Another 50-something year-old passes away; another "unknown" cause of death; and another awaited autopsy.
Also, another opportunity to delve further into neurology.
E. (Everette) Lynn Harris was a prolific author, who introduced the uninitiated to the "down low," starting with his book, Invisible Life. Prior to hitting the scene as one of the most influential black (and later) openly gay author, he worked at IBM, Hewlett-Packard and AT&T.
At the University of Arkansas he became the first black editor of the school newspaper and the first black male Razorbacks cheerleader. Just as he gave courage to his readers to not keep everything on the "down low," he gained courage from them and came out of the closet. He gave many black (and other races) gay men who were living their public lives as married heterosexuals while having sex with other men, the courage to be more open about their sexuality.
So, how does this all tie into neurology?
He was only 54 years-old and died fairly suddenly. His publicist, Laura Gilmore, has been quoted as saying that he fell ill on a train to Los Angeles a few days ago and blacked out for a few minutes, but seemed fine after that.
In neurology (as in much of medicine, hopefully), we start with an extensive history. Unfortunately here, all we know is that we have (we presume) a previously healthy 54 year-old man who develops a sub-acute illness with a brief loss of consciousness. We know that this occurred on a train ride and this may or may not be an important detail (or it may be a red herring).
Unfortunately, we do not know his past medical history (besides diabetes) or family history. His social history may be significant for him being a homosexual, but he was a strong and vocal anti-HIV/AIDS advocate (we cannot exclude this as a possibility, though).
We would then move on to a physical examination, which obviously cannot be performed with this “patient” (after all, isn’t an examination done with the patient and not on or to the patient?).
We have no laboratory or imaging studies to review, which means we have to rely on the history of the present illness alone.
How apt for a writer.
“Feeling ill” is a very nonspecific phrase and could be interpreted as an antecedent symptom to the ‘blacking out” or it could be a further description of the “blacking out” – note the word “and.” Does “and” mean that there are two separate symptoms or does it the illness simply an alternate description of the blacking out? Furthermore, if they are two separate symptoms, then which one occurred first: feeling ill or blacking out? Could we use the backing out as the physical exam of a patient who has a symptom of feeling ill?
Some may argue that there was no one there to examine Mr. Harris, so how could we refer to an examination. We do know that in many lifetime diagnoses (remember, not chronic diseases – language may be stigmatizing), the patient’s exam may be more reliable than the physician’s exam (what is more important, the reflex hammer or the description of further weakness – actually, both are important).
Returning to the “case” at hand (last time I checked, cases were left to bellhops or lawyers), let’s first address the “blacking out.”
Where does a loss of consciousness localize to?
1. Neurologic
2. Non-neurologic
a. Syncope (fainting) may be neurologic or it may cardiologic. A transient decrease in blood flow to the brain, may lead to a brief loss of consciousness. Usually this should last for less than “a few minutes,” but observers are notoriously bad at estimating the length of an event, such as loss of consciousness or seizures, for example. Vasovagal syncope is the most common form in adults, but he seems not to have had any accompanying autonomic features. He may have had a cardiac arrhythmia (abnormal heart rhythm) leading to his brief loss of consciousness and later to death.
b. Seizure. As far as we are aware, he had no history of epilepsy, in which case this is the first seizure. 6% of the U.S. population will have a nonfebrile seizure sometime during their life. There is a cumulative risk in developing epilepsy (more than one seizure): By 20 years of age, 1% of the population has epilepsy and by 75 years of age, 3% of the population has been diagnosed with epilepsy, and 10% will have experienced some type of seizure. Seizures are more common in blacks than in whites. Seizures themselves have a differential diagnosis, including different types of seizures, drug intoxication and psychogenic nonepileptic pseudoseizures. He “seemed fine” after the event, so there was presumably no postictal state. Most seizures last well below two minutes, but as we noted above observers (even medically trained ones) often overestimate the amount of time a person is “out.” People with seizures may also cause SUDEP (Sudden Unexplained Death in Epilepsy), which is the sudden, unexpected death of someone with epilepsy, but who was otherwise healthy, and for whom no other cause of death can be found. SUDEP accounts for 10% of all epilepsy-related deaths; 85% of these fatalities occur between the ages of 20-50 years. The incidence of SUDEP is approximately 1 in 1000 people with epilepsy per year which is at least 10 times of the sudden death rate found in the general population. How should neurologists discuss the risk for SUDEP with their epilepsy patients? Should it be discussed with everyone or those you are trying to scare into be more compliant with the treatment regimen or should it be “don’t ask, don’t tell?”
c. Central nervous system (CNS) infection (meningitis or encephalitis) - - he “seemed fine” after the event (and presumably before), which makes an infectious cause less likely, but it may explain his fairly rapid death.
d. Hypoglycemia (low blood sugar) could cause a loss of consciousness, but without receiving any sugar after it happened, it would seem less likely that he would seem “fine after that” (he did, however, have diabetes mellitus). The same would be true for dehydration.
e. Narcolepsy (from the Greek for “seized by somnolence”) could cause him to suddenly fall into REM (rapid eye movement) sleep. It has an incidence of 0.02% to 0.18% (similar to multiple sclerosis and like MS, it may take 10 years from first symptom to finally being diagnosed). Also like MS, narcolepsy seems to involve the T cells and is associated with HLA-DQB1*0602.
f. Intoxication would seem less likely because he “seemed fine after that.”
g. Stroke (especially vertebrobasilar insufficiency -- temporary lack of blood flow in the arteries in the back of the head) would not allow him to “seem fine” after the event. He was, however, on a train ride, which can lead to dehydration and blood clots. A deep venous thrombosis (blood clot in the vein) could be dislodged from the leg and return via the venous system to the heart. 20% of the population have a patent foramen ovale (opening between the right and left side of the heart, which usually closes around the time of birth), and then this clot could shoot up into the carotid or vertebral arteries and obstruct blood flow to the brain or the clot could travel to the blood vessels in the brain itself). A venous blood clot could also form in the superior sagittal sinus (a big vein that drains blood from the arteries feeding the brain, and then returns the blood to the right side of the heart). This cerebral sinus thrombosis could lead to venous strokes, which have a tendency to bleed.
So, what did E. Lynn Harris die from?
We’ll have to wait and see.
- Dr. Daniel Kantor, MD BSE
Medical Director
Neurologique
info@neurologique.org
www.neurologique.org
Monday, July 27, 2009
Thursday, July 23, 2009
Holy Grail
Merck KGaA (not to be confused with Merck & Co.) announced in a press release that they will be filing a marketing authorization application (MAA) to the European Medicines Agency (EMEA) for Cladribine Tablets (Mylinax). In the future EMD Serono (their subsidiary) will be submitting an NDA with the FDA.
Merck KGaA estimates that sales will be $1 billion.
I am not that such a rosy picture is justified.
