Post by unlawflcombatnt on Aug 14, 2009 16:51:43 GMT -6
As I alluded to in a previous post, the current Health Care Reform Legislation was written by the health insurance industry and for the health insurance industry. It's an overt plan to subsidize health insurers with taxpayers' money. It's goal is to add 50 million Americans to private health insurers' revenue stream by government edict. If insurance lobbyists successfully block the public option, the People receive no overall benefit from the bill. To the contrary, they will be fleeced by private insurers, with the Government's blessing.
There are many things wrong with the current legislation, both on specifics and broad underlying concepts. Some involve deceptive & falsely claimed broad general goals. Some involve exaggerated or completely fictitious benefits from certain policies. Some truly worthy goals have suggested solutions that are worthless, and even counterproductive to those very goals. I'll discuss some of them here.
The 1st of these areas is preventative care.
One myth revolves around how to save money through preventative care. The proposed guidelines for preventative care are minimally effective at best. They require that more physician time be devoted to counseling patients to change dietary and lifestyle habits. And since such counseling rarely accomplishes anything, physician time is largely wasted. As such, payment for this counseling is also wasted.
The best single "preventative" measure would be to eliminate the deductible. Deductibles discourage patients from seeing the doctor for an initial visit—the visit that has THE most potential for preventative care. If preventative care were a genuine goal, deductibles would be banned. The whole notion of "catching a disease early" is best served on the patient's 1st visit. Discouraging that 1st visit works directly against that goal.
A 1st visit can easily screen for some of the major factors that increase the risk of the #1 killer of Americans—Heart Disease. Most of this is related to coronary artery atherosclerosis (narrowing of the arteries from plaque deposition in the arterial walls). The major factors affecting this—increased blood pressure, diabetes, & increased cholesterol—can be easily screened for. All 3 conditions have multiple treatment options available that cost patients less than $10/month. All have at least some treatment options for less than $5/month. All treatments for these 3 conditions reduce the incidence of atherosclerotic heart disease, along with the mortality associated with them. Effective treatment of any of these 3 conditions prolongs life, & reduces the annual incidence of heart attacks, strokes, & amputations due to vascular disease.
When it comes to preventative care, identification & treatment of just these 3 conditions reduces annual mortality & morbidity. And again, these can all be identified from the labs on the 1st visit. In fact, diabetes and high blood pressure can be identified DURING the 1st visit.
The notion that these 3 diseases—high cholesterol, diabetes, & high blood pressure—can be prevented from "healthy life styles" is somewhere between grossly exaggerated and completely fictitious.
Let's start with cholesterol.
Most cholesterol is made by the liver, with dietary ingestion making only a small contribution. And when dietary intake is high, it evokes at least a partial feedback on the liver, causing the liver to produce less cholesterol. Dietary management is rarely successful in bringing elevated cholesterol levels down to the desired level. In contrast, "statin" drugs are extremely effective at doing so, and are quite inexpensive, even to a patient paying the full cash price. For example, 90 days worth of pravastatin is available at a cash price for as little as $10—or less than $4/month.
{It's worth noting the scene from one of President Obama's town hall meetings where a patient bemoaned the fact that his insurance company wouldn't pay for his brand name "statin" — Lipitor (or atorvastatin) — but would pay for a cheaper generic substitute. In fact, Irish-made Lipitor is one of the statins there is no generic available for, due to patent exclusivity. However, multiple generic statins are available, and work every bit as well as Lipitor. (Pravastatin is one example, though other generics such as simvastatin, lovastatin, and fluvastatin are also available and inexpensive. Lovastatin is also available for less than $4/month).}
And in the case of statins and the lowering of cholesterol, cost-effectiveness is not the only benefit (i.e., the benefit of lowering cholesterol with statins, vs. through diet). Statins also have an independent, anti-atherosclerotic effect beyond their simple lowering of cholesterol. Thus, even if patients could actually lower their cholesterol 20% through diet, they would be better off lowering it 20% with a statin. The statin confers an additional anti-atherosclerotic effect that dietary treatment does not.
The same applies to the treatment of high blood pressure. Dietary intervention is rarely successful, and even less so over the long term. Here again, multiple effective drugs are available for treatment. Most are available generically, and most are quite inexpensive.
The most important class of drugs in this category is the angiotensin-converting-enzyme-inhibitors (ACEIs). These drugs ultimately work by dilating arterioles, which reduces blood pressure at a sufficient dose. Here again, a 90-day dose of an ACEI—such as lisinopril—has a cash price as low as $10. This would put the monthly cost at less than $4.
