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May 28, 2005

What is a disease? (II)

In my last post, I argued that we should settle Viagra coverage question by old fashioned cost/benefit analysis.

By cost/benefit analysis, I just mean that Viagra should be judged by the same criteria as any other drug jockeying for a spot on a public insurance formulary. The challenge is to create the best overall insurance package in a zero-sum game--every dollar we spend on Viagra means less money for something else.

We should be asking the same basic questions about every drug:

  • How much does this treatment cost?
  • How many people will benefit?
  • What kind of benefit will they get: longer life, pain relief, better marriages...?
  • How great is the benefit to the individual patient?
  • How great is the benefit to society?

All I'm saying is that that we've got to survey the options, crunch the numbers, and see how much value Viagra delivers for the money. Cost/benefit analysis sounds cold and inflexible, but it isn't necessarily so. Private insurance companies only consider profit and loss, but a public health insurance scheme can take a much broader view of costs and benefits. Non-monetary benefits include effects on society at large, fairness, fulfillment of public preferences, etc.

Of course, we can't rank Viagra without assigning a value to sexual health. There are fundamental differences of opinion about the value of a healthy sex life. That said, much of the rhetoric about the dispensability of sex seems out of step with most people's priorities. (Not my brain, that's my second-favorite organ!)

At this point you're probably wondering, "Cost benefit analysis, as opposed to what?" As opposed to using an overarching mission statement or criterion like "Medicaid's mission is to prevent and treat disease."

If we use a criterion model and we want to know whether Medicaid should cover Viagra, we have to determine whether Viagra prevents or treats any diseases.

Clearly, Viagra is often prescribed to treat impotence that is a complication or a symptom a disease like diabetes or cancer. If our criterion allows for symptomatic treatment for pain and nausea, why shouldn't it extend to the symptomatic relief of erectile dysfunction?

Of course, real bone of contention, if you will, is whether health insurance should cover Viagra for men whose impotence can't be explained by any other medical condition. "Erectile dysfunction" (ED) and it's low-key cousin "erectile difficulty" are Pfizer's buzzwords, they mean, roughly, "anyone who can't get it up as often as he wants." Armed with billions of dollars and a good acronym, Pfizer set out to convince the world that ED is a disease and therefore that insurance ought to cover Viagra.

Pfizer is exploiting the defective assumption that medical insurance should use conceptual analysis to allocate coverage: We're here to treat disease. So, is X really a disease? For real, now...Well, okay then, I guess we'd better make some room on the forumulary.

Allocating insurance coverage based on the alleged reality of a disease plays into Pfizer's hands. They supplied a ridiculously expansive definition of ED, and we accepted their terms. If we concede that ED is a disease, we "diagnose" a lot of men who aren't sick by any stretch of the imagination, e.g. the 25-year-olds who who pester their doctors for a little "insurance" of their own. But within Pfizer's frame, we can't deny that ED is a disease without giving insurers an excuse not go cover ED meds even the most severe cases.

The ED debate is just one of dozens of fruitless arguments about whether an alleged disease is real. We're all familiar with the ADHD wars, the Autism spectrum skirmishes, and the battle royal about whether severe PMS is really premenstrual dysphoric disorder. These arguments are usually pretty confused. Ultimately, these disputes come down to insurance coverage. If you've got a recognized disease, you've got a claim to health insurance.

There are difficult decisions to be made, but splitting hairs about the "reality" of disease is pointless. We don't even have a rigorous definition of "disease" to work with. Better to remain agnostic about whether certain controversial clinical entities are "real diseases" and focus instead on the costs and benefits of the available treatments.

The fact is that we have clinical solutions for symptoms like impotence and hyperactivity. The question we should be asking is whether it would be a good use of our finite resources to cover these treatments.

A public health insurance system doesn't need to draw sharp a priori distinctions between treating the diseases of individuals vs. conferring other benefits to society. We still have to ask whether it's effective, expedient, or fair to address a particular problem through the health care system. Creeping medicalization is bad, but we don't need an arbitrary standard of disease to combat it. We are only vulnerable if we also assume that every treatable condition must therefore be addressed by medical care for individuals. Even if something's a disease, it may be still more appropriate to address the problem through public health, economic policy, educational reform, or some other means.

