Why is medicine expensive?

[dieseltaylor]

I was casting around for possible reasons that the US spent vast amounts on medicine and yet had generally poor value for the money spent. And part of me wonders how coarsely made are the amounts calculated and I would be interested in how the figures are calculated. Is it possible that plastic surgery makes up a large chunk of the overall total? after labour are drugs the biggest cost?

Now some of the possibilities for why there is poor health might be

1. in the obesity levels where Australia and the US lead the world

2. poor nutrition regardless of amount

3. environmental factors - these excellent articles reveals aspects

4. Over-medication

5. Making the system more expensive - as in abortion cases

1. http://www.cdc.gov/obesity/data/trends.html

2. http://www.healthnewstrack.com/health-news-2424.html

http://en.wikipedia.org/wiki/Nutrition

Heart disease, cancer, obesity, and diabetes are commonly called "Western" diseases because these maladies were once rarely seen in developing countries. One study in China found some regions had essentially no cancer or heart disease, while in other areas they reflected "up to a 100-fold increase" coincident with diets that were found to be entirely plant-based to heavily animal-based, respectively.[30] In contrast, diseases of affluence like cancer and heart disease are common throughout the United States. Adjusted for age and exercise, large regional clusters of people in China rarely suffered from these "Western" diseases possibly because their diets are rich in vegetables, fruits and whole grains

Wikipedia

3. http://www.alternet.org/environment/150888/say_what_a_chemical_can_damage_your_lungs%2C_liver_and_kidneys_and_still_be_labeled_%22non-toxic%22

http://www.alternet.org/food/150443/breasts_at_7_years_old%3A_how_chemical_hazards_may_wreak_havoc_on_children%27s_bodies?page=2

4. http://www.propublica.org/blog/item/citing-drug-industry-influence-watchdog-says-overmedication-of-nursing-home

Yet when the government examined 1.4 million Medicare claims from 2007 for atypical antipsychotics for elderly nursing home residents, the government found that 88 percent of the time, the drugs were prescribed to individuals diagnosed with dementia.

Doctors and nursing homes aren’t the only ones to blame, according to HHS Inspector General Daniel Levinson. ...............................

“Despite the fact that it is potentially lethal to prescribe antipsychotics to patients with dementia, there's ample evidence that some drug companies aggressively marketed their products towards such populations, putting profits before safety,” Levinson said.

5.

To date, legislators have introduced 916 measures related to reproductive health and rights in the 49 legislatures that have convened their regular sessions. (Louisiana’s legislature will not convene until late April.) By the end of March, seven states had enacted 15 new laws on these issues, including provisions that:

• expand the pre-abortion waiting period requirement in South Dakota to make it more onerous than that in any other state, by extending the time from 24 hours to 72 hours and requiring women to obtain counseling from a crisis pregnancy center in the interim;
  
• expand the abortion counseling requirement in South Dakota to mandate that counseling be provided in-person by the physician who will perform the abortion and that counseling include information published after 1972 on all the risk factors related to abortion complications, even if the data are scientifically flawed;
  
• require the health departments in Utah and Virginia to develop new regulations governing abortion clinics;
  
• revise the Utah abortion refusal clause to allow any hospital employee to refuse to “participate in any way” in an abortion;
  
• limit abortion coverage in all private health plans in Utah, including plans that will be offered in the state’s health exchange; and
  
• revise the Mississippi sex education law to require all school districts to provide abstinence-only sex education while permitting discussion of contraception only with prior approval from the state.

In addition to these laws, more than 120 other bills have been approved by at least one chamber of the legislature, and some interesting trends are emerging. As a whole, the proposals introduced this year are more hostile to abortion rights than in the past: 56% of the bills introduced so far this year seek to restrict abortion access, compared with 38% last year. Three topics—insurance coverage of abortion, restriction of abortion after a specific point in gestation and ultrasound requirements—are topping the agenda in several states. At the same time, legislators are proposing little in the way of proactive initiatives aimed at expanding access to reproductive health –related services; this stands in sharp contrast to recent years when a range of initiatives to promote comprehensive sex education, permit expedited STI treatment for patients’ partners and ensure insurance coverage of contraception were adopted. For the moment, at least, supporters of reproductive health and rights are almost uniformly playing defense at the state level.

http://www.guttmacher.org/statecenter/updates/2011/statetrends12011.html

[dieseltaylor]

But perhaps this one case shows just how corrupting money can be to a doctor, and how drug companies and they collude. And sod the patients.

http://www.propublica.org/article/reinstein-seroquel-astrazeneca-chicago-1111

Drugmaker Paid Psychiatrist Nearly $500,000 to Promote Antipsychotic, Despite Doubts About Research

by Christina Jewett, ProPublica, and Sam Roe, Chicago Tribune Nov. 11, 2009, 2:42 a.m.

