http://www.businessweek.com/magazine/content/09_45/b4154034724383.htm?chan=magazine+channel_top+stories
So Washington is jumping for joy that the 3rd quarter GDP growth numbers were POSITIVE (3.5%) after 4 straight negative quarters. The stock market has surged from its low in March (Dow 6,000s) to now (Dow 9,700). Auto and home sales are up too (mostly due to gov't incentives, and are expected to decline as rebates expire, so really it was just a loan from the future). Consumer spending has risen in some months, and of course the US personal savings rate has grown. Though unemployment is around 10% (those jobs may not return for years), and recent college grads are having a harder time getting hired than ever before. The White House says its spring stimulus package created or saved 1.2M new jobs (then reduced the figure to 0.65M when errors were exposed). But many of those jobs are temporary (highway projects) or non-white-collar, and 0.65M is less than 10% of the ~7M jobs lost since last fall. The stimulus did have some benefits, and gov't spending will always create jobs. But is it worth it? Nearly $1T in stimulus spending saved/created jobs for 0.43% of the American workforce, at the cost of $153K/job (triple the average household income). I know that is an unfair calculation since the stimulus was not 100% geared for job creation, but you get my point.
So what is going on? Are we out of the woods yet? GDP doesn't take into account R&D or other business investments that pay off big for the future economy. Of course those things are challenging to quantify, but it is possible. "Intangible business investments" were 40% smaller than tangible assets (equipment, buildings, etc. that the GDP can capture) in 1985, then the two were equal by 1995, and now intangibles are actually higher. America's wealth, innovation, and productivity have grown tremendously since 1985, and intangibles played a big part. The Bureau of Economic Analysis (the overworked and underfunded agency that calculates the GDP) plans to include some measure of intangibles into the GDP by 2013, so it is clearly important. Based on the author's rough calculations, drops in intangibles could make the real GDP 1-1.5% lower than the published figure.
While the GDP was supposedly rising, more and more professionals got pink slips (especially R&D scientists and engineers) in order to cut costs. In fact, techies are getting laid off at 150% the rate of the overall workforce, so it's not just the assembly line workers in the Rust Belt suffering this year. Companies want to do this to inflate their profit margins and please Wall Street (hence gains in the Dow), but they're sacrificing their future for short-term fiscal savings. Venture capital investments are half of what they were in 2008 (much of that money goes to hiring smart people to develop cool stuff), and big names like Texas Instruments and J&J have cut their R&D budgets by over 10%. Expenditures on worker training is also down (it was already down 4% in 2008, so 2009 is probably higher - though the data is not available yet), which is contrary to one of the stimulus package's goals of retraining workers for the 21st Century economy.
So what is the point of an economic recovery that threatens future development and productivity? We're just kicking the can down the road, like the Band-Aid patches for California's debt. I don't have brilliant ideas to truly end the recession, but it seems that declaring a recovery is premature.
Friday, October 30, 2009
Thursday, October 29, 2009
Tim Donaghy book on NBA corruption
http://deadspin.com/5392067/excerpts-from-the-book-the-nba-doesnt-want-you-to-read
Disgraced and incarcerated former NBA referee Tim Donaghy just finished a tell-all book about NBA corruption that was supposed to be published by Random House, but strangely the company changed their mind after investing thousands of dollars on the venture (maybe Stern made a few calls). So it was taken off Amazon pre-order, but this website managed to transcribe some excerpts, and maybe a smaller publishing house will give it a try. Of course we have to consider the source and his motives, like Canseco's tell-all about steroids in baseball. But we should also remember that Canseco turned out to be right with several of his allegations.
We all know that refs influence (deliberately or not) NBA games probably more than officials in all the other pro sports, maybe apart from the goof-riddled MLB playoffs this year. But it's just the nature of the big-money, big-media modern NBA and ref culture that controversies are likely, especially due to the subjective, inconsistent, and vague nature of personal foul rules and enforcement in basketball. Literally millions of dollars are at stake from a whistle at a critical moment. NFL and soccer refs believe that they do a great job if no one notices they're even there. But NBA refs have big egos and want to be noticed. They're a sideshow like the cheerleaders, even at the expense of fairness and correctness.
So Donaghy says what we all suspect: the NBA front office wants to promote big stars, keep games close and interesting, extend playoff series, help the home teams win, and maybe have more interesting/profitable teams succeed. This will make the NBA and its sponsors richer. And officiating can help that. Stars walk all over and rarely get in foul trouble (except clumsy big men), yet defensive specialists get whistles just for breathing on a star. Often home teams or teams down in a game get more calls and go to the foul line more (give the people what they want!). But fans have all the data available for foul calls and which teams/ref crews were participating, so someone should crunch the numbers and see if there is measurable bias (if all else fails, I will take a week off work and try). That doesn't prove intent, but at least could expose a problem.
Donaghy talks crap about several refs, but alleges that Dick Bavetta is the league's "cleaner". He makes sure the proper result plays out in critical games, and even brags about how good he is at it. Coincidentally, he was on the floor during several controversial playoff games, such as game 6 between LAL-SAC in 2002 with SAC up 3-2 against the Juggernaut Lakers (yeah, I'm still bitter). It's also strange that the NBA picks the officiating crew a few days before the game. Why wouldn't they have ref schedules randomized and pre-set even before the playoffs began, in order to reduce the chance of tampering?
http://www.youtube.com/watch?v=b0KJvlSUB-w
Well some might say that the NBA already is very popular and makes a ton of loot, so why would they risk it all to squeeze a few more millions out? An exposed scandal would ruin everything. Pete Rose was rich, successful, and still broke the rules; same with A-Rod. Success can't stop greed and corruption. In fact in may be a strong motivator; enough is never enough and Stern has to keep growing the NBA's success or he'll be fired. And maybe scandals won't deep-six a pro sport anyway, so it's worth the risk. Although MLB attendance was severely down this year (probably due to the recession), fans still keep coming after the unpopular players' strike and steroids scandals.
But what about ugly, small-market teams doing well in recent times, like SA, DET, NO, and SAC? There are a lot of series sweeps in the playoffs too. And Bron/Nash still haven't won rings. Shouldn't Stern have pulled enough strings so those things didn't happen? Well the NBA can't be blatantly obvious. Some teams are way better than others and should get a sweep. And SA, DET, and SAC did have good, championship-worthy squads for a while. Even with tampering, they still could have overcame and won. It's not like Stern could hire a sniper to take out Duncan with a rifle during a time out. They are clever and they pick their spots, like the DAL-MIA Finals or the LAL-SAC 2002 series. I wish the refs did strike this season so we could see what a properly-officiated pro game looks like.
Wednesday, October 28, 2009
Rethinking the SF Bay Bridge
http://www.insidebayarea.com/sanmateocountytimes/localnews/ci_13658982?source=rss
http://baybridgeinfo.org/faqs
http://www.dot.ca.gov/hq/esc/tollbridge/SFOBB/Sfobbfacts.html
After yet another near-lethal accident and emergency bridge closure for repairs that costs the region millions in economic productivity loss, maybe we should rethink the entire bridge concept anyway. We know the eastern span of the bridge is a piece of crap and won't withstand a 7.0 quake, which is why a new bridge is under construction.
The bridge's construction began in 1933 at a cost of $77M ($1.2B in 2009 dollars; a cool website to calculate: http://www.dollartimes.com/calculators/inflation.htm). Another $49M was spent in 1958 ($362M in 2009 dollars). In CA bill AB 1171 in 2001, $3.3B was allocated for bridge seismic retrofitting. $20B in new transportation bonds were issued in 2006 to address cost over-runs, which now total $6.2B and counting.
So instead of wasting ~$8B on building/maintaining the bridge, why not destroy it and dredge a land bridge instead? A Google search didn't find any proposals in circulation. You could have a small high-rise section for ships to pass underneath. We know the tourism snobs would say that a land bridge wouldn't be as picturesque, but we still have the Golden Gate don't we? Obviously a land bridge would be safer in a quake or storm (assuming the dredged Earth was stabilized properly and won't liquify from tremors). It will ease pressure on traffic, emergency responders, and Caltrans as well.
So the big question remains - would this idea be more or less economical? Under the bridge, nautical charts show an average water depth of ~55 feet. The bridge spans 3.68 miles of water. So assuming the land bridge would be 500 feet wide (very generous), that is 0.35 square miles. Well how much did a similar project cost? Dubai had Van Oord company (and the Dutch know their stuff when it comes to land reclaimation) build its famous "Palm Jumeirah" islands. They needed 90M cubic meters of sand and 7M tons of rock to dredge water that was 11 meters deep (28 feet). The archipelago extends 5 miles offshore and totals 700 hectares of land, which is 2.73 square miles - 8X the size of my proposed land bridge project. So it's a much larger project than the Bay Bridge span would need, albeit constructed with the help of dirt-cheap South Asian laborers. The whole Jumeirah cost $12B, but not sure what fraction was dredging. Maybe to get a sense, Van Oord won a new $4B contract to build an even bigger Palm (the Deira) in Dubai. This one is 4,000 hectares or 5.7X bigger than the Jumeirah, or 45X bigger than the land bridge. But since the Bay is 2X deeper than the Dubai coast, lets quadruple the cost to be fair. I am sure dredging jobs don't scale linearly, but just for argument's sake, that's a cost of only $360M. $6B just to retrofit the bridge vs. $0.36B to make a land bridge, hmmmm.
http://en.wikipedia.org/wiki/Palm_Jumeirah
http://www.sandandgravel.com/news/article.asp?v1=8727
But ~270,000 vehicles use the bridge every day, which at $4 per car is over $1M in revenues each day (and there are proposals to raise the toll to $5-6). So I guess it's a cash cow and a "pretty landmark" for the area, so we'll continue to sacrifice time, resources, and safety to maintain the bridge, when cheaper and safer alternatives exist.