Private insurance companies want to draw as many lines as the can. Sophistry is profitable if you can convince your customers not to demand birth control coverage because contraception doesn't treat any diseases. Public health insurance needn't obsess over this boundary. It's convenient and cost-effective to include birth control in a public health insurance program, so it's irrelevant whether this kind health care falls under a preconceived mission statement delineating the scope of medicine.

The same principle applies to Viagra. The drug deserves to be considered for formulary coverage because it's an effective treatment for a troublesome physical symptom. Whether Medicaid covers Viagra should depend entirely on how the costs and benefits of the drug compare to other agents competing for a finite budget.

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Comments

"Creeping medicalization is bad, but we don't need an arbitrary standard of disease to combat it. We are only vulnerable if we assume that everything that's a disease must therefore be addressed by medical care for individuals."

Lindsay's got it exactly backwards. What makes us vulnerable to inappropriate medicalization is the assumption that if medical knowledge and techniques _can_ address a problem, then that problem _should_ be classified as a disease or pathological condition. If Smith has always wanted to be a quadraplegic, and surgery is a cost-efective way to solve his problem, then a conscientious surgeon should not worry herself about whether "elective amputation" is consistent with the goals of medicine? (a "real world" example, by the way...) So much for professional and disciplinary integrity.

Oh, and the fact that the "definition" of concepts like 'health' and 'disease' is contested, and will inevitably be infected by vagueness most definitely does not mean that the resulting standard is "arbitrary." In fact, the "definition" of concepts like 'cost' and 'benefit' is similarly contested and vague at the margins.

You seem not to have accounted for the environmental impact, medical costs and economic contribution of all the people who wouldn't be born if not for Viagra. Anyway, I agree.

What I'm saying is that agnosticism about disease doesn't necessarily commit us to inappropriate medicalisation. Basically we're dealing with a kind of slippery slope argument. The worry is that there's no limit to the number of problems we could address as diseases, unless we have some sharp, principled definition of disease.

That's a legitimate concern. However, a strict definition of disease doesn't protect us from creeping medicalization. It certainly hasn't so far. Quite the opposite. The interested parties just start lobbying to have their particular problem classified as a disease. It's hard to refute them because the concept of "disease" is so vague.

Bob, I think we agree about a crucial point. We shouldn't assume that every problem that can be solved medically should be handled by the health care system. It's this faulty assumption that opens the door to inappropriate medicalization. (How do we know what's appropriate? Presumably by the bad consequences of the proposed solutions: expense, coercion, inefficiency, ineffectiveness, etc.)

Whether a problem is a disease or not shouldn't matter. What matters are the costs and benefits of the interventions we propose. For example, I don't care whether addiction is really a disease or not. I just want to know who's better at curbing addiction: the courts, the hospitals, or a collaboration between the two.

The disease criterion is unsatisfactory because it doesn't give us clear guidance for the difficult cases. Pfizer's marketing team is right or not. Maybe ED deserves the mantle of "disease" or "medical condition." The Pfizerites can point to a lot of uncontroversial precedents in which we care for other ill-effects of normal aging such as osteoarthritis and cataracts. Why not age-related impotence, too?

If you want to draw a line, you've got to make a value judgment. You've got to come right out and say "Fucking after 50 isn't worth insuring." You can't just say that we don't have to cover Viagra because it's "normal" for old people to be impotent. It's perfectly legitimate for a public insurer to say that Viagra shouldn't be a priority as long as there are lifesaving treatments we can't afford to cover, but the disease argument doesn't help their case.

I think that the problem of the word "disease" is exactly why doctors prefer the word "condition". Pregnancy, for instance, is not a disease, but it is a condition.

What if the drug industry develops a substance that will enlarge men's sexual apparatus? What if that industry develops a substance that will enhance the sexual attractiveness of the opposite sex for those who are bisexual? Would those qualify for insurance coverage too? Both would enhance sexual experiences, both would benefit marriages, both would improve the quality of life. Why don't we just accept that there is a very wide spectrum of sexual performance, abilities, and attractions? Why assume all of us are entitled to experience the "best" corner of that spectrum?

