Sunday, September 17, 2017

Why Are Drug Prices So High? Explanations Welcome

Most of us do not know the basics of economics, although we should.  It impacts every one of us every day that we are alive.  Yet, for most of us, once we get beyond the law of supply and demand, our knowledge of the subject starts to vaporize.  I can't explain fiscal or monetary policy.  While I regard economics as a science, it seems that experts routinely interpret data differently, which confuses beginners like me.  What are novices to think when one expert hails our continued job gains while another laments our anemic recovery?

The Puppeteers

I have a general feel for market forces.  If consumer demand for an item rises, then I will expect to pay more.  If I want to make a purchase at an independent appliance store, then I will expect to pay more in return for superior customer service.  If the item is manufactured in China, it will likely cost me less as this factory is not burdened with worker protections, environmental regulation and union wages.

The above common sense realizations do not compute in the medical universe.  My fees, which I do not control, are unrelated to supply, demand or quality of the product.  Moreover, medical costs are a mysterious enigma which confound physicians and our patients.  Why does the cost of a simple bandage for a hospital patient remind us of the defense department’s $400 hammer?  Why can’t I, a gastroenterologist, give a straight answer to the question, ‘how much does a colonoscopy cost?’

Reimbursement strategies in medicine are changing to a system that will pay physicians and hospitals for the ‘value’ of their service, rather than the quantity.  Like any slogan, it will sound appealing but will bring forth a bevy of burdens that will create foreseeable controversies and challenges.  Stay tuned.

Let me share an absurd medical economic observation that occurred a few days prior to this writing.  I received a phone call over the weekend from one of my patients who was suffering from a recurrence of C difficile (C. diff) infection and needed antibiotic treatment for this as soon as possible.  The drug of choice was Vancomycin (Vanco).  Physicians know that the cost of this medicine is often prohibitive.  The patient and I made phone calls to area pharmacies in an effort to find the most affordable option.  Let me juxtapose below results from two different pharmacies.

Pharmacy #1                  Pharmacy #2

Vanco Cost                        $110                             $2,500

Okay, my economist friends, explain this discrepancy to me, if you can.  Good luck.   

Would it make sense to you if a Big Mac costs $3 at one McDonalds and $500 at another? 






Sunday, September 10, 2017

Hospital Acquired Infections and C. diff. Is My Hospital Safe?

If any reader has heard of C. difficile, affectionately known as C. diff, than I presume you have had closer contact with this germ than you would have liked.  It’s an infection of the colon that can be serious, or even fatal.  There isn’t a hospital in the country that isn’t battling against the infection.  

We are not winning the war against this crafty and cunning adversary. 

We Need Better Weapons Against C. diff

While the infection is not new, the strength and seriousness of current strains of the germ have tilted the odds against doctors and our patients.  The infection usually is a ‘side-effect’ of antibiotic treatment, but it can also be contracted from infected surfaces and people that reside in hospitals and extended care facilities and nursing homes.  For example, nowadays a patient can be admitted to a hospital and pick up the germ from hospital personnel who are contaminated from contact with an actual C. diff patient.  For this reason, C diff patients are kept in a form of isolation to protect against spreading the disease.  When a C. diff patient is discharged, the room must be scrupulously cleaned.  Hospital housekeepers today have an incredibly important job for reasons that need not be explained.  While my intent is not to frighten readers, every room in your hospital has likely housed a C diff patient at one time or another. 
  • Imagine the consequences if hospital rooms are not cleaned fastidiously every time?
  • Imagine the risk to patients if personnel do not observe proper handwashing techniques?
  • Imagine the hazard from overuse of antibiotics which are a known risk of C. difficile?
C. diff is not a simple infection like a urinary tract infection that can be easily wiped out. It can be severe and stubborn. The germ has a spore form where it stays protected within a type of armor and can survive on surfaces for months.  This is why it is so tough for hospitals who are striving every day to destroy these millions of microscopic germs who resist attack and hide in waiting.  It’s not really a fair fight.

Some patients carry the infection for life.  Many have died from it.  It’s especially tragic when a patient battles against C. diff which resulted from antibiotics that were not necessary in the first place.  Think of this when your dentist insists on giving you antibiotics because you have a heart murmur of have an artificial joint, neither of which is supported by medical evidence.

There’s a new treatment called fecal transplantation, where healthy donor stool is introduced into the C diff patient’s digestive system and cures an infection that seemed to be chronic and incurable.  In my view, this is a game changer and I predict that every hospital in America will offer it in the forseeable future.
 
My advice?  Refuse any antibiotics advised by any physician, including me, unless the doctor makes a case for them beyond a reasonable doubt. 