Friday, October 23, 2009
More on prescription drugs
Yeah, for a culture that's so gung-ho about wars on drugs, just saying no to drugs, etc. there sure is a lot of accommodation of prescription drugs; yet another mystery of American life, eh?
BTW, I did want to add one thing to the discussion (top-posted per request, cross-posted with T's Blogger Blog, & duplicated to Google Groups for posterity): it could be that the real villain with respect to over-prescription of drugs is actually the privacy policies which make data collection regarding drug interaction as well as long-term efficacy something of a question rather than a no-brainer... I know that there are plenty of systems (and algorithms) which are capable of automatic collection and anonymization of such data so the technology definitely exists; as far as I'm know the only reason such systems haven't been deployed (or federated) is a lack of will and/or legal framework to allow the needful to be done.
PS: DTC marketing is obnoxious and more existential than hanging out at a gym; it's reason enough to turn off the TV for good and/or abandon network television for good.
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Thanks for writing. Yeah Rx painkillers are I think in the top 5 for illicit drug abuse in America. But instead of brown people smuggling blow across the Rio Grande to poison our kids, American drug pushers just have to raid grandma's medicine cabinet or obtain a bogus Rx. I am sure most of you have heard stories of even teens selling their leftover vicodin to classmates after a wisdom teeth removal or whatnot. Customer service is generally pretty poor at most retirement homes and hospice care centers for the sub-rich, but one thing they're great at is medicating the elderly. Then they have to deal with fewer complaints and whining.
Another problem is how to dispose of all the surplus drugs. It's fairly well documented that doctors overprescribe antibiotics for even viral illnesses or patients whose symptoms are not severe (and would probably recover on their own, but the doc wants to be careful and not upset the patient/get sued). This selective pressure gives an evolutionary advantage to drug-resistant bacteria strains. Discarded antibiotics and other drugs are winding up in our water supply. Our water purity tools are now more sensitive, so maybe drugs were always there and now we can finally detect them, but still - it's quite likely that we're ingesting trace amounts of all sorts of drug cocktails when we drink tap water (or even cheap bottled water).
http://www.staphaseptic.com/news.cfm?id=18FE4C5D-C6C9-0EF9-9F1678797221DAA9
http://www.usatoday.com/news/nation/2008-03-10-drugs-tap-water_N.htm
As you said, there isn't much data on long-term drug effects, drug interaction, or even acute side effects. With pressure from drug companies and even overzealous patient advocacy groups to get products to market ASAP, the FDA is unable to be totally thorough. There is a new prostate cancer vaccine (Provenge) being reviewed by the FDA. 4/17 docs on the advisory panel have concerns about the drug's efficacy, and two published their findings. The authors now need 24/7 bodyguards because crazy people are making death threats to them, because they think the docs' obstruction is threatening theirs. Even though the docs are doing this out of concerns for potential patients and have no financial incentive, unlike other docs who praise drugs from companies that do them favors. This is the state of medicine today.
http://www.psa-rising.com/blog/2007/06/prostate-cancer-doctor-receives-death-threat-over-provenge/
As we know, haste causes mistakes, like in the cases of Vioxx, Raplon, Palladone, Trasylol, Baycol, Raptiva, or other drugs that were initially approved and pulled after drug-related deaths/complications were reported. Just do a Google search for "drugs pulled from market" and you will find a huge list. The FDA, NIH, and other gov't entities are underfunded and understaffed. In fact, most drug testing is funded and conducted by the company itself, and the FDA just reviews their paperwork. Or resources are poorly allocated: breast cancer research gets the most funding (30% of all NCI grant funding), even though it is not the most common nor lethal cancer, probably due to America's Oedipal fixation with mammaries and maternal guilt issues. But long-term studies are expensive and time-consuming, and it's hard to follow patients for years. We hope academics will conduct these critical studies for us, but they have their own constraints and there's still so much we don't know. Maybe with more electronic records, information sharing, and sophisticated computational methods, we can learn more about the pharmacokinetics/dynamics of various drugs, but as you would expect, the medical field is not at the cutting edge with respect to computing. As you said, without the gov't will and legal mandate to obtain these data, it will never happen on its own.
http://www.cancer.gov/cancertopics/factsheet/NCI/research-funding
Attitude-wise, I think patients should stop expecting new miracle drugs to keep curing them of illnesses and improving/extending their lives. Practically everything out there is a carcinogen or pathogen. Maybe diseases evolve faster than science (and bureaucracy) can combat them anyway. The "George Bush approach" that technology will always save us from ourselves is not valid in most cases, and probably foolhardy. Yes we should rationally and ethically continue research and try to help the sick get better, and yes drug companies and doctors deserve reasonable compensation for the products/services they provide, but let's remember that we are all mortal and fragile. Death is part of life, and let's face it with some zen and humility. Why are you so important that society needs to spend half a million dollars so you can see your 86th birthday? Research isn't really the problem either. The top killers in the world are respiratory complications (from flu, pneumonia, etc.), tuberculosis, and malaria. All those are easily and CHEAPLY preventable/treatable. But of course the people who die from them are from the Third World, and we don't give a shit about them. The top killers in the West are probably heart disease and cancer. So we pour billions of dollars into research and care for those diseases. Probably one infusion of chemotherapy ($10k in some cases) could pay for an entire village's anti-malarials for a year.
BTW, I did want to add one thing to the discussion (top-posted per request, cross-posted with T's Blogger Blog, & duplicated to Google Groups for posterity): it could be that the real villain with respect to over-prescription of drugs is actually the privacy policies which make data collection regarding drug interaction as well as long-term efficacy something of a question rather than a no-brainer... I know that there are plenty of systems (and algorithms) which are capable of automatic collection and anonymization of such data so the technology definitely exists; as far as I'm know the only reason such systems haven't been deployed (or federated) is a lack of will and/or legal framework to allow the needful to be done.
PS: DTC marketing is obnoxious and more existential than hanging out at a gym; it's reason enough to turn off the TV for good and/or abandon network television for good.
-------
Thanks for writing. Yeah Rx painkillers are I think in the top 5 for illicit drug abuse in America. But instead of brown people smuggling blow across the Rio Grande to poison our kids, American drug pushers just have to raid grandma's medicine cabinet or obtain a bogus Rx. I am sure most of you have heard stories of even teens selling their leftover vicodin to classmates after a wisdom teeth removal or whatnot. Customer service is generally pretty poor at most retirement homes and hospice care centers for the sub-rich, but one thing they're great at is medicating the elderly. Then they have to deal with fewer complaints and whining.
Another problem is how to dispose of all the surplus drugs. It's fairly well documented that doctors overprescribe antibiotics for even viral illnesses or patients whose symptoms are not severe (and would probably recover on their own, but the doc wants to be careful and not upset the patient/get sued). This selective pressure gives an evolutionary advantage to drug-resistant bacteria strains. Discarded antibiotics and other drugs are winding up in our water supply. Our water purity tools are now more sensitive, so maybe drugs were always there and now we can finally detect them, but still - it's quite likely that we're ingesting trace amounts of all sorts of drug cocktails when we drink tap water (or even cheap bottled water).
http://www.staphaseptic.com/news.cfm?id=18FE4C5D-C6C9-0EF9-9F1678797221DAA9
http://www.usatoday.com/news/nation/2008-03-10-drugs-tap-water_N.htm
As you said, there isn't much data on long-term drug effects, drug interaction, or even acute side effects. With pressure from drug companies and even overzealous patient advocacy groups to get products to market ASAP, the FDA is unable to be totally thorough. There is a new prostate cancer vaccine (Provenge) being reviewed by the FDA. 4/17 docs on the advisory panel have concerns about the drug's efficacy, and two published their findings. The authors now need 24/7 bodyguards because crazy people are making death threats to them, because they think the docs' obstruction is threatening theirs. Even though the docs are doing this out of concerns for potential patients and have no financial incentive, unlike other docs who praise drugs from companies that do them favors. This is the state of medicine today.
http://www.psa-rising.com/blog/2007/06/prostate-cancer-doctor-receives-death-threat-over-provenge/
As we know, haste causes mistakes, like in the cases of Vioxx, Raplon, Palladone, Trasylol, Baycol, Raptiva, or other drugs that were initially approved and pulled after drug-related deaths/complications were reported. Just do a Google search for "drugs pulled from market" and you will find a huge list. The FDA, NIH, and other gov't entities are underfunded and understaffed. In fact, most drug testing is funded and conducted by the company itself, and the FDA just reviews their paperwork. Or resources are poorly allocated: breast cancer research gets the most funding (30% of all NCI grant funding), even though it is not the most common nor lethal cancer, probably due to America's Oedipal fixation with mammaries and maternal guilt issues. But long-term studies are expensive and time-consuming, and it's hard to follow patients for years. We hope academics will conduct these critical studies for us, but they have their own constraints and there's still so much we don't know. Maybe with more electronic records, information sharing, and sophisticated computational methods, we can learn more about the pharmacokinetics/dynamics of various drugs, but as you would expect, the medical field is not at the cutting edge with respect to computing. As you said, without the gov't will and legal mandate to obtain these data, it will never happen on its own.
http://www.cancer.gov/cancertopics/factsheet/NCI/research-funding
Attitude-wise, I think patients should stop expecting new miracle drugs to keep curing them of illnesses and improving/extending their lives. Practically everything out there is a carcinogen or pathogen. Maybe diseases evolve faster than science (and bureaucracy) can combat them anyway. The "George Bush approach" that technology will always save us from ourselves is not valid in most cases, and probably foolhardy. Yes we should rationally and ethically continue research and try to help the sick get better, and yes drug companies and doctors deserve reasonable compensation for the products/services they provide, but let's remember that we are all mortal and fragile. Death is part of life, and let's face it with some zen and humility. Why are you so important that society needs to spend half a million dollars so you can see your 86th birthday? Research isn't really the problem either. The top killers in the world are respiratory complications (from flu, pneumonia, etc.), tuberculosis, and malaria. All those are easily and CHEAPLY preventable/treatable. But of course the people who die from them are from the Third World, and we don't give a shit about them. The top killers in the West are probably heart disease and cancer. So we pour billions of dollars into research and care for those diseases. Probably one infusion of chemotherapy ($10k in some cases) could pay for an entire village's anti-malarials for a year.
