Category Archives: Health Policy

The drug industry’s uncool move

Two antibiotics –  Pyrimethamine (branded Daraprim) and Cycloserine (branded Seromycin) were in the news recently for the same reason. Both of them were subjected to price increases of astronomical proportions, in a feat of price gouging that seems to be the new modus operandi of drug companies.

Turing Pharmaceuticals recently acquired Daraprim from Impax pharmaceuticals. It then promptly increased the drug price from $13.50 to $750, an increase of about 5000%. Daraprim is an important drug that is used to treat Toxoplaxmosis, a parasitic disease of the brain that affects people with weakened immune systems. Around 3 billion people in the world are said to be carriers of the protozoan.

In a similar move, Rodelis Therapeutics acquired Cycloserine from the Chao Center  (a Purdue Research Foundation affiliate) and increased to increase the price of the drug from about $500 dollars to an astronomical $10,800 for 30 pills. Rodelis later backtracked after protests by Chao, and now has returned the drug back to them.

Cycloserine is used as a second line therapy for the treatment of multidrug resistant TB. At the new prices, the price of cyclosercine alone required to treat  MDR-TB for the 24 month course would have been an astronomical 500,000 dollars. Manufacturers in the developing world make generic Cycloserine for as little as $20 per 30 pills. Chao says it will increase the price of the drug to about $1,050 dollars. The manufacture of Cycloserine has been a loss making operation for Chao.

And these are not stand alone incidents. The price of Doxycyclne has been up to $1849 dollars per bottle from about $20 dollars in 2013. Some cardiovascular drugs, that have been around for a long time, have seen price increases as well.

The script for the story seems eerily prototypical. Take a relatively rare or neglected disease drug that is  off patent, has no local manufacturing competition, and market it as a specialty drug with a hefty price tag. Althuough these drugs may be manufactured for much cheaper outside of the OECD countries, they can’t really be imported to the rich world because these manufacturers have not been approved by the regulatory bodies. Chao for example is the only FDA approved manufacturer of Cycloserine in the world. Furthermore, some of these drugs could find indications that are currently not in use for. D-Cycloserine has a putative role in increasing neuroplasticity, thereby potentially lending itself to use in schizophrenia and tinnitus treatment. This would mean a huge increase in the market for a drug that has already been available for more than 50 years.

The general public has always been a little ambivalent about its opinion of the  pharmaceutical industry. On the one hand drug companies bring valuable skill and expertise to the drug discovery, manufacture and marketing process. On the other, they seem to leverage thier valuable role in healthcare by running, what appears to many as  an extractive inudustry  bent on maximizing profits at the cost of everyone else. Incidents like these will only work to reinforce the latter notion.

The scare of the Trans-Pacific Partnership Agreement

The Trans-Pacific Partnership (TPP) agreement is the current US administration’s signature multinational trade policy initiative in the last several years. The policy  is seen as a means to facilitate trade around 12 pacific rim countries currently sans, importantly China.  Some see this as President Obama’s attempt to give some economic muscle to his Asia pivot policy. However from a public health point of view, the TPP is turning out to be a potentially scary monster  –  what some people are calling the restrictive WTO IP regime on steroids.

Terms of negotiations for the TPP are highly secretive, as negotiators feel open negotiations could undermine their bargaining chips. However, some drafts of the negotiations have been leaked by Wikileaks. If the provisions outlined on the leaked documents were to pass, the TPP could seriously jeopardize public health, especially access to medicines, here in the US, but also across the rest of the world.

The TPP attempts to further tighten current intellectual property laws, heavily in favor of the originator companies. First, it has proposed additional impositions on data exclusivity, making them unavailable for generics manufacturers to use these data before launching their own generic drugs. Second, it makes it easier for holders of originator molecule patents to file for process patents and renew their patents, in a process that is often derisively called evergreening. Third and more dangerously, it extensively expands the the purview of what’s called the Investor State Dispute Settlement (ISDS) tribunals, an extra-judicial mechanism mostly comprised of corporate lawyers that will enable corporations to bring on cases against states for curtailing or perceived curtailing of their profits.

This could seriously impede the government’s ability to advance a public health agenda and secure means to make drugs and health services more affordable. Under this provision, even arrangements like drug formularies, preferred drug lists or generic substitution may be considered anti-trade and be subjected to the ISDS tribunal, thereby forcing governments to pay hundreds of millions to corporations while attempting to safeguard public health. Drug companies like Eli Lily, and tobacco manufacturer Philip Morris have used this mechanism under provisions of various trade agreements to bring on cases worth hundreds of millions of dollars when governments tried to impose policies to ensure public health.

