Saturday, July 19, 2008


I finally got to see "Sicko", Michael Moore's tirade against the American Health Insurance industry. It is, of course, a polemic rather than a documentary and therefore it can't be expected to tell the truth, but it does make some valid points.

One point was that being part of what Americans call a socialized medicine system doesn't have to impoverish doctors. Cuban doctors may work for cents but British doctors are very well paid. There are certainly multi-millionaires, but most of these have a private practice income outside the NHS. Nevertheless, there are a lot of NHS doctors taking home $200,000 a year or more.

He raved about the French system, but French taxes are very high and you have to put up with the natives taking to the streets every so often and disrupting public services. If you want a government servant to come and do your laundry during your maternity leave you have to pay for it some way.

One of the cases that he highlighted was the unwillingness of an insurance company to pay for a bone marrow transplant in a man metastatic kidney cancer who had failed high dose interleukin-2. They claimed that it was an experimental approach. Well, you can be certain that it is not available on the NHS unless it is as an experimental approach. Should Insurance Companies be expected to pay for medical experiments? I know that the NHS stem cell transplant program does fund the large transplant centers at a rate so that they can do a certain number of experimental procedures every year. The NIH also has a program of experimental transplant procedures at no cost to the patient. But such programs are run under the direction of the doctor in charge and there is no obligation that any particular patient should be taken on. In answer to the question, "Are you doing this for me, doctor, or am I doing it for you?" the answer is very much the latter. As an aside it is very unlikely that the patient would even have got high dose IL-2 under the NHS since this is not a NICE approved treatment and no-one in the UK is doing any research on it.

He also showed a case of a citizen of Detroit hopping across the border to take advantage of the free Canadian system by pretending to be the 'common-law' wife of a Canadian citizen. The first visit had to be aborted as the cops turned up. And why not? Moore seemed to be endorsing a criminal offence. Defrauding the Canadian taxpayer is no way to improve US medicine.

The truth is that whatever system of health care you have, there are flaws in it. Pharmaceutical companies have produced drugs that are more expensive that people can afford. We should see these drugs in the same way that we would see any other expensive product - a house or a yacht, for instance. I could afford a yacht if I really wanted one. I would have to arrange some way of paying for it over a period, and I would have to work out how much I would use it. Perhaps I would do it as a timeshare or perhaps rent one when I needed one.

For medicine I would also work out whether it was value for money. It is a certain as snow in Greenland that one day I am going to die. If someone offered to extend my life, I would want to know for how long, what the chances were and what it would cost in both suffering and cash.

In the UK NICE has declared that if you get a year of good quality life with a 100% certainty for $60,000 then the community will pay. If it is more expensive than that it won't. Though it is not so overt as that elsewhere, I believe that a similar value is put on human life in other Western communities. In a free market it should be possible for someone to put a value on their own life and if necessary to pay the difference, or if they can haggle with the supplier.

In reality, most communities enter into an arrangement that spreads the cost. Only a small proportion of the people will ever need Herceptin, but it might be you. Therefore, you a buy a ticket for the lottery hoping you never win, but if you do, you won't be left unable to cope. Those who don't buy a ticket are taking a risk. The trouble is that there are lots more products like Herceptin and therefore a lot more lotteries. Some people can't afford all the lottery tickets that they need. Even when the lottery organizations (insurance companies) offer you deals (ten tickets for the price of seven) there are still many people priced out of the market and some people who buy a cheaper product that quibbles when required to pay out (you didn't buy it from a recognized agent; you didn't tell us you had two left feet; you never said your grandmother was a communist). So the government steps in with safety net provisions. The argument for a national system is that if the government is going to have to underwrite the thing anyway it is going to turn out cheaper to run the whole thing than to licence a load of crooks to skim off the profits and leave you to pick up the difficult cases.

I have spent today haggling with a car dealer over a replacement for my 15 year old Mitsubishi Space Wagon. The trouble is that I want a particular model and I can't find another one nearer than 75 miles away and that is no cheaper. The dealer knows that, of course, which is why he has priced the car where he has. It's like that with Big Pharma. They know that there is a $60,000 threshold, so they price their drugs a bit above that. They are trying to drive prices up. The only thing that will bring them down is competition, but if they have a unique product why would they want to reduce their price? You might say, "You'd be better off selling some drugs for $60,000 than none at all." but they might reply, "Very well we'll sell it in Germany."

In fact, while the American market is so profligate, prices will never come down. Even if you can beat them down to $60,000, they are likely to make up the difference by raising the price for a different product that currently retails for less than $60,000.

'Sicko' over-eggs the benefit of other systems of health care and unfairly criticises the American system and there is absolute no need to. The following piece of doggerel exemplifies the attitude:

You cannot hope to bribe or twist
Thank God, the British journalist,
But seeing what the man will do
Unbribed, there's no occasion to. (Humbert Wolfe)

Michael Moore is a journalist and the three rules of journalism are : Make it juicy; Make it brief; Make it up.


Anonymous said...

Today I sit and consider my treatment options. We have one of the best health insurance plans in the United States. Yet, the $60,000price tag for a year of Revlimid will not be covered.

