Hospitals increase cost of health care...and pick and choose what they market to whom

The greed of pharmaceutical and insurance companies is the stuff of legend. There can be no justification for the huge costs that the American people have to bear as a result. Their administrative costs and profits alone are unconscionable and drive up the cost of health care so much that it takes a completely self-serving and willfully ignorant Democratic presidential candidate to disingenuously ask “how will we pay for” Medicare for All – and we  have a lot of them. The financial cost is, however, is not the most evil part of what they do. That would be the deaths and disability and bankruptcy that affects so many Americans because the insurance companies deny them care and the pharmaceutical companies make their drugs unaffordable. (This is a mild term for drugs that can cost $30,000-$100,000 a year and more!)

I have written about these issues many times. More recently I have also written about the role that providers (mainly hospitals and “health systems”, but also some physicians, nursing homes, etc.) play in the two-pronged scandal of the US health care system – too expensive and too unavailable to too many. There are some hospitals (I include “health systems” but will use “hospital” to avoid confusion with the “health care system”) that are actually for-profit, but most are officially “non-profit”. This means that they don’t have shareholders – and don’t pay taxes – but they otherwise behave just the same, trying to make as much money as possible. They say that they plow this back into the services that the hospitals provide, but it also includes salaries for C-suite executives that look just as outrageous as those in the “for-profit” sector.

More important, the “improvement” in services does not always – or even usually – create new services that were absent from the community previously, or make them available to more people than previously, say the poor and uninsured. They are usually efforts to attract insured, paying, profitable patients away from other hospitals by building a new, fancier cancer center, or heart center, or orthopedic center. Hardly ever pediatrics (except neonatal intensive care) or mental health – they only want to expand those services that are big profit centers. In this way, it is parallel to the behavior of drug companies; they prefer to minimally modify existing big sellers to get a piece of that market (“me-too” drugs) rather than to develop drugs to meet needs not currently being met.

It is good to see the hospitals being called out by major health system critics. Elisabeth Rosenthal, president of Kaiser Health News, wrote an important article on September 1, 2019 in the New York Times (where was once the health reporter) titled “That Beloved Hospital? It’s Driving Up Health Care Costs”, in which she makes many of the same points. She writes that

Data shows that hospitals are by far the biggest cost in our $3.5 trillion health care system, where spending is growing faster than gross domestic product, inflation and wage growth. Spending on hospitals represents 44 percent of personal expenses for the privately insured, according to Rand.

A report this year from researchers at Yale and other universities found that hospital prices increased a whopping 42 percent from 2007 to 2014 for inpatient care and 25 percent for outpatient care, compared with 18 percent and 6 percent for physicians.

The reason, of course is the political clout that the big hospitals can buy (with, of course, our money!).The Democratic presidential candidates are beholden (with the exception of Sens. Sanders) to both hospital contributions and the role of big hospitals as major employers and economic drivers. “In 2018, PACs associated with the Greater New York Hospital Association, and individuals linked to it, gave $4.5 million to the Democrats’ Senate Majority PAC and $1 million to their House Majority PAC. Its chief lobbyist personally gave nearly a quarter of a million dollars to dozens of campaigns last year.” Could this have anything to do with why “The cost of a hospital stay in the United States averaged $5,220 a day in 2015 — and could be as high as over $17,000, compared with $765 in Australia”? Ya think? Ask you politicians what they are going to do about it…

The media, including Kaiser Health News, has been running stories on hospitals that are aggressively pursuing lawsuits against patients who have been unable to pay their bills. On September 3, 2019, the Times ran a long piece on the poster child for this practice, Carlsbad Medical Center in New Mexico, in “As Patients Struggle With Bills, Hospital Sues Thousands”, but Carlsbad is by far not the only one. The practice is most common in towns with just one hospital, and of course, patients do not know how much they owe – or for what. It doesn’t matter if you are insured: “Ms. Price, 40, a nurse and local 4-H leader, has been sued five times by Carlsbad Medical Center, for bills totaling more than $17,000….Ms. Price said she had never received an itemized bill outlining exactly what she owed money for. The collection agency wanted the balance in full, and she was not able to work out a payment plan until after she was sued.”