Here’s why:
Biogen Idec (BIIB) and Elan’s (ELA) Natalizumab (Tysabri) had $481 in global sales in the first half of 2009; our estimate is that worldwide sales for 2009 will be between $1.057 and $1.1 billion. But, remember, this is a drug that has been on the market and is not new (with potentially new side effects).
So, let’s compare the advantages of Tysabri and Cladribine:
1. Tysabri has great efficacy (~60% better than placebo in SENTINEL and ~50% when combined with Avonex vs. Avonex alone in AFFIRM).
2. Tysabri is not an injectable and instead is into the vein (intravenous/IV).
3. Tysabri is well tolerated.
4. Tysabri has an easy dosing schedule and is only given 12 times a year.
On the other hand,
1. Cladribine is ~50% better than better than placebo in CLARITY.
2. Cladribine is the first oral
3. Cladribine is well tolerated.
4. Cladribine is taken 8 (to 20 – who knows what the regulators will finally say).
Wait! What about side effects?
Oh, I almost forgot to mention* (does that sound familiar?):
A. PML (progressive multifocal leukoencephalopathy) in Tysabri.
B. PCNSL (primary CNS lymphoma) in Tysabri (and rumors of two more – one in Germany and one in the U.S.).
C. Cancers in Cladribine (female cancers in a diagnosis that is 2/3 women and usually stats when they are young: ovarian, cervical and choriocarcinoma – as well as pancreatic cancer and melanoma).
So, what strategies are the representatives going to use to sell against each other (welcome to the interferon wars again)?
1. Efficacy:
a. EMD Serono is going to say that you can’t compare between trials.
b. Biogen Idec is going to say they are superior.
2. Oral vs. not:
a. EMD Serono is selling the first oral; he MS community has been waiting for this Holy Grail.
b. Biogen Idec is going to stress the convenience of being monitored for treatments, instead of possibly the dreaded “lost to follow-up”).
3. Tolerability:
a. EMD Serono is going to stress the lack of infusion reactions.
b. Biogen Idec is going to stress the patient advocates and their strong message of how Tysabri changed their lives (anecdotally, neurologists do sometimes see that patients on Tysabri have a reduction in their pain – but you didn’t hear this from the company).
4. Dosing:
a. EMD Serono is going to stress how seldomly a patient needs to take the medication and that they don’t need to come into an infusion center.
b. Biogen Idec is going to stress the lack of dose adjustments and the fact that Tysabri is only 12 times a year (they should have sold it this way from the beginning – it sounds a lot less than “monthly” or “every month”). It is difficult to forget a monthly infusion outside the home, while a pill you take a few times a year may be easily forgotten.
So, what are clinicians going to do?
Neurologists care about:
A. Efficacy:
a. Disability
b. Relapses
B. Safety:
a. We know how to reverse Tysabri with plasma exchange (plasmapheresis) but we don’t know what to do with Cladribine.
b. Future pregnancies: are there issues?
c. What to do next in patients who “fail” the medication (isn’t it the drug failing them?).
d. New unknown side effects (we are finally getting used to Tysabri).
C. Tolerability:
a. Are patients going to have problems leading to additional phone calls or problems?
Now this doesn’t even take into account the next oral medication, FTY720 (Fingolimod). A daily medication is more annoying than Cladribine, but also easier to remember. How many patients with hypertension forget to take their daily blood pressure medication and then have a heart attack or stroke? Also, Fingolimod is 50% better than Avonex – does this beat cladribine, and even Tysabri. What’s going to happen when there is a subcutaneous Tysabri – is it going to be more convenient because it will be given at home, or will it be seen as a regression back to injectable medications?
So what does this mean for the MS market, MS drugs, and most importantly the individual MS patient?
It depends who you ask.
Technical and Scientific Details:
Many people want to know how these medications work and what their mechanism of action is:
1. Interferons (Avonex, Betaseron, Rebif, Pegylated Avonex, Rebif New Formulation) – noone (no one) fully understands.
2. Glatiramer Acetate (Copaxone) – ditto.
3. Natalizumab (Tysabri) – A monoclonal antibody directed against the part (VLA4 / integrin) of the lining of the central nervous system (CNS) that sticks to white blood cells (lymphocytes). Thus reducing the amount of immune cells that get through the blood brain barrier).
4. Cladribine (Mylinax) – A molecule that is changed (phosphorylated) to a different form (its corresponding nucleotide CdATP), which accumulates in the lymphocytes and gets into their DNA. High levels of CdATP lead to DNA strand breaks, inhibition of DNA synthesis, and cell death.
5. FTY720 (Fingolimod) – Stops lymphocytes from leaving the lymph nodes; this keeps them away from the bloodstream and reaching the BBB; thereby reducing the immune attack on the brain, optic nerves and spinal cord (cervical and thoracic cord).
Now, for the rest of the emerging medications (Laquinomod, Teriflunomide, BG00012, MBP8298, Daclizumab, Campath, Rituximab, Ocrelizumab, …)** you will have to wait for more in the future.
* Why do these biotech companies seldomly (seldom) mention the serious side effects.
** The … is the most exciting advance of all (think pre-1993 …).
- Dr. Daniel Kantor, MD BSE
Medical Director
Neurologique
info@neurologique.org
http://www.neurologique.org/
Merck KGaA estimates that sales will be $1 billion.
I am not that such a rosy picture is justified.
Here’s why:
Biogen Idec (BIIB) and Elan’s (ELA) Natalizumab (Tysabri) had $481 in global sales in the first half of 2009; our estimate is that worldwide sales for 2009 will be between $1.057 and $1.1 billion. But, remember, this is a drug that has been on the market and is not new (with potentially new side effects).
So, let’s compare the advantages of Tysabri and Cladribine:
1. Tysabri has great efficacy (~60% better than placebo in SENTINEL and ~50% when combined with Avonex vs. Avonex alone in AFFIRM).
2. Tysabri is not an injectable and instead is into the vein (intravenous/IV).
3. Tysabri is well tolerated.
4. Tysabri has an easy dosing schedule and is only given 12 times a year.
On the other hand,
1. Cladribine is ~50% better than better than placebo in CLARITY.
2. Cladribine is the first oral
3. Cladribine is well tolerated.
4. Cladribine is taken 8 (to 20 – who knows what the regulators will finally say).
Wait! What about side effects?
Oh, I almost forgot to mention* (does that sound familiar?):
A. PML (progressive multifocal leukoencephalopathy) in Tysabri.
B. PCNSL (primary CNS lymphoma) in Tysabri (and rumors of two more – one in Germany and one in the U.S.).
C. Cancers in Cladribine (female cancers in a diagnosis that is 2/3 women and usually stats when they are young: ovarian, cervical and choriocarcinoma – as well as pancreatic cancer and melanoma).
So, what strategies are the representatives going to use to sell against each other (welcome to the interferon wars again)?
1. Efficacy:
a. EMD Serono is going to say that you can’t compare between trials.
b. Biogen Idec is going to say they are superior.
