until there is legitimate reform. Even when we try to police ourselves the result is lawsuits - From the “damned if you do, damned if you don’t” files

Canadian sites look overseas for drug supply

But during the last year, U.S. customers using Canadian websites have faced increasing difficulty getting top-selling medications such as Celebrex to treat arthritis and the antidepressant Effexor. That’s because several of the world’s biggest pharmaceutical makers are restricting supply to online Canadian pharmacies that ship to the U.S., leading to delays of several weeks for many customers. In severe cases, some sites have stopped accepting new clients looking for the hardest-to-get medications.

Faced with the growing shortages, Canadian Internet pharmacies are looking abroad themselves and increasingly selling U.S. consumers drugs that originate through pharmacies in England, Fiji, Israel and Chile. Depending on the country, that is raising concerns that U.S. consumers — many of them senior citizens — are getting medications from countries with less-stringent safety regulations than those in North America.

“It’s a potentially scary situation” that a significant number of Canada-to-U.S. prescriptions could soon originate from other countries, says Marv Shepherd, a pharmacy professor at the University of Texas, Austin, and an expert in the field of cross-border prescription sales. It’s particularly worrisome if Canadian companies “start to partner up with some of the more shaky countries,” he says.

Shepherd says that most U.S. consumers believe Canadian drugs are safe, but that could change if they start running into problems with drugs from other countries.

Robert Heinlein coined a word in 1966 - TANSTAAFL (there ain’t no such thing as a free lunch). Those who thought that importing drugs from Canada would solve the pharmaceutical cost problem are guilty of level 1 thinking. As demand for drugs from Canada increases, the Canadian pharmacies must develop supply problems. This is simple economics. Certainly the pharmaceutical industry understands this, and will eventually limit supply to Canada. Thus Canadian pharmacies look elsewhere for product.

You should not treat a deep abdominal knife wound with a bandaid. The Canadian “solution” makes for good politics, but bad policy. This “solution” is destined to fail.

We need higher level thinking to better understand pharmaceutical costs and our resultant expenditures. The “wonder drugs” are not created by spontaneous combustion. They result from expensive research.

Physicians need to understand newer drugs very well. We need to understand when an expensive drug is a better alternative, and when a cheaper generic works as well.

We need the NIH (and associated Institutes) to sponsor important drug studies. Relying on the pharmaceutical industry to fund drug studies seems cost effective in the short run, but from a long term perspective, such studies are rarely designed to answer the important cost questions.

We must start considering costs and benefits when prescribing. To do this, we need better data.

But we must treat the disease not the symptom. Importing drugs from Canada is treating a symptom, but not addressing the disease. The disease is intelligent drug prescribing. And we (the US) should take the lead in providing the research needed to develop intelligent prescribing.

I often rant about the balance between risks and benefits. This article discusses the potential risks of whole body CT scanning. I first discussed this phenomenon 2 years ago - On whole body CT scans and followed that rant with - More on ‘body CT scans’.

Now we read about another potential problem - Study stirs debate over full-body scans’ cancer risk

Proponents of the increasingly popular full-body scans say the exams are safe and can discover disease in early, more curable stages. The risk of cancer, they say, is too small to worry about.

In Tuesday’s article, however, researchers say the scans expose people to about 13 milligrays of radiation, which is about the same exposure suffered by people who were 1.5 miles from the center of the World War II atomic blasts in Japan, says David Brenner, the study’s lead author and professor of radiation oncology and public health at Columbia University Medical Center.

Brenner says the cancer risk varies with age. Among 45-year-olds, for example, a single full-body scan will cause fatal cancer in one in every 1,250 people who have the exams. One full-body scan increases a person’s lifetime cancer risk by a fraction of 1% - a small amount, considering that about one in five Americans overall die from cancer.

But opponents of the scans say even a small increase in mortality is significant because full-body screenings have never been scientifically proven to benefit healthy patients.

Lawyers must love this. If we do not do a whole body scan - they could sue us for missing a cancer. If we do one, they could sue us for causing a cancer. We need a guideline which would hold up in court.

My earlier post today referred to these amendments. For those who do not regularly read the comments, I feel these are too important to leave just there. I asked Remy to comment, and he did so in a very thorough manner:

The battle over this dueling amendments has been heating up, with the integrity of Florida’s health system at stake.