This article names other hospitals that sue patients as a core business practice, and mentions over 20,000 suits in Virginia. Turns out that this was in no small part driven by the state-owned University of Virginia hospital in Charlottesville, documented by the Washington Post and MSN in “‘UVA has ruined us’: Health system sues thousands of patients, seizing paychecks and putting liens on homes”. In a quick response, the Governor of Virginia and the University vow to stop suing patients, but this has apparently not affected those already sued: ‘“Fixing the problem “is complicated,” in part because “we are legally obligated as a state agency to collect debts,” he [UVA president Ryan] said. “But we have discretion within those legal constraints to make our system more generous and more humane.”’ It also has not hurt the CEO of the hospital “…Pamela Sutton-Wallace, who will leave in November to join New York-Presbyterian Hospital as a senior vice president”. Maybe she can teach them to sue their patients…

Many of us have sort of emotional attachments to our local hospitals, where we were born, or delivered our babies, or had our life-saving surgery or other treatment; for which we raised money through bake sales and car washes, or maybe volunteered in the gift shop. But these are not the warm fuzzy hospitals you remember. Rosenthal acknowledges that many rural hospitals are in financial trouble – and they are – but supporting the fantastic (“non-”) profit of these major hospitals is not going to change that. As in every other sector of society, we have two classes of service. One is to those in major metropolitan areas with money or good insurance, with conditions that are highly-profitably reimbursed, like cancer. Preferably all of the above. There is no limit to what will be invested in them. Then there are those without money, or good insurance, who live in rural areas, or have problems that are not well reimbursed, like mental health or substance use. They will not get investment. Simple as that.

Major hospitals are big businesses and act like it. You are a customer – but, compared to other industries in which you are a customer, a particularly uninformed one. Need a car? A refrigerator? Financial services? Dental care in Mexico (had to get that one in)? You can find out what it will cost and compare prices. Hospital care? In the US? You gotta be kidding.

The answer? Improved an expanded Medicare for All, a single-payer system in which, as in Canada, hospitals get global budgets, and separate capital budgets so that they cannot use the money (profit) they earn on your care to build spas to attract high-paying patients from competitors. Where everyone gets the care they need, and no one gets excessive care. Possible? Too expensive? Ask the Canadians. Or Australians, where the average hospital bill is less than $800. Or British, or French, or Swedish, or Danish, or Dutch, or German, or Taiwanese….

Opioids, deaths, and capitalism: It's the capitalism, people!

The opioid epidemic is real. Far more opioids (the term that includes opiates, naturally-derived from opium, and synthetic drugs) are consumed than could conceivably be used for medical reasons, whether for short-term use post-surgery or injury, or chronic use for terminal diseases like cancer. The explanation, at one level, is the excessive use of opioids for pain relief for chronic conditions (like back pain, for which other drugs are often more effective) or excessive duration for what should be short-term (acute) reasons, and the fact that they are very addictive. This last has led to the creation of new addicts, who have been placed on prescription opioids for pain, and means that they can be used to substitute for opiates (such as heroin) for those who became addicted to street drugs. This is especially true with the increased availability of extremely potent synthetic opioids, such as fentanyl (50-80 times more potent than morphine), but can go both ways; when those who have become addicted to prescription opioids find the supply drying up, they often move to heroin.

But, like most things, it is complicated. The biggest complication is that many of those who have become “hooked” on opioids are suffering in pain, and opioid withdrawal is, to put it mildly, not fun. The pain relief is greater than that of other pain relievers, for many (but not all) problems, but opioids increase tolerance, so the doses people need to take to relieve their pain, or get their high, continually increases. The “consensus” pendulum has swung, from the message that people are not getting sufficient pain relief (“pain is the fifth vital sign”) to “doctors are creating addicts by overprescribing opioids”. Patients – people -- are caught in the middle.

Another complication is, as is usual in any big issue in the US, race. Opiate addiction and problems were a focus more of criminalization than treatment when it was perceived as mainly a problem for minority populations. The increasing revelation of white, albeit often poorer, less educated, and more rural, white people suffering from the prevalence of opioid abuse, has changed the discussion. Not that this is unimportant – the message that for the first time in a century a portion of the population – middle aged white people – have an increasing death rate (discussed in Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015, and based on the work of Case and Deaton, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century”) is shocking. So is the finding that poor white women born in 1950 will live shorter lives than their mothers born in 1920 (“Life expectancy, socialism, and the determinants of health”, February 14, 2016). None of this to deny or ignore the fact that death rates for minorities, although dropping are still higher than those of whites.

The New York Times has had a series of exposé articles on the opioid crisis, and a recent installment completely pulls back the curtain on the marketing and sales practices of opioid manufacturers. “3,271 Pill Bottles, a Town of 2,831: Court Filings Say Corporations Fed Opioid Epidemic” reveals that many manufacturers, not simply Purdue, the maker of Oxy-Contin®, and many pharmacies including all the big chains, have been complicit in the spread of this epidemic. Its content is damning, and the evil acts of these companies are made public, and the information needed to ascertain the reason for the problem is clear.

