Health Care systems

[Shinova]

To those in socialized health care countries like Canada, is it true that because of the socialized system people could end up waiting weeks, or even months for treatment to arrive for them?

So you trade off cost for waiting time. Is this true?

[Darth Wong]

To those in socialized health care countries like Canada, is it true that because of the socialized system people could end up waiting weeks, or even months for treatment to arrive for them?

Sometimes, if your treatment is considered non life-threatening. Case in point: my hernia operation had to be booked several months in advance at the Shouldice Clinic. When I was there, they brought in a guy who had only been waiting less than 24 hours, because his case was considered serious, and mine was not (interesting side-note: many of the patients at Shouldice were Americans).

Logically, this is the same point I made earlier; for any given amount of total medical resources, you could theoretically increase the speed of service for some by simply cutting off others. The question is whether you think it is moral to do this.

[tharkûn]

Additionally, if what I've heard is true, the US system only covers 60% of the population, because 20% of the population under 65 is uninsured and everyone over 65 (another 20% of pop) is automatically excluded. So at 60% efficiency the US system spends more than twice as much as the Canadian system at 100% efficiency, and over two and a half times as much as the Finnish system at 100% efficiency.

That is bloody BS. In the US every hospital is required BY LAW to treat emergency patients regardless of ability to pay. Second people over 65 are eligable for medicare which is a HUGE medical program and they face lower hurtles getting into medicaid. And medicaid does cover the absolute poor.

Seniors in the US enjoy the best medical care in the world, the only way they don't is if they don't fill out the paperwork.

The real bulk of the uninsured in the US tend to be the transient unemployed who don't shell out for a policy while between jobs and the young who simply beleive they don't require a policy.

Let me see the vast amount of evidence you provided for this claim ... oh wait, not a shred!

Colorectal cancer survival rates:
US 90%
Germany 80%
UK 70%

Breast cancer survival rates:
UK 78%
EU 93%
US 97%

And those are just the figures the BBC elected to rehash in a quick blurb. One major factor for the discrepancies is that in the US people are far more likely to be diagnosed early, because the screening technology is more widespread and less restricted; not to mention more likely to be newer and more accurate. Another factor is that median waiting times for procedures and to see specialists are lower in the US.

Even in Canada Circulation: Journal of the American Heart Foundation found that surival rates for heart attacks were lower for Canada. Granted the difference was only about 3% of something, but given the basic relationship (in the sample populations the Canadians had lower incidence of diabetes, high blood pressure, obesity, etc.) it should have been skewed the other way. The fun data was that when the cause was a completely blocked artery American doctors were far more likely to use angioplasty or bypass.

By and large detection of serious health problems occurs earlier in the US, treatment is more timely and aggressive, and superior treatments are used. When you look at five year survival rates, particularly if you can find the exceedingly rare fitness normalized ones, the US seems to do a better job of keeping people alive.

Did you know that 75% of all medical expense-related personal bankruptcies in the US involve people who actually had medical insurance?

And that means what exactly? You have scads of people on revolving credit card debt and when an unexpected bill, like a healthcare deductable, makes them miss payments. Penalty charges and predatory interest rates (say goodbye 0% APR) often lead to a downward spiral. Just because the final straw was a medical bill does not mean that poor healthcare caused their insolvency in total.

Oh wait, could that mean insurance companies are not completely honest and might rip people off? Oh no, that's impossible! The free market would never allow that, right?

It could, or it could mean that when they are forced to pay the deductible, and many people carry high ones because they mean lower premiums, they are unable to pay that month's credit card bills and watch it spiral and die from there.

The greed has taken over - the pharmaceutical companies are churning out "me-too" drugs, often for non-lifethreatening conditions ("lifestyle drugs") and outrageous prices, rather than coming up with truly novel treatments - like a better flu vaccine or a new, more effective antibiotic.

And why is that a problem? Me-too drugs break up monopolies, cause more cost reduction (long term), and often offer particularly advantages (oral vs injected, longterm vs immediate relief), etc. The drug companies produce the pills people want to buy. As far as outrageous prices, how are you benchmarking that? Compared to the alternative therapies drugs tend to be an order of magnitude cheaper. If you have a product that saves the consumer 4,000 dollars they would have otherwise expected to pay then its worth, according to some methodologies IS 4,000 dollars.

Medical device manufacturers will buy tech that might potentially threaten their market dominance and, rather than develop it, SHELVE it - an economic, not a medical decision.

Give me a specific example. I know the people at ISYSS, a few people in Medtronics, and a smattering of other medical device companies ... generally a disruptive technology is viewed as a license to print money. Shelving these things most often happens because the cost needed to bring it to market exceeds the payout once it reaches the market. The funny thing about that is that the market for such devices is divided into the US and everywhere else. For the cutting edge, it is even more skewed towards the US.

As someone who researchs in the lifesciences I must say the American system is far better suited to bring new medical devices to the market. There is more venture capital out there, there is a far friendlier patent system (international patenting costs up around 150,000 a pop ... let alone defending it), and it is ludicriously easier to find initial consumers to slowly ramp up production rather than convincing a monolithic buyer to add it to the tables. There is a reason why there are more med tech startups in the US than anywhere else. Hell look at the discrepencies in R&D budgets, like say comparing the budgets of Rice, Johns Hopkins, and MIT to all of Canada.

I'm sorry but I've frikking heard the CEO of ISYSS deride Europe as a viable market for lifesaving MEMS sensors (integrated chips smaller than a penny, with sensors smaller than Lincoln's bowtie) - going so far to say that they don't even bother to patent protect 3/4ths of their US patents over there. I have yet to hear of a technology that got squashed by a corporation, I have heard innumerable stories about the hell of IP protection, licensing, production, and sales in Europe.

But, to be honest, the US has had very little innovation in the past decade, which is why the research unit I work for has been working with Canadians and Europeans on various projects these last few years rather than with other Americans.

BS. In the last decade we have seen the massive minaturization of medical devices. The other day I saw a frigging brain implantable pressure sensor and another that directly measures pressure differentials across heart valves. In pharma we have whole bloody new anti-retriviral medications coming through. In surgergy we are doing brain surgery coming in through the GROIN. Don't even get me started about GM and SCIDS.

rather than coming up with truly novel treatments - like a better flu vaccine or a new, more effective antibiotic.

Oh please. Do you know why no-one touches the flu-vaccine? Because you have to meet some ludicriously idiotic government regulations, you have to reengineer it every bloody year, and demand swings wildly as all hell. If people consistently bought flu-vaccines or were willing to pay the real R&D costs to get beyond decades old production methods - i.e. move from eggs to vats.

As far as antibiotics ... do you have any idea how restrictive FDA rules on those are? Likewise let's say you do sink hundreds of millions of dollars into a more effective antibiotic - if it doesn't offer a dramatic improvement over current medicines it won't make a dent in the market place.

The "bottom line" in health care should be HEALTH, not money. But that's NOT the way it is in the US today.

I could easily rattle off a list of truly benificial treatments and programs for any individual that would easily reach 100K per annum. At some point money has to enter into the equation and some form of resource rationing simply must take place. But let me ask you a simple a question, what type of gross profit (as a percentage of revenue) do you think a medical company should have?

. Making flu vaccine available and affordable (even free) not only maximizes health, it's cheaper over the course the year because you have fewer flu-related hospitalizations and deaths. But even if it wasn't cheaper, it is STILL within our means and resources to do this.

The problem with Flu vaccine manufacture is that it has production costs, no ability to develop inventory, and you have to forecast much of your production run before you have a clue what is going to happen. The reason the industry consolidated so dramaticly ended up hinging on a single point: people don't get flu shots unless they feel a pressing need to do so. Year after year high percentages of the production run simply wasted away in boxes - 15 MILLION in 2002.

If you could actually GET most people to have a flu shot there would be no problem delivering a regular, relatively cheap supply. Right now such a small percentage of people are willing to take them that economies of scale are collapsing. Hell look at the dismal performance of MedImmune's

If we put health first we'd pony up the bucks, fewer people would get, those that did get sick wouldn't get as sick, and there you go.

Then have the FDA change the rules. The liability risks for flu vaccine are assinine. Likewise the FDA required so many idiotic changes to Wyeth's plant, two years after they licensed it, that Wyeth simply quit producing the vaccine. The single biggest reasons few people want to make flu vaccine are simple: people don't use them and the FDA requires hellish regulations to be met.

Our society DOES have the resources to hire adequate numbers of nurses, but does not, putting short term profit over the lives and health of patients.

No it doesn't. The limiting resource being the number of nursing degrees being handed out. As a society America simply does not graduate enough nurses even to maintain replacement, let alone deal with the increasing demand for nurses. The bottleneck is at the collegiate level, currently there is no such thing as compotent unemployed nurse (at least if willing to relocate for a hefty monetary bonus). There are more vacanies in nursing rosters than could ever hope to be filled without a substantial increase in the number of RN's being graduated out of college.

Actually, I'd be quite interested to know how long you have to wait for treatment in the US. Can anyone tell me?

Like anywhere else it depends on location and how bad off you are. For a true emergency you get immediate care irregardless of your isurance. The only wait is getting an ambulence or triage in the waiting room if something like a running gun battle among crack dealers breaks out on Detroit's east side. If you need urgent care you wait a few minutes an hour to a few hours and the hours is most often due to triage or understaffing in small facilities.

Seeing a doctor, I normally have to wait about a week and a half, a specialist takes around a month and half - though that number goes drasticly down if it is something extremely urgent.

Its just an uninformed opinion, but if the subisdy for healthcare is given to the hospitals instead of the people, some of the cons of both private and socialised healthcare seems to be degraded.

It already is. If it weren't for millions of dollars flowing into all three of the local major hospitals they'd have gone under decades ago. Government subsidizes education through grants, capital purchases, and even some direct payments. There simply is no way to make truely modern healthcare cheap. At best you can opt for monopsony, but that leads to less investment, fewer choices, and ultimately higher prices. Major gains from monopsony can be had when dealing with de facto monopolies, and this is indeed where socialized medicine has shined. It is a fun fact - drugs are cheaper in Canada than the US; but only name-brand drugs (on average). Because of how the system works fewer generic manufacturers with fewer resources are in play in the Canadian market. If the generic market where ever to outprice the brandname market, then Canada would actually spend more on pharma per capita than the US.

Organ transplants, for example, can involve very long waits because we have to wait for someone able to donate to come along. No amount of money is going to change the current system (although a medical breakthrough might help here and there)

Medical breakthroughs have been happening, such as partial liver transplants. Also one way that appears to work is to bump up donor relatives. Suppose your spouse needs a kidney and none of the family matches, well if you agree to donate a kidney to someone else on the waitlist then your spouse gets bumped up the list. This has everything to do with appealing to familial self-interest to increase the supply of organs. In similar vein massive education about organ donation appears to bringing 10-20% increases in organ donations. Another fun step has been finding ways of encouraging dialogue with the terminally ill about organ donation.

Americans love to point out that those with the Golden Privilege of health-care in the US tend to get better-quality care than those in a typical universal healthcare system. They misrepresent this as a healthcare system that offers better-quality care in general, totally ignoring the fact that for those who are not so privileged, it offers no care at all.

Complete and utter BS. In the US no one is offered "no care at all". It is bloody mandatory that emergency care be given irregardless of ability to pay, dicking with that is a quick way to terminate the career of whichever administrator makes the responsible call. Even for non-emergency care if you truly cannot afford it there are things like Medicaid for providing care. The problem is the so called "working poor" who have enough money not to be eligible for Medicaid, but not enough money to pay all the other bills and medical ones to boot. These people have some medical care, but it tends to be insufficient - compared to first world norms. They 'economize' medical care in order to keep premiums down, limit out of pocket expense, and tend to overlook preventative healthcare.

The system is not perfect, but no one truly has "no healthcare".

While I do think the American health care system is absurdly broken and I would support a Canada-esque system, America has around 294 million people. Canada has 32 million, Australia has 20 million. That may affect the costs somewhat.

Easily. If the US congress ever allows "reimportation" of Canadian drugs then either the Canadians will be trying to stop the practice at the border ... or the drug companies will stop selling drugs to Canada under the current price controls. Right now a massive number of firms follow the business model of research it according to US requirements, market it in the US, and then whatever left to be squeezed out of the patent can be marketed in Europe. If the US goes monopsonistic and leverages lower prices a whole slew of medical devices, drugs, and other cutting edge products simply will never be developed because the R&D costs won't be recoupable in a timely fashion.

In some very real sense the US healthcare market drives and subsidizes the world healthcare market.



All in all socialized medicine is a mixed bag. There does appear to be significant cost savings currently via monopsony. Undoubtedly the standardization of paperwork would save billions, of course the caveat is it is theoreticly possible to standardize paperwork without socializing medicine. The flip side is that there are pressures on limitation of care - fewer capital investments, lower rate of cutting edge procedures, and increased wait times for non-urgent care. To some degree all of that shows up in the patient survival and diagnosis rates, but the numbers tend to be occluded by the fact that Americans are the most unhealthy people in the western world (if you give an obese man superior medical care he tends to still be more likely to croak). Likewise in current socialized medicine there tends to be a pressure towards R&D limitations.

Single purchaser health care, which socialize medicine tends toward to some degree, makes it much, much more difficult to ramp up production. When a new medical device is first made it may cost 15,000 dollars; devices 10-100 might be 750 each; devices 1000 - 10,000 might be 22.50 a pop and 100,000+ be as little as 1.13 a device. In true single purchaser systems that means that if you are in the 100-1,000 range no-one will consume your product as it isn't cost effective at that range, and so being uprofitable the production line is shut down, and the device dies. In a multi-purchaser system, particularly an inegalitarian one, there will be a body of purchasers willing to pay the higher costs which will justify expansion leader to greater economies of sale. I've seen this at dozens of biotech companies - sell in the US market until you have gone through at least 10,000 units and then once you have sufficient market prescence to justify total ramp up go sell abroad.

The current US system needs DRASTIC reform. For a start medical school and nursing school need to be ramped up to produce more human talent. For another congress needs to blackmail the insurance industry into standardizing the paperwork - one set of paperwork irregardless of who pays the bill. For a third something has to be done about the insurance gap, some type of subsidized insurance might be possible. Lastly I'll just say that laws and regulation need a complete and total rewrite to irradicate defensive medicine, bogus treatments/'science', and byzantine barriers to bringing new products to market.

[Darth Wong]

Colorectal cancer survival rates:
US 90%
Germany 80%
UK 70%

Breast cancer survival rates:
UK 78%
EU 93%
US 97%

And those are just the figures the BBC elected to rehash in a quick blurb.

Could you provide a link? When I checked the BBC, I couldn't find this article. At wrongdiagnosis.com, they said the following:

Code: Select all

5-year survival rate for black women with breast cancer is 65.8% in the US 1983-90 (SEER) 
5-year survival rate for white women with breast cancer is 81.6% in the US 1983-90 (SEER) 
5-year survival rate for women with breast cancer is 80.4% in the US 1983-90 (SEER)

Interestingly enough, they did confirm a 98% survival rate for breast cancer but only for patients where it is detected before it reaches 2cm in diameter; could your source be based on selective data? Or have breast cancer survival rates skyrocketed in the last 15 years?

