Tuesday, August 27, 2013

‘The Cancer Chronicles’ Wanders Through the Disease’s World - NYTimes.com

We have no shortage of dispatches from the cancer wars, what with doctors, patients, essayists, scientists and journalists in every possible combination and permutation all checking in at length from the front.

Dr. Siddhartha Mukherjee's authoritative 2010 Pulitzer Prize-winning "biography" of cancer, "The Emperor of All Maladies," ran almost 600 pages. In comparison, George Johnson has written a very small book, barely half that length. That Mr. Johnson's story is as gripping, illuminating and affecting as the bigger book — or, for that matter, any other book out there — is testament to both his poet's talents and his unusual perspective.

An award-winning science writer, Mr. Johnson was for some years an editor at The New York Times and a contributor to Science Times (where portions of this book eventually appeared). Initially, though, his interests kept him firmly on the physical science side of things, covering particles and planets, a foreign terrain that often seems enviably organized, if a little dry, to those of us in the mushier, less rigorous zones of health.

Then came a sad new assignment, self-imposed: Mr. Johnson set out to learn everything he could about cancer when his then-wife received a diagnosis at a relatively young age. So he gamely crossed over from the hard sciences to the soft, Gulliver with a notepad and a recorder. He understood the language well enough, but the customs were surpassing strange.

For comfort, perhaps, Mr. Johnson starts his cancer tour where any self-respecting cosmology fan would: not with humans but with dinosaurs. When did it all begin? In 1999, an Ohio rheumatologist with a sideline in fossils identified the oldest presumed example of metastatic cancer in a fragment of 150-million-year-old mineralized dinosaur bone. It turns out that the overall estimated rate of bone cancer in dinosaurs is actually quite similar to that identified in at least one random collection of human bones (not much support there for a theory that cosmic rays killed off the dinosaurs in a cancer epidemic).

But barring that catastrophe, what made that one poor, limping dinosaur so unlucky? Was it too few lycopene-rich fruits? Too much secondhand forest-fire smoke? And how extraordinary, speaking of risk factors, that the rotten luck of our fellow humans still perplexes us almost as much as the luck of that petrified reptile.

Mr. Johnson's wife, Nancy, was a trim, exercising, vegetable- and fiber-chomping nonsmoker in her early 40s when she felt a lump in her groin. It proved to be a metastasis from a malevolent form of uterine cancer, one whose cells are atypically aggressive and prone to spreading. Her situation and her terrible prognosis reminded Mr. Johnson of nothing more than his New Mexico backyard, with headstrong wildflowers blooming where they choose and intractable weeds exploding by night.

A man may plan a garden, but nature has different patterns in mind, patterns so intricate and orderly in their chaotic way that scientists now understand cancers to be collections of cells as complex and ambitious as any healthy organ. The extraordinary determination of those cells wins Mr. Johnson's grudging admiration: "Cancer cells are those that rebel against their fate — they hope for so much more."

So his story moves between the Santa Fe facilities where Nancy gets her grueling but ultimately successful treatments and the many scientific planes of cancer — from the disregulated events in the cells to the sometimes equally confusing proceedings in hospitals, labs and conference halls, as humans muster their defenses, often feeble but sometimes effective. (Nancy's treatment led to a prolonged, continuing remission of her disease.)

It turns out that Mr. Johnson's deceptively casual narrative route is cannily chosen. He wanders everywhere, an intelligent, skeptical, interested and saddened observer with no particular prejudices or axes to grind. He knows how biologic systems work — and, equally important, he is an expert observer of those who observe for a living, and well acquainted with scientific doublespeak. Mr. Johnson finds little in the cancer world to startle him except for the occasional rudeness of some clerical personnel.

"No cancer drug is as good as it sounds": this observation elicits neither surprise nor outrage. Instead, it seems to him perfectly logical, now that cancer appears to be not a single disease but thousands, each with its distinct molecular signature. He considers research into carcinogens of edible, breathable and radiant forms, and concludes, "Sometimes it feels like we're chasing our tails, obsessed with finding causes where there may be none."

"That is the nature of living in a universe dominated by entropy — the natural tendency for order to give way to disorder," Mr. Johnson elaborates. "That doesn't mean we can't reduce the odds, even if only modestly, that we will get cancer before something else kills us. But genetic errors are inevitable and necessary for us to evolve."

Most books about cancer strive to transcend their particulars. Some aim for a spiritual moral. Some, like Dr. Mukherjee's, celebrate how far we have come in the struggle against cancer. Others deplore how far we have to go: the recently published "The Truth in Small Doses," by Clifton Leaf, vehemently decries the ineptitude of our present campaign and calls for a complete reorganization.

But perhaps not since Susan Sontag has anyone put cancer so firmly and eloquently in its place as Mr. Johnson does, casting it as neither metaphor nor enemy, but simply a natural part of the orderly disorder of the natural world.


