Minor Thoughts from me to you

Coffee Linked to Lower Dementia Risk

A 21-year study finds that moderate coffee drinkers are much less likely to develop Alzheimer's disease and other forms of dementia.

Well, no hope for me then. I can't stand the taste of coffee.

The Cato Institute's Michael F. Cannon shares his thoughts on Governor Jindal's proposed overhaul of Louisiana's Medicaid program.

Why is it that when politicians propose giving taxpayer dollars to private companies, people think that's "market-based"?

Jindal's plan is not market-based reform. As a general matter, market-based charity care is just that: private charity. So the only market-based Medicaid reforms are those that remove people from the Medicaid rolls — e.g., federal block grants, eligibility restrictions, etc.

Jindal wants to expand eligiblity. For a welfare program. And we call that market-based?

Jindal may be able to improve the quality of care through greater coordination. Which looks good on paper. But if the quality of care in Medicaid improves, more people will enroll. Only 2/3 of those eligible actually sign up for the program. (Many of the 1/3 who don't enroll actually have private coverage.) So improving Medicaid benefits could cause enrollment to increase 50 percent. And that's before Jindal expands the eligibility rules.

With all the additional cost pressure, what's going to happen to Medicaid payments and enrollees' access to docs? (There are reasons why Medicaid pays so little.)

Louisiana's Medicaid program could someday achieve the most coordinated system of care that no one can access. Should we pull people out of private health plans for that?

Is Alzheimer's disease caused by cold sores? Possibly.

The virus behind cold sores is a major cause of the insoluble protein plaques found in the brains of Alzheimer's disease sufferers, University of Manchester researchers have revealed.

They believe the herpes simplex virus is a significant factor in developing the debilitating disease and could be treated by antiviral agents such as acyclovir, which is already used to treat cold sores and other diseases caused by the herpes virus. Another future possibility is vaccination against the virus to prevent the development of the disease in the first place.

Most people are infected with this virus, which then remains life-long in the peripheral nervous system, and in 20-40% of those infected it causes cold sores. Evidence of a viral role in AD would point to the use of antiviral agents to stop progression of the disease.

The team discovered that the HSV1 DNA is located very specifically in amyloid plaques: 90% of plaques in Alzheimer's disease sufferers' brains contain HSV1 DNA, and most of the viral DNA is located within amyloid plaques. The team had previously shown that HSV1 infection of nerve-type cells induces deposition of the main component, beta amyloid, of amyloid plaques. Together, these findings strongly implicate HSV1 as a major factor in the formation of amyloid deposits and plaques, abnormalities thought by many in the field to be major contributors to Alzheimer's disease.

See, this is why I never read drug labels.

Research has shown that expecting to feel ill can bring illness on in some instances, particularly when stress is involved. The technical term is the "nocebo effect," and it's placebo's evil twin. "It's not a psychiatric disorder -- it's the way the mind works," says Arthur Barsky, director of Psychiatric Research at Brigham and Women's Hospital in Boston.

Research deliberately causing nocebos has been limited (after all, it's kind of cruel). But in one 1960s test, when hospital patients were given sugar water and told it would make them vomit, 80% of them did.

Studies have also shown that patients forewarned about possible side effects are more likely to encounter them. In a study last year at the University of Turin, Italy, men taking finesteride for enlarged prostates who were informed that it could cause erectile dysfunction and decreased libido were three times as likely to experience such side effects as men who weren't told.

A genetic mutation may hold an AIDS cure.

The startling case of an AIDS patient who underwent a bone marrow transplant to treat leukemia is stirring new hope that gene-therapy strategies on the far edges of AIDS research might someday cure the disease.

The patient, a 42-year-old American living in Berlin, is still recovering from his leukemia therapy, but he appears to have won his battle with AIDS. Doctors have not been able to detect the virus in his blood for more than 600 days, despite his having ceased all conventional AIDS medication. Normally when a patient stops taking AIDS drugs, the virus stampedes through the body within weeks, or days.

"I was very surprised," said the doctor, Gero Hutter.