But the Times does not explicitly call it out. That is because the problem is capitalism, specifically “unfettered” capitalism, essentially unregulated capitalism that not only permits, but encourages, anything that will make more money, regardless of the cost, including (and perhaps especially) the human cost. These corporations are responding to the pressure of Wall St. and their stockholders not only to make more money, but to “exceed expectations”. The value of a stock is not based on whether the company is actually earning a profit, but whether it is earning enough of a profit to please the casino players. This is augmented by the incentives for often huge bonuses for the top management based upon – how much profit the company makes. There are no bonuses for actually helping more people, or even not killing them, or not destroying the world. Sorry, you who die from opioids or suicide, you are collateral damage. Oh, yes, you also, future generations.

To be clear, this is not a result of Republican or Trumpian policies, although they have been both more open about it and have further pushed the envelope with their gargantuan tax cuts for corporations and the 0.1%. It has been the policy of every government at least since Reagan in the 1980s, Clinton and Obama certainly included. Of course, every US government has been pro-capitalist, but for much of the 20^th century, starting with (Republican) Teddy Roosevelt, there were both implicit and explicit limits set. Even conservative economic guru Milton (“the only goal of a business is to maximize shareholder profit”) Friedman believed that monopolies were ultimately not a problem because technology and the market would take them down. He was wrong; there are no limits to what they will do for more money.

So we have Americans dying by the tens of thousands from opiate and opioid overdose, and from the “suicides of despair”. We have children being separated from their parents and migrants being housed in prisons because it makes money for the private prison industry, a major donor to politicians. (Kudos to Illinois for being the first state to ban private prisons.) We have the environment being irreparably destroyed for the profit of some companies, with government complicity. We have wars being fought across the globe, killing hundreds of thousands, and each being the potential spark that could destroy the world more quickly through nuclear war. We continue to increase the defense budget although we already spend several-fold more than all our potential adversaries put together, because it is the way that the federal government subsidizes US industries.

Why do we do these things? Our oligarchs (a term the media seems to reserve only for foreigners, especially Russians, even though the US has so many more of them) demand it, and pay for it, essentially through kickbacks. They care not for the future, even for their grandchildren, or for whether there is a world.

They must be stopped. Our health, and our lives, depend upon it.

The high cost of US Healthcare: It's not mostly the demanding patients!

Did you know that American healthcare is the most expensive in the world? And did you know that health outcomes here are way lower than in other developed countries? Well, since you’re reading this blog, you probably did. But here’s a scoop: one of the main reasons for this high cost is apparently the demanding nature of American patients!

Wow, you’re thinking! I was under the impression that it was greedy drug manufacturers who sell drugs in the US at many times the price they are available in other countries! And insurance companies, making huge profits by collecting high premiums, co-pays, and deductibles and then trying their best to not pay for care! And the health industry itself, providers like hospitals and health systems, who, even when ostensibly “non-profit” act like for-profits trying to make the most money possible and paying their executives in the millions (although maybe less than the C-suites of the drug and insurance companies). You probably thought it was the whole corrupt end-stage gangster capitalist system that never met a dollar it didn’t want, no matter who it hurts.

Well, sorry you’re so naïve! Just read this article by David H. Freedman in the July, 2019 Atlantic, “The Worst Patients in the World”. The reason health care in the US is so expensive is the fault of people like his 74-year old father: “An accomplished scientist who was sharp as a tack right to the end, my father had nothing but disdain for the entire U.S. health-care system, which he believed piled on tests and treatments intended to benefit its bottom line rather than his health.”

And yet, Freedman points out, he demanded tests when he was sick! And he not only did nothing medical to try to help his health (like going to get checkups or preventive care), he actively undermined it by

…practically using the list of prohibited foods as a menu. He chain-smoked cigars (for good measure, he inhaled rather than puffed). He took his pills if and when he felt like it. By his late 60s, he’d been rewarded with an impressive rack of life-threatening ailments, including failing kidneys, emphysema, severe arrhythmia, and a series of chronic infections. Various high-tech feats by some of Boston’s best hospitals nevertheless kept him alive to the age of 76.

He also punched a doctor.

Then Freedman goes on to argue that it is both these characteristics, abusing oneself and not taking care of one’s health, including eschewing tests that were “intended to benefit its bottom line rather than his health,” but then demanding that the medical care system provide all the most expensive possible of those tests once he was sick, that typify the behavior and approach of many Americans and account for, in large part, the high costs of health care. While Freedman acknowledges his agreement with the concept of Medicare for All, he suggests that “We ought to consider the possibility that if we exported Americans to those other countries, their systems might end up with our costs and outcomes.”

