Priming for the Future

Looking back on this semester, I realize I have learned so much more than I ever thought I would. I came to this class knowing that the healthcare system was considerably flawed, but this class opened my eyes to the extent at which our healthcare system is flawed. Some politicians (more recently some presidential nominees) talk about fixing this country’s healthcare as if it could be accomplished overnight and suddenly everyone who should be covered, would be covered. However, the healthcare system is so much more intricate than that as its problems stem from a wide variety of sources, starting from the very birth of healthcare. Where most people think that its problems stem from doctors charging a lot for their services or insurance companies being unwilling to cover certain medical treatments or procedures, these people fail to see that it is also the fault of pharmaceutical companies, the way it is so difficult for people to attain a higher socioeconomic class, and so much more that influences the amount and level of care that is accessible and also importantly, affordable to everyone in this country.

It’s hard pill to swallow when one sees exactly how many people are without adequate healthcare or medical insurance in this country, more often than not through no fault of their own. We even went through stories in class of people who worked their entire lives, bought a house, and have retired, only to be pulled out of retirement and lose everything they had because of a medical issue that they have to pay out of pocket for. It’s an even harder pill to swallow when we see how people from other countries thrive under their country’s version of healthcare, other countries having universal healthcare. Politicians in the United States argue that our government cannot afford to provide universal healthcare for everyone in the country. How then, are other countries able to afford universal healthcare for their citizens? In addition, how then does US government have enough money to spend trillions of dollars on wars in the Middle East? Though many of these questions will take more research and taking related classes to answer, SO215 has primed me to begin questioning these aspects of healthcare not just through the length of the course, but for the rest of my life as an active and voting citizen of this country.

Pharmaceutical Price Hike: Only 66,566%

Cancer. It is a word the strikes fear in the hearts of many as many still equate being told one has cancer with one being given a death sentence. From that point on, one becomes somewhat of a living time bomb. However, for you, the cancer has been caught early on enough that you can still get treatment to combat the deadly illness. Immediately, one’s thoughts then go to how much will this treatment cost? For someone without insurance, the costs could be crippling. Imatinib is from a class of drugs commonly used to combat cancer. In the United States, a single year’s worth of treatment can cost upwards of $106,000. Luckily, you live in India.

In India, a year’s worth of treatment using Imatinib costs around $159. The difference between the costs for this type of drug between India and the United States is a price hike of over 66,566%. That’s right, five digits. A recent review of drug production costs and pricing presented this past September at the 2015 European Cancer Congress mapped out the money an individual would spend for a year’s treatment of three classes of drugs commonly used to combat cancer: Imatinibs, Erlotinibs, and Lapatinibs. In addition, these prices are already allowing for a 50% profit margin for pharmaceutical companies. The main reason why these life-saving drugs are cheaper in both India and in Europe (the price hike between Europe and the United States for Imatinib hovering at around 231%) is because generic versions of the drugs using Imatinibs are so much more readily available in India. The article takes the specific example of Gleevec, a drug used by people with leukemia and gastric cancer. Its patent, first approved by the FDA in 2001, should have expired this year. However, Novartis, the pharmaceutical company who has the patent, has managed to keep other companies trying to make generic version at bay by making the large amounts the drug needed to synthesize a generic version hard to attain by these other companies. This is a problem faced by many pharmaceutical companies as they try to produce cheaper generic versions of much more expensive drugs. The reason why expensive drugs are able to stay expensive is because there are no other competitors. As a result, people with these illnesses (usually more rare and not as researched) are forced to buy these expensive drugs as they have to alternative drug to turn to.

Why then, are these cancer drugs so much cheaper in India? With not as many restrictions within drug production and with drugs being so readily available, companies are able to attain enough samples to create many different generic versions of a single drug. As a result, the buying medication in India is more of a true free market as consumers can see how expensive each drug that would do the same thing is. Companies are then either forced to lower prices to beat out their competition or risk going out of business. As it would not really be beneficial for anyone (but Pharmaceutical companies) to lower drug production restrictions, the more feasible solution for the United States would be to put a cap on prices for each specific type of drug. Adopting something similar to Canada’s pharmaceutical policy where certain drugs cannot be sold within the county unless the price can be negotiated to a suitable arrangement would get affordable life-saving medication to those who need it the most without making them have to move halfway across the world to receive it.

Better Balance

In the article, “The Patient in the Intensive Care Unit,” Robert Zussman discusses how patients tend to fade from being a individual to being a series of numbers and symptoms. As many of the patients in the ICU tend to either be very sick or unresponsive, doctors come off as not being empathetic towards the patients as they focus more on their symptoms. While I agree that doctors should be more empathetic and pay attention to the feelings and needs of their patients that may not be directly related to the patient’s symptoms, I would argue that the doctors themselves are not much at fault themselves. I believe that the doctors in the ICU are focusing their time on what is most pressing at the time: saving someone’s life. As there are only a limited amount of physicians at any given time in the ICU, doctors must allot their time carefully in order to make sure that the immediate concerns of their patient are met in order for their patient to live another day. However, there are also many accounts that the mentality of the patient is also very important in fighting sickness and recovering. As a result my question would be, “Is there a better way to balance addressing the immediate symptomatic needs of a patient with the patient’s other needs (not necessarily related to the reasons they are in the ICU for) such as the patient’s mental health?”