In any case, notice the effect of race (and by application of socio-economic data, wealth) on survival rates.

Even in Canada Circulation: Journal of the American Heart Foundation found that surival rates for heart attacks were lower for Canada. Granted the difference was only about 3% of something, but given the basic relationship (in the sample populations the Canadians had lower incidence of diabetes, high blood pressure, obesity, etc.) it should have been skewed the other way. The fun data was that when the cause was a completely blocked artery American doctors were far more likely to use angioplasty or bypass.

Could you show me a link to this article, since the only information I could find about your previous claim massively contradicted it?

Did you know that 75% of all medical expense-related personal bankruptcies in the US involve people who actually had medical insurance?

And that means what exactly? You have scads of people on revolving credit card debt and when an unexpected bill, like a healthcare deductable, makes them miss payments. Penalty charges and predatory interest rates (say goodbye 0% APR) often lead to a downward spiral. Just because the final straw was a medical bill does not mean that poor healthcare caused their insolvency in total.

Please read http://content.healthaffairs.org/cgi/co ... .w5.63/DC1 where they discuss medical bankruptcies. So-called "major medical bankruptcies" are classified as such only when the medical expenses are a major contributing factor, not just a tiny final straw.

Oh wait, could that mean insurance companies are not completely honest and might rip people off? Oh no, that's impossible! The free market would never allow that, right?

It could, or it could mean that when they are forced to pay the deductible, and many people carry high ones because they mean lower premiums, they are unable to pay that month's credit card bills and watch it spiral and die from there.

And that excuses the situation ... how?

Americans love to point out that those with the Golden Privilege of health-care in the US tend to get better-quality care than those in a typical universal healthcare system. They misrepresent this as a healthcare system that offers better-quality care in general, totally ignoring the fact that for those who are not so privileged, it offers no care at all.

Complete and utter BS. In the US no one is offered "no care at all". It is bloody mandatory that emergency care be given irregardless of ability to pay, dicking with that is a quick way to terminate the career of whichever administrator makes the responsible call. Even for non-emergency care if you truly cannot afford it there are things like Medicaid for providing care. The problem is the so called "working poor" who have enough money not to be eligible for Medicaid, but not enough money to pay all the other bills and medical ones to boot. These people have some medical care, but it tends to be insufficient - compared to first world norms. They 'economize' medical care in order to keep premiums down, limit out of pocket expense, and tend to overlook preventative healthcare.

So first you say that there's nobody out there who's dicked by the system by nitpicking the wording of my statement, then you admit that the entire class of the "working poor" is indeed dicked over by the system. Which is it? And how do you explain the major medical bankruptcies where people did have health insurance?

The system is not perfect, but no one truly has "no healthcare".

Citing emergency rooms as an excuse is sophistic bullshit and you know it. In the US, your lifespan is determined by your economic status. Blacks in America have a lower breast cancer survival rate than fucking former eastern bloc Soviet countries, for fuck's sake.

[Xon]

To those in socialized health care countries like Canada, is it true that because of the socialized system people could end up waiting weeks, or even months for treatment to arrive for them?

So you trade off cost for waiting time. Is this true?

In Australia you can spend some time waiting for a public hospital system, if you are non-serious. However, the result of using the public health system if practically free treatment.

If you dont want to wait, you can goto a private hospital system and have something like 80-90% of the bill covered by private health cover + government health cover and be treated fast.

[Broomstick]

That is bloody BS. In the US every hospital is required BY LAW to treat emergency patients regardless of ability to pay.

After which the hospital can garnish your wages or attempt to confiscate property, such as your house, to pay medical bills. Or didn't you know that those are some of the mechanisms used?

And medicaid does cover the absolute poor.

What if you're not "absolute poor", though? What if you're working enough to put a roof over your head and no more, then suddenly you have this other expense? If you're above poverty line but have no insurance and you get seriously sick/injured you are fucked in the US.

The real bulk of the uninsured in the US tend to be the transient unemployed who don't shell out for a policy while between jobs

How the hell are they supposed to pay for an insurance policy when they're unemployed and therefore have no income?

and the young who simply beleive they don't require a policy.

Or are young an in entry level jobs that don't offer insurance, nor pay enough to allow purchase of an individual policy.

Not to mention the heads of households who, again, work at jobs that don't offer insurance. Or employers who insured only the employed and not the dependents (a perfectly legal option for companies in this country).

Did you know that 75% of all medical expense-related personal bankruptcies in the US involve people who actually had medical insurance?

And that means what exactly? You have scads of people on revolving credit card debt and when an unexpected bill, like a healthcare deductable, makes them miss payments. Penalty charges and predatory interest rates (say goodbye 0% APR) often lead to a downward spiral. Just because the final straw was a medical bill does not mean that poor healthcare caused their insolvency in total.

That's not how "medical care" bankruptcies are reckoned, as has already been mentioned prior to this post.

"Medical bankruptcy" is that caused by medical bills, and in such cases the medical debts dwarf any others.

Last year my husband was in the hospital for 8 days. Because we have excellent insurance, our share was "only" about $7,000 and because we are frugal by nature we had it on hand to pay it.

If we had had no insurance the bill for those 8 days would have exceeded our entire yearly income - and my income is above both the median and average incomes of the typical US citizen. If my employer did not offer health insurance I would, in fact, be bankrupt right now despite having NO credit card debt and, in fact, NO debt except a car loan, despite a comfortable income.

The greed has taken over - the pharmaceutical companies are churning out "me-too" drugs, often for non-lifethreatening conditions ("lifestyle drugs") and outrageous prices, rather than coming up with truly novel treatments - like a better flu vaccine or a new, more effective antibiotic.

And why is that a problem? Me-too drugs break up monopolies, cause more cost reduction (long term), and often offer particularly advantages (oral vs injected, longterm vs immediate relief), etc. The drug companies produce the pills people want to buy

"Me-too" drugs do not advance medical care, they do not cure new diseases or more effectively treat old diseases, they do not solve the problem that our antibiotics are becoming less and less effective.

Nor do they "break up monopolies" - thanks to dragging competitors into court, a series of "me-too" drugs can effectively prevent anyone else from entering a market segment.

There is nothing inherently wrong with "me-too" drugs --- there IS something wrong when those are the only new drugs coming to market.

"Me-too" drugs while close to their predecessors are not exactly the same... meaning there is the potential for new side effects. There is much more information about a drug with a 20-30 year history of use vs. one with a 2 year history, and a lot fewer surprises.

As far as outrageous prices, how are you benchmarking that?

When people need a medication in order to continue living, but are unable to buy such medications because they simply do not have the money.

When Prilosec went over-the-counter (and the price dropped substantially), then the same company came out with "Nexium", a me-too with just the minimal differences required to rebrand the drug, at three times the cost (at least) of Prilosec.... THEN, all of a sudden, there's a shortage of Prilosec being made and the company recommends folks go to Nexium until the shortage is relieved (at three times the profit to the company).... I'd say there is something outrageous going on.

Compared to the alternative therapies drugs tend to be an order of magnitude cheaper.

IF the drugs are actually needed in the first place. I have to wonder if everyone on Prozac really needs Prozac, or if changing their lifestyle would have the same but a more permanent effect.

It's a continuing and all too common problem for the elderly and chronically ill to be prescribed more drugs than they need, or to have incompatible prescriptions.

Drug therapy is NOT cheaper if, say, statins induce rhabdomyolysis and you wind up with kidney damage and on dialysis. Drugs are NOT automatically cheaper or less risky.

Another example of this is in the treatment of obesity. There are been effective drugs for weight reduction - and virtually all of them have been withdrawn due to side effects that are, in some cases, lethal. It's an area where surgery actually seems to have fewer risks than most of the drug threapies tried. (Although the surgery does carry real risks)

There is a reason why there are more med tech startups in the US than anywhere else.

And more failures, too.

But, to be honest, the US has had very little innovation in the past decade, which is why the research unit I work for has been working with Canadians and Europeans on various projects these last few years rather than with other Americans.

BS. In the last decade we have seen the massive minaturization of medical devices.

And why does miniturization automatically equate to progress in your mind? It's not enough to simply say it's high-tech or smaller, you have to quantify the improvement in terms like faster recovery, more accurate information, fewer complications, and so forth. And the cost has to be within the realm of affordable. Remember, if the patient doesn't have the money to buy medical tech from their viewpoint it might as well not exist.

As an example - there is some amazing new medical imaging technology. Truly amazing, like scans on Star Trek. However - it's amazingly expensive, highly dependent on software that isn't completely debugged as of yet, and in many cases does NOT yield any more information your basic x-ray. The typical broken arm or leg needs an x-ray, not a whiz-bang "imaging technology" and spending money on the higher-tech scan for every fracture is a waste of resources, pure and simple. This sort of tech should be reserved for those cases where it truly IS an asset and an improvement.

There's some wonderful stuff being done with detecting the genetic basis of various diseases as well... but if you can diagnose the same condition with a $40 test as opposed to a $2,000 test then, hey, the "high tech" solution is a waste of money. It's a waste of resources.

High tech is NOT inherently better. See Wong's essays about technology in Star Trek and nonsense like touch-screens on freeweights and laser vs. projectile weapons (which I should probably re-read - I really enjoyed them). Same thing in medicine - new and hi-tech is NOT inherently better

In an ideal world - which we do not and probably never will live in - people would eat right and excercise adequately and that alone would drastically reduce the need for medical care over entire lifetimes. Add in better regard for safety/safety equipment - simple stuff like use your seat belt and don't speed, wear a helmet to prevent head injuries in sports when appropriate, etc. - and you'd drop the injury rate. Once that's done, a LOT of resources going to treat ills of obesity, inactivity, and accidents would be freed up for those items remaining that require treatment. Sure, sprained ankles are cheaper to treat than, say, third degree burns but there are so many sprained ankles that the total cost of them is immense.

The other day I saw a frigging brain implantable pressure sensor

Haven't we had those for awhile for brain injuries?

another that directly measures pressure differentials across heart valves.

And that tells us... what? How many conditions is this appropriate for? Does it have any real effect on outcomes, or is it "gee-whizz" technology?

rather than coming up with truly novel treatments - like a better flu vaccine or a new, more effective antibiotic.

Oh please. Do you know why no-one touches the flu-vaccine? Because you have to meet some ludicriously idiotic government regulations, you have to reengineer it every bloody year, and demand swings wildly as all hell. If people consistently bought flu-vaccines or were willing to pay the real R&D costs to get beyond decades old production methods - i.e. move from eggs to vats.

Which is why I say that flu vaccine is a great example of why profit motive doesn't always work.

For the greater good of society perhaps the government should pay for its production, and never expect a monetary profit from it. It's not that different than the government taking over long-term dialysis in this country - whcih was done because there was no way in hell the average kidney failure patient was every going to be able to pay for the treatment on their own.

If the free market can't reliably produce a needed item - such as a vaccine - then 'fess up that the free market is NOT almighty and find an alternate means to get what you need. Like taking it out of taxes, just as we do for maintenance of roads and paying for the military.

As far as antibiotics ... do you have any idea how restrictive FDA rules on those are? Likewise let's say you do sink hundreds of millions of dollars into a more effective antibiotic - if it doesn't offer a dramatic improvement over current medicines it won't make a dent in the market place.

If it doesn't offer a "dramatic improvement" then I have to wonder if it's a "me-too". We don't need "me-too" antibiotics - we need NEW antibiotics, which would automatically have a market if they were, as an example, effective against things like that variety of staph that's resistant to just about every damn thing we currently have.

The "bottom line" in health care should be HEALTH, not money. But that's NOT the way it is in the US today.

I could easily rattle off a list of truly benificial treatments and programs for any individual that would easily reach 100K per annum. At some point money has to enter into the equation and some form of resource rationing simply must take place. But let me ask you a simple a question, what type of gross profit (as a percentage of revenue) do you think a medical company should have?

It's NOT just about profits.... it's also about being able to buy.

If a cure for a disease cost a nickel a pill I frankly wouldn't give a damn if at that price the company in question was making a 500% profit. If it cost $100,000 a dose...well, the profit margin doesn't matter because virtually no one could buy even one pill.

There are some illnesses and conditions that no individual could be expected to pay for on their own. (the Bill Gate's of the world being such a small fraction as to not be relevant to the discussion) Recovery from extensive third degree burns, for example, can exceed $1,000,000 a year for several years. I don't know anyone who could pay that out of pocket, and it gets periously close to the lifetime cap of most health insurance policies (in fact, people DO exceed those caps).

So... what would you have society do? Look at someone and say "Gee, we're terribly sorry you were horribly burned or you have this awful disease, but we've spent enough money on you - we're going to roll you into this corner and just let you die." Except we don't do that, we find such actions immoral (most of us, anyway) and SOMEONE winds up paying - through charity, through writing off of bad debt, through government subsidies....

You might as well criticize the doctors and nurses for demanding pay in excess of minimum wage for the work they do.

. Making flu vaccine available and affordable (even free) not only maximizes health, it's cheaper over the course the year because you have fewer flu-related hospitalizations and deaths. But even if it wasn't cheaper, it is STILL within our means and resources to do this.

The problem with Flu vaccine manufacture is that it has production costs, no ability to develop inventory, and you have to forecast much of your production run before you have a clue what is going to happen. The reason the industry consolidated so dramaticly ended up hinging on a single point: people don't get flu shots unless they feel a pressing need to do so. Year after year high percentages of the production run simply wasted away in boxes - 15 MILLION in 2002.

If you could actually GET most people to have a flu shot there would be no problem delivering a regular, relatively cheap supply. Right now such a small percentage of people are willing to take them that economies of scale are collapsing. Hell look at the dismal performance of MedImmune's

Which is PRECISELY why flu vaccine should not be in the realm of the "free market". It's a public health issue and, frankly, public health costs money, it doesn't make an obvious profit. The benefits can be uncovered, but they're not obvious. Food inspection, for example, does prevent illness (although not perfectly) even though the regulations "interfere" with profits and business, and NO ONE is generating revenue from it. However, for the greater good, meaning reduction of food borne illness and death, it is worth the cost. Paying nurses to go to TB patients daily and observe them taking their meds and making sure they comply with medication schedules is, to be frank, expensive... but it's what controls TB these days, reduces the spread, and reduces the number of drug-resistant strains. Should we give that up because it's not "free market" and no one profits?

THAT's what I mean when I say health should be the bottom line, NOT money. Yes, money is important, it's a limited resource like many others, but is this about profit or about health? Decide.

Our society DOES have the resources to hire adequate numbers of nurses, but does not, putting short term profit over the lives and health of patients.

No it doesn't. The limiting resource being the number of nursing degrees being handed out. As a society America simply does not graduate enough nurses even to maintain replacement, let alone deal with the increasing demand for nurses. The bottleneck is at the collegiate level, currently there is no such thing as compotent unemployed nurse (at least if willing to relocate for a hefty monetary bonus). There are more vacanies in nursing rosters than could ever hope to be filled without a substantial increase in the number of RN's being graduated out of college.