The greatest adverse impact however, could be on medicine access in some of the low and middle income countries like Vietnam, that are directly affected by the TPP. The TPP attempts to impose US standards of IP regulation on  signatories. This will have a direct effect of raising drug prices across much of the world, but more so in less developed countries. Furthermore because how sweeping the TPP proposes to be, its impact will be far reaching in that it will be a template for future such regulation.

In New England Journal this week, Amy Kapczynski in a commentary outlines the possible effects of the TPP on access to medicines all over the world. Several other organizations like Public Citizen and MSF have outlined the dangers imposed by the current draft of the TPP on medicine access. A few months ago, organizations including the MSF, AFL-CIO, AARP, Oxfam-America and Generics Pharmaceutical Association wrote to President Obama outlining their fears of the dangers posed by the TPP on public health, and especially access to medicines across the US and the world. Whether these fears are assuaged, or the TPP does indeed turn out to the scary monster that several public health advocates have been predicting, only time will tell.

The Truth about Tobacco Taxes

I am not going to drive up the traffic for someone with a clear intent on trolling the internet with disinformation, so I am not going to post a link here, but there is an story on the website called Hotair (right, the name is telling enough) about how the World Health Organization (WHO) is pushing a tobacco tax agenda. The story is prejudiced, but the prejudice clearly shows and most readers are likely to figure out soon enough that the writer has an axe to grind. (By comparison, even the Tax Foundation’s story from last year on the same topic reads much more balanced). However for the sake of truth and to crowd out the disinformation from the internet, I could not help point out why what’s peddled for sound logic in that story is in fact – in politer terms – faulty logic.

Here is the TLDR (too long didn’t read, if I must) version of the story’s thrust. That high cigarette taxes are responsible for the illicit trade in tobacco. But before I go into what causes the illicit trade in tobacco in the first place, a little bit of background.

Tobacco is the single most preventable cause of death in the world by far, causing as many as 6 million deaths every year. The WHO launched the Framework Convention for Tobacco Control (FCTC) back in 2005 to curtail this public health problem. The FCTC has been hugely successful in reducing global tobacco consumption, largely through a combination of supply as well as demand reduction strategies. As as result, today in many parts of the world, illicit tobacco is now the main source (57% in New York City for example) of tobacco consumption. In fact, curbing the illicit trade in tobacco may save up as many as 160,000 additional lives and increase revenues by about 31 billion dollars.

But illicit tobacco trade did not go up in absolute terms in most parts of the world because of high taxes or the FCTC. Research shows, illicit tobacco trade is directly a function of poor provision or lax implementation of laws to curb such trade. Places around the South China sea for example, like China and Malaysia have a huge illicit tobacco trade because it is easier to get away with illicit tobacco trade. In contrast, countries like the UK, which have very high tobacco taxes have been able to curb tobacco consumption as well as the illicit tobacco trade due to strong laws against illicit tobacco trade.

The data clearly shows, there is no clear relationship between high tobacco taxes and increase in illicit trade. Of course there are issues with differential tax rates within a close geography like the US. Differential tax rates have indeed been responsible for the increase in interstate smuggling of tobacco in the US. An article I wrote a while back dwells on this a little. But the way to reduce that is to harmonize taxes, much like the EU has managed to do.

Balanced discussion of this issue are made on this World Bank blog, and a paper on the MMWR from the CDC. Of course, supply reduction strategies like taxes aren’t the single solution to the problem of of tobacco consumption, and he FCTC recognizes that. The way to go about his problem is to make tobacco smoking “uncool” for the kids, to educate the public on the harmful effects of tobacco and to make it really hard for people to lay their hands on to tobacco by means of excise taxes and reducing illicit tobacco that makes tobacco cheaply available for people. If the WHO “Protocol to Eliminate Illicit Trade in Tobacco Products” is ratified, it will be a significant achievement in reducing the menace of tobacco – something that earns the unique distinction of being completely legal and at times even promoted by governments despite the overwhelming evidence that it is literally the most pervasive poison for people’s health.

