Wednesday, May 27, 2009

Field Day

I'm living a sort of good-news-bad-news joke today.The bad news is that the business picture for my business hasn't gotten any better so, as advertised, my employer has cut the staff hours down to 24 per week.Working - or not working - a three-day week pretty much sucks. Getting by on 60% of your normal income isn't a good thing, either. But there's not much I can do about it at the moment, anyway, except try and look at the good-news aspect, which is that if I am going to have to take a day off without pay, today was a good day for it. The weather is gorgeous and my little boy's "Field Day" was today, so I got to go over and play with him and his little kindergarten classmates as they raced and jumped and wriggled and were otherwise as energetic and adorable as a clowder of kittens.After Field Day I went and had a delicious leisurely lunch at the Little Red Bike Cafe, absolutely a Cool Thing in North Portland, and spent the next several hours doing household chores, making phone calls to try and reduce our spending on things like insurance, cable TV and the Internet, and re-reading Diane Gabaldon's entertaining "Outlander", as much fun now as it was when I first read it several years ago. Watched part of a truly bizarre Johnny Weismuller "Jungle Jim" movie on TCM and taped the UEFA Champions League Final - I haven't watched it in hopes of luring Brent and his current inamorata Heidi over to see it this weekend, but...go, Barca!And then sat down to post this.At some point today a friend from this blog, Charles Gittings, is going to try and drop in. He's passing through between Seattle and California, where he's getting some medical work done, and his situation got me thinking of medicine, health care and the contretemps surrounding "health care reform".I think, and have thought for some time, that the way we distribute and pay for our medicine in this country is beyond flawed. It is, quite literally, insane. The notion that sickness and injury need to somehow become profit for everyone involved except the sick or injured person, from the insurers to the doctors to the hospitals, clinics, laboratories and hospices...that's lunacy. It's like making war for profit, or making love for profit. The incentives for misbehavior are legion, and the restraints on any sort of mischief, well...Atul Gawande has a good piece up at the New Yorker that looks at this as exemplified by the little town of MacAllen, Texas. It's not pretty, and it should make you think.

The bottom line is that sick people or injured people are going to need care. And only the most over-rich communities can afford such care without some limits on the amount and the cost. So in some way that care will be rationed. At the moment we have chosen to ration care by income. If you are wealthy, you can afford care without limit. Make a living wage and hold down a decent job - and remain relatively healthy - and you can still afford a lavish regime of treatmeent for your ailments.

Become old, or sick, or unemployed...well, one hopes that Illness will be merciful and Death will be kind.That seems fundamentally unjust. Does the elderly woman dying in her broken bed in her unheated shack love her life less than the elderly woman in her soft sheets and elegant bedroom? We seem to believe so, for we have set up a system that punishes the poor and rewards the wealthy. One suspects that this is a reflection of our political system, which empowers the powerful and disenfranchises the powerless.I wish I saw a change in the future. I do not. The forces arracyed against such a change are simply too strong.Oh, and the pictures are all from the Astor School 2009 Field Day. Go, kindergartners!


Lisa said...

Hello to Charles, and to Chief. I hope you guys enjoy a lovely visit.

Ael said...

Canada has had single payer universal health care for less than 50 years.
There were huge vested interests opposing it. Doctors even went on strike to prevent it.

And yet, it took less than five years to go from first implementation in Saskatchewan to national coverage.

sheerahkahn said...

Well, Chief, I can understand having been on both sides of the issue as far as health care goes.
The one thing Americans have to realize is that America, i.e. joe average citizen is paying for the research that is being done in the labs.
Granted, the legion of abuses is there, as it is in any system, but herein is the bench view of what goes on when you're holding that little white bottle.