This story was co-published with the Chicago Tribune.

Executives inside pharmaceutical giant AstraZeneca faced a high-stakes dilemma. On one hand, Chicago psychiatrist Dr. Michael Reinstein was bringing the company a small fortune in sales and was conducting research that made one of its most promising drugs look spectacular. On the other, some worried that his research findings might be too good to be true.

As Reinstein grew irritated with what he perceived as the company's slights, a top executive outlined the scenario in an e-mail to colleagues.

"If he is in fact worth half a billion dollars to (AstraZeneca)," the company's U.S. sales chief wrote in 2001, "we need to put him in a different category." To avoid scaring Reinstein away, he said, the firm should answer "his every query and satisfy any of his quirky behaviors."

Putting aside its concerns, AstraZeneca would continue its relationship with Reinstein, paying him $490,000 over a decade to travel the nation promoting its best-selling antipsychotic drug, Seroquel. In return, Reinstein provided the company a vast customer base: thousands of indigent, mentally ill residents in Chicago-area nursing homes.

During this period, Reinstein also faced accusations that he overmedicated and neglected patients who took a variety of drugs. But his research and promotional work went on, including studies and presentations examining many of the antipsychotics he prescribed on his daily rounds.

The AstraZeneca payments, filed as exhibits in a federal lawsuit, highlight the extent to which a leading drug company helped sustain one of the busiest psychiatrists working in local nursing facilities.

In an interview and in response to written questions, Reinstein said industry payments he has received for speeches and other engagements have had no bearing on his research results or patient care. He said he does not "accept any money from corporations to study their medications. This eliminates any possible conflicts of interest."

But he does receive money from the Uptown Research Institute, a for-profit business that conducts industry and federally funded studies on psychotropic drugs to help mentally ill patients. Reinstein's office in Uptown is adjacent to the research institute, which is owned by John Sonnenberg, a clinical psychologist who describes Reinstein as "a mentor of mine" and "brilliant."

Sonnenberg said drugmakers and others pay his institute to do research, and the group, in turn, pays Reinstein a consulting fee "under $2,000 a month" and has for many years. "But my research organization is separate from him, financially and organizationally," Sonnenberg said.

While payments from drugmakers to researchers are legal, critics have long argued that they should be publicly disclosed. Legislation to make Illinois one of a handful of states to require disclosure died in Springfield this year but is included in the U.S. House and Senate versions of health care reform proposals.

"We need to know that we can fully trust the relationship we have with our doctor and that another, more lucrative relationship with industry does not outweigh it," Sen. Herb Kohl, D-Wis., who is pushing for such reform, told ProPublica and the Tribune.

Health professionals who have encountered Reinstein have had similar concerns. When he gave promotional presentations about various medications at Grasmere Place nursing home in Chicago, case manager Staci Burton recalled that she was pleased to get free lunches. But she said she wondered why Reinstein put his patients on twice as many drugs as other psychiatrists who treated residents.

"I was thinking, `Why are you using so many medications?' " Burton, who worked at the facility from 2004 to 2006, said in an interview. "(His patients) would have symptoms, they'd have all these side effects, and their doctor was not listening."

Psychotropics to lose weight?

Chanile Hayes, a South Side resident, is among thousands of patients nationwide suing AstraZeneca for allegedly concealing Seroquel's links to weight gain and diabetes. Hayes is a plaintiff in a 2007 case in New York County Supreme Court. Numerous e-mails and exhibits referenced in this story were filed in federal court in Orlando, Fla.