Spot on Lindsay...

"If you want to draw a line, you've got to make a value judgment. You've got to come right out and say "Fucking after 50 isn't worth insuring." You can't just say that we don't have to cover Viagra because it's "normal" for old people to be impotent. It's perfectly legitimate for a public insurer to say that Viagra shouldn't be a priority as long as there are lifesaving treatments we can't afford to cover, but the disease argument doesn't help their case."


Agreed! its hollow when you consider the impact of denying others life saving treatments no matter what you call it. This of course is applicable to public funded health care. If private insurer's want to offer a "protect your winky" package for and additional fee... knock yur socks off!

I think its also pragmatic to treat some "conditions of aging" like catraracts and Alzheimers because if left untreated these people lose their self sufficiency and unless you can justify euthanasia... you just can't let them die. ED doesn't meet that standard.

Right now many hospital have been closing their ER units because this is a primary access route for the uninsured and the 10.5 Billion in Medicaid cuts in Bush's current budget means no reimbursement... hence the ER shutdowns. Congress just authorized some reimbursement for hospitals last week but it is doubtful that it will cover the amount in the cuts.

That's why in the earlier thread I raised the issue of price regulations on pharmacuetical manufacturer's because many of them are working off of insane profit margins as in 6000% to 9000%.

We are hitting a point where people's lives are going to be dramtically shortened due to lack of treatment... the equation is becoming profit vs. life.

A bit off topic but I lived in San Francisco and while I was there the city approved sex changes for city employees... $175,000 for men to women and $250,000 for women to men. This was public funds that were being used.

San Francisco has an estimated 5000 homeless people and a very large precentage of them are children. I feel that our national moral compass has turned into a roullette wheel sometimes.

I think the question accentuates many of the problems with the US's non-health care system. The fact that you can't get insurance unless you're in a certain class (roughly) shows us why Viagra was developed in the first place. It's not meant to treat disease or help the common man (and woman). It's sole purpose is to help old closeted - and powerful - queens get it up at the latest Bohemian Grove meeting. It - and drugs like it - will continue to be produced by big pharma until there's a huge pardigm shift in this country, and hence the world, and people start demanding medical insurance for all.

Flint - I'd say being a man in a woman's body, or vice versa is a pretty serious disease.

Having a principled definition of disease can't offer any protection from creeping medicalization unless it's actually _used_ by the medical profession and the public to delimit the practice of medicine. And even then, the protection it provides will be imperfect and incomplete -- there will always be borderline cases. But turning to the example of viagra, nobody has made a plausible case for viewing the inability of many men to control ejeaculation, or to maintain an erection for any length of time after ejaculating, as fitting the medical criteria for erectile dysfunction (duration is what so-called "recreational" users [or their deprived partners] usually want). Loss of erectile function that often accompanies aging, on the other hand, is still loss of function, so it's not medically normal even if it is statistically normal. (truth in advertising: I utterly reject the theory that equates health [i.e., medical normality] with _statistically_ normal functional capacity.)

And remember, saying that an intervention is not part of medicine qua medicine does not imply that it shouldn't be available, or even that physicians should be prohibited from providing it. It just means that the justification for providing it is not a medical justification. Taking it a step further, there might even be a medical justification for having a physician provide the intervention -- for example, if its safe and effective provision requires the kinds of skills which normally only physicians have (that's why physicians started providing abortions, for example). But even in such cases, I think it is important to be clear that the intervention itself is justified in non-medical terms, by appeal to non-medical but equally legitimate values and goals.

Perhaps the reason I am so (hyper?)sensitive to the question of whether an intervention is medically justified is because I view disciplinary integrity as an important constraint on the extraordinary powers and privileges accorded to medical professionals. Having a reasonably clear understanding of the domain and goals of medicine helps us to delimit the scope of associated professional rights and responsibilities.(For example, I favor the decriminalization of assisted suicide, but I'm opposed to the legalization of physician assisted suicide because I believe physicians are no more qualified than friends or family to provide such assistance.)