Opinion on Obamacare among the tweeple is changing

The Affordable Care Act (ACA), now colloquially known as Obamacare, passed with a narrow margin in March 2010, with congressional votes roughly along party lines. Such ideological divide over the law has cast a long shadow over people’s opinion about it  – some well considered, others may be not so much. Now that the law has been implemented, people’s opinion about the law may be changing. History tells us, there was  similar opposition to the Social Security Act (1935) and the Medicare Act (1965), with opinions deeply divided over idealogical lines. However, both the social security and medicare are well accepted in the american society today; so much so that the same stripe of politicians who opposed them some decades earlier, are now seen to scamper to its defense.

Tracking if opinion about the law has been changing over time may provide us with insight about whether it is gaining acceptance in the country. Organizations like Gallup conduct telephone surveys every few months to gather data on people’s opinion about the law. Newer techniques like Sentiment analysis may offer an easier and faster way of finding people’s opinion about the law.

In order to do such analysis I used data from Twitter to mine people’s opinion about the law. I used the TwitteR package for R, written by Jeff Gentry, to download 1000 tweets every week about Obamacare. I then used an approach used by Jeff Breen to score the sentiment in these tweets  over a period of time. With this approach, each tweet is chopped down to its individual words and these words are then compared to a lexicon of positive and negative words. A score is then given for each tweet depending upon the number of positive or negative words present in the tweet. A positive score denotes a positive sentiment whereas a negative score denotes a negative sentiment. A score of zero denotes a neutral sentiment.

I labelled all tweets with a negative score as  a negative sentiment and those with a positive score as a positive sentiment. Tweets with a score of zero were labelled a neutral sentiment.

Here are the results from the data for the last few months.

Rplot

 

Overall opinion about Obamacare seems to be more negative than positive. However, based on these results the total number of tweeple (read Twitter people) with either a negative or a neutral opinion about Obamacare seems to be falling while the number of people with a positive opinion about Obamacare seems to be increasing. The dotted lines in the adjacent graph represent the overall temporal trend of opinion about the law among Twitter users. If these trends were to continue, opinion about Obamacare will be more positive than negative in the next few weeks.

As a comparison, here are the results from Gallup’s survey until May 2014. It is difficult to exactly compare between the two results for  1) Gallup’s survey asked people a dichotomous question about opinion about the law 2) they cover different time periods

One concern about using Obamacare as a search term was that the word essentially had derogatory connotations about it when it was first used. That may be changing with time, as the word finds more use in the mainstream, but using ACA as a search term for the law in Twitter gave inaccurate results and #ACA just does not seem to be used often enough in twitter.

While democratic controlled states have chosen to expand Medicaid, a key element of the law, some republican controlled states have chosen to do so while some others have chosen not to. This forms a sort of natural experiment where we could study if implementation of the law in any state changes opinion on the law one way or the other. In order to study such temporospatial trend, I downloaded tweets from 10 cities around the US: 2 blue state cities: Chicago and LA, 4 red state cities that expanded Medicaid under Obamacare: Columbus, Denver, Phoenix and Louisville and 4 red state cities that did not expand Medicaid under Obamacare: Memphis, Miami, Milwaukee and Houston.

Here is the spatial variation of opinion on Obamacare for these 10 cities and the US in general for the week leading unto August 1.

IMG_BAR_5

 

And here is the same for the week leading up to August 18.

IMA_BAR3

 

Future results will follow on this blog.

I will post the code on github shortly.

Healthcare’s performance report: Virginia

That was Virginia’s second visit to the hospital in the ten days of the new year. It also ended up being the last.

Virginia was a patient we all knew. She came to the hospital frequently. The aphorism of our intern year was, if you had not taken care of Virginia once, you were not going to graduate out of internship. And that was hardly an exaggeration- almost no one in my internal medicine residency class had been through their internships without admitting her at least once. I admitted her twice. She knew our faces- she never really knew our names though- although she would give us a bored “I know you” every time we met her in the ER exam bay for an admission.

That evening I was signing out in the ICU after a rather long shift; an attending physician came asking if we knew about a certain patient who had died in the OR the previous night. “Some Vivian Hunt or something”, he said. “She used to come frequently to the hospital”. You mean Virginia Hunt? I suggested. “Yes that’s the one”.

She died? A sigh of incredulity escaped my mouth; it suddenly felt as if a wall had fallen off the room we were standing in. Virginia had become some sort of an irrefutable constant in our working lives- I had met Virginia in the ER just a few day ago, she was in with some cold- and the constant was suddenly gone.