Reinstein is not a defendant in either ongoing case, but Orlando plaintiffs have cast him as a key figure: an influential promoter of Seroquel who was financially backed by AstraZeneca. They allege that Reinstein has claimed that the antipsychotic drug helps patients lose weight.

Hayes said she came under Reinstein's care at a psychiatric hospital after she suffered a nervous breakdown nearly 10 years ago. She said she found it odd when Reinstein told her that taking Seroquel would help her lose weight.

"I couldn't understand why he wasn't taking it because he was a plus-sized man himself," said Hayes, now 37. Hayes said she went from 140 pounds to nearly 300 within two years of taking the drug and later developed diabetes.

Reinstein has done studies, funded by AstraZeneca and two other drugmakers, that found that various medications, including Seroquel, carry an unexpected yet welcome side effect: They help some patients shed pounds.

That claim runs counter to established research that links so-called atypical antipsychotic drugs, such as Seroquel, to considerable weight gain. Drugs in this class, approved for schizophrenia and bipolar disorder, can have other serious side effects that include spastic movement disorders and fainting and can cause premature death among the elderly.

A Seroquel flier dated 1999 features a photograph of Reinstein on the cover. Inside, Reinstein describes one patient losing weight and no longer needing insulin shots because his diabetes had improved so much.

In a 2001 promotional telecast to 5,000 physicians nationwide, Reinstein said he had "jokingly kind of suggested to AstraZeneca" that the drug could be used for "taking away excessive appetite."

"There's actually some nurses in some of our facilities who have actually requested (Seroquel) because they noticed it really did suppress the appetite, and they wanted to lose weight themselves," Reinstein said, according to a transcript of the speech, sponsored by AstraZeneca and broadcast from Somerset Place, a Chicago nursing home.

Two years after the speech, the Food and Drug Administration, armed with mounting research, asked AstraZeneca to warn patients of Seroquel's diabetes risk. The drug's label now cautions that the medication is linked to diabetes and weight gain – with nearly four times more patients gaining weight on Seroquel than on a placebo.

In his response to reporters, Reinstein characterized Seroquel as "generally weight neutral, although some patients gain weight and others lose weight."

"I would never recommend" that patients take antipsychotics "to lose weight," he wrote, and "using any of these drugs involves careful attention to weight" and other risk factors.

AstraZeneca spokesman Tony Jewell said plaintiffs in the lawsuit have not proved that Seroquel was responsible for their injuries. He said the company, based in London, provided appropriate safety data about Seroquel to the FDA.

Chanile Hayes, who said she saw Reinstein during visits to his office, questioned why he prescribed her the drug: "How could you tell me that it would help me lose weight if it doesn't help (people) lose weight?"

At AstraZeneca, early doubts

In the corporate halls of AstraZeneca, the company's scientific staff also questioned Reinstein's work.

Copies of e-mails filed as part of the Seroquel litigation reveal executives' misgivings about a Reinstein study involving patients on high doses of the drug. The results that came back were too rosy for AstraZeneca's own executives to accept.

One called Reinstein's conclusion that patients experienced no adverse effects "suspect" and "hard to believe." Executives "decided that we would ... try to distance ourselves from this study," according to e-mails from John Tumas, an AstraZeneca publications manager.

Reinstein presented his findings in 2001 at the annual meeting of the American Psychiatric Association, the profession's most high-profile gathering. At least three researchers have subsequently cited his study in medical journals.

During a deposition for the Seroquel case, Reinstein said he was unaware of any criticism from AstraZeneca about his research.

But he had some criticisms of his own. Reinstein vented to one AstraZeneca employee in 2001, saying the firm was giving him the "run around," an internal company e-mail shows. He also complained that the firm did not help present his research findings or include him in high-profile studies.

Within days, Reinstein wrote a letter to AstraZeneca's CEO in the U.S., identifying himself and four doctors in his practice as "the largest prescribers of Seroquel in the world." He complained that his travel expenses weren't paid upfront and called for "new leadership" in Seroquel's marketing.

Reinstein's complaints caused a stir

In a strongly worded 2001 e-mail, Georgia Tugend, the U.S. brand manager for Seroquel, reminded colleagues that research conducted by Reinstein and his partners "is often criticized by their peers in psychiatry."