I hope that clarifies (somewhat) where I'm coming from.

Mudkitty...

"Flint - I'd say being a man in a woman's body, or vice versa is a pretty serious disease."

I make no statement of its seriousness or non-seriousness other than the value judgment that if it comes to taking a single mother with children out of a derelict car, where she has to hide form family services because they will take her children away from her and putting her and the kids into a home where they are fed, clothed, and educated... with medical attention or... using my tax dollars to perform a sex change for someone... My money is on the homeless mother and the kids!

Bob...

"And remember, saying that an intervention is not part of medicine qua medicine does not imply that it shouldn't be available, or even that physicians should be prohibited from providing it."

No one is saying that physicians can't provide any thing... the discussion is framed by the funding issue... Medicaid!

Given the choice between using public Medicaid funds for ED or a poor kids chemotherapy for hodgkins lymphoma... Mr. Wiggley loses again.

I hope that clarifies (somewhat) where I'm coming from.

Definitely. I think we're agreeing on a lot of substantive points. Loosening the disease model also constrains the power of the medical profession. I'm a huge admirer of medicine, but I'm also skeptical about the disproportionate power of physicians within medicine and in society at large.

Practically, society defers to physicians' opinions about what is a disease and what isn't. I'm not arguing that the medical community's opinion isn't important, not by any means. Doctors have a unique perspective because they tend to have more biomedical training and at least as much practical experience as any other health care professional. On the other hand, I don't believe that doctors have a monopoly on defining disease.

For example, non-clinical scientists aren't usually in the business of issuing position statements on whether ADHD is an empirically identifiable disease state. On the other hand, their expertise should probably carry as much if not more weight than most of the medical wheeler dealers who write position statements in journals.

We in pharma advertising proceed as if doctors were the last word. They're the people we spend the most money to convince, not just with ads, but with CME, sponsored articles, ghosted editorials, reprints, logo pens, monogrammed stress balls and the whole bit. We don't pull out nearly as many stops for insurance company executives, even though it's a smaller audience and the payoffs are much bigger per person influenced. When we pitch to the consumer we just teach them to pester their doctors more effectively.

I think our approach is informed by society's assumptions about doctors. We elevate doctors as if they were shamen. Our culture invests them with an almost mystical authority that we confer more for our own peace of mind than for any moral or intellectual reason. Doctors are very qualified technicians with a lot responsibility and (we hope, on average) a lot of accumulated wisdom. But even so, the consensus of the medical profession should not be the last word on what's a disease and what isn't. Or if we decide to use "disease" to mean "whatever the medical community deems a disease," we shouldn't go on to assume that curing disease is what society should hire doctors to do. (IMO, medicine is what society licenses doctors to do, not what medical associations deem medicine to be.)

I'd much rather let the whole polity hash out the value judgments, instead of having everyone defer to professional opinion about what's a disease.

Vaughn raises a legitimate point. I'm not saying that everyone has a right to be as well off as medical science can make them. I'm just saying that the decision about who gets what benefits should be hashed out through public consultation and direct or indirect democracy. I say this even though I know that most of my value are on the wrong side of public opinion. I can't prove that sexual health for millions is worth more than prolonging the lives for a small minority. You could buy a lot of Viagra for the price of certain quasi-experimental cancer drugs. I'd rather spend the money on prolonging the sex lives for thousands of men for several years than have it go to a few doses of some pancreatic cancer drug which, at best, extends the miserable lives of its recipients for six weeks.

(Having worked to promote ED drugs and certain sketchy experimental cancer drugs, I'm familiar with the strengths and weakness of the specific products I've worked on. I'm not making any judgments about large classes of drugs. It's entirely possible that there are pancreatic cancer drugs that blow Viagra out of the water on a cost/benefit basis, I just don't know of any. Just for the record, I'm not being paid by either of those products now. I'm a free agent, so I have no vested interest in any of these products, except perhaps in keeping my mouth shut, but I don't really care enough to do so.)

Bob... You posted...

