The TAVR Procedure and Other Medical Advances

During my 50 years of medical practice I've witnessed some pretty dramatic changes. As examples I can still recall the amazement I felt the first time I saw the results of coronary angiograms before and after angioplasty showing blockages eliminated. Likewise when I first viewed a 3 dimensional echocardiogram showing the ventricles contracting and the valves moving inside the heart. These things have advanced greatly and are now commonplace, matter of fact techniques but were breathtaking events at the time.

 

Even so for a new report I just saw from the ongoing annual American College of Cardiology meeting regarding the TAVR procedure, the technique of replacing a constricted aortic valve, the main one leading from the heart, by a device passed by a catheter from the groin instead of by a major surgical procedure. The procedure, initially restricted to those who were too frail to undergo surgery, has been  advancing in its use over a few short years. New studies reported in the meeting indicate that it is working as well or better than the surgical approach in low risk patients as well. There are some lingering questions about how long the replaced valves will function. However there is no doubt that treatment of this lethal condition, which was a death sentence at the start of my career, is being transformed before our eyes to one which will be easily treated, perhaps without even a hospital stay.

 

I've seen many other similar medical miracles in other areas, but this one caught my eye and I couldn't resist mentioning it. What a privilege it has been to be a participant in applying these advances as they've come along to patients. But mostly I have to give tribute and profess the greatest admiration to the pioneers and innovators who are inspired to seek new ways and go through the very difficult process of developing their dreams for the benefit of the rest of us.

 

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Lilly and the Price of Insulin

I just saw a New York Times article reporting that Lilly company has decided that they would be selling an authorized generic version of their rapid acting insulin, Humalog, for $135 a vial. The actual brand name version, for those paying out of pocket, is around $330 at your local pharmacy. You can print out a discount coupon from GoodRx that lets you pay $177. A vial might last the average diabetic about a month.

 

Humalog came out in the mid 1990's. The price has ramped up exponentially in the past few years. Pretty obviously they can actually produce this insulin at a far lower price. There are 2 other major companies producing very similar rapid acting insulin brands, but they all sell in the same price range. Why isn't competition working? Well I think mostly it's the same reason that medical costs generally are too high – that most of us pay for medical items indirectly and so at the point of sale the cost to the customer is only a small amount of copay. In medical care, prices are not set by the market, but instead by negotiations with third party payers, insurance companies and government. As in any negotiation the initial seller's price is set high to be  negotiated downward. Those who don't pay through third parties are left holding the bag.

 

The market works differently. Prices, except for very high ticket items like cars and houses, are not negotiated but are fixed and consumers choose from competing options. All other things being equal they flock to the lowest price, forcing prices down and in this case leaving the high priced seller holding the bag.

 

But payment for medical care is changing. Although more of us are insured, there's a great increase in high deductible insurance. I think it's this factor, and the public pressure resulting from it, that is forcing Lilly to relent. One thing worth noting in all of this is that older types of insulin, regular and NPH are still available at a price of about $28 a vial. These are less convenient but perfectly effective, so that there is no reason whatsoever for anyone to get sick or die for lack of insulin. Nevertheless, when I was still in practice, seeing a lot of diabetics taking insulin, almost everybody was paying through third parties and very few took advantage of these cheaper varieties. On the other hand in the free clinic where I volunteer, where no one has insurance, they're the only insulins we prescribe.

 

Just to put everything in perspective I want to point out that Dr Banting, who received the Nobel prize for working out the initial extraction and production of effective insulin in the early 1920's, was totally swamped by requests for his product from all over the world by desperate sufferers. He worked out an arrangement with the newly organized Eli Lilly company, which in the space of about 2 years, with the use of effective production techniques, was making enough to supply everybody.

 

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Of Men and Monkeys

Here's something that puzzles me.

If monkeys evolved into men, how come we still have monkeys.

I asked Mr. Google about it, and I find that there is lots of debate about the question. The usual response seems to be that men did not evolve from monkeys but instead both men and monkeys evolved from a common ancestor.