Modern Hospitals: Lack of Competition

Charles Rosenberg’s piece “The Rise of the Modern Hospital” illustrates how hospitals, once seen to be unimportant and maybe even unnecessary back in the 1800s, have since evolved into centers of knowledge and influence. Rosenberg seems to mainly attribute this evolution of hospitals into their own sphere of influence within the public eye to the rapid development of scientific theories and technology. Because certain technology which could further one’s healthcare such as x-rays could only be found in hospitals, people were forced to acknowledge hospitals’ importance and it was even possible then for hospitals to compete with each other by trying to draw in more patients with more technologically advanced machinery and more effective procedures (and treatments). What were other factors leading to the rapid expansion of hospitals? In addition, as I mentioned possible competition between hospitals to draw in patients by providing better technology and better care, why then, does it seem that this competition no longer exists? Though some research hospitals do make it a priority to further advancements in healthcare, many seem to operate solely to profit off of those who cannot receive medical treatment in any way. This seems especially apparent now knowing of the existence of charge masters and how there is a lack of transparency with how the prices for procedures in different hospitals are set.

Bought Doctors: Pharmaceutical Marketing

As part of Chapter 9 in his book “How Doctors Think”, Groopman describes how deeply pharmaceutical companies can affect the decisions that doctors make for their patients through aggressive marketing strategies. By offering things ranging from free samples of drugs available to patients at the doctor’s office in order to get a patient hooked on more expensive drugs to “gifts” (monetary or otherwise) given to doctors who push for the use of specific drugs or treatments, pharmaceutical companies can easily influence the medical field’s determination of what conditions should be medicalized.

The way pharmaceutical companies in a way “buy off” doctors really reminded me of how big corporations “buy off” politicians (essentially paying for the re-election campaigns of these politicians) to lobby (for example) bills to create tax or regulation loopholes. As there is a big push right now to get money out of politics, I was wondering, why there is not a big push to also get money out of the medical field? Has medicine really become so corporatized that the priority is no longer the well-being of the patient and is now more focused on how much profit everyone in each tier of the medical system can make? A more important question would probably be, would it even be possible to get money out of the medical field, with possible solutions including but not being limited to the standardization of drug prices (like in Canada)?

The Degree of Desensitization

In the article “Managing Emotions in Medical School: Students’ Contacts with the Living and the Dead”, Smith and Kleinman analyze the relationship between physicians and patients. Smith and Kleinman bring up how medical school students must constantly wrestle between the emotions of staying professional and sympathizing with their patients. They continue on to describe how medical schools are trying to emphasize the importance of not allowing ones emotions to cloud their decisions for their patients both medically and clinically.

When I shadowed with a pediatrician last summer, he emphasized to me the importance of fostering trust with patients. As he was a pediatrician, he also displayed how involved he was with not only the physical health of the child, but also with the mental health of the child. He strongly believed that the job of a pediatrician was not only to keep children healthy, but to also assist the parents in raising their child. During appointments, he would ask what kind of out-of-school activities children would participate in, and even specifically refer parents to certain programs that he knew of (ex. if a child mentioned they were interested in volleyball, he [the pediatrician] would bring up names of the organizers of several volleyball programs around the state that he knew of and would cite the experiences of parents/other children who had gone through the program). By showing this level of depth and concern, he was able to not only gain the trust of his patients, but he also able to tailor treatments for them based on a variety of factors (cost depending on the family situation, working with/around activities the child already participated in, etc.). As a result, I question the point of medical schools desensitizing doctors that the article brought up. I would ask to what degree do medical schools think that doctors should be desensitized to their patients? In addition, I would like to ask “Do desensitized doctors who keep their relationships with their patients strictly professional really provide better care for their patients?”

Daraprim Part 2: Competitors Don’t Mean Competition

After last month’s famous story of how Martin Shkreli, the CEO of Pharmaceutical Company Turing Pharmaceuticals raised the price of an AIDS drug from $13.50 to $750 overnight, a new story has emerged of a competitor company coming out with a $1 version of the drug. This competitor is Imprimis Pharmaceuticals, a pharmaceutical company that mixes approved drug ingredients to fill individualized patient prescriptions. Imprimis Pharmaceuticals Chief Executive Mark Baum announced last week that they would be supplying pills containing Daraprim’s active ingredients, pyrimethamine and leucovorin, in 100 pill count bottles for $99. Baum has also announced that they will be developing generic alternatives to many other drugs that have sky rocketed recently over the years- mainly drugs treating cancer and other rare diseases that the general public does not take much notice of.