The breakthrough appears to be that Dr. Hutter, a soft-spoken hematologist who isn't an AIDS specialist, deliberately replaced the patient's bone marrow cells with those from a donor who has a naturally occurring genetic mutation that renders his cells immune to almost all strains of HIV, the virus that causes AIDS.

Caveats are legion. If enough time passes, the extraordinarily protean HIV might evolve to overcome the mutant cells' invulnerability. Blocking CCR5 might have side effects: A study suggests that people with the mutation are more likely to die from West Nile virus. Most worrisome: The transplant treatment itself, given only to late-stage cancer patients, kills up to 30% of patients. While scientists are drawing up research protocols to try this approach on other leukemia and lymphoma patients, they know it will never be widely used to treat AIDS because of the mortality risk.

Politicians of all stripes are talking about preventative medicine. They claim that if we catch medical problems earlier, we can fix them for less. By paying a little more now, we can save a lot more later. The only problem? It doesn't work.

It boils down to encouraging the well to have themselves tested to make sure they are not sick. And that approach doesn't save money; it costs money.

Increasing the amount of testing for an ever-expanding list of problems always identifies many more people as having disease and still more as being "at risk." Screening for heart disease, problems in major blood vessels and a variety of cancers has led to millions of diagnoses of these diseases in people who would never have become sick.

Likewise, recent expansions in the definitions of diabetes, high cholesterol and osteoporosis defined millions more as suddenly needing therapy. A new definition of "abnormal bone density," for example, turned 6.8 million American women into osteoporosis patients literally overnight.

These interventions do prevent advanced illness in some patients, but relatively few. Any savings from preventing those cases is dwarfed by the cost of intervening early in millions of additional patients. No wonder pharmaceutical companies and medical centers see preventive medicine as a great way to turn people into patients -- and paying customers.

Early screening is like the "check engine" light in your car. It can alert you to problems that need to be fixed, but too often it picks up trivial abnormalities that don't affect performance, like one sensor's recognizing that another sensor isn't sensing.

And if we look hard enough, we'll probably find out that one of your check-engine lights is on.

What's wrong with that? Getting extra -- possibly unneeded -- medical care can't hurt, can it?

It's hard to ignore a "check-engine" light. Some mechanics reset them and see if they come on again, but often they lead you to a repair. And you may have had the unfortunate experience that a repair makes matters worse.

If so, you have some feel for the problem of overdiagnosis. Almost everybody with a diagnosis undergoes treatment. And all of our treatments have some harms. From 1 to 5 percent of patients die after major surgery, and as we are all increasingly aware, prescription medicines carry real risks. Recent experiences with hormone replacement (breast cancer) and Vioxx (heart attacks) are potent reminders that our "best" new treatments may harbor unpleasant surprises.

Oh. Not only is "preventative medicine" more expensive, it's also riskier. Maybe I'll stick to going to the doctor only when I actually feel sick.

Australia has socialized its medical services. Australian friends tell me that providing basic medical care for free is the only fair and just thing to do. Well, how fair and just is this?

A German doctor hoping to gain permanent residency in Australia said Friday he will fight a decision by the immigration department to deny his application because his son has Down syndrome.

Bernhard Moeller came to Australia with his family two years ago to help fill a doctor shortage in a rural area of Victoria state.

His temporary work visa is valid until 2010, but his application for permanent residency was rejected this week. The immigration department said Moeller's 13-year-old son, Lukas, "did not meet the health requirement."

"A medical officer of the Commonwealth assessed that his son's existing medical condition was likely to result in a significant and ongoing cost to the Australian community," a departmental spokesman said in a statement issued Thursday by the Department of Immigration and Citizenship.

"This is not discrimination. A disability in itself is not grounds for failing the health requirement -- it is a question of the cost implications to the community," the statement said.

This is the end result of socialized medicine. Everyone will be judged based on how much they cost the community. Do you cost too much? Goodbye, nice knowing you. It's impossible to preserve individual human dignity and worth as long as the community has to pay for that individuals. Communities will quickly find ways to exclude the costliest people and include the cheapest people. A system that was supposed to remove the "indignity" of making people pay their own quickly degrades to a system that values people solely on the basis of a cost / benefit analysis.

Ironic, no?

