The Uninsured:

1
The Uninsured

• Keep Them That Way Its Safer
• National Congress on the Un and Underinsured
• December 11, 2007
• Edward T. Gluckmann, M.S.
• President, Health Matters, Inc.
• 20/200 Visionary
• healthmatters_at_delhitel.net
• The opinions expressed are those of Mr. Gluckmann

2
The Uninsured Keep Them That Way Its Safer
National Congress On the Un and
UnderinsuredTable of Contents

• Introduction-Solutions
• Some Tables on Costs and Medical Care
  Received
• MCR Impact
• Infections Impact
• Cancer Death Rates, Deaths and Survivals
• Two Consumer Revolutions, One Women, One
  Men
• Pillow Talk A Foot Note On Aging Impact
• Alzheimers
• Research On Research
• How We Treat Those Who Treat Our Most Ill
• Stents, Devises
• Florida, Land Of Opportunity
• Different Visions
• Myths Deconstructed
• Can You Play This Game?
• Does He Or Does He Not?
• Political Ploys
• Cancer First and Last Word
• Q A Anybody?

3

• Solutions-change the thinking
• Solutions-eliminate profit and advertising
• Solutions-establish independent body-a public
  trust that approves only what can be platinum
  standard validated
• Solutions-convert the word medical in any title,
  activity or name to wellness and then make its
  parts comport to that goal
• Compensation is based on action to prevent first
  and treat later
• Criminalize all activity that benefits an
  individual, institution or entity that is or
  appears as a conflict
• Make them wash their hands
• Create a National Wellness Service

4

• Best Health Care System in the World
• Today, the United States is undergoing a
  significant change in the language of medicine.
• Words that once were said about the health care
  system reflexively, used to be assumed,
  increasingly cannot be said in public, or if
  uttered have to be seriously qualified.
• Unlike Carlins words, it is not that words about
  health care are profane or offensive, it is that
  they are increasingly untenable and unbelievable.
  
• Saying them suggests the speaker is out of touch
  with reality they are the equivalent of former
  President George H. W. Bushs shock at the
  supermarket checkout scanner.(5)
• They are a sign that the speaker fails to
  appreciate the experiences of the average
  American who interacts with the health care
  system.
• JAMA, V. 297, No. 19, 2131-33,May 16,
  2007Ezekiel J. Emanuel, MD, PhD, (Department of
  Clinical Bioethics, The Clinical Center, National
  Institutes of Health), Note Authors references
  numbers are in (..). Italic are mine for
  emphasis. Bold is quote from another source.

5

• Best Health Care System in the
  World
• The statistics are
  damning The system a mess
• 
  Country Per Capita ()
  of GNP
• USA
  6,000 16.0
• Switzerland
  4,077 11.5
• Norway
  3,966 9.7
• Germany
  3,043 10.6
• S. Korea
  1,149 8.2
• 
  USA Ranking
• Life Expectancy
  45th (behind Bosnia)
• Infant Mortality
  Rates
• (Per 1,000
  live births)
• All
  6.37 (behind Cuba)
• White
  5.7 (two times the rate of
• 
  Singapore/Sweden/Japan)

6

• Number of Americans With Coverage By Type
• Type Level of Insurance
  (000,000)
• Total Full Under
  Un
• Med/Hosp/Drug 300 30 50
  220
• Dental 300 30
  140 130
• Health/Wellness 300 30 10
  260

7

• Americans Rate Medical Care Received

8

• California HMOs
• Meets National Member
• Care Standards Rating
• 55 63
• Based on reports for nine top HMOs that
• cover 90 of HMO covered population in CA
• State of California
  Website 10/2007

9

• Comparison of Selected Benchmarks
• Before/After Expanded Insurance
• 
  Before
  After .
• Total Cost
  2,200,000,000,000 2,604,000,000,000
  
• Cost Per Insured 7,333 -
  8,800 8,000 - 9,600
• GDP 16
  -18 20 - 22
• Quality Rating 37th -
  45th 37th - 45th
• Waste 20 -
  70 35 - 75
• Deaths Due to Care 449,000 -
  1,000,000 529,000 - 1,080,000
• Add 50 billion to cover price
  increases and correction of estimated costs.
• Depends on who is doing the count. But
  who is? Everyone!
• USA compared to the world for selected
  benchmarks.
• Estimated based on various indicators
  of waste.
• Used conservative 80,000 additional
  deaths due to medical care received (MCR)

10

• Standard Leading Cause of American Death
  Rankings
• Rank/Cause
  Deaths () /Total Death Rate
• All causes . . . . . . . .
  2,443,387 100.0 847.31
• 1 Diseases of heart . .
  696,947 28.5 241.72
• 2 Malignant neoplasms .
  557,271 22.8 193.23
• 3 Cerebrovascular diseases . . . . . .
  162,672 6.7 56.44
• 4 Chronic lower respiratory diseases. 124,816
  5.1 43.35
• 5 Accidents (unintentional injuries) .
  106,742 4.4 37.06
• 6 Diabetes mellitus . . . . . . . . . .
  73,249 3.0 25.47
• 7 Influenza and pneumonia . . . . . .
  65,681 2.7 22.88
• 8 Alzheimers disease. . . . . . . . . . .
  58,866 2.4 20.49
• 9 Nephritis, nephrotic syndrome
• and nephrosis
  . . . 40,974 1.7 14.21
• 10 Septicemia . . . . . . . . . . . . . .
  33,865 1.4 11.70
• 11 All other causes . . . (Residual)
  522,304 21.4 181.10

