| Accelerating Diabetes
Participants in a recent conference on diabetes said “there aren’t enough
doctors or hospitals in the country” to provide care to the burgeoning diabetic
and pre-diabetic population in the United States, reports Holly Edwards in
The Tennessean. They call therefore for community-level preventive
programs on diet and exercise.
Good diet and exercise could prevent so much diabetes, but there are two
troubling questions. First, is society prepared to pay for prevention? The
paucity of spending on preventive programs and the failure to regulate the food
industry would suggest it is not, even though it ends up spending far more in
remedial care. The second question is whether people’s dietary and exercise
habits can be changed anyway, given the myriad attractions, from TV to fast
food, that mitigate against the success of preventive programs, however well
funded. HFD suspects the answer is that habits cannot be changed in a
non-coercive, technologically advancing society; that the public will expect
healthy, trim bodies to be obtained from a pill; and that accaelerating
technological innovation is poised to deliver that pill.
* But a good deal could be done at the source —
the food manufacturers — on the dietary side.
Reference: Edwards, Holly (2003). “Doctors
fear devastating diabetes epidemic.” The Tennessean, November 16.
The Trend to Superhealth
Despite a high risk of complications, a high cost-per-procedure of
US$20,000-25,000, a high startup cost of US$2 million or more to the hospital,
and very expensive malpractice insurance for surgeons who perform it, the demand
for bariatric surgery is booming, reports Graham Scott in the Baltimore
Business Journal, citing numbers from Johns Hopkins, Sinai, and other major
hospitals. An obvious major reason is the rise in obesity — about 60 percent in
American adults over the past decade, according to the Centers for Disease
Control and Prevention (CDC), which assesses the current financial burden of
obesity on healthcare at $99 billion annually.
One can (and insurance companies seem to do) argue whether obesity is a
disease and that its surgical removal is therefore standard medicine, but to the
extent the motivation of patients who undergo the surgery is for appearance’
rather than for health’s sake, the boom in bariatrics is further evidence of the
trend to superhealth.
Reference: Graham, Scott (2003). “Weight-loss
surgery hefty business for area hospitals.” Baltimore Business Journal,
November 7.
Med-Tech-Savvy Patients
Concerned when the results of an MRI scan of her head proved to be incorrect,
Nancy Keates of the Wall Street Journal had her head examined again —
and again — at ten medical centers and specialty MRI facilities in the US. Her
goal was to find out “Just how good is MRI?” Her conclusions: “Not all machines
are the same (even two-year-old models can be outdated), and it pays to find out
how powerful a machine’s magnet is (1.5 Tesla: good). And don’t assume the elite
places have it down pat; one of my best scans came from a relatively small
center.”
The detailed article describing her MRI odyssey is instructive in showing not
only that patients are becoming savvy about medical technology, but also that
“tesla” will soon be bandied about as freely in hospital and specialty clinic
marketing departments as it is in their technology planning committees.
Reference: Keates, Nancy (2003). “We Get Our
Head Examined.” Wall Street Journal, November 21.
Paying for Med Tech
The number of people without access to healthcare in the United States
continues to rise (from already unconscionable levels) as healthcare costs and
job losses also rise and states cut subsidies for the poor. But, notes Stephanie
Strom in the New York Times, the majority of the uninsured are not poor,
at least not by official standards; neither are they unemployed. They are
“accountants, employees of small businesses, civil servants, single working
mothers and those working part time or on contract.” Strom provides a depressing
litany of stories of suffering Americans. A Texas (where one in every four
residents is uninsured) county official told her: “Welcome to middle-class
poverty.”
Technology, properly financed, could eliminate this stain on American
society, but it would seem to require a radical conversion among the nation’s
leaders. Perhaps when radiologists and other highly paid healthcare workers join
the ranks of the uninsured poor middle classes (see “Welcome to the Working
Class” in this section), we’ll begin to see a change. In the meantime, even of
those who do have access to healthcare, 98,000 die in hospitals as a result of
medical errors, consultant Jay Srini also depressingly reminds us in the
Pittsburgh Post-Gazette. Reporting from the National Medical Innovation
Summit at the Cleveland Clinic in November, he writes that “New medical
technologies are the only way to address the ever-increasing demands of the
aging baby boomer generation and eliminating the high cost of traditional
approaches.”