OK then if that's how it works, how come there were just two branches and not a whole bunch of intermediate creatures.(Maybe we do have them - they're called liberals!)

Couldn't resist kidding my liberal friends, but the question is serious even if it seems dumb to any real biologists.

 

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Should the President Accept the Bipartisan Compromise?

I think the President should accept the new compromise bipartisan bill. Yes, the amount allotted for the wall is a ridiculously paltry sum, but nevertheless it is an important admission that a barrier is a reasonable measure in the fight for border security. The Democrats up to this point have resisted a wall on principle, terming it alternatively ineffective, too costly and immoral. They have caved I believe to political pressure. Although they must placate their leftist base who desire open borders, their polling has revealed the major problem that a large majority of the public are concerned with the present uncontrolled immigration situation, want better border security and think a barrier is a sensible tool to use.

 

The compromise bill is a foot in the door. The Democrats will no longer be able to claim that they oppose a wall on principle, but only that they are agreeable to a wall of inadequate length, a fairly absurd unconvincing position. When the prototype wall section is built and it is seen to be effective public pressure will build further for extension where it is needed.

 

 

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The Trump Border Crisis Address and the Democrat Response

The problem of a porous southern border which our politicians have done nothing about has been festering for decades. President Trump has now brought the issue to a head and has started a real national debate. In actuality Mr. Trump is just a vehicle for bringing this situation to the forefront. The peculiar circumstances of his election was the result of large masses of U.S. citizens being disgusted with our dysfunctional federal government. The real instigators of all this fuss are the people who voted for him, the people who are increasingly concerned about the enlarging numbers of illegal immigrants among us along with drug traffic and the influx of some truly bad actors, the people that finally want some action about this fundamental federal government function.

Mr. Schumer and speaker Pelosi argue that a barrier would be ineffective, which defies common sense. Border walls have been shown to work dramatically in Israel and Hungary, and for that matter in our own country where they exist. Their idea that the present request for $5 billion is too expensive is laughable, considering the way billions are thrown around by their colleagues, not to mention the national expenses that would be reduced by truly controlling the border. Mrs. Pelosi argues that a border wall is immoral which is silliness. If that were true we should tear down the effective border walls we already have, such as in San Diego and El Paso. For that matter why would all our other efforts to prevent unauthorized entry such as the Border Patrol not then be considered immoral.

They argue that the President should sign their budget bill, and allow the federal government to fully function and then they will seriously address border security. How dumb do they think he is? The veto power is the one serious tool that the President has been given by the constitution to serve as a check on the congress. The obvious truth is that the main reason for the opposition of the Democrat leaders to principles they vigorously espoused in the recent past is to avoid giving Mr. Trump a political victory. I suppose that's understandable, but in doing this they are also thwarting the strong will and desire of those who put him in office. In truth I believe that a large majority of our people see the need to control our southern border, and indeed fix our broken immigration system generally, and are ready to have something serious done about the matter. Mr. Trump has put his plan on the table and it seems like a reasonable start. The Democrats offer us – opposition!

 

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The Cost of Government, and Especially the Federal Government

 

Since I now have the time, I've been using a software program which tracks and broadly categorizes all my personal income and expenses and it's enlightening.

 

One thing that's notable is that the largest expense category of all is taxes. And that doesn't even account for added on taxes like sales and gasoline tax. Breaking that down further I found that federal taxes amounted to more than twice the amount of all other types of taxes combined together.

 

Now despite what it may seem I'm not an anti-government anarchist. Government is essential in human society for protection, settling of differences and as Jefferson put it, for the pursuit of happiness. And for these United States a federal government that's strong enough to carry out its essential functions is important. Our founders determined that point after observing the results of the weak federal government embodied in the original Articles of Confederation. The U.S. Constitution which they devised was truly a work of practical genius, world-changing really. They established the principle that governmental authority is derived from the consent of the citizens and they laid out a simple framework in which this principal could be expressed in practice. They came up with a system dividing up specific functions, balancing each with specific powers over the other, and accommodating regional differences.