However, as much as Imprimis Pharmaceuticals is championed as a hero of the people (as they should be), it turns out that Turing Pharmaceuticals really will not lose much from this competition. Imprimis’ ability to compete with Turing is greatly limited as it is a compounding pharmacy which means it can only provide medicine after a doctor requests it, meaning that doctors have to specifically be requesting their version of the pill. As we have learned in class, there are many ways for Turing Pharmaceuticals to take advantage of this system as they may begin to incentivize doctors (whether they do it over or under the table, monetarily or otherwise) to continue prescribing their version of Daraprim. In addition, rather than pharmacies having to specifically order the new version of Daraprim every time someone asks for it, it is much easier for pharmacies to dispense a drug they already readily have on hand such as the original version of Daraprim. There is already a system set in place where if the pharmacy cannot get the insurer to pay for the medicine but cannot, the pharmacy will usually dispense the drug regardless, using either charities or –where legally possible- by making the drug maker itself cover the difference in cost. Due to these reasons, despite the fact that a $1 competitor would trigger the notion of a free market happening where the people will choose the most cost-effective drug for them –where that company would make profit and the other would go out of business because no one would buy that drug, – there is really no free-market at all. Until these loopholes are closed and something like a standard price for drugs are set, these practices will continue unchallenged, and Americans will continue to bear the consequences.

Stress From Social Stigmas

In the article we read for class, The Social Construction of Illness: Key Insights and Policy Implications by Peter Conrad and Kristin Barker, they define disease as being the biological condition and illness as being the social meanings or implications of that biological condition. They emphasize in the article how due to this stigmatization, patients diagnosed with these diseases face not only the physical/biological consequences of having the disease, but also the social constructs accumulated by society by those that have the disease. For example, specifically in Somalia, because HIV is so socially construed with being the result of a moral fault (more specifically infidelity), many people who live in Somalia will go as far as traveling to other countries in order to receive treatment while still hiding their condition. In addition, despite the face that the government has supported TV and radio campaigns in order to lessen the social stigma that comes with having HIV, the stigma continues and people are left with feeling not only the physical consequences of having HIV, but also the social pressures of hiding the condition. A question I have would be how does society choose which illnesses to stigmatize? Also, when physicians diagnose patients with particularly stigmatized diseases, should they also be referring patients to support groups to help alleviate social pressures? In addition, should insurance companies be made to cover certain treatments linked to alleviating the stress caused by these social pressures as this may deeply affect the patients psychologically?

Primary Prevention vs. Tertiary Prevention

Chapter 2 in Weitz explains how modern medicine focuses more on treating the symptoms of those already sick (tertiary prevention) as opposed to more primary prevention which would prevent the illness completely. Despite the fact that there is data showing the cost effectiveness of primary prevention (in that treatments and medication for tertiary prevention are much more expensive and drawn out than the steps/medication/treatment needed for primary prevention), why is tertiary prevention still what is more emphasized in healthcare? Citing the data and statistics on how primary prevention would help decrease premature deaths attributed to controllable factors, why did the Affordable Care Act not include more coverage or access to primary prevention? In addition, what or who is preventing other measures/bills that would make primary prevention more accessible to the general public today?

Process Reflection (Section 2)

If someone were to talk about someone dying from a condition or a disease before this class, I would mostly assume that it was a condition or disease that we as a society in the US did not yet have a treatment or cure for. And most of the time, I would be right as what we usually hear about people suffering from medically in the media are diseases or conditions such as cancer or an epidemic such as SARS. There would be the occasional story about either a very young child or a senior citizen who died from a common illness such as the flu, but those stories were not very out of place either as very young children and senior citizens for the most part have immune systems that are weaker than a typical healthy middle aged American’s immune system. As a result, what hit me the hardest in this class were the films and articles we would cover that involved previously healthy people dying from conditions or illnesses that we already have treatments or cures for.

One such film was a film we watched in the beginning of the semester, “Sick Around America”. The film featured Nikki White, a young woman who learned she had lupus at the age of 21. While lupus can be a serious autoimmune disease, treatments for lupus have been developed that would allow the victim to live a mostly normal and healthy life. After graduating college, Nikki found she was no longer covered by her parents’ health insurance so she tried to take on jobs that carried health benefits. However, her lupus worsened and she moved back with her parents, abandoning her dream of being a doctor. Left with no health insurance as Nikki could find no company that would insure her and with her parents being unable to cover the quickly escalating medical costs, Nikki was unable to afford the midicines and regular visits to specialists. Nikki eventually died from complications from her lupus condition, but in the larger picture she really died from a healthcare system that failed her when she needed it the most.

As we delve deeper into the sociology of healthcare in this class, more and more backstories such as Nikki’s story continue to uncover themselves, highlighting the very large flaws in the US Healthcare system. Despite the horror that comes attached with learning about these stories, I hope these stories will allow me to learn and understand more about the US Healthcare system.