The background of the physicians’ amendment, as I wrote on a previous blog, was the failure of the state legislature to approve a cap of $250,000 cap on non-economic damages, an amount endorsed by a task force made up of five state university presidents, including Donna Shalala(from the University of Miami)who served in the Clinton administration.

Physicians were not happy with this, which impelled the Florida Medical Association to draft this amendment to cap lawyers’ fees to 30% of the first $250,000 in a malpractice award, and 10 % of any award exceeding that amount. This is in contrast to as much as 40-50% that they now can charge for their fees.

By so proposing this amendment, physicians felt that this would address an imbalance that now exists in the current tort system in terms of exorbitant fees to lawyers, and at the same time allow injured patients to claim a major portion of the awards.

In addition, the number of multi-million dollar awards has been increasing, forcing many medical insurers out and the remaining six insurers last year to increase their premiums, making it difficult for a number of physicians to continue their coverage at prohibitive levels. At least 3,000 physicians in Miami and the surrounding areas are practicing bare, while obstetricians, neurosurgeons, and other high-risk specialists have either retired or cut down on their services. In central Florida area where I practiced for over 30 years, threats of ER, obstetric suites, and trauma centers closing rocked the area last year. Even radiologists were shying away from reading mammograms.

In short, there was indeed a crisis. In contrast to California, considered one of the five most litigious states in the country, Florida physicians are paying as much as three to four times for their malpractice premiums. MICRA, the cornerstone of California’s medical tort system, has as one its features what Florida physicians are seeking now: a cap on lawyers’ contingency fees.

Polls done for the FMA indicate that its amendment will likely pass.

As for the trial bar’s two amendments, physicians are fighting hard to educate the public about the devastating consequences that they would inflict, if passed.

The three-strikes amendments, for example, would practically wipe out all neurosurgeons and cardiovascular surgeons from the map of Florida, since statistics show that they are sued at least once every other year. Nor far from then are obstetricians, orthopedists, plastic surgeons, and other procedure-oriented specialists. That would leave a big gap in access to a number of surgical services, as happened last year when all the neurosurgeons quit the trauma center at the Orlando Regional Medical Center, forcing the Orange County government to bail the hospital out with an infusion of money, which at least temporarily cools down the crisis.

Lawyers, in addition, want this amendment to be retroactive, which again would force a number of physicians out of practice. We all feel this is illegal.

Since cases settled out of court, and before they go to trial, are not considered as strikes, this would give trial lawyers an instrument to bludgeon physicians into settling, even if they feel they have strong reasons to win. The unpredictability of jury verdicts, with a possible strike, can cower physicians into a corner where settling appears more inviting than risking a loss.

But most of all, this amendment would usurp the functions of the state’s Board of Medicine which reviews all cases of medical malpractice, with the discretion to suspend physicians’ licenses. This Board has been doing an excellent job, ranking at the top in terms of percentages of physicians disciplined last year.

Regarding the second lawyers’ amendment broadening access to medical records, including proceedings of Peer Review and other committees like Credentials and Quality Improvement, this would end the era of peer review in hospitals as we know it. That would impact heavily on promoting safety and high-quality medical care.

The language of the amendment is couched in language intended to make it appear this is a routine matter, although patients how have ways to obtain these records in cases of litigation. In truth, this would expand the data base which trial lawyers can use to mount ever increasing lawsuits against health providers. It would also supersede a long-standing state law which exempts discovery of peer review proceedings. After all, cases from negligence resulting in death, permanent disability, and other serious impairment are reported, mandatorily, to the state Agency for Health Care administration.

The trial lawyers admit readily they drafted their amendments mainly in retaliation for the physicians’ proposed amendment. They would withdraw their amendments, they told the FMA, if physicians do the same. NO WAY, physicians responded.

And so the battle is joined. The trial bar has a budget of $12 million, as opposed to $4 million for physicians. We are doing it on the grass-roots level, and we think the odds are in our favor. Florida will indeed make history and blaze new trails for other states to follow if we win our case.

I am hoping (and certainly assume) that Roaring Remy will weigh in on this issue. Here is the AMA News story - Ballot battle: Two professions square off over attorney fees and quality of care.

Doctors and lawyers in Florida have taken the tort reform fight to a new level – dueling ballot initiatives.