Are you telling me our society does not have the resources to open more nursing colleges, or to increase the student capacity of nursing schools? Or is it a matter of other factors - politics, economy, whatever - interfering with increasing the school capacities? Perhaps medical organizations have found it cheaper to hire nurses trained abroad than to educate them here. Whatever. The facts of the matter are that people decided NOT to expand the means of producing nurses. That doesn't mean we couldn't make that expansion. We DO have the resouces to do that... we just choose not to use them for that purpose. I don't know, maybe it's more profitable to turn out MBA's than MD's, and that's why the choice was made... but long term that may not have been the best choice.

Organ transplants, for example, can involve very long waits because we have to wait for someone able to donate to come along. No amount of money is going to change the current system (although a medical breakthrough might help here and there)

Medical breakthroughs have been happening, such as partial liver transplants.

Which are still considered ethically questionable by many doctors and other medical professionals due to the very real risks to the donors. You are, after all, taking a healthy person, subjecting them to major surgery, and removing a significant chunk of a very vital organ. Sure, it's a breakthrough, it's amazing, it save lives... and it takes lives, too.

Also one way that appears to work is to bump up donor relatives. Suppose your spouse needs a kidney and none of the family matches, well if you agree to donate a kidney to someone else on the waitlist then your spouse gets bumped up the list. This has everything to do with appealing to familial self-interest to increase the supply of organs.

But that's assuming someone in the family exists who CAN supply an organ. If it's a matter of a hereditary form of kidney disease, for example, there may be no one who is able to donate due to medical reasons. Then what do you do?

Yes, it's a worthwhile strategy... but it doesn't solve the entire problem. What is needed is a way of VASTLY increasing the pool of available organs, not simply bumping it up slightly, or a means to avoid needing the transplants altogether.

In similar vein massive education about organ donation appears to bringing 10-20% increases in organ donations. Another fun step has been finding ways of encouraging dialogue with the terminally ill about organ donation.

Except that most terminal diseases rule out donating of organs.

Where I work we recently did a big study on islet cell transplants for diabetes (that was the work with the Canadians, in fact, who are leading the efforts with this thanks to a Dr. Shapiro in Edmonton). The math folks sat down and figured out that even if ALL potential donors gave up their islet cells for this purpose - meaning they all qualified and didn't have problems like viral infections or history of cancer or other disqualifiers, which isn't going to happen in the real world, AND no one refused to donate, eveyone asked said "yes" - there would STILL not be enough available donors to benefit everyone who would, through a risk vs. benefit calculation, qualify for the procedure. Supply will never keep up with demand. What we need is a way to manufacture these cells and organs without cutting them out of other human beings. THAT's the sort of breakthrough we need.

Americans love to point out that those with the Golden Privilege of health-care in the US tend to get better-quality care than those in a typical universal healthcare system. They misrepresent this as a healthcare system that offers better-quality care in general, totally ignoring the fact that for those who are not so privileged, it offers no care at all.

Complete and utter BS. In the US no one is offered "no care at all". It is bloody mandatory that emergency care be given irregardless of ability to pay, dicking with that is a quick way to terminate the career of whichever administrator makes the responsible call. Even for non-emergency care if you truly cannot afford it there are things like Medicaid for providing care. The problem is the so called "working poor" who have enough money not to be eligible for Medicaid, but not enough money to pay all the other bills and medical ones to boot. These people have some medical care, but it tends to be insufficient - compared to first world norms. They 'economize' medical care in order to keep premiums down, limit out of pocket expense, and tend to overlook preventative healthcare.

Um... yes, you have that right. There are millions of people in the US who make enough to pay normal bills - housing, food, etc. - but who are not making enough to cover the cost of a catastrophic illness or injury. In other words, they do NOT have the "best medical care in the world" because they simply do not have access to it. The economies you mention is how you survive in such a situation. You try to stay healthy and hope nothing goes wrong.

Have you truly looked at the price of "preventive healthcare" if you have no insurance? The annual gynecological exam of a typical woman can easily exceed $150. I don't know of any doctor charging less than $85 an office visit. Dental is... what? $75 every six months? Screening for cholesterol, blood pressure, various cancer exams (breast, prostate, colorectal) all cost money.... It adds up, and that's assuming nothing is wrong. Any treatment costs are above that. If you're already living paycheck to paycheck how do you pay for that? And not just for one person, but for a husband and wife plus however many kids are involved? That's why these folks don't have health insurance - the premiums alone would exceed the cost of paying for this out of pocket over the course of a year

In some very real sense the US healthcare market drives and subsidizes the world healthcare market.

And when the US can no longer afford to subsidize the rest of the world... then what?

Or do you cherish the illusion that the US will be on top forever? We won't, you know. Sooner or later we'll run into problems, be it of our own making or just some really kick-ass natural disaster that fucks with our nation.

The current US system needs DRASTIC reform. For a start medical school and nursing school need to be ramped up to produce more human talent. For another congress needs to blackmail the insurance industry into standardizing the paperwork - one set of paperwork irregardless of who pays the bill.

Oh, how charming - let's fix the system through blackmail. Are you sure that's the term you wanted to use?

Oh, and by the way - you'll have to get the Feds to strong-arm the states for this universal paperwork scheme to work, because some of the divergence is driven by STATE requirements, not just the whims of private companies. Just as pharma is caught in a net of regulations, so, too, are the insurance companies which are a highly regulated industry.

It's futile to point a finger at any one segment of the medical industry and say "their fault". Until we realize that ALL the players bear some responsibility for the mess we won't be able to clean up.

[tharkûn]

Could you provide a link? When I checked the BBC, I couldn't find this article.

Certainly :

http://news.bbc.co.uk/1/hi/health/2077996.stm

This is a quick blurb about a previous study. I read an orginal rehash of it a while back but that was on wood pulp and I can't recall the journal name.

Interestingly enough, they did confirm a 98% survival rate for breast cancer but only for patients where it is detected before it reaches 2cm in diameter; could your source be based on selective data? Or have breast cancer survival rates skyrocketed in the last 15 years?

Absolutely the detection technology is astoundingly more accurate these days, not to mention that breast exams, mammograms, and other screening measures are FAR more pervasive than 15 years ago. On average all cancers are found earlier in the US, which tends to increase survival rates.

Could you show me a link to this article, since the only information I could find about your previous claim massively contradicted it?

Of course:
http://circ.ahajournals.org/cgi/content ... 10/13/1754

The most succinct point would be, " Five-year mortality rate was 19.6% among US and 21.4% among Canadian patients (P=0.02). After baseline adjustment, enrollment in Canada was associated with a higher hazard of death (1.17; 95% confidence interval, 1.07 to 1.28, P=0.001)." In other words Canadian care is around 17% more likely to leave you dead after 5 years, ceteris parabis.

I would also note that your data weighted back into the frigging 80's and did not adjust for baseline health - i.e. no mention of the rate of obesity or other factors that decrease baseline survival rates. Besides the comparison is still there in your source:
UK - 72.8%
US - 80.4%

7% difference even though the UK data is taken from 1991 and the US from 1983.

The UK should kick American ass here. Its population is healthier in general (fewer diabetics, obese, etc.) and it is has 7 crucial years of technological lead. I'm sorry but when you still lose an unfair fight it ain't a point of pride.

Please read http://content.healthaffairs.org/cgi/co ... .w5.63/DC1 where they discuss medical bankruptcies. So-called "major medical bankruptcies" are classified as such only when the medical expenses are a major contributing factor, not just a tiny final straw.

"out-of-pocket costs averaged $11,854 since the start of illness"

Slightly higher than I expected, I was betting around 8,000, however it does not change the point. Most people have sufficient income and credit to get 12 grand on unsecured loans. The problem is they have already tapped their credit line up near maximum and once predatory interest rates set in that 12 grand will spiral out of control.

And that excuses the situation ... how?

The problem is not the medical bill and insurance companies dicking them over. The problem is that they have already blown their safety margin. With even 1980's levels of savings and debt loading these bankruptcies wouldn't happen.

So first you say that there's nobody out there who's dicked by the system by nitpicking the wording of my statement, then you admit that the entire class of the "working poor" is indeed dicked over by the system. Which is it? And how do you explain the major medical bankruptcies where people did have health insurance?

What you post I take at face value. If you mean "dicked over by the system" then I expect you to post it. If you mean "has insufficient medical coverage" I expect you to post that. When you explicitly state "no care at all", I assume you mean what you post.

The working poor have some health care. When they have insurance it tends to have extremely high deductables and percentage payments up higher. This alone is not sufficient to drive the current record number of medical bankrupcies. The fact that they are 'economizing' healthcare and that they have tapped their safety margin for other purposes is what drives bankruptcies.

n the US, your lifespan is determined by your economic status

Yes and no. Your economic status also determines your diet, oh didn't you know the poor are more prone to obesity? Your economic status also determines your propensity to use low quality drugs - drugs far more likely to eat into your life expectency. Likewise economic status plays into gang violence, single parenthood, educational failure, etc. - just about every other damn life expectency lowering factor is statisticly confounded with economic status. Yes having better health care is a factor, so to is the fact that soul food is unhealthy as eating lard.

When looking at these types of data you need either controlled samples - only one difference among samples; or normalized samples. When samples aren't controlled or normalized then you HAVE to do statistical correction to get valid numbers.

Broom:

After which the hospital can garnish your wages or attempt to confiscate property, such as your house, to pay medical bills. Or didn't you know that those are some of the mechanisms used?

Yes I know. And frankly I think they should. I'd far rather have the hospital get paid than the car lease if an individual overextends. For those who cannot simultaneously meet the medical bills and their minimum subsistence then in those circumstances a social safety net should scale in to cushion the blow.

What if you're not "absolute poor", though? What if you're working enough to put a roof over your head and no more, then suddenly you have this other expense?

Then you hit the hole in the US system. Which I absolutely think requires major policy change to plug. I don't beleive that plugging that hole can solely be done by going to monopsony.

How the hell are they supposed to pay for an insurance policy when they're unemployed and therefore have no income?

Transient. In a rational universe people would say save money when they are employed so that they have a reserve to live off of. I am seriously the only one here who even trys to maintain a 6 month reserve of liquid assets to use in exactly such a contingency?

That's not how "medical care" bankruptcies are reckoned, as has already been mentioned prior to this post.

"Medical bankruptcy" is that caused by medical bills, and in such cases the medical debts dwarf any others.

Source? Mike's cite showed a whopping 12,000 dollars out of pocket median expense for medical bankrupcies. I find it incredulious that a 24,000 dollar debt would be sufficient to drive anywhere close to all the medical bankrupcies reported.

Last year my husband was in the hospital for 8 days. Because we have excellent insurance, our share was "only" about $7,000 and because we are frugal by nature we had it on hand to pay it.

That is exactly my point. When people live responsibly they HAVE cash on hand or at the very least a clean credit line to take that type of monetary hit without going insolvent. When you have already exhausted your margins then a hit around 12,000 dollars will pull you into insolvency.

If my employer did not offer health insurance I would, in fact, be bankrupt right now despite having NO credit card debt and, in fact, NO debt except a car loan, despite a comfortable income.

If your employer did not offer healthcare exactly why couldn't you devote a portion of your disposable income towards health premiums? I realize it would be a sacrifice, but could you truly not afford to pay healthcare solely out of your salary?

"Me-too" drugs do not advance medical care, they do not cure new diseases or more effectively treat old diseases, they do not solve the problem that our antibiotics are becoming less and less effective.

Cox II inhibitors are "me too" drugs, at least in the industry, their selling point was their ease of uptake. Zithromax treats old diseases, it just does it in a quicker timeframe.

Antibiotics is a thread in its own right. The problem is the vast majority of infections are still treatable with a single antibiotic. Even among resistent bugs, most are not doubly resistent. MRS do exist and are an increasingly pervasive problem ... but it is still a distant storm gathering. Yes the market is not all that long term foresighted, however neither are the policy makers. This particular impending failure has plenty of blame to lay on all sides. Of course I should mention that majority of new antibiotics in the pipeline I know of are coming out of US pharma and tailored for the US market, but unfortunately that is comparing a jot to a tittle.

Nor do they "break up monopolies" - thanks to dragging competitors into court, a series of "me-too" drugs can effectively prevent anyone else from entering a market segment.

That problem is not limited to "me-too" drugs. I can cite a dozen assraping legal tactics pharma can use to prevent competition. The laws, some of which date back to the 1800's, need a frikking rewrite yesterday.

There is nothing inherently wrong with "me-too" drugs --- there IS something wrong when those are the only new drugs coming to market.

They aren't. AIDS drugs have whole new classes of drugs coming forward. MRI contrast agents are coming down the pipeland with extensive novel capabilities. 4 new cancer drugs hit the market in 2000, Kaletra was the FIRST pediatric protease inhibitor, and another 23 drugs were introduced. But hey novel cancer treatments are just "me too", a frigging HIV drug for infants is of course useless

"Me-too" drugs while close to their predecessors are not exactly the same... meaning there is the potential for new side effects. There is much more information about a drug with a 20-30 year history of use vs. one with a 2 year history, and a lot fewer surprises.

So why are people BUYING THEM? Why would this change under monopsony - and not under limited reform of the current system?

IF the drugs are actually needed in the first place. I have to wonder if everyone on Prozac really needs Prozac, or if changing their lifestyle would have the same but a more permanent effect.

This is why we have doctors and medical standards. Yes those standards need revision, but on average pharma saves GRATUITIOUSLY on medical expenses or PREVENTS DEATH.

Drug therapy is NOT cheaper if, say, statins induce rhabdomyolysis and you wind up with kidney damage and on dialysis. Drugs are NOT automatically cheaper or less risky.

Automaticly cheaper? Of course not, the optimum outcome - keeping you alive and fully functioning longer is always more expensive than the alternative - dying young. Likely to be cheaper? Oh hell yes. Surgery is unbelievably bloody expensive, hosptilization only slightly less so, even physical therapy tends to be more expensive than pills. Sure some basic things like say losing weight, quitting smoking, or not frying your organs on drugs would be more cost effective ... but people simply won't do those things.

Another example of this is in the treatment of obesity. There are been effective drugs for weight reduction - and virtually all of them have been withdrawn due to side effects that are, in some cases, lethal. It's an area where surgery actually seems to have fewer risks than most of the drug threapies tried. (Although the surgery does carry real risks)

Data?

And more failures, too.

More novel medical devices are brought into the US. More capital is put into their production and there are even firms devoted to heading hunting European brains to the US to set up shop here.

And why does miniturization automatically equate to progress in your mind? It's not enough to simply say it's high-tech or smaller, you have to quantify the improvement in terms like faster recovery, more accurate information, fewer complications, and so forth. And the cost has to be within the realm of affordable. Remember, if the patient doesn't have the money to buy medical tech from their viewpoint it might as well not exist.

Why is miniturization better? Because fewer people die. The larger the sensor you plug into the body, the greater the surface area, and the more likely chance of infection, biofouling, and rejection reactions. Medtronics ran an actual double blind clinical on one of their new devices and they had a 30% mortality reduction.

Of course the obvious things stand. If you want a pressure sensor on heart valve differentials to be implanted it needs to frikking fit in the heart. Without minaturization THAT ISN'T POSSIBLE. Of course in your terms that would be measured, which ISSYS has done, by more accurate information, fewer complications, and ultimately greater survival rates.