This is cool. It's amazing how far and fast medical technology is developing. I can't wait to see what will be available by the time I need serious medical help.

In 2001, the FDA approved the use of capsule endoscopy, which uses a capsule size camera [1.2 inches long by 0.4 inches in diameter]. These are passive systems. There is work to make smaller robotic systems and systems that can perform more of the capabilities of regular endoscopes. These capabilities include therapeutic and diagnostic operations such as ultrasound, electrocautery, biopsy, laser, and heat with a retractable arm.

Scientists at the Technion University, teamed with a researcher from the College of Judea and Samaria, have developed a miniature robot that can move within the bloodstream.

The miniature robot has been planned and constructed (2007), that has the unique ability to crawl within the human body's veins and arteries," said Dr. Nir Shvalb of the College of Judea and Samaria. The Israeli robot's diameter is one millimeter.

The researchers stress that the project is an "interesting development, but it has a long way to go before it is used in medicine." Solomon says that the tiny robot could be controlled for an unlimited amount of time to carry out any necessary medical procedure. The power source is an external magnetic field created near the patient that does not cause any harm to humans but supplies an endless supply of power for it to function. The robot's special structure enables it to move while being controlled by the operator using the magnetic field.

Next Big Future: Pill-size to bacteria sized robots for surgery and in-body therapies:

Last month, in a meeting at work, I listened to a presentation about medical billing and denials. During the presentation, the presenter made an offhand remark at insurance companies denying claims "without ever seeing the patient or knowing what the needs are". The unstated assumption was that a government run health plan would do a better job of making sure that people got the healthcare they need. (At my job, that's usually the assumption, stated or otherwise.)

But is that really true? Well, not if you hold up Medicare as an example of well-run government healthcare. This week, Scott Gottlieb wrote an interesting op-ed for the Wall Street Journal: "What's at Stake in the Medicare Showdown".

First, there's a mistaken belief that Medicare is better staffed than private plans, and can therefore make better decisions about patients' clinical circumstances and the access to new therapies they should have. Yet at any time, Medicare has about 20 doctors and 40 total clinicians (including nurses) inside the coverage office, and fewer than a dozen in the office that sets the rates that doctors are reimbursed for the care they provide. Private insurers employ thousands of doctors, nurses and pharmacists, many experts in new technologies.

Aetna has more than 140 physicians and about 3,300 nurses, pharmacists and other clinicians across its health plans. Wellpoint has 4,000 clinicians across its different businesses, including 125 doctors and 3,180 nurses. That works out to one clinician for every 9,000 people covered. United Healthcare employs about 600 doctors and 12,000 clinicians across all of its health plans and various health-care businesses.

Private plans use clinically trained people to establish access to new technologies and services, but they also consult with doctors on a case-by-case basis, determining whether a product or service should be covered. Competition for beneficiaries means private plans need to provide better access for appeals, modern services and more personal considerations than what's offered by Medicare, a monopoly supplier.

Recent data from Price Waterhouse Coopers found that private plans spend roughly four times more than Medicare on "consumer services, provider support, and marketing," which includes money spent answering the telephone to adjudicate individual issues. Smaller health plans use one clinician for every 10,000 beneficiaries. Medicare would need 4,500 clinicians to keep pace.

One place where the clinician disparity is most obvious is the delivery of cancer benefits. Medicare doesn't have a single oncologist on staff, yet since the year 2000 the program issued, by my count, 165 restrictions and directives on the use of cancer drugs and diagnostic tools.

A second common refrain is that Medicare is more efficient than private plans, spending less money per beneficiary to administer health services. But a lot of the money that private plans spend is on clinical specialists charged not only with reviewing individual cases, but also with ensuring that doctors and beneficiaries comply with plan contracts. Far from a selling point, not having these functions is one of Medicare's shortcomings.

Medicare doesn't need to hire doctors to weigh individual medical cases because it uses formulaic rules made in Washington to set broad and inflexible restrictions on medical practice. Nor does the program need to hire clinical staff to monitor compliance. It passes costs for that on to the broader health-care system by backing up its rules with the threat of costly civil and even criminal sanctions. Providers and medical product developers spend hundreds of millions of dollars on systems, personnel and paperwork to ensure compliance with Medicare's sticky morass of regulations - tasks made more expensive by the fuzziness of the program's regulations and the arbitrary way they are enforced.