Friday, October 16, 2009
Doctors prescribing drugs
In my experience, primary care physicians are very responsible in providing their patients with the correct medications and education. Being a news article, it is easy to cite a few examples of patients that are unaware to skew towards a general opinion rather than an official study supported by lots of data from a balanced group of subjects. The majority of my patients that are taking medications are mostly aware of their drug names and why they are taking them, and some also know the exact dosages. It is true that the majority are for high cholesterol, blood pressure, anti-coagulants, diabetic medication, etc. There are many drugs that can be prescribed, however there are fine differences in the mechanisms of the drugs, so the physicians may prescribe a drug, but then change the prescription due to the medication's effects of that patient's blood chemistry, exam, etc to titrate them for the best effect on their patient. I feel that they are putting the patient's best interest first, especially since there is no tort reform. The rise in pharm sales can be attributed to patients asking for a specific drug by name, but it will not be prescribed unless it is the right drug for them. In the case where many drugs can work, if a patient feels more satisfaction for a certain drug name, it will probably be prescribed. Otherwise, it is just new technological advancements that are helping patients live longer than the had in the past and a new generation in which Prevention is the mode of operation.
It used to be that a patient would have a heart attack before medication was prescribed. Now, we have many indicators to help prevent heart attacks. So instead of a patient having a heart attack/stroke and living 10 years longer the previous generation after the attack and dealing with the repercussions of that heart attack, we are moving towards a generation of patients living 20 years longer than the previous generation, but not having that heart attack and living a normal life. With the baby boomer generation taking bp/cholesterol/anticoagulants/diabetic meds younger than the current older generation, we can expect them to live even longer with less ailments. When patients live longer than they are supposed to, new ailments arise however, that never had before been seen because they would be dead in the past. So, new medications will need to be prescribed/developed.
It's true that American's are also not healthy and they do rely are on multiple drugs to live longer, but not because they are hypochondriacs (its malpractice to prescribe drugs that pts don't need, plus insurance won't cover it without a diagnosis backed with exam information), but because they would be dead otherwise or living miserably having survived a medical emergency.
In general, most doctors do try to prescribe generics when they can. On prescription forms you check a box that says "Generic Substitute" which is checked 99% of the time unless the patient feels better with a prescription name, i.e Hydrocodone 5/500 vs. Vicodin.
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Plenty of drugs are prescribed that have nothing to do with extending life, yet are quite expensive: antihistamines or other immunomodulators, digestive medications, sleeping pills, penis pills, PMS pills, behavioral drugs, and anti-depressants (unless for severe suicide risk, though teens taking anti-depressants may actually increase their risk of suicide, but of course patients who are prescribed anti-depressants are more likely to attempt suicide anyway: http://www.redorbit.com/news/health/731343/new_look_at_antidepressant_suicide_risk/index.html). Yes those drugs may improve a patient's quality of life (either marginally or significantly), but they are not a matter of life and death.
Drugs are one of several factors contributing to the huge drop in cardiovascular-related mortality. Fewer Americans smoke (I also believe alcohol consumption is down) and there is more education about healthful living and eating vs. the previous generation. Our diagnostic technologies have improved, so hypertension can be detected and addressed earlier. It's not just these wonder drugs that are making Americans live into their 80s. And if the drugs were so great, why is it that America is the most pill-popping nation per capita, yet our overall life expectancy is ranked 24th worldwide (see my previous email "Health care overhaul potpourri")?
It's naive to think that drugs are only prescribed out of critical medical necessity. Plenty of doctors prescribe drugs off-label (as in, for indications not officially approved by the FDA), because some data shows the drug could help, but in that case the prescribing doc is responsible for any adverse effects (since thorough safety/efficacy tests have not been conducted). Maybe they help the patients by doing so, and maybe it's excessive. Not all doctors are greedy con men, and not all doctors are saints. There's a mix of the two and plenty in between. Insurance and Medicare don't have the time and resources to scrutinize every Rx. The CDC said that 14M Americans misused their Rx's in 2004, resulting in 20,000 deaths. So obviously they were using the wrong drug, or not taking it properly, so either they are junkies or their physicians/pharmacists did not properly Rx or educate them on the risks.
The Centers for Medicare & Medicaid Services reported that 30% of the nursing home population is receiving an antipsychotic, yet 21% of those cases do not suffer from psychosis. In 2007 doctors filled more than 45 million prescriptions for an antipsychotic, according to IMS Health. Yet there are only 2.4 million schizophrenic patients (for whom the drugs were originally intended), according to the National Institute of Mental Health.
http://www.businessweek.com/debateroom/archives/2008/06/stop_casual_rx.html
Yes it is malpractice to Rx a drug that the patient doesn't need, and guess what - malpractice occurs a lot in America (~14K settlements paid out each year, either valid or frivolous, though few are drug-related). The attached report (I can't vouch for the data since I haven't read it all and am unfamiliar with the org, but just food for thought) suggests that malpractice settlements are not the bogeyman that physicians make them out to be. Before federal anti-kickback laws were enacted in 1972 & 1989 (42 CFR Part 1001), pharma companies were routinely paying for doctor's gifts, posh meals, and junkets to conferences in Hawaii (and some of it persists today). Why would they do that? They have a business to run and can't afford to throw money away as goodwill. They are investing in quid pro quo obviously. This is from the New England Journal of Medicine (scary stuff actually), written by doctors:
Interactions between drug companies and doctors are pervasive. Relationships begin in medical school, continue during residency training, and persist throughout physicians' careers. The pervasiveness of these interactions results in part from a huge investment by the pharmaceutical industry in marketing. In 2002, the industry expended 33 percent of its revenues on "selling and administration."12 In 2001, one company, Novartis, reported spending 36 percent of its revenues on marketing alone.2 The marketing expenditures of the drug industry have been estimated variously at $12 billion to $15 billion yearly, or $8,000 to $15,000 per physician.7,8,13 In 2001, the industry's sales force of drug detailers, whose job is to meet individually with physicians and promote company products, numbered nearly 90,000 in the United States2,8 — 1 salesperson for every 4.7 office-based physicians.8
Moynihan14 catalogued 16 different ways in which drug companies relate directly or indirectly with doctors. These range from the seemingly trivial (e.g., the ubiquitous dispensing of gifts such as pens and pads with drug names inscribed) to the much more troubling (e.g., the ghostwriting of articles for academic physicians, the payment of large honoraria and consulting fees to prominent physicians who extol the virtues of company products, and the support of lavish trips and entertainment for physicians who commonly prescribe company products).
Surveys of residents indicate that they receive an average of six gifts from pharmaceutical companies annually.15 In a survey of 106 directors of emergency-department programs in 2002, 41 percent responded that their programs allowed residents to be taught by representatives of drug companies, 35 percent reported that residents received free industry samples at work, and 29 percent said that residents' travel to meetings was sometimes dependent on the availability of company support.16 According to another report, residents in a psychiatry program in Toronto attended up to 70 lunches that had been sponsored by drug companies and received 75 promotional items over the course of one year.17
... As many as 59 percent of the authors of clinical guidelines endorsed by many professional associations have had financial relationships with companies whose drugs might be affected by those guidelines.23
... In a very thorough review of the literature on the effects of interactions with drug companies on physician behavior, Wazana15 identified 16 relevant studies. These studies found that a wide variety of interactions — meetings with company representatives; the receipt of gifts, free drug samples, and free meals; company support for travel to and lodging at educational events; attendance at lectures by representatives of pharmaceutical companies; acceptance of honoraria; and other relationships — were associated with changes in physicians' use of medications. Involved physicians were more likely to request the inclusion of the company's drugs on hospital or health maintenance organization formularies, more likely to prescribe the company's products, and less likely to prescribe generic medications. The resulting changes in the use of medication were often costly and "nonrational" in that the newly prescribed or requested drugs had no therapeutic advantage over the alternatives. Interestingly, several studies have found that the larger the number of gifts that physicians received, the more likely they were to believe that gifts did not affect their prescribing behavior.15,28
http://content.nejm.org/cgi/content/full/351/18/1885?ijkey=8tzMb5l1u.Np2&keytype=ref&siteid=nejm
So if doctors can enjoy millions of dollars of gifts/assistance/what-have-you from pharma companies and still prescribe their products ethically and scientifically, then medical school is really worth the $40k/year.