Some scientists have "significant and numerous issues ... with the quality of research this group has produced in the past," Tugend wrote, yet Reinstein's group persists in "demanding research grants from us."

At one point, according to an e-mail from an AstraZeneca executive, Reinstein and his partners had "blatantly threatened" to switch patients to a Seroquel competitor. Reinstein later denied that accusation during a deposition, testifying that he "cannot imagine" making such a threat.

Malcolm May, AstraZeneca's U.S. sales director, had a much different reaction to Reinstein's discontent: The company should be careful not to alienate a psychiatrist worth up to a half-billion dollars to the firm.

"I am not suggesting we kowtow to his whims, nor to support any unethical behavior," May wrote in 2001 in an e-mail to fellow AstraZeneca executives. "I am suggesting ... we need to be more responsive to his opinion and needs."

May continued: "It seems we are annoying possibly our most important single customer, and that is not acceptable... My concern is that Dr. Reinstein could be looking for a trigger to leave our fold. That would be disastrous for our Seroquel business in the short and long term."

May's message did not cite a basis for the half-billion-dollar estimate.

Reached by phone, May said he did not recall sending the e-mail.

Court documents show that AstraZeneca continued to pay Reinstein to promote Seroquel until 2007. A Reinstein ledger lists hundreds of payments beginning in 1997. The payments, in increments from $10 to $20,000, totaled $490,000.

During that period, Reinstein ordered Seroquel for as many as 1,000 Chicago-area Medicaid patients per year at a total cost of $7.6 million to taxpayers, records show.

AstraZeneca spokesman Jewell said the company wasn't paying Reinstein to prescribe its drug but rather to make promotional speeches. Reinstein and AstraZeneca mutually declined to renew their ties in 2008, but Jewell wouldn't say why.

Today, Reinstein said, he gets money from the maker of a dissolvable form of clozapine, another antipsychotic that he often prescribes. He said he receives less than $25,000 per year to be in its speakers bureau, which drug companies commonly set up to promote their products.

Reinstein said payments from drugmakers do not influence his prescribing or research. He said the AstraZeneca e-mails grew critical of him only after he complained to the firm's U.S. chief executive.

In a deposition last year, Reinstein himself expressed surprise about some of his research results, saying one study's findings were "hard for me to believe" – in line with concerns expressed at AstraZeneca. When asked about another study in which patients lost weight on Seroquel, he said the results could have been affected by a change in the nursing home's cook or possible problems with the scales.

In all, Reinstein has published at least eight research articles, mostly about antipsychotic drugs. He has been cited in at least 20 others. Uptown Research Institute is now working on four studies involving psychotropics, said Sonnenberg, the owner.

Sonnenberg said studies by his institute "are highly scrutinized for accuracy and credibility" by the drugmakers, third-party ethics review boards and, potentially, the FDA.

Dr. Jerome Kassirer, a professor at Tufts University School of Medicine and a former editor of the New England Journal of Medicine, read the AstraZeneca e-mails at the request of ProPublica and the Tribune. He concluded that editors of medical journals should investigate Reinstein's published studies.

"Once you know that he has done a study that has been discredited," Kassirer said, "you have to ask yourself about all other studies done."

Researchers Lisa Schwartz and Kitty Bennett contributed to this report.

[Magpie_Oz]

But perhaps this one case shows just how corrupting money can be to a doctor, and how drug companies and they collude. And sod the patients.

Yeh I always get a bit cheesed off by all the pens, notepads and computers with drug names on them in my Doc's surgery.

The Anusol Pentium 4 is a real pain in the arse

[dieseltaylor]

MO - Ouch!

What seems to be missing from the article is whether the fine MD is actually under any criminal charges, or disbarment. Mmmmm.

http://www.healthgrades.com/directory_search/physician/profiles/dr-md-reports/dr-michael-reinstein-md-b70cc656

No malpractice?!

And a track record

No psychiatrist in Illinois -- or Texas, Florida and California, for that matter -- has come close to Dr. Michael Reinstein in prescribing the antipsychotic drug clozapine to public aid patients, Medicaid records show.

At the request of ProPublica and the Tribune, Columbia University researcher Dr. Mark Olfson reviewed Reinstein's prescribing numbers. In 2005, the year Reinstein wrote the most clozapine prescriptions, Olfson said the number was 70 times greater than what would be expected of even a busy psychiatrist.