Memories flooded my mind on the drive back home. The first time I met her must have been sometime in October 2010, when I was still a greenhorn of an intern. She had come in with chest pain. “Are you my doctor?”, she asked, when I walked into the room. Yes I am, I said. “I need my Benadryl. I take 25 mg four times a day. And don’t give me the pills, they don’t do me no good. I need IV.” I was almost taken aback by my patient’s surefootedness. Her skin was dry all through, maybe it’s the kidney failure giving her the itch, I thought.  I ordered the Benadryl. Virginia was happy.

On any given day, Virginia was as sick as anyone able to walk on two legs could get. She had a barely pumping heart  with valves that leaked like a sieve, her kidneys did not work- she was on dialysis, she had seizures, she had had strokes in the past, her heart rhythm was abnormal and without blood thinning medications, she had a chance upward of 10 percent of being felled with a blood clot in the brain year on year. Barely in her early 50s, and  Virginia was already walking in and out of death’s door everyday.

Every other week or so, she would come to the hospital with chest pain, or some variation thereof. Although the vessels in her heart were not blocked, she had enough reasons to have heart related symptoms. The constant fuelling on heroin did not help. Yet Virginia was rather unapologetic about her habits- any conversation about the risks of drug abuse ended with a terse “I know”.

In April 2011, Virginia had a major heart surgery to replace the leaky valves in her heart. The surgery went well, but within a week or so she was back in the ER. We were worried the new valve may have something to do with the chest pain she came with. The valve appeared okay, it was the surgical wound on the chest that was hurting. She had also managed to lay her hands on some heroin.

Every time she came in with something like chest pain, she would often develop some other problem in the hospital completely unrelated to the first one, like an infection. She would be discharged in a few days and then she would be back in  a week or two. This went on in an unending loop. Virginia’s being in the hospital at any time was almost a given, not to mention the times she was admitted to some other hospital.

Stunned by her death, the next day I sat at a computer to reflect on her hospital visits. In 2012 she had been to the hospital 19 times. In 2011 she was in the hospital a whopping 51 times. After her surgery in 2011, we changed her primary care provider. She had 4 visits with him in the 20 odd months since then. She had a home health nurse visiting her every so often. In the last few years, she had had in excess of 100 x-rays, close to two dozen CT scans and every other kind of test imaginable. The only test she did not get done seemed to be a urine study- she just did not make any urine.

That fateful evening when she died Virginia had a fall at her home. She was dizzy when she came to the hospital. An initial CT scan was normal however within a few hours she was progressively worse. She was then found to have bled in her head. She was whisked to the OR and the blood collection evacuated. However she was not able to make it out of the OR- after half an hour of desperate resuscitation Virginia was declared dead.

Virginia is the very reflection of our healthcare system, it’s performance report: everything that is wrong and right about it, from over and inappropriate use, poor coordination, goals and priorities that are at times misplaced,  to the availability of modern advances and plenty resources at our disposal. Too bad such bottomless resources were not able to save Virginia’s life. Worse still, our failure to steward such resources threatens to pull the entire economy, and everybody else down together in a landslide.

Name changed.

The challenges of tobacco control

The WHO FCTC (Framework Convention on Tobacco Control) has been trying to regulate tobacco production the world over by restricting the use of land available for tobacco farming. The reasoning behind this is  two-fold: first tobacco has been singled out as the greatest preventable cause of death. Second the use of scarce farmland, especially in food deficient areas around the world, has been said to contribute to food shortage and hunger.

As expected, the convention has drawn the ire of tobacco farmers, the tobacco industry and their interest groups. Focal interest groups have amassed a war-chest to put up a fight. The FCTC isn’t any far behind; it has painted tobacco use as the greatest evil plaguing public health today.

What makes this battle interesting to watch is that both the sides have a valid point to the argument. The farmers point out, nothing gives them as much of a return from the land as tobacco. That is a valid argument, though not entirely so. Tobacco farming is very high up indeed in the value chain but projects elsewhere have  shown that it is indeed possible to derive as much returns from the land by means of farming other suitable cash crops.

Tobacco related illnesses are known to cause almost 100 billions dollars of healthcare costs in the US alone every year. Such costs have to been borne by pooled resources, either through the government or through private insurance. So it is no surprise that people will look to curb such costs for the sake of the greater common good.