On Nov. 2, Florida citizens will vote “yes” or “no” on three proposed constitutional amendments that address medical liability issues. Early polling shows that all of them are likely to pass.

The ballot box battle comes a little more than a year after the Florida Legislature passed a $500,000 noneconomic damages cap that doctors say won’t prevent premium hikes that are forcing them to leave the state, retire early or forgo high-risk procedures.

To solve the problem, doctors are proposing a constitutional change that would limit the amount that trial lawyers could collect in medical malpractice lawsuits so that injured patients get a bigger chunk of awards.

Trial lawyers are proposing two constitutional amendments. The first – commonly referred to as the “three-strikes” rule – calls for stripping doctors of their medical licenses if they have three medical malpractice judgments against them. The second amendment would let patients see medical records and reports connected with “adverse” incidents, including documents generated during peer-review procedures.

Between now and Election Day, airwaves will be buzzing with ads telling voters why they should vote for or against each constitutional change.

The amendment battle is widely portrayed as two professions pitting themselves against one another. But many of the people involved insist the campaigns are about quality health care.

These initiatives will help us gauge public opinion. I am very interested in following this vote. I certainly hope that the Florida physicians are successful at making their case.

America’s Failing Health

Krugman decides that we should go towards the Canadian system (despite the many problems often highlighted in this blog). He does frame the issue fairly though.

In most advanced countries, the government provides everyone with health insurance. In America, however, the government offers insurance only if you’re elderly (Medicare) or poor (Medicaid). Otherwise, you’re expected to get private health insurance, usually through your job. But insurance premiums are exploding, and the system of employment-linked insurance is falling apart.

Some employers have dropped their health plans. Others have maintained benefits for current workers, but are finding ways to avoid paying benefits to new hires - for example, by using temporary workers. And some businesses, while continuing to provide health benefits, are refusing to hire more workers.

In other words, rising health care costs aren’t just causing a rapid rise in the ranks of the uninsured (confirmed by yesterday’s Census Bureau report); they’re also, because of their link to employment, a major reason why this economic recovery has generated fewer jobs than any previous economic expansion.

Clearly, health care reform is an urgent social and economic issue. But who has the right answer?

The 2004 Economic Report of the President told us what George Bush’s economists think, though we’re unlikely to hear anything as blunt at next week’s convention. According to the report, health costs are too high because people have too much insurance and purchase too much medical care. What we need, then, are policies, like tax-advantaged health savings accounts tied to plans with high deductibles, that induce people to pay more of their medical expenses out of pocket. (Cynics would say that this is just a rationale for yet another tax shelter for the wealthy, but the economists who wrote the report are probably sincere.)

John Kerry’s economic advisers have a very different analysis: they believe that health costs are too high because private insurance companies have excessive overhead, mainly because they are trying to avoid covering high-risk patients. What we need, according to this view, is for the government to assume more of the risk, for example by picking up catastrophic health costs, thereby reducing the incentive for socially wasteful spending, and making employment-based insurance easier to get.

A smart economist can come up with theoretical justifications for either argument. The evidence suggests, however, that the Kerry position is much closer to the truth.

I often blog about the necessity of connecting the health care consumer (the patient) to the cost decision. We can decrease costs only if patients really want us to do that.

Moving to Health Savings Accounts would decrease overhead. Having insurance companies less involved is a desirable outcome. I believe that having the government more involved is an undesirable outcome.

Powerful players lead stem-cell effort in Calif.

Silicon Valley tycoons, Nobel laureates and Hollywood celebrities are backing a measure on California’s Nov. 2 ballot to devote $3 billion to human embryonic stem cell experiments in what would be the biggest-ever state-supported scientific research program in the country.

The measure - designed to get around the Bush administration’s restrictions on the funding of such research - would put California at the very forefront of the field. It would dwarf all current stem cell projects in the United States, whether privately or publicly financed.

Proposition 71 promises to be one of the most contentious election issues in California, pitting scientists, sympathetic patients who could benefit from stem cells and biotechnology interests against the Roman Catholic Church and conservatives opposed to the research because it involves destroying days-old embryos and cloning.

This vote will help us understand popular opinion on this issue.