"A concern that arises when you have someone seeing an inordinate number of patients is: Do they have time to care for people?" said Olfson, who specializes in psychiatric practices.

Reinstein said he had not seen Olfson's analysis but disagreed with the findings.

Besides clozapine, Reinstein tops the charts in Illinois in prescribing two other common antipsychotics, Seroquel and Haldol, Medicaid records show.

Medicaid paid out $55 million over the last five years for Reinstein's bills, prescriptions and orders for emergency care. He also treats patients covered by Medicare, but that agency declined to release Reinstein's billing data.

In an interview, Reinstein disputed state Medicaid's prescribing figures. He said the state tends to overcount and he recently lodged a complaint about that with Medicaid. Agency officials would not say whether they are following up but did note that pharmacists -- not doctors -- report the prescriber's name, potentially creating errors for any physician.

Reinstein also said the state has counted his partners' services and prescriptions as his own. But state officials said audits have not turned up such double-counting.

The huge prescribing numbers have not gone unnoticed by regulators. Twice the state has tried to exclude Reinstein from getting reimbursement through Medicaid, but both efforts failed.

In a 1992 case, a Medicaid audit found about $95,000 in improper bills, said John Allen, inspector general of the Illinois Department of Healthcare and Family Services. A re-audit brought the repayment amount below the threshold for termination.

"There's always one guy you just can't seem to get your finger on," Allen said.

Medicaid has assigned specialized nurse consultants to scrutinize Reinstein's care in recent years. They have found problems with patient diagnoses, transfers to psychiatric hospitals and communication with medical doctors. The reviews can lead to tough sanctions but in each case did not.

Chicago Tribune

http://pharmagossip.blogspot.com/2009/11/dr-michael-reinstein-clozaril-king-is.html

[Affentitten]

Yeh I always get a bit cheesed off by all the pens, notepads and computers with drug names on them in my Doc's surgery.

The Anusol Pentium 4 is a real pain in the arse

Actually Australia is one of the most vigilant countries in the world when it comes to this sort of thing. And if you think your doctor is persuaded by a biro, you need to get another quack.

[Magpie_Oz]

Actually Australia is one of the most vigilant countries in the world when it comes to this sort of thing. And if you think your doctor is persuaded by a biro, you need to get another quack.

I know for a fact that the merchandising does influence doctor's decisions and why wouldn't it?

If they decide to prescribe a drug why not the one from the company that is written on the pen because it is just that same as those other bastards who didn't give them a pen.

It is the ultimate in product placement and direct marketing.

[Affentitten]

You know for a fact? Great proof.

What if the product is not the same? If it's a patent product it's likely not. If it's a generic or post-patent, then you as the consumer have the choice at the pharmacy counter. In fact, you're far more likely to be constrained by your pharmacist's business deal than your doctor's post-it note block.

What you're rather stupidly alledging is that your doctor will say "Gee, this product would be perfect for my patient....but these other guys gave me a pen. It's not quite the right drug, but what the hell. A biro's a biro."

[dieseltaylor]

You do know that the fine country of Australia was the home of a bogus medical journal recommending drugs. AFAIR as I can recall it is somewhere buried here in the Forum.

You may have noticed my concerns for the health of America, and the stupidity of some of their officials - I may have an answer. The US is busy poisoning itself both in brain power and general health!!!!!!

The results of three recent studies have found that children exposed to organophosphates (OPs) in the womb have a lower IQ at seven years than those that have not.

http://www.gizmag.com/pesticides-food-iq-children/18583

See here for a variety of other chemicals that have been subject to research and shown to have dangerous health effects.

http://ehp03.niehs.nih.gov/home.action

[abneo3sierra]

I think to stereotypically accuse doctors as a group of being corrupt is an awful thing.. next time that people who feel this way need a doctor, perhaps they can "suck it up" and take care of themselves? My then-fiancee went through 36 hour shifts of residency training, then after our marriage, still had days where she did not sleep,taking care of this or that patient, while usually having to deal with things such as Medicare and Medicaid which essentially prevent a doctor from even making enough to pay back their own expenses, all the while having to pay outrageous malpractice insurance,student loans,etc. It is not 'greed' that pushes them through this, but rather a genuine desire to help..it generally takes years of practice, AFTER the years of school and of residency, before doctors even begin to see an overall 'profit' for their long hours and years of work.