Like statins, ACEIs have anti-atherosclerotic effects that are independent of their blood pressure-lowering effect. This is even more easily demonstrated here, as an insufficient dose of an ACEI will not lower blood pressure any. Yet even at non-blood pressure lowering doses, ACEIs reduce atherosclerosis, and acute events resulting from atherosclerosis. As with statins, patients receive more benefit from a 20% reduction in blood pressure with ACEIs, than they do from a 20% reduction from any type of lifestyle modification.
The case with diabetes is similar. Inexpensive generic drugs are available that will lower blood sugar into the normal range. Again, there are many drug choices available. Most work by increasing the pancreatic insulin output. Typical of these is glyburide, which can be purchased at a cash price for as little as $10 for 90, 5mg. tablets.
Another category of anti-diabetes drugs are those that increase the body's sensitivity to insulin, thus reducing high blood sugar levels without increasing insulin output.
There are 2 general classes of drugs of drugs here. The 1st category is exemplified by metformin, which is available generically. In some areas of the country metformin can be purchased for a cash price of $10 for a 90-day supply. Here again, this puts the 1-month patient cost at less than $4.
The other category is the thiazolidinediones, or "glitazones" for short. The best example is pioglitazone. Pioglitazone works by increasing the sensitivity of the body to insulin, causing blood sugar to be reduced at any given level of insulin. Since the drug works only by facilitating the effect of the body's own insulin, it does not cause hypo-glycemia.
But pioglitazone is also believed to have additional anti-atherosclerotic effects, beyond just the lowering of blood sugar. Multiple studies show that it reduces several pro-atherosclerotic inflammatory mediators. It also reduces LDL cholesterol, or "bad" cholesterol.
Perhaps more importantly, however, some studies suggest that glitazones reduce the actual occurrence of diabetes, and may either delay its onset, or completely prevent its occurrence altogether. This is thought to be due to the preservation of the insulin-secreting cells of the pancreas, by either reducing the amount of insulin that is secreted, by reducing triglycerides which may damage the pancreas, or some combination of both. (These studies should be viewed with some caution, however, as most were conducted by the drugs' manufacturers).
Assuming that there is truth to these studies, however, means that these drugs may delay the onset of diabetes, or prevent its occurrence altogether. Thus the taking of a "glitazone" may literally be a "preventative" measure by itself.
Unfortunately, glitazones are not yet available generically. Thus preventative treatment with them would not be as inexpensive as the simple treatment of high blood pressure or high cholesterol. However, if the long-term costs of diabetes are as high as some claim, then preventative treatment with glitazones may still be very cost effective.
Preventative treatment may well improve health and increase longevity. But if it is to do so, that treatment must be truly effective. And the effectiveness should be determined by established, well-documented medical studies--not by wishful thinking, and not by the self-serving & opportunistic fantasies of politicians & bureaucrats, from either government or the private insurance industry.
There are many things wrong with the current legislation, both on specifics and broad underlying concepts. Some involve deceptive & falsely claimed broad general goals. Some involve exaggerated or completely fictitious benefits from certain policies. Some truly worthy goals have suggested solutions that are worthless, and even counterproductive to those very goals. I'll discuss some of them here.
The 1st of these areas is preventative care.
One myth revolves around how to save money through preventative care. The proposed guidelines for preventative care are minimally effective at best. They require that more physician time be devoted to counseling patients to change dietary and lifestyle habits. And since such counseling rarely accomplishes anything, physician time is largely wasted. As such, payment for this counseling is also wasted.
The best single "preventative" measure would be to eliminate the deductible. Deductibles discourage patients from seeing the doctor for an initial visit—the visit that has THE most potential for preventative care. If preventative care were a genuine goal, deductibles would be banned. The whole notion of "catching a disease early" is best served on the patient's 1st visit. Discouraging that 1st visit works directly against that goal.
A 1st visit can easily screen for some of the major factors that increase the risk of the #1 killer of Americans—Heart Disease. Most of this is related to coronary artery atherosclerosis (narrowing of the arteries from plaque deposition in the arterial walls). The major factors affecting this—increased blood pressure, diabetes, & increased cholesterol—can be easily screened for. All 3 conditions have multiple treatment options available that cost patients less than $10/month. All have at least some treatment options for less than $5/month. All treatments for these 3 conditions reduce the incidence of atherosclerotic heart disease, along with the mortality associated with them. Effective treatment of any of these 3 conditions prolongs life, & reduces the annual incidence of heart attacks, strokes, & amputations due to vascular disease.
When it comes to preventative care, identification & treatment of just these 3 conditions reduces annual mortality & morbidity. And again, these can all be identified from the labs on the 1st visit. In fact, diabetes and high blood pressure can be identified DURING the 1st visit.
The notion that these 3 diseases—high cholesterol, diabetes, & high blood pressure—can be prevented from "healthy life styles" is somewhere between grossly exaggerated and completely fictitious.
Let's start with cholesterol.