The FCTC isn’t the first blow anti-tobacco campaigners have managed to land at the tobacco industry. Tobacco tariffs are already stiff in many parts of the world. A few months ago the Australian government passed a legislation to enforce uniform (read visually unattractive) labeling on tobacco products, a move that has been upheld by the Australian High Court. Similar attempts are underway in many part of the world.

And some people are even talking about disallowing cigarette smoking without a license.

Legislating tough tobacco laws may however be the easy part. The exorbitantly high cigarette tax in New York has proliferated an entire industry trafficking cigarettes along I-95, from Virginia where such taxes are almost non existent to New York where such taxes are the highest. Gangsters that used to engage in gun and narcotic trade earlier now engage in the much easier and lucrative tobacco trade. This not only defeats the public health purpose of such legislation, but also causes loss of much needed revenues (illegal tobacco trade costs as much as 10 billion dollars in lost revenues in the US).

Our attempt at enforcing a strict ban on drugs holds valuable lessons. While enforcement has been very heavy in the US, drugs of abuse are still very easily available undercover and usage is alarmingly high in the general population. What this has essentially done is drive the whole trade underground. In the meantime, strict enforcement of drug control related rules has resulted in the largest prison population in the world in the US (25% of the entire global prison population). Incarceration on the other hand leads to its own irreversible social rot in the affected. Furthermore, underground drug trade in the US has fueled and fanned a drug Mafiosi in Mexico that has been declared almost impossible to wipe out even after the loss of tens of thousands of people in drug related violence and billions of dollars spent in the fight.

Tobacco certainly is one of the greatest preventable public health threats; tobacco use in no way should be encouraged or facilitated or condoned. However trying to force tobacco use to one dark corner using all our might may prove to  be another social disaster the with hitherto unfathomed consequences, the way our battle with drug enforcement has been.

Educating  and subtly modulating behaviour against tobacco use will likely give us the best results; trying to ham-handedly force people out of tobacco may ultimately backfire. After all, humans are a creature defined by free will; they certainly appreciate better health but also appreciate the the right to exercise their free will at least equally so.

The Adoption of EMR

It is no news a lot of doctors like to stick up a rather snotty nose to EMR, despite all the rage in town. The defenders of the EMR tend to label such doctors as archetypal Luddites, sticking to their archaic ways and unbecoming of change and the new times. But as is usually the case with any two heated but opposite arguments, the truth likely lies somewhere between the two extremes.

On an objective basis, there is no denying that automatisation of medical record keeping is the new way forward. In theory, if the machine could keep records for you and give it back to you when and where you want it, thus freeing up valuable time for the patient encounter, that should be winsome for everyone. That alas, is a vision of the EMR utopia, and let alone being anywhere close to such utopia, it is difficult to ascertain if we are even set in the road leading us there.

Sometime ago, exasperated at the sheer waste of time that the clunky new discharge module was causing because it would not work the way it is supposed to (my hospital is means challenged, so they are building a patchwork of cheapskate EMR suite on top of their legacy system from the 90s, just to placate the gods of CMS), I complained to the IT guy that the thing barely works! The guy was sympathetic and said- “look I know the discharge module sucks, just bear with it until the end of the year when we should be able to weed out the bugs” But that’s not all, I said, even if it were working just the way it is supposed to, the discharge still takes me longer than what it used to with paper. “That’s something you will have to learn to live with” he retorted, “computer records do take a longer time than paper, and there is nothing I can do to change that”.

Right there, I think is where EMR loses a lot of ground against paper records. At any practice, time is the most valuable resource, and anything that doesn’t offer a straight off benefit to save time will have a hard time being adapted. Add to that the inertia people have about their old ways and you have a deal breaker right there. (digression alert) I once heard an attending at the hospital say, “I really like the feel of pen on paper. Computers just don’t give me that feel.” The attending has beautifully symmetric cursive handwriting that looks like artwork on paper. And needless to say, she hates EMRs from the bottom of her guts!