Wow again! If w. imported US people (“patients” is the medical term for people) to, say, Canada or the UK or Denmark or France, their healthcare costs and outcomes might be, respectively, as high and poor as ours. It is not the first time that this argument has been made, but it is being featured in a major magazine, and written by a presumed progressive (or at least supporter of Medicare for All). Maybe it is worthy of being considered!

Or rejected. Maybe it is a fallacy to presume that it is a flaw in the character of the people who live in the US, compared with those in other countries, that is responsible for the high cost and poor outcomes of our health care system. Or maybe not, considering everything else about us (which I will not now consider in depth), our collective national character illustrated by things like putting migrant children in cages, denying global warming and the climate crisis, supporting the fossil fuel industry with far more money than we spend on education, or maintaining a ubiquitous system of racist law enforcement and imprisonment, just to name a few. I think it is a fallacy, though. I am sure there is a wide range of personality types within the US as well as in other countries; people who are more or less hostile, people who are more or less demanding, people who are more or less suspicious of anything that smacks of authority, and people who are more or less willing to do what they themselves can do to help themselves. So why does it seem like there are so many more in the US, and that this is a major contributor to our health care costs?

Because it does seem as if there are. I have been a doctor for a lot of years, and I have seen lots of people who do little or nothing that should be in their own control to improve their health, and yet are very demanding of expensive resources being used not only when they get sick, but after there is little chance of it benefiting them. People who, like Freedman’s father, contrary to all that “should” happen, are kept alive many years after they “should” have died as a result of the bad genes, habits, environmental factors, and luck that led them to the diseases they had. Yup. Bad behaviors. Shame! And then wanting “everything done” when it is too late, and, oh yeah, you don’t have to pay – the insurance pays. Which raises everyone’s rates. Yup, selfish.

But why would Americans be so selfish, mean, demanding? Why would they be different from other people? Would, in fact, exporting Americans to other countries raise their costs and worsen their health outcomes? That’s not an experiment that we can do easily, although there is no evidence anecdotally of this occurring. The real issue is the one I talked about at the start of this piece: a health system designed to enhance profit for the companies who own it (and the pieces of it). It is their practices that encourage many of the sorts of behaviors that Freedman and others note.

The entire health system is built on high-cost, high-tech interventions. There is far less profit in controlling, say, diabetes, with cheap generic drugs than in the newest high-cost patented drugs. There is enormous emphasis on procedures, diagnostic and therapeutic, that have little evidence of benefit, or evidence of benefit in a very narrowly-defined population. It is absolutely NOT true that a screening test of benefit for a high-risk population, for example, is of benefit for lower-risk people. There is incredible expenditure at the end of life, when often all that can be done is prolonging suffering. It is done because people, and companies, make money on it. And to complain that people behaving relatively rationally in response to these incentives is the problem is to engage, as is all too common, in victim blaming.

And if we blame the victims, we are hardest on those who are victimized in the most ways. The poor, the uneducated, the jobless, the homeless, the imprisoned, the children. Those who “demand” care because, historically, they are members of a class, race, or group that was systematically denied it. You may not feel a lot of sympathy for Freedman’s father (or maybe you do) since he had so much – a scientist, presumably with a reasonable income – who took poor care of himself and then cost the system piles of money to keep him alive until 76. But the system is hardest on those with the least.

And that is why “compromise” solutions to increase health care access rather than make it universal are not only morally wrong but bound to fail. The biggest question about “Medicare for All” is how much it will cost. But the answer is that the cost will be made up for by eliminating exorbitant private-sector profits. Half-measures, “Medicare for More” or “Improved ACA” don’t do that.

Everybody in, nobody out!

Corporate control corrupts medicine and reduces healthcare quality

Medicine and health care is always changing, and the pace of change seems to be accelerating. Some of this change is good for people -- some of the new drugs that come out actually help, either a lot of people, or more commonly a few people. Sometimes new treatments are more effective, less painful, shorter, or less debilitating than older ones. And, sometimes, they are not. One thing we can be sure of, though, when we see a new treatment advertised, whether on TV or in a magazine or on a billboard, is that someone is making a lot of money on it.

