Tag Archives: healthcare costs

The Emotional Costs of Inequality

The Globe and Mail reviewed “The Spirit Level: Why More Equal Societies Almost Always Do Better,” by Richard Wilkinson and Kate Pickett, Allen Lane.

The reviewers write that:
“This is the authors’ “big idea”: People’s health depends on the quality of their social relationships, and the most important determinant of the quality of social relationships is the level of inequality.”

The book argues that as inequality increases so, too, does infant mortality, illiteracy, obesity, mental illness, incarceration, homicide, drug use and teenage pregnancy. Life expectancy decreases where inequality rises.

It’s well worth the time to read the article.

Treatments for Adolescent Depression

A new study takes a look at the effectiveness of various treatments for teenage depression. Unfortunately, I cannot give you a link to the article as it is on a subscription service. But here’s the citation for the article:
Treatment of adolescent depression: what we have come to know
Benedetto Vitiello, M.D
Depression and Anxiety
Volume 26, Issue 5, 2009.
Pages: 393-395

Three months after starting treatment, fluoxetine (Prozac) brought about a higher response rate than cognitive behavioral therapy (CBT). A response rate is a reduction in some but not all of the symptoms. Whereas the elimination of all symptoms of the depression is called a remission. 61% of the patients studied showed improvement from fluoxetine alone versus 43% of the patients who had CBT by itself. So fluoxetine is clearly better at bringing more adolescents into the response range than CBT or placebo. And fluoxetine is more cost-effective (cheaper than) psychotherapy at the three month point.

But a combination of fluoxetine and CBT was most effective at achieving remission of symptoms at three months (37%). Furthermore, “the combination (of medication and psychotherapy) was also superior to (medication alone or CBT alone) at improving functioning, overall health, and quality of life at the 3-month assessment.”

“(A)t the 9-month assessment, fluoxetine, CBT, and their combination did not differ in response rate (81, 81, and 86%, respectively) or remission rate (55, 64, and 60%, respectively). Thus, it appears that the value of antidepressant medication consists in speeding up the process of improvement and recovery, whereas psychotherapy gradually catches up and, given enough time, it does not seem to make too much difference which treatment modality was used.”

There was “a greater incidence of suicidal events (a category including suicide attempts and suicidal ideation) was found in the fluoxetine condition (14.7%) than on CBT (6.3%).” But there appears to be “a protective role of CBT when used in conjunction with medication” because “the suicidality rate in the combination group” dropped down significantly to 8.4%. And this level of suicidality was not statistically higher than when patients were treated with CBT alone.

In conclusion, the study found that “Although fluoxetine was clearly the most cost-effective treatment modality during the first 3 months…, combined treatment was more cost effective than fluoxetine when the entire 9-month outcomes were taken into account, primarily due to the higher number of suicidality-related hospitalizations in the fluoxetine group.”

More Lucre in Healthcare

The Boston Globe is reporting today that Dr. Joseph Biederman is “asking a judge to seal his testimony and accompanying documents in a huge multistate lawsuit, saying they “could be immensely damaging to him, both personally and professionally.”

Dr. Biederman is professor of psychiatry at Harvard Medical School and Director of Massachusetts General Hospital’s Pediatric Psychopharmacology Unit.

He is, according to the New York Times, “the world’s most prominent advocate of diagnosing bipolar disorder in even the youngest children and of using antipsychotic medicines to treat the disease, but much of his work has been underwritten by drug makers for whom he privately consults.”

The Times reports that he “earned at least $1.6 million in consulting fees from drug makers from 2000 to 2007 but failed to report all but about $200,000 of this income to university officials.”

The documents that he would like sealed relate to his research on psychiatric medications, chiefly those manufactured by Johnson & Johnson. One document, again according to the Times, is a power point slide that describes “a proposed trial in preschool children of risperidone, an antipsychotic drug made by the drug company. The trial, the slide stated, ‘will support the safety and effectiveness of risperidone in this age group.'”