2. Oral vs. not:
a. EMD Serono is selling the first oral; he MS community has been waiting for this Holy Grail.
b. Biogen Idec is going to stress the convenience of being monitored for treatments, instead of possibly the dreaded “lost to follow-up”).
3. Tolerability:
a. EMD Serono is going to stress the lack of infusion reactions.
b. Biogen Idec is going to stress the patient advocates and their strong message of how Tysabri changed their lives (anecdotally, neurologists do sometimes see that patients on Tysabri have a reduction in their pain – but you didn’t hear this from the company).
4. Dosing:
a. EMD Serono is going to stress how seldomly a patient needs to take the medication and that they don’t need to come into an infusion center.
b. Biogen Idec is going to stress the lack of dose adjustments and the fact that Tysabri is only 12 times a year (they should have sold it this way from the beginning – it sounds a lot less than “monthly” or “every month”). It is difficult to forget a monthly infusion outside the home, while a pill you take a few times a year may be easily forgotten.
So, what are clinicians going to do?
Neurologists care about:
A. Efficacy:
a. Disability
b. Relapses
B. Safety:
a. We know how to reverse Tysabri with plasma exchange (plasmapheresis) but we don’t know what to do with Cladribine.
b. Future pregnancies: are there issues?
c. What to do next in patients who “fail” the medication (isn’t it the drug failing them?).
d. New unknown side effects (we are finally getting used to Tysabri).
C. Tolerability:
a. Are patients going to have problems leading to additional phone calls or problems?
Now this doesn’t even take into account the next oral medication, FTY720 (Fingolimod). A daily medication is more annoying than Cladribine, but also easier to remember. How many patients with hypertension forget to take their daily blood pressure medication and then have a heart attack or stroke? Also, Fingolimod is 50% better than Avonex – does this beat cladribine, and even Tysabri. What’s going to happen when there is a subcutaneous Tysabri – is it going to be more convenient because it will be given at home, or will it be seen as a regression back to injectable medications?
So what does this mean for the MS market, MS drugs, and most importantly the individual MS patient?
It depends who you ask.
Technical and Scientific Details:
Many people want to know how these medications work and what their mechanism of action is:
1. Interferons (Avonex, Betaseron, Rebif, Pegylated Avonex, Rebif New Formulation) – noone (no one) fully understands.
2. Glatiramer Acetate (Copaxone) – ditto.
3. Natalizumab (Tysabri) – A monoclonal antibody directed against the part (VLA4 / integrin) of the lining of the central nervous system (CNS) that sticks to white blood cells (lymphocytes). Thus reducing the amount of immune cells that get through the blood brain barrier).
4. Cladribine (Mylinax) – A molecule that is changed (phosphorylated) to a different form (its corresponding nucleotide CdATP), which accumulates in the lymphocytes and gets into their DNA. High levels of CdATP lead to DNA strand breaks, inhibition of DNA synthesis, and cell death.
5. FTY720 (Fingolimod) – Stops lymphocytes from leaving the lymph nodes; this keeps them away from the bloodstream and reaching the BBB; thereby reducing the immune attack on the brain, optic nerves and spinal cord (cervical and thoracic cord).
Now, for the rest of the emerging medications (Laquinomod, Teriflunomide, BG00012, MBP8298, Daclizumab, Campath, Rituximab, Ocrelizumab, …)** you will have to wait for more in the future.
* Why do these biotech companies seldomly (seldom) mention the serious side effects.
** The … is the most exciting advance of all (think pre-1993 …).
- Dr. Daniel Kantor, MD BSE
Medical Director
Neurologique
info@neurologique.org
http://www.neurologique.org/
Monday, July 20, 2009
Back to basics for investors and analysts
Global medicine ... it means a lot more than helping refugees in Darfur and it can be a lot more profitable ... for analysts and investors.
I noticed that there has been some confusion regarding lymphoma, primary CNS lymphoma and Tysabri (natalizumab).
At the website investorvillage.com, there is a discussion (and some confusion) regarding Biogen Idec's (BIIB) and Elan's (ELN) drug -- Tysabri (high and strong efficacy, but with potential serious side effects -- is the risk of PML 1:1,000 or 1:5,000 or ...?).
Besides other opportunistic infections caused by the immunosuppressed state (look at the cerebrospinal fluid, CSF, CD4 to CD8 ratio), there has been a recent scare concerning the risk of PML.
So, let me summarize the discussion and then clarify some of the medical terms:
1. samssong73 quotes Barclays' report from their German consultant (are we all quoting the same source but in different ways? -- possibly since this KOL from Germany discussed the possibility of a U.S. case and the rumored German case, as I have discussed with Piper Jaffray & Co. Bridge Scientific Consulting LLC: you will have to guess which one) and discusses the prior known cases of lymphoma.
2. nichtmoeglich then ask whether CNS lymphoma is a previously unidentified side effect of Tysabri use.
3. lotus52 then responds that there has been lymphoma in the past in a Tysabri patient in the clinical trials (however unlikely the causation is) so there shouldn't be alarm or panic now. That 49 year-old man who had been previously treated with infliximab and 6-mercaptopurine (did this patient also have Crohn's disease or psoriasis/arthritis; I doubt this was off-label for MS). That patient had B-cell lymphoma (this is different from PCNSL) -- it originates in the B-cells in the lymph nodes, unlike PCNSL, which originates in the CNS (central nervous system itself) -- see my information page on PCNSL at www.neurologique.org under the "Links" heading.
4. lotus52 then notices the oversight at quotes us at: http://www.investorvillage.com/smbd.asp?mb=160&mn=369285&pt=msg&mid=7610732
5. Bear River then asserts that Biogen Idec did not waffle about this when Geoffrey Porges - Sanford Bernstein asked Dr. Alfred (Al) Sandrock about the PCNSL case.
6. rosemountbomber asks whether he was discussing the published case or not -- he was clearly discussing the published case; his point is that they have known about that case for over a year (why have we not?). The SVP Neurology R&D points out that Biogen does not believe that this was related to the drug; this kind of assertion is similar to EMD Serono's Dr. Viglietta's response concerning the malignancies in the oral cladribine (mylinax) trial (CLARITY). It is unclear to me how these biotechnology companies can make such assertions. This is similar to when Novartis said that the cases of melanoma were not related to FTY720 (fingolimod) or when some of their medical side still asserts that the herpes encephalitis and disseminated varicella zoster were unrelated to their investigational drug.
So, what does this all mean?
1. Lymphoma is different from PCNSL;
2. There may be more PCNSL cases we do not yet know about (it took 1 year for us to find out about the recently published case in the Annals of Neurology);
3. For now it does not appear that neurologist prescribing habits have changed;
and most importantly:
Noone knows what the future will hold.
- Dr. Daniel Kantor, MD BSE
Medical Director
Neurologique
info@neurologique.org
www.neurologique.org
I noticed that there has been some confusion regarding lymphoma, primary CNS lymphoma and Tysabri (natalizumab).
