Sunday, May 13, 2007

Health System - The New York Times Reports “Good News” About American Health Care

That’ll Be The Day

“All I know is just what I read in the papers.”

Will Rodgers,1879-1935

I await the day when The New York Times runs a series of “good news” articles about the state of American health care. The series might have these titles,

• Americans Trust Their Doctors
• Americans Have Greater and Quicker Access to High Tech Diagnostic and Curative Care Than Any Other Nation
• Foreign Physicians Flock to America for Training Unavailable in Their Country
• Record Numbers of Canadians Cross Border for Life-Saving Care
• America Achieves Unprecedented Longevity Gains in Last Decade
• Americans Receive 80 Percent of Noble Prizes in Medicine
• Research at American Pharmaceutical Companies Produces 90 Percent of the World’s New Drugs
• America’s Innovative Health System’s Variety and Choice the Wonder of The World

That’ll be the day.

The Times in 2005 and 2006 had a series of a dozen articles entitled “Being A Patient.” These focused largely on the perils of being a patient in America. Now The Times is embarked on a series on medicine and money, focusing on profit-mongering drug and medical device companies in league with greedy specialists to bilk the public.

It all comes down to altitude and attitude. From their lofty perch, The New York Time’s editorial staff has yet to tumble to the reality America is basically a conservative nation, distrusts centralized government, wants choices of care and providers, demands access to the wonders of high tech medicine, and believes a market-based system, with all its faults, such as profits for entrepreneurial and innovative health care companies and doctors, are worth the price and value received.

It is almost as though The Times denies the existence of entrepreneurial capitalism in American health care. Our health system blends innovative large and small firms striving for economic growth. Such a system entails risk – workers who lose jobs and health insurance, widening of gaps between winners and losers, competition with some jobs going to skilled workers abroad who have increasing skills, occasional bankruptcies among those unable to pay health care bills. American capitalism is imperfect. It requires oversight to reduce risks without losing entrepreneurial vigor. Unremitting accusations of bad faith and constant “bad news” stories don’t strengthen health care.

Read the The New York Times, and you’ll come away believing pervasive avaricious greed corrupts American health care and will break our already “broken” system.

From May 9 through May 11, The Times ran 10 articles on how drug companies deceived the public and entered into unholy alliances with doctors to sell more drugs to produce more revenue for doctors, how doctors willingly entered into these alliances solely for material gain, and how lobbyist-tainted and incompetent FDA failed to monitor new drugs and harmed patient safety.

The May 9 front page, right top column, the prime spot for highlighting news, featured these headlines,

Doctors Reaping Millions for Use of Anemia Drugs. Payments from Industry. Concerns over Safety – Critics See Incentives for Higher Doses.

The opening Section read:

“Two of the world’s largest drug companies are paying hundreds of millions of dollars to doctors every year in return for giving their patients anemia medicines, which regulators now say may be unsafe at commonly used doses.
The payments are legal, but very few people outside of the doctors who receive them are aware of their size. Critics, including prominent cancer and kidney doctors, say the payments give physicians an incentive to prescribe the medicines at levels that might increase patients’ risks of heart attacks or strokes.
Industry analysts estimate that such payments — to cancer doctors and the other big users of the drugs, kidney dialysis centers — total hundreds of millions of dollars a year and are an important source of profit for doctors and the centers. The payments have risen over the last several years, as the makers of the drugs, Amgen and Johnson & Johnson, compete for market share and try to expand the overall business.”

The Times
appears bent on publishing on its front pages “All the Bad News that’s Fit to Print about U.S. Health Care.” The May 9 article is part of a series of medicine and money, all decrying collusive relationships between big business and bad doctors. The Times series focus on the pharmaceutical industry and medical device industries , and how these industries reward specialists who overuse products for financial gain.

To The Times, the American health system has become a morality play,

• the good guys (The Times and other assorted elites and policy pundits) vs. the bad guys (profiteering health companies and doctors);
• the greedy (well-healed executives and “rich” doctors) vs. the needy (poor patients in the throes of cancer or kidney dialysis);
• the high brows (academics and journalists who know what’s right for the common good) vs. the low brow commercial types (who do almost everything wrong as long as it suits their own financial self-interest).

I don’t wish to pick a fight with a media outlet who buys ink by the barrel. I know “bad news” sells better than “good news.” I know The Times considers itself the Watchdog and Whistle-Blower against mean-spirited, profiteering conservatives. I don’t question our capitalistic system needs oversight to reduce abuses.