Health care technology brings costs down: How I did my part - Slate

Here's an anecdote from the struggle against Baumol's Disease. I was having a kind of weird problem with my left thumb over the course of the past few days. Uncomfortable and annoying, especially when trying to hit the space bar on the keyboard, but not like crippling or horrible. Finally I figured out that it looked to me like an infection of the cuticle so I should do web search for "cuticle infection." That brought me to a Wikipedia page on which I learned that the technical term for such a thing is "paronychia" and also saw a photo of someone with paronychia, which let me confirm that this is indeed what I had.

That led to a bit more Googling so I could check out what the Mayo Clinic and the National Institutes of Health had to say about the matter. They made me even more confident that this was the condition by noting that it typically happens to habitual fingernail biters (guilty) or people who've recently been in the water a lot (swimming pool on vacation).

Everyone basically agrees that this isn't a huge deal and that you can obtain some physical relief by occasionally soaking the thumb in hot water while waiting for it to clear up. I took that advice starting yesterday morning, and today I feel a lot better. Not really because the hot water is such a great cure for the discomfort (though it does help) but because of the immense psychological relief associated with getting a diagnosis and a prescribed course of treatment. Even in cases where the indicated treatment is basically "do nothing" (which is very often the case—people who are sick tend to get better) it makes you feel a lot better to specifically hear that from an authoritative person.

So there we have it. In a small but real way, information technology reduced the cost of this particular health care service. Productivity for the win.

Obviously there are lots of things we aren't going to treat in this way, but I'm quite optimistic that information technology in the health care sector is going to do us a lot of good. Health needs are oddly distributed between the more or less routine maladies that everyone experiences multiple times a year, and the relatively rare serious conditions that cost huge sums of money. IT doesn't show a lot of immediate promise on the latter kind of issues if you ask me, but the routine care is very important to day-to-day quality of life for the bulk of people and IT is very promising in this sphere. And the key thing to remember is that when it comes to routine care, the output of the health care system isn't just curing illness it's making people feel better. Moderately more intelligent computers systems than the ones we have today, plus the infusion of a few dollops of human labor (a bunch of nurses in a command center, say), plus the continued diffusion of computer literacy could easily give working- and middle-class Americans very cheap access to 24/7 diagnostic services.


Sunday, August 25, 2013

Exploring Saline’s Secret Costs - NYTimes.com

It is one of the most common components of emergency medicine: an intravenous bag of sterile saltwater.

Luckily for anyone who has ever needed an IV bag to replenish lost fluids or to receive medication, it is also one of the least expensive. The average manufacturer's price, according to government data, has fluctuated in recent years from 44 cents to $1.

Yet there is nothing either cheap or simple about its ultimate cost, as I learned when I tried to trace the commercial path of IV bags from the factory to the veins of more than 100 patients struck by a May 2012 outbreak of food poisoning in upstate New York.

Some of the patients' bills would later include markups of 100 to 200 times the manufacturer's price, not counting separate charges for "IV administration." And on other bills, a bundled charge for "IV therapy" was almost 1,000 times the official cost of the solution.

It is no secret that medical care in the United States is overpriced. But as the tale of the humble IV bag shows all too clearly, it is secrecy that helps keep prices high: hidden in the underbrush of transactions among multiple buyers and sellers, and in the hieroglyphics of hospital bills.

At every step from manufacturer to patient, there are confidential deals among the major players, including drug companies, purchasing organizations and distributors, and insurers. These deals so obscure prices and profits that even participants cannot say what the simplest component of care actually costs, let alone what it should cost.

And that leaves taxpayers and patients alike with an inflated bottom line and little or no way to challenge it.


In the food-poisoning case, some of the stricken were affluent, and others barely made ends meet. Some had private insurance; some were covered by government programs like Medicare andMedicaid; and some were uninsured.

In the end, those factors strongly (and sometimes perversely) affected overall charges for treatment, including how much patients were expected to pay out of pocket. But at the beginning, there was the cost of an IV bag of normal saline, one of more than a billion units used in the United States each year.

"People are shocked when they hear that a bag of saline solution costs far less than their cup of coffee in the morning," said Deborah Spak, a spokeswoman for Baxter International, one of three global pharmaceutical companies that make nearly all the IV solutions used in the United States.

It was a rare unguarded comment. Ms. Spak — like a spokesman for Hospira, another giant in the field — later insisted that all information about saline solution prices was private.

In fact, manufacturers are required to report such prices annually to the federal government, which bases Medicare payments on the average national price plus 6 percent. The limit for one liter of normal saline (a little more than a quart) went to $1.07 this year from 46 cents in 2010, an increase manufacturers linked to the cost of raw materials, fuel and transportation. That would seem to make it the rare medical item that is cheaper in the United States than in France, where the price at a typical hospital in Paris last year was 3.62 euros, or $4.73. One-liter IV bags normally contain nine grams of salt, less than two teaspoons. Much of it comes from a major Morton Salt operation in Rittman, Ohio, which uses a subterranean salt deposit formed millions of years ago. The water is local to places like Round Lake, Ill., or Rocky Mount, N.C., where Baxter and Hospira, respectively, run their biggest automated production plants under sterility standards set by the Food and Drug Administration.