At the website investorvillage.com, there is a discussion (and some confusion) regarding Biogen Idec's (BIIB) and Elan's (ELN) drug -- Tysabri (high and strong efficacy, but with potential serious side effects -- is the risk of PML 1:1,000 or 1:5,000 or ...?).
Besides other opportunistic infections caused by the immunosuppressed state (look at the cerebrospinal fluid, CSF, CD4 to CD8 ratio), there has been a recent scare concerning the risk of PML.
So, let me summarize the discussion and then clarify some of the medical terms:
1. samssong73 quotes Barclays' report from their German consultant (are we all quoting the same source but in different ways? -- possibly since this KOL from Germany discussed the possibility of a U.S. case and the rumored German case, as I have discussed with Piper Jaffray & Co. Bridge Scientific Consulting LLC: you will have to guess which one) and discusses the prior known cases of lymphoma.
2. nichtmoeglich then ask whether CNS lymphoma is a previously unidentified side effect of Tysabri use.
3. lotus52 then responds that there has been lymphoma in the past in a Tysabri patient in the clinical trials (however unlikely the causation is) so there shouldn't be alarm or panic now. That 49 year-old man who had been previously treated with infliximab and 6-mercaptopurine (did this patient also have Crohn's disease or psoriasis/arthritis; I doubt this was off-label for MS). That patient had B-cell lymphoma (this is different from PCNSL) -- it originates in the B-cells in the lymph nodes, unlike PCNSL, which originates in the CNS (central nervous system itself) -- see my information page on PCNSL at www.neurologique.org under the "Links" heading.
4. lotus52 then notices the oversight at quotes us at: http://www.investorvillage.com/smbd.asp?mb=160&mn=369285&pt=msg&mid=7610732
5. Bear River then asserts that Biogen Idec did not waffle about this when Geoffrey Porges - Sanford Bernstein asked Dr. Alfred (Al) Sandrock about the PCNSL case.
6. rosemountbomber asks whether he was discussing the published case or not -- he was clearly discussing the published case; his point is that they have known about that case for over a year (why have we not?). The SVP Neurology R&D points out that Biogen does not believe that this was related to the drug; this kind of assertion is similar to EMD Serono's Dr. Viglietta's response concerning the malignancies in the oral cladribine (mylinax) trial (CLARITY). It is unclear to me how these biotechnology companies can make such assertions. This is similar to when Novartis said that the cases of melanoma were not related to FTY720 (fingolimod) or when some of their medical side still asserts that the herpes encephalitis and disseminated varicella zoster were unrelated to their investigational drug.
So, what does this all mean?
1. Lymphoma is different from PCNSL;
2. There may be more PCNSL cases we do not yet know about (it took 1 year for us to find out about the recently published case in the Annals of Neurology);
3. For now it does not appear that neurologist prescribing habits have changed;
and most importantly:
Noone knows what the future will hold.
- Dr. Daniel Kantor, MD BSE
Medical Director
Neurologique
info@neurologique.org
www.neurologique.org
Healthcare stimulus
The fundamental tenet of a capitalist society (of which we are hopefully still one) is that a free market and competition improve the quality for the consumer.
The problem is that the health care industry is falling prey to over-regulation, making it less and less attractive for investors to invest their money in. With less investment, comes reduced quality; with reduced quality comes greater potential harm to individual health.
While the government has good intentions by writing Acts (such 3200 as H.R, the “America’s Affordable Health Care Choices Act of 2009,” more regulation and less freedom spell risks to good medicine.
The reason why the United States can boast the most advanced and highest quality medical care is that innovation has been rewarded. While our educational system (I am not singling out education, but many countries have equally good system) may not be recognized as a global powerhouse, there is a reason that Middle Eastern sheikhs travel across the Great Pond to seek advanced, high quality medical care.
If we allow ourselves (Congress represents We The People) to over-regulate health care, then we are doing a disservice to all Americans.
Some public rules and laws makes sense – hospitals should not discriminate based on race, sex etc. This is why we have evolved (this is NOT a Creationism debate) from tribal communities to civilized society – to protect all Americans. Other proposed rules, however, do not necessarily serve us well. H.R, 3200 is a 1,017 page tome, which makes it difficult for the average, cash-strapped American, to invest their time in reading, fully digesting and commenting on it.
The headlines and sound bites surrounding health care reform, make it an obvious cause to champion. How could someone be so cruel as to not want to offer adequate health care to all Americans? Adequate is the key word here; do we want average, mediocre, rushed, adequate care or do we want to encourage innovation, medical breakthroughs and excellence? A corollary of this is how many medical students are opting to not go into primary care, but instead to enter specialties. If we reward technical skills over cognitive skills, are we doing a service to the community? If we reward following the government cost-saving plans over comprehensive, are we doing a service to the community?
As Americans, we should stimulate and demand high quality in medical care, just as we demand high quality in every other facet of our lives – by investing (our time, money, efforts) in it.
--Daniel Kantor, MD BSE
Medical Director
Neurologique
info@neurologique.org
www.neurologique.org
The problem is that the health care industry is falling prey to over-regulation, making it less and less attractive for investors to invest their money in. With less investment, comes reduced quality; with reduced quality comes greater potential harm to individual health.
While the government has good intentions by writing Acts (such 3200 as H.R, the “America’s Affordable Health Care Choices Act of 2009,” more regulation and less freedom spell risks to good medicine.
The reason why the United States can boast the most advanced and highest quality medical care is that innovation has been rewarded. While our educational system (I am not singling out education, but many countries have equally good system) may not be recognized as a global powerhouse, there is a reason that Middle Eastern sheikhs travel across the Great Pond to seek advanced, high quality medical care.
If we allow ourselves (Congress represents We The People) to over-regulate health care, then we are doing a disservice to all Americans.
Some public rules and laws makes sense – hospitals should not discriminate based on race, sex etc. This is why we have evolved (this is NOT a Creationism debate) from tribal communities to civilized society – to protect all Americans. Other proposed rules, however, do not necessarily serve us well. H.R, 3200 is a 1,017 page tome, which makes it difficult for the average, cash-strapped American, to invest their time in reading, fully digesting and commenting on it.
The headlines and sound bites surrounding health care reform, make it an obvious cause to champion. How could someone be so cruel as to not want to offer adequate health care to all Americans? Adequate is the key word here; do we want average, mediocre, rushed, adequate care or do we want to encourage innovation, medical breakthroughs and excellence? A corollary of this is how many medical students are opting to not go into primary care, but instead to enter specialties. If we reward technical skills over cognitive skills, are we doing a service to the community? If we reward following the government cost-saving plans over comprehensive, are we doing a service to the community?
As Americans, we should stimulate and demand high quality in medical care, just as we demand high quality in every other facet of our lives – by investing (our time, money, efforts) in it.