Doctors and “blogs”

As I expected, we already have some heated debate on the stem cell post. These 2 quotes make the point that I implied:

The anti-stem cell research crowd thinks that some embryos are worth more protection than others, or they would be just as outraged over fertility clinics and treatments that result in the overt and intentional destruction of many more embryos daily than stem cell research would probably require in a year.

and

My dilemma with stem cell research is that I don’t think that as a society we are facing the reality of what we want to do. With stem cell research, we are taking an embryo that with proper care and handling will have a very high likelihood of developing into a fully functional human, and sacrificing it because there is a small chance that someday, somehow, the research might result in helping someone.

Let me summarize my understanding. Those who favor stem cell research do not regard an embryo as life, but rather a potential for life. If we regard an embryo as life, then we should regard sperm and ova as life - for they together lead to the potential for life. (I do understand the absurdity of my argument, but I believe that I have used the same logic).

Those who oppose harvesting new stem cells, make a leap of faith (as the second quote does) that an embryo is life, because it can become a human being!

As I stated a couple of days ago, this debate is unresolvable, because we cannot get agreement on the premise. Those who sanctify embryos as life, believe their argument is correct, ethical and moral. Those who regard embryos as potential life believe that until an embryo is implanted and growing it is only potential.

To consider my reductio ad absurdum (if my Latin is obscure - Reductio ad absurdum), one could argue that we should never refrain from sexual activity, because we are preventing the creation of human beings.

I have gone off the deep end in this argument. The key here is understanding why we cannot resolve the argument. We cannot agree on the suppositions. Our language and semantics differ. Thus, we will continue to write, argue and give speeches that our opponents must reject (whichever side we espouse).

Sometimes we must agree to disagree. I believe this is such a case. To think otherwise is to misunderstand the discordance of the viewpoints.

Clean houses ‘may trigger asthma’

Messy homes ‘cause messy minds’

So I guess we need dirty but neat homes? These articles are certainly interesting, but do they really help?

Kerry on med-mal: symbolism over substance

While I personally disagree with those who oppose stem cell research, I do try to understand their concern. The debate concerns religious belief. We all understand the impossibility of settling religious debates. Mona Charen explains - Misleading stem cell debate

But like millions of others, I am troubled by the idea of embryonic stem cell research. It crosses a moral line this society should be loath to cross — even for the best of motives. Taking the stem cells from human embryos kills them. Before turning to the arguments of the pro-research side, permit a word about the pro-life position. Too many pro-life activists, it seems to me, have argued this case on the wrong grounds. My in-box is full of missives about the scientific misfires that stem cell research has led to, as well as breathless announcements that adult stem cells actually hold more promise.
This is neither an honest nor a productive line of argument. Pro-lifers oppose embryonic stem cell research because they hold life sacred at all stages of development. They ought not to deny this or dress it up in a lab coat to give it greater palatability. It’s an honorable moral case. Leave it at that.

This debate cannot have a winner, because the two sides debate differing arguments. Medical ethics are often murky. We should all strive to understand the murkiness in this issue.

Please read this account of a young physician who died from AIDS in the 1980s. His story is important for all physicians to remember. For a Young Doctor, the Ultimate Sacrifice

Walter Olson has an op-ed in today’s WSJ about recent attempts by the Kerry Edwards campaign to endorse tort reform. Here is his reference to that op-ed - “Symbolism 1, Substance 0″

From the opinion piece:

Guess who’s suddenly saying nice things about litigation reform? None other than John Kerry. Explains his campaign Web site: “There is no question that abuses of our legal system have hurt companies and individuals who are acting responsibly.” The scarcity of insurance for doctors should spur us to action: “Access to care is threatened. . . . Lawsuits should be the last, not the first, line of defense.” You might almost think the Massachusetts senator had just accepted the Republican nomination.

==============================

With each of these proposals, the details left blank are likely to be crucial. For example, during this year’s “med-mal” debate on Capitol Hill, several of the ideas above surfaced in an amendment that Rep. John Conyers put forth as a Democratic alternative to the GOP-backed reform bill. But the pleasant-sounding generalities concealed some nasty traps: The language prescribing nonbinding mediation turned out on inspection to include a kicker that would have pre-empted and invalidated all forms of alternative dispute resolution other than mediation – including arbitration programs that work well in some states in forestalling litigation – as well as all contractual barriers to suit.