Sunday, September 3, 2017

Labor Day 2017

Couldn't cover every tool or trade here, but a shout out to all.   All work is honorable.

Warm wishes from the Whistelblower.














Sunday, August 27, 2017

Jury Blames Talcum Powder for Ovarian Cancer - No Evidence Needed!

I have written about talcum powder previously.  Indeed, I have not only opined on the slippery substance, but I am also a regular consumer of the product.  Talcum powder has become magic legal dust that brings forth zillions of dollars to those who have been attacked by the poisonous toxin. 

Just last year, I informed readers of $55 million and $72 million judgments to cancer victims who used powder against the manufacturer Johnson & Johnson.  Earlier this year a Missouri woman was awarded $110 in damages. 

Recently, a jury in California, where the cost of everything is stratospheric, ordered J & J to pay damages to a victim of ovarian cancer.   The jury clearly wanted to send the company and corporate America a monetary message that went beyond the pinprick judgements that were issued against J & J last year. 

Readers at this point are invited to consider what would constitute reasonable damages if it were proven true that the product caused the cancer and the company knew of this risk and did not provide adequate warning to the public.   Make your guess before reading on.

Here are some price comparisons to test your sanity

Private Gulfstream Jet                     $70 million
Penthouse in NYC’s Plaza Hotel    $40 million
Alexander Hamilton Autograph             $1,000
Bentley Automobile                            $230,000
100 meter Superyacht                    $275 million
California Jury Award                    $417 million

You may resume breathing now.  Of course, the plaintiff’s attorneys were able to string  a circuitous array of dots that connected talcum powder to cancer in front of a jury who was likely more sympathetic to a dying victim than to a megacorporation.  But, sympathy is not evidence and being a successful company does not define negligence.   


Few strands of GW's hair is a bargain at $22,800!

This mega-judgment is rendered beyond absurd when one accepts that there is no convincing and consistent scientific conclusion that talcum powder is the responsible agent.  The studies have largely demonstrated an association, which are not designed to determine cause and effect.

What should product manufacturers do?  Should every package include a boxed warning that the product can cause misery and death just to cover themselves?   Perhaps, not. This would only give customers anxiety, pain and suffering.  Guess what would happen next?

Sunday, August 20, 2017

Yikes! There's Food Stuck in My Throat! The Steakhouse Syndrome Explained

While I typically offer readers thoughts and commentary on the medical universe, or musings on politics, I am serving up some lighter fare today.  Hopefully, unlike the patient highlighted below, you will be able to chew on, swallow and digest this post.  If this blog had a category entitled, A Day in the Life of a Gastroenterologist, this piece would reside there.

I was called to the emergency room yesterday to attend to an elderly woman who had steak lodged in her esophagus.  While this sounds life threatening to ordinary folks, it poses no mortal danger.  The airway is uninvolved and normal respirations proceed without interruption.

These patients, while fully alive, are rather uncomfortable. 

This is one of the tasks that gastroenterologists are routinely called to undertake, often at inhospitable hours.

Sometimes, these folks have known esophageal narrowed regions where food that is not masticated with enthusiasm can hold up.  On other occasions, a person with a totally normal esophagus tears into a steak like a famished wolf and forces down a mass of meat that has no chance of passing through.  Bar patrons who are inebriated and then grab a handful of chicken wings are prime candidates for an emergency room visit with a gastroenterologist when the wings just won't fly through.  And, if granny forgot to put in her dentures before biting into a chicken sandwich…


Don't bite off more than you can chew.


No one involved enjoys the experience, and the procedure has more risk that our routine scope examinations of the stomach and esophagus.   Usually, these episodes can be prevented with proper attention to making wise food choices and chewing well. 

How do we get the job done?  Basically, we serve as plumbers and use our usual scope instrument to unclog your food pipe.  (Reminds me of a joke when a customer complained to a plumber over his bill.  "I'm a doctor, " the customer said, "and I don't charge that much!"  The plumber replied, "I used to be a doctor also, but I wasn't earning enough money."

The curious aspect of this case is I asked the woman prior to the procedure if she has difficulty swallowing foods with regularity.  She responded that the only food that she has consistent difficulty swallowing is the type of meat she ate that day.

Can you guess my next question?

Sunday, August 13, 2017

The Heartbreak of Psoriais - Guilt by Association

I was asked this week for an informal opinion by someone who was advised by his dermatologist to take a biologic medicine for psoriasis.   Now, my knowledge of this disorder is barely skin deep, yet knowledge alone will not set you free in the murky world of medicine.  Knowing something is not as significant as knowing when to do something.


Can guacamole really cause cancer?  Read on.