As an example - there is some amazing new medical imaging technology. Truly amazing, like scans on Star Trek. However - it's amazingly expensive, highly dependent on software that isn't completely debugged as of yet, and in many cases does NOT yield any more information your basic x-ray. The typical broken arm or leg needs an x-ray, not a whiz-bang "imaging technology" and spending money on the higher-tech scan for every fracture is a waste of resources, pure and simple. This sort of tech should be reserved for those cases where it truly IS an asset and an improvement.

And I agree with that. High tech does not automaticly mean more cost effective. We don't put pressure sensors in compound fractures, even though the information they give is useful; however when you have a patient whose brain is being compressed it is worth its weight in gold. Every single specific device or medication I have cited here I have seen numbers showing some type of comparative advantage.

Haven't we had those for awhile for brain injuries?

These are rf MEMS that can be implanted and left in the patient, and if the regulators argee could be left in permently instead of having to continiously put new sensors in and risking infection everytime you do it. Of course the advantage that the patient can take it home and his neurologist can monitor the data over the phone line means nothing

Does it have any real effect on outcomes, or is it "gee-whizz" technology?

Only if you count 10% plus lower mortality rates "real effect"

Which is why I say that flu vaccine is a great example of why profit motive doesn't always work.

The profit motive alone didn't kill the flu vaccine. Wyeth specificly cited, and had some convincing numbers, showing that government interference doomed their vaccine unit.

The basic problem is still the frigging same - people don't take flu shots.

For the greater good of society perhaps the government should pay for its production, and never expect a monetary profit from it. It's not that different than the government taking over long-term dialysis in this country - whcih was done because there was no way in hell the average kidney failure patient was every going to be able to pay for the treatment on their own.

It was done as a political ploy to kill the last Apollo missions and gut NASA. In any event single payer is not synonomous with socialized production.

If the free market can't reliably produce a needed item - such as a vaccine - then 'fess up that the free market is NOT almighty and find an alternate means to get what you need. Like taking it out of taxes, just as we do for maintenance of roads and paying for the military.

The free market can and does produce flu vaccine, going so far as to offer up a NEW and novel vaccine. The problem isn't that it can't be supplied, but that people WON'T USE IT. If you want pharma producing it, all you need is a garunteed order by Uncle Sam for their full production run. If you could convince congress to fork over the cash, I could have pharma ready in a matter of months to deliver. If SOMEBODY is willing to actually buy every dose that is manufactured the free market will provide it.

If it doesn't offer a "dramatic improvement" then I have to wonder if it's a "me-too". We don't need "me-too" antibiotics - we need NEW antibiotics, which would automatically have a market if they were, as an example, effective against things like that variety of staph that's resistant to just about every damn thing we currently have.

Oh yes a market for a few thousand patients - tops - in the US. To the best of my knowledge there has yet to be a completely resistant staph strain (resistent to EVERY antibiotic on the shelves) that wasn't in a biohazard lab. I'm sorry but you are ignorant of the realities here, your average hospital can treat EVERY staph infection they will ever encounter, the problem tends to be they don't recognize the problem quickly enough to take effective action. There simply aren't enough cases of truely massively resistent infections to payback a 100 million investment.

It's NOT just about profits.... it's also about being able to buy.

I see, you refuse to answer the question.

If a cure for a disease cost a nickel a pill I frankly wouldn't give a damn if at that price the company in question was making a 500% profit. If it cost $100,000 a dose...well, the profit margin doesn't matter because virtually no one could buy even one pill.

And as such society is better off letting people dependent on such doses simply die. Cold, harsh, and utilitarian.

There are some illnesses and conditions that no individual could be expected to pay for on their own. (the Bill Gate's of the world being such a small fraction as to not be relevant to the discussion) Recovery from extensive third degree burns, for example, can exceed $1,000,000 a year for several years. I don't know anyone who could pay that out of pocket, and it gets periously close to the lifetime cap of most health insurance policies (in fact, people DO exceed those caps).

When a patient cannot afford basic subsistence and medical bills some type of social safety net is required in a civilized world. The problem comes in rationing. Even if the full US GDP were devoted to treatment I could bankrupt the system with benifical but not cost effective treatments. At some point somebody has to make the hard choice of when is a life simply too costly to save.

So... what would you have society do? Look at someone and say "Gee, we're terribly sorry you were horribly burned or you have this awful disease, but we've spent enough money on you - we're going to roll you into this corner and just let you die." Except we don't do that, we find such actions immoral (most of us, anyway) and SOMEONE winds up paying - through charity, through writing off of bad debt, through government subsidies....

At some point we as a society do let people die. Besides it is not enough to merely provide todays medicine - there must be R&D and I for one would rather have the venture capital and stock investments going towards better medicine than spill resistent cloths.

Which are still considered ethically questionable by many doctors and other medical professionals due to the very real risks to the donors. You are, after all, taking a healthy person, subjecting them to major surgery, and removing a significant chunk of a very vital organ. Sure, it's a breakthrough, it's amazing, it save lives... and it takes lives, too.

Yes I know the balance is saving lives. And like all novel medical procedures survival rates take a while to get up to baseline. As long as it is full and open disclosure for the donor about the real risks the medical 'professionals' can stuff it up their ass. Is some one else is willing to take a risk with a benificial expectation value it IS ethical.

Yes, it's a worthwhile strategy... but it doesn't solve the entire problem. What is needed is a way of VASTLY increasing the pool of available organs, not simply bumping it up slightly, or a means to avoid needing the transplants altogether.

No it doesn't solve the entire problem, for instance it does nothing for heart transplants. But progress is being made.

Except that most terminal diseases rule out donating of organs.

That depends. Congenital heart failure tends not to do a damn thing to the kidneys. Somewhere I have actual numbers showing that this strategy leads to a net increase in organs - you see it was tried and it WORKED.

Where I work we recently did a big study on islet cell transplants for diabetes (that was the work with the Canadians, in fact, who are leading the efforts with this thanks to a Dr. Shapiro in Edmonton). The math folks sat down and figured out that even if ALL potential donors gave up their islet cells for this purpose - meaning they all qualified and didn't have problems like viral infections or history of cancer or other disqualifiers, which isn't going to happen in the real world, AND no one refused to donate, eveyone asked said "yes" - there would STILL not be enough available donors to benefit everyone who would, through a risk vs. benefit calculation, qualify for the procedure. Supply will never keep up with demand. What we need is a way to manufacture these cells and organs without cutting them out of other human beings. THAT's the sort of breakthrough we need

Good luck finding the holy grail. That sort of breakthrough would be instant Nobel worthy and a license to print money. Which is why I know a guy in pharma working on something similar.

And when the US can no longer afford to subsidize the rest of the world... then what?

Socialized medicine budgets go tits up, governments (including the US) get hammered in elections and assuming current levels of popular education we are in for some seriously lousy times.

Or do you cherish the illusion that the US will be on top forever? We won't, you know.

I cherish the day illusion that at some point in time the US makes free trade in medicine a policy position. Reimportation of drugs, anti-monopsony trade bills, etc. just about whatever can be done to remove de facto subsidies should be done.

Oh, how charming - let's fix the system through blackmail. Are you sure that's the term you wanted to use?

Yes that is exactly what I want to use. I don't trust congress to write compotent standardized forms - have you ever seen Medicare forms? Besides the problem is that congress cannot simply declare standards by fiat without the full compliance of the states. So we do what Libby Dole did and blackmail. Congress gives the insurance industry a timeline to write their own standards meeting basic guidelines; if they fail to comply then congress blackmails them through some type of federal funding scheme aimed at the states who then can bring about compliance. The actual 'proposals' I've seen batted around can get quite byzantine, but the long and the short of it is give the industry an "or else" ultimatum that congress can enforce and that is drasticly more onerus than rational standardized paperwork.

Oh, and by the way - you'll have to get the Feds to strong-arm the states for this universal paperwork scheme to work, because some of the divergence is driven by STATE requirements, not just the whims of private companies. Just as pharma is caught in a net of regulations, so, too, are the insurance companies which are a highly regulated industry.

Yes I know the blackmail I'm talking about is going to have to threaten federal spending in the states to get full compliance if it isn't massively and popularly supported in state legislatures.

It's futile to point a finger at any one segment of the medical industry and say "their fault". Until we realize that ALL the players bear some responsibility for the mess we won't be able to clean up.

There is more than enough blame to go around. I can cite chapter and verse of idioacy in consumers, government, and industry. My problem is this BS idea that going to monopsony, or even oligopsony like Canada, is a painless way to alleviate problems that could not otherwise be corrected - maybe even in a more benificial manner.

[Darth Wong]

Absolutely the detection technology is astoundingly more accurate these days, not to mention that breast exams, mammograms, and other screening measures are FAR more pervasive than 15 years ago. On average all cancers are found earlier in the US, which tends to increase survival rates.

In short, you are talking about a transient situation. The US healthcare system 20 years ago was not more public than it is now, nor was the UK system more private than it is now. So if the gap has widened considerably in the last 20 years, it is not due to public vs private healthcare but to other factors. According to the article you cited, the US spends 3 times more money per capita on cancer therapy than the UK does; this will obviously produce some results, but it hardly validates the "private is more efficient and better than public" meme.

Of course:
http://circ.ahajournals.org/cgi/content ... 10/13/1754

The most succinct point would be, " Five-year mortality rate was 19.6% among US and 21.4% among Canadian patients (P=0.02). After baseline adjustment, enrollment in Canada was associated with a higher hazard of death (1.17; 95% confidence interval, 1.07 to 1.28, P=0.001)." In other words Canadian care is around 17% more likely to leave you dead after 5 years, ceteris parabis.

Interestingly enough, the full quote looks like this:

Methods and Results— Mortality data for 23 105 US and 2898 Canadian patients enrolled in GUSTO-I were obtained from national mortality databases. Median follow-up was 5.46 years in the US and 5.33 years in the Canadian cohort. Five-year mortality rate was 19.6% among US and 21.4% among Canadian patients (P=0.02). After baseline adjustment, enrollment in Canada was associated with a higher hazard of death (1.17; 95% confidence interval, 1.07 to 1.28, P=0.001). Revascularization rates during the index hospitalization in the United States were almost 3 times those in Canada: 30.5% versus 11.4% for angioplasty and 13.1% versus 4.0% for bypass surgery (P<0.01 for both). After accounting for revascularization status as a time-dependent covariate, country was no longer a significant predictor of long-term mortality. These results were confirmed in a propensity-matched analysis.

Conclusions— Our results suggest, for the first time, that the more conservative pattern of care with regard to early revascularization in Canada for ST-segment elevation acute myocardial infarction may have a detrimental effect on long-term survival. Our results have important policy implications for cardiac care in countries and healthcare systems wherein use of invasive procedures is similarly conservative.

Funny; their conclusions do not match yours. Instead, they say that the "country was no longer a significant predictor of long-term mortality" after accounting for all of the differences that you lambast me for not taking into account.

The UK should kick American ass here. Its population is healthier in general (fewer diabetics, obese, etc.) and it is has 7 crucial years of technological lead. I'm sorry but when you still lose an unfair fight it ain't a point of pride.

When the US spends 3 times more than the UK, it's a pretty big stretch to say that the UK should "kick American ass here." Not to mention the article pointing out that UK residents have very poor awareness of cancer issues, which will drive down their use of tests and consequently, their rate of early detection.

Slightly higher than I expected, I was betting around 8,000, however it does not change the point. Most people have sufficient income and credit to get 12 grand on unsecured loans. The problem is they have already tapped their credit line up near maximum and once predatory interest rates set in that 12 grand will spiral out of control.

So you figure that anybody who can't get a $12k unsecured loan can just go fuck himself?

What you post I take at face value. If you mean "dicked over by the system" then I expect you to post it. If you mean "has insufficient medical coverage" I expect you to post that. When you explicitly state "no care at all", I assume you mean what you post.

They get no insurance at all; sure, they can walk into a hospital ER and pay their pound of flesh after the fact, but that hardly equates to care being provided for them, does it?

n the US, your lifespan is determined by your economic status

Yes and no. Your economic status also determines your diet, oh didn't you know the poor are more prone to obesity? Your economic status also determines your propensity to use low quality drugs - drugs far more likely to eat into your life expectency. Likewise economic status plays into gang violence, single parenthood, educational failure, etc. - just about every other damn life expectency lowering factor is statisticly confounded with economic status. Yes having better health care is a factor, so to is the fact that soul food is unhealthy as eating lard.

When looking at these types of data you need either controlled samples - only one difference among samples; or normalized samples. When samples aren't controlled or normalized then you HAVE to do statistical correction to get valid numbers.

You mean like the article you referenced which concluded that after statistical correction, country was no longer a significant predictor of survival rates between the US and Canada?

[mr friendly guy]

We have a socialised heatlh care in Australia as well. I will go into some of the details of it since the OP wanted to know.

Medical decisions are based on clinical status / need.

As Broomstick said, for an injured limb, the most I have ever ordered was an x-ray. If it turned out to have a fracture which needed operation (as opposed to just a plaster cast), I refer to the orthopaedic surgeons. If they want more detailed imaging they can arrange it. We don't waste money on unnecessary scans. And if I tried calling the radiologist to perform a CT / MRI I would have to justify it to them - ie how would this scan change my management of the patient. If I couldn't I would get slammed on the phone.

AFAIK from other Doctors I have talked to, the system in the US is highly medically-legal orientated. That is the doctors do these scans to protect themselves medically- legally due to your higher litigation rates. Personally i don't blame doctors in this case (they have to protect themselves after all), but it highlights the point that unnecessary tests are ordered.

Waiting lists - public patients do have to wait a few months for elective surgeries - ie not emergency. Things like hernia repairs for example. Again operations which are more urgent take precedence.

In my state of Western Australia there is a problem getting lists down. The state government has tried paying private hospitals to take elective patients, however this doesn't seem to have done much. The problem of course is that even if you plan for an elective surgery to take place on a certain day, emergencies can turn up.

AFAIK private hospitals deal mainly with elective procedures. They also cater to less people, so they have shorter waiting lists

If a private patient is seriously ill or there are no beds available, they are sent to public hospitals (I am not just talking about surgical patients here).
They can come even switch their status to a public patient and their care is paid for by the government. Having worked in the haematology ward I know of a few haematological patients coming in for stem cell transplants (the consultant haematologist works in both the public and private systems) and seen as a public patient. In fact, if you can't afford to pay privately, they encourage you to come in as a public patient.

Emergency departments

If you come in with category 4 or 5 ailments, you wait. The ED (ER in north america) triages you by severity. If you are category 4 or 5, you may as well go to your GP (if its in office hours). Some people don't go to the GP because they can't afford it. Essentially the Federal government reimburses GPs, so they charge less. This has for a time led to a lot GP consultations being "free" (for the patient obviously and not the taxpayer).
However with the rising costs of maintaining a clinic, some GPs are charging a bit more and some people claim they can't afford it, prefering to wait hours in the ED to be seen.

I guess that the public health system is a safety net for people who can't afford private health, ie people from a lower socio-economic status. If you can, it takes a load off the public system (makes my job easier ). The government even gives you tax breaks if you take out private health. My private health cover costs me only $33.30 AUS a month after government rebate (no its not that high a rebate, it would cost aroudn $46 before the rebate).

[tharkûn]

In short, you are talking about a transient situation.