Experimental failure.
Matrix study.
Place molecule back on the shelf for later consideration.
For every successful molecule that can be medicinized, there are at least five to six failures.
Phizer had a two failures in Phase two trials...those failures were catastrophic to those molecules, and so they were canned.
Those two failures represent hundreds of millions of dollars gone, thousands and thousands of man hours gone, and years gone.
I'm currently watching two molecules go the same way at my company. Years and years, backed by tens of millions and hundreds millions of dollars...only to go nowhere. So the plug is being pulled on them.
Ael, you're benefiting from America's research efforts, as is Europe, and the rest of the world.
If you ask me, I think if the US is going to be the bio-pharma research center for the world, we should start charging the world the costs of that research.
Medicine costs money, research costs even more money, and with the new bio-engineering that is going on...wonderful things are coming out...but it costs money. A lot of money.
Unfortunately, as Chief pointed out, there are the raiders who seek to makes scads of cash hand over the expense of both the scientists and the patients.

Publius said...

Chief, sorry to hear of the reduced hours deal. That's tough. Saw something in the paper this AM to the effect economists now see the recession ending later this year. Let's hope.

BTW, speaking of Oregon and Portland specifically, I was reminded a couple of days ago that Oregon had the second highest unemployment rate in the nation. This was when I was talking to my best friend's nephew, who's like a nephew to me, who was axed from a fairly senior position with your local evil empire, Nike, last week. He has mixed feelings: relief that he won't hear digs about his despised employer, but concern about the future. Fortunately, he got a fairly decent package and is a frugal person.

I read the New Yorker article focusing on McAllen last night. Very, very illuminating, and I'd recommend it to anyone concerned with health care expenses. That should be everyone. I'm going to take you to task about one thing I believe you should have PUT IN GREAT BIG CAPS: Nothing that's on the table right now will do anything to fix the problem. Why is this? Well, because the McAllen situation is specifically caused by rotten, greedy venal DOCTORS. Not insurance companies. DOCTORS.

Takeaway from the article: Where doctors are motivated by professional ethics rather than by avarice, medical costs can be contained. Where they're greedy—and this includes an increasing number of areas in the country—costs cannot be contained.

I always knew it. It's the doctors.

Hope you and Charly have a great visit. Say hi to him and tell him not to slack off on his email updates.

Pluto said...

I've worked a LOT of different angles in the Medical industry and even did a stint in insurance and I've studied healthcare costs for almost the entire time.

In MN, for example, the average cost to insure a family of four went from $880 per year in 1987 to $10,200 last year. That's almost a 1200% increase in 21 years.

The power of double-digit compounding of medical expenses is truly phenomenal. This is a perfect exammple of why Eistein identified compound interest to be the most powerful force in the universe.

Sheera has identified part of the problem, which is the way we pay for the high costs of research and the rest of the world eventually benefits. It would be very interesting to see what would happen if we shared out the costs more equitably with the rest of the world. Would they be willing to pony up and pay the tab or would they explain that they aren't willing to purchase treatments at the real price? And what would that teach us about the real value of the treatments?

But the heart of the problem is that there really ISN'T an American Healthcare System. We've got several discrete groups that influence healthcare decisions(companies that provide new treatments and services, clinics and hospitals, medical schools, doctors, insurance companies) but none of them receive any benefit from actually lowering the costs to the consumer.

Insurance companies appear to benefit from helping people control their healthcare costs but they get most of their income from two sources:
1) A fixed profit percentage based on the total dollar volume of claims processed
2) What amounts to legal kickbacks from the companies that provide the services

Considering the information above, insurance company profits (and they are VERY profitable) can only grow by increasing the total dollar volume of their claims (more healthcare expenditures) or by expanding kickbacks from the companies that provide the services (which pass the extra cost on to the consumer). And it's only American to want your company's profits to grow...

The net effect is a runaway feedback loop as the companies find ever more effective ways to bill the patient and to cope with ever spiralling costs of competing for healthcare dollars.

I disagree with the Chief on the likelihood of action from the Federal government this year. Medical expenses have gone so fast that many companies are dropping healthcare benefits and people are discovering that they can't afford to get sick and they are beginning to apply real pressure on the government to change things.