There has been a great deal of coverage of two of the most important and egregious industries in which large corporations make lots of money at the expense of our health: pharmaceuticals and insurance. They deserve it, and I have written about them often. But another extremely important area where corporatism and corporate culture has taken hold and is expanding is in the ownership and management of hospitals. The most important thing about this increasing corporatism is that it is about making money (even in “non-profit” hospitals), not primarily about providing the health care that people need; of course, if what you need (or can be persuaded to buy) is profitable for the hospital, they’re all about it. For example, new surgical techniques and imaging, and particularly high-margin, low risk procedures like joint repair and replacement in otherwise relatively young healthy people (let’s go for that high school quarterback or 40-something weekend warrior). Not so much problems that occur in people who have multisystem disease, are old, are high risk, or are poor and uninsured. And some stuff – like psychiatric treatment for the most needy, or trauma care, are big money losers. Hate that if you’re a CEO, although might be good if you are a person who needs it.

This trend has been going on for a long time, particularly in large metropolitan areas, where most big hospitals are, and most of them are now part of hospital systems. Of course, big hospitals were always big, but the overemphasis on making decisions based upon money rather than people’s health has been accelerating. And more recently the process has taken over hospitals in smaller communities, including Critical Access Hospitals in rural areas. The Critical Access designation is meant to reflect the geographic isolation of a community, such that travel to the next-closest hospital creates real health risks for the population, and so even if operating it is inefficient, it receives federal support.

This is discussed in an outstanding editorial by Andrea Wendling in the October 2018 issue of Family Medicine, “Times Are Changing”. Dr. Wendling focuses on two major areas, the reinterpretation of the “value” of physicians and the role of family physicians. Family physicians are the most common specialists in rural areas, in part because they can have such a wide scope of practice. They can care for the medical problems of adults and children, deliver babies, provide care for many musculoskeletal problems, mental health, women’s health care, and provide many procedures. At least as important to patients, they can see them in all the venues where they need to be seen – the office, the hospital, the nursing home, and even the patient’s home. Dr. Wendling notes that this is threatened by the corporate perception of physicians’ value, which is their value to the system, measured financially, rather than their value to the health of the community. Yes, you might find it beneficial to have a doctor who knows you, who has cared for you and your family for years, be able to see you in whatever setting you find yourself in, but the system has decided it is more efficient (read “more profitable”) to have your doctor be only an ambulatory care provider, or only a hospitalist.

It is not only family physicians who are affected, although they predominate in rural areas. While some specialists – those that provide care that is not necessarily the most important, but is the most profitable – have always been more highly paid and more sought after by health systems, even they are seeing decreases in their pay and status. It is hard for the family physician to cry for slight cuts in the income and power of doctors (like orthopedists and radiologists) who are making many times what they do, and in fact it is hard for most Americans to cry for the plight of even the lowest-paid doctors. Perhaps it feels like crying for the white men who bemoan their loss of privileges (real and desired) because women and minorities are finally moving the playing field to being, at least a little, more equal. But the corporate influence is far more malignant.

Family doctors believe that their contribution to people’s health is relatively greater than their income. Doctors believe that, whatever their income, they are working to improve people’s health. CEOs and corporations believe that health is a good thing to try to sell, provided we sell the kind that makes money. They do not put the health of the community first; they put the financial well-being of the corporation first. And, not surprisingly, this affects both poor and rural communities the most, because of the limited access to services they had in the first place; an arrogant and self-serving corporation taking over the only hospital in a community does not bode well for the overall health of the people who live there.

And, adding insult to injury, it is not only the dollar-centered approach that is a problem, it is the egos of the local leaders who, emulating their corporate bosses and our political class, think that they as individuals are important and deserve respect and obeisance. I have a friend who led the physician group at a rural hospital when it was taken over by a larger system, and helped negotiate the criteria for bonuses for the medical staff. Soon after, that physician was fired by the local CEO for “embarrassing them”! The doctor got their job back with the help of lawyers, but imagine the gall of that CEO! If what they were doing was right and good, they had no reason to be embarrassed; if they had reason to be embarrassed because what they were doing was corrupt, self-centered, not good for the physicians or for the community’s health, what they were doing was wrong and should have been exposed. I have no doubt that if the people in that town were asked who they valued more, the physician who had cared for them for years or the new CEO put in by a corporation, which one would get more votes. Maybe the CEO would get that of their spouse.

So we have a health care system that is structured to be corrupt, from the insurance companies, to the drug and device makers, to the big health systems, all geared to profit. We have many physicians, in all specialties from the rich and powerful subspecialists to the family physician, who are trying to figure out how to stay on the “good side” of these corporate systems and of the local martinets. We have physician leaders, in hospitals and medical societies and academic departments who often are looking mostly at themselves and how to show that they as individuals are important (like that rural CEO), maybe believing that what is good for them is somehow good for people. Sadly, this is even true in family medicine, no longer the ‘counterculture’[1]its founders, like Gayle Stephens, wrote about, but now often simply other supplicants for corporate largesse.