And yet, “the focus on the tremendous value derived from medical innovation
is usually left largely ignored” — for example, national economic value
assessed at $48 trillion would be attained by eliminating deaths from heart
disease and $47 trillion by eliminating deaths from cancer.* The more difficult
question, he says, is who is going to pay for the innovation that will be
necessary for that eventual value to be realized?
As an example of our failure to deal with the question, he cites inadequate
reimbursement for innovative drug-coated stents — which, by eliminating repeat
angioplasties, cut the national healthcare bill (read: hospital revenues) by
about a billion dollars. The device manufacturers and drug companies show no
sign of willingness to give up any portion of their share of the take; which,
said venture capitalists at the summit, is as it should be.
Adding up the enormous cost of developing new drugs under the “blockbuster”
paradigm, and the drop off in the number of new drugs reaching the market in
2001 and 2002, Srini concludes that the paradigm is “clearly not working both in
terms of cost and efficacy,” and that personalized medicine — pharmacogenomics
— is the answer.* Even the venture capitalists agreed with that, though they
were less enthusiastic about the potential of cell-based regenerative or
reparative therapies, which the academic research community has not yet gotten
to a point where the venture community is ready to invest.
Srini is surely right. Assessing the savings from (and not just the cost of)
innovation is necessary, but evidently not sufficient to move the decision
makers to answer his key question of Who will pay? Witness healthcare’s failure
to embrace information technologies (electronic medical records in particular**)
knowing they would save money, because no-one would put up the money for
long-term investment 20 years ago, when IT was innovative. Not that it’s
easy — we write elsewhere in this issue about the acceleration of obsolescence,
which makes long-term investing difficult.
The sentiments expressed in Srini’s article are echoed by Tania Anderson
writing in the Washington Business Journal, who reports that according to
the Advanced Medical Technology Association (AMTA), spending on medical
technology increased from US$62.2 billion in 1998 to $75 billion in 2002. Some
of the spending is on brand new technologies such as videocam capsules that move
through the gastrointestetinal tract relaying images back to the physician as
they go, genetics-based lab tests, and implantable vital-sign monitors. Then
there are minimally- to non-invasive surgical devices such as the US$4 million
Gamma Knife for brain surgery, and the da Vinci robotic surgical system.
Not to mention drug-coated stents, which reduce the need for expensive and
dangerous open-heart procedures.
And some of the spending is on new generations of older technologies, such as
improved scanners that deliver sharper images and better accuracy — at a cost
of US$1.5-2.2 million, not counting associated software that can cost in the
tens of thousands. A computer-aided detection system for mammograms cost one
hospital US$100,000, but it increased detection of early breast cancer by 23
percent. At another hospital, new CT scanners expose children to much lower
levels of radiation.
Information technology spending is big at some hospitals. One has
devoted 40 percent of its technology budget to a PACS (picture archiving and
communications system) and a CPOE (computerized physician order-entry) system to
reduce medication errors.
Anderson provides a partial answer to Srini’s question: To raise the money
needed for all this technology, hospitals are getting creative — holding
fund-raisers, soliciting private donations, and testing new equipment in return
for a discount from vendors. Meanwhile, AMTA is searching for a more stable
solution by lobbying for higher Medicare reimbursements to pay for new medical
technology. “The impact on productivity will be stunning,” an AMTA executive
told Anderson. “But we don’t measure that. We just measure the [initial] cost.”
Srini does not provide the specific source for
these enormous numbers — just “according to some economists”; nor does he say
over what time period they accrue. Caveat lector.
* See also “Pharmacogenomics Speed Bump” in
the Acceleration section of this issue.
** HFD’s editor is biased toward EMRs in his
capacity as a director of the Michigan Electronic Medical Record
Initiative.