Walmart and the AFL-CIO joined forces back in 2002 to hire a bunch of first-rank lobbyists to start laying the groundwork for some sort of universal healthcare system. Their two lead lobbists were Newt Gingrich and Hillary Clinton. The Bush administration fought hard against these two and mostly held the line but the times are a changing...

On the downside, while I'm fairly sure that SOMETHING will happen this year, I'm fairly pessimistic that it will be an effective without a LOT of additional tinkering.

But, as Ael has noted, once an effective system appears to be in place in a state or region, the pressure to take the rest of the country there will be overwhelming.

I only hope we don't make too many misteps on the road to success.

Ael said...

Canada has a vibrant drug research community. It is not immediately obvious that we are not pulling our weight, research wise.

Drug marketing costs are significantly larger than research costs. I suspect that marketing costs are cheaper in Canada as we buy in bigger lots than the americans. This improves our efficiency.

Finally, health care is not just drug costs (and in Canada, drug costs are not entirely covered by our health care system).

In any case, there are other benefits to a single payer health care system.

A single mother friend of ours just had her baby (a month early). It was a breach birth and an emergency C section was required. The baby is still in an incubator cause the lungs are quite up to par.

This has been a hectic week, starting with the unexpected labour at 4am, taking her two kids into our house, dealing with the after effects of surgery, visiting mom and babe in the hospital, getting her place organized for the extra baby, etc. etc.

It only occurred to me as I was typing up this post, that not once, during the whole process, did I even think about how she is going to have to pay for all that completely unexpected extra care.

To my mind, the benefit of health care money simply not being an issue is a considerable one.

FDChief said...

Lisa: We did have a good visit, and the Peeper even worked up the courage to visit Charles' camper and got some cool beach glass!

Charles has a tough road ahead, but he's up for the challenge, and is eager to move ahead with his project to bring our governmental malefactors to the bar of justice. I wish him well!

Ael: I think the timing is crucial. If the U.S. had moved to a national health care back when much of the rest of the industrialized world did, that is, right after WW2, I think it would have been practical. But 2009 isn't 1959. The forces aligned against NH are just too rich, too organized and too strong, and the American sheeple have been dog-whistle trained by nearly thirty years of Reaganism into knee-jerking at the words "socialism" and "rationing". The Perfect Storm of Rich and Stupid? Too much for reform...

Sheerah: But a big part of the story here is that pharma in general has lots of other bad habits (and Ael points out a few). The insistence with which Big Pharma keeps shaking the "Research is Costly" tree makes me think that research really ISN'T that costly.

Publius: I agree with you on the docs. But the takeaway I got from the New Yorker article was that this isn't a bug; it's a feature. It's no different from AIG or the Keating Five or Teapot Dome. Make the rules so that an unscrupulous person (doctor, lawyer, securities trader, Indian chief) can warp the system to make a buck? They're gonna do it.

The GOP hates to be reminded that their idol, Adam Smith, says right there in The Wealth of Nations that businessmen can't be trusted. "People of the same trade seldom meet together," he says, "even for merriment and diversion, but the conversation ends in a conspiracy against the publick, or in some contrivance to raise prices."

The solution is right there in the article: the Mayo system puts everyone on salary. Push more drugs? Push more surgery? Invent clever ways to mulct the patient? Doesn't matter; you collect your $49.95 a day same as everyone...

So it IS the doctors. But it's because our system is set up to make the patient the cow and allow everyone in the medical game to invent their own Unlimited Turbo milking machine...