11

• Leading Cause of American Death Rankings-Another
  View
• Rank/Cause
  Deaths () /Total Death Rate
• All causes . . . . . . . .
  2,443,387 100.0 847.31
• 1 MCR (Liberal)
  783,936 32.0
• 2 Diseases of heart . .
  696,947 28.5 241.72
• 3 Malignant neoplasms..
  557,271 22.8 193.20
• 4 MCR (Conservative) 424,000
  17.0
• 5 Cerebrovascular diseases . . . . 162,672
  6.7 56.44
• 6 Chronic lower respiratory dis. 124,816
  5.1 43.35
• 7 Accidents (unintentional injuries).. 106,742
  4.4 37.06
• 8 Diabetes mellitus . . . . . . . . . .
  73,249 3.0 25.47
• 9 All other causes

12

• A Leading Cause of Death Medical Care
  Received (MCR)
• ANNUAL PHYSICAL AND ECONOMIC COST OF
  MEDICAL INTERVENTION
• Condition Deaths
  Cost Author
• Adverse Drug Reactions 106,000 12
  billion Lazarou(1), Suh(49)
• Medical Error 98,000
  2 billion IOM(6)
• Bedsore 115,000
  55 billion Xakellis(7), Barczak(8)
• Infection
  88,000 5 billion Weinstein(9),
  MMWR(10)
• Malnutrition 108,800
  -------- Nurses Coalition(11)
• Outpatients 199,000
  77 billion Starfield(12),
  Weingart(112)
• Unnecessary Procedures 37,136 122
  billion HCUP(3,13)
• Surgery-Related 32,000
  9 billion AHRQ(85)
• Totals 783,936
  282 billion or 12.8 of 2.2 trillion
• The American Medical System Is The Leading Cause
  Of Death And Injury In The United States, Gary
  Null PhD,
• Carolyn Dean MD ND, Martin Feldman MD, Debora
  Rasio MD, Dorothy Smith PhD. (..) indicates
  reference numbers
• in original

13

• Hospital MCR Deaths Per Year By Type
• 12,000 - Unnecessary surgery
• 7,000 - Medication errors
• 20,000 - Other errors
• 80,000 - Nosocomial infections
• 106,000 - No error, adverse effects of
• medications
• Is US Health Really the Best in the World?,
  JAMA, July 26, 2000V. 284, No. 4 483-85

14

• Hospital MCR Deaths Per Year
• Medical Care Received (MCR)
• Caused Deaths Per Year
• 225,000
• Is US Health Really the Best in
  the World?, JAMA, July 26, 2000, V. 284, No. 4
  483-85

15

• Medical Injury Is Significant Threat
• In conclusion, our results clearly show
• that medical injuries in hospitals
  pose
• a significant threat to patients and
  incur
• substantial costs to society.
• Excess Length of Stay, Charges, and Mortality
  Attributable to Medical Injuries During
  Hospitalization, JAMA, 2003290 1868-1874

16

• There is trouble at
• the most unlikely of places
• An ambulance just arrived at the famous
• Pinata Hospital
• The patient was heard screaming
• to the ER Nurse!
• Please hurry, Im losing my candy.

17

• Is There An Extra Doctor In the House?
• One analysis overcomes some of these
  limitations by estimating adverse effects in
  outpatient care and including adverse effects
  other than death.11.
• Adverse effects 4-18
• Extra doc visits
  116,000,000
• Extra prescriptions
  77,000,000
• Extra ER Visits
  17,000,000
• Extra Hospital
  Admissions 8,000,000
• Extra Long Term
  Admissions 3,000,000
• Extra Deaths 199,000
• Extra Cost
  77,000,000,000
• Is US Health Really the Best in the
  World?, JAMA.2000 284 483-485 Barbara
  Starfield, MD, MPH, Department of Health Policy
  and Management, Johns Hopkins School of Hygiene
  and Public Health. Her reference in article 11
  Epidemiology and medical error, Weingart SN,
  Wilson RM, Gibberd RW, Harrison B.. BMJ.
  2000320774-777

18

• Just Keep Me From The ER This Time
• 50 million unnecessary annual visits to the ER
• 95 per minute
• by the time I finish?
• What is the cost?
• What is the benefit?
• National Center for Health Statistics

19

• Medical Care Received (MCR)
• Caused Deaths Per Year
• Hospital Based Deaths
  225,000
• Non-Hospital Based Deaths
  199,000
• Total Deaths 424,000
• Is US Health Really the Best in the World?, JAMA,
  July 26, 2000, V. 284, No. 4 483-85

20

• A Hospital Is No Place To Be Sick
• Infections Acquired During Hospital Stays
  Kill More People Than Breast Cancer, Auto
  Accidents and AIDS Combined Reports on the
  impact of 19,154 reported hospital acquired
  infections (HAI) in 2005 at 168 hospitals in
  Pennsylvania
• BENCHMARK HAI
  INVOLVED HAI NOT INVOLVED
• Average Length of Stay 20.6
  (days) 4.5 (days)
• Extra Days
  396,129 - 0 -
• Extra Hospital Charges 3.5
  billion - 0 -
• Average Hospital Charges 185,260
  31,289
• Hospital Patients Who Died 12.9
  2.3
• This report recommends that everyone wash
  their hands!
• Other reports suggest that patients have
  friends stay with them in the hospital to
  protect them from human errors and complacency!
• Hospital-acquired Infections in
  Pennsylvania, Pennsylvania Health Care Cost
  Containment Council, November 2006, Data
  Reporting Period January 1, 2005 - December 31,
  2005, Pennsylvania Health Care Cost Containment
  Council, November 2006

21

• A Hospital Is Just A Taxi With The Meter Running
• The .
  Excess .
• Event LOS Charges
  Mortality
• Surgical Care
• Post-op
• Sepsis 10.89 57,727
  21.96
• Dehiscence 9.42 40,323
  9.63
• Medical Care
• Infection 9.58 38,656
  4.31
• Attributable
• Excess Length of Stay, Charges, and Mortality
  Attributable to Medical Injuries During
  Hospitalization,
• JAMA, 2003 290 1868-1874