All of this is at worst immaterial and at best subsidiary. The criteria for whether a healthcare system or aspects of it are good is whether it improves the health of people and the community. We have a long way to go in our healthcare system. And it’s long since time to get started.

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[1] Stephens GG. Family Medicine as Counterculture. Fam Med 1989; 21(2):103-9.

Blasey Ford, Kavanaugh, bias and arrogance: present in medicine, not just politics

Mostly it is pretty easy for me to think of things I want to write about in the area of medicine and social justice; there is so much awful stuff going on there. But today it was harder; I want to write about the bravery of Christine Blasey Ford, and how powerful the calm, collected testimony that she gave was, especially given the fact that she had nothing to gain except harassment for herself and her family, and even death threats that required her to go into hiding.

I want to write about the atrocious behavior of Brett Kavanaugh, who has a lot to gain -- a lifetime appointment to the Supreme Court of the United States – but chose to take the low road, not just denying the charges but displaying aggrieved entitlement, snarling and attacking and refusing to give straight answers to straight questions. Right out of the Donald Trump playbook. And absolutely not the behavior we want on the Supreme Court, or even that we heard about his control in his current Appeals Court job. Much more, in fact, like the 17-year old Kavanaugh that Dr. Blasey Ford described.

I want to write about the tone-deaf but mission-focused hubris of the 11 white men who formed the majority on the Judiciary Committee. Ten of them having made up their minds in advance, they were not going to be derailed by anything, certainly not the testimony of the witnesses. Led by their chair, Sen. Grassley, who never made eye contact with Dr. Blasey Ford but kept his eyes on the paper he was reading from, and their attack dogs (Lindsey Graham, harsh, and John Cornyn, snide) they had a woman prosecutor question the female witness so as not to look like they were who, in fact, they were. That the format never allowed Rachel Mitchell to pursue a line of questioning was irrelevant, since it was all a charade for them. It is a shame that they made old men look so dumb and evil; remember that Grassley (85) and Hatch (84) were arrogant misogynists when they were younger, and that those (like Crapo and Cruz and Sasse) still in the 40s already are the same.

But this is a blog about medicine and social justice, and while there are certainly social justice lessons to be learned (in the negative) from the disingenuous cavorting of racist, sexist, we’ll-do-this-because-we-can behavior of white men in the hearing room, it has little to do with medicine or public health. Except, of course, to the extent that this entitled behavior is so frequently seen in those fields.

I recently wrote about an example of entitled corruption in José Balsega, the former Chief Medical Officer of Memorial Sloan-Kettering Medical Center (“Baselga, graft and corruption in medical research: why should we tolerate it?”, September 16, 2018), and we just learned that their vice president in charge of corporate relations has been required to pay them back the $1.4M he made from, essentially, insider trading.

I have also written about other corrupt executives, mainly in the pharmaceutical industry (e.g., “Epi-Pen® and Predatory Pricing: You thought our health system was designed for people’s health?”, September 3, 2016). These “Masters of the Universe” (h/t Tom Robbins) think they deserve everything they can get, and the rest of us be damned. Thanks to women like Heather Bresch of Mylan (Epi-Pen®) and criminal mastermind Elizabeth Holmes of Theranos, they are not all men. But mostly they are, and even these women had the protection of old men; Bresch’s father is Sen. Joe Manchin (D-WV) and Holmes attracted rich old white guys like Riley Bechtel of Bechtel, George Schultz, former Secretary of State and Bechtel CEO, and William Foege, former head of the CDC and hero of the anti-smallpox crusade, in a real-life parody of a bad thriller femme fatale.

Bad behavior is rife in the medical and public health communities, motivated, like that in the pharmaceutical sector and politics, by self-interest, a desire for money and power. Aaron Carroll, in “The Upshot” in the New York Times on September 24, 2018, writes about the many forms of bias in scientific and medical publication. He takes off from an article in Psychological Medicine, “The cumulative effect of reporting and citation biases on the apparent efficacy of treatments: the case of depression”, but he points out the many forms of bias affect research and research papers in general. These include publication bias, which means journals are more likely to publish papers with positive results (our study showed this new treatment worked!) rather than negative (well, we thought this would work but it didn’t, 😞); outcome reporting bias where only the positive outcomes are published and the negatives are left out; spin where, when unable to avoid reporting results that are negative, you use language to make them seem more positive; and citation bias, whereby other authors are much more like to refer to (“cite”) papers with positive results than those with negative, thus increasing their visibility. He does not specifically discuss confirmation bias, in which researchers are much more likely to notice and report on findings that confirm their prior ideas and dismiss those that contradict them, but this is also very insidious.