When you put it that way, I'd far rather have my expenses reviewed by private insurance than by Medicare. Instead of an example to follow, Medicare looks like a cautionary tale of what not to do.

I work with a lot of bright people. I wish they would question their assumptions more often and not just fall back on the tired rhetoric of "profit-seeking companies are bad" and "government programs really do help people".

Why does healthcare in America seem so broken? There's actually a very simply reason: the people receiving the care are not the people paying for the care. As always, he who pays the piper calls the tune. Russ Roberts breaks it down:

So why doesn't a hospital work better? The answer I think, is that the level of specialization in medicine has emerged from a process that has very few incentives to make sure that the level of specialization is as productive as it should be. There are very few informational feedback loops. Very little accountability. Sure, if a surgeon leaves a scalpel in your chest cavity and sews you back up, the surgeon bears a cost. And as a result, it doesn't happen very often. But the kind of errors that Arnold worries about, the kind of errors that I've worried about with my Dad in the hospital (and the kind I've seen made) are the ones that have little or no consequence to anyone other than the patient.

These errors are built into the system. When a drug leads to unexpected side effects because the right questions weren't asked, when an opportunity for a safer treatment is missed, when an aggressive treatment for one illness weakens the immune system and leads to other problems, who can you blame? Who bears a cost other than the patient?

You can blame the hospital of course, whatever that means, but the costs to the human beings who work in the hospital are small. There are no feedback loops within the hospital to reward generalists who look for the costs of specializations. And the reason there are not is because the patient is not the customer. The patient is not paying the bill. The financial incentives that do exist are coming from Medicare and Medicaid and the insurance companies. The normal feedback loops that protect the customer from error and greed and simple stupidity are missing. In a way, it's amazing it works as well as it does. It works as well as it does presumably because most doctors and nurses do care about the lives in their hands. But it's imperfect and could be much better.

( Via Cafe Hayek.)

Division of Labour: I fall victim to the drug war:

As I've mentioned, I had transplant surgery on Tuesday. After removing my IV lines, the doctors put me on the controlled substance Percocet for pain relief, to be taken as needed up to 4x daily. (Note: the stuff works.) Under federal rules, I had to request each dose, and the nurse had to watch me take it upon delivery. (I might hoard and resell them?) The hospital could not give me any Percocet to take home with me when I was discharged on Saturday. But they could write me a prescription, to be filled at my pharmacy. Problem: I was discharged at 7pm, and my pharmacy had closed at 6pm. The hospital pharmacy was also closed. So, thanks to federal anti-narcotic hysteria, I would be without pain relief until my pharmacy opened on Sunday at 10am. The hospital said that they had faxed all my new prescriptions there, so my agent went to pick them up. But no Percocet was among the pills she returned with - under federal rules, prescriptions for narcotic pain relievers can't be faxed or phoned in; only presented in person in hard copy. She had to make a second trip, carrying the written script they'd given me.

I think it's time to return to a free market in narcotics.

I haven't been organized enough to write here for quite a while. I did, however, find some time to get into a discussion about health insurance over at Coyote Blog.

You may find it interesting.

Yesterday, I read a very interesting op-ed about universal coverage: Bad Medicine For Health Care.

Individual mandate supporters typically justify the policy by citing the problem of uncompensated care. When uninsured patients receive health services but don't pay for them, the rest of us end up footing the bill one way or another. So advocates of insurance mandates contend, plausibly enough, that we should make the free riders pay.

But how big is the free-rider problem, really? According to an Urban Institute study released in 2003, uncompensated care for the uninsured constitutes less than 3% of all health expenditures. Even if the individual mandate works exactly as planned, that's the effective upper boundary on the mandate's impact.

Savings of less than 3%? That doesn't sound so good.

What about the states that mandate minimum coverage levels? Surely that does some good?

Some proposals couple mandates with subsidies for the purchase of private insurance. As far as policies to encourage more private coverage go, you could do worse. But as long as the public has to subsidize the formerly uninsured, the problem with free riders has not been solved. We're just paying for them in a different way.

