Category: Economics

I guess we’ll have to think of another reason to oppose single payer

published date
January 8th, 2007 by

If there’s one thing everyone hates about single payer health systems it’s waiting lists for treatment. The trade-off is that costs are lower in single payer systems and everyone has access to care.

We can rationalize the situation in the US by saying we’ve decided not to make the trade-off. We’ve decided as a country that we don’t wan to “ration” health care or artificially limit its supply. Assuming you have access to the system you should be able to get as much care as needed to make you better.
But maybe there isn’t a trade-off. The US spends more on health care per capita and as a percent of GDP than anywhere else in the world. Massachusetts is the highest spender in the US. And Boston is the capital of the state and of its health care system.

Yet according to a new study reported in the Boston Globe (Dangerous delays to see skin doctors; Hub patients wait longest, study says), patients in Boston wait an average of 10.5 weeks to see a dermatologist for a “changing mole” –perhaps the closest thing in dermatology to an emergency. At the Brigham and Women’s Hospital, patients wait 3.5 months on average for a routine visit!

No one can really figure out what’s going on, especially when Boston has so many dermatologists.

  • Some physicians say the data must be wrong
  • Others cite the expansion of cosmetic services
  • Others blame it on the high percentage of researchers

In any case, no one’s accountable. (By the way this is not the first time physician access in Boston has been shown to be wanting.)
Just for kicks, I had a look at the UK’s National Health Service website, which has detailed, up-to-date information on waiting times by specialty. I looked at the “Provider Based Hospital Waiting Times for 1st Outpatient Appointments: England,” and checked the “Effective length of wait from receipt of GP written referral request to first Outpatient attendance (weeks). I’m not expert in reading these tables –so maybe I’m reading something wrong– but according to my calculations:

  • 37% of patients were seen in under 4 weeks
  • 63% in under 8 weeks
  • 98% in under 13 weeks

These numbers aren’t directly comparable with the Boston statistics. Still, it shows something terribly wrong with health care in my fair town.

Who’s afraid of the big bad debate?

published date
January 8th, 2007 by

The American Society of Hypertension (ASH) has taken a lot of heat from those (including the journal Hypertension) who think it is too cozy with the pharmaceutical industry. Responding to the pressure, ASH scheduled a panel discussion on “Conflicts of Interest” for its upcoming conference. However, the society then canceled the session –calling it one-sided– and this was reported in the Boston Globe (Medical group puts stop to talks on drug-firm ties). Once news of the cancellation got out it caused more controversy; now ASH is reversing course again.

This time, according to the Globe (In shift, medical society to hold panel), ASH plans to invite advocates of pharmaceutical company involvement in addition to industry critics. That has the critics (including Harvard Medical School professor Jerry Avorn and former New England Journal of Medicine editors Marcia Angell and Jerome Kassirer) up in arms.

“It seems to be standing the whole thing on its head,” said Angell. She said the original intent of the panel had been to provide a counterweight to the drug industry’s sponsorship of scientific papers and physicians at the annual meeting.

“This seems like a very different panel than the one originally proposed,” Avorn said. “Those two individuals [the industry advocates] will be expressing views that are quite different from those that were originally envisioned.”

I don’t know why Angell and Avorn are complaining. Angell’s opposition, in particular, seems silly. Does it really make sense to balance one biased part of the conference with another biased part? I say get all sides in a room and argue it out in a lively debate. Certainly the drug companies deserve a chance to put forth their arguments. If the room is full of people with the same views no one will learn much.

It would also be useful to have some participants who aren’t physicians. A patient advocate or economist, for example. One reason physicians and pharmaceutical companies have become so intertwined is that physicians don’t understand economics very well.

Chinese capitalism, US socialism

published date
January 5th, 2007 by

When I first visited China in 1990 I was surprised at how capitalistic it was. Somehow I’d always thought of China as a communist country but especially in the southern provinces near Hong Kong I experienced some of the most capitalistic attitudes and practices I’ve seen anywhere. Even to a dyed in the wool capitalist like myself the brash materialism and focus on money was a bit nauseating.
As I wrote in (In health care, the rich and powerful aren’t really insulated):

Overall, the rich and powerful are highly constrained in their ability to get exceptional service and quality in health care compared to other spheres in their lives.

Of course there are differences, but they are nowhere near as stark as in sectors like housing or travel.

In China it’s a different story, according to yesterday’s Wall Street Journal (Hospital Caters to China’s Wealthy and Poor):

At the TEDA International Cardiovascular Hospital just outside Beijing, patients can choose from six levels of service.

At the lowest end, for about $6.70 a night, patients must share a small room with others. The biggest suite at the hospital, on the other hand, costs about $3,200 a night and occupies half the floor of a building. It offers satellite television, an indoor garden, a conference room, two bedrooms, a massage chair and a private gym.

“It’s just like an airplane,” says Liu Xiaocheng, the hospital’s president. “In the front of the plane, they have the first class. In the middle, business class. At the end they have the economy class. But they’re all going to the same destination. It’s the market!”

The article focused on the differences in amenities (essentially the hotel aspects of the hospital). The article implies that the level of medical care  is the same for everyone  –mentioning, for example, free care given to orphans to build goodwill with the government.  To some extent that’s the situation that prevails in certain US hospitals –VIP suites for extra charge, but  the same medical care for all (mostly).

It would have been interesting if the reporters probed more on this point.  I’d be interested to know how many levels of medical care are being provided and how the hospital chooses what resources to commit to those in the lower service tiers. I wonder whether Liu’s statement about everyone “going to the same destination” is a fair metaphor.

More secondary drug trading fallout

published date
January 4th, 2007 by

Over a year ago drug wholesaler Cardinal Health announced it would stop trading drugs in the secondary market. Such trading was a lucrative sideline for Cardinal, offering the potential for much higher margins than the traditional wholesaling business. On the other hand it opened up the possibility of letting counterfeit drugs into the supply chain.

Recently, then New York Attorney General (now Governor) Eliot Spitzer settled a suit with Cardinal, which included an $11 million payment and additional changes in the company’s business practices. I heard about this from Attorney Eric Turkewitz, who represents counterfeit drug victim Tim Fagan. Some unsavory aspects of Cardinal’s conduct came out as a result of the suit. The upshot is that when Cardinal assessed the risks of secondary trading it focused too heavily on risks to its reputation and too little on the risks to patients.

You can read more on the topic here and here on Turkewitz’s blog.

Death by fashion in Iran

published date
January 4th, 2007 by

Women in Iran are providing sex in exchange for discounts on fashionable clothing, as reported by the Kaiser Family Foundation:

The “increasingly common” practice in Tehran, Iran, between commercial sex workers and shopkeepers of trading sex for no-cost or discounted fashion clothing is undermining efforts to fight the spread of HIV in the country, according to health education workers, London’s Guardian reports. One business owner in north Tehran’s “affluent” Tajrish district said that about 50% of shopkeepers in the mall had accepted sex in exchange for clothes, the Guardian reports. Another worker in the same mall, who admitted to accepting sex for clothes, said that the sex workers provide their phone numbers and services in exchange for an increased discount on clothing.

Perhaps these newly fashionable ladies will do everyone a favor by paying a visit to Iran’s nuclear scientists and engineers.