"Having a principled definition of disease can't offer any protection from creeping medicalization unless it's actually _used_ by the medical profession and the public to delimit the practice of medicine. And even then, the protection it provides will be imperfect and incomplete"


You raise an interesting point here and that is medical ethics and practices of physicians. A few years ago Congress fined one of the Pharmaceutical manufacturers $500K because they were paying $100 per presription written to the physicians prescribing their drugs.

This was an attempt to create a vertical marketing and distribution network where the physicians were in essence... distributors of their products.

A few months ago the National Institute of Health was rocked when it was discovered that many of their researchers were being funded by the Pharmacuetical manufacturers and were told not to reveal the source of their funding. Congress enacted legislation prohibiting the researchers from holding stock in those companies because of the bias it introduced into their findings.

More recently when I was researching some medications on the web, the search engine found a backdoor past a firewall and I found myself in a restricted area (inadvertently) where a pharamceutical manufacturer was offering special stock options to physicians based on specific medications of theirs.

So my question is what role does physician ownership of stock in the manufacturers has in the "creeping medicalization" and do you think that their should be prohibitions to that on ethical grounds?

Lindsay...

"I'd rather spend the money on prolonging the sex lives for thousands of men for several years than have it go to a few doses of some pancreatic cancer drug which, at best, extends the miserable lives of its recipients for six weeks."

But what if the kid lives. Would you really choose a thousand erections over one kids life?

But what if the kid lives. Would you really choose a thousand erections over one kids life?

No, not even close. That's why Viagra is a pretty low priority, all things considered. If I had to choose between one course of lifesaving chemotherapy for one kid with leukemia vs. 10 extra years of sex for 20,000 couples, I'd pick the chemo every time. On the other hand, there are a lot of medical treatments that are covered just because they do something for a clear-cut disease, not because they actually confer much value overall. There are so many worthless treatments out there. Two nights ago, I heard that certain cardiac defibrillators cost one million dollars per year of life saved. I haven't verified that figure myself, so I can't confirm that it's accurate. However, if it's accurate, I'd rather budget a million bucks a pop to the Viagra fund.

Assuming an otherwise average life expectancy, would you give up intercourse for the last 25 years of your life in exchange for 1 extra year as an invalid? (Assume 25 years is at least 1/4 of your life, with or without the extra year.)

I wouldn't.

Obviously, I'm not entitled to impose that choice on everyone else. But I will plead the case enthusiastically. For all I know, I'm totally misguided. But it seems like there's a plausible case for Viagra over some relatively unsuccessful but expensive medical treatments covered by Medicare. If we're already willing to cover some symptomatic treatments that don't save lives or prevent major disability, I think we should be open to proposals for covering prescriptions that dramatically improve people's quality of life at relatively low risk.

Lindsay -
I certainly wouldn't grant doctors a monopoly on defining 'disease.' Giving them the last word on what's a disease and what isn't would be inconsistent with my appeal to this notion to delimit the scope of their professional practice. Indeed, I think the task of defining 'disease' requires an admixture of empirical knowledge about organisms and the skills associated with philosophical analysis. And the empirical knowledge about organisms that I think is most relevant to defining 'disease' is more likely to be found among evolutionary scientists than in a medical school. Knowing a lot about the wide variety of ways that concept is instantiated is where specifically "medical" knowledge comes to the fore.

I think our deepest difference concerns how we view the place of medicine in the broader society. You see medicine as "what society licenses doctors to do," and so, are most concerned with securing the most favorable ratio of social benefits to costs. No particular _sort_ of social benefit is privileged. What matters is whether doctors' knowledge and skills can contribute to the realization of the benefits.

I, on the other hand, view medicine as a traditional professional discipline with a long history that predates any thought of licensure by society. (Some people view the story of how medicine became a "licensed" profession a very dark chapter in the history of the profession.) As a professional discipline, medicine has traditionally identified disease (understood as the disturbance or loss of natural functional capacity) as its domain of inquiry and activity, and health as its goal. As traditional professionals, physicians accept fiduciary duties to their patients, as well as the duty to maintain and promote the integrity of their discipline. Call me old fashioned, but I think there is something worth preserving in this tradition. But I'll admit that it might be too late -- maybe medicine has been corrupted to the point where the tradition of professionalism can't be salvaged.