It used to be that a patient would have a heart attack before medication was prescribed. Now, we have many indicators to help prevent heart attacks. So instead of a patient having a heart attack/stroke and living 10 years longer the previous generation after the attack and dealing with the repercussions of that heart attack, we are moving towards a generation of patients living 20 years longer than the previous generation, but not having that heart attack and living a normal life. With the baby boomer generation taking bp/cholesterol/anticoagulants/diabetic meds younger than the current older generation, we can expect them to live even longer with less ailments. When patients live longer than they are supposed to, new ailments arise however, that never had before been seen because they would be dead in the past. So, new medications will need to be prescribed/developed.
It's true that American's are also not healthy and they do rely are on multiple drugs to live longer, but not because they are hypochondriacs (its malpractice to prescribe drugs that pts don't need, plus insurance won't cover it without a diagnosis backed with exam information), but because they would be dead otherwise or living miserably having survived a medical emergency.
In general, most doctors do try to prescribe generics when they can. On prescription forms you check a box that says "Generic Substitute" which is checked 99% of the time unless the patient feels better with a prescription name, i.e Hydrocodone 5/500 vs. Vicodin.
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Plenty of drugs are prescribed that have nothing to do with extending life, yet are quite expensive: antihistamines or other immunomodulators, digestive medications, sleeping pills, penis pills, PMS pills, behavioral drugs, and anti-depressants (unless for severe suicide risk, though teens taking anti-depressants may actually increase their risk of suicide, but of course patients who are prescribed anti-depressants are more likely to attempt suicide anyway: http://www.redorbit.com/news/health/731343/new_look_at_antidepressant_suicide_risk/index.html). Yes those drugs may improve a patient's quality of life (either marginally or significantly), but they are not a matter of life and death.
Drugs are one of several factors contributing to the huge drop in cardiovascular-related mortality. Fewer Americans smoke (I also believe alcohol consumption is down) and there is more education about healthful living and eating vs. the previous generation. Our diagnostic technologies have improved, so hypertension can be detected and addressed earlier. It's not just these wonder drugs that are making Americans live into their 80s. And if the drugs were so great, why is it that America is the most pill-popping nation per capita, yet our overall life expectancy is ranked 24th worldwide (see my previous email "Health care overhaul potpourri")?
It's naive to think that drugs are only prescribed out of critical medical necessity. Plenty of doctors prescribe drugs off-label (as in, for indications not officially approved by the FDA), because some data shows the drug could help, but in that case the prescribing doc is responsible for any adverse effects (since thorough safety/efficacy tests have not been conducted). Maybe they help the patients by doing so, and maybe it's excessive. Not all doctors are greedy con men, and not all doctors are saints. There's a mix of the two and plenty in between. Insurance and Medicare don't have the time and resources to scrutinize every Rx. The CDC said that 14M Americans misused their Rx's in 2004, resulting in 20,000 deaths. So obviously they were using the wrong drug, or not taking it properly, so either they are junkies or their physicians/pharmacists did not properly Rx or educate them on the risks.
The Centers for Medicare & Medicaid Services reported that 30% of the nursing home population is receiving an antipsychotic, yet 21% of those cases do not suffer from psychosis. In 2007 doctors filled more than 45 million prescriptions for an antipsychotic, according to IMS Health. Yet there are only 2.4 million schizophrenic patients (for whom the drugs were originally intended), according to the National Institute of Mental Health.
http://www.businessweek.com/debateroom/archives/2008/06/stop_casual_rx.html
Yes it is malpractice to Rx a drug that the patient doesn't need, and guess what - malpractice occurs a lot in America (~14K settlements paid out each year, either valid or frivolous, though few are drug-related). The attached report (I can't vouch for the data since I haven't read it all and am unfamiliar with the org, but just food for thought) suggests that malpractice settlements are not the bogeyman that physicians make them out to be. Before federal anti-kickback laws were enacted in 1972 & 1989 (42 CFR Part 1001), pharma companies were routinely paying for doctor's gifts, posh meals, and junkets to conferences in Hawaii (and some of it persists today). Why would they do that? They have a business to run and can't afford to throw money away as goodwill. They are investing in quid pro quo obviously. This is from the New England Journal of Medicine (scary stuff actually), written by doctors:
Interactions between drug companies and doctors are pervasive. Relationships begin in medical school, continue during residency training, and persist throughout physicians' careers. The pervasiveness of these interactions results in part from a huge investment by the pharmaceutical industry in marketing. In 2002, the industry expended 33 percent of its revenues on "selling and administration."12 In 2001, one company, Novartis, reported spending 36 percent of its revenues on marketing alone.2 The marketing expenditures of the drug industry have been estimated variously at $12 billion to $15 billion yearly, or $8,000 to $15,000 per physician.7,8,13 In 2001, the industry's sales force of drug detailers, whose job is to meet individually with physicians and promote company products, numbered nearly 90,000 in the United States2,8 — 1 salesperson for every 4.7 office-based physicians.8
Moynihan14 catalogued 16 different ways in which drug companies relate directly or indirectly with doctors. These range from the seemingly trivial (e.g., the ubiquitous dispensing of gifts such as pens and pads with drug names inscribed) to the much more troubling (e.g., the ghostwriting of articles for academic physicians, the payment of large honoraria and consulting fees to prominent physicians who extol the virtues of company products, and the support of lavish trips and entertainment for physicians who commonly prescribe company products).
Surveys of residents indicate that they receive an average of six gifts from pharmaceutical companies annually.15 In a survey of 106 directors of emergency-department programs in 2002, 41 percent responded that their programs allowed residents to be taught by representatives of drug companies, 35 percent reported that residents received free industry samples at work, and 29 percent said that residents' travel to meetings was sometimes dependent on the availability of company support.16 According to another report, residents in a psychiatry program in Toronto attended up to 70 lunches that had been sponsored by drug companies and received 75 promotional items over the course of one year.17
... As many as 59 percent of the authors of clinical guidelines endorsed by many professional associations have had financial relationships with companies whose drugs might be affected by those guidelines.23
... In a very thorough review of the literature on the effects of interactions with drug companies on physician behavior, Wazana15 identified 16 relevant studies. These studies found that a wide variety of interactions — meetings with company representatives; the receipt of gifts, free drug samples, and free meals; company support for travel to and lodging at educational events; attendance at lectures by representatives of pharmaceutical companies; acceptance of honoraria; and other relationships — were associated with changes in physicians' use of medications. Involved physicians were more likely to request the inclusion of the company's drugs on hospital or health maintenance organization formularies, more likely to prescribe the company's products, and less likely to prescribe generic medications. The resulting changes in the use of medication were often costly and "nonrational" in that the newly prescribed or requested drugs had no therapeutic advantage over the alternatives. Interestingly, several studies have found that the larger the number of gifts that physicians received, the more likely they were to believe that gifts did not affect their prescribing behavior.15,28
http://content.nejm.org/cgi/content/full/351/18/1885?ijkey=8tzMb5l1u.Np2&keytype=ref&siteid=nejm
So if doctors can enjoy millions of dollars of gifts/assistance/what-have-you from pharma companies and still prescribe their products ethically and scientifically, then medical school is really worth the $40k/year.
Thursday, October 15, 2009
Baucus health bill passing: historic progress but unimpressive impact
http://www.kqed.org/epArchive/R910140900
An interesting panel discussion of the recent Baucus health bill passage and challenges ahead. Some points to consider:
- This bill will increase the number of Americans covered by health insurance from ~85% now to 94% by 2014. Is that much to celebrate? And there is very little in the bill that would control costs, increase competition, or help under-insured individuals (some studies have shown that "health care cooperatives" would do little and may not even get off the ground). At least new rules would prohibit companies from rejecting customers based on pre-existing health conditions, but that would probably increase costs.
- Did Senator Snowe incur GOP ire by endorsing the Baucus bill (the only version without a public option currently in circulation) in order to actually help the GOP and pre-empt more liberal provisions such as the possibility of a public option?
- The Republicans have no health reform alternative, absolutely ZERO. They just want to impede action, but by doing so are missing a key opportunity to advance conservative changes. The GOP have spoken for years about reforming and trimming down Medicare/Medicaid, and now they could achieve it by playing ball and gaining concessions from the Dems for yes votes. But instead they are just the "Party of No".
- In order to get the 60 Senate votes to send the bill to the president's desk, all Dems, 2 Independents, and 1 Republican need to vote yes. It could be very close, because Senator Lieberman was not thrilled with the bill (many health insurance companies are based in CT).
- It will be very difficult to reconcile the arch-liberal and arch-conservative wings of the Dem Party, who are both against this middle-of-the-road bill for different reasons. House Dems are irate with the lack of a public option (which they see as integral to "real reform", and they are probably right).
- In order to keep this bill deficit-neutral (or positive), the "Cadillac" health plan tax (taxing the most generous health plans) and/or a tax on millionaire Americans seems inevitable. But unions are against the former (some union members enjoy Cadillac coverage), and the House is against the latter (no one wants to be labeled as a tax raiser prior to the 2010 midterms).
- By mandating that more Americans get coverage, it would help if coverage was more affordable, but that looks doubtful. And if families who can't afford coverage (even with more gov't subsidies) remain uncovered, they will be fined. On the flipside, the penalty is meager, so this may encourage more affluent people to game the system. While healthy, they will remain uninsured (since that will save them money overall, even after paying the fee), and then only purchase coverage when seriously ill (since they know they won't be rejected). This will of course increase costs to insurers, who will pass that along to us.
- The plan taxes comprehensive, low-cost, long-term delivery health systems such as Mayo Clinic, InterMountain Health Care, and Kaiser Permanente, even though Obama and others have touted those companies as models for reform. Why penalize the companies who are doing it well, and give their more wasteful competitors a pass?