22

• Rising Resistance Rising
• S. aureus (staph) 32 vs. methicillin
• S. aureus (staph) 98 vs. penicillin
• E. faecium 70 vs. cirpofloxian/ampicillin
• S. pneumoniae (strep) 37 vs. penicillin
• Everyday exposure to toxic pollutants,
  Scientific American, Feb/March 1998 86-91

23

• Staph Infections Life Threatening
• CC/Symptoms
• 94,000 MRSA Infections
• 19,000 MRSA Deaths
• Risk Factors Most MRSA associated with health
  care
• Unnecessary, recent or long-term
  prescribing of antibiotics
• Antibiotics in food and water
• Current or recent hospitalization
  or residing in a long-term care facility
• Invasive procedures/Bacterial
  mutations
• History They do not wash their hands
• Takes time to wash
• Time is money
• No incentive to wash
• More illness, more income
• Diagnosis Dirty Hands
• Treatment Wash Hands
• Prognosis Uncertain
• Medical Drugs Pollute Water Supply,
  Maria P. Elliott and Edward T. Gluckmann, Green
  Times, V.27, No. 3, 2007 Pages 11-12

24
Two Views Professional Practice Of Medicine I
recently went to a new doctor and noticed he was
located in something called the Professional
Building. I felt better right away.  Isnt it a
bit unnerving that doctors call what they do
practice?

George Carlin
25

• Program to Get Them to Wash Their Hands
• Teach hand washing (Medical School and Residency)
• Put hand washing questions on all board exams
  (Competency)
• Add to credentialing process (Washes hands
  Often? Vigorously?)
• Have soap companies fund research and CME (Reduce
  costs)
• Develop a new CPT code (P4P, Positive Incentive)
• Report failure to wash to Homeland Security (Be
  Alert and Report!)
• Rate all providers who fail to wash hands.
  (Transparency)
• Fine providers for failure to wash hands
  (Negative Incentive)
• Provide universal insurance for 50,000,000
  uninsured Americans?
• Fail! Hear my mothers, Edward, wash your
  hands. over intercom.
• (Equivalent of
  legal water-boarding.)
• System Failure versus Personal
  Accountability The Case for Clean Hands, NEJM,
  V. 355, No. 2, 121-123, 7/13/2006

26
Change in the US Death Rates by Cause, 1950
2003
Rate Per 100,000
1950 2003
HeartDiseases
CerebrovascularDiseases
Pneumonia/Influenza
Cancer
Age-adjusted to 2000 US standard
population. Sources 1950 Mortality Data -
CDC/NCHS, NVSS, Mortality Revised. 2003 Mortality
Data US Mortality Public Use Data Tape, 2003,
NCHS, Centers for Disease Control and Prevention,
2006
27
Trends in the Number of Cancer Deaths Among Men
and Women, US, 1930-2003
Men
Men
Women
Women
Number of Cancer Deaths
Source US Mortality Public Use Data Tape, 2003,
National Center for Health Statistics, Centers
for Disease Control and Prevention, 2006.
28
Five-year Relative Survival () During Three
Time Periods By Cancer Site
1983-1985
1995-2001
Site
1974-1976
     

• All sites 50 53 65
• Breast (female) 75 78 88
• Colon 50 58 64
• Leukemia 34 41 48
• Lung and bronchus 12 14 15
• Melanoma 80 85 92
• Non-Hodgkin lymphoma 47 54 60
• Ovary 37 41 45
• Pancreas 3 3 5
• Prostate 67 75 100
• Rectum 49 55 65
• Urinary bladder 73 78 82

5-year relative survival rates based on follow
up of patients through 2002. Recent changes in
classification of ovarian cancer have affected
1995-2001 survival rates. Source Surveillance,
Epidemiology, and End Results Program, 1975-2002,
Division of Cancer Control and Population
Sciences, National Cancer Institute, 2005.
29

• Another Warrior Fights Cancer
• 'Her determination to fight the disease is an
  inspiration to all of us. President Bush
• 'I always admired Congresswoman strong
  convictions and the tenacity.. John W. Warner
• She underwent chemotherapy treatments and a
  mastectomyin 2005. When the cancer returned, she
  underwent chemotherapy again...
• ..she died...after a 2-year battle with the
  disease.
• Congresswoman Dies After Cancer Fight, New
  York Times, October 10, 2007

30

• Womens Revolution
• HRT associated with cancer, heart disease and
  stroke in media
• Millions of women stopped following physician
  orders
• Millions stopped hormone replacement therapy
  (HRT)
• 14,000 fewer new cases in 2003
• 7 decline in breast cancer between 2002 and 2003
• It takes breast cancer a long time to develop
• ..but here we are primarily talking about
  existing cancers that are fueled by hormones and
  that slow or stop their growing when a source of
  fuel is cut.
• "It is the largest single drop in breast cancer
  incidence within a single year..
• Fewer breast cancers linked to less hormone
  therapy, Reuters, December 14, 2006
• Findings reported by MD Anderson based
  researchers at the 29th Annual San Antonio Breast
  Cancer Symposium

31

• Lung Cancer - Black Revolution
• Lower rate of lung cancer surgery among black
  patients due partly to communication problems,
  study finds
• Even with equal access, blacks are about half as
  likely as whites to undergo surgery that could
  save their lives
• Black men have higher death rates than white men
  for lung cancer
• Smoking explains virtually all the disparity
  between black men and white men in cancer
  mortality rates Dana-Farber Cancer Institute,
  Website, Christopher Lathan, MD, Spring/Summer
  2006

32

• Lung Cancer - Black Revolution
• Death rates for black men went up as smoking
  increased
• Smoking among black men peaked in 1990
• CDC has registered sharp declines in black men
  smoking since 2001
• When smoking declined cancer rates dropped
• 1990 - 2000, the mortality rate dropped 11
• If black men stopped smoking, their cancer rates
  would drop 66
• Lung cancer rates as an index of tobacco
  smoke exposures validation against black male
  non- lung cancer death rates, 1969-2000, Prev
  Med. 38(5)511-15