--Daniel Kantor, MD BSE
Medical Director
Neurologique
info@neurologique.org
www.neurologique.org
Saturday, July 18, 2009
Bad year to be a celebrity: Walter Cronkite dies of unclear causes
Another celebrity, Walter Cronkite, dies of nee urological causes.
While we are all saddened for his family, the death of this 92 year-old (I believe, right-handed) white man, allows us to discuss major neurological issues.
This will, hopefully, raise several advocacy issues:
1. In most reports, it states that he died of cerebrovascular disease (some have termed it cerebral vascular disease), while it seems that according to his son, he died from complications of dementia.
So, how do we reconcile these two possibilities?
Cerebrovascular means that it affects the vasculature of the cerebrum (brain), just as cardiovascular means that it affects the vasculature of the heart.
A CVA (cerebrovascular "accident") is also called a stroke (it is sometimes called a brain attack -- to emphasize its urgency, much like a heart attack). Stroke is the third most common cause of death in the United States and is usually ischemic in nature. Ischemic strokes are caused by a process that reduces blood flow (and hence oxygen and other nutrients) to an area of the brain. This can be caused by thinning of the diameter of the arteries (and other blood vessels) where blood can flow through, caused by atherosclerosis (often because of cholesterol build up), blockage from a clot originating in the heart or other blood vessels (usually arteries, but sometimes from veins through a patent foramen ovale). Less commonly, a stroke also means bleeding in the brain (hemorrhagic stroke). This may be caused by high blood pressure (hypertension), cocaine use or a disease called cerebral amyloidosis (cerebral amyloid angiopathy).
Bleeding in the brain is much more fatal than ischemic strokes. if a patient survives the initial stroke, the chances are that they will not die directly from the stroke (but can from its complications -- such as swallowing difficulties, leading to food going down the breathing tubes and causing infection).
As the baby-boomers age, dementia is becoming a growing epidemic and is set to be a major public health crisis. Dementia (memory loss) may lead to complications, such as infections medication side effects and, most alarmingly, abuse by caretakers.
We do know that "Uncle Walter" was ill at least a month prior to his death on Friday night July 17th, 2009, because of the various reports (which were denied by his aide at the time and CBS gave "no comment" -- isn't that a comment in itself?) and by Katie Couric's recent statement reflecting that.
So, how do reconcile his family's statement and the overwhelming reports by online pundit/bloggers/writers?
There are several possibilities:
1. Someone is reporting inaccurately (the Anchorman would not be proud)
2. He had vascular (multi-infarct dementia)
3. He had cerebral amyloidosis
Multi-infarct dementia is a process whereby serial small strokes lead to a step-wise decline in memory (dementia). Just like Multiple Sclerosis (MS), strokes can happen in different parts of the brain and this may lead to memory difficulties (although the cognitive problems in MS are different from those in multi-infarct dementia).
Cerebral amyloidosis or cerebral amyloid angiopathy is a pathological process where amyloid gets deposited in brain, and can lead to bleeding in the brain (a form of cerebrovascular disease) and dementia.
[For more information on stroke and dementia, please visit http://www.neurologique.org/ and my National Library of Medicine reviews of these topics (go to "Links" section of website.]
2. Walter Cronkite received individualized care at his home. This sort of care will personalized not be possible through the nationalized healthcare system (if healthcare reform goes through). Instead of bringing doctors and their patients closer together, this reform will turn medicine further into an industry and remove the Art of Medicine. As doctors are rushed even more to see more and more patients in less and less time, the relationship and partnership between doctor and patient will further erode (this is why we offer housecalls).
Hopefully, even in death, Walter Cronkite can inspire all of us to reach for the stars (as he cared for the space missions so much) and advocate for improvements (not financial or political programs) in the quality of life of all Americans.
--
Daniel Kantor, MD BSE
Medical Director
Neurologique
info@neurologique.org
While we are all saddened for his family, the death of this 92 year-old (I believe, right-handed) white man, allows us to discuss major neurological issues.
This will, hopefully, raise several advocacy issues:
1. In most reports, it states that he died of cerebrovascular disease (some have termed it cerebral vascular disease), while it seems that according to his son, he died from complications of dementia.
So, how do we reconcile these two possibilities?
Cerebrovascular means that it affects the vasculature of the cerebrum (brain), just as cardiovascular means that it affects the vasculature of the heart.
A CVA (cerebrovascular "accident") is also called a stroke (it is sometimes called a brain attack -- to emphasize its urgency, much like a heart attack). Stroke is the third most common cause of death in the United States and is usually ischemic in nature. Ischemic strokes are caused by a process that reduces blood flow (and hence oxygen and other nutrients) to an area of the brain. This can be caused by thinning of the diameter of the arteries (and other blood vessels) where blood can flow through, caused by atherosclerosis (often because of cholesterol build up), blockage from a clot originating in the heart or other blood vessels (usually arteries, but sometimes from veins through a patent foramen ovale). Less commonly, a stroke also means bleeding in the brain (hemorrhagic stroke). This may be caused by high blood pressure (hypertension), cocaine use or a disease called cerebral amyloidosis (cerebral amyloid angiopathy).
Bleeding in the brain is much more fatal than ischemic strokes. if a patient survives the initial stroke, the chances are that they will not die directly from the stroke (but can from its complications -- such as swallowing difficulties, leading to food going down the breathing tubes and causing infection).
As the baby-boomers age, dementia is becoming a growing epidemic and is set to be a major public health crisis. Dementia (memory loss) may lead to complications, such as infections medication side effects and, most alarmingly, abuse by caretakers.
We do know that "Uncle Walter" was ill at least a month prior to his death on Friday night July 17th, 2009, because of the various reports (which were denied by his aide at the time and CBS gave "no comment" -- isn't that a comment in itself?) and by Katie Couric's recent statement reflecting that.
So, how do reconcile his family's statement and the overwhelming reports by online pundit/bloggers/writers?
There are several possibilities:
1. Someone is reporting inaccurately (the Anchorman would not be proud)
2. He had vascular (multi-infarct dementia)
3. He had cerebral amyloidosis
Multi-infarct dementia is a process whereby serial small strokes lead to a step-wise decline in memory (dementia). Just like Multiple Sclerosis (MS), strokes can happen in different parts of the brain and this may lead to memory difficulties (although the cognitive problems in MS are different from those in multi-infarct dementia).
Cerebral amyloidosis or cerebral amyloid angiopathy is a pathological process where amyloid gets deposited in brain, and can lead to bleeding in the brain (a form of cerebrovascular disease) and dementia.
[For more information on stroke and dementia, please visit http://www.neurologique.org/ and my National Library of Medicine reviews of these topics (go to "Links" section of website.]
2. Walter Cronkite received individualized care at his home. This sort of care will personalized not be possible through the nationalized healthcare system (if healthcare reform goes through). Instead of bringing doctors and their patients closer together, this reform will turn medicine further into an industry and remove the Art of Medicine. As doctors are rushed even more to see more and more patients in less and less time, the relationship and partnership between doctor and patient will further erode (this is why we offer housecalls).