Until we see more details on the Kerry proposals, we should resist the temptation to dismiss them as no more than an insincere feint to the center. At worst they’ll turn out to be mere lip service; but lip service to an opponent’s issue is itself important in electoral politics: It can signal when a fight over principle is ending and a new consensus has begun to emerge. On curbing the excesses of the American litigation system, we may be nearing the end of a national debate on whether, and moving on to a debate on how.

I hope that we really are nearing a solution to our current tort crisis. I hope the Democrats are serious and not just talking for sound bites.

Try to get a copy of the WSJ op-ed - it defines the issue beautifully.

This article describes a highly desirable practice style - for both patients and physicians. ‘Same-day’ doctors catching on

The idea, which experts say is gaining steam, is that scheduling patients immediately for even routine physicals will keep them healthier and happier, while saving money in the long run. If people know they’ll get quick appointments, the reasoning goes, they’re less likely to ignore their health problems, which will reduce costly emergency-room visits.

“We’ve seen it work in every kind of clinic imaginable,” said Marie Schall, a training director at the Boston-based Institute for Healthcare Improvement, an organization pushing for same-day service, known in the industry as “open access.”

The American Academy of Family Physicians and the U.S. Department of Veterans Affairs also adopted open access as their goal.

Moore, 43, who treats the Lunt family at his Ideal Medical Care clinic in the suburbs of Rochester, made the transition three years ago. Tired of working long hours with patients double- and triple-booked into time slots, Moore left the physicians’ group he was with and started his own family practice.

“People used to be shocked when they’d call up – and half the time I answered the phone – and we’d say, ‘Come in at 3 p.m.,"‘ said Moore.

“I don’t have cranky patients. I don’t get the no-show thing I used to have,” he said. “My schedule is much more reliable. Doctors make a fine income, that’s not the problem. The problem is imbalance and burnout. I have three small children. I want to be there for them.”

The majority of patients, however, still wait for their care. A recent survey in 15 cities found that the average wait for a cardiology exam was 19 days. The average wait was 24 days for a dermatology appointment, and 23 days for an obstetrics-gynecology exam, according to the survey by Merritt, Hawkins & Associates, a national firm that recruits medical workers.

Boston, despite a worldwide reputation for medical care, had the longest waits in three of the categories surveyed.

Kurt Mosley of the Dallas-based MH&A said the biggest hurdle for open access is persuading doctors to rethink their scheduling habits.

The idea actually makes sense. I would combine this with a cash only practice and develop a much more satisfying life style.

Any blogger relishes consistent readers and commentors. Bernie certainly reads and comments. I have often disagreed with Bernie - but this time he makes great sense!

Actually there are two problems. First, the efficient allocation of resources. This is a problem the free market was invented to solve. The solution is to bring free market forces back into the health care system. My two solutions: make health care expenditures fully deductible to individuals and remove the deduction for businesses. The “disintermediation” that will happen when people pay for their own health care will force efficiencies on the system. And, of course, end the artificial monopoly of drugs by the forced licensing of patents.

The second problem is the equity problem. No one wants to see a kid die because he couldn’t afford a medical treatment. The solution has to be some sort of government funded health insurance for the poor and unemployed.

I mostly agree with Bernie here. He understands that the middle men (i.e., the medical insurance industry) prevents efficiencies through dissociating health care costs from patients. We do need some provision for catastrophic insurance (in my opinion). I suspect that catastropic insurance and a “set aside” for health care would bring expenditures into focus.

Of course I cannot totally agree with Bernie. We do need to give the pharmaceutical industry a reasonable incentive to develop new drugs. Perhaps a creative economist could develop a system which provides the companies a fair return on investment.

Finally, Bernie has the right idea on the equity issue. I really cannot figure out how we can realistically fund univeral insurance.

My big fear is that when a bureaucracy provides insurance, then that bureaucracy will act to control medical expenditures, sometimes without regard to patient preference. Bernie has the right ideals here. I will quibble over the details, but not his intent.

And Bernie, thanks for your loyal readership!

Cholesterol drug helps all diabetics, study finds

People suffering from the most common form of diabetes could sharply cut their risk for heart attacks and strokes by taking a cholesterol-lowering drug even if they have normal cholesterol levels, according to a major new study.