The problem, if there is one, is the companies selling the medicine, who run television ads "ask your doctor if xxxxx is right for you" AS WELL AS a generally uninformed populace who would take medical advice from a television advertisement to begin with...in the same way as they take their political opinions, etc from spot moments on the daily news, rather than using their own intelligence to research things of importance to them.

[dieseltaylor]

Having had three doctors [by marriage] in the family I am can faithfully report they are as flawed as the next person. And yes it is a struggle getting qualified and I suspect UK doctors work as hard as US doctors to qualify. And yes they do protect either actively or passively doctors who are going wrong.

And I suspect nobody likes to rock the boat when cash is around.

AB I see you are complaining that the US advertising industry is peddling unwise adverts to unwise people! Can this be a democratic right being assailed : 0

It is a sorry can of worms the US health industry. It would be nice to see the doctors take on the lawyers in a trial of strength to get tort reform. If necessary and the doctors withdrew cover for lawyers they could become folk heroes over night : )

[abneo3sierra]

I am not saying there are not "crooked" docs, Diesel, just am saying that to place them all in that category is wrong.

And I am not sure where I stand on the "right" of advertising being a democratic right..I realize that to enforce things in that area, is to begin down a slippery slope though, so not an easy solution..I do think that there should be SOME type of "fact check" that is actually visible or audible maybe during these advertisements, rather than the "speed talking" or tiny letters that generally follow it...but as I said, yes, a tough one, and not easy to solve that, without risking infringement of any number of rights along the path..

[Affentitten]

You do know that the fine country of Australia was the home of a bogus medical journal recommending drugs. AFAIR as I can recall it is somewhere buried here in the Forum.

And as a result of things like that, the medical marketing side of things is now very tightly controlled and fines/prosecutions have been handed out.

You and others seem to have the impresison that medical companies make their money from having doctors prescribe their products. It's not really the case. In countries with socialised medicine, drug companies make their money by getting their (own, innovated) products accepted onto what we in Australia call the PBS, but which is essentially the list of medicines that the government has agreed to subsidise. Usually, this list is very limited. There won't be 15 types of medication for each condition on the list, but just a couple, and possibly even only one in the high end sort of treatments.

That means that if you have a certain condition, your doctor / specialist won't really have much choice about what they prescribe you anyway, unless you're happy to pay the full retail price. And of course in general terms, you would trust that your doctor is prescribing you exactly what is right for you anyway.

The sort of drugs handed out by GPs by the ton, like amoxycillin, paroxetine, diazepan and so on are long out of patent and mostly supplied by generic companies. That's where your pharmacist can come in. In Australia, if your doctor has written you a prescription for, say, Valium*, your chemist will ask if you are OK with a generic brand. But where the chemist himself sources this stuff from is up to him. So your generic diazepan might come from AlphaPharm, Apotex....any one of a dozen or so generic manufacturers. You'll save some bucks but won't be able to choose which company provides it. (No point anyway, because the compositions are identical and often from the same factories.)

* Which he won't these days if there are alternative versions of the same molecule. the only time he would name a drug by brand name would be if there is no alternative.

[Stalins Organ]

Here in NZ with a nationalised health system we have something called "Pharmac" - dunno if the Ausies have similar.

It is teh NZ Govt drug purchasing agency - a single buyer for all publically supplied medicines. So not only are only a limited number of drugs subsidised, but all drugs purchased for use in the public system are purchased through Pharmac, at contracturally agreed rates.

As such they can and do "play off" drug manufacturers against each other, use generics to push the price down, etc.

Pharmac buys whatever gives the best cost-benefit - so it is prety unlikely to buy (say) a $250,000/year treatment that will help 1 person if that means it can't buy 100 x $2500/yr treatments that will give benefits to more people.

and yes we regularly have cases where ppl complain that they can't get something through Pharmac that would save their lives and Pharmac replying that they can't afford it on a limited budget, criticisms that better drugs could be bought (invariably at much higher cost), etc which is used to pressure the Govt to increase health spending, etc (which is already about 18-19% of the NZ Govt budget!).