No I'm talk about R&D, capital outlay, and economies of scale. US R&D made most of those improved diagnostic techniques and devices. US capital outlay buys them. Said capital outlay introduces economies of scale, rather impressive ones at that, so that other countries can start to afford them.

Even if it is just a transient phenemona it means millions of lives. Once the US pays off the R&D, huge numbers of people get cost effective access that they otherwise wouldn't. More Canadians, Britons, and Germans would die if the US didn't have over half the world market relatively unregulated.

I suppose in the coming centuries it will all be a wash, but present trends show an increasing gap, not a decreasing one. Even there the world, as a whole, will be worse off as a those survival differentials readily translate into billions dead during the "transient" phase.

The US healthcare system 20 years ago was not more public than it is now, nor was the UK system more private than it is now.

In socialized medicine then tends to be a negative pressure on capital outlays that the American system lacks. Because the American system is market driven novel, expensive techniques have a healthy market. The capital outlays in the initial market justify further R&D as well as economies of sale that drive down prices. If the US had adopted the UK health system, particularly its procurement and capital expenditure system, many of these devices would have been still born and there would have been no mechanism for scale up and cost cutting.

So if the gap has widened considerably in the last 20 years, it is not due to public vs private healthcare but to other factors. According to the article you cited, the US spends 3 times more money per capita on cancer therapy than the UK does; this will obviously produce some results, but it hardly validates the "private is more efficient and better than public" meme.

The US also has a higher cancer rate per capita, unhealthier citizens, etc.

Seriously look at the microeconomics side of it. You are a CEO of a biosensor company. You manage to find a reliable chemical test to detect 98% of breast cancers. Intially it would be cost prohibitive for mass consumption, but a small niche of affluent individuals would consume it. Now you have a profitable commidity with a proven track record, it becomes orders of magnitude easier to get further funding - venture, traditional investment, or public - and ramp up production while bringing down costs. Why couldn't the government just buck up the cash ahead of time? Because you need a vetting process which a niche market model does a relatively good job at.

In Europe you essentially have to sell it to public health system, if they won't buy you have very small chances of finding a viable entry market. So you have this a reliable test, the purchasing officer looks over the cost/benifit analysis and rightly concludes it to be uneconomic, and with no orders rolling in ... nobody is going to be willing to sink 100 million into scale up or cost cutting R&D. And this is not idle theory, I've had this first hand from venture capitalists, expatriate researchers, and biotech entrepeneurs.

This is a nolinear relationship and the benifits are notsolely American. There is a good bit of truth to the idea that the US subsidizes the R&D of the world's medical services. I know dozens of devices that are currently being piped into the American market to recoup R&D costs, and only after that occurs will they make it to the rest of the world.

Funny; their conclusions do not match yours. Instead, they say that the "country was no longer a significant predictor of long-term mortality" after accounting for all of the differences that you lambast me for not taking into account.

No the their conclusion was, "After accounting for revascularization status as a time-dependent covariate, country was no longer a significant predictor of long-term mortality. These results were confirmed in a propensity-matched analysis. "

In other words after correcting for the fact that Canadians received less advanced procedures and after correcting for the fact that Americans in the study were generally less healthy, then there wasn't a major difference. Meaning - patient care was roughly equivalent as was a lot of related medical infrastructure.

That data is clear - 1.8% more Canadians were dying in the study than Americans. After correcting for the worse baseline health of the Americans it means the risk was 17% greater for Canadians. So what caused that risk? Colder climate? The doctors beleive it to be the more prevelent use of better more advanced techniques.

"Conclusions— Our results suggest, for the first time, that the more conservative pattern of care with regard to early revascularization in Canada for ST-segment elevation acute myocardial infarction may have a detrimental effect on long-term survival."

Now a socialized medical system could correct a problem like this, but these types of problems tend to be common in socialized and monopsonistic systems. And really Canada is more oligopsonistic and less socialized than most other western nations.

But here let me quote from the full article:
"Rates of cardiac catheterization, coronary angioplasty, and coronary bypass surgery are 2 to 3 times higher in US patients than in their Canadian counterparts.3,6,7 These dramatic differences in procedure rates have persisted during the past decade and highlight the disparity in the availability of onsite facilities in the 2 countries."

" In addition to higher rates of previous angina and anterior infarctions, time from symptom onset to treatment was significantly longer among Canadian patients."

"Differences in rates of revascularization during index hospitalization between Canada and the United States appeared to account for the intercountry difference in mortality. On inclusion of revascularization as a time-dependent covariate into the baseline Cox regression model, revascularization status was associated with a significantly lower 5-year mortality rate (HR, 0.72; 95% CI, 0.68 to 0.77; P<0.01), and country of enrollment was no longer a significant predictor (HR, 1.07; 95% CI, 0.98, 1.17; P=0.14)."

"Canada’s regionalized system of care, availability of cardiac catheterization and revascularization services is restricted to selected tertiary care centers. It is therefore not surprising that Canada uses substantially fewer invasive cardiac procedures compared with the United States. In contrast, evidence-based medication use has been shown to be consistently higher in Canada compared with the United States."

"In countries such as Canada, with limited availability of revascularization facilities, substantial reorganization and investment in healthcare infrastructure will be required to improve efficiency of the referral process and transfer and triage of patients."

"Our results suggest, for the first time, that the conservative pattern of care in Canada may be associated with a detrimental effect on long-term survival. Canadian rates of revascularization after myocardial infarction are, if anything, higher than those in Britain and most of continental Europe. For hundreds of thousands of patients who suffer an acute myocardial infarction in developing nations, revascularization is inaccessible. The results of our study may therefore have important policy implications for the delivery of cardiac care services worldwide."

It is pretty simple - more Canadians are dying, despite being healthier, because the Great White North has fewer facilities capable of of doing newer and better procedures; hence it performs fewer such procedures per capita. Such a problem is a classic example of the type of thing which theory predicts to be more common under Canadian style healthcare. Sacre bleu

When the US spends 3 times more than the UK, it's a pretty big stretch to say that the UK should "kick American ass here." Not to mention the article pointing out that UK residents have very poor awareness of cancer issues, which will drive down their use of tests and consequently, their rate of early detection.

When comparing 1983 vs 1991 rates and no baseline health correction? I'm sorry but no, that the applicable law of diminishing returns makes that type of expenditure insufficient to overcome the gap. Not to mention that I don't think the US and UK were at a 300% differential back in 1991.

Slightly higher than I expected, I was betting around 8,000, however it does not change the point. Most people have sufficient income and credit to get 12 grand on unsecured loans. The problem is they have already tapped their credit line up near maximum and once predatory interest rates set in that 12 grand will spiral out of control.

Well for starters we need to define this individual? Is he indigent? If so then a system like, I dunno, MEDICAID might be appropriate Is he working poor? Then I agree the American system has a shortfall currently, medicaid or some other program should scale down so that the working poor get some subsidization of their healthcare so they meet western norms. If they are at an economic level where they could afford both basic subsistence and medical bills then they should be forced to pay it or maybe actually go bankrupt if they've made a hash of their finances otherwise.

They get no insurance at all; sure, they can walk into a hospital ER and pay their pound of flesh after the fact, but that hardly equates to care being provided for them, does it?

No some get Medicaid which ironicly is superior to private many health insurance plans. Some just carry insufficient health care coverage - essentially catastrophic with too high of deductibles. Some do honestly have no health insurance, but do have the cash to pay for some health care.

Other people simply don't buy healthcare because they don't beleive it to be a sound economic investment.

You mean like the article you referenced which concluded that after statistical correction, country was no longer a significant predictor of survival rates between the US and Canada?

No I mean like the article I referenced which concluded, "Differences in rates of revascularization during index hospitalization between Canada and the United States appeared to account for the intercountry difference in mortality."

Canadians are more likely to die, look at the bloody numbers. Canadians are more likely to be healthy, look at the bloody numbers. Rather than incorrectly seize upon a peice of a sentence in the conclusion, why not offer your explanation of why the relative hazard of death is 1.17 particulary in light of the, you know, hard data ?

AFAIK from other Doctors I have talked to, the system in the US is highly medically-legal orientated. That is the doctors do these scans to protect themselves medically- legally due to your higher litigation rates. Personally i don't blame doctors in this case (they have to protect themselves after all), but it highlights the point that unnecessary tests are ordered.

Tort reform is needed in America. Even going full monoposonistic wouldn't likely do as much as getting the lawyers out of the decision making process.

[PainRack]

Question: Should the government stop focusing on the "consumer" and instead focus on cutting the costs of the "supplier"?

Part of the problem is that people don't know who the hell the "consumer" is in these situations..

So, like I said, let's ignore this problem and focus on the supplier instead. Hospitals, clinics and doctors/nurses. The coverage definitely won't be as great as universal healthcare, but being able to cut the costs of running a hospital must surely translate into more available healthcare................... well, in theory at least.

[PainRack]

Its just an uninformed opinion, but if the subisdy for healthcare is given to the hospitals instead of the people, some of the cons of both private and socialised healthcare seems to be degraded.

It already is. If it weren't for millions of dollars flowing into all three of the local major hospitals they'd have gone under decades ago. Government subsidizes education through grants, capital purchases, and even some direct payments. There simply is no way to make truely modern healthcare cheap. At best you can opt for monopsony, but that leads to less investment, fewer choices, and ultimately higher prices. Major gains from monopsony can be had when dealing with de facto monopolies, and this is indeed where socialized medicine has shined. It is a fun fact - drugs are cheaper in Canada than the US; but only name-brand drugs (on average). Because of how the system works fewer generic manufacturers with fewer resources are in play in the Canadian market. If the generic market where ever to outprice the brandname market, then Canada would actually spend more on pharma per capita than the US.

Okay..

We have a socialised heatlh care in Australia as well. I will go into some of the details of it since the OP wanted to know.

Medical decisions are based on clinical status / need.

As Broomstick said, for an injured limb, the most I have ever ordered was an x-ray. If it turned out to have a fracture which needed operation (as opposed to just a plaster cast), I refer to the orthopaedic surgeons. If they want more detailed imaging they can arrange it. We don't waste money on unnecessary scans. And if I tried calling the radiologist to perform a CT / MRI I would have to justify it to them - ie how would this scan change my management of the patient. If I couldn't I would get slammed on the phone.

What if the patient wanted additional scans or a second opinion?

[mr friendly guy]

We have a socialised heatlh care in Australia as well. I will go into some of the details of it since the OP wanted to know.

Medical decisions are based on clinical status / need.

As Broomstick said, for an injured limb, the most I have ever ordered was an x-ray. If it turned out to have a fracture which needed operation (as opposed to just a plaster cast), I refer to the orthopaedic surgeons. If they want more detailed imaging they can arrange it. We don't waste money on unnecessary scans. And if I tried calling the radiologist to perform a CT / MRI I would have to justify it to them - ie how would this scan change my management of the patient. If I couldn't I would get slammed on the phone.

What if the patient wanted additional scans or a second opinion?

They can see another Doctor either privately or publicly. There are plenty of GPs around. If it is a specialist doctor, your GP can refer to another.

There are some "frequent flyer" patients who go around the various public hospitals wanting "treatment" when there is nothing more to treat, or its a chronic condition with nothing acute management being required.

If the second doctor thinks a scan (presumably you mean more detailed scans than the x-ray like CT or MRI) is warranted, he/she can arrange it. If the patient wants the scan for the hell of it, then presumably they can pay with their own pocket for a scan which is not clinically warranted (far be it for me to put a price on "piece of mind") from a private radiology clinic.

[Stark]

In AU, there's essentially free medical care for all. Course, because most people here are bogans (come the fuck on, 1k a year for private? Who can't afford that? I'm a fucking student!) and enjoy free things and being lazy, there are waiting lists. But if you really wanted to complain, you'd pop 1k and get private medical care, which is usually better in any case. I don't see how people can complain about public health being crap or slow or whatever, when the alternative is right there and fucking cheap. One less carton of beer a week and you're covered.

[mr friendly guy]

In AU, there's essentially free medical care for all. Course, because most people here are bogans (come the fuck on, 1k a year for private? Who can't afford that? I'm a fucking student!) and enjoy free things and being lazy, there are waiting lists. But if you really wanted to complain, you'd pop 1k and get private medical care, which is usually better in any case. I don't see how people can complain about public health being crap or slow or whatever, when the alternative is right there and fucking cheap. One less carton of beer a week and you're covered.

Not to mention that you won't be charged the medicare surcharge (for those earning over 50 K) if you take out private health insurance, so you may as well if you earn that much.

Private would definitely give you shorter waiting lists, better food and other amenities like single rooms, television (you can get it publicly as well if you pay) etc. As for the standard of medical care, since a lot of consultant Doctors work in both the public and private sectors, the standard of care can't be too different if the doctors are the same.

[Broomstick]

Slightly higher than I expected, I was betting around 8,000, however it does not change the point. Most people have sufficient income and credit to get 12 grand on unsecured loans.

At what interest rate?

There is a HUGE difference between $12k at 5% and $12k at 30%

Also, if you've got a family of four trying to live on $30k a year in an urban area like Chicago there's not going to be a hell of a lot left over after the basic bills are paid.

And that excuses the situation ... how?

The problem is not the medical bill and insurance companies dicking them over. The problem is that they have already blown their safety margin. With even 1980's levels of savings and debt loading these bankruptcies wouldn't happen.

Yes, they would.

Because even the most frugal people of average income - which is under $30k - trying to raise a couple of kids can be run over by medical bills. And keep in mind that 12k figure is an average - there are folks with a hell of a lot higher bill out there.

Despite have no debt other than a single car loan, AND a comfortable income, plus savings, if our share of my husband's hospitalization had been $12k I assure you I'd be in dire financial straits right now, looking at years to get back to where I was before he got sick. Bankrupt? No - but all it would take would be another illnes, an injury, a car accident and we'd be over the brink.

So first you say that there's nobody out there who's dicked by the system by nitpicking the wording of my statement, then you admit that the entire class of the "working poor" is indeed dicked over by the system. Which is it? And how do you explain the major medical bankruptcies where people did have health insurance?

What you post I take at face value. If you mean "dicked over by the system" then I expect you to post it. If you mean "has insufficient medical coverage" I expect you to post that. When you explicitly state "no care at all", I assume you mean what you post.

The working poor have some health care.

Yes - when they're about to die they can get health care.

When they have insurance it tends to have extremely high deductables and percentage payments up higher.

WHEN they have insurance - most have NO insurance at all.

This alone is not sufficient to drive the current record number of medical bankrupcies.

You're a fool if you don't think it's a major factor.

The fact that they are 'economizing' healthcare and that they have tapped their safety margin for other purposes is what drives bankruptcies.

Gee, I thought when I was making minimum wage I was "economizing" on healthcare because the choice was a $70 doctor visit vs. eating that week. By the way - I wasn't in debt at that time, either. I just didn't have much money. That is, after all, what being poor is about - not having much money.

n the US, your lifespan is determined by your economic status

Yes and no. Your economic status also determines your diet, oh didn't you know the poor are more prone to obesity? Your economic status also determines your propensity to use low quality drugs - drugs far more likely to eat into your life expectency. Likewise economic status plays into gang violence, single parenthood, educational failure, etc. - just about every other damn life expectency lowering factor is statisticly confounded with economic status. Yes having better health care is a factor, so to is the fact that soul food is unhealthy as eating lard.