Sometimes the stakes, seen by the really rich and powerful, are minor – status and reputation in the academic scientific community (recalling the old adage “competition in academics is so vicious because the stakes are so low”). However, it is not just the researchers who are at fault. Journal editors and publishers are motivated by their own metrics of success, such as the “impact factor” based upon how often articles in their journals are cited by others. And, of course, our old “friends”, the pharmaceutical companies, are behind much of this bias, suppressing negative results for the drugs they make and emphasizing secondary outcomes (unethical!). For them, the stakes are financial and very high.

Carroll does a masterful job, supported by research published in a number of journals. He ends by discussing the ways in which these practices hurt we, the people, by getting false or misleading information out to other physicians and scientists. This can lead to us receiving treatments that don’t actually work, or work as well as they are portrayed as doing, or may even be more likely to harm us than help us. He emphasizes the important fact that not all, or even most, published scientific research is not to be trusted, but that these scurrilous articles are out there, and depend upon not only reporters and the public, but doctors not reading them carefully. Sadly, many medical (and other) professionals often hear only the reports of research in the popular press or, if they read the study, read only the Summary, or the Discussion section (most easy to “spin”) instead of carefully looking at the reported Methods and Results and drawing their own conclusions. Carroll makes a series of suggestions as to how the discipline might change this culture of bias; they are good and should be pursued.

I am not sure where the blame originates, whether from our leaders like our politicians and businessmen who see truth as an option which can be disregarded in the pursuit of money and power, or our scientists who take these illegitimate roads to further their own careers, or the public which has become agnostic about truth and searches only for confirmation of their own preconceived notions (or biases). But I am sure that, at all these levels, it is a bad thing and corrosive of the progress that should come from new knowledge.

Most of us will never get the chance to publicly put ourselves out there on the line like Dr. Blasey Ford, and very likely wouldn’t if we could. We can, however, stand for the idea that truth is not “revealed” but emerges from continuing work, from confirmation by replication of studies, from more work that further elucidates the truth. And that the enemy of truth is the kinds of biases that Dr. Carroll discusses.

In talking about his suggestions for correcting them, Carroll writes “These actions might make for more boring news and more tempered enthusiasm. But they might also lead to more accurate science.” And that would be good for us all.

Tom Petty, the opioid epidemic and changing structural inequities in the US

In October 2017, the rock musician Tom Petty died at the age of 66. Given Mr. Petty’s history of heroin addiction back to at least the 1990s and the frequency with which overdoses seem to cause the death of celebrities, there was some early assumption that it may have caused his. This was confirmed by the coroner, (NY Times, January 19 2018); however, the cause was not heroin but rather prescription opioids (oxycodone plus 3 types of fentanyl), combined with two also-addictive anti-anxiety medicines known as benzodiazepines: “The coroner, Jonathan Lucas, said that Mr. Petty’s system showed traces of the drugs fentanyl, oxycodone, temazepam, alprazolam, citalopram, acetyl fentanyl and despropionyl fentanyl.” (The citalopram is an SSRI anti-depressant). According to a statement from his wife and daughter, he had many ailments including a fractured hip that caused him great pain.

Thus, Mr. Petty becomes another victim of the epidemic of prescription opioid-related deaths. His previous heroin addiction (chronic use of opiates or opioids leads to tolerance, requiring higher and higher doses for relief) and his stature as a rich and famous person (which seems to make it even easier to find doctors who will prescribe such drugs) may have increased his risk, but his death is one instance of a widespread American problem that has been the subject of academic articles, government reports, and opinion pieces from medical providers, patients, and the general range of pundits.

David Blumenthal and Shanoor Servai of the Commonwealth Foundation write in their report “To Combat the Opioid Epidemic, We Must Be Honest About All Its Causes” that “History offers only one other recent example of a large industrialized country where mortality rates rose over an extended period among working-age white adults: Russia in the decades before and after the Soviet Union’s collapse. The economic and social contexts have been eerily similar, and substance abuse has been a dominant factor in both countries: alcohol in Russia, opiates in the United States.” A major study by Princeton economists Anne Case and Angus Deaton in 2015, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century” (which I have previously cited, Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015) posits opioid-related deaths as a major cause of the surprising  increase in mortality rate among white Americans. Blumenthal and Servai note that “Based on weighted estimates, 92 million, or 37.8%, of American adults used prescription opioids the prior year (2014); 11.5 million, or 4.7%, misused them; and 1.9 million, or 0.8%, had a use disorder. The epidemic is spreading so rapidly that it’s likely the numbers are higher now.”