Flint -
I'm very distressed by the influence of pharmaceutical companies (as well as medical device manufacturers) on the practice of medicine. Much of their marketing effort is a blatant attempt to bias the judgment of physicians. And though physicians regularly protest that they would never allow their decisions to be influenced by non-medical considerations, it's been demonstrated over and over that something as "insignificant" as a free pen does produce measurable effects on prescribing practices. So, do I think docs with financial ties to medical manufacturers is a problem? You bet! If physicians want to exercise their right to own such stock, I think it has to be done through a mechanism like a blind trust, so they won't know what specific companies they have a personal stake in.

Bob...

At first glance your suggestion about the blind trust seems reasonable, but on further consideration I think it would yield the same result on a blanket basis.

My personal experience is with elder care and the docs dole out prescription drugs like they were candy to the elderly. It is not uncommon to find patients taking 10 to 15 medications, frequently for nothing more than to treat side effects of some of the earlier medications that they prescribed.

I'm caring for my parents now and was told that my dad was hospice care for CHF and my mother was crippled by a statin drug which produced motor neuron damage. I selectively looked at each drug and where I could eliminate it by the use of vitamins and supplements, coupled with diet and exercise (progressive resistance training), have gotten them off this pharamceutical cornicopia that was being prescribed for them.

The doc and the visitng nurse have both told me that my dad is now not hospice care and that he would have died had it not been for the program that I implemented. My mother is regaining some of the use of her legs and the physicians seem amazed at the improvement in cognitive functions as well. All of them have asked me about the supplement regimine which is a story in itself and germaine to our discussion.

In this country vitamins and supplements can not be patented and the Pharmacuetical industry doesn't support any good research as a result. In Europe, however, that is not the case and there is a ton of good research done. Most of the supplements are naturally occuring substances in the body and don't have the side effects of the presription drugs. The cost factors are minimal by comparison to the prescription drugs, but physicians are prohibited by law from prescribing supplements for medical conditions. The pharmacuetical lobby has been very effective in this matter.

Costs have been readily discussed in this thread as a limiting factor to the number of patients that can receive treatment from public supported programs like Medicare and Medicaid. Lindsay correctly pointed out the million dollar defibrilator and my contention is that presription drugs and medical devices should not be priced with outrageous profit margins built in to them.

"Free market" concepts don't work because the ability to pay is not a factor in determining pricing because of the government programs. It could be argued that if you end those programs the pharmaceutical and medical device industry would lower their costs accordingly when they saw that the gravey train had ended... but in doing so you would have an health care crisis of unimaginable size that would dwarf our current one.

Additionally, when Bush advocated Medicare cuts the docs went nuts... medicare billing for all its faults is a real revenue generator for them. They can bill at extraordinary rates for medicare reimbursed consults and the like. In fairness to the docs... these days they have a tough time because the ones making the big bucks are the insurance companies and the pharmaceutical manufacturers.

Mind you... I'm not anti-prescription drug at all. Many are absolutely wonderful and life saving substances. It is how they are used and priced, as well as their impact on public health care programs are what I have a problem with.

Getting back to your Viagra example. If you understand the aging process and the metabolic cliff that the body falls off of after the age of forty... you can by instituting life style changes in diet and exercise, as well as the use of vitamins and supplements, counter and manage a significant number of the effects of aging. This includes disorders such as ED, although it won't work in all cases but it will for a substantial number of them.

I know that this was supposed to be a philosophical discussion on disease definitions, but for me it raised practical issues that I have to deal with daily. Sorry if it was a waste of bandwidth.