Reference: Srini, Jay (2003). “Innovative technology is
the way out of the health-care dilemma, but who will pay?” Pittsburgh
Post-Gazette, November 4.
Reference: Anderson, Tania (2003). “Operating
in a competitive environment.” Washington Business Journal, November 21.
Reference: Strom, Stephanie (2003). “For Middle
Class, Health Insurance Becomes a Luxury.” New York Times, November
16.
UK May Ban Sex Selection
Britain’s equivalent to President Bush’s Council on Bioethics has expressed
similar concerns about the use and abuse of sex selection methods, but has gone
a step further than the Council in specifically recommending a government
intervention. The Human Fertilisation and Embryology Authority (HFEA) has asked
to be given the power to regulate the use of sperm-sorting for sex selection,
based on its recommendation that sex selection should only be used when an
embryo is at risk of a serious sex-linked disorder.
The HFEA already regulates all fertility procedures in the UK involving
frozen or stored sperm or embryos, but does not regulate the use of fresh sperm.
Its recommendation was based partly on the health risks involved in the current
“gradient sorting” method of sex selection, and partly on social and
psychological factors uncovered in surveys, which reveal that 80 percent of
Britons oppose sex selection used for non-medical reasons. The UK Department of
Health is said to be inclined to accept the recommendation, but it would require
legislation for it to go into effect.
We are still working on a review of the Council on Bioethics’ report, “Beyond
Therapy,” but would comment that the Council and its British counterpart seem
not to have adequately grasped the significance and impact of the innovation
exponent and the evolutionary imperative driving it; and that tinkering with the
law is unlikely to settle the ethical issues with which they are concerned.
Reference: Bhattacharya, Shaoni (2003). “UK moves to ban
human sex selection.” New Scientist, November 12.
Public -> Private Patents
In 2002, 13 of the top 25 universities in the US saw a 50 percent or greater
increase over the number of patents issued in 1997. Six universities have seen
increases of 100 percent or more, reports Stacy Staedter in Innovation
News. There was concomitant growth in the number of university-related
startup companies and in income from patent licensing, which increasing from
US$699 million in 1997 to $1.07 billion in 2001.
“More and more,” Staedter writes, “researchers are taking time away from the
lab to write patents, consulting on technology licensed from their labs, and
even taking leaves of absence to found companies and commercialize
technologies.” Said one university official, scholars “have the sparkle in their
eye to start their own business,” and that this “can lead to innovative
educational initiatives, research breakthroughs, and a greater recognition of
the university’s role in the community.” One only hopes it will also lead to a
greater recognition of the community’s role in the university and in funding the
sparkle in the scholar-‘preneurial eye.
Reference: Staedter, Tracy (2003). “Academic
Patent Binge.” Innovation News, December /January 2004.
Spotting Fake Drugs
Counterfeit drugs are a growing problem in the United States, fueled in part
by Internet purchases from overseas suppliers. Two pharmacy professors have
developed a near-infrared spectroscope that could instantly match the unique
refractive index of a drug to a database (that would have to be supplied by
manufacturers), to determine the drug’s legitimacy. The FDA is reviewing this
and a number of other anti-counterfeit technologies, including putting tiny bar
codes on pills and holograms or RFID tags into packaging.
Reference: O’Brien, Dennis (2003). “‘Fingerprinting’
drugs could stop fakes Technology: Infrared light beams can identify medication
by chemical composition.” Baltimore Sun, November 24.
Stem Cell Research Moves Ahead in EU
The European Parliament has voted to fund research using human embryonic stem
cells (ESCs), although the EU already has in place a moratorium preventing EU
cash from going to ESC experiments, which are banned in several EU member
states. However, a vote among EU ministers to lift (or confirm) the moratorium
is imminent. The US allows federal funding for ESC research, but only for a
limited number of aging ESC lines. Supporters of lifting the European moratorium
point out that the creation of newer stem cell lines would be cheaper and result
in better research.
Reference: Reuters (2003). “EU May Fund
Embryo Cell Studies.” Wired News, November 19.
