Mexico is even more local, from a US perspective. Those who argue that the free market is a more efficient mechanism (than, say, Medicare or Medicaid in the US) for distributing healthcare to the poor can cite what seems to be a pretty good example in Mexico, where a massive pharmacy chain is medicating the masses at prices lower than they would pay through the Mexican government’s own new program for poor Mexicans.

The prescribing of drugs for off-label uses is one reason why the concept of evidence-based medicine (EBM) needs to be expanded to encompass more than just evidence from formal trials and studies, which is how many people currently think of EBM. If all the patients receiving off-label therapy had an electronic medical record (EMR), and all EMRs nationwide were available for data mining, then it would be enormously useful in providing evidence of the safety and effectiveness of the off-label uses, and could even be tailored by specific patient demographics. The key is a nationwide system of EMRs — and while paying lip service to it by creating an underfunded coordinating office, the Bush administration has done very little to advance that cause for the US. As an article in Health Affairs noted again recently, the US is about at the bottom of the list of civilized nations creating national EMR infrastructures.

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Johns Hopkins Medicine International has cut ribbons on new Hopkins-affiliated hospitals in Lebanon and Panama, is consulting a new hospital in Ireland, has opened a “co-branded” Center for Safety, Quality and Management with a technical institute in Mexico, signed a contract to run a hospital in the UAE state of Abu Dhabi, and runs what Baltimore Sun reporter William Salganik calls “a micro-Hopkins” in Singapore. The trend is catching on, he says, with “somewhere between a dozen and two dozen . . . seeking patients — and income — overseas.”

It is too early to tell whether such “reverse outsourcing” makes business sense, though “The kinds of deals being pursued now target countries that need modern medical facilities and can pay for them.” In any event, the business case looks bleak enough for US hospital systems squeezed at home as a result of discounts forced on them by insurers, the outmigration of inpatient procedures to the outpatient setting, and reduced lengths of stay. Academic hospitals in particular must find new revenue sources somewhere, as the squeeze on patient revenue is a squeeze on teaching and research. International patients, Salganik points out, pay full price and don’t need an HMO’s permission for a hospital stay or a procedure. “I had the CFO of a major teaching hospital tell me international patients made up 5 percent of their patients and 50 percent of their profit,” said Dr. Robert K. Crone, dean for international programs at Harvard Medical School and president and chief executive of Harvard Medical International.

The Sept. 11 attacks caused US visa restrictions and delays for international patients. While Hopkins treated more than 4,500 international patients in fiscal 2001, the number fell to about half that in fiscal 2003, and is projected at fewer than 3,500 for the current fiscal year. “[T]hose patients are not coming back,” Crone said, so the mountains must go to Mohammed. In some cases, as for Harvard Mecial International – the mountain merely (but presumably profitably) offers its brand and reputation for quality to overseas hospitals, setting up the quality assurance systems and monitoring outcomes for foreign hospitals. The University of Pittsburgh Medical Center, on the other hand, has a direct hand in operating and staffing hospitals in Italy and Ireland.

Johns Hopkins’ “micro-Hopkins” employs the staff and runs two 18-bed oncology units inside a Singapore hospital, and also does research and teaching there, with funding from the government of Singapore. “So,” Salganik concludes, “the precise model — limited consulting, more comprehensive consulting, management, full operation — varies among American hospitals and even within Hopkins.” The corresponding revenue models range from consulting fees to share in operating profits. A JHMI spokesman admitted to “some profit the past two years,” though the consulting revenue was still just a small fraction of the US$50 million (before costs) received by the hospital and doctors from patients who traveled to Baltimore in fiscal 2005.

Market Medicine for the Mexican Masses

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To the consternation of the Mexican government and the pharmaceutical companies, millions of impoverished Mexicans (and people in 11 other countries) have turned their backs on the crowded government health care system and its high-priced brand-name medications, and instead flock to a discount drugstore chain called Farmacias Similares, reports Eliza Barclay in the Houston Chronicle.

Founded in 1997, Farmacias follows the Wal-Mart business model — keeping costs low through large volume purchases and by cutting out middlemen. It has its own packaging company, a laboratory for manufacturing generic versions of patented drugs, and 3,685 pharmacy franchise branches which in 2005 the chain sold US$570 million-worth of drugs and healthcare services at prices “that seem cheap even in Mexico,” says Barclay. A consultation with a Farmacias doctor costs only US$2, most medications are under $5, and lab services like ultrasounds go for $12.

The Mexican government’s recently launched “Seguro Popular” health insurance plan for 55 million uninsured Mexicans (about half the population) had 3.5 million members in May, with another 1.6 million expected to join by year’s end. An economist who has studied the Mexican medical sector told Barclay that Seguro Popular is flawed because it only covers specific illnesses as part of a limited package of services.

Off-label Drug Use

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Once a drug reaches the market, doctors can legally prescribe it for any diagnosis, writes Shari Roan in the Los Angeles Times. And they do: 20 percent of all prescriptions are written for nonapproved or “off-label” uses, according to a recent study. Psychiatric drugs and allergy medications were the most likely types of drugs to be used off-label, yet scientific support was lacking for 96 percent of the off-label uses of psychiatric drugs. Off-label use is not necessarily bad, because sometimes the use is not wildly off-label, sometimes it works, and sometimes there is no other choice. What worries the study’s authors is the off-label use of drugs without good information.

(Editor’s comment: What worries Health Futures Digest is that the technology to collect that information — in the form of a national health information network of linked EMRs — could be built in the US, but progress is too slow.)