Most cholesterol is made by the liver, with dietary ingestion making only a small contribution. And when dietary intake is high, it evokes at least a partial feedback on the liver, causing the liver to produce less cholesterol. Dietary management is rarely successful in bringing elevated cholesterol levels down to the desired level. In contrast, "statin" drugs are extremely effective at doing so, and are quite inexpensive, even to a patient paying the full cash price. For example, 90 days worth of pravastatin is available at a cash price for as little as $10—or less than $4/month.
{It's worth noting the scene from one of President Obama's town hall meetings where a patient bemoaned the fact that his insurance company wouldn't pay for his brand name "statin" — Lipitor (or atorvastatin) — but would pay for a cheaper generic substitute. In fact, Irish-made Lipitor is one of the statins there is no generic available for, due to patent exclusivity. However, multiple generic statins are available, and work every bit as well as Lipitor. (Pravastatin is one example, though other generics such as simvastatin, lovastatin, and fluvastatin are also available and inexpensive. Lovastatin is also available for less than $4/month).}
And in the case of statins and the lowering of cholesterol, cost-effectiveness is not the only benefit (i.e., the benefit of lowering cholesterol with statins, vs. through diet). Statins also have an independent, anti-atherosclerotic effect beyond their simple lowering of cholesterol. Thus, even if patients could actually lower their cholesterol 20% through diet, they would be better off lowering it 20% with a statin. The statin confers an additional anti-atherosclerotic effect that dietary treatment does not.
The same applies to the treatment of high blood pressure. Dietary intervention is rarely successful, and even less so over the long term. Here again, multiple effective drugs are available for treatment. Most are available generically, and most are quite inexpensive.
The most important class of drugs in this category is the angiotensin-converting-enzyme-inhibitors (ACEIs). These drugs ultimately work by dilating arterioles, which reduces blood pressure at a sufficient dose. Here again, a 90-day dose of an ACEI—such as lisinopril—has a cash price as low as $10. This would put the monthly cost at less than $4.
Like statins, ACEIs have anti-atherosclerotic effects that are independent of their blood pressure-lowering effect. This is even more easily demonstrated here, as an insufficient dose of an ACEI will not lower blood pressure any. Yet even at non-blood pressure lowering doses, ACEIs reduce atherosclerosis, and acute events resulting from atherosclerosis. As with statins, patients receive more benefit from a 20% reduction in blood pressure with ACEIs, than they do from a 20% reduction from any type of lifestyle modification.
The case with diabetes is similar. Inexpensive generic drugs are available that will lower blood sugar into the normal range. Again, there are many drug choices available. Most work by increasing the pancreatic insulin output. Typical of these is glyburide, which can be purchased at a cash price for as little as $10 for 90, 5mg. tablets.
Another category of anti-diabetes drugs are those that increase the body's sensitivity to insulin, thus reducing high blood sugar levels without increasing insulin output.
There are 2 general classes of drugs of drugs here. The 1st category is exemplified by metformin, which is available generically. In some areas of the country metformin can be purchased for a cash price of $10 for a 90-day supply. Here again, this puts the 1-month patient cost at less than $4.
The other category is the thiazolidinediones, or "glitazones" for short. The best example is pioglitazone. Pioglitazone works by increasing the sensitivity of the body to insulin, causing blood sugar to be reduced at any given level of insulin. Since the drug works only by facilitating the effect of the body's own insulin, it does not cause hypo-glycemia.
But pioglitazone is also believed to have additional anti-atherosclerotic effects, beyond just the lowering of blood sugar. Multiple studies show that it reduces several pro-atherosclerotic inflammatory mediators. It also reduces LDL cholesterol, or "bad" cholesterol.
Perhaps more importantly, however, some studies suggest that glitazones reduce the actual occurrence of diabetes, and may either delay its onset, or completely prevent its occurrence altogether. This is thought to be due to the preservation of the insulin-secreting cells of the pancreas, by either reducing the amount of insulin that is secreted, by reducing triglycerides which may damage the pancreas, or some combination of both. (These studies should be viewed with some caution, however, as most were conducted by the drugs' manufacturers).
Assuming that there is truth to these studies, however, means that these drugs may delay the onset of diabetes, or prevent its occurrence altogether. Thus the taking of a "glitazone" may literally be a "preventative" measure by itself.
Unfortunately, glitazones are not yet available generically. Thus preventative treatment with them would not be as inexpensive as the simple treatment of high blood pressure or high cholesterol. However, if the long-term costs of diabetes are as high as some claim, then preventative treatment with glitazones may still be very cost effective.
Preventative treatment may well improve health and increase longevity. But if it is to do so, that treatment must be truly effective. And the effectiveness should be determined by established, well-documented medical studies--not by wishful thinking, and not by the self-serving & opportunistic fantasies of politicians & bureaucrats, from either government or the private insurance industry.