33

• Cancer Care More Aggressive
• Near Death Study
• Doctors efforts are costly, futile attempt to
  extend lives
• Chemo up 6
• Chemo up 34 in patients who died within two
  weeks
• Doctors should review their treatment regimens
• Doctors should in some cases focus on palliative
  care
• Hospice care reduces aggressive treatment
  improves quality of life for terminally ill
• Study suggests more cancer patients
  receiving aggressive care at end-of-life,
  Dan-Farber Cancer Institute,
• June 4, 2003

34

• Annualized Cost To Buy 20 Days
• 143,612 - Localized Cancer
• 145,861 - Regional Cancer
• 1,190,322 - Metastatic Cancer
• 70-90 of lung cancer smoking related
• Smoking prevention and cessation programs are
  more promising
• Survival Benefit Minimal Despite Rising Cost
  of Lung Cancer Treatment in Elderly, Cancer, 2007
  (reported in) MedScape Medical News, October 25,
  2007

35

• Sleep On This For A While
• Poor sleep among the elderly, it turns out,
• is not because of aging itself, but mostly
• because of illnesses or the medications
• used to treat them.
• The Elderly Always Sleep Worse, and Other
  Myths of Aging, NY Times, October 23, 2007

36
Dark Blue Is Medical Cost Increases Due To Aging!
37

• Early Detection, Survival and Marketing
• Claims made
• -Cancer survival rates increased
• -2.3 million breast cancer survivors
• SCR Best Cancer Treatment (Surgery,
• Chemo, Radiation)
• New Ventures Help Fight the Frustrations of
  Fighting Breast Cancer, New York Times, October
  25, 2007

38

• Early Detection, Survival and Advertising
• Disfigurement/Pain/Realism/Death
• Cancer as bad as it is, emotionally had an end
• Lymphedema complication, forever affects quality
  of life
• Optimistic survivors also realists
• Since their book was published, 2 of 3 co-authors
  died
• New Ventures Help Fight the Frustrations
  of Fighting Breast Cancer, New York
• Times, October 25, 2007

39

• Early Detection, Survival and Sales
• Drive to find disease early that leads to..
• Diagnostic epidemic that leads to..
• Medicalization of everyday life that leads to..
• 50 of Americans diagnosed as diseased that leads
  to..
• More disease caused by tests, treatment and drugs
  that leads to..
• Threat to Americans health that leads to..
• America spends more than any other country that
  leads to..
• America having (Please check all that apply)
• ___ The best care in the world
• ___ A need to stop the hemorrhaging first
  
• ___ Some of the lowest world wide
  rankings
• ___ A need to spend an additional
  300,000,000,000
• Whats Making Us Sick Is an Epidemic of
  Diagnoses, New York Times, January 2, 2007

40

• Early Detection, Survival and
  Collection
• 40 of summer camp kids on chronic prescription
  drugs
• Arthritis without joint pain
• Stomach damage without heartburn
• Million prostate cancers patients who have lived
  as long without being diagnosed as a cancer
  patient
• Biggest health threat is our health-care system
• Pre-diseased population gt those who get the
  disease
• Labeling causes anxiety, sense of vulnerability
• a
  particular concern in children
• Whats Making Us Sick Is an Epidemic of
  Diagnoses, New York Times, January 2, 2007

41

• Early Detection, Survival and Impact on Children
• Psychiatrists in several states get most drug
  money
• Psychiatrists who do take the money, tend to
  prescribe the most antipsychotic drugs to
  children
• These drugs are risky and not FDA approved for
  kids
• Psychiatrists know the dangers
• Antipsychotic drugs are a large expense for
  Medicaid
• Psychiatrists Top List in Drug Maker Gifts,
  New York Times, June 27, 2007

42

• Early Detection, Survival and Causes of Disease
• Assumption is all diagnosis are beneficial.
• Early Detection Prevention Threat
• But at the extreme, the logic of early detection
  is absurd
• Biggest health threat is our health-care system
• Pre-diseased population gt those who get the
  disease
• Labeling causes anxiety, sense of vulnerability
• a particular
  concern in children
• Whats Making Us Sick Is an Epidemic of
  Diagnoses, New York Times, January 2, 2007

43

• Early Detection, Survival,
  Harm
• Disease epidemic Treatment epidemic
• Not all treatments have important benefits
• Some involve potential harm
• Some harm is not immediately known
• Being labeled pre-diseased or at risk but
  destined to remain healthy, treatment can only
  cause harm.
• Whats Making Us Sick Is an Epidemic of
  Diagnoses, New York Times, January 2, 2007

44

• Early Detection, Survival
• Good 4 Business! Bad 4 Business?
• The epidemic of diagnoses has many causes.
• More diagnoses mean more money, stature
  for
• - Drug and device manufacturers
• - Hospitals and physicians,
• - Disease-based advocacy organizations
• - Researchers
• - National Institutes of Health
• - Anyone promoting a disease
• Whats Making Us Sick Is an Epidemic of
  Diagnoses, New York Times, January 2, 2007

45

• Wheres Proof Treatment Works, Works Safely
• Gold Standard-randomized double blind,
  placebo-controlled trials.
• Platinum Standard-monitor actual outcomes for all
  patients for 1,3,5,7,10 years.
• How many physicians, surgeons or hospitals can
  produce cost/benefit data (i.e. positive and
  negative outcomes vs. charges/fees)?
• Without the proof there is information, value or
• meaningful use by consumers!

