Reading Notes #2 (For-profit medicine): Cancer drugs. Expensive doctors. Health care monopolies. Dental care.


Here are more articles of interest I’ve come across recently while reading NEJM, JAMA, and New Scientist. These items all relate to for-profit medicine.

Bulleted titles in the following list link to the individual items below. Under References I indicate the accessibility of articles: OA means open access, $ indicates a pay wall. Note that emphasis in quotations has been added by me.


• Big pharma and cancer drugs

It shouldn’t take years and a billion dollars to create a new cancer drug. Biohacker Andrew Hessel aims to do it in a day.

When he was working for big pharma, Andrew Hessel was frustrated by how much time, money, and resources were expended while producing meager results. After spending a year on a beach in Thailand, he decided he could do better himself. Thanks to the technology for printing DNA, genetic engineering no longer requires a laboratory. It can be done on a computer.

Hessel’s focus is cancer-fighting viruses. He’s interviewed in the New Scientist article Print a virus to kill the cancer.

What I especially admire about Hessel’s biopunk, DIY approach to the discovery and marketing of new drugs is his attitude towards for-profit medicine: He’s against it.

I want N-of-1 treatments for humans to be free. I never want to sell a drug. I see the business model shifting away from the blockbuster-drug model of the pharma industry — getting the best product for the most people and charging the most for it — to more of a Netflix model, in which you might purchase a subscription for all-that-you-need medicines to manage your cancer. So I see the designs for human cancer treatments, maybe even the designs of other disease-treatments, being very nearly free.

• How doctors learn to be expensive

The cost of health care varies depending on where you live. When you analyze the data, the cost differences between geographic regions can’t be explained either by the diseases prevalent in a region or by the characteristics of patients.

One explanation may be the location of physicians’ residency programs. According to a study published in JAMA, residency training leaves a lasting impact on how expensive a doctor’s services will be (Spending Patterns in Region of Residency Training and Subsequent Expenditures for Care Provided by Practicing Physicians for Medicare Beneficiaries).

Among general internists and family physicians who completed residency training between 1992 and 2010, the spending patterns in the HRR [Hospital Referral Region] in which their residency program was located were associated with expenditures for subsequent care they provided as practicing physicians for Medicare beneficiaries.

In their discussion, the study’s authors suggest that an “imprinting of care-related spending” takes place during residency. The imprint “decays” over time, but can last as long as 15 years. An interesting implication is that doctors who do their residency in medical centers known for high costs may face a hiring challenge. A health care practice that has a financial incentive to reduce spending may want to take a closer look at the spending pattern of the region where a doctor trained.

• Monopolies

Arguments in favor of a for-profit health care system include claims that competition will reduce costs, motivate high-quality care, and encourage investment and innovation. The desire for profits, however, encourages health care providers to consolidate, since this allows them (as a monopoly) to raise rates without any improvement in the quality of care.

Edith Ramirez, chairwoman of the Federal Trade Commission (FTC), discusses competition versus monopoly in a recent NEJM article, Antitrust Enforcement in Health Care — Controlling Costs, Improving Quality.

Critics question whether promoting competition should still be a central aim of the FTC’s agenda when it comes to health care markets. They claim that active enforcement of antitrust laws undermines efforts to contain costs through provider collaboration and is therefore at odds with the policy aims of the Affordable Care Act. In some states, legislation has been proposed that would exempt health care providers that engage in collaborative activity, including joint ventures and mergers, from antitrust review. At their extreme, these bills would encourage providers to negotiate collectively with health plans in order to extract higher rates, in effect allowing providers to fix their prices. By permitting conduct that would ordinarily violate antitrust laws, the bills would lead to higher prices and lower-quality care — undercutting the very objectives they aim to achieve. More fundamentally, the proposed legislation betrays a misunderstanding of the crucial role that competition plays in the health care sector.

Not surprisingly, in an article by someone whose job depends on the need to regulate our free market system, the question of whether medicine’s overriding objective should be profit never comes up.

• Dental care

Bruce Donoff, a dentist and MD, believes that dental care should be combined with general medical care. He and two public health colleagues make their case in the NEJM article Integrating Oral and General Health Care.

It’s time, they write, to end the “harmful separation between the mouth and the rest of the body.” Serious oral health needs, especially of adults, are not being addressed. The federal government should require all health insurance policies — Medicare, Medicaid, and private providers — to include coverage for dental care. (Medicare currently does not cover dental care unless it requires hospitalization.) Electronic health records should include information on dental health. The practice of dentistry and medicine should intersect.

Ideally, dentists and other oral health professionals would screen their patients for and address general health issues, while physicians and other health professionals assumed appropriate responsibility for their patients’ oral health, providing such services as motivational and prevention counseling and perhaps even fluoride varnishing.

The public should be educated to see access to dental care as a health issue, not simply a matter of economics, the authors argue. (In the US, a reputable dentist in private practice can be quite expensive.)

I think Donoff and his colleagues make a good case for the health benefits of dental care. I would have found their argument more convincing if the policy changes they propose came from authors who did not have a financial interest in their implementation.

There’s something else the authors avoid mentioning. Yes, we might all be healthier if we had regular dental care, covered by our insurance. The reason people fail to visit their dentist, however, is not necessarily a lack of insurance. Going to the dentist is associated with discomfort, pain, and unpleasant loud noises. If we did manage to implement universal dental coverage and integrate it with medical care, we would still have to deal with psychological resistance to the dentist’s chair.

Related posts:
Pharma finds creative new ways to be reprehensible
Profit-driven medicine: Satisfying patients at the expense of their health
Can pharmaceutical drugs benefit society?
Are the most heavily marketed drugs the least beneficial?
Patient safety and corporate profits
From MD to MBA: The business of primary care

Image source: Medical Daily


Catherine de Lange, Print a virus to kill the cancer, New Scientist, December 13, 2014, pp 28-29 ($)

Candice Chen, Stephen Petterson, Robert Phillips, Andrew Bazemore, and Fitzhugh Mullan, Spending Patterns in Region of Residency Training and Subsequent Expenditures for Care Provided by Practicing Physicians for Medicare Beneficiaries, JAMA, December 10, 2014, Vol 312, No 22, pp 2385-2393 ($)

Edith Ramirez, Antitrust Enforcement in Health Care — Controlling Costs, Improving Quality, NEJM, December 11, 2014,Vol 371, No 24, pp 2245-2247 (OA)

Bruce Donoff, John E. McDonough, and Christine A. Riedy, Integrating Oral and General Health Care, NEJM, December 11, 2014,Vol 371, No 24, pp 2247-2249 ($)


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