- The financing for this bill is hardly transparent, and relies on many short-term gimmicks to balance costs. So even if it passes to law, it is likely that we will be doing this all over again in the near future. Also, the bill expands Medicaid eligibility (covering 11M more Americans, which in theory is good), which will be supposedly 90% covered by the feds. But states would still be on the hook for 5-22% of their own costs (which would range in the billions, depending on numerous factors). As we know, most states are in terrible financial shape, and the bipartisan National Governor's Association came out against the Baucus bill. The bills in the House would cover Medicaid expansions 100% by Washington.
- There is nothing in the bill to address Medicare/Medicaid physicians' reimbursement modernization. So as Congress is trying to cover more people under Medicaid, more and more doctors are turning away those patients because they make less money from them.
http://www.ama-assn.org/amednews/2009/09/28/gvsb0928.htm
An interesting panel discussion of the recent Baucus health bill passage and challenges ahead. Some points to consider:
- This bill will increase the number of Americans covered by health insurance from ~85% now to 94% by 2014. Is that much to celebrate? And there is very little in the bill that would control costs, increase competition, or help under-insured individuals (some studies have shown that "health care cooperatives" would do little and may not even get off the ground). At least new rules would prohibit companies from rejecting customers based on pre-existing health conditions, but that would probably increase costs.
- Did Senator Snowe incur GOP ire by endorsing the Baucus bill (the only version without a public option currently in circulation) in order to actually help the GOP and pre-empt more liberal provisions such as the possibility of a public option?
- The Republicans have no health reform alternative, absolutely ZERO. They just want to impede action, but by doing so are missing a key opportunity to advance conservative changes. The GOP have spoken for years about reforming and trimming down Medicare/Medicaid, and now they could achieve it by playing ball and gaining concessions from the Dems for yes votes. But instead they are just the "Party of No".
- In order to get the 60 Senate votes to send the bill to the president's desk, all Dems, 2 Independents, and 1 Republican need to vote yes. It could be very close, because Senator Lieberman was not thrilled with the bill (many health insurance companies are based in CT).
- It will be very difficult to reconcile the arch-liberal and arch-conservative wings of the Dem Party, who are both against this middle-of-the-road bill for different reasons. House Dems are irate with the lack of a public option (which they see as integral to "real reform", and they are probably right).
- In order to keep this bill deficit-neutral (or positive), the "Cadillac" health plan tax (taxing the most generous health plans) and/or a tax on millionaire Americans seems inevitable. But unions are against the former (some union members enjoy Cadillac coverage), and the House is against the latter (no one wants to be labeled as a tax raiser prior to the 2010 midterms).
- By mandating that more Americans get coverage, it would help if coverage was more affordable, but that looks doubtful. And if families who can't afford coverage (even with more gov't subsidies) remain uncovered, they will be fined. On the flipside, the penalty is meager, so this may encourage more affluent people to game the system. While healthy, they will remain uninsured (since that will save them money overall, even after paying the fee), and then only purchase coverage when seriously ill (since they know they won't be rejected). This will of course increase costs to insurers, who will pass that along to us.
- The plan taxes comprehensive, low-cost, long-term delivery health systems such as Mayo Clinic, InterMountain Health Care, and Kaiser Permanente, even though Obama and others have touted those companies as models for reform. Why penalize the companies who are doing it well, and give their more wasteful competitors a pass?
- The financing for this bill is hardly transparent, and relies on many short-term gimmicks to balance costs. So even if it passes to law, it is likely that we will be doing this all over again in the near future. Also, the bill expands Medicaid eligibility (covering 11M more Americans, which in theory is good), which will be supposedly 90% covered by the feds. But states would still be on the hook for 5-22% of their own costs (which would range in the billions, depending on numerous factors). As we know, most states are in terrible financial shape, and the bipartisan National Governor's Association came out against the Baucus bill. The bills in the House would cover Medicaid expansions 100% by Washington.
- There is nothing in the bill to address Medicare/Medicaid physicians' reimbursement modernization. So as Congress is trying to cover more people under Medicaid, more and more doctors are turning away those patients because they make less money from them.
http://www.ama-assn.org/amednews/2009/09/28/gvsb0928.htm
Tuesday, October 13, 2009
How "direct to consumer" marketing inflates health care costs
http://www.npr.org/templates/story/story.php?storyId=113675737
CorrectionThe audio and a previous Web version of this story mistakenly said that between 1992 and 2008 the average number of prescriptions that Americans get increased by 58 percent. The actual increase was 71 percent.
Part 1: Doctor Decisions All Things Considered, Oct. 8
In the mid-1970s, an unconventional health researcher named Jack Wennberg discovered an unusually high rate of hysterectomies in a small town in Maine. If the rate continued, nearly 70 percent of Lewiston women would be without their wombs by age 70. That was just one of a series of studies conducted by Wennberg that led him to a very surprising conclusion about health care: A large portion of the medical care Americans get is unnecessary, and the structure of the health care system is the reason why. The system can push doctors to prescribe care that doesn't improve patient health.Read this story.
Part 2: Patient Behavior Morning Edition, Oct. 12
The behavior of patients in the U.S. health system has changed dramatically over the past couple of decades. We've been transformed from passive patients who almost blindly follow doctors' orders into active and aggressive consumers of health services. A look at how that change came about, and how it affects the behavior of doctors. Read this story.
Part 3: Marketing Sickness Morning Edition, Oct. 13
Prescription drug spending is the third most expensive cost in the U.S. health care system. The average American gets 12 prescriptions a year, and this number only seems to grow larger. There are more medicines on the market today than in 1992, with Americans now spending $175 billion more per year. A look behind these numbers and what drove the increase in prescription drug consumption in America.
October 13, 2009
David Couper went to his doctor after watching a small green creature jump up and down on the nail of an infected toe.
For Anne Nissan, a 17-year-old in Prescott, Ariz., the image that stayed with her was of a party. Women were on a roof in a city, pimple-free and laughing, utterly unbothered by the cramps that immobilized her once a month.
And then there is Samantha Saveri, a transportation planner in Baltimore. She remembers bunnies and the promise of digestive regularity.
Three different people in three different places were all driven to contact their doctors after watching an ad for a prescription medication on television. Each walked into a doctor's office with a specific request, and walked out with a prescription for exactly the medication he or she desired.
The Rise Of Prescription Drugs In America
Prescription drug spending is the third most expensive cost in our health care system. And spending seems to grow larger every year. Just last year, the average American got 12 prescriptions a year, as compared with 1992, when Americans got an average of seven prescriptions. In a decade and a half, the use of prescription medication went up 71 percent. This has added about $180 billion to our medical spending.
While there are more medicines on the market today than in 1992, researchers estimate that around 20 percent of the $180 billion increase has absolutely nothing to do with the number of medications available, or increases in the cost of that medication.
To understand this change, one place to look is Wilder, Vt. There, in a tasteful housing complex on the side of a mountain, is the home of Joe Davis.
Davis is retired now, but in his speech and manner it's easy to hear the breezy salesmanship that made him so successful. Davis was an adman: "I was trained — or I was toilet-trained as we like to say — in packaged goods," Davis says. "General Foods, Procter & Gamble — that kind of thing."
Until the 1980s, the kind of people who sold stuff like packaged goods were completely different from the kind of people who sold stuff like prescription drugs. In those days, drugs ads were for doctors, not the public. They were designed by people who worked at these small, technically minded medical advertising companies and targeted this small, technically minded audience.
"Nobody had ever thought that these drugs should be or could be advertised to the patients. It was just outside of people's brains," Davis says. "They thought that only doctors could understand the products. They're technical products. They're scientific products."
But it was more than that. There was a fear — shared by doctors and drug companies alike — that advertising drugs directly to consumers could be harmful. Both the drug companies and the doctors worried that even though consumers couldn't really evaluate whether or not a drug was appropriate, they might become convinced by an ad, and pressure their doctor to prescribe it.
Not only might doctors end up passing out inappropriate medications, but also, drug ads could disrupt the doctor-patient relationship — a relationship that, at the time, was mostly a one-way street. Davis tells this story about his own mother, a sophisticated woman whom he found fumbling with a bottle of pills one day. When he asked what she was taking:
" 'Well,' she said, 'I take a yellow pill, a green pill and a white pill.' I said, 'That's great. What are they for?' "
His mother had no idea what they were for, Davis says. All she knew was that her doctor had told her to take them.
"It was very passive from the patient standpoint," Davis says. "The patient just took whatever orders were given by the doctor."
An Advertising Revolution
It used to work like this: Doctors decided what to prescribe. Drug companies — through medical advertisers — tried to influence doctors. Patients did what they were told.
The only problem, says Davis, was that the system wasn't working out for the drug companies. For them, the system was much too slow.
Because doctors exclusively held the keys to the kingdom, drug companies spent enormous amounts of time and money trying to get their attention. To give you a sense, the average doctor got around 3,000 pieces of mail a year from the drug industry, and to break through this noise often took years.
And so Davis, who had previously only sold packaged goods, approached William Castagnoli, the then-president of a large medical advertising company. The two came up with a solution: They would advertise directly to the patient. They'd get the patient to go in and ask the doctor for the drug. "Pull the drug through the system," Davis says with a certain amount of glee.
There was only one small problem with this solution: It was almost impossible to do.
In the early 1980s, FDA regulations required that drug ads include both the name of a drug and its purpose, as well as information about all the side effects. But side-effect information often took two or three magazine pages of mouse print to catalog, and this wouldn't do for a major television campaign. As Castagnoli says, "We couldn't scroll the whole disclosure information over the television screen — OK?"
