Three days of a severe headache that would not respond to the ibuprofen, naproxen, or acetaminophen. “I never get headaches” is what I said multiple times to my wife and to colleagues. The morning of day three, a rash started to appear on my forehead, in the left eyebrow, in the scalp, with swelling around the left eye and swollen lymph nodes at the angle of the jaw on the left. My wife mentioned “shingles”. Poor early diagnosis on my part, and, I said “Oh !*#%! that is what I have”.  I was starting to feel as if I had been taken out by an NFL linebacker.
Multiple news outlets are reporting that a letter signed by Representatives Henry Waxman, Frank Pallone Jr., and Diana DeGette was sent last week to the CEO of Gilead asking for justification for the high price set on its new Hepatitis C medication, Sovaldi. (See this story.) The lawmakers also stressed that they expect Gilead to explain how the drug will get to patients in government funded programs, like Medicaid and Medicare.
Remember when many predicted that accountable care organizations (ACOs) will save health care? A study by the Health Research and Educational Trust (HRET) states that “ACOs are entities willing to be held accountable for the costs and quality of care for a defined population of patients. When the ACA [Affordable Care Act] became law, such would-be organizations were likened by some observers to unicorns — they exist in our imagination, but no one has actually seen one.” (Certainly not Regina Herzlinger, PhD, as we reported here.)

Harsh, perhaps, but a recent study by the Centers for Disease Control and Prevention searched in vain for the cost savings in Medicare ACO pilots. The HRET says that “only 25% of physician practices have joined or formed ACOs, and another 15% plan to do so.”

Recently a Minnesota school was evacuated after 10 students got sick during choir practice. A carbon monoxide leak was the presumed cause, given the similarity of student’s symptoms and the rapid spread of complaints. Thirty students in all were taken to the hospital and the school was closed for the day. Tests proved negative, recovery was quick, and the Minnesota Department of Health (MDH) now reports that the likely cause was psychogenic illness.

The state spokesman said that when people in a group become ill at the same time with subjective complaints, “It is no less real.”

It seems that when an affliction — real or imagined — hits, it can spread quickly among some people. According to one of the more recent CBS News Poll, 61% of Americans disapprove of how the ACA rollout is being handled. Nevertheless more Americans are in favor of fixing the law (48%) or keeping it as is (7%) than repealing the ACA altogether (43%). More telling perhaps, according to several opinion polls about the ACA since 2010, is the stability of opinions concerning Americans’ support for or opposition to the law.

Only time will tell whether the latest ACA anguish from the chorus will fade without treatment, but one thing seems increasingly obvious: Debates about the ACA are distracting from the inertia needed for additional reforms if we are serious about reducing health care costs and improving the health of the nation.

Germany is the third biggest drug market in the world, with $42 billion spent on pharma products in 2012. Germany allows its insurers to work together to negotiate with pharmaceutical companies to create one price for all Germans. There’s the official list price, which is made public, and the proprietary discounted price. The German public price list is used widely in Europe and Japan for drug pricing and negotiations.

The German government is looking to make the discounts public knowledge as well. This is designed to reduce margins for suppliers and pharmacies, so that they base their margins off of the true prices, rather than list. The pharmaceutical companies are concerned that the release of the discounts will eat into their revenue from the other countries that use the current public list, which seems to me to be tacit admission that the discounts offered elsewhere aren’t as aggressive as the ones Germany’s pooled insurers can get.

This comes after the aggressive actions of Germany’s Institute for Quality and Efficiency in Healthcare, which is the equivalent of Britain’s National Institute for Health and Care Excellence (NICE). They’ve been aggressive about looking for deeper value before allowing products access to the German market, which seems largely cost driven.

My concern is how this affects the U. S. market.

It is widely believed that the American health care system subsidizes the markets where access is more limited and prices are set. For example, Britain just worked with pharms to hold the NHS spend on brand drugs flat over the next two years, so growth in that market is limited. The pharma companies’ need for growth means that they will be raising prices elsewhere to support flat trend in the UK.