That’s not all. Driven by the constant government whip to adopt EMR- no EMR, no pay (reminds me of junior Bush’s iconic rhetoric- if you are not with us, you are with them!), and an EMR industry that is hell bent upon imposing itself on healthcare (they can’t believe they don’t have a sizable share of the multi-trillion dollar healthcare bounty) a lot of makeshift EMR adoption has taken place. So you have hospitals where one part is using one system while the other is using a completely different one. At one clinic I recently worked at, we had to switch between 3 different EMR systems, just to get the patients records. And there still was the paper records not to mention the dictation.The constant juggling not only made the patient encounters time consuming and cumbersome, it literally made us curse at the computers and ruin an otherwise perfectly normal day at work. Patient volumes have gone down from 15-16 patients per day to a half of that after EMR adoption.

What’s wrong with the current adoption of EMR? Why are even the converted like me (most of us doctors trust me, are the opposite of Luddites, the first thing I learnt to do with a computer was write code; I freely use LaTeX and R) questioning EMR?

I think there are two reasons for such seemingly epic failure. First, how we interface with an EMR. Second how the EMR tries to impose its will on to us instead of the other way around. A keyboard and a point and click device may well have worked for many other interactions with the computer, but with an EMR it doesn’t always appear to be nifty. It is a common experience that most people find dictating their notes much faster than typing them. Accurate automated transcribers (current bunch of transcribers are known to be as much a 6 times more inaccurate over human transcribers) could really speed up record keeping, thereby selling EMR to the unconverted while saving costs over manual transcription. On the same note, no EMR is going to be see a faster adoption if something like writing a prescription takes a minute when in paper it barely takes  10 seconds. Right now doing something as simple as writing a prescription feels like running through a bunch of fire breathing hoops. Someone may argue, you can at least read it better, but don’t get me started on how the EMR can come up with its own ludicrous set of errors, something that would never be possible with paper.

Trying to impose a readymade architecture on to health care will not work. “It works for retail and banking”, some people seem to offer cluelessly. But a patient encounter is no visit to your bank cashier. And human body is not your bank account, it is way more complicated and it is bound to generate way more complex information that is difficult to straight jacket into the rigid and rudimentary pipeline of set information pathways. An ideal EMR is supposed to be a seamless body-glove; today they feel like the hangman’s cloak, not only are they cumbersome, dark and dreary and suffocating, under their apparition, they force things you to do things you wouldn’t otherwise do.

Such forced behaviour modification may make the administrator, the insurance company the government happy but I can’t understand how selecting a dozen pesky radio buttons (like the one that tells the patient to shower everyday; another one says- don’t smoke, if you do quit- tobacco counseling for the sake of the payer!) while doing the discharge makes the patient lead a healthy life or make his doctor particularly enamoured with the EMR, just because the government said so or that it made the IT companies a few million dollars richer.

Ensuring universal health care around the himalayas

Two unique experiments in health care are being orchestrated on either sides of the Himalayas. Both China and India are grappling with the ideals of universal health care(UHC): trying to provide equitable and accessible healthcare to the entirety of its populace, an idea that has been up for talks here in Nepal as well for a few years now. The lessons we learn from the either of our two neighbors’ experiments should prove to be very insightful.

Universal health care has been dubbed as the next big thing in public health. Its ability to shape people’s health over the next several decades has been thought to be nothing short of phenomenal. Our own priorities match hand in hand with that of UHC: the last constitution has enshrined universal health care as a fundamental right. But so have some 19 countries of Latin America, and numerous others all over the world. Without a formidable plan and commensurate action, such policies will be just that: vacuous rhetorics.

That’s where China and India shine. They are putting money where their words are and have a restless audacity to achieve out of this world results previously thought unattainable. Between these two giants, they aim to provide accessible and equitable health care to more than a third of humanity, irrespective of an individual’s ability to pay, thereby preventing people spiralling into a vortex of poverty due to a catastrophic illness as it often the case for poor and middle income people right now.

China has audacious plans. The country has earmarked more than a hundred  and twenty five  billion dollars in additional health care spending to scale up health services to its entire people, and by some estimates health care spending in China will easily top more than half a trillion dollars by the year 2020.  Such spending will come mostly from the government, but private spending out of pooled sources like private insurance will also play a part. Between a hybrid network of public and private providers and pooled resources using public and private funds, China aims to achieve its goals of ensuring the health of everyone of its citizens.

India’s plans are equally bold if not bolder. It plans to provide a basic set of health services to everyone, with costs offset by the government from resources collected from general taxation. For a country that has helped rescue much of the developing world from their AIDS epidemics by means of its cheap generics, it is such an embarrassment that thus far, healthcare seemed so distant for a majority of its people due to unaffordable drug and service charges.