I’m simply seeking more balance in The Times reporting. For an example of this imbalance, in its May 9 piece, The Times dismisses America doctors’ overuse of anemia-correcting drugs for cancer and dialysis as a deliberate effort to make money. To make its case, The Times notes American doctors,

• prescribe more drugs than European counterparts ( Did it ever occur to The Times maybe, just maybe, European doctors “under-prescribe” and maybe their patients have less positive results? )

• conssciously endanger patients for profit when they know anemia drugs are unsafe (Has it occurred to The Times American physicians prescribing these drugs believe higher hemoglobin levels are “good” for improving health and alleviated distressing symptoms attributable to anemia.)

• Continued to prescribe drugs even after studies indicated hemoglobin levels above 12 might endanger patients ( Did it ever occur to The Times the studies indicating “possible” risk studies were far from conclusive and only appeared in March?)

Nor does The Times point out doctors themselves often criticize thenselves. For instance, on a May 11 blog, “The Doctors Weighs in on Cancer,” Dr. Dov Michaeli, an academic physician and biochemist who does cancer research takes the American Society of Clinical Oncologists (ASCO) to task for responding to the Times defensively (see epilogue to this blog for a reprint of ASCO letter to The Times).

Of the ASCO letter to the times (reprinted in epilogue), Dr. Michaeli acidly comments “ASCO makes that same argument that professional people make when colleagues are caught with their hands in the cookie jar: most of us are conscientious, hardworking people. Granted, but it turns a blind eye to the corrosive influence of pharmaceutical companies on the use of drugs. This is denial of how our health system ‘works’ on a daily basis.”

Michaeli concludes: “As the wheels are coming off our broken health system, more revelations of waste, abuse, greed and outright criminality are bound to surface. What are we going to do about it?”

Good question. I suggest we start with a more balanced view of the system.

• First, I reject the notion the system is “broken” – and constant reference by academic critics of greed by practitioners as a cause for this brokenness ( Michaeli, an academic researcher, shows some of this bias when he says, “ ASCO is led by academic clinicians and researchers, whose motivation and dedication is admirable. But many of the rank and file, community practitioners, are not beyond temptation.”

I doubt medical academicians, who compete for pharmaceutical company grants and who run clinical trials, are beyond temptation. I’m unaware academic physicians wear halos and only practicing doctors are vulnerable to “temptation.”

• Second, I believe critics ought to acknowledge health care is an innovate force in our economy, will soon represent 20 percent of the nation’s GNP, and is the nation’s largest employer. Professional managers, whose job is to maximize resources and revenues, run most health care enterprises - hospitals, medical practices, drug and device manufacturers. If overzealous pursuit of revenues and resources leads to excess, managers should be condemned, even fined and jailed, but it shouldn’t be assumed or taken for granted pharmaceutical and medical device companies and doctors are always seeking mutually beneficial arrangements are ipso facto evil doers.

What the media in general, and The New York Times in particular, needs is a more balanced view. An occasional dollop of good news, such as more than 50 percent of cancer victims are now surviving, more than 10 million cancer victims are living with their disease, and genetically engineered cancer drugs are contributing significantly to cancer cures, would help achieve that balance.

I’m pleased to report the May 12 issue of The Times contains a “good news” piece on Becton, Dickinson & Company. It’s buried on the third page of the business section. It’s titled “Medical Gear That Rarely Makes News.” It consists of an interview with Edward J. Ludwig, CEO of Becton and Dickenson, with revenues of $5.7 billion last year, on sales of syringes, diagnostic kits, lab equipment, and related gear.

The unifying theme behind the company’s success is its emphasis on safety in its products to protect doctors, nurses, and patients with shields, sliding clasps, and needle retracting into the device. Its ambition is to make a significant dent in the 2 million infections each year from antibiotic resistant staphococci killing 90,000 Americans each year and costing $6 billion yearly to treat. Toward that end, B &D has acquired a diagnostic system allowing them to quickly identify the offending bacteria. Use of this system to screen every patient. entering Evanston Northwestern Hospital reduced infections by 60 percent. Ludwig contend s private innovation will help the “broken” health system to heal itself by attacking safety problems, and improving care. What the media needs is a new more flexible mindset allowing them to become more innovative in reporting the “good news” of our resourceful and responsive health system.

Epilogue: In the interest of being “fair and balanced” (a term the mainstream media now considers anathema since Fox News adopted it as their slogan), I reprint six letters from the May 13, Sunday, New York Times. The Times deserves credit for publishing letters representing both points of view.

Best Drug, or Best Money Maker? (6 Letters)
1) To the Editor:

So two drug companies are paying hundreds of millions of dollars to doctors who prescribe anemia medicines that lack effectiveness and put a patient’s health at risk. This is not a surprise because it reflects our broken health system, a system driven by greed.

Although drug companies say their intentions are not to promote the use of more medicine for profit, there will always be the risk that some doctors will prescribe higher doses to gain that extra dollar.