That why it seem inevitable to me that the US government will step in. The global pharma market is far from free. It is a messy amalgam of single-payer, third party payers, supplemental plans, private insurers and the U.S. Centers for Medicare & Medicaid Services. As health care costs continue to rise in the U.S. a convenient target will be drugs that are available in other countries for a fraction of the American price.

“Welcome to Moe’s”  is the warm and friendly greeting of the staff at one of my favorite cantinas — Moe’s Southwest Grill, where a rice bowl and iced tea set me back just $9 and change. But for one woman who underwent Mohs surgery for a very minor lesion that may not have required the Mohs procedure and the subsequent plastic surgery repair, her bill for the day was over $25,000, as reported in a January 18, 2014 New York Times article titled “Patients’ Costs Skyrocket; Specialists’ Incomes Soar”.

In the article, the Times journalist Elizabeth Rosenthal notes:

“Use of the surgery has skyrocketed in the United States — over 400 percent in a little over a decade — to the point that last summer Medicare put it at the top of its “potentially misvalued” list of overused or overpriced procedures. Even the American Academy of Dermatology agrees that the surgery is sometimes used inappropriately”

In this instance, the patient, a professor at the University of Central Arkansas, pushed back on the $25,000-plus charges, and, after months of wrangling, Baptist Health Medical Center reduced the bill to around $5,000, with the largest component of the reduction being the plastic surgeon’s fee — from $14,407 to $1,375 (Still a nice paycheck for what was likely less than an hour of time!).

The patient subsequently went to a dermatologist at the University of Arkansas who said that she likely did not need “such an extensive procedure.” The patient’s final comment in the article: “It was like, “Take your purse out, we’re robbing you'”

Welcome to Mohs!

The memory tape of the golden oldie from Lovin’ Spoonful was playing in my head before watching Dr. Eric Topol’s interview with Dr. Paul Offit about his recently published book, Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine

The book tackles with rigor and vigor the lack of evidence for assertions and testimonials made by celebrity physicians, politicians, and stars of the small and big screen regarding the benefits for megadoses of vitamins, various nutraceuticals, and misuse of FDA-approved drugs, such as prolonged IV antibiotics for chronic Lyme Disease. Indeed, some of these may actually harm the person.

To me, the most fascinating part of this debunking of pseudo-science is the power of the placebo. Offit acknowledges the ability of the human being to heal itself. Through the connection of mind and body and conscious or unconscious thought affecting neurobiological or neurohormonal up or down regulation, we have remarkable abilities to positively or negatively impact our immune system, our perception of pain, blood circulation, digestion, and other vital functions that may profoundly help or harm our health and well being.

Just as the vaccines stimulate an immune response that prepares the body to defend itself from a viral or bacterial attack, we have the ability to autoregulate in other ways to heal ourselves. Not magic, but magical!


January 1, 2014 marks the most monumental day in the history of American health policy. The individual insurance mandate, the sunsetting of underwriting as we know it, and the planned obsolescence of the term “pre-existing conditions” in insurance all presage a fundamentally different era for access to health care. Of the 5.7% of those in the individual market, .6% will not be eligible for financial help if they want to continue buying in the individual market. In exchange, starting today, up to 47 million nonelderly uninsured will be eligible for new and/or more affordable health insurance. The good news is that there is no turning back from this miracle arrival. The bad news is there is no starting over either. The stork delivered it with warts and all.


Health reform means that much of what health insurance plans did is being taken on by providers. An obvious example is the Choosing Wisely campaign, an effort by physician professional organizations to cut down on overtreatment and overtesting.

Nowadays, every turn of a newspaper page, click of a media page on the Internet, or flip to a news channel brings us to an update, or more likely a criticism, of the public exchanges. With all of the attention on this side of the exchanges, we might be forgetting about the private exchange.   The private exchange serves as a channel for individuals and employers to purchase health insurance that is separate from the newly opened public exchanges developed under the Patient Protection and Affordable Care Act.

 The biggest difference between the two stems from the fact that government subsidies aren’t available to those choosing to purchase health insurance from the private exchange. This explains why much of the news regarding private exchanges focuses on the group market, as employers that choose to participate in a private exchange provide employees with an subsidy to be used toward the purchase of health insurance, a method also known as defined contribution.