46

• Off-Label Prescribing Thars AU,
• But No Standard, In Them Thar Hills
• Summary of Number of Drug Uses, By Off-label
  Status and Level of Supporting Evidence, United
  States, July 2005 through December 2006, IMS
  Health National Therapeutic and Disease Index,
  Estimated DRUG USES IN THOUSANDS, United States
• Generic Total Uncertain/ Evidence
  Evidence
• On-Label Off-Label Inadequate Inadequate
  Uncertain
• 112,033 42,692 37,387 7,380
  30,007
• 72 28 87
  17 70
• of total prescriptions generic
  on-label total off-label of total that
  are off-label 5,305,000 or 12 off-label
  prescriptions were deemed OK. Off-Label Drug Use,
  Stanford School of Medicine, Stanford Prevention
  Research Center, Randall Stafford, MD, PhD., Week
  of 06/04/2007

47

• 3,430 Billion Reasons Explain Rising Costs
• Mo./Year Company/Drug/Disease Allegations
  Settlement
• 9/2007 Sanofi-Aventis
  Violated False 190
• /Anzemet/Cancer Claims
  Act
• 
  Inflated Prices/Physicians
• 
  Profits, Medicare/Medicaid
• 9/2007 Bristol Meyers Squibb/ Illegally
  Promoted 515
• Abilify/Anti-psychotic use
  for Off-label
• Drug
  Use-Pediatric/ Dementia
• 
  By Consulting Fees/Luxury Trips
• 9/2007 Zommer, Biomet
  Kickbacks/Surgeons 311
• DePuy Orthopaedics (JJ)
• Smith Nephew/
• Replacement Hips Knees
• 2006 Medtronics
  Consulting Fees/Free 40
• Spinal Implants
  Travel/Other Perks
• 2007
  Again Accused of
• 
  Similar Charges-not Settled (yet)
• 2007 Purdue Frederick/
  Misbranding/Misleading 634

• When asked why he robbed banks, Willy Sutton said
  Thats Where the Money Is
• Willie was wrong!
• Willie would not find 3,430,000,000 in most
  banks.
• This is the tip of the iceberg.
• Nothing went to any victim.
• No part of these settlements went to improve
  patient safety.
• No physician was
• reported,
• disciplined
• charged with accepting bribes,
• compromising patient care or
• censured for reflecting poorly on the profession.

48

• 4.85 Billion Settlement Is Victory
• For Drug Company
• 2001 JAMA article warns of Vioxx risks
• 9/2002 Vioxx increased risk of heart
  attacks/strokes
• Merck spends more than 1.2 billion on
  Vioxx-related legal fees
• 9/2004 Vioxx withdrawn by Merck
• 8/2005 First verdict 253,500,000 (Reduced to
  less than 25,000,000)
• 2006/2007, Merck defeats 8 of 10 plaintiffs in
  CA, FL, NJ, IL, LA
• 11/2007 Merck settles 27,000 Vioxx suits for
  4.85 billion
• Settlement 9 months profits
• Wall Street reacted favorably
• Merck still facing civil and criminal action by
  several states and feds
• Merck Agrees to Settle Vioxx Suits for
  4.85 Billion, New York Times, November 9, 2007
• Analysts See Merck Victory in Vioxx
  Settlement, New York Times, November 10, 2007

49

• Regrettable Human Error
• September 2006
• F.D.A. reconvenes safety panel and OKs continued
  use of drug
• Company study showing adverse impact of drug not
  revealed to F.D.A.
• Company says failure to report findings was due
  to Click here to return to Regrets
• October 2007
• Researchers stopped a study of drug because 50
  more likely to die vs. alternatives
• Drug increased the risks of kidney
  failure, heart attack and stroke
• Causes 10,000 to 11,000 kidney
  failures a year (Click here to return to Regrets)
• Stop and save more than 1 billion a
  year in dialysis costs
• November 2007
• Bayer AG announced agreed to withdraw its
  controversial heart surgery drug
• F.D.A. could not identify any population where
  the benefits outweigh the risks
• Bayer says drug is beneficial when used as
  directed (Click here to return to Regrets)
• Heart Surgery Drug Pulled From Market,
  New York Times, November 6,2007

50
How Many Errors Were Not Detected?
51

• Non-Hospital Drug Adverse
  Effects Reported
• To the FDA in 1998 and
  2005
• Event 1998
  2005 Increase
• All Drugs
• Serious, adverse 34,966
  89,842 260
• Serious, fatal 5,519
  15,107 270
• 13 new biotech products 580
  9,181 1,580
• These data show a marked increase in
  reported deaths and serious injuries associated
  with drug therapy over the study period. The
  results highlight the importance of this public
  health problem and illustrate the need for
  improved systems to manage the risks of
  prescription drugs.
• Serious Adverse Drug Events Reported to
  the Food and Drug Administration, 1998-2005, Arch
  Intern Med,  20071671752-1759

52

• A Drug Sharks Tale
• Lipitor patent runs till 2010
• Generic for Zocor, a Lipitor competitor, is now
  available
• Pfizers response
• Tell Wall Street Will spend two times
  more for ads
• Argue that a non-gold standard study
  shows value
• Attack insurers
• Hire a BIG name, hit man for ads
• Maker of Lipitor Digs In to Fight Generic Rival,
  New York Times, November 3, 2007

53

• Some More Tales
• FDA cannot guarantee the safety of the nation's
  drug supply
• Foreign companies manufacture 80 of all
  ingredients used by American drug makers
• FDAs records are poor
• FDA cannot even say what it inspected
• F.D.A. Is Unable to Ensure Drugs Are
  Safe, Panel Is Told, NYT, November 2, 2007
• 20,157 buys a patient less than one month of
  increased survival
• Results are not surprising
• There is no early detection screen of
  proven worth as yet,.."
• There are no good predictors to
  identify lung cancer at an early stage,.
• ..so you would not expect an increase
  in early diagnosis to affect improvement in
  survival. (Stephen Spiro, MD, head, department
  of thoracic medicine, University College London
  Hospitals National Health Service Trust, UK)
• Survival Benefit Minimal Despite
  Rising Cost of Lung Cancer Treatment in Elderly,
  Medscape Medical News, October 25, 2007