That is finally about to mend. And that is not an unachievable goal. Based on some conservative estimates, the government of India will have to spend at least 3-4% of the GDP on health, in order to achieve such results. That is not a big number to spend in healthcare: The UK government through the NHS spends some 8% of the GDP on healthcare. The US spends a whopping 18% of the GDP on healthcare, sixty percent of which comes from the government in the form of programs such as Medicare and Medicaid.

Current health spending by the Government of India is at around 1.4% of the GDP, only a quarter of the total health care spending. Two thirds of health spending in that country is out of pocket. As a result, for the poor the consequences of a severe illness are sometimes more catastrophic than the illness itself. No wonder then that poor people lose lives to an illness at an alarming rate, through lack of adequate care or by refusing to seek care, because the health system has failed them.

Our own experiences match much of India’s. A large section of our population has been effectively barred from formal health services. Like India, we have toyed with the idea of eliminating user fees at government health facilities to improve access to health care to a subset of underserved people. Research from much else of the world shows, user fees, howsoever nominal deter the most vulnerable and the marginalised from much needed health services. Revenues from such fees have also been shown to be a very poor and an unreliable means of financing health care. Our results since eliminating such fees have been encouraging; health services usage has gone up in these select groups.

It pays for us to be cognizant of a mix of  insurance based and government funded healthcare system like that in China, but that may be difficult for us to implement given that the organised sector through which we could implement employment based insurance system is miniscule. Leaving health care hostage to a predatory for-profit multi-payer private insurance system like the one in the US should not be anyone’s idea of universal health care given how such has healthcare system has systematically excluded a sixth of the population in that country, even while it threatens to usurp the entire economy due to runaway costs.

While stalled politics in the country has left every other priority on the back burner, tomorrow’s Nepal can’t be built no matter what kind of ingenious constitution the politicians come up with, if today’s children continue to risk perennial ill health and preventable death. Our commitment to universal health care is barely a start to end this injustice. Realising this dream will mean matching the talk with the walk, much the way our neighbours are starting to do.

Pirates of the healthcare industry

The New York Times recently did an expose on hospital overbilling by a group of cardiologists at some hospitals owned by the Hospital Corporation of America (HCA). Immediately after a few days, a rather gloating article about how HCA had become the poster boy of Wall Street with its double digit growth strategy appeared. If the first story had not raised enough doubt about the prudence of the profit motive in healthcare, the second story rammed the point right into place.

Back in the 1950s Kenneth Arrow (a side note: the Nobel winning economist is Larry Summers’ uncle if that’s of any interest) published a paper in the American Economic Review about how healthcare is unlike any other commodity that is freely tradable at the markets. The core of his argument was  that healthcare unlike regular commodities follows a warped logic that does not bow at the altar of demand and supply economics.

Here’s why: first, there is no real linkage between demand and supply with healthcare. In ordinary market economics, demand and supply tend to have an inverse relationship  with each other. Not so with health care; since nobody can really predict the need for a certain health service. And when you do need it, there isn’t really the time to shop around. So the demand and supply can’t really be moderated based on each other.

Second, and equally important, is the fact that there is a huge information asymmetry between the provider and the consumer of the service. As a result, not only is the consumer not able to shop around for healthcare when he needs it, he has no idea about making an estimate about the quality of the same. Think about haggling around for a cardiac cath when  you have a heart attack. Or for that matter, think about trying to second guess your doctor when she says you need a certain procedure. That puts the doctor at a rather unusual predicament for a service provider; he is not only the provider but also oftentimes the person who determines when there is a need for a certain service. In an idealised situation, the doctor is expected to not only provide services to his consumers, but also be a vanguard the interests of his patients and the society at large.

When doctors are able to fulfill that obligation as the custodians of the well being of their patients and communities, that’s where they derive their reverence. When doctors choose to forgo that obligation, like the Florida cardiologists, it is too easy to make a quick profit. The price that you pay for earning that quick buck however depends upon how much of importance you place upon your moral obligations and failings. Physicians have ordinarily been expected to subscribe to their own ethical tenet. When they fail to do so, they can do undue harm to our communities by virtue of the trust that has been laid on them. The lure of money can be a powerful force to cause a breach of such trust.

And that has already been happening at an alarming pace. HCA is a very relevant case in point. Fuelled by their own greed and the pressure from their administrators to upcode on their services as well as provide services that were not really required, these doctors sold themselves for a quick buck.