Even now, every state has a list of benefits that any health-insurance policy must cover--from contraception to psychotherapy to chiropractic to hair transplants. All states together have created nearly 1,900 mandated benefits. Of course, more generous benefits make insurance more expensive. A 2007 study estimates existing mandates boost premiums by more than 20%.

Oops. Maybe if we allowed people to buy only the coverage that they actually needed, more people could afford coverage.

Finally,

Some people will not comply: 47 states require drivers to buy liability auto insurance, yet the median percentage of uninsured drivers in those states is 12%. Granted, that number might be even higher without the mandates. The point, however, is that any amount of noncompliance reduces the efficacy of the mandate.

Let's assume that 12% of the U.S. populace ignores an individual mandate and doesn't buy health coverage. What's 12% of 300 million people? Oh, about 36,000,000 people. That's about the number of people in the U.S. that currently don't have healthcare.

I'm supremely skeptical that passing universal healthcare will do much to help Americans get better healthcare.

Everyone "knows" that Canadian's get better healthcare than Americans do. After all, not only do Canadians live longer but their healthcare is free too!

Recently, June O'Neill and Dave O'Neill submitted a new working paper to NBER (National Bureau of Economic Research), comparing the U.S. and Canadian healthcare systems. Their results may surprise you.

First,

It turns out that once we condition on infant birth weight -- a significant predictor of infant health -- the U.S. has equivalent infant mortality rates. In fact U.S. infant mortality is lower for low-birthweight babies than Canadian infant mortality for low birthweight babies. Overall infant mortality, however, is higher in the U.S. because the incidence of babies with low birthweight is higher than in Canada. This may be due to demographic or epidemiological factors, or it may be the case that the U.S. is better at having a live birth for a low birthweight baby.

Second,

Why do Canadians live longer? One reason is due to the excess number of accidents and homicides in the U.S. compared to Canada. In fact 50%-85% of the mortality gap between American and Canadian adults in their twenties can be explained by the increased American accident/homicide rates. For people over 50, 30-50% of the difference in age-specific mortality rates can be attributed to the excess number of heart disease patients in the U.S. These heart disease findings are more likely driven by American lifestyle choices rather than the efficacy of the U.S. medical system.

Moving to Canada won't increase the quality of your healthcare nearly as much as you think it will.

Mitt Romney recently wrote an op-ed for the Wall Street Journal comparing his own healthcare plan to Hillary Clinton's plan. He tried his best to present his plan as a small-government solution to the healthcare problem.

As governor of Massachusetts, I led the fight for reforms that used free markets and innovation, rather than big-government control, to lower health-care costs and cover the uninsured. I recently proposed a federalist reform plan that will use these principles to improve America's health-care system.

There's only one problem with his editorial. It's misleading. The Cato Institute explains why RomneyCare and HillaryCare are really two sides of the same (bad) coin.

The cost of healthcare goes up every year. Prescription drugs get more expensive too. But, even though they get more expensive, they're different from the rest of healthcare. While the rest of healthcare was increasing in cost by 6-7%, prescription drugs were only increasing in cost at the rate of 1%!

What caused this remarkably slow growth? Maybe it's because 25 cents out of every dollar spent on prescription drugs comes straight out of consumers' pockets. Maybe consumers really are more frugal when they're spending their own money.

This story (Ban Sought on Cold Medicine for Very Young - New York Times) made my pharmacist wife shake her head.

It seems more than a little overkill to ban an entire class of medicines just because a few doctors start jumping up and down and yelling "There's no proof that it works! No proof!"

And look at the number of children supposedly killed by these medicines in a 37 year period: 123. That's about 3.3 children per year. Far, far more than that are killed via accidents every year (such as parents backing over kiddies with the SUV) than by baby dimetap. Some perspective might be in order here.

Drugstore Clinics Spread, and Scrutiny Grows - New York Times

The concept has been called urgent care "lite": Patients who are tired of waiting days to see a doctor for bronchitis, pinkeye or a sprained ankle can instead walk into a nearby drugstore and, at lower cost, with brief waits, see a doctor or a nurse and then fill a prescription on the spot.