"Big Pharma" hates it, and is lobbying the heck out of the US Govt to make NZ give this up as part of any "free trade" deal.

Note that people ARE still free to buy whatever they can under insurance or other private schemes, or even direct from manufacturers if they have whatever connections it takes to do so legally. Although as I understand it insurance mostly deals through Pharmac too, as the drugs are cheaper than buying "retail".

but probably 90% or more of NZ drugs are supplied through Pharmac.

[Magpie_Oz]

You know for a fact? Great proof.

Wasn't intending to provide proof, my brother-in-law is a doctor and I have attended numerous dinners parties with medicos where this very subject has been debated at length. Thought I would contribute personal experience to the discussion.

What you're rather stupidly alledging ....

Not sure that a comment like that contributes anything useful

is that your doctor will say "Gee, this product would be perfect for my patient....but these other guys gave me a pen. It's not quite the right drug, but what the hell. A biro's a biro."

No that is not what I am saying at all. I am not suggesting that a doctor's diagnosis is influenced by the drug companies (but that is one of the concerns of the issue), what I am saying is that choice of which brand of medicine to dispense is influenced by pharmaceutical company direct marketing, why else would it be that the only place prescritpion medicines are advertised is in medical journals or doctor's consultation rooms? Having their products placed at the point of sale contributes hugely to their returns.

[Magpie_Oz]

Here in NZ with a nationalised health system we have something called "Pharmac" - dunno if the Ausies have similar.

That sounds very similar to our PBS, Pharmaceutical Benefit Scheme.

The only downside of that is that medicines that don't make it into the PBS don't stand a chance in the market as they cannot compete, not sure what that does for choice and competition.

[costard]

Stalins Organist..

I am fairly certain that all parts of the transport system are taxpayer supported, as well they should be..my break from that is the difference between using money to help fund something, vs taking over the management of whatever it is. Roads do not count, because they are not a service, but rather in a different category. A better example for mine would be the AMTRAK system mentioned, where not only are they federally funded, they are run by the government in the same way as the Postal Service, and the VA medical service..very very poorly, especially when looked at in a side-by-side comparison with private industries that do the same things, better.

The combination of low oil price and the ubiquity of a road transport system (1970's - 2000) would have sent any privately run (non-government subsidised) rail system into bankruptcy. Interestingly enough, this is an unacceptable circumstance for the military to find itself in: the need for a large, interconnected domestic rail network is essential to the US military logistics crew. Of course, if you now wish to sell the infrastructure back into private hands, you should probably point out that profiteering, scam running or denial of service to the military in time of war will be met with the use of detention and summary execution. (Of course, that wouldn't happen.. except for the banks, yeah, well, what would you expect.)

[abneo3sierra]

Ken, I do believe that I will make my final post for the next few months at least, to you. Wish you good luck!

FYI..other than AMTRAK, all rail systems in the USA are private companies. This includes rail systems used by the military.

[Stalins Organ]

Costard AFAIK most US rail track IS actually in private lands, and them scheduling their freight trains over Amtrak passenger trains has been an issue that has required several law changes to address.

[costard]

Ken, I do believe that I will make my final post for the next few months at least, to you. Wish you good luck!

FYI..other than AMTRAK, all rail systems in the USA are private companies. This includes rail systems used by the military.

Have a safe trip Ron - come back with all your bits.

I'll dig around on this AMTRAK thing - there has to be a good reason for the gummint participation in the market (I suspect it's to do with the funding of maintenance costs from the federal budget). If not, then by all means, turf the bugger.

[Affentitten]

The only downside of that is that medicines that don't make it into the PBS don't stand a chance in the market as they cannot compete, not sure what that does for choice and competition.

The PBS people I think do a pretty good job because you have to jump through a lot of hoops to get on it and where pharma companies really are dubious is when they try and get onto the list mulitple times with the same drug.

For example, a company has a drug which has been developed to treat breast cancer and the clinical trials prove it's a good thing. They get on the PBS no problems. But then they try and take the same drug and show that it is also good for prostate, bowel, lung, bone etc etc cancers, trying to get a PBS indication each time and effectively double dipping.