Funny - when I was poor I never became obese, didn't use drugs, didn't involve myself in gang violence, was never a single parent, managed to not only graduate high school but also earn a college degree.... it's just too damn easy to lump the poor together as "losers" rather than admit that yes, you can do everything "correctly" and still wind up in the shithole.

After which the hospital can garnish your wages or attempt to confiscate property, such as your house, to pay medical bills. Or didn't you know that those are some of the mechanisms used?

Yes I know. And frankly I think they should. I'd far rather have the hospital get paid than the car lease if an individual overextends. For those who cannot simultaneously meet the medical bills and their minimum subsistence then in those circumstances a social safety net should scale in to cushion the blow.

The current "social safety net" will NOT cushion the blow - what's left of it is being dismantled further.

Fine take away someone's house - where are they going to live? It's hard to rent when your credit is fucked. Getting to work without a car is fucking hard in most of the US - should they go on welfare, then? You have to leave people enough to live on, and the means to make a living.

How the hell are they supposed to pay for an insurance policy when they're unemployed and therefore have no income?

Transient. In a rational universe people would say save money when they are employed so that they have a reserve to live off of. I am seriously the only one here who even trys to maintain a 6 month reserve of liquid assets to use in exactly such a contingency?

Average length of unemployment in the Chicago area for the past four years has been 14-18 months.... which indicates to me that perhaps you aren't saving enough, hmm?

And, again, if a family of four is living paycheck to paycheck just to meet basic needs of shelter, food, clothing, etc. how in the hell are they supposed to save 6 months worth of living expenses?

Source? Mike's cite showed a whopping 12,000 dollars out of pocket median expense for medical bankrupcies. I find it incredulious that a 24,000 dollar debt would be sufficient to drive anywhere close to all the medical bankrupcies reported.

That's the average debt - in that group you've got folks fucked over by a $6k debt and others looking at $60k.

And yes, $24k is enough to bankrupt someone. Bankruptcy means you can't pay back the debt. Let's assume someone is making $18k a year - how do they pay back $24k at 20% interest in anything like a reasonable amount of time?

Last year my husband was in the hospital for 8 days. Because we have excellent insurance, our share was "only" about $7,000 and because we are frugal by nature we had it on hand to pay it.

That is exactly my point. When people live responsibly they HAVE cash on hand or at the very least a clean credit line to take that type of monetary hit without going insolvent.

It's the credit at usurious rates that is a big part of driving people into debt.

If my employer did not offer health insurance I would, in fact, be bankrupt right now despite having NO credit card debt and, in fact, NO debt except a car loan, despite a comfortable income.

If your employer did not offer healthcare exactly why couldn't you devote a portion of your disposable income towards health premiums? I realize it would be a sacrifice, but could you truly not afford to pay healthcare solely out of your salary?

No, I could not.

11 years ago, just prior to my current job, I looked into a high-deductible plan ($10,000 deductible) for my husband and myself. The best quoted premium was $1,200 per month. Due to pre-existing conditions. Since, in my husband's case, that was due to a birth defect you can hardly blame it on dissapated lifestyle or really any fault of his. The fact that keeping my husband healthy despite the consequences of his medical condition is running about $150 a month (which such a plan wound nost cover at all) would mean a MINIMUM of $1,350 a month on healthcare alone. Who the hell can pay that AND the rent/mortgage and food and gas and everything else? Mind you, the husband is hardly incapcitated - he's up and walking around and at the time he had a successful busines and two employees. None of which had employer offered health insurance, by the way. We just couldn't afford to provide it.

So, at the time, our strategy was to try to stay healthy and, if we DID have a catastrophic illnes/accident, declare bankruptcy. What choice did we have?

We actually weren't "working poor" - which is precisely why we couldn't qualify for any "safety net" programs. Nor were we an isolated case. We made too much for the safety net, yet still couldn't afford healthcare on our own.

"Me-too" drugs do not advance medical care, they do not cure new diseases or more effectively treat old diseases, they do not solve the problem that our antibiotics are becoming less and less effective.

Cox II inhibitors are "me too" drugs, at least in the industry, their selling point was their ease of uptake.

Yeah, except that was bullshit. Cox II inhibitors were no more effective at pain relief than traditional NSAIDs, nor were they "taken up" more effectively. They're ONLY advantage was that they were less likely to cause gastrointestinal irritation and/or bleeds. That's it. First line therapy for the ills they treat should be asprin or other regular NSAID - only if the dose is high or the patient can't tolerate it or there are other contra-indications should a Cox II be given first.... but that's NOT what happened. Everyone dropped their Aleve and asked for a script for Celebrex. A hell of a lot more money was spent, but the average patient gained no extra benefit.

"Me-too" drugs while close to their predecessors are not exactly the same... meaning there is the potential for new side effects. There is much more information about a drug with a 20-30 year history of use vs. one with a 2 year history, and a lot fewer surprises.

So why are people BUYING THEM?

People are buying them because, in part, direct-to-consumer advertising which is a blot and a stain upon modern medicine and should be abolished.

Doctors are prescribing the newest drug instead of trying old, known, reliable therapies first. This is in part because of the samples and hard-sell and "continuing education" informercial "conferences" big pharma uses to influence doctors and their prescribing habits.

Our society is in love with technology for its own sake - "new" being equated to "better".

People are "buying" the new drugs because they don't really make choices - they buy what their doctors tell them to, and in all too many cases their doctors are influenced by Big Pharma.

Hey, I don't make the choice to buy an antibiotic - that's a decision my doctor makes. He also decides which one I'm going to purchase as well. The only choice I make is whether or not to follow orders.

IF the drugs are actually needed in the first place. I have to wonder if everyone on Prozac really needs Prozac, or if changing their lifestyle would have the same but a more permanent effect.

This is why we have doctors and medical standards. Yes those standards need revision,

No, those standards need to be followed. Particularly among the GP's, they aren't keeping up with the evidence or medical society recommended standards of care. The specialists aren't doing too good a job, either.

Another example of this is in the treatment of obesity. There are been effective drugs for weight reduction - and virtually all of them have been withdrawn due to side effects that are, in some cases, lethal. It's an area where surgery actually seems to have fewer risks than most of the drug threapies tried. (Although the surgery does carry real risks)

Data?

When the research group I work for publishes their results, I'll let you know.

And why does miniturization automatically equate to progress in your mind? It's not enough to simply say it's high-tech or smaller, you have to quantify the improvement in terms like faster recovery, more accurate information, fewer complications, and so forth. And the cost has to be within the realm of affordable. Remember, if the patient doesn't have the money to buy medical tech from their viewpoint it might as well not exist.

Why is miniturization better? Because fewer people die. The larger the sensor you plug into the body, the greater the surface area, and the more likely chance of infection, biofouling, and rejection reactions.

But do we always need that implanted sensor in the first place? It not enough to miniaturize a camera to look inside the body, or a new cardiovascular pressure sensor you can implant in an artery, or what have you and say "WONDERFUL!" - you have to actually PROVE it's better. It's NOT enough to say it "logically" follows that it's better you have to PROVE IT - every single time.

Haven't we had those for awhile for brain injuries?

These are rf MEMS that can be implanted and left in the patient, and if the regulators argee could be left in permently instead of having to continiously put new sensors in and risking infection everytime you do it. Of course the advantage that the patient can take it home and his neurologist can monitor the data over the phone line means nothing

If you had said that up front I wouldn't have had to ask you - I'm not a fucking mind reader. Be more specific.

By the way - what are the long-term effects of leaving these in place? 5 years out? 10 years out? 15? 20? Don't know yet, huh? Well, then the jury is still out.

Human growth hormone seemed like a good idea - except for those poors recipients who later on died of Crutzfeld-Jacob acquired from the treatment. Me, I'd rather be short than dead of prion disease. Of course, genetic engineering did solve that one, but it's a great example of how what appears to be wonderful medicine turns out to have nasty, unforseen consequences 10 or 20 years down the line.

The basic problem is still the frigging same - people don't take flu shots.

Then maybe we should re-evaluate the number of doses, hmmm?

Fact is, people DO take flu shots... just not universally. We still need it for certain healthcare workers and certain high-risk patients. Or maybe we should mandate it for children, who are the main spreaders of viral illness in our soceity anyhow.

For the greater good of society perhaps the government should pay for its production, and never expect a monetary profit from it. It's not that different than the government taking over long-term dialysis in this country - whcih was done because there was no way in hell the average kidney failure patient was every going to be able to pay for the treatment on their own.

It was done as a political ploy to kill the last Apollo missions and gut NASA.

Uh, right... it's completely impossible there was any hint of compassion here. What utter bullshit.

If the free market can't reliably produce a needed item - such as a vaccine - then 'fess up that the free market is NOT almighty and find an alternate means to get what you need. Like taking it out of taxes, just as we do for maintenance of roads and paying for the military.

The free market can and does produce flu vaccine, going so far as to offer up a NEW and novel vaccine. The problem isn't that it can't be supplied, but that people WON'T USE IT.

Correction - won't use it in the numbers advocated by medical authorities. There's no question flu vaccine is not only used but sought out by certain categories of people. But not your average Joe or Jane.

Partly, it's the jab in the arm thing - there are good and valid reasons why people don't like to get poked. As a general rule, organisms that avoid having the skin barrier violated tend to live longer and leave more offspring - evolution occurred without vaccination as a factor. If you could swallow a pill to avoid flu I suspect vaccination compliance would be much, much higher.

Oh yes a market for a few thousand patients - tops - in the US. To the best of my knowledge there has yet to be a completely resistant staph strain (resistent to EVERY antibiotic on the shelves) that wasn't in a biohazard lab.

One turned up in a hospital in a Chicago suburb about three years ago. The patient died of the infection, but they put the guy in isolation in time to keep it from spreading. Or, at least they think they contained it - no one else has come down with that strain of staph.

I'm sorry but you are ignorant of the realities here, your average hospital can treat EVERY staph infection they will ever encounter, the problem tends to be they don't recognize the problem quickly enough to take effective action.

It's so cute, the faith you have in medicine... it also helps when the patient gets to the hospital in time for the doc to do something. Then we have "flesh-eating" strep, which can kill even if treatment starts early in the process.

There simply aren't enough cases of truely massively resistent infections to payback a 100 million investment.

Not yet...

It's NOT just about profits.... it's also about being able to buy.

I see, you refuse to answer the question.

I did answer - you refused to hear me.

What I did refuse to do is give a flip, off-the-cuff answer to a question that's more complicated than it initially appears.

If a cure for a disease cost a nickel a pill I frankly wouldn't give a damn if at that price the company in question was making a 500% profit. If it cost $100,000 a dose...well, the profit margin doesn't matter because virtually no one could buy even one pill.

And as such society is better off letting people dependent on such doses simply die. Cold, harsh, and utilitarian.

So... let's abolish organ transplants - not only are they in the $100k per incident range, there's that $12-20k per year maintenance fee to keep the person alive afterward.

There are some illnesses and conditions that no individual could be expected to pay for on their own. (the Bill Gate's of the world being such a small fraction as to not be relevant to the discussion) Recovery from extensive third degree burns, for example, can exceed $1,000,000 a year for several years. I don't know anyone who could pay that out of pocket, and it gets periously close to the lifetime cap of most health insurance policies (in fact, people DO exceed those caps).

When a patient cannot afford basic subsistence and medical bills some type of social safety net is required in a civilized world.

The problem is, that safety net doesn't really exist in the US.

In order to qualify for Medicaid in most states you not only have to get rid of any real estate - such as a house - you also have to empty out your savings accounts, including IRA's and 401(k)'s in a process called a "spend down" until you're destitute enough to qualify. In Colorado and a couple other states the spouse also has to go through the same process. So.. what the fuck does that leave a person (or persons) to live on after the crisis is over? The rules were really written with the assumption that a catastrophic illness/injury was always terminal.. but that's not the case any more, if it ever was.

Except that most terminal diseases rule out donating of organs.

That depends. Congenital heart failure tends not to do a damn thing to the kidneys. Somewhere I have actual numbers showing that this strategy leads to a net increase in organs - you see it was tried and it WORKED.

Most heart failure these days is not congenital - it's a lifestyle triggered illness and that illness leaves pretty much all the blood vessels fucked up, which can certainly disqualify a donor. Cancer - even if it's not terminal - rules out solid organ donation.

It's a great idea when you can make it work - problem is, it doesn't work out that often. So while it lessens the organ shortage it still doesn't solve the problem.

Where I work we recently did a big study on islet cell transplants for diabetes (that was the work with the Canadians, in fact, who are leading the efforts with this thanks to a Dr. Shapiro in Edmonton). The math folks sat down and figured out that even if ALL potential donors gave up their islet cells for this purpose - meaning they all qualified and didn't have problems like viral infections or history of cancer or other disqualifiers, which isn't going to happen in the real world, AND no one refused to donate, eveyone asked said "yes" - there would STILL not be enough available donors to benefit everyone who would, through a risk vs. benefit calculation, qualify for the procedure. Supply will never keep up with demand. What we need is a way to manufacture these cells and organs without cutting them out of other human beings. THAT's the sort of breakthrough we need

Good luck finding the holy grail. That sort of breakthrough would be instant Nobel worthy and a license to print money.

Unless it costs $100,000,000 to grow the cells for each patient, in which case it's not cost-effective, is it? We couldn't afford to implement such a cure.

But that level is what I call a "breakthrough", not merely an incremental improvement in an already existing technique.

It's futile to point a finger at any one segment of the medical industry and say "their fault". Until we realize that ALL the players bear some responsibility for the mess we won't be able to clean up.

There is more than enough blame to go around. I can cite chapter and verse of idioacy in consumers, government, and industry. My problem is this BS idea that going to monopsony, or even oligopsony like Canada, is a painless way to alleviate problems that could not otherwise be corrected - maybe even in a more benificial manner.

OK, you're on - what's your solution? Please include details.

[Xon]

In AU, there's essentially free medical care for all.

As much as Australians bitch about their health care system, its lightyears ahead of others around the world for not leaving financial wreckage when ever the general public touches the health system.

The Pharmaceutical Benefits Scheme which basicly sets the maxium prices for sales of drugs(via subsidized approved drugs) in Australia is a blessing.

Apparently the pharmaceutical companies hate it, and there was some large pressure during the free trade agreement to have it changed. I'm fairly sure there werent any major changes, but I'm not 100% positive.

However, we did USA IP & copyright laws imported wholesale.

There is a law suit against an ISP which will be the 1st challenge to the new copyright laws, I'm hoping the new copyright laws dont work as expected(that is they are much weaker than the USA expected).

[mr friendly guy]

The UK also have a socialised health system, the NHS. Apparently its struggling to keep up and I know of UK visitors telling us we don't know how good we got it.

Drug companies most likely hate the Pharmaceutical benefits scheme because they would need to send in paper work with no guarantee that their product would be subsidised by the government. Obviously if a rival company's product is governement subsidise they would have an advantage, in that doctors do take some financial considerations when prescribing meds.

That being said, from what little I know, I am unaware of a case where the government would fail to subsidise products from different companies if they are essentially the same class of drugs.

[tharkûn]

At what interest rate?