But then, in 1986, while designing an ad for a new allergy medication called Seldane, Davis hit on a way around the fine print. He checked with the Food and Drug Administration to see if it would be OK.
"We didn't give the drug's name, Seldane," he says. "All we said was: 'Your doctor now has treatment which won't make you drowsy. See your doctor.' "
This was one of the very first national direct-to-consumer television ad campaigns. The results were nothing short of astounding. Before the ads, Davis says, Seldane made about $34 million in sales a year, which at the time was considered pretty good.
"Our goal was maybe to get this drug up to $100 million in sales. But we went through $100 million," Davis says. "And we said, 'Holy smokes.' And then it went through $300 million. Then $400 million. Then $500 million. $600 [million]! It was unbelievable. We were flabbergasted. And eventually it went to $800 million."
Pharmaceutical companies took note.
Today, drug companies spend $4 billion a year on ads to consumers. In 1997, the FDA rules governing pharmaceutical advertising changed, and now companies can name both the drug and what it's for, while only naming the most significant potential side effects. Then, the number of ads really exploded. The Nielsen Co. estimates that there's an average of 80 drug ads every hour of every day on American television. And those ads clearly produce results:
"Something like a third of consumers who've seen a drug ad have talked to their doctor about it," says Julie Donohue, a professor of public health at the University of Pittsburgh who is considered a leading expert on this subject.
"About two-thirds of those have asked for a prescription. And the majority of people who ask for a prescription have that request honored."
Whether the increase in the number of prescription drugs taken is good or bad for patient health is an open question. There's evidence on both sides. What's not up for debate is this: By taking their case to patients instead of doctors, drug companies increased the amount of money we spend on medicine in America.
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So yeah, totally buy that brand-name pills are a huge source of unnecessary cost. There's certainly value in making drug research profitable so people have an incentive to do it, but it's well beyond that.
The two things I thought were most interesting from this bit: First, the average American has twelve prescriptions per year? Holy hell. I can't even fathom that. I assume that's probably inflated by short-duration prescriptions (docs don't like giving you a prescription for more than a couple weeks of Vicodin at a time), but still. Twelve is the *average*?
The second was the comment about drug ads "disrupting the doctor-patient relationship". The relationship they describe, where the woman takes the pills with nfi what they're for, sounds pretty dysfunctional. For really common, obvious medical cases maybe that's fine, but if your medical situation is even slightly complicated, the only way you're going to get good care is by talking with the doctor and understanding your situation.
Ultimately it seems like you need to get the doctors properly incentivized so when someone comes in asking for a drug, the doc can explain why it is/n't appropriate, what the options are, and all that. We're obviously not going to get that in a broad systematic way from this administration, but at least encouraging people to ask their doctors questions is a step in the right direction.
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Yeah the numbers are pretty scary. As you said, 12 Rx/year on average? Damn. So for all the reasonably healthy people out there with 1-3 Rx per year, they're cancelled out by the hypochondriacs with 20 Rx/year. Probably many of the culprits are the obese, the depressed, and seniors. They take pill A for some disease, but they need pill B for pill A's side effect, and then pill C for pill B's side effect, and pill D enhances the efficacy of pill C, and so on. I guess that's why in Holland and probably other universal health care nations, doctors are actually given cash bonuses for prescribing cheaper generics when available. If a generic is 10 Euros and brand-name is 15, the doctor can pocket like half of the difference. People need to remember that pain is part of life. Your body can't feel perfect all the time. Don't they say "just tough it out" and "whatever doesn't kill you makes you stronger"?
Especially for seniors who complain about every little discomfort - it's irresponsible and maybe even harmful to them (drugs may help but cause side effects, long-term addiction, reduced efficacy over time, etc.). Some seniors have a huge pill case like a tackle box full of daily meds, and some have doctor's appointments like 3x/week! The psychiatric drugs really concern me. Sometimes you're sad, and sometimes your kid is hyper at school. That doesn't mean you have clinical depression and your kid is ADHD. Yet they get medicated all the same, every day, at huge cost. I know some people have legitimate mental conditions where drugs really improve their quality of life, but most of us would believe without data that such drugs are over-prescribed in America.
Apart from the short-term drugs, I think some of the big money-sinks are the "daily until you die" drugs like Lipitor. These "lifestyle" drugs are shortcuts for healthy living. I know some people have legitimate cholesterol issues and need statins to be healthier. But for the elderly or lazy folks who don't want to exercise and eat right, popping a statin will make up in part for your bad habits. Lipitor cleared nearly $7B in the US in 2004, which is more than the GDPs of many nations. And 66% of Lipitor's worldwide sales are to Americans, even though we're only 5% of the world's population. I know Americans are more obese on average, but come on.
The other top-selling drugs are here: http://www.forbes.com/technology/2004/03/16/cx_mh_0316bestselling.html
As you can see, they are mostly "dailies" for chronic diseases like depression, asthma, ulcers, circulatory issues. I think the penis drugs make a lot of money too, though not sure if they are covered by insurance. Viagra topped $1.6B in 2005.
http://money.cnn.com/2006/01/05/news/companies/sexdysfunction/index.htm
Obviously DTC ads play right into this problem. You have a discomfort or are not feeling right about some aspect of your body. Then the TV says a magic pill just makes it all better and you will be like the happy, pretty people in the commercials. But people haven't done the research about side effects, which patient sub-population would benefit most, cheaper alternatives, etc. And doctors may not have time to discuss in detail (15 min per patient at Kaiser, or so the rumor goes), or don't want to say no because they worry about angering customers and losing them to competitors who will prescribe anything they want. Jeez - 2/3 of patient-requested Rx's get honored? I guess 2/3 of people deserve honorary MD or PharmD degrees. As you said, marketeers get in the way of the doctor-patient relationship. People become consumers instead of patients, and we all know Americans don't consume very responsibly. As you said, the doctor is ultimately responsible because he or she signs the Rx. So if we can incent or threaten them to be more austere with Rx's, maybe it will get better. Like if we chart doc Rx habits and see that some are several standard deviations above the mean, then they get a fine or whatnot. And we can combine that data with patient outcome metrics to see which drugs deliver the most bang for the buck, and which docs are managing resources most efficiently. Some of this is already going on behind the scenes, and now our data collection, stats, and computing power align for more thorough analyses. So if we can build on that, and reward the docs who use drugs most effectively for their patients, then maybe some behavioral changes can happen. Because obviously we can't count on the patient to make the right choices, just as we can't trust children to own a gun or drive a vehicle.
CorrectionThe audio and a previous Web version of this story mistakenly said that between 1992 and 2008 the average number of prescriptions that Americans get increased by 58 percent. The actual increase was 71 percent.
Part 1: Doctor Decisions All Things Considered, Oct. 8
In the mid-1970s, an unconventional health researcher named Jack Wennberg discovered an unusually high rate of hysterectomies in a small town in Maine. If the rate continued, nearly 70 percent of Lewiston women would be without their wombs by age 70. That was just one of a series of studies conducted by Wennberg that led him to a very surprising conclusion about health care: A large portion of the medical care Americans get is unnecessary, and the structure of the health care system is the reason why. The system can push doctors to prescribe care that doesn't improve patient health.Read this story.
Part 2: Patient Behavior Morning Edition, Oct. 12
The behavior of patients in the U.S. health system has changed dramatically over the past couple of decades. We've been transformed from passive patients who almost blindly follow doctors' orders into active and aggressive consumers of health services. A look at how that change came about, and how it affects the behavior of doctors. Read this story.
Part 3: Marketing Sickness Morning Edition, Oct. 13
Prescription drug spending is the third most expensive cost in the U.S. health care system. The average American gets 12 prescriptions a year, and this number only seems to grow larger. There are more medicines on the market today than in 1992, with Americans now spending $175 billion more per year. A look behind these numbers and what drove the increase in prescription drug consumption in America.
October 13, 2009
David Couper went to his doctor after watching a small green creature jump up and down on the nail of an infected toe.
For Anne Nissan, a 17-year-old in Prescott, Ariz., the image that stayed with her was of a party. Women were on a roof in a city, pimple-free and laughing, utterly unbothered by the cramps that immobilized her once a month.
And then there is Samantha Saveri, a transportation planner in Baltimore. She remembers bunnies and the promise of digestive regularity.
Three different people in three different places were all driven to contact their doctors after watching an ad for a prescription medication on television. Each walked into a doctor's office with a specific request, and walked out with a prescription for exactly the medication he or she desired.
The Rise Of Prescription Drugs In America
Prescription drug spending is the third most expensive cost in our health care system. And spending seems to grow larger every year. Just last year, the average American got 12 prescriptions a year, as compared with 1992, when Americans got an average of seven prescriptions. In a decade and a half, the use of prescription medication went up 71 percent. This has added about $180 billion to our medical spending.
While there are more medicines on the market today than in 1992, researchers estimate that around 20 percent of the $180 billion increase has absolutely nothing to do with the number of medications available, or increases in the cost of that medication.
To understand this change, one place to look is Wilder, Vt. There, in a tasteful housing complex on the side of a mountain, is the home of Joe Davis.
Davis is retired now, but in his speech and manner it's easy to hear the breezy salesmanship that made him so successful. Davis was an adman: "I was trained — or I was toilet-trained as we like to say — in packaged goods," Davis says. "General Foods, Procter & Gamble — that kind of thing."
Until the 1980s, the kind of people who sold stuff like packaged goods were completely different from the kind of people who sold stuff like prescription drugs. In those days, drugs ads were for doctors, not the public. They were designed by people who worked at these small, technically minded medical advertising companies and targeted this small, technically minded audience.