The study of more than 2,800 patients with Type 2, or adult, diabetes found that those who took the cholesterol drug Lipitor were more than one- third less likely to have a heart attack, nearly half as likely to have a stroke and about one-third less likely to die from any form of cardiovascular disease.

“This is a landmark study with watertight data showing clear evidence of a benefit that warrants people to really look at their treatment of this group of patients,” said the study’s lead author, Helen Colhoun, a professor at the University College Dublin. The study was terminated two years early because the results were so striking.

Most other experts agreed, saying the findings provide the most convincing evidence yet that most diabetics should consider taking the drugs regardless of their cholesterol levels. The research is the latest in a series of studies showing that the widely popular class of cholesterol-lowering drugs called statins could benefit far more people than are taking them.

“This is another extraordinary result,” said Peter Libby, a Harvard Medical School cardiologist.

Although the study, being published in Saturday’s issue of the journal the Lancet, received some funding from Lipitor’s maker, Pfizer Inc., it was supported primarily by the British government and the British equivalent of the American Diabetes Association and conducted independently of the company, Colhoun said.

Critics will continue to focus on who supports these studies. These same critics decried the newest NCEP III revision. As I read the data, statins will help many type II diabetic patients - apparently regardless of their initial cholesterol level. These data should change how we treat patients.

Prostate cancer confounds me. I understand that many men die with prostate cancer rather than of prostate cancer. Thus, we have the classic dilemma in medicine: which is worse, the treatment or the disease? This article suggests that perhaps we can treat early prostate cancer with a combination of radiation therapy and short course hormonal therapy (with less side effects than surgical therapy). The article is not definitive, but does provide some guidance for physicians and patients.

Combination of Treatments on Prostate Is Promising

Men with prostate cancer that does not appear to have spread have better survival chances when they get short-term hormone treatment along with standard radiation, rather than radiation alone, a small study has found.

Almost five years after treatment, 88 percent of men who received the combined treatment were still alive, compared with 78 percent who had only radiation. The study involved about 200 men and was conducted by researchers at Brigham and Women’s Hospital and Dana Farber Cancer Institute in Boston.

We await further data.

For many years, physicians have considered the VA an inferior care system. Unbeknownst to most physicians whose only VA experience occurred during their training, the VA has made significant strides over the past 10 years. Attending on the VA wards for 5-6 months each year, I have noticed these strides. A major contributing factor is the BEST electronic medical record that I have seen.

A new study shows that the VA does a better job caring for diabetes than does managed care - Study: VA Bests Managed Care on Diabetes

Diabetic patients treated by the country’s long-maligned VA health system got better care than diabetics under managed health care plans, according to a new study.

Researchers found that the diabetics served by the Department of Veterans Affairs had better control over their cholesterol and got more frequent blood tests, eye and foot exams than diabetics served by the commercial health groups.

The findings appear in Tuesday’s issue of Annals of Internal Medicine. The study was funded by the VA, the U.S. Centers for Disease Control and Prevention, and the National Institute of Diabetes and Digestive Kidney Diseases.

“The VA has made great strides in the past 10 years,'’ said Dr. Eve A. Kerr, the study’s lead author, who is a research scientist at the VA Ann Arbor Healthcare System and assistant professor of internal medicine at the University of Michigan Medical School. “What this tells us is that a nationally funded health care system can provide excellent quality of care.'’

Researchers compared the care received by 6,900 diabetics in eight managed care health plans with about 1,300 diabetics in five VA medical centers in Indiana, California, Texas, Michigan, Pennsylvania and New Jersey. They matched the two patient groups geographically and used statistical sampling to make the demographics comparable.

Compared to their managed care counterparts, diabetes patients treated by VA doctors more often received the recommended annual blood tests (93 percent vs. 83 percent), eye exams (91 percent vs. 75 percent); and foot exams (98 percent vs. 84 percent).

The VA group also received more cholesterol testing (79 percent vs. 63 percent) and had better control of their cholesterol levels as a result, according to the study.

Both groups of patients reported similarly high levels of satisfaction for the care they received.

Why? I would submit that 2 major factors make this result happen. First, VA doctors have more time to see each patient. As physicians have more time, they more likely will address more issues. Second, the VA electronic medical record facilitates tracking.

This study suggests an important subsequent study. We need to better understand the factors that have enabled the VA to surpass managed care. That study might inform a reconsideration of primary care.