There is a HUGE difference between $12k at 5% and $12k at 30%

That depends on the financial situation. I know on my own I have a credit line far higher than that at a point or three above prime, but my circumstances are highly atypical. Really the interest rate is going to depend on your credit level and the inflation rate a priori, other factors will also play in. If you are already in a precarious credit situation then you are either indigent, in the gap, or have already hashed your credit.

Also, if you've got a family of four trying to live on $30k a year in an urban area like Chicago there's not going to be a hell of a lot left over after the basic bills are paid.

Exactly how many people do that? And does that not, given Chicago's cost of living inflation relative to national norm, qualify them as 'working poor'?

Because even the most frugal people of average income - which is under $30k - trying to raise a couple of kids can be run over by medical bills. And keep in mind that 12k figure is an average - there are folks with a hell of a lot higher bill out there.

Average income for families with multiple dependent minors is higher than national average by a significant amount; the national average includes teenagers to seniors.

Yes - when they're about to die they can get health care.

No most working poor tend to be able to go when symptoms arrive. It is not merely terminal care that they receive.

WHEN they have insurance - most have NO insurance at all.

Varies heavily by state. I'm not denying there is a signficant gap nor that they currently have insufficient coverage, merely that they have no access to healthcare.

You're a fool if you don't think it's a major factor.

I have never denied it. I beleive it is a major factor, along with predatory credit card interest, insufficient savings, and in general living beyond one's means. My point is that it is neither a necessary nor sufficient factor. Most medical bills alone do not cause insolvency, other choices are situations cannot be ignored.

Gee, I thought when I was making minimum wage I was "economizing" on healthcare because the choice was a $70 doctor visit vs. eating that week. By the way - I wasn't in debt at that time, either. I just didn't have much money. That is, after all, what being poor is about - not having much money.

Most of the 'working poor' are making more than minimum wage. Most minimum wage earners are not 'working poor'. Most 'working poor' opt to 'economize' by waiting until symptomatic onset to seek limited medical care. Likewise they tend to economize by opting for cheaping care options when they receive treatment.

Funny - when I was poor I never became obese, didn't use drugs, didn't involve myself in gang violence, was never a single parent, managed to not only graduate high school but also earn a college degree.... it's just too damn easy to lump the poor together as "losers" rather than admit that yes, you can do everything "correctly" and still wind up in the shithole.

Funny I know a single mother who was working poor for the vast majority of her life and lived most of it pre-civil rights (try getting a job as a single black widow in the 1930's). She is 103 or something and still isn't dead.

Ancedotes are not a substitute for data. Poor people tend to be more obese. Poor people tend to use lower quality recreational drugs (homebrew crack vs. pure cocaine). Poor people tend to be more likely to drop out of high school or graduate with insufficient mastry of the material. Yes there a whole slew of qualifiers one should be talking about when looking at the impact of economic class and its confounding with other life expectancy altering factors ... however rather than nitpick DW's terminology I simply copied it and hope that he and everyone else would implicitly acknowledge their existence.

The current "social safety net" will NOT cushion the blow - what's left of it is being dismantled further.

Gee really? Could that possibly be why I call for DRASTIC change?

Average length of unemployment in the Chicago area for the past four years has been 14-18 months.... which indicates to me that perhaps you aren't saving enough, hmm?

No 6 months of reserve is six months of income, not six months of basic subsistence. If I pare my lifestyle all the way down to Raman I could make 18 months on that reserve.

And, again, if a family of four is living paycheck to paycheck just to meet basic needs of shelter, food, clothing, etc. how in the hell are they supposed to save 6 months worth of living expenses?

The problem is then why are they living paycheck to paycheck; every ill in society is not due to medical costs.

And yes, $24k is enough to bankrupt someone. Bankruptcy means you can't pay back the debt. Let's assume someone is making $18k a year - how do they pay back $24k at 20% interest in anything like a reasonable amount of time?

Define reasonable amount of time. Besides at some point bankruptcy is an option. Particularly chapter 13. The bankruptcy laws exist so that people who go insolvent due to circumstances beyond their control woulddn't be over the eightball for the rest of their lives. Yes some penalties exist with bankruptcy, but something is needed to prevent wholesale abuse of the system. At some point society should say okay we take a hit because you cannot afford the debt you've racked up and we will forgive a portion or preferably more rarely all your debt for a price.

Many bankruptcies should not be happen that do, those which do appear to be driven by usurious interest and poor fininacial planning above and beyond medical expenses. Of the specific cases which are not so driven it is not out of the question to have people declare bankruptcy when the case warrents it. There isn't a problem if unexpected medical problems drive some bankruptcies - bankruptcy laws exist to allow a person to overcome crippling debt, particularly debt created by things beyond their control. The problem isn't that some individuals in truly dire straights go bust, but that so many people not in such dire straights are insolvent.

It's the credit at usurious rates that is a big part of driving people into debt.

In my opinion, predatory credit card policy is THE driving force behind the recent explosion of bankruptcies.

Cox II inhibitors were no more effective at pain relief than traditional NSAIDs, nor were they "taken up" more effectively.

Umm BS. Do I really need to cite the data showing less gastrointestinal distress caused by COX II? For most people aspirin or tylenol works.

They're ONLY advantage was that they were less likely to cause gastrointestinal irritation and/or bleeds. That's it.

And that is a significant population of ulcer sufferers in the US, around 5 million I think. There is a larger population of individuals who have other GI problems that would witness a significant improvement switching from aspirin to COX II. Given that 6,000 people die per annum due to ulcer complications; and that a significant number of ulcer complications arise from NSAID use ... do you think something which doesn't do that might have a valid selling point?

First line therapy for the ills they treat should be asprin or other regular NSAID - only if the dose is high or the patient can't tolerate it or there are other contra-indications should a Cox II be given first.... but that's NOT what happened. Everyone dropped their Aleve and asked for a script for Celebrex. A hell of a lot more money was spent, but the average patient gained no extra benefit.

Yes because the doctors were morons who didn't follow good practice guidelines. See point about revising said guidelines.

People are buying them because, in part, direct-to-consumer advertising which is a blot and a stain upon modern medicine and should be abolished.

While some of it is obvious crap, on the flip side you have a lot of people who don't know they have a condition and seek treatment because of those ads. It is a good thing if patients are more informed about the medications availible for their conditions. It is a good thing if more people seek out professional advice to treat medical conditions - rather than wait for gross symptomatic onset. Yes tons of crap comes out of BS advertisement, buckets of good (read saved lives) comes out of the good stuff. All told the numbers I've seen show it to be either a wash or slightly benificial.

The real problem is that too many doctors have had a spinectomy and don't tell their patients that they don't need those new fangled pills. There needs to be OVERSIGHT of doctors and PENALITIES for gratuitious breach of good practice that "merely" results in increased health care costs.

Doctors are prescribing the newest drug instead of trying old, known, reliable therapies first. This is in part because of the samples and hard-sell and "continuing education" informercial "conferences" big pharma uses to influence doctors and their prescribing habits.

This is because doctors are either incompotent or unwilling to follow good practice. Such tactics only work if:
a. The new pill really does has something good going for it.
b. The doctor is not willing or able to practice good medicine.

Hey, I don't make the choice to buy an antibiotic - that's a decision my doctor makes. He also decides which one I'm going to purchase as well. The only choice I make is whether or not to follow orders.

So why then did you just state:

People are buying them because, in part, direct-to-consumer advertising which is a blot and a stain upon modern medicine and should be abolished.

If your doctor decides which medicine you take and which you shall purchase how then is direct-to-consumer advertisement effecting sales of new pills? The good part of such consumer orientated advertisement is that people who might have a condition are more likely to actually tell their doctor their early stage symptoms. The bad part is that patients tell their doctor they want this new drug and their doctor is unable or unwilling to tell that that taking that drug would be bad medicine.

No, those standards need to be followed. Particularly among the GP's, they aren't keeping up with the evidence or medical society recommended standards of care. The specialists aren't doing too good a job, either.

My biggest point of revision would be instituting some type of regulation mechanism so that doctors who prescribe pills against good medical practice (COX II over aspirin as SOP) get an appropriate penalty. For the truly aggregious cases doctors should lose their prescription privileges. Right now as long as the only harm done is to the insurance company's pocketbook nobody can do much of anything.

But do we always need that implanted sensor in the first place? It not enough to miniaturize a camera to look inside the body, or a new cardiovascular pressure sensor you can implant in an artery, or what have you and say "WONDERFUL!" - you have to actually PROVE it's better. It's NOT enough to say it "logically" follows that it's better you have to PROVE IT - every single time.

Some of the devices I'm describing are still in primate trials - where they have cut mortality rates by double digit percentages. Some of them are in early clinical trials awaiting FDA approval. A minority are just entering the market. Every single one of them I have seen numbers that decrease cost or increase quality/quanty of life for patients.

Some of them should indeed be obvious. Take a realtime continious glucose monitor. Instead of having to prick a finger multiple times a day and use plateued insulin dosages you could do real time feedback and drasticly reduce the time periods of imbalance. Imbalance is KNOWN to directly correlate with amputation, wound complications, and early death. It should be readily obvious that an implantable glucose rf MEMS would be a good thing if it isn't more costly than other MEMS already in use (BTW it looks like they might be able to make one cheaper than supplying testing strips to the patient, given a crapload of assumptions)

By the way - what are the long-term effects of leaving these in place? 5 years out? 10 years out? 15? 20? Don't know yet, huh? Well, then the jury is still out.

In primates 5 year data looks like it will show essentially nothing (mind you the 5 year stuff is using an older, less minaturized model), which is a quantum leap over long term monitoring with the older methodolgy.

Yes the jury is still out on the specifics, however all these devices are related. They are etched Si with possibly some microelectronics tacked on inside of a casing (which is extremely costly). Once you have data on a say a pressure sensor it will not appreciably change for say a thermocouple or an accelerometer.

Then maybe we should re-evaluate the number of doses, hmmm?

To what? The private market has continiously managed to supply millions of dosages. The only reason there was a 'shortage' last season was because a British plant, you know in the land of socialized medicine, went down. Whatever the number of doses somebody is willing to pay for, then the market is more than able to provide exactly that number. When private firms have to toss 15 million doses then you have problems.

Fact is, people DO take flu shots... just not universally. We still need it for certain healthcare workers and certain high-risk patients. Or maybe we should mandate it for children, who are the main spreaders of viral illness in our soceity anyhow.

My point is that regardless of if it is the federal government or private industry manufacturing the flu vaccine the problem is still going to be that forecasting the dosage requirements is going to be shoddy as all hell. That doesn't change with socialization. Mandatory vaccination would alleviate a huge amount of risk in the process and might tempt pharma back into the market.

Uh, right... it's completely impossible there was any hint of compassion here.

Oh there was compassion there, but let's look at the budgets back then. The government could have easily deficit spent to pay off dialysis, like it did so many other things and not broken the budget, they could have cut into any number of federal programs. However it was a direct hit at NASA in exchange for dialysis. The people who egineered that vote played the public's compassion like a fine tuned violin and used it to gut NASA ... which was the original intent.

Correction - won't use it in the numbers advocated by medical authorities. There's no question flu vaccine is not only used but sought out by certain categories of people.

True. Even those who do use, unfortunately are not consistent reliable users.

Partly, it's the jab in the arm thing - there are good and valid reasons why people don't like to get poked.

No it isn't. MedImmune makes a nasal vaccine that is inhaled and has experienced significant problems penetrating the market. Last I heard they were only selling 4 million doses or something like that, compared to the 70 plus million that typicly are sold by traditional vaccine makers. Now part of it may be that people don't know an inhaled vaccine exists (gee something, I dunno, advertising might fix neh?) or that availibility and cost factor in. However the bean counters at MedImmune had high hopes of displacing the traditional vaccine by avoiding the issues you cite, they simply are not getting that type of market penetration.

One turned up in a hospital in a Chicago suburb about three years ago. The patient died of the infection, but they put the guy in isolation in time to keep it from spreading. Or, at least they think they contained it - no one else has come down with that strain of staph.

Did they actually dose him with the entire pharmocopedia in a timely fashion? Once you turn on the stress response genes you need to go shotgun with both barrels; after a certain point you simply don't have the time needed to let the antibiotics work. As I said an antibiotic to specificly designed to fight this is not short term viable, there simply isn't a market above a few thousand patients per annum for heavy gun antibiotics.

If you really want to make this research happen you could just grant indefinate patents.

It's so cute, the faith you have in medicine... it also helps when the patient gets to the hospital in time for the doc to do something. Then we have "flesh-eating" strep, which can kill even if treatment starts early in the process.

And unsurpisingly there is work being done on earlier detection methods. The problem tends not to be that drugs don't exist to hammer bacterial infections, but that by the time doctors know what the hell they are dealing with there isn't time to run through the pharmacopedia. Money would be far better spent on early diagnosis that works on single and doubly resistent bugs ... as well as nasty MRS bugs; rather than just on fighting the relatively rare uber MRS bugs.

Not yet...

The last market projection I saw put the date around 2080 or something like that. I don't put any faith in that number because it was most definately a first order hand wave.

So... let's abolish organ transplants - not only are they in the $100k per incident range, there's that $12-20k per year maintenance fee to keep the person alive afterward.

You said 100k per dose. At typical dosages that is several million per annum and at that point the utilitarian calculus has tipped the other way. 100k per incident is nothing like 100k a pill.

The problem is, that safety net doesn't really exist in the US.

The problem is a gap exists in the safety net where you are too rich for medicaid and too poor for sufficient coverage through other means. I am well aware of the crap that occurs in that gap and hence I think the system should be changed.

It's a great idea when you can make it work - problem is, it doesn't work out that often. So while it lessens the organ shortage it still doesn't solve the problem.

Very few medical problems are solved overnight, most aren't even solved in a generation. When I see a program that can save thousands of lives a year I tend to view it as a partial solution, particularly something so cost effective as this.

Unless it costs $100,000,000 to grow the cells for each patient, in which case it's not cost-effective, is it? We couldn't afford to implement such a cure.

Costs come down. Once you have a working device or precedure somebody else will be looking at how to do it cheaper. Once you patent the procedure you get a leg up on further R&D, the money will pour in by the billion to reduce costs and unless you are dealing with antimatter or something screwball that cost WILL come down.

OK, you're on - what's your solution? Please include details.

This is not an exhaustive list but I think a good start:
1. Tort reform.
a. Pain and suffering needs to be limited. Other awards (like lost wages) that can be documented and quantitified would not be be affected by the hard cap. This would drasticly cut the number of BS lawsuits in the system.
b. Loser/loser's lawyer pays. Right now medical malpractice on BS grounds is a lottery, but a good lawyer can expect to make a net winning. If a judge deems a lawsuit to be frivilous under my propsoed rules the loser's lawyer pays for not counseling his client to drop the case; in the event that a client wants to ligitigate even after their lawyer has counseled otherwise they must meet independently with the judge who will witness them sign a legal affidavit that they will be held finicially responible for the defendent's legal bills. Conversely if the insurance companies dick over an obvious case they will automaticly be forced to pay off legal fees for the plaintiff.
c. Rework punative damages. Currently if punative damages are levied they go to the litigant and his lawyer - the litigant has demonstrated no personal sacrifice entitling him to these funds - they are levied to penalize the defendent for negligence and encourage better practice. I would immediately require all such punative fines to be awarded to a charitable third party. I.e. your asswhipe doctor botches your kidney operation and gets socked with a 5 million dollar punative fine, instead of it going to you and your attorney, it would go towards a dialysis fund or kidney research. You would still be able to hit him for the full cap on pain and suffering, lost wages, and remedial medical costs ... the punative money would be spent on making healthcare more affordable for others, not on a new house for you.
d. Knowingly using fraudentlent science as a lawyer makes you liable for the full finicial cost it imparted on your opponent and a sizeable punative fine. Also it would trigger an immediate inquery into bar status and aggregious offenders would then be disbarred. I'd really like to make such twats be thrown in the federal pen or better still beaten with sticks but I doubt you can get that through.