Bob:

Having worked both in a hospital setting and in the pharma industry, I can tell you the pens & stress balls have no impact on prescribing - neither do the lunches provided by pharma for monthly critical care conference/grand rounds. I'm sure there are many docs in private practice who are swayed in prescribing patterns over the bigger things the sales reps could get away with (theoretically, they're not supposed to get away with them now), but I don't think the other stuff has much impact. What does have impact to some docs is a patient's insistence on a drug (which was bad before DTC and is exponentially worse now) and formularies (both hospital and insurance formulary). Do I give a shit if my doc prescribes one ARB over another (if I'm the average HTN patient needing an ARB) because the BMS rep took a him to a nicer dinner than the AZ rep did? All things being equal, I don't. However, I do want to be sure that if things aren't equal and there's a reason to prescribe one over another for me (believe it or not, there are some seemingly minor differences between "me too" drugs that do make a difference between patients), I want good clinical judgment used. Where I have a bigger concern is the doc that will prescribe the the "newer better drug" for as a first line when older, less expensive drugs may do the trick. This problem is endemic in our culture for two reasons: #1 patients demand what they perceive as "better" (new = better to the average American) due both to DTC as well as what the hear from their friends; and #2 docs are afraid of unwarranted malpractice suits which won't go to court but do increase premiums and/or incur settlements even when there is no wrong-doing.

Americans are woefully uneducated about how their bodies work and tend to believe in any new miracle treatment. DTC takes great advantage of that and really has to stop (the fault for DTC lies with the FDA not pharma - pharma was shocked when the FDA started to allow it and you can't blame any industry from taking advantage of a very stupid government decision that can increase a company's bottom line). Media is also a huge problem that we tend to ignore when it comes to health & drug issues. Mainstream media especially thrives on ratings so they'll report on an abstract or small study as a miracle, they give mixed messages and patients/potential patients hear what they want to hear (good or bad). I personally think mainstream media should also stop reporting on clinical trial results and approvals. Go back to the old detailing requirements (to physicians) and make them actually read the literature so they can make CLINICAL decisions based on their patient's signs, symptoms, history and concomitant medications instead of competing with what's being publicized and trying to fight to get things that aren't applicable out of their patient's minds.

Lindsay, it's always a pleasure to watch you make good utilitarian sense.

Flint, we're the richest country in the world. If we can afford the Bush taxcut for the rich, we can afford to insure both the homeless single mother (who obviously shouldn't be homeless in the first place) and the suicidal person who needs gender reasignment. It shouldn't be an either/or. And it isn't in Scandinavian countries.

Flint -
Truth be told, I am very, very critical of how medicine is practiced in the US. The interplay between manufacturers, health care deliverers and consumers, all of whom behave irresponsibly, has created a medical dystopia.

Physicians here tend to practice a very aggressive form of medicine that is most appropriate for medical crises. They show little to no understanding, let alone respect, for vis medica naturae (the natural ability of the organism to heal itself), and consequently employ very powerful and dangerous interventions to treat even self-limiting health problems. This results in many medications being prescribed for the sole purpose of controlling side effects from other meds.

Most medical manufacturers are in it strictly for the money. They stoke consumer demands for the very latest, most expensive meds with little or no net benefit when compared to last year's (expired patent) model. And they employ very smart people in their marketing departments who know how to push the buttons of MDs. When they have a drug on the shelf that isn't effective against any known disease, they manufacture new diseases where the drug will be "effective." They lie (or at least, don't tell what they know) about the risks associated with their products. And despite all this, they operate with profit margins that loan sharks can only dream about.

Consumers are willing participants in the charade, claiming "entitlement" to whatever the latest medical fad might be -- the more expensive, the better. The one thing consumers will not tolerate is leaving their doctor's office without a prescription. This is just a perverse form of keeping up with the Joneses.

And what do we get for committing about a sixth of our GDP to this game? Well, if you look to the WHO statistics on health status around the world, we are _marginally_ ahead of countries that spend very little on medical care, but do manage to provide decent public health services. In other words, if you have a reasonably clean environment, good nutrition, and then provide decent prenatal and postnatal care (up to the age of about 5 or 6), there's not a lot more benefit (on the scale of populations) provided by US style "healthcare."

Bob... well said!

I couldn't agree more with everything that people have put on this thread.

Ol Crancky...

Advertising and Medicine:

too true... the advetising for drugs should be curtailed. Congress did restrict ads targeting children, but when they it comes to drugs it is assumed that adults know better... but as you point out... they know very little about their bodies and not enough about medications.