Hopefully, even in death, Walter Cronkite can inspire all of us to reach for the stars (as he cared for the space missions so much) and advocate for improvements (not financial or political programs) in the quality of life of all Americans.
--
Daniel Kantor, MD BSE
Medical Director
Neurologique
info@neurologique.org
Thursday, July 16, 2009
Biogen corporate with rosy outlook
This post may be technical for some, but I feel that it is important for patients, carepartners and physicians to have an idea where the MS market
At 8:30 AM EST this morning, the Biogen team: Eric Hoffman, Jim Mullen (CEO), Alfred Sandrock, MD, PhD, Bob Hamm, Paul Clancy, and Evan Beckman presented Biogen's Q2 performance.
The analysts were very hopeful about the good Q2 performance -- revenues were up 10%, product revenues were up even higher at 16%. -- these were fueled mostly by Tysabri (natalizumab), Avonex (intramuscular IFNB-1a) and, to a lesser degree, Rituxan (rituximab).
Biogen's (Nasdaq BIIB) rich research & development (R&D) was emphasized and is obviously laudable.
Fampridine-SR and the new relationship with Acorda (ACO) was discussed, but even in the Q&A session, noone brought up the elephant in the room, nerispirdine (Sanofi-Aventis;SNY) and the potential reduced risk of epilepsy (seizures).
Analysts brought up potential screening for PML (progressive multifocal leukoencephalopathy) and Biogen made clear that they are looking at ways of ensuring that patients with PML are detected early.
The other elephant in the room was the potential risk of PCNSL (primary CNS lymphoma) -- rumors continue about another case in Germany and even one in the United States.
So, what does all this mean?
There are two possibilities:
1. If the rumors about PCNSL are true, then there will definitely be some action taken (hopefully by Biogen Idec and Elan (ELN), but maybe by regulatory authorities, such as the FDA and MAA).
2. If the rumors are false, then Biogen will continue to plug along (overall worldwide post-marketing exposure. of 56,500).
So, what does this mean?
We'll wait and see.
[For more on PCNSL, go to www.neurologique.org, navigate to the "Links" area and you will be directed right there.]
- Daniel Kantor, MD BSE
Medical Director
Neurologique
info@neurologique.org
www.neurologique.org
At 8:30 AM EST this morning, the Biogen team: Eric Hoffman, Jim Mullen (CEO), Alfred Sandrock, MD, PhD, Bob Hamm, Paul Clancy, and Evan Beckman presented Biogen's Q2 performance.
The analysts were very hopeful about the good Q2 performance -- revenues were up 10%, product revenues were up even higher at 16%. -- these were fueled mostly by Tysabri (natalizumab), Avonex (intramuscular IFNB-1a) and, to a lesser degree, Rituxan (rituximab).
Biogen's (Nasdaq BIIB) rich research & development (R&D) was emphasized and is obviously laudable.
Fampridine-SR and the new relationship with Acorda (ACO) was discussed, but even in the Q&A session, noone brought up the elephant in the room, nerispirdine (Sanofi-Aventis;SNY) and the potential reduced risk of epilepsy (seizures).
Analysts brought up potential screening for PML (progressive multifocal leukoencephalopathy) and Biogen made clear that they are looking at ways of ensuring that patients with PML are detected early.
The other elephant in the room was the potential risk of PCNSL (primary CNS lymphoma) -- rumors continue about another case in Germany and even one in the United States.
So, what does all this mean?
There are two possibilities:
1. If the rumors about PCNSL are true, then there will definitely be some action taken (hopefully by Biogen Idec and Elan (ELN), but maybe by regulatory authorities, such as the FDA and MAA).
2. If the rumors are false, then Biogen will continue to plug along (overall worldwide post-marketing exposure. of 56,500).
So, what does this mean?
We'll wait and see.
[For more on PCNSL, go to www.neurologique.org, navigate to the "Links" area and you will be directed right there.]
- Daniel Kantor, MD BSE
Medical Director
Neurologique
info@neurologique.org
www.neurologique.org
Wednesday, July 15, 2009
Cancer rears its ugly head in MS ... again
Remember how we said that the older MS (multiple sclerosis) injectable drugs do not cause cancer, well the newer ones look like they may be doing so ... with a vengeance.
An report accepted to the Annals of Neurology with lead authors: Andreas Schweikert, MD, Marcus Kremer, MD, Florian Ringel, MD, Thomas Liebig, MD, Justus Duyster, MD, Olaf Stüve,MD , PhD, Bernhard Hemmer, MD, Achim Berthele, MD, presents a 40-year-old MS patient treated with 21 courses of Tysabri (natalizumab) who developed primary CNS lymphoma (PCNSL). This horrible disease occurs in the population at a rate of 0.46 per 100,000. There have only been 4 reported cases in MS patients in the last 10 years.
So, are these two things related?
Well, Tysabri does suppress the immune system and PCNSL occurs in immunosuppressed individuals, so ... maybe. The real question is whether the rumors of another case in the EU (is the case true and is it German as well? I doubt it is from Munich, Germany since the lead and senior author are both from the Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany; if they had another case, they probably would have reported it as well).
Other questions include:
- Why is this patient also a man? Is it because being a man is a worse prognostic indicator of MS than being a woman? In Germany (and for that matter globally and in the United States) are men preferentially treated with Tysabri?
- Did this patient receive 21 month of Tysabri in a row or were they in the original clinical trials (AFFIRM or SENTINEL, or Phase II studies). Did this patient have a drug holiday?
- How sure were the pathologists after the biopsy?
- Is a report from Iran in Infection 2003 about a non-Tysabri patient with meningitis/encephalitis "...who was positive for JCV PCR died with a diagnosis of cerebral lymphoma..." important to think about?
The final question is, what does all this mean for MS treatment?
Cladribine [Mylinax - EMD Serono, Ivax, Teva; see CLARITY and ongoing ONWARD] (perhaps, despite the bold statement concerning them not being related by Dr. Viglietta at EMD Serono: "malignancies..unrelated to the MOA of cladribine" -- see our earlier tweat on twitter: http://twitter.com/Neurologique), Fingolimod [FTY720 - Novartis; see FREEDOMS and TRANSFORMS] with breast and skin cancer, who knows about Laquinimod [Teva Neurosciences and Active Biotech (NASDAQ OMX NORDIC: ACTI; see ALLEGRO); also spelled alternatively by some as Laquinomod, including analysts, investors and in the Financial Times by Pharmawire on FT.com], Teriflunomide [Sanofi-Aventis; see TEMSO and TOPICS], BG00012 [fumaric acid - Biogen Idec; see CONFIRM] and Campath [alemtuzumab - Genzyme (GENZ), Bayer Healthcare Pharmaceuticals; see CARE-MS].