Open-Source DNA
Scientists in the UK have documented two billion letters of human, mouse,
zebra fish, malaria, whooping cough, typhoid, and other DNA in a database they
have made freely available to anyone, anywhere, anytime — in contrast to the
private ventures that charge for access to proprietary DNA databases. An
“open-source” DNA databank is “far more important than keeping the moon or
Antarctica from being private property,” one US researcher told Wired‘s
Kristen Philipkoski; “It keeps the playing field level so that 100,000
scientists have a chance to make a contribution to 21st-century understanding of
health and biology, not just those in a few private big labs.” As proof that the
open-source method delivers on that promise, more than 100 studies using the
open-source data have been published prestigious journals such as Nature
and Science.
Reference: Philipkoski, Kristen (2003). “DNA That’s Yours
for the Taking.” Wired News, November 5.
See also “Open Source and Healthcare” in
the November issue of HFD.
Welcome to the Working Class
Ostensibly to relieve a staff shortage, last year a radiologist at
Massachusetts General Hospital began outsourcing the interpretation of X-rays
and MRI scans to radiologists in India, who receive the images over high-speed
data links and, at about US$25,000 per year, are much cheaper than US
radiologists earning $250,000-350,000 a year. Needless to say, there have been
protests from American radiologists, and the American College of Radiology has
established a task force to look into the issue.
However, reports Andrew Pollack in the New York Times, “the number of
X-rays from the United States now being read in India is minuscule and . . .
regulatory restrictions are likely to keep it from growing rapidly.” Still, US
healthcare workers — even the highest-paid — are as vulnerable to the ravages
of globalization as manufacturing and white-collar workers. The outsourcing of
radiology could be followed by pathology, cytology, electrocardiogram reading,
remote intensivist monitoring of ICUs, and even remote robotic surgery.
Back-office medical work such as transcription, coding, claims processing,
billing, and bill collection has been moving offshore for years, particularly to
India, with its large population of well-educated English-speakers. Concerns
about the privacy of patient information notwithstanding, the growing pressure
on hospitals to cut costs (and to creatively finance medical technologies, as
discussed in “Paying for Med Tech” in this section) will likely lead to more
outsourcing.
Patient safety-related concerns about the competency of overseas radiologists
and other front-line medical workers will also likely take a back seat to the
unfettered free market paradigm of globalization championed by the US, not to
mention to the shortage of radiologists in the US, which is “almost in crisis
proportions,” according to the chairman of the American College of Radiology,
who acknowledges that “Demand for radiologists is growing at twice the rate that
we’re turning [them] out . . . .”
State licensure laws and Medicare non-reimbursement for off-shore services
are not the insurmountable barriers one might think. Radiologists at one of
India’s biggest outsourcers, Wipro, are not licensed in any state or approved by
any hospital. In one approach to sidestep the barriers, off-shore radiologists
do a preliminary reading (which, Pollack points out, is nonetheless used to
guide treatment of the patient at night), while a local staff radiologist
performs a final reading the next morning and bills Medicare. One doctor, who
was not even aware that preliminary readings were being done overseas, said it
was better to have them done by a qualified radiologist overseas than by a
resident still in training in the US, as is the practice at some teaching
hospitals. (Which begs another question: How are residents to gain experience?)
Wipro gets around the licensure barrier by providing image interpretations from
Wipro-employed radiologists in India to Wipro-employed licensed radiologists in
the US, who then consult with the client radiologist and bill the payer
accordingly.
The president of the American Telemedicine Association foresees a day when
online universities train doctors in foreign countries to meet American
requirements. But he also points out, reports Pollack, that it’s a two-way
street. “Telemedicine might provide a net gain to the United States because of
the expertise here to provide diagnoses for patients in other countries.”
Indeed, Pollack names several US healthcare institutions selling, or planning to
sell, their expertise in pathology, hospital management, and second opinions to
foreigners.
Reference: Pollack, Andrew (2003). “Who’s
Reading Your X-Ray?” New York Times, November 16. |