"Nobody had ever thought that these drugs should be or could be advertised to the patients. It was just outside of people's brains," Davis says. "They thought that only doctors could understand the products. They're technical products. They're scientific products."
But it was more than that. There was a fear — shared by doctors and drug companies alike — that advertising drugs directly to consumers could be harmful. Both the drug companies and the doctors worried that even though consumers couldn't really evaluate whether or not a drug was appropriate, they might become convinced by an ad, and pressure their doctor to prescribe it.
Not only might doctors end up passing out inappropriate medications, but also, drug ads could disrupt the doctor-patient relationship — a relationship that, at the time, was mostly a one-way street. Davis tells this story about his own mother, a sophisticated woman whom he found fumbling with a bottle of pills one day. When he asked what she was taking:
" 'Well,' she said, 'I take a yellow pill, a green pill and a white pill.' I said, 'That's great. What are they for?' "
His mother had no idea what they were for, Davis says. All she knew was that her doctor had told her to take them.
"It was very passive from the patient standpoint," Davis says. "The patient just took whatever orders were given by the doctor."
An Advertising Revolution
It used to work like this: Doctors decided what to prescribe. Drug companies — through medical advertisers — tried to influence doctors. Patients did what they were told.
The only problem, says Davis, was that the system wasn't working out for the drug companies. For them, the system was much too slow.
Because doctors exclusively held the keys to the kingdom, drug companies spent enormous amounts of time and money trying to get their attention. To give you a sense, the average doctor got around 3,000 pieces of mail a year from the drug industry, and to break through this noise often took years.
And so Davis, who had previously only sold packaged goods, approached William Castagnoli, the then-president of a large medical advertising company. The two came up with a solution: They would advertise directly to the patient. They'd get the patient to go in and ask the doctor for the drug. "Pull the drug through the system," Davis says with a certain amount of glee.
There was only one small problem with this solution: It was almost impossible to do.
In the early 1980s, FDA regulations required that drug ads include both the name of a drug and its purpose, as well as information about all the side effects. But side-effect information often took two or three magazine pages of mouse print to catalog, and this wouldn't do for a major television campaign. As Castagnoli says, "We couldn't scroll the whole disclosure information over the television screen — OK?"
But then, in 1986, while designing an ad for a new allergy medication called Seldane, Davis hit on a way around the fine print. He checked with the Food and Drug Administration to see if it would be OK.
"We didn't give the drug's name, Seldane," he says. "All we said was: 'Your doctor now has treatment which won't make you drowsy. See your doctor.' "
This was one of the very first national direct-to-consumer television ad campaigns. The results were nothing short of astounding. Before the ads, Davis says, Seldane made about $34 million in sales a year, which at the time was considered pretty good.
"Our goal was maybe to get this drug up to $100 million in sales. But we went through $100 million," Davis says. "And we said, 'Holy smokes.' And then it went through $300 million. Then $400 million. Then $500 million. $600 [million]! It was unbelievable. We were flabbergasted. And eventually it went to $800 million."
Pharmaceutical companies took note.
Today, drug companies spend $4 billion a year on ads to consumers. In 1997, the FDA rules governing pharmaceutical advertising changed, and now companies can name both the drug and what it's for, while only naming the most significant potential side effects. Then, the number of ads really exploded. The Nielsen Co. estimates that there's an average of 80 drug ads every hour of every day on American television. And those ads clearly produce results:
"Something like a third of consumers who've seen a drug ad have talked to their doctor about it," says Julie Donohue, a professor of public health at the University of Pittsburgh who is considered a leading expert on this subject.
"About two-thirds of those have asked for a prescription. And the majority of people who ask for a prescription have that request honored."
Whether the increase in the number of prescription drugs taken is good or bad for patient health is an open question. There's evidence on both sides. What's not up for debate is this: By taking their case to patients instead of doctors, drug companies increased the amount of money we spend on medicine in America.
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So yeah, totally buy that brand-name pills are a huge source of unnecessary cost. There's certainly value in making drug research profitable so people have an incentive to do it, but it's well beyond that.
The two things I thought were most interesting from this bit: First, the average American has twelve prescriptions per year? Holy hell. I can't even fathom that. I assume that's probably inflated by short-duration prescriptions (docs don't like giving you a prescription for more than a couple weeks of Vicodin at a time), but still. Twelve is the *average*?
The second was the comment about drug ads "disrupting the doctor-patient relationship". The relationship they describe, where the woman takes the pills with nfi what they're for, sounds pretty dysfunctional. For really common, obvious medical cases maybe that's fine, but if your medical situation is even slightly complicated, the only way you're going to get good care is by talking with the doctor and understanding your situation.
Ultimately it seems like you need to get the doctors properly incentivized so when someone comes in asking for a drug, the doc can explain why it is/n't appropriate, what the options are, and all that. We're obviously not going to get that in a broad systematic way from this administration, but at least encouraging people to ask their doctors questions is a step in the right direction.
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Yeah the numbers are pretty scary. As you said, 12 Rx/year on average? Damn. So for all the reasonably healthy people out there with 1-3 Rx per year, they're cancelled out by the hypochondriacs with 20 Rx/year. Probably many of the culprits are the obese, the depressed, and seniors. They take pill A for some disease, but they need pill B for pill A's side effect, and then pill C for pill B's side effect, and pill D enhances the efficacy of pill C, and so on. I guess that's why in Holland and probably other universal health care nations, doctors are actually given cash bonuses for prescribing cheaper generics when available. If a generic is 10 Euros and brand-name is 15, the doctor can pocket like half of the difference. People need to remember that pain is part of life. Your body can't feel perfect all the time. Don't they say "just tough it out" and "whatever doesn't kill you makes you stronger"?
Especially for seniors who complain about every little discomfort - it's irresponsible and maybe even harmful to them (drugs may help but cause side effects, long-term addiction, reduced efficacy over time, etc.). Some seniors have a huge pill case like a tackle box full of daily meds, and some have doctor's appointments like 3x/week! The psychiatric drugs really concern me. Sometimes you're sad, and sometimes your kid is hyper at school. That doesn't mean you have clinical depression and your kid is ADHD. Yet they get medicated all the same, every day, at huge cost. I know some people have legitimate mental conditions where drugs really improve their quality of life, but most of us would believe without data that such drugs are over-prescribed in America.
Apart from the short-term drugs, I think some of the big money-sinks are the "daily until you die" drugs like Lipitor. These "lifestyle" drugs are shortcuts for healthy living. I know some people have legitimate cholesterol issues and need statins to be healthier. But for the elderly or lazy folks who don't want to exercise and eat right, popping a statin will make up in part for your bad habits. Lipitor cleared nearly $7B in the US in 2004, which is more than the GDPs of many nations. And 66% of Lipitor's worldwide sales are to Americans, even though we're only 5% of the world's population. I know Americans are more obese on average, but come on.
The other top-selling drugs are here: http://www.forbes.com/technology/2004/03/16/cx_mh_0316bestselling.html
As you can see, they are mostly "dailies" for chronic diseases like depression, asthma, ulcers, circulatory issues. I think the penis drugs make a lot of money too, though not sure if they are covered by insurance. Viagra topped $1.6B in 2005.
http://money.cnn.com/2006/01/05/news/companies/sexdysfunction/index.htm
Obviously DTC ads play right into this problem. You have a discomfort or are not feeling right about some aspect of your body. Then the TV says a magic pill just makes it all better and you will be like the happy, pretty people in the commercials. But people haven't done the research about side effects, which patient sub-population would benefit most, cheaper alternatives, etc. And doctors may not have time to discuss in detail (15 min per patient at Kaiser, or so the rumor goes), or don't want to say no because they worry about angering customers and losing them to competitors who will prescribe anything they want. Jeez - 2/3 of patient-requested Rx's get honored? I guess 2/3 of people deserve honorary MD or PharmD degrees. As you said, marketeers get in the way of the doctor-patient relationship. People become consumers instead of patients, and we all know Americans don't consume very responsibly. As you said, the doctor is ultimately responsible because he or she signs the Rx. So if we can incent or threaten them to be more austere with Rx's, maybe it will get better. Like if we chart doc Rx habits and see that some are several standard deviations above the mean, then they get a fine or whatnot. And we can combine that data with patient outcome metrics to see which drugs deliver the most bang for the buck, and which docs are managing resources most efficiently. Some of this is already going on behind the scenes, and now our data collection, stats, and computing power align for more thorough analyses. So if we can build on that, and reward the docs who use drugs most effectively for their patients, then maybe some behavioral changes can happen. Because obviously we can't count on the patient to make the right choices, just as we can't trust children to own a gun or drive a vehicle.
Monday, October 5, 2009
No Olympics for Chicago
http://sports.yahoo.com/olympics/news?slug=reu-riosponsors&prov=reuters&type=lgns
Man, Rio gets the 2014 W Cup AND the 2016 Olympics? Not that I wanted Chicago to get it; that city sucks. All the tourists will get mugged. I guess there has never been an Olympics in South America, so they are playing affirmative action. And I think all the hoopla over the Obamas going over to Denmark to lobby was BS. The IOC is so damn corrupt anyway. If we wanted the Olympics so bad, Obama should just buy the IOC with our tax dollars and have them pick Chicago (why not, add them to the stable with AIG and GM!).