Twelve years of CLL has spent a majority of our lifetime limit on our policy. A transplant might save my life but it is doubtful that we have enough remaining coverage for that procedure left on our policy ($500,000+).

If God continues to bless me with added years, we will eventually face battling CLL with no remaining insurance coverage.

This is our reward for being two people who have worked hard our entire lives. Had we not worked and been on Medicaid, I would not have these worries today.

Terry Hamblin said...

Under the NHS you would certainly not get Revlimid. A transplant would be covered if you fitted teh criteria. Celgene are ripping off the public with the price they expect for Revlimid.

Anonymous said...

What annoys me the most about the American medical system is the system of deep price discounts worked out between providers and insurance companies. For example my insurance company was charged $220 for my last blood tests, but only paid $50 because of “negotiated discounts”. The insurance companies claim their volume of business give them the leverage to get command big discounts from providers. But in fact since the vast majority of health care is provided through insurance companies, this is by default the normal price for services and not a discount and I think a good part of the elevated price charged by providers is in anticipation of having to give these discounts.

The two effect of this which piss me off the most are , first that it falsely inflates the value of having insurance and therefore insurance companies can charge more for coverage (lottery tickets), and second that those who are least able to afford it get priced gouged because they don’t have coverage.

Another dirty little secret about this arrangement might be that provider like it because they really don’t want to deal with the uninsured.

John Liston

Anonymous said...

There are multiple reasons why the cost of health care in the US has risen steadily during the last 30 years and most likely will continue to do.

When I began practice, the number of available "goods and services" (ie, drugs, diagnostic studies and other therapeutic modalities) were far fewer than they are today.

The availability of these new 'goods and services' (which always seem to come with ever steeper prices) has steadily contributed to the overall cost of healthcare.

In the US, the system is tilted toward overuse for several reasons:

1. most care is paid for when given.

2. most care is provided for on a 'fee for service' basis, driving providers subconsciously at times to provide service that might otherwise not be given.

3. Americans "want it all", many people feel that it is their right to receive any and all treatments, even if they may only prolong a life of questionable quality.

4. The tort system in the US drives many providers to perform excessive tests of dubious merit and to provide services of marginal benefit so as to avoid the plague of malpractice claims.

5. the pricing system has long been one which has simply driven fees ever higher and continues to do so.

For many years most insurance companies used "UCR" pricing to pay providers...the U represents the 'usual' charge, the C represents the 'customary' charge and the R represents the 'reasonable" charge.

Using rather simple formulas these data were employed to provide the "price points" or fees paid for each provider for every service and were recalculated each year. Most providers learned how to "game" the system, raising their fees each year so that they remained above every company's UCR fees, thus guaranteeing the providers the maximal reimbursement, but simultaneously driving up the fees all services and costing the uninsured ever higher costs as it is illegal to charge less than the stated fee. (this also applies to medicare).

Certainly a provider may choose to accept less than the full payment from an individual or even from an insurer with whom he or she has not previously contracted, but it is considered fraudulent not to bill for the full amount and to make at least some effort to collect.

Compounding the problem has been the advent of provider owned diagnostic laboratories, surgicenters and X-ray, CT and MRI equipment which generates great additional cost to the system by doubling efforts and likely increasing utilization.

Although doctor's might not like to admit it, they are no different from other people at the heart of it and if they invest a lot of money in owning a CT or MRI machine they are more inclined to use it than not.

I have personally seen how much one's income can be increased by ownership in a surgicenter. Even though my patients received excellent care and preferred going there to going to the hospital, I know that it has cost the system a lot by duplicating things already available.

I can see most (surely not all) of the problems, but admit that I don't have all of the solutions.


John said...

I've been uninsured for much of my life. As a perennial student- 11 years as a undergrad and graduate student- when I have had insurance it wasn't all that good. That being said, I've never had a problem getting quality health care. Even when I couldn't pay at the time of the service, I was cared for and ended up with a bill that I could pay over time. I am still paying for an appendectomy I had back in 2001. Am I mad? Nope. The surgeon who performed it did an excellent job and deserves every penny.

Barry B. said...

Dr. Hamblin feels that drug companies 'rip people off' when it comes to some drugs.

He may be right in this case, since the drug is a variant of thalidomide, which is off patent and has undesirable side effects.

However, it must be remembered that it takes about $802 million to get a drug from discovery to the marketplace. And if a drug fails in a phase III trial, the money is never recouped.

One would hope that drug companies, hospitals, doctors and everyone else where saints and tempered their monetary expectations with concern for the patient. That is not true all of the time, or perhaps most of the time.

However, I would much rather have a private entity that had to compete for business run the medical insurance system than the government. The government is incompetent and does only two things well; national defense and collecting taxes.

Medical care is expensive because there are more medical tests, equipment, and procedures these days.

The UK and other socialized medicine countries don't offer all that the American system does. Why anyone would want to mess with that is beyond me.

Terry Hamblin said...

Another example of companies ripping off the customer is Treanda. This is a very old drug devloped in the old East Germany under the communists. It has long been off patent and there are virtually no development of manufacturing costs. You would never think so given the price! There will need to be a clinical trial, but the marketing costs will never justify the price being asked.