54

• AlzheimersDiseaseResearchDrugs
• Scientists reported progress blood test90
  percent accurate in distinguishing 80 percent
  accurate in predicting
• Outside experts called the results promising but
  preliminary
• At present, treatments for Alzheimers disease
  are not very effective
• when drugs are developed that slow or halt
• Alzheimers sent out signals to the bodys immune
  systemcommunication between cells
• paid for by and Satoris, a company co-foundedto
  commercialize the test.
• Progress Cited in Alzheimers Diagnosis,
  NY Times, October 15, 2007

55

• Alzheimers Prevention Forgotten
• 
  
• Not one word about a cure!
• Not one word about prevention!
• Not one word about what the body is missing!
• Not one word about using the cells
  communications!
• Not one word about the role of the immune system!
  
• Progress Cited in Alzheimers Diagnosis, NY
  Times, October 15, 2007

56

• Four Red Dots?
• Science 313 670-673 (August 4, 2006)

57

• Research Finding What Is Known
• Place Rockefeller Universitys Leonard Wagner
  Laboratory of Molecular Genetics and Immunology
• Problem The IgG paradox! IgG antibodies can
  prevent or cause autoimmune disorders (lupus,
  arthritis, asthma)
• Findings Terminal sialic acid on the Fc portions
  of the IgG molecule stopped inflammation
• Explanation IgG can shift from a state that is
  quite inflammatory to a state that is actively
  anti-inflammatory by just changing a sugar
• Solution Want to develop another drug
• Issue Natural remedy already exists
• Science 313 670-673 (August 4, 2006)
• Harpers Biochemistry, 25th Edition,
  Chapter 56, Page 675, McGraw-Hill, 2000

58

• An Educated Consumer Is Our Best Customer
• Once paid 11.60 per month for Blue Cross
• In one week, received three pieces of mail
• 43 pages about Medicare drug plan options
• Letter from company What happens if
  selected plan
• is dropped
• Letter from a politician saying how great
  drug plan is
• Had to research 30 plans to get doctor/hospital,
  drug and cost info
• Times Herald-Record, Letter to Editor,
  November 8, 2007, Page 27

59

• We Are Rated By How We Treat
• The Least Among US
• 1974 - 1975 House Staff physicians go on strike
  at 25 hospitals
• Demands include end of abusive work schedules
• Demands for more nursing, lab, messenger staff
• Most strikes settlements are inconclusive
• Some reductions in work hours and temporary staff
  improvements
• 1984 - one patient dies after ER admission at New
  York Hospital
• Grand Jury finds overworked and under supervised
  house staff
• New laws and professional GME guidelines are
  established
• GME groups concerned that training and patient
  care suffer
• Intern and Resident Organizations in the
  United States 1934-1977, Robert G. Harmon, M.D.,
  The Milbank Memorial Fund Quarterly. Health and
  Society, V. 56, No. 4 (Autumn 1978), pp. 500-530,
  supplemented by the presenter

60

• Even The Pros Have
• Trouble With Handoffs!
• Improved patient care conditions are less
  evident than improved house staff conditions.(1)
• But do these benefits mean that today's
  interns and residents have it better? Are they
  learning more? Probably not.(2)
• In addition to problems with handoffs, house
  staff are particularly vulnerable to medical
  errors owing to teamwork failures, especially
  lack of supervision. Graduate medical education
  reform should focus on strengthening these
  aspects of training(3)Serious consequences 33
  or 889 cases resulted in deaths.(4)
• (1) Intern and Resident Organizations in
  the United States 1934-1977, Robert G. Harmon,
  M.D., The Milbank Memorial Fund Quarterly. Health
  and Society, Vol. 56, No. 4 (Autumn, 1978), pp.
  500-530
• (2) Do today's medical residents really
  have it better? Cleveland Clinic Journal of
  Medicine, Frank Michota, MD
• (3) Medical Errors Involving Trainees, A
  Study of Closed Malpractice Claims From 5
  Insurers, Arch Intern Med, 20071672030-2036.
• (4) Lack of communication tied to errors
  report, Modern Healthcares Daily Dose, October
  10, 2007

61

• House Staff Training Fatigue Errors
• 
  
• Number of
  Extended Duration Shifts/Month
• Event Base/None
  One-Four Five
• Reported-Fatigue
• Related Significant
• Medical Error 100
  300 700
• Adverse Event 100
  700 800
• Preventable
• Adverse Event 100
  100 300
• Interns were also more likely to fall
  asleep during lectures, rounds, and clinical
  activities, even surgeryIn our survey,
  extended-duration work shifts were associated
  with an increased risk of significant medical
  errors, adverse events, and attentional failures
  in interns across the United States. These
  results have important public policy implications
  for postgraduate medical education
• Impact of
  Extended-Duration Shifts on Medical Errors,
  Adverse Events, and Attentional Failures,
  National Institute for Occupational Safety and
  Health within the US Centers for Disease Control
  (Grant R01OH07567) and the Agency for Healthcare
  Research and Quality (AHRQ) (Grant R01 HS12032)

62

• Stents Sugar or Diet
• No clear comparative evidence studies to show
  which treatment is best, best over time, best in
  terms of disease type, level, and cost and how
  each treatment compares to other treatments,
  including prescription drugs, angioplasty alone,
  by-pass surgery, and changes in nutrition,
  supplements and other life style modifications.
  (Edward Gluckmann, Health Matters, Inc.)
• Its striking that we do so little to evaluate
  what were getting in return for it, (CBO
  Director Peter Orszag)
• A Heart Stent Gets a Reprieve From
  Doctors, New York Times, November 13, 2007
• Aging population isnt the real threat,
  says CBO, Modern Healthcares Daily Dose,
  November 13, 2007
• The type of funding may have determinant effects
  on the design of studies and on the
  interpretation of findings funding by the
  industry is associated with design features less
  likely to lead to finding statistically
  significant adverse effects and with a more
  favorable clinical interpretation of such
  findings. Disclosure of conflicts of interest
  should be strengthened for a more balanced
  opinion on the safety of drugs.
• Adverse Effects of Inhaled
  Corticosteroids in Funded and Non-funded Studies,
  Arch Intern Med. 
• 20071672047-2053
• For the Record In Tests of Inhalers,
  Results May Depend on Who Pays, New York Times,
  November 13, 2007