As patients, we should work to eliminate the incentives to doctors and to raise patient awareness about them. We deserve the right to know the benefits of a medicine, both for us and for the doctors.
Luis Rodriguez
Daly City, Calif., May 9, 2007

2) To the Editor:

Medical care should be guided only by what is best for patients. But throughout the medical system, rebates and volume discounts are common and can create the perception of improper incentives.

Our organization has long advocated evidence-based guidelines, including those we produced in 2002 with the American Society of Hematology on erythropoietin use for chemotherapy-related anemia. With the appropriate use of erythropoietin, many thousands of patients have avoided potentially dangerous blood transfusions.
Oncologists care deeply about their patients, and the overwhelming majority treat them based on the best available evidence.

In the case of erythropoietin, recent studies prompted the Food and Drug Administration to issue a “black box” warning in March about the potential dangers of using erythropoietin to boost hemoglobin to levels higher than guidelines recommend. Early evidence suggests that doctors factored this new data into their prescribing decisions and have reduced erythropoietin use.

As a whole, the medical community needs to better determine the impact financial incentives may have on prescribing patterns and patient care, to ensure that patient needs continue to be at the forefront of medical decisions.

Allen S. Lichter, M.D.
Exec. V.P., American Society of Clinical Oncology
Alexandria, Va., May 10, 2007

3) To the Editor:

Many doctors appear dissatisfied with fees ethically garnered from clinical evaluation and management. They can and will prescribe for personal profit, and will readily reshape and expand diseases to suit the available reimbursement. Without disclosure, patients are typically the last to know there might be a problem.

The investigation of anemia drugs no doubt could expose the self-serving logic, unethical inducements and poor administrative surveillance that permit exploitation of the public’s soft financial underbelly. Unfortunately, there are plenty of other specialties of medicine where such professional betrayals occur. And adequate regulation is not likely to occur in the financial free-for-all of private medicine.

James H. Lampman, M.D.
Bismarck, N.D., May 9, 2007

4) To the Editor:

The discovery and development of growth factors that stimulate the bone marrow to produce red cells was a milestone in modern medicine. In the appropriate setting, these growth factors can improve blood counts and quality of life and spare patients time-consuming, expensive, short-lasting and risky transfusions.

In our practice the increasing use of these medicines is driven by the fact that they work so well. As with any new therapy, these medicines need to be used within established and developing guidelines to avoid serious side effects.

Since there are two competing and equally effective drugs, the drug makers are offering incentives for preferential use — the natural outcome of a free-market economy.

Deciding how regulators might control drug makers is an important undertaking, but it should not detract from the tremendous benefits of these drugs when used in the right situation.

Birjis Akhund, M.D.
Chief of Medical Oncology
Huntington Hospital
Huntington, N.Y., May 9, 2007

5) To the Editor:

America has the best medical care in the world. It is the most advanced and expensive. The first two qualifications are debatable, but the third is difficult to refute.

The great expense is complicated by the high cost of drugs and procedures of dubious benefit.

The likelihood of being prescribed drugs of dubious benefit is obviously increased by kickbacks to doctors. The kickbacks may be legal, but should they really be allowed? The cost of medicine is increased by this practice, and the quality is sure to suffer.

Alex Floyd
Lexington, Ky., May 9, 2007

6) To the Editor:

“Doctors Reaping Millions for Use of Anemia Drugs” (front page, May 9) was disturbing. I found it equally disturbing that the continuation of the article was in Business Day. In the past two decades, I have observed that news of important medical advances increasingly appears in, or is continued in, the business section.

This practice advances the thinking that health care is primarily a business in which providers reap riches, rather than a humane social endeavor in which providers earn their living.

Ira D. Feirstein, M.D.
New York, May 9, 2007


Exile said...

Very good observations Doctor. There's still too little popular opinion leaders who would be able to balance the views of public opinion on how it really is with pharma - MD - Patient relations. I haven't read your blog before. Got here through 'Google Alerts' but I will be a returing visitor surely. Yours Sincerely Doctor.

Mike said...

The anemia articles were prompted by NEJM articles from a few weeks ago exposing the problem. We've known the evidence for pumping up Hgb above 11 was not improving outcomes and increasing risk of stoke.

Bottom line is, the media's job is to keep a watch on this. Also, MD's are forced to resell drugs to paitnets for profit because of dwindling reimbursement, as you say. but doctors don't like it.

As far as FOX news, the NYTimes is worse because people believe they are liberal, yet they trash democratic candidates and ideas to no end. FOX isnt the problem. They're a fringe channel. No one is getting new opinions from FOX. They only watch to reinforce their old opinions.

But NYTimes readers can be swayed by the slanted diatribes. (i.e. Maureen Dowd, Frank Rich). So the Times has truly been stinking for awhile.