Biologic medicines, which have surpassed in frequency the nearly omnipresent TV ads for erectile dysfunction, are expensive medications that have risks of serious, albeit uncommon, side effects.  And, unlike chemotherapy for cancer, which has a finite course, biologic medicines are administered forever, that is without a clear stopping point. 

The individual who questioned me was not suffering from insufferable psoriasis and was satisfied with the conventional topical treatments he has been using for years.  His dermatologist offered the biologic in an effort to reduce his risk of heart disease.  Let me try to explain.

If you GOOGLE psoriasis and heart disease, you will find a surfeit of hits claiming some kind of connection between the two conditions. However, if you GOOGLE any two items on any subject, you are likely to hit upon some ‘connection’.   I just randomly GOOGLED guacamole and cancer and sure enough, there is a 'connection'!  Presumably, the dermatologist accepted the psoriasis-cardiac connection to be one of causality, meaning that psoriais can cause heart disease.  Extrapolating beyond this FAKE NEWS, he assumed that treating the psoriasis would mitigate the risk of an adverse cardiac event.   It is exactly this false reasoning that so often gets patients into trouble.  The logic of the intervention seems sound, but it is entirely specious.

The facts are here that there is no proof that psoriasis causes heart disease.  Clearly then, it makes no sense to treat the skin condition hoping to prevent a complication for which there is no proof that psoriasis causes.  Psoriasis may be associated with or linked to heart disease, which understandably suggests to an ordinary patient that there is a strong connection where Condition A causes Condition B.  I address this fallacy several times each week when I am asked if heartburn medications cause hip fractures or dementia.  They are associated with these complications in a statistical sense, but have not been shown to cause the complications.

Say I publish a study showing that tall individuals are associated with high blood pressure.  This does not mean that height is responsible or that we should hope that our children remain short.


Do you think that this blog is associated with astute and discerning readers?   If so, can I write next week that reading the Whistleblower blog is powerful brain food?

Sunday, August 6, 2017

Will Genetic Engineering Save or Sink Humanity?

We cannot let the anecdote rule over us.   We don’t make sound policy if we are swayed by isolated emotional vignettes.  Of course, a vignette describes a living, breathing human being, but we must consider the greater good, the overall context and the risk of letting our hearts triumph over our heads when making general policy.  Consider these examples.

If an expensive drug treatment program keeps 5 addicts clean for 6 months, do we champion this success in asking for funding to be renewed while omitting that 400 enrolled addicts failed?

If an experimental medical treatment seems to be effective in one patient with a stubborn disease, should physicians lurch toward it leaving aside standard treatments which have been subjected to Food and Drug Administration approval and years of clinical experience?

If a high school student attends an SAT prep course and achieves a near perfect score, do we conclude that every student should enroll in this course?

It is natural to be drawn to a shiny object, but on closer review, the shine often tarnishes quickly.

Earlier this week, we learned of an astonishing scientific breakthrough that seems utterly fantastic and futuristic, even though it has actually occurred. Scientists amended the DNA of human embryos to correct a mutation - a genetic defect - that causes a very serious medical disease.   This suggests that with additional research and testing that embryos who otherwise might be destined for misery could be rescued. 

We will hear heartwarming and breathtaking anecdotes that, if considered in isolation, will generate excitement and support. 

Would you argue against the following headlines?

Embryo with fatal cystic fibrosis mutation saved.

Tay-Sachs embryo rescued from fatal outcome.

Hemophiliac embryo expected to live normal life.

As is always the case, there will be ethical mission creep, despite the usual bromides that “scientists and research institutions will conform to the highest ethical standards”.   The fact that there is a fortune to be made in the genetics industry can be expected to alter the direction of our ethical compass.  And, while the initial rollout will be discussing how genetic intervention can reverse the course of devastating and fatal diseases, does anyone believe it will stop there?  Once the concept has been normalized, other medical conditions will be targeted.   The creep will be inexorable.  Boundaries will be shattered.


Einstein said 'God does not play dice with the universe.'

Should we?


Who doesn’t want a perfect child?  Over time, how will all of us regard the disabled community or even folks of average intellect and ability?  Will a disabled person be defined as anyone who is imperfect?

Beyond medical mission creep, I believe there is a very serious risk that genetic engineering will be used to achieve non-medical results. 

Imagine that you are new parents.  If medical science could perform a procedure that would add 20 IQ points to your child, would you pursue it?  Would you submit to a minor DNA tinker that would produce an excellent athlete or a musician?  See where I'm going with this?

Are you really ready for the curtain to rise on the Genetic Engineering Show?  I'm not.  To me, all this sounds like coming attractions of a horror show.






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