 

There are essential services that belong at the federal level and these are timelessly spelled out in general in the Federalist Papers. That must have been a remarkable time when there was a real national debate on whether to accept the new constitution. The Feds are needed to protect the general integrity of the country from outside forces, to interact with foreign powers, to settle differences between the States, to establish a common currency, and importantly as a general protector of individual rights. On the other hand the principle was established that governing should be done as close to home as possible, where we can get our hands on it if need be, and where its services pertain specifically to the community. I like especially the 10^th amendment to the Bill of Rights which states that "The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people."

 

So back to taxes. We certainly have to provide the funds for all this necessary government functioning. But I ask myself, should it be the largest expense category? Well then I look at what I'm getting in return. It's significant – roads, schools, garbage pickup, the courts and so on. But then it strikes me that most of that stuff is all fairly local, paid for by local and state taxes, plus the added on sales and gas tax. To be sure there are some important federal services that are not so evident, like the military and the ambassadors. But are these enough to justify federal taxes that are more than twice all the other taxes combined.

 

Then I look at the statistic about half of all the richest counties in the U.S. being with an hours drive from Washington and the $20 trillion dollar national debt, and it makes me wonder what's going on here. No real answers but it's worth thinking about.

 

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The Bizarre World of Hospital Charges

I'm involved in a minor financial battle with a hospital where I stayed overnight back in July. Being what's called technically an "observation" admission, my Medicare covered everything but "self administrable" medications. Why the distinction is anybody's guess. These are meds you normally take at home, but in the hospital they're provided for you and you're never given the option to bring them from home, and I don't even know if hospital policy allows it.

 

In any case, while I was in the hospital a nice lady from the business office came by and briefly mentioned the charge along with other details. I was feeling fine and everything was hunky-dory.

 

Three months later I got my bill for $200 for the one day supply of my meds. I take a few, and one expensive one, but nothing even close to that price. So I wrote back that I thought the charge was unreasonable and requested an adjustment. I recently got back an itemized bill listing the individual meds and the charges and sure enough they were all anywhere from 5 to more than 20 times  their out of pocket cost from the pharmacy, that is, not the discounted cost that the hospital would pay.  I won't go into the details, but for example 1 baby aspirin for $5.50.

 

So it brings up the whole subject of medical prices which is a great mystery, since no one pays for anything directly. We get letters from Medicare monthly in 20 different languages explaining the unexplainable, what the charges are, what Medicare approves, and what we may be responsible for, which is of course the only thing we're interested in. But that leaves out the secondary coverage which adds to the mystery.

 

At least now I have the actual charges detailed, after the fact of course which is a bizarre aspect of the whole transaction. I mean how many restaurants do you go into without prices listed on the menu and you find out when the bill comes. If you're in the rare one with no prices, you shouldn't be unless you are a multi-millionaire or a Washington politician.

 

So I wrote them back, thanked them for their service, which was good by the way, but still contended that the $5.50 baby aspirin, etc. was pretty absurd and I still want an adjustment. After all, I could just as well have brought in my pills from home and taken them with no problem.

 

Hospitals are a particularly byzantine component of the high cost of medical care. The ins and outs of the finances of these "non-profit" institutions is a great mystery, even for someone who worked in them for many years. It's true that they must write off a lot of services that they're obliged to do because they get federal financing. So they shift the cost to other payers, and that's where things get really complicated. But the bottom line is that they're a big player in the medical care cost picture. These "non-profit" institutions pay their CEO's big salaries, are presently in the process of buying up doctor practices wholesale, and are a bright spot in our somewhat shoddy infrastructure picture in that they seem to have the dough to build shiny new high tech buildings all over the place.

 

If you think handing over medical payments to the government would solve the problem, think again. One big reason for the present comfortable status of such mega health care institutions is that they're hand in glove with the federal government.

 

So it's going to be interesting to see how my little battle works out. The service was done, the hospital was out of town, so I could just blow it off, but I like to pay my bills. I just don't like getting caught up in this shell game. Emily says I should just pay the bill, but I'm too stubborn for that. Medical consumers should fight back, but it's hard to do when everything is a secret until you get the bill.

 

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