Pluto: Your analysis actually gives me some hope. The only way that this mess will ever be straightened out is if the medical leeches suck the patient dry. They're doing that now. But I thought that the recent Wall Street goatfuck would cause the Powers The Be to question the rush to deregulate everything financial. It hasn't. Can the health care vampires suck enough lucre out of the American economy to fail where the Masters of the Universe succeeded? It'll be an interesting next couple of years...

basilbeast said...

from the new yorker article:

This will by necessity be an experiment. We will need to do in-depth research on what makes the best systems successful—the peer-review committees? recruiting more primary-care doctors and nurses? putting doctors on salary?—and disseminate what we learn. Congress has provided vital funding for research that compares the effectiveness of different treatments, and this should help reduce uncertainty about which treatments are best. But we also need to fund research that compares the effectiveness of different systems of care—to reduce our uncertainty about which systems work best for communities. These are empirical, not ideological, questions. And we would do well to form a national institute for health-care delivery, bringing together clinicians, hospitals, insurers, employers, and citizens to assess, regularly, the quality and the cost of our care, review the strategies that produce good results, and make clear recommendations for local systems..
Oh this really reeks.

Death by committee.


The whole civilized world ( except the US ) has extensive experience in operating some form of publicly financed and run national health care systems for years and years. And this SFB offers to jawbone it to death. Crazy.

Well sorry, I do get carried away sometimes. I keep forgetting that those stinkin' foreigners lie about everything, especially how good their health care is. And those goddam Canadians banging on their doctors' office doors for every splinter and hangnail while poor folk with heart attacks gotta wait 6 months to see anybody. And those Canadian doctors leaving in droves for the US to make a decent living.

Smug foreign jerks.

( PS - - - AEL, any room left up north where you are for a couple more Murcans wanting something more civilized?

And Charles if you're reading this, wish you well. )


sheerahkahn said...

"Sheerah: But a big part of the story here is that pharma in general has lots of other bad habits (and Ael points out a few). The insistence with which Big Pharma keeps shaking the "Research is Costly" tree makes me think that research really ISN'T that costly."

I know it seems that it isn't, but it is.
For example, in my lab I have two FACS Arias, full suite, cell sorters, LSR II, partial suite research analysis platform, and a Clinical full suite CANTO II analysis instrument. Along with a dated ADVIA 120 clinical blood analyzer, and a CONFOCAL microscope, along with two kinetic microscopes, and a slide scanner that that images slides electronically.
All total, a bout seven million dollars...just in eqiupment, in this one lab out of eight labs in this facility.
Just eqiupment, not including the costs of upkeep, repairs, and reagents to keep them going.
Add in the scientists salaries, and you're looking at a 50 million dollar a year budget for one ain't cheap. And we're just one facility.
Then there is the chemistry, toxicology, immunochemistry labs...
But thats not where it ends, then there is the OMG costs for phase I, phase II, and phase III trials, and the molecule just to bring this far has gone into close to a couple of hundred million dollars.
And still there is no product, just a molecule looking for a problem to deal with.
So, for example, lets say zetia is your drug that took about nine years to validate, which burned a lot of midnight oil, paperwork, research, testing, isolating, more paperwork, retesting, and more retesting...and it still hasn't gone to trials yet...then when it does hit trials the maker of zetia has to walk on freaking water to ensure that it won't kill anyone, or make them sicker than they are.
After that, number crunching, more testing, validations, paperwork, and what not.
Till finally, the FDA craps out it's approval, and the company now has a product that it can sell, and the whole's several hundred million dollars in the hole for this product, not to mention the several hundred million dollars that the other five that were being studied concurrently with zetia were sacked due to what ever reasons there were (most likely failing toxicology testing which will sack any molecule in a heartbeat).
It's expensive, and I will grant that the Pharma execs acting like nobility doesn't make the case for fact, it just makes us look bad.
But I will admit one thing which we on the inside do comment to each other on...that pharma's penchant for targeting "commercial" products rather than seeking "cures" really doesn't make the case for us.
I point to the current spate of "cholesterol" reducing drugs.../sigh...everyone has one, and that is where the ridiculous costs in marketing comes from.
Franchise OTC products. Hence the reason why I refuse to work on any project that even remotely has to do with franchise products. I'm in the business of researching cures for life threatening diseases, not humping golden calf's leg.

Lisa said...

I'm glad to hear you all had a good visit.