The PBS is pretty hardline about this though. In a sense, they are not really stifling competiton by only having the one or two drugs on the list, they're just saying "best solution only".

[costard]

OK, so well off topic but:

AMTRAK was brought into being and gave participating railway companies with the right not to provide passenger services (demanded by federal legislation, The Rail Passenger Service Act).

AMTRAK also funds the railway pensions (whether the former employees were AMTRAK or otherwise). From Wiki:

Today, the burden of nascent railroad worker pensions, including those of freight railroad workers, are financed by Amtrak, regardless of whether such workers were ever employed by Amtrak or worked in passenger railroad service. In effect, Amtrak subsidizes the pensions of thousands of railroad workers who would otherwise not receive any pension

Any railroad operating intercity passenger service could contract with the NRPC, thereby joining the national system.

Participating railroads bought into the NRPC using a formula based on their recent intercity passenger losses. The purchase price could be satisfied either by cash or rolling stock; in exchange, the railroads received NRPC common stock.

Any participating railroad was freed of the obligation to operate intercity passenger service after May 1, 1971, except for those services chosen by the Department of Transportation as part of a "basic system" of service and paid for by NRPC using its federal funds.

Railroads that chose not to join the NRPC system were required to continue operating their existing passenger service until 1975 and thenceforth had to pursue the customary Interstate Commerce Commission (ICC) approval process for any discontinuance or alteration to the service.

Through the late 1990s and very early 21st century, Amtrak could not add sufficient express freight revenue or cut sufficient other services to break even. By 2002, it was clear that Amtrak could not achieve self-sufficiency, but Congress continued to authorize funding and released Amtrak from the requirement.

Amtrak's leader at the time, David L. Gunn, was polite but direct in response to congressional criticism. In a departure from his predecessors' promises to make Amtrak self-sufficient in the short term, Gunn argued that no form of passenger transportation in the United States is self-sufficient as the economy is currently structured. Highways, airports, and air traffic control all require large government expenditures to build and operate, coming from the Highway Trust Fund and Aviation Trust Fund paid for by user fees, highway fuel and road taxes, and, in the case of the General Fund, by people who own cars and do not.

Before a congressional hearing, Gunn answered a demand by leading Amtrak critic Arizona Senator John McCain to eliminate all operating subsidies by asking the Senator if he would also demand the same of the commuter airlines, upon which the citizens of Arizona are dependent. McCain, usually not at a loss for words when debating Amtrak funding, did not reply.

Under Gunn, almost all the controversial express freight business was eliminated. The practice of tolerating deferred maintenance was reversed to eliminate a safety issue.

AMTRAK offered to buy out the common stock shareholders (i.e. other railway companies) in 2002: they declined. Obviously it is in their interest to maintain the current arrangement and it is difficult to see how the US federal government would get support to dismantle AMTRAK (or get it to operate at a profit for that matter).

[Stalins Organ]

And interesting article in today's papers about US drug companies lobbying to de-fang Pharmac here - http://www.stuff.co.nz/business/5005467/Pharmac-under-fire-ahead-of-US-free-trade-talks

[dieseltaylor]

Excerpt from the linky

However, Morgan and Simmons respond that no credence should be given to the claims. Slower budget growth is a sign of Pharmac's success and is the only part of the health budget growing at a sustainable rate. The businessmen, who co-wrote a book on the New Zealand health system in 2009, say Pharmac's ability to bid down prices has meant we buy statins, drugs used to control cholesterol, at a fifth of the price Australians pay.

"If there was a need to spend more, the Minister of Health could dedicate more of the Health vote to Pharmac," they write. "Getting rid of Pharmac would not be clever."

The pair say Pharmac funds tried-and-tested drugs rather than approving experimental ones.

In an article on the Pharma Times website, Pharmac spokeswoman Jude Ulrich pointed to cases where drugs declined for funding here have subsequently been withdrawn abroad.

"For example, if Pharmac had funded COX-2 inhibitors at the same rate as Australia, it would have had 330 – 1900 people die of heart attacks over a four-year period," she said, while its decision not to do so had allowed funding for 18 other drugs, saving 487 statistical lives a year.

Interesting. You wonder what the US price is.