63

• Devices, Implants And
• Either This Guy Is Dead Or My Watch
  Stopped!
• 
  
• Nations largest maker of implanted heart devices
  to docs stop using a crucial component of our
  most recent defibrillator models.
• These devises caused malfunctions in hundreds of
  patients and may have contributed to five deaths.
• 235,000 patients have these devices that can make
  them misread heart-rhythm data.
• Cost 30,000/device
• Cost per year 7,050,000,000
• Patients Warned as Maker Halts Sale of
  Heart Implant Part, New York Times, October 15,
  2007

64

• Florida Land Of Opportunity
• The wheelchair billed for 5 million
• Millions billed by an air conditioning repairman
  for specially formulated asthma medication
• High level of AIDS billing with no clinical
  explanation
• Criminal entrepreneurship funded by public
• Fraud penalties much less severe than they are
  for narcotics trafficking
• Fraud and Florida's multimillion-dollar
  wheelchair, Reuters, October 22, 2007

65

• Visions of Medical Care-Ideal
• Group medicine is not a financial arrangement
  .. 
• ..(do) we take sufficient care to make a
  thorough physical examination..? 
• ..some loss in appreciation of the individuality
  of the patient.. 
• the main purpose to be served by the Clinic is
  the care of the sick.
• Operate ..intended not to create wealth but to
  provide a financial return sufficient for present
  and future needs. 
• 30 of less fortunate patients received hand
  written bills marked paid in full. (They werent
  paid. They were just written off!)
• No one charged more than 10 of his or her annual
  income, no matter how expensive the treatment.
• Every dollar on bills over 1,000 went to help
  other sick people
• Mayo Clinic Foundation Website and The
  Value of Sharing, The Story of the Mayo Brothers,
  by Spencer Johnson, M.D. (Education includes a
  psychology degree from the University of Southern
  California, an M.D. from the Royal College of
  Surgeons and medical clerkships at Harvard
  Medical School and the Mayo Clinic)
• 
  

66

• Visions of Medical Care-Investment Opportunity
• HCA buyers got 175 million in fees
• The group that bought HCA, will receive 175
  million in transaction fees, and other fees down
  the road. Thomas Frist, Jr., a relative of the
  former Republican Party (Congressional leader)
  and members of his family, and top-level HCA
  executives, will also get 15 million annually
  under a management contract with HCA, which
  includes possible increases based on the new
  companys profits. The buyout was for 33
  billion. Several executives are guaranteed board
  seats as part of their employment agreements.
• Modern Healths Daily Dose, a daily e-mail
  report on current healthcare events. The exact
  date is not crucial. This is a sample of many
  such reports that run into the billions
  nationwide over the course of any year.

67

• Visions of Medical Care-Wellness
  (First)
• A Drug Makers Views of What Ails
  American Health Care
• Holstein
• What should Americans be doing to fix the
  system?
• Vasella
• One aspect is better patient education and
  better nutritionwe should look at how to give
  incentives to people to avoid disease-prone
  behaviors
• Saturday Interview of Daniel L. Vasella,
  chief executive of Novartis by William Holstein,
  New York Times, September 8, 2007

68

• Myths Deconstruction
• Another way of saying, we are doing nothing to
  save money. If all these claims actually worked,
  medical care would be free. Total costs would be
  going down. They are not.
• Maybe for one patient here and there, but not
  overall. (See above.)
• Almost without exception, buying and selling (M
  A) or just gross transfers from one investment
  group to another is a business transaction loaded
  with costly stock options, profit/loss
  considerations, market positioning, golden
  parachutes, lucrative broker and other fees and
  has nothing to do with improving care or quality.
• Putting an investigation or litigation behind
  without any acceptance of wrong doing is just
  another way of saying We got caught (acceptable
  business risk) with our hands in the cookie jar,
  and we got away with it (as we thought we would)
  by buying off prosecution with pennies on the
  dollar settlement, (another acceptable business
  cost). Now we can get on to make more money
  claiming to care about saving lives while
  agreeing to keep our hands out of the cookie
  jars, (but just for a while) and making more
  money.

69

• Myths Deconstruction
• Cost shifting is just that, the shifting of costs
  from the insurer, to the insured and among the
  insured and underinsured. It costs more not less.
• Consumer empowerment started in the 1970s and
  failed then. Everyone speaks for the consumer,
  yet no one really does. Consumers have few
  choices and options. Most consumers have time to
  surf the Internet, but few understand the
  implications of what is going on when told they
  have cancer, or have had a serious heart attack
  or experiencing a stroke.
• Ditto Alzheimers, autism, emotional and mental
  turmoil.
• People with diabetes, are overweight, or obese
  are facing information that is contradictory,
  unproven and often not supported in a variety of
  ways, not least of which, is that the
  recommendations of what to do and what will be
  done have no consistent pattern of working.
  Proof Look around. Read the statistics. See
  Americas world comparative rankings.