2. Social safety net.
a. Introduce a scaling benifit component to medicaid. If people's incomes fall into a range between the cutoff point for medicaid and wherever it is finicially viable to both pay for basic subsistence and insurance premiums plus a small buffer ... there you'd have a benifit that roughly correlates inversely with income.
b. Paying for the above would be done by introducing means testing to Medicare. If you have sufficient income as a senior or superlative net wealth then you would get a reciprocal scaling of your benifit.

3. Medical R&D subsidy.
a. Any patented device being sold abroad that rests on IP developed with USG funding would be subject to a slight licensing fee. This fee would be waived for countries which do not engage in pricefixing or contribute a like percentage of funding for medical R&D.
b. Drug reimportation would be legalized from all nations with working drug regulatory agencies. The US government would actively seek out bulk importers to suck the pharmacies of the rest of the world dry until pharma can no longer offer drastic price differentials to monopsonies and oligopsonies outside the US. I figure in about a month Canada will abandon price controls or adopt domestic use legislation. In the latter the US government should then work a free trade in pharma clause into general trade agreements. Europe will follow Canada within a year or two. Long term this will equalize prices regardless of health system and spur domestic drug development for markets outside the US.

4. Medical oversight.
a. Prescriptions. Doctors will be required to follow a best practice methodology. They must explain to each and every patient the absolute cost and benifits of every drug. Random spot checks will be initiated. If a doctor habitually disregards best practice he will face penalty; including loss of prescription privileges in extreme cases.
b. Monopoly laws need to be rewritten for patented drugs. Unethical legal loopholes to reduce competition, of which there are too many varieties to list, need to be closed. Companies found to be engaged in illegal monopolostic practices MUST be prosecuted and penalized for so doing.
c. Antibiotics and vaccine regulation needs a complete rewrite from the top down. Patent protections for novel antibiotics with proven MRS fighting ability need to be extended, and depending on the case possibly decades. The use of mass antibiotic administration to feed animals, even in export markets, must be banned except with antibiotics retired from human use (as a side note political pressure from European, American, and Asian sources must be leveraged against ALL manufacturers and consuming nations worldwide). Intentional prescription of antibiotics for viral infections needs to be a frigging crime. Vaccines need to be held to similar standards of QA and QC as other medical consumables, specifically quantifiable risk above a predesignated threshold must be associated with new regulation.

5. Education.
a. More medical colleges, particularly for nurses need to be established or existing schools must be expanded. Direct funding, government backed loans, etc. could all be used depending upon how you want to do it.
b. Educational grants need to be tiered based on the value you contribute to society. I.e. a fine arts major would have a hard time getting an education grant than an egineer - society gets more out of the egineer. For labor shortage professions loans could be offerred that need not be repaid after sufficient time spent in said profession. I.e. the federal government offers 70k in loans to a aspiring nurses and each year they spend in the field averages out to 10k in loan forgiveness (individual years would be back loaded so the last years would forgive more debt). For truly critical fields the government will more than recoup the costs, in nursing lower patient to nurse ratios mean lower incidince of complications and over a 7 year period the government savings would be in the billions.
c. Science education needs to be more pervasive at the high school and early collegiate level. If that means cutting into the social sciences and even English literature, that's too frikking bad. If you do this from the federal level you will need to play hardball with federal monies to states.

6. Paperwork and administration.
a. Standardized forms. Using a variety of threats the federal government needs to establish basic guidelines and then let a consortium of private insurers, hospitalsm, doctors, state agencies, and federal agencies make one exhaustive set of forms. If need be I opt for the Vatican solution and lock them in low quality hotel with bread and water until they produce a workable standardized form.
b. IT. The federal government would save money and have a better biodefense system if every medical provider had onsight IT access to the internet and high bandwidth channels to send information from one sight to another. This would allow greater offsight analysis of screening done in the stixs, increasing coverage, decreasing treatment costs, and ultimately lowering mortality.
c. Alll medical providers receiving government funding must audit their administration and submit those results. Hospitals with chronicly poor fiscal standing due to horrid administration (an unbeleivably common problem) would be required to fire said administration or lose government funding.

The above should do a good job at hitting the major inefficiencies of the US system. I completely understand that a half dozen powerful lobbies absolutely hate every single bloody point, but if the federal government were serious about improving healthcare I think all the above would be easier to practicly implement than socialized healthcare.

[Darth Wong]

Even if it is just a transient phenemona it means millions of lives.

And the US's terrible infant mortality rate doesn't? You're engaging in a nice game of selective number quoting, aren't you? For any system as mind-bogglingly complex as a nation's healthcare system, it is utterly absurd to expect every single metric to be identical, even if overall patient outcomes are similar. Some metrics will be higher in one system, some will be higher in the other system. Case in point: in 2001, the WHO reported that the infant mortality rate in the US was 7 per1000 live births, compared to 5 in Canada. That's a rather huge difference; much bigger than the 1.8% difference in breast cancer survival rates that you've been crowing about at length.

No less a stalwart right-wing conservative organization than the Wall Street Journal admitted that there is no significant difference in overall patient health outcomes between the US and Canada. The key differences are in wait times for Canada and uninsured/bankrupted victims in the USA, and they acknowledged the truth that no one dares speak: that only a grossly inefficient healthcare system would not have any wait times, because no wait times mean under-utilized facilities.

[tharkûn]

And the US's terrible infant mortality rate doesn't?

Relative to the worldwide death tolls that come by delaying life saving treatments by a even a decade? Sorry but more dead people lie on the depress medical R&D.

In any event infant mortality is subject to the same problems as other medical indicators - the US baseline is crap. Mothers are more likely to be going it alone, be obese, abuse alcohol/drugs, give their children insufficient care, etc. in the US. Without doing some type of baseline correction, comparing infant mortality rates is bad science.

Some metrics will be higher in one system, some will be higher in the other system. Case in point: in 2001, the WHO reported that the infant mortality rate in the US was 7 per1000 live births, compared to 5 in Canada. That's a rather huge difference; much bigger than the 1.8% difference in breast cancer survival rates that you've been crowing about at length.

For the sake of completeness the 1.8% is an uncorrected comparison in heart attack patients, it may even be further limited to cardiac infarction patients. Breast cancer survival rates are a 20% differential.

Again the 40% difference in infant mortality is an uncorrected figure. It doesn't take into account all the factors besides healthcare which have a very real impact on mortality.

No less a stalwart right-wing conservative organization than the Wall Street Journal admitted that there is no significant difference in overall patient health outcomes between the US and Canada.

Yes because for all of Canada being an oligopsony with "single" payer healthcare, it is quite efficient. The US has a far superior system for R&D as well as capital investment, but it is inefficient as all hell in several key areas. Canadian shorfalls in one area are made up in another. Likewise US shortfalls, most notably the 'working poor' gap, are made up in other areas. Not to mention that the Canadian healthcare market benifits enormously from the flow of 'subsidized' medical R&D permeating the border.

Of course if patient outcomes are equal, then something in Canada is worse than the US. Obesity rates alone (21% - 14% for US vs Canada) should have a significant increase in relative mortality. What is so hard about this concept? Americans are the just about the most unhealthy people in the western world; if your health outcomes don't beat the US, then something on your side is worse than the US. That could be climate, religious practice, mental health, the efficacy of healthcare, etc. SOMETHING is making up for the fact that Americans are fatter and resulting in peope dying at equal rates.

The key differences are in wait times for Canada and uninsured/bankrupted victims in the USA, and they acknowledged the truth that no one dares speak: that only a grossly inefficient healthcare system would not have any wait times, because no wait times mean under-utilized facilities.

Longer wait periods, even for non-urgent procedures, show a direct correlation with worse medical outcomes, ceteris parabis. With all due respect to the WSJ, there are better sources showing that longer waiting periods have significant adverse health effects.

To quote the Canadian Medical Association Journal, "The significant decrease in physical and social functioning, both before and after surgery, for patients waiting more than 3 months for CABG [Coronary artery bypass grafting] is an important observation. Longer waiting times were also associated with increased postoperative adverse events. By decreasing waiting times for CABG, we may improve patients' quality of life and decrease the psychological morbidity associated with CABG."

Mind you this is, or at least was, based on data for 'elective' surgery. At a certain point longer waiting times are unhealthy and at slightly further out they are a significant factor in increased mortality. Building buffer capacity into the system is, generally speaking, a good thing; facilities go down, surgeons can lose ability to practice and leave one cite inoperable, acts of nature can muck up the flow of service, etc.. The exact cost effectiveness of how much buffering is a good thing is extremely complex, but having none is definately not good. On an average day you WANT to be underutilizing your facilities, when the inevitable upticks in demand or disruptions of service occur you have some buffer space to keep providing everyone with service.

All vital services and products should have some slight overproduction or buffer capacity. I want my farmers to grow a little bit too much food, I want the eletrical companies to have a little bit too much power generation, I want my egineers to put a little bit too much steel in the bridge I'm driving over ... I sure as hell want the healthcare system to have underutilized capacity.

[Glocksman]

As a member of the 'working class' in the US, let me offer my 2 cents.

Right now I have *excellent* health insurance through my employer.
My copays are $10 for office visits, 10% for durable medical equipment, and $50 for ER visits. I have no out of pocket expenses if I'm hospitalized.

When I had my gastric bypass, it would have been over $35,000 without insurance. I paid $0. Last month when I had a bleeding ulcer and lost a couple of pints of blood, I was admitted immediately upon examination in the ER after a half hour wait. My out of pocket was $50.

Is it perfect? No. The insurance tries to limit costs with differing levels of prescription copays and will only cover drugs that are on a list unless your doctor certifies in writing that only a certain drug will treat your illness.

For this I pay about $16 a week and God only know what my employer's actual costs are.

In fact, the big sticking point in our upcoming contract negotiations is health care costs, not wages.

[Glocksman]

Oh yeah, forgot to mention that a lot of the doctors in my HMO are foreign born.

My GB surgeon was from Venezuela, the GI doc who treated my ulcer was Indian, my current Orthopedist is from the Ivory Coast (the previous one was Korean), and my Primary care doc is Canadian (my previous one was Indian).

Hell, we have a mini-UN down here.

It'd be interesting to know why they're here practicing medicine?
The money? Prefer the US to their home countries? Learning opportunities?

[mr friendly guy]

Oh yeah, forgot to mention that a lot of the doctors in my HMO are foreign born.

My GB surgeon was from Venezuela, the GI doc who treated my ulcer was Indian, my current Orthopedist is from the Ivory Coast (the previous one was Korean), and my Primary care doc is Canadian (my previous one was Indian).

Hell, we have a mini-UN down here.

It'd be interesting to know why they're here practicing medicine?
The money? Prefer the US to their home countries? Learning opportunities?

I don't know about the US situation, but in Australia and a lot of parts of the world there is a Doctor shortage. So its not uncommon to hire foreign doctors to pick up the slack. Some of them will choose to stay in which case they take a test, or come here just to see another country.

In fact quite a few doctors seem to have the "travelling bug" and want to to to different countries as a "working holiday". I see lots of British doctors working here for one year.

[Darth Wong]

In any event infant mortality is subject to the same problems as other medical indicators - the US baseline is crap. Mothers are more likely to be going it alone, be obese, abuse alcohol/drugs, give their children insufficient care, etc. in the US. Without doing some type of baseline correction, comparing infant mortality rates is bad science.

You are so full of shit it's oozing out your ears. Why the fuck do you think so many people choose to "go it alone" in the United States if not for the nature of for-profit medicine, fucktard? The notion of trying to "correct" for factors which are a direct consequence of the very nature of a for-profit health-care system is pure sophistry of the highest order.

For the sake of completeness the 1.8% is an uncorrected comparison in heart attack patients, it may even be further limited to cardiac infarction patients. Breast cancer survival rates are a 20% differential.

Again the 40% difference in infant mortality is an uncorrected figure. It doesn't take into account all the factors besides healthcare which have a very real impact on mortality.

Once again, you're full of shit. Not only is the American propensity for lower classes to avoid medical care a direct result of the type of system you use (hence not a factor which should be "corrected" out), but Canada has numerous serious disadvantages which are normally ignored. The cold weather and snow shoveling alone have been attributed as causes to countless heart attacks and injuries every year, particularly along the elderly. The great isolation of small communities due to our low population density means that many people literally need plane or helicopter rides to get to a hospital. Don't sell me some line of bullshit about how the US system is handicapped.

Yes because for all of Canada being an oligopsony with "single" payer healthcare, it is quite efficient. The US has a far superior system for R&D as well as capital investment, but it is inefficient as all hell in several key areas. Canadian shorfalls in one area are made up in another. Likewise US shortfalls, most notably the 'working poor' gap, are made up in other areas. Not to mention that the Canadian healthcare market benifits enormously from the flow of 'subsidized' medical R&D permeating the border.

So as the WSJ says, you win some and you lose some. That sounds like a tossup until you remember that Canadians are not routinely bankrupted by medical care. Not to mention the steady stream of televised pleas for charity to help some poor family's kid pay for surgery that you see on American TV; a lovely American cultural fixture which is completely alien to Canada.

Of course if patient outcomes are equal, then something in Canada is worse than the US. Obesity rates alone (21% - 14% for US vs Canada) should have a significant increase in relative mortality. What is so hard about this concept? Americans are the just about the most unhealthy people in the western world; if your health outcomes don't beat the US, then something on your side is worse than the US. That could be climate, religious practice, mental health, the efficacy of healthcare, etc. SOMETHING is making up for the fact that Americans are fatter and resulting in peope dying at equal rates.

Oh puh-lease, does it occur to you that healthy people don't ever need to go to the hospital in the first place, thus having no effect on patient outcomes?

Longer wait periods, even for non-urgent procedures, show a direct correlation with worse medical outcomes, ceteris parabis. With all due respect to the WSJ, there are better sources showing that longer waiting periods have significant adverse health effects.

Of course longer waiting periods can have adverse health effects, but wait times are prioritized based on medical need in Canada, not financial factors as in the US. More importantly, outright avoidance of medical care due to financial limitations has even worse health effects, doesn't it? Of course, this is a factor which you dishonestly try to ignore because you think it's somehow irrelevant and should be "corrected" out.

All vital services and products should have some slight overproduction or buffer capacity. I want my farmers to grow a little bit too much food, I want the eletrical companies to have a little bit too much power generation, I want my egineers to put a little bit too much steel in the bridge I'm driving over ... I sure as hell want the healthcare system to have underutilized capacity.

Ah yes, better to have excess capacity which is not used even though people are out there who are literally begging for it on TV because they don't make enough money.