In fact docs don't know enough either. I almost lost my dad in December because of a drug interaction between an antibiotic, Levequin and his Insulin. When the doc prescribed it I caught the interaction warning in the PDR and called a CVS pharmacist to discuss it. I got some little girl who said not to worry it wasn't serious.

After a week my dad had a sudden sugar low of 25, began hemoraging from the birth marks on his skin, went into severe Congestive Heart failure, and was anemic on admit and later he lost over a pint of blood in twenty four hours.

A week later when I got him home a Medco pharmacist called me to alert me of an interaction warning about the Levequin and Insulin. Unlike the CVS pharamcist he said that it was serious and and statistically very significant. The interactions he stated were severe hypoglycemic states, anemia, and breakdown in blood clotting factors.

I'm more literate about this stuff than the average person... but I think we need health care advocates in the loop because the public is uniformed and frequently we find so are the docs and the occasional pharmacist.

FDA... the best Supervisors money can buy:

You're also right here the Vioxx scandal is a good case in point. Vioxx got recertified because of the 32 physician reviewers... ten had lobbyist ties with Big Pharma. They voted as a block and had they not been there, as observers have noted, Vioxx wouldn't be back on the market.


Lindsay and Bob...

You both make perfect sense especially about cost/benefit analysis. Bob this part is especially telling in your post:

"
"And what do we get for committing about a sixth of our GDP to this game? Well, if you look to the WHO statistics on health status around the world, we are _marginally_ ahead of countries that spend very little on medical care, but do manage to provide decent public health services. In other words, if you have a reasonably clean environment, good nutrition, and then provide decent prenatal and postnatal care (up to the age of about 5 or 6), there's not a lot more benefit (on the scale of populations) provided by US style "healthcare."

Americans are getting ripped off by an inefficient and corrupted health care system. Further, its not just about the money... it really limits the ability to save lives. The dollars spent on Medicaid patients could go a whole lot further, do a whole lot more good, but as it is now those ill spent bucks cost lives!!!


Mudkitty...

The tax cuts are an obscenity... give 102 Billion dollars in tax cuts to the top .05% of the population... throw in 290 Billion in Estate tax cuts and while they are doing this...

10.5 Billion in Medicaid cuts, cut all funding for Traumatic brain injuries, cut veterans health care benefits, cut funding for programs to assist handicapped to find jobs and the list goes on... insanity!

We used to be the richest nation in the world, but now we are the biggest debtor nation in the history of the world facing a 6.6 trillion dollar debt. The "borrow and spend" policies of this administration are now threatening the underpinnings of the global economy. The "lenders" have quietly decided that we have dug ourselves in too deep and are divesting US holdings. The sale of US treasuries is down by 47% and the lenders are transfering their assets into Euros and Yen as quickly as they can.

The Housing industry that has kept our economy chugging is now the latest bubble that economist are waiting to burst and Greenspan and others are predicting possible bank failures, stock market "readjustments" (ie. like the crash of the late 80s).

Ya can't have record trade deficits, record budget deficits, while borrowing record amounts of foreign capital. Some day ya gotta pay off the national credit card! What do you think that the heath care system will look like then?

Part of the problem is the line between testable diseases and self-reported diseases, i.e. diabetes, proved by blood sugar tests, vs. ED, you tell the doc you're having trouble getting it up. Now that's not to say that men with pickle problems are lying, just that the definition of "trouble getting it up" is highly vague. (Although it must be noted that male patients with erectile dysfunction (gives me a giggle just to type it) are being taken seriously as having a medical problem, whereas women with sexual problems are often not.)

This is a problem of American medicine - the patient is assumed to be correct when they say they are sick. To be accurately describing their symptoms, following doctor's recommendations and their meds schedule. This is often not the case. I have read that 20% of American medical costs are for hypochondriac patients. Our poor science education is costing us in many, many ways.

Addendum: My solution to pharma advertising is to not allow it until the medicine has been on the market for two years, and after extensive post-introduction testing. Also, hiding any adverse studies would be grounds for losing advertising priviledges.

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