70

• DOES ANYBODY HERE KNOW
• HOW TO PLAY THIS GAME?
• Health insurance companies cited ..for violation
  of Medicare standards...(said) they were
  addressing the deficiencies and would improve
  service to patients, who will be able to switch
  plans in the last six weeks of the year.
• ...WellPoint, one of the nations largest
  insurers, said the company had hired additional
  employees to answer telephones and pay claims
  filed by or for Medicare beneficiaries..WellPoint
  was reducing its claims backlog and telephone
  waiting times and expected to be in compliance
  with federal standards by the end of this month.
• Coventry Health Care, which recently had a civil
  penalty of 264,000 assessed for violation of
  Medicare marketing standards, said it had taken
  steps to prevent a repetition of the problems.
  
• After Audit, Insurers Vow to Improve
  Medicare Service, New York Times, 10/10/2007

71

• DOES ANYBODY HERE KNOW
• HOW TO PLAY THIS GAME?
• ..a spokeswoman for Coventry, said the company
  had retrained its agents and changed the timing
  of commission payment to discourage inappropriate
  sales.
• ..(a) public policy director at CareOregon, based
  in Portland, said her company was very serious
  about correcting deficiencies and was revising
  its procedures.
• ..CareOregon, which serves low-income people
  enrolled in both Medicare and Medicaid,
  questioned the wisdom of one recommendation,
  involving notices to beneficiaries about the
  denial of claims. To send all these notices
  could confuse and scare our patients,..
• After Audit, Insurers Vow to Improve
  Medicare Service, New York Times, October 10, 2007

72

• DOES ANYBODY HERE KNOW
• HOW TO PLAY THIS GAME?
• When Dealing With The Insane, It Is Best To
  Pretend To Be Sane
  
  
• Senator Max Baucus, Democrat of Montana, chair,
  Finance Committee
• The unscrupulous tactics of some plans have led
  me to be skeptical about how well this market
  works for seniors.
• And Representative Pete Stark, California
  Democrat, chair of the Ways and Means
  Subcommittee on Health that the Bush
  administration had been reluctant to regulate
  or offend these large companies.
• But Kerry N. Weems, acting administrator of the
  Centers for Medicare and Medicaid Services
  contract compliance and beneficiary protection
  had been among his top priorities since he took
  office last month.
• Karen M. Ignagni, president of Americas Health
  Insurance Plans said the audits did not reflect
  the fact that private plans generally offer
  better benefits than original Medicare.
• The answer is yes. They all know
  how to play this game.
• After Audit, Insurers Vow to Improve
  Medicare Service, New York Times, October 10,
  2007

73

• Does He Or Does He Not?
• A Senator says his disease had progressed
• a very tough disease, it could progress
  rapidly.. Its possible the diagnosis is
  wrong, Bruce Miller, Neurologist, UC
• .tests can monitor the progression of the
  disease
• In some cases Ive followed patients for many
  years
• Norman Relkind, Neurologist, Cornell
  Medical Center
• And they need regular medical visits to monitor
  the progression of the disease
• The larger question for societywill be figuring
  out how and by whom decisions should be made
  about other peoples mental capacity to work,
  vote and make choices for themselves. Often, he
  said, doctors will have to be involved (Dr.
  Karlawish, Medicine Medical Ethics, U of P)
• Senators Illness Requires Monitoring,
  New York Times, October 7, 2007

74
Politics is the art of looking for trouble,
finding it everywhere, diagnosing it incorrectly
and applying the wrong remedies.
Grouch Marx
75

• Politicians Emotional Statement and Some Facts
• Dialogue Dispute vs Dishonest Discourse
• -A Case Study
• Politicians emotional statement I am alive
  because I am free to choose my doctor (free
  enterprise), where as in other countries
  (socialized medicine) I cannot.
• He claims these facts support his position
  USA prostrate cancer survival rate is 82 and UK
  prostate cancer survival rate is 44. But the
  facts involved are The 44 figure is bogus,
  called crude by the politicians own consultant
  and disavowed by the Commonwealth Fund, the
  original source.
• Giulianis Prostate Cancer Figure Is
  Disputed, New York Times, October 31, 2007

76

• No, no, you're not thinking
• you're just being logical.
• 
  Niels Bohr

77

• Cancer A First and Last Word
• Because no cancer cell exists, the respiration
  of which is intact, it cannot be disputed that
  cancer could be prevented if the respiration of
  the body cells would be kept intact.
• For cancer formation there is necessary not only
  an irreversible damaging of the respiration but
  also an increase in the fermentation.
  (Fermentation is a way that cells with impaired
  respiration try to survive by converting body
  sugars glucose into a weak form of ATP energy.)
• The most important fact in this field is that
  there is no physical or chemical agent with which
  the fermentation of cells in the body can be
  increased directly for increasing fermentation,
  a long time and many cell divisions are always
  necessary.
• The mysterious latency period of the production
  of cancer is, therefore, nothing more than the
  time in which the fermentation increases after a
  damaging of the respiration.
• There would be no cancers if there were no
  fermentation of normal body cells.
• Carcinogenesis by x-rays is obviously nothing
  else than destruction of respiration by
  elimination of the respiring grana. You kill
  cancer cells with radiation but you weaken
  healthier cells at the same time, so the
  descendents of the surviving normal cells may in
  the course of the latent period compensate the
  respiration decrease by the fermentation increase
  and thence become cancer cells.
• The Prime Cause and Prevention of Cancer, Revised
  Lindau Lecture, 1966, Otto Warburg, M.D., PhD
  (Chemistry), Noble Laureate, 1931, 1944
  Director, Max Planck Institute for Cell
  Physiology, Berlin-Dahlem, Germany

78

• Solutions-change the thinking
• Solutions-eliminate profit and advertising
• Solutions-establish independent body-a public
  trust that approves only what can be platinum
  standard validated
• Solutions-convert everything that starts with or
  contains the word medical into wellness and then
  make its parts comport to that goal
• Compensate based on results to prevent first and
  treat later
• Criminalize all activity that benefits an
  individual, institution or entity that is or
  appears as a conflict
• Make them wash their hands
• Create a National Wellness Service