- Daniel Kantor, MD BSE
Medical Director
Neurologique
info@neurologique.org
www.neurologique.org
An report accepted to the Annals of Neurology with lead authors: Andreas Schweikert, MD, Marcus Kremer, MD, Florian Ringel, MD, Thomas Liebig, MD, Justus Duyster, MD, Olaf Stüve,MD , PhD, Bernhard Hemmer, MD, Achim Berthele, MD, presents a 40-year-old MS patient treated with 21 courses of Tysabri (natalizumab) who developed primary CNS lymphoma (PCNSL). This horrible disease occurs in the population at a rate of 0.46 per 100,000. There have only been 4 reported cases in MS patients in the last 10 years.
So, are these two things related?
Well, Tysabri does suppress the immune system and PCNSL occurs in immunosuppressed individuals, so ... maybe. The real question is whether the rumors of another case in the EU (is the case true and is it German as well? I doubt it is from Munich, Germany since the lead and senior author are both from the Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany; if they had another case, they probably would have reported it as well).
Other questions include:
- Why is this patient also a man? Is it because being a man is a worse prognostic indicator of MS than being a woman? In Germany (and for that matter globally and in the United States) are men preferentially treated with Tysabri?
- Did this patient receive 21 month of Tysabri in a row or were they in the original clinical trials (AFFIRM or SENTINEL, or Phase II studies). Did this patient have a drug holiday?
- How sure were the pathologists after the biopsy?
- Is a report from Iran in Infection 2003 about a non-Tysabri patient with meningitis/encephalitis "...who was positive for JCV PCR died with a diagnosis of cerebral lymphoma..." important to think about?
The final question is, what does all this mean for MS treatment?
Cladribine [Mylinax - EMD Serono, Ivax, Teva; see CLARITY and ongoing ONWARD] (perhaps, despite the bold statement concerning them not being related by Dr. Viglietta at EMD Serono: "malignancies..unrelated to the MOA of cladribine" -- see our earlier tweat on twitter: http://twitter.com/Neurologique), Fingolimod [FTY720 - Novartis; see FREEDOMS and TRANSFORMS] with breast and skin cancer, who knows about Laquinimod [Teva Neurosciences and Active Biotech (NASDAQ OMX NORDIC: ACTI; see ALLEGRO); also spelled alternatively by some as Laquinomod, including analysts, investors and in the Financial Times by Pharmawire on FT.com], Teriflunomide [Sanofi-Aventis; see TEMSO and TOPICS], BG00012 [fumaric acid - Biogen Idec; see CONFIRM] and Campath [alemtuzumab - Genzyme (GENZ), Bayer Healthcare Pharmaceuticals; see CARE-MS].
- Daniel Kantor, MD BSE
Medical Director
Neurologique
info@neurologique.org
www.neurologique.org
Tuesday, July 14, 2009
Leerink Swann Enigma
Analysts at Leerink Swann & Co. gave Biogen Idec (Nasdaq BIIB) an "outperform rating" for unclear reasons.
Note that my comments are unrelated to what I think (it is not a feeling -- I think patients and, even, doctors place too much personal feeling behind the medications to treat MS. MS is a diagnosis and medications are treatments. When they work for you -- or your patients -- great, but when they don't, it doesn't make them evil or CRAB. All it means is that you should work as the leader of your MS team to find a more suitable option for you -- remember, everything about MS is individualized, even the treatment) about Tysabri (natalizumab). Tysabri has great efficacy and tolerability data, but there are serious, if rare, potential infectious side effects.
The analyst writes, "...[g]iven Tysabri's generous suppression of CNS immunity, these events are not necessarily unexpected..." With most of the newer medications we are going to see a suppression, but that doesn't take away from the potential risks. Patient, carepartners, loved ones and neurologists are going to have to weigh risk vs. benefit, more than they have ever needed to in the past.
The MS community (and it is a community) has been lucky for the past 15 years -- we have had medications, which may be injectables, but have also been extremely safe. When we take or give these medications, we are not concerned about cancer, death or even serious life-threatening infections.
That is all changing -- Tysabri with PML, cladribine potentially with cancer (still unclear), fingolimod with cancers and life-threatening infections, teriflunomide's parent compound (leflunomide) with PML Campath with /itp /9idiopathic thrombocytopenic purpura) / other humoral autoimmune diseases, and the list goes on. BG0012 looks like it will be safer than the others, but it causes flushing and, most importantly has the inconvenience f being three times a day.
What are newly diagnosed multiple sclerosis patients going to do, when faced with the decision of four injectables and an oral medication. They may choose the "easy" orals, but they may also have responded to the older injectables (without the potentially life-threatening side effects). We physicians hate telling our patients that "you may not be doing as well as we would like, but you may have been worse without the medication." This may, however, be the closest we can come to predicitng patients' outcome (until we reach the holy grail of biomarkers). In my opinion, the MS community should come together to make educational programs for the newly diagnosed, highlighting the excellent safety and relative good efficacy of the older medications. I am fearful that new members of the community will be blind-sighted by the seductive sirens of oral medications.
The analyst goes on to say that, "... [n]otably, there appears to be a geographic clustering of these cases suggesting the risk of these events ex-Germany may be lower than the global rate would suggest...." I am unsure why that is relevant and how you can make such a statistical inference from a small sample size (expected to increase, but 10 at the current time). This may be intellectually disingenuous and unfair to casual, unwitting investors. This is akin to predicting and estimating the rate of PML with a constantly moving numerator (with a much faster rate than the denominator).
So what does this mean and should you buy or sell Biogen Idec or Elan stocks?
Maybe it depends if you are German or not and, alternatively, maybe it doesn't.
--
Dr. Daniel Kantor, MD BSE
Medical Director
Neurologique
Note that my comments are unrelated to what I think (it is not a feeling -- I think patients and, even, doctors place too much personal feeling behind the medications to treat MS. MS is a diagnosis and medications are treatments. When they work for you -- or your patients -- great, but when they don't, it doesn't make them evil or CRAB. All it means is that you should work as the leader of your MS team to find a more suitable option for you -- remember, everything about MS is individualized, even the treatment) about Tysabri (natalizumab). Tysabri has great efficacy and tolerability data, but there are serious, if rare, potential infectious side effects.
The analyst writes, "...[g]iven Tysabri's generous suppression of CNS immunity, these events are not necessarily unexpected..." With most of the newer medications we are going to see a suppression, but that doesn't take away from the potential risks. Patient, carepartners, loved ones and neurologists are going to have to weigh risk vs. benefit, more than they have ever needed to in the past.
The MS community (and it is a community) has been lucky for the past 15 years -- we have had medications, which may be injectables, but have also been extremely safe. When we take or give these medications, we are not concerned about cancer, death or even serious life-threatening infections.