You will note that the study will support as opposed to investigate “the safety and effectiveness of risperidone…”

As the Times phrases it, he “told the drug giant Johnson & Johnson that planned studies of its medicines in children would yield results benefiting the company.”

The reader will see that these studies are “planned” not actually completed. Yet, it is already known that the study will “yield results benefiting the company.”

Last November, the Times reported that “Dr. Biederman pushed the company [Johnson & Johnson] to finance a research center at Massachusetts General Hospital, in Boston, with a goal to “move forward the commercial goals of J.& J.”

The Boston Globe reports that “court documents say the company gave at least $700,000 to the center.”

In the biographical excerpt of Dr. Biederman on Mass General’s website, it is noted that “as of March 2007, Dr. Biederman has been ranked as the second highest producer of high-impact papers in psychiatry overall throughout the world with 235 papers cited a total of 7048 times over the past 10 years…”

That’s a lot of influence.

The Times reports that “Dr. Biederman’s work helped to fuel a fortyfold increase from 1994 to 2003 in the diagnosis of pediatric bipolar disorder and a rapid rise in the use of powerful, risky and expensive antipsychotic medicines in children.”

The same Times article finds that “documents also show that the company [not Dr. Biederman] prepared a draft summary of a study that Dr. Biederman, of Harvard, was said to have written.”

Back in February, 2000, a study, “Trends in the Prescribing of Psychotropic Medications to Preschoolers,” was published by the Journal of the American Medical Association. One of its conclusions was that “psychotropic medications prescribed for preschoolers increased dramatically between 1991 and 1995.” The authors went on to say that “unresolved questions involve the long-term safety of psychotropic medications, particularly in light of earlier ages of initiation and longer durations of treatment.”

At the time, a post on school.familyeducation.com related that “Dr. Joseph Biederman, chief of pediatric psychopharmacology at Massachusetts General Hospital in Boston, angrily dismisses the study and accuses its authors of having ‘an ideological bent.'”

I cannot help but wonder if, in light of the above information, if it wasn’t Johnson & Johnson’s money that gave an ‘ideological bent’ to Dr. Biederman instead.

And is it any wonder that he thinks the release of the documents could be “immensely damaging to him, both personally and professionally.”

Finally, does anyone else see parallels to the current greed-induced problems in the financial sector?

Notes on Lucre and Healthcare

Two recent articles show the influence of healthcare related industries on the provision of treatment.

The first is obviously scandalous. Scientific American reports on Dr. Scott Reuben. He evidently traded his professional integrity for rewards from the big pharmaceutical companies. As Scientific American puts it: “Anesthesiologist Faked Data in 21 Studies.” The result was “the sale of billions of dollars worth of the potentially dangerous drugs known as COX2 inhibitors, Pfizer’s Celebrex (celecoxib) and Merck’s Vioxx (rofecoxib), for applications whose therapeutic benefits are now in question.”

There are many unanswered questions in this story. One is how much Dr. Reuben was paid by the pharmaceutical companies. “Pfizer spokesperson Sally Beatty…was unable to provide information on the dollar amount of the grants.” And Baystate, the hospital where Reuben worked and carried out the studies, says that it “has no records of those payments and says that the research funds could have been paid directly to Reuben. Such an arrangement would be ‘highly unusual…'”

Another question is why it took 12 years for the hospital to perform a “‘routine audit’ [that] revealed Reuben’s widespread data fabrication?”

Still another question is the role of Pfizer in reviewing and vetting the studies. The same question holds for the peer-reviewed journals in which Reuben’s articles were published.

Reflect, if you will, on the “billions of dollars” that was needlessly, erroneously spent on those medications in the past 12 years.