Anyone who loves where they live doesn't get out enough. Like would any of us want the Olympics in SF? Of course not because we know it sucks. Most cities suck. How the hell can you love the city you live in? Unless your'e rich like Michelle Obama I guess, only going to eat at Spago and shopping at Bloomie's. Plus the belief that Olympics make money for the host city is actually false (except if you include increases in international trade following the games):
http://www.pbs.org/newshour/updates/business/july-dec09/olympics_10-01.html
It took one city 30 years to pay off its Olympics debt, and that was during pre-9/11 security cheaper times! Chicago can't even figure out its train and traffic problems, how can it handle a Games?
http://www.npr.org/templates/story/story.php?storyId=92633264
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my coworker said the RIO is worse in terms of crime versus chicago against visitors. this is unsubstantiated but I thought I'd share it. did you read all the articles on China after the Olympics and how the Bird's nest stadium is being remodeled into a shopping center?
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OMG so typical for China. Where will they hold their big sporting events then? In the rice fields out back?
Yeah true about Rio. A lot of drug violence and slums too (ever seen "City of God"?). If they wanted no crime they shoulda picked Tokyo or Stockholm or something. But if I'm gonna get jacked by a gang, I'd rather it be down in Rio with beaches, honeys, and Carnival!
Man, Rio gets the 2014 W Cup AND the 2016 Olympics? Not that I wanted Chicago to get it; that city sucks. All the tourists will get mugged. I guess there has never been an Olympics in South America, so they are playing affirmative action. And I think all the hoopla over the Obamas going over to Denmark to lobby was BS. The IOC is so damn corrupt anyway. If we wanted the Olympics so bad, Obama should just buy the IOC with our tax dollars and have them pick Chicago (why not, add them to the stable with AIG and GM!).
Anyone who loves where they live doesn't get out enough. Like would any of us want the Olympics in SF? Of course not because we know it sucks. Most cities suck. How the hell can you love the city you live in? Unless your'e rich like Michelle Obama I guess, only going to eat at Spago and shopping at Bloomie's. Plus the belief that Olympics make money for the host city is actually false (except if you include increases in international trade following the games):
http://www.pbs.org/newshour/updates/business/july-dec09/olympics_10-01.html
It took one city 30 years to pay off its Olympics debt, and that was during pre-9/11 security cheaper times! Chicago can't even figure out its train and traffic problems, how can it handle a Games?
http://www.npr.org/templates/story/story.php?storyId=92633264
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my coworker said the RIO is worse in terms of crime versus chicago against visitors. this is unsubstantiated but I thought I'd share it. did you read all the articles on China after the Olympics and how the Bird's nest stadium is being remodeled into a shopping center?
--------
OMG so typical for China. Where will they hold their big sporting events then? In the rice fields out back?
Yeah true about Rio. A lot of drug violence and slums too (ever seen "City of God"?). If they wanted no crime they shoulda picked Tokyo or Stockholm or something. But if I'm gonna get jacked by a gang, I'd rather it be down in Rio with beaches, honeys, and Carnival!
Friday, October 2, 2009
The FUBAR Afghan election
http://www.pbs.org/newshour/bb/asia/july-dec09/afghanistan_10-01.html
http://www.nybooks.com/articles/23113#
These links tell a scary story of how the recent Afghan presidential election was, instead of a victory for democracy against the Taliban menace, actually a major setback undermining that nation and the West's hopes for its improvement. It seems that once the Obama administration took power and Richard Holbrooke was appointed as special envoy, corrupt and paranoid President Karzai was convinced that America sought to replace him. So he plotted for months to stack the upcoming election in his favor. The UN assistance mission to Afghanistan (UNAMA), desperate for some milestones of success amidst major security deterioration and stalled development under their watch, craved a "successful election". In order to demonstrate political progress, they turned over the reins to the Afghan government, instead of running and monitoring the process directly, as they did during the last election in 2004. So that is basically a recipe for disaster. And as in America, unfortunately the preparations for election caused governmental tunnel-vision and forced all other pressing Afghan issues to the back burner (education, infrastructure, justice, armed forces training, counter-narcotics, etc.). Security was concentrated on the polling stations instead of hunting Taliban, and it showed with several brazen Taliban attacks and bombings in "secure" urban areas like downtown Kabul. NATO deaths in the summer months leading up to the election were the highest in the war's 8-year history.
As one would expect, Karzai stacked the "independent election commission" with members partial to him, including foreigners to feign impartiality. All the warning signs of major fraud were obvious prior to the election. An American diplomat and deputy special rep to the UN Afghan mission, Peter Galbraith (son of the economist John Galbraith) raised these concerns to UNAMA, and was summarily ignored by chief Kai Eide. Galbraith's investigations had shown that the Afghan election commission set up many voting stations in Taliban-controlled regions where less than 10% of the populace was expected to turn out (due to poor security and threats to their lives). Those stations were located in areas too remote or dangerous for monitoring, and probably only existed on paper. Yet after the election, thousands of pro-Karzai votes came streaming in from those locations. Karzai eventually and improbably netted 54% of the overall vote, and his leading challenger, Abdullah Abdullah has challenged the legitimacy.
Galbraith's office had collected evidence of this, and he feels that his boss deliberately suppressed it. Their professional relationship deteriorated to the point where Eide complained to Secretary-General Ban Ki Moon and had Galbraith removed. Ban chose appearances over the truth. The UN and the West were so desperate to pronounce the election a success as a propaganda blow to the Taliban that they covered up fraud. But as presidential challenger Abdullah said, the Taliban are obviously the biggest threat to Afghanistan's future, but an illegitimate, corrupt government is second. The UN doesn't seem to care. Somehow Karzai has convinced them to back him, maybe through bribery. Of course the UN's official excuse is that it has no "right" to interfere in the elections of a sovereign state, and we should be patient and let the Afghans sort it out. They do admit that fraud took place, but do not concede that the fraud was preventable, and overwhelmingly in Karzai's favor. The Obama administration and Holbrooke have been fairly quiet on the issue as well, even moreso than the disputed Iranian elections and Honduras coup d'etat.
If America, NATO, and the UN came to Afghanistan to help the people, show them good governance, and bring them into the 21st Century, then how can we tolerate this result? We toppled the "illegitimate" regime of the Taliban in 2001, but now we sit on the sidelines while a corrupt, inept political parasite (of course appointed by the Bushies) hijacks a nation that is vital to our security interests in the region. The only worse result would be if Osama won the election, legitimately (and by now I'm sure he is more popular among Afghans than Karzai). No wonder no one trusts or respects us and the Smurfs. We screw up Yugoslavia, Congo, Haiti, Rwanda, East Timor, Iraq, Afghanistan, and pretty much every other warzone we go.
Thursday, October 1, 2009
Growing up
Regarding aging, it's too bad that people on the post-graduate education route need to devote so many years (and money) towards that cause, while not really being able to set down roots due to student loan repayments, less-than-secure employment, high cost of housing, etc. So when all is said and done, people are almost "starting adult life" at 30, when a generation ago they would have 2 kids and the white picket fence by then. And for those who want a family these days (I'm still on the fence, but my wife wants kids, so I guess it would be selfish of me to deprive her of that), they have to navigate that social maze while also working long hours as a junior-level employee hoping to advance. There just doesn't seem to be enough time for all the stuff that adults said we were entitiled to growing up. And like your friend working for the foreign service in Asia, I think there are many really interesting, rewarding international jobs out there where one could learn a lot and grow as a person, but it seems fairly incompatible with relationships/family. Plus our parents are getting older and we may need to support them more and more with our time and resources.
So I guess I am feeling some trepidation about the future after all, and how to balance these various commitments and choices. After visiting some friends in France/Holland recently, and seeing how their way of life is becoming more and more "American" (i.e. competitive, stressful, hurried, individualistic, unhealthy), I can't help but feel a bit sad. Their postwar governments and companies made strong efforts to maintain a decent quality of life for people (immigrants and the poor still falling through the cracks of course) through universal health care, generous unemployment insurance, free or heavily subsidized child care and university, as well as the 35-hour week and 5 weeks vacation. Maybe such a paradigm is foolish and unsustainable in the cost-cutting globalized economy, but I respect them for trying. It's not like Europe is Utopia, but their health and happiness metrics are higher than ours, even though they are less rich by some measures.
All the young American parents I know are stressed as hell. I am not sure if your relatives and circle of friends are the same. I know they say their kids give them so much joy (would any parent admit that they regret having kids though?), but they're always running around, behind on work, mostly eating fast food, and getting ill more often. They don't follow the news much and seem "out of touch". I know it's just qualitative and anecdotal, but their bodies look worn and their lives seem to revolve around kid stuff (like they don't do their hobbies anymore, and if they are lucky enough to have a night out to the cinema, it's to see "Finding Nemo"). I think parents should spend a lot of time with their kids of course, but maybe more balance is healthier? Of course if we had to work less, and wasted less time in traffic or at the mall, there would be more time for recreation and self-maintenance. And then there are those freaky "super-parents" who run 5 miles a day, have great, well-behaved kids, and kick butt at their jobs. Maybe it's the cocaine! But seriously, it's a sad reflection on our society that moms are a surprisingly prominent demographic for meth use. There's just too much for them to do to be "good moms", trying to live up to the impossible expectations that the jerks in media, marketing, etc. place on women.
I don't know. There are many ways to live life happily, and it's not required for everyone to have kids (actually if we did, it would be really bad for the Earth). Many people find great satisfaction with their spouses, jobs, or life callings and that seems to be enough. I just know that I will never love my job on my current path, and probably jobs I could love are now out of reach due to my life choices. Lauren and I just adopted a dog, and I think my plate is plenty full with taking care of the dog, condo, and trying to be a good husband/son. I am sure you, Mark, and most everyone else feels pressed for time too. I guess I am mostly content with my life at present, but I am not thrilled with the possible paths ahead of me.
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