Like the NYT story points out, it’s for a reason why the for profit healthcare industry has become the new darling of the private equity industry. At a time when demand for goods and services is sagging almost everywhere, healthcare continues to be a major exception. And when the provider himself can be the arbiter of demand, that is too fertile a ground for private equity firm to not try to stick its feet in.

One may argue, so what is wrong with making money if they provide better services, bring in efficiency and add value to the system. Here’s why that argument is faulty. First, the Florida story is a firm rebuttal to the fact that for profit hospitals provide efficient services. They just provide services that makes them more money irrespective of the need. That loses money for everyone in the longer run. Second the belief that such hospitals create value is faulty as well. Paul Levy has a really interesting blog post on his Not Running a Hospital blog, about how private equity firms dress up results for the short term for the consumption of wall street, fatten up the stock and make their quick exit, while holding such institutions hostage to maverick financial instruments in the longer run. There is a reason why the term “vulture-capitalism” sticks. Dive in, make a quick buck and make an equally quick exit.

A third argument is made about how private entities bring in investment that no non profit institution would have been able to manage on their own. That argument too has no merit when you consider the fact that, as Levy mentions,  no for profit hospital will have access to cheap capital the way a non profit will have given the need to pay taxes, the lack of access to charitable donation  and the constant need to placate the demigods of the markets.

As long as healthcare continues to be a societal good hinged on our belief that it should be a right for all irrespective of the ability to pay, health care services will not be tradable like every other good or service. When it’s defined as a societal good, healthcare is too easy a target to profit from; and making a quick buck out of it is not a terribly difficult thing to do; unfortunately such profiteering tends to be antithetical to larger societal interests. Either the profits or the common good. Unless we recognise that fact,our confusion with whether the market is the best vehicle for delivery of healthcare will continue to throw up buccaneers like these that try to make a quick buck at the expense of everyone else.

Primary care’s woes: It’s in the way you see

Primary care is ever the cinderella-esque tragedy. Ever so maligned, ever engulfed in misery and never really the belle of the ball like she rightfully deserves to be. There may be reasons galore to this. Not least of which is the way primary care work is perceived in this country.

Let me illustrate.

The primary care attending I work with recounted a story from the early 2000s. As is usually the case with visits at the primary care doctor, one day she took care of a sixty something lady with a slew of medical problems: diabetes, heart failure, respiratory disease, high blood pressure and depression. Additionally, the lady had recently lost her husband and had an agonizingly traumatic  bereavement. She spent time counseling her. In addition to all that she had to take care of a retinue of screening and preventive health measures that the primary care physician has to coordinate.

At the end of it all, the lady had a little wart on her great toe that she wanted fulgurated. As a makeshift measure the doctor removed the wart with liquid nitrogen, in a procedure that took less than 5 minutes.

In all the office visit took almost an hour. Orchestrating and coordinating her care took an intense amount of patience, attention to detail and diligence on part of the doctor. Assuming responsibility for the management of such an array of medical conditions is an onerous task by any yardstick.

Some time later, her reimbursements for the visit arrived. She had been reimbursed more for the makeshift procedure that lasted less than 5 minutes over all the rest of the care that she had rendered on the lady!

Such asymmetrical compensation approach produces adverse incentives. Therefore we have family physicians who have to train in minor podiatric and orthopedic procedures like nail clipping and intra-articular injections to make a little extra income to pay their bills! It’s been well established that a well-rounded primary and preventive care is the best health intervention at a systems level. Such routine care can ensure good health while preventing expensive care at the sub-specialists that may accrue later on. However there is no real incentive for the primary care physician to provide such economical care while there is every incentive for the interventionist to jump onto expensive procedures that often are a result of poor primary care and prevention.

It may pay the primary care physician well to start doing more office based procedures, but that beats the point. The point is the recognition of the fact that the meticulous, thoughtful and cerebral work done by primary care physicians is as valuable, if not more, than the procedural work done by interventionists. After all, despite the thankless compensation, the work done by the primary care physician adds way more productive life years to people’s lives per dollar spent than that done by the interventionist for the same dollar spent.

Until we are able to recognise such a fact, primary care’s godsend fairy mother will never arrive, she will never be the belle of the ball. And as long as primary care is not the center of the attraction, healthcare in this country will be eternally doomed to cost overruns that threaten to sink the entire boat on their weight.