So it’s a very big problem, with many causes, and the solutions are not simple. Doctors play a big role, since they must prescribe the opioids (whether these are taken by the designated patient or illicitly redistributed). While well-known surgeon and author Atul Gawande, in an interview with Sarah Kliff on Vox.com, says “We started it”, I don’t think that is completely true. Certainly doctors have been vehicles for its perpetration but there are other forces at work. One is the movement that began in the 1990s to adequately address patients’ pain, which was seen as insufficient by many critics. In many institutions pain was labeled the “fifth vital sign”, and staff were instructed to ask about pain relief in every interaction. While this is important, especially for acute short-lived pain (such as post-operative or post-traumatic), the use of opiates for chronic pain skyrocketed. The obvious problem is, as cited above, the more you have taken them the more you need; tolerance to opiate and opioid effects often requires increasing doses. The “high” resulting from these drugs (whether intended or not) increases their potential for abuse.

Long-acting opiates and opioids (such as extended release morphine or oxycodone, methadone, and fentanyl patches) are preferred as they can control pain with less of a “high”, but they still lead to tolerance. While addiction is not an issue for people who are dying of their cancer, it is for people with chronic diseases such as sickle-cell and chronic pain syndromes, most commonly in the US back pain. Opiates and opioids have been shown to be poor choices for long-term treatment of chronic back pain, but taking them is often easier and cheaper for patients than complicated (and often expensive) modalities such as physical therapy, and it relieves the pain more quickly and completely until higher and higher doses are needed. So patients, as well as physicians, are part of the problem, and physicians are working to try to help people, while complicating the problem.

Real villains include those who have originated and perpetuated this crisis only to make money. This includes insurance companies, who often deny more expensive treatments such as extended physical therapy or drugs such as buprenorphine, essentially pushing doctors and patients into the use of opioids. They certainly include the pharmaceutical companies who have developed and heavily marketed these drugs, notably the Sackler family who owned Purdue and made and pushed Oxy-Contin®, as documented in the New Yorker article “The family that built an empire of pain” (October 30, 2017). In brief, they acquired the rights to long-acting morphine, but because this was losing its patent protection (and thus its profitability), they developed a long-acting form of oxycodone, which was patented and thus more profitable. Counting on the negative associations that the public and even physicians associated with morphine, they pushed Oxy-Contin, which was at least as addictive and dangerous, for an ever-expanding list of chronic conditions. Back pain, of course, was the target market, and it soon seemed as almost everyone had an indication for opioids. And we have since been paying the price with their deaths.

The flaws of capitalism that directly drove and continue to drive this epidemic through the pursuit of profit should be clear enough. The structural flaws that have and continue to ruin the lives of so many Americans (not to mention people in the rest of the world) may be less obvious but are no less real. The dramatic redistribution of wealth from the vast majority of us to the already-wealthiest, with the concomitant decrease in the quality of life for so many, proceeds apace. The 1%, maybe even the 5%, are doing great, although the biggest benefit (including from the new GOP tax “reform”) law goes to the 0.1% or less. The richest 1% now owns half the world’s wealth and the 8 richest men have as much as half the world’s population!  Worldwide, it is those in the poorest countries that suffer most. In the US, it remains minorities. While the shocker in the Case and Deaton study was the fact that white mortality is increasing, the fact remains that minorities, especially African-Americans, still have far higher mortality rates.

If we wish to decrease this excess mortality, it certainly will be important to address the opioid crisis, by physicians becoming more reticent to prescribe long-term opioids for chronic conditions, patients to accept alternative treatments, and insurers being willing to pay for those treatments. It will also be important to address other chronic addictions, like alcohol (Blumenthal and Seervai observe that while “11.5 million, or 4.7%, misused them [opioids and opiates]; and 1.9 million, or 0.8%, had a use disorder…By comparison, there are 17.1 million heavy alcohol users among adults over 18.” Legal does not mean safer, whether we are talking alcohol abuse or “legitimized” (by prescription) opioid abuse. It most often reflects the relative power of the industries that financially benefit.

The core problem is in the unfair, unjustifiable, and oppressive structural inequities in our society. These are so deeply seated that we often assume they are inevitable, and that there is no other way. There is. We may not be able to eliminate inequality, but if we are to seriously address the epidemic of unnecessary deaths, we need to do more than treat the symptoms; we must grapple head-on with and change our society’s structure.