With demand for primary care doctors surpassing the supply in many parts of the country, the number of these retail clinics in drugstores has exploded over the past two years, and several companies operating them are now aggressively seeking to open clinics in New York City.

But many regulators and doctors are only interested in one thing -- shutting down these low cost competitors.

New York State regulators are investigating the business relationships between drugstore companies and medical providers to determine whether the clinics are being used improperly to increase business or steer patients to the pharmacies in which the clinics are located.

And doctors' groups, whose members stand to lose business from the clinics, are citing concerns about standards of care, safety and hygiene, and they have urged the federal and state governments to step in to more rigorously regulate the new businesses.

"We've got big problems in health care, and this is not the answer," said Dr. Rick Kellerman, president of the American Academy of Family Physicians.

State officials acknowledged the clinics' appeal. But they said they were looking into possible violations of state law prohibiting unauthorized corporations like pharmacies, which are licensed only to provide pharmaceutical services, from delivering medical care.

"If we determine the business corporations are practicing medicine, then they are illegally practicing the profession and we have the authority to investigate," said Frank Munoz, associate commissioner of the State Education Department's Office of the Professions.

The American Medical Association, contending that patients might be sacrificing quality for convenience or seeking help at drugstore clinics for problems that should be addressed by their doctors or a hospital, has proposed a series of guidelines, including a requirement that the clinics have a "well-defined and limited scope." The association has also urged federal and state governments to investigate how the clinics operate.

But New York State officials are still looking at these "physician based models," Mr. Munoz said, to determine whether there were any inappropriate connections between the prescribing doctors at the clinics and the pharmacy's bottom line.

It sounds to me like someone is afraid of a little competition. Rather than doing whatever possible to improve healthcare, they're all focused on attacking and shutting down the new kid on the block. Is that any way to help lower the cost of healthcare?

You may have heard recently that the U.S. healthcare system is a national embarrassment. I wouldn't be so quick to believe those reports.

John Stossel -- Why the U.S. ranks low on WHO's health-care study

Even with all that, it strains credulity to hear that the U.S. ranks far from the top. Sick people come to the United States for treatment. When was the last time you heard of someone leaving this country to get medical care? The last famous case I can remember is Rock Hudson, who went to France in the 1980s to seek treatment for AIDS.

So what's wrong with the WHO and Commonwealth Fund studies? Let me count the ways.

The WHO judged a country's quality of health on life expectancy. But that's a lousy measure of a health-care system. Many things that cause premature death have nothing do with medical care. We have far more fatal transportation accidents than other countries. That's not a health-care problem.

Similarly, our homicide rate is 10 times higher than in the U.K., eight times higher than in France, and five times greater than in Canada.

When you adjust for these "fatal injury" rates, U.S. life expectancy is actually higher than in nearly every other industrialized nation.

Diet and lack of exercise also bring down average life expectancy.

For more evidence to suport John's argument, check out UK cancer survival rate lowest in Europe - Telegraph. The article includes a chart listing cancer survival rates for various countries. The U.S. leads the list with a 62.9% survival rate for women and a 66.3% survival rate for men. Where do you want to get cancer?

UW eye doctor gives world better vision

"In the past 25 years, the cases of avoidable blindness have doubled to 35 million presently. At this rate, by 2020 the number will double again to 70 million," he explains. But in the face of those statistics, he finds great hope: Aided by recent improvements in lens manufacturing and surgical techniques, 90 percent are curable with simple cataract surgery that costs $20 and takes 20 minutes of surgery.

There have been roadblocks along the way, however. Cataract surgery removes the clouded eye lens and replaces it with a synthetic intraocular lens. When CBF started the eye camps, these lenses cost about $300, making them "unaffordable" for the program.

...

In 1992, CBF and its partners helped create Aurolab, an intraocluar lens and suture factory in Madurai, India. The factory produces high quality lenses and sutures at a low cost, making the surgery available to poor people throughout the world. At $2.50 per lens and $1.00 per suture, Aurolab distributes the supplies to not-for-profit organizations in 120 countries.

Now that's the kind of charity -- and innovation -- I can get behind. Way to go Dr. Suresh Chandra!