This episode of malfeasance comes on the heels of the Dr. Fred Goodwin, formerly of The Infinite Mind which aired on NPR. (For those interested, you can read a rather rambling disclaimer from Alicia C. Shepard, the NPR Ombudsman.) Slate.com broke the story after Goodwin and three other physicians touted the benefits of Prozac and minimized the risk of some of the potential side-effects, including suicide, during an episode.

However, as Slate points out, “All four of the experts on the show, including Goodwin, have financial ties to the makers of antidepressants. Also unmentioned were the “unrestricted grants” that The Infinite Mind has received from drug makers, including Eli Lilly, the manufacturer of the antidepressant Prozac.” The incident caused something of a tempest and Goodwin is no longer host of The Infinite Mind.

Clearly, you want your doctor to prescribe only medications that are helpful and where you are clearly advised of the actual risks, benefits and side-effects. That cannot happen when money and quests for fame taint the process.

On another front, the scandal is less obvious but nonetheless still present. The New York Times published a story on March 15 about the costs of the health insurance programs in Massachusetts. They note that the costs of healthcare in Massachusetts are rising faster than the national average. Moreover, the healthcare program is “threatened first by rapid early enrollment in its new subsidized insurance program and now by a withering economy…”

A commission on payment reform was recently established. The Times reports that “The commission is looking at various options, but all would do away with the fee-for-service system, which provides perverse incentives by paying physicians and hospitals for each patient visit. The changes under consideration include reimbursing for episodes of care rather than individual visits and bundling payments to groups of providers who would together take responsibility for a patient’s health.

Blue Cross and Blue Shield of Massachusetts, the state’s largest insurer, recently devised an innovative model that pays doctors a flat fee per patient, with adjustments for age, gender and health status, and then adds bonus payments for high standards of care.”

Take a moment and read those last two paragraphs a second time, if you will.

The “solution” proposed is a capitation system that offers financial rewards for the briefest episode of care. Providers would not be reimbursed or would be otherwise penalized when dealing with patients who have treatment resistant or refractory conditions or disorders which require more treatment than the insurance companies’ algorithms suggest.

I am all for quick, efficient treatment. But I have seen the effects of capitation first hand. They are not good. And contrary to the Times opinion, it is not innovative. Nor do I consider it “perverse,” as the Times seems to think, that a provider should be paid for services rendered.

Do you really want your provider to be thinking in the back of his/her mind how they are going to explain to an administrator why they are scheduling another appointment for you, a statistical “outlier,” when the hospital, agency or practice is not going to be paid for that session?

Or do you want your practitioner to be first and foremost considering what is in your best interest?

Let’s recall Deep Throat’s advice back in the days of Nixon, “Follow the money.”

In none of the recent debates on healthcare have I heard discussions of limiting the salaries of health insurance executives, pharmaceutical employees or hospital administrators.

Yet I do relentlessly hear that doctors and direct healthcare providers make too much money. So let’s take a closer look.

First, as a point of reference, what is the total compensation of one of the most consistently profitable CEO’s in the country?  According to salary.com, Warren Buffet, the Oracle of Omaha, received $175,000 in 2008.

With that in mind, consider that, according to the Providence Journal, Lifespan President George Vecchione “made $2.9 million in 2006.”

Then there is Stephen J. Hemsley, CEO of United Healthgroup, who, according to salary.com received a total compensation in 2008 of $13,164,529.

Looking at the pharmaceutical industry, salary.com informs us that Henry A. McKinnell of Pfizer received a total compensation of $19,418,446.

Now, compare that to the average salary of a psychiatrist, according to allied-physicians.com,: $169,000.

The average for social workers in 2006, according to innovatorsguide.org,: $37,480.

A registered nurse with a bachelor’s degree working in a large agency or hospital in Rhode Island, according to salary.com, earns an average of $59,900 yearly.

And for a certified nurse’s assistant in the Northeast, salary.com reveals the yearly income of $25,700.

I leave it to the reader to determine where there is room for salary reviews and fiscal oversight and legislative mandates to help cut back on the high costs of healthcare while maintaining the quality of care.