That is all changing -- Tysabri with PML, cladribine potentially with cancer (still unclear), fingolimod with cancers and life-threatening infections, teriflunomide's parent compound (leflunomide) with PML Campath with /itp /9idiopathic thrombocytopenic purpura) / other humoral autoimmune diseases, and the list goes on. BG0012 looks like it will be safer than the others, but it causes flushing and, most importantly has the inconvenience f being three times a day.
What are newly diagnosed multiple sclerosis patients going to do, when faced with the decision of four injectables and an oral medication. They may choose the "easy" orals, but they may also have responded to the older injectables (without the potentially life-threatening side effects). We physicians hate telling our patients that "you may not be doing as well as we would like, but you may have been worse without the medication." This may, however, be the closest we can come to predicitng patients' outcome (until we reach the holy grail of biomarkers). In my opinion, the MS community should come together to make educational programs for the newly diagnosed, highlighting the excellent safety and relative good efficacy of the older medications. I am fearful that new members of the community will be blind-sighted by the seductive sirens of oral medications.
The analyst goes on to say that, "... [n]otably, there appears to be a geographic clustering of these cases suggesting the risk of these events ex-Germany may be lower than the global rate would suggest...." I am unsure why that is relevant and how you can make such a statistical inference from a small sample size (expected to increase, but 10 at the current time). This may be intellectually disingenuous and unfair to casual, unwitting investors. This is akin to predicting and estimating the rate of PML with a constantly moving numerator (with a much faster rate than the denominator).
So what does this mean and should you buy or sell Biogen Idec or Elan stocks?
Maybe it depends if you are German or not and, alternatively, maybe it doesn't.
--
Dr. Daniel Kantor, MD BSE
Medical Director
Neurologique
Wednesday, July 8, 2009
Healthcare reform -- is it new?
Healthcare reform seems like a good idea -- everyone should have access to healthcare, regardless of income level.
So, how is this different from what we already have?
Currently, if you are too impoverished to afford your own health insurance, you may be eligible for State insurance programs, namely Medicaid. If you are older or disabled, there is Medicare.
But, what about the working under-insured?
If you work for a living and pay your taxes, you may not have enough left over to pay for health insurance premiums. If healthcare reform (as it is currently envisioned) goes through, then you may still find it hard to afford. Your taxes may increase and you will still be paying a monthly premium.
Even if this saves you some money (this is not entirely clear), it may reduce your choice in coverage, medications etc. (also not entirely clear).
In America, we also believe that we have a right to a public education, but the school facilities, access to textbooks etc. may not be on par with those available at private schools. You are able to pay, however, to improve the quality of education (this is NOT at all to say that public education is in any way of inferior quality to private) -- with healthcare it isn't the same. It will be unacceptable to the general population for there to be a difference in clinical care between private and public hospitals. Medicare and Medicaid beneficiaries receive the highest caliber healthcare in the world. When you enter an American hospital, you can not be turned away for insurance reasons (this is something under-appreciated by non-Americans sometimes).
What makes discussions about healthcare so difficult are that it is not entirely akin to other industries. When you choose a new car to drive, you base your decision on many factors: price, appearance, speed, horsepower etc., but when someone chooses their health coverage and are faced with a 100% coinsurance vs. an 80-20 plan, they don't actually mean that if their life is dependant on it, they understand that they have to pay 20% or they won't survive. Obviously we all want to live (most of us anyway) and the person who chose the 80-20 plan over the 100% plan did so to save money on the monthly premiums. Unlike car insurance, where if you don't pay it, they may impound your car, no one is suggesting that we impound someone's life if you don't pay your health insurance premiums (this is one of the flaws with the idea of mandatory health insurance). So, choosing how much health insurance coverage you want, is akin to gambling with a communal pot of money -- the person who saves on the premiums and buys less health insurance, is still going to be covered (through our taxes) if their life depends on it The incentive to be responsible and buy adequate health insurance is that if you don't do so you will go into bankruptcy from your bills.
So with nationalized healthcare reform, the working under-insured will not have a choice of being under-insured (taking a gamble and saving their money for other things) and will be insured by a mixture of paying their taxes and paying their premiums. The poor, will continue to have access to care, but their formulary may be even further curtailed (to cut costs).
The question is, what is going to happen to the healthcare industry -- what happens to all the executives, administrators, clerks, janitorial staff etc. if the private healthcare insurance industry collapses under a nationalized healthcare system?
Are we going to bail it out?
--
Dr. Daniel Kantor, MD BSE
Medical Director
Neurologique
So, how is this different from what we already have?
Currently, if you are too impoverished to afford your own health insurance, you may be eligible for State insurance programs, namely Medicaid. If you are older or disabled, there is Medicare.
But, what about the working under-insured?
If you work for a living and pay your taxes, you may not have enough left over to pay for health insurance premiums. If healthcare reform (as it is currently envisioned) goes through, then you may still find it hard to afford. Your taxes may increase and you will still be paying a monthly premium.
Even if this saves you some money (this is not entirely clear), it may reduce your choice in coverage, medications etc. (also not entirely clear).
In America, we also believe that we have a right to a public education, but the school facilities, access to textbooks etc. may not be on par with those available at private schools. You are able to pay, however, to improve the quality of education (this is NOT at all to say that public education is in any way of inferior quality to private) -- with healthcare it isn't the same. It will be unacceptable to the general population for there to be a difference in clinical care between private and public hospitals. Medicare and Medicaid beneficiaries receive the highest caliber healthcare in the world. When you enter an American hospital, you can not be turned away for insurance reasons (this is something under-appreciated by non-Americans sometimes).
What makes discussions about healthcare so difficult are that it is not entirely akin to other industries. When you choose a new car to drive, you base your decision on many factors: price, appearance, speed, horsepower etc., but when someone chooses their health coverage and are faced with a 100% coinsurance vs. an 80-20 plan, they don't actually mean that if their life is dependant on it, they understand that they have to pay 20% or they won't survive. Obviously we all want to live (most of us anyway) and the person who chose the 80-20 plan over the 100% plan did so to save money on the monthly premiums. Unlike car insurance, where if you don't pay it, they may impound your car, no one is suggesting that we impound someone's life if you don't pay your health insurance premiums (this is one of the flaws with the idea of mandatory health insurance). So, choosing how much health insurance coverage you want, is akin to gambling with a communal pot of money -- the person who saves on the premiums and buys less health insurance, is still going to be covered (through our taxes) if their life depends on it The incentive to be responsible and buy adequate health insurance is that if you don't do so you will go into bankruptcy from your bills.
So with nationalized healthcare reform, the working under-insured will not have a choice of being under-insured (taking a gamble and saving their money for other things) and will be insured by a mixture of paying their taxes and paying their premiums. The poor, will continue to have access to care, but their formulary may be even further curtailed (to cut costs).
The question is, what is going to happen to the healthcare industry -- what happens to all the executives, administrators, clerks, janitorial staff etc. if the private healthcare insurance industry collapses under a nationalized healthcare system?
Are we going to bail it out?
--
Dr. Daniel Kantor, MD BSE
Medical Director
Neurologique
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