But even before the finished product is sold by the case or the truckload, the real cost of a bag of normal saline, like the true cost of medical supplies from gauze to heart implants, disappears into an opaque realm of byzantine contracts, confidential rebates and fees that would be considered illegal kickbacks in many other industries.

IV bags can function like cheap milk and eggs in a high-priced grocery store, or like the one-cent cellphone locked into an expensive service contract. They serve as loss leaders in exclusive contracts with "preferred manufacturers" that bundle together expensive drugs and basics, or throw in "free" medical equipment with costly consequences.

Few hospitals negotiate these deals themselves. Instead, they rely on two formidable sets of middlemen: a few giant group-purchasing organizations that negotiate high-volume contracts, and a few giant distributors that buy and store medical supplies and deliver them to client hospitals.

Proponents of this system say it saves hospitals billions in economies of scale. Critics say the middlemen not only take their cut, but they have a strong interest in keeping most prices high and competition minimal.

The top three group-purchasing organizations now handle contracts for more than half of all institutional medical supplies sold in the United States, including the IVs used in the food-poisoning case, which were bought and taken by truck to regional warehouses by big distributors.

These contracts proved to be another black box. Debbie Mitchell, a spokeswoman for Cardinal Health, one of the three largest distributors, said she could not discuss costs or prices under "disclosure rules relative to our investor relations."

Distributors match different confidential prices for the same product with each hospital's contract, she said, and sell information about the buyers back to manufacturers.

A huge Cardinal distribution center is in Montgomery, N.Y. — only 30 miles, as it happens, from the landscaped grounds of the Buddhist monastery in Carmel, N.Y., where many of the food-poisoning victims fell ill on Mother's Day 2012.

Among them were families on 10 tour buses that had left Chinatown in Manhattan that morning to watch dragon dances at the monastery. After eating lunch from food stalls there, some traveled on to the designer outlet stores at Woodbury Commons, about 30 miles away, before falling sick.

The symptoms were vicious. "Within two hours of eating that rice that I had bought, I was lying on the ground barely conscious," said Dr. Elizabeth Frost, 73, an anesthesiologist from Purchase in Westchester County who was visiting the monastery gardens with two friends. "I can't believe no one died."

About 100 people were taken to hospitals in the region by ambulance; 5 were admitted and the rest released the same day. The New York State Department of Health later found the cause was a common bacterium, Staphylococcus aureus, from improperly cooked or stored food sold in the stalls.


The sick entered a health care ecosystem under strain, swept by consolidation and past efforts at cost containment.

For more than a decade, hospitals in the Hudson Valley, like those across the country, have scrambled for mergers and alliances to offset economic pressures from all sides. The five hospitals where most of the victims were treated are all part of merged entities jockeying for bargaining power and market share — or worrying that other players will leave them struggling to survive.

The Affordable Care Act encourages these developments as it drives toward a reimbursement system that strives to keep people out of hospitals through more coordinated, cost-efficient care paid on the basis of results, not services. But the billing mysteries in the food poisoning case show how easily cost-cutting can turn into cost-shifting.

A Chinese-American toddler from Brooklyn and her 56-year-old grandmother, treated and released within hours from the emergency room at St. Luke's Cornwall Hospital, ran up charges of more than $4,000 and were billed for $1,400 — the hospital's rate for the uninsured, even though the family is covered by a health maintenance organization under Medicaid, the federal-state program for poor people.

The charges included "IV therapy," billed at $787 for the adult and $393 for the child, which suggests that the difference in the amount of saline infused, typically less than a liter, could alone account for several hundred dollars.

Tricia O'Malley, a spokeswoman for the hospital, would not disclose the price it pays per IV bag or break down the therapy charge, which she called the hospital's "private pay rate," or the sticker price charged to people without insurance. She said she could not explain why patients covered by Medicaid were billed at all.

Eventually the head of the family, an electrician's helper who speaks little English, complained to HealthFirst, the Medicaid H.M.O. It paid $119 to settle the grandmother's $2,168 bill, without specifying how much of the payment was for the IV. It paid $66.50 to the doctor, who had billed $606.

At White Plains Hospital, a patient with private insurance from Aetna was charged $91 for one unit of Hospira IV that cost the hospital 86 cents, according to a hospital spokeswoman, Eliza O'Neill.

Ms. O'Neill defended the markup as "consistent with industry standards." She said it reflected "not only the cost of the solution but a variety of related services and processes," like procurement, biomedical handling and storage, apparently not included in a charge of $127 for administering the IV and $893 for emergency-room services.

The patient, a financial services professional in her 50s, ended up paying $100 for her visit. "Honestly, I don't understand the system at all," said the woman, who shared the information on the condition that she not be named.

Dr. Frost, the anesthesiologist, spent three days in the same hospital and owed only $8, thanks to insurance coverage by United HealthCare. Still, she was baffled by the charges: $6,844, including $546 for six liters of saline that cost the hospital $5.16.

"It's just absolutely absurd." she said. "That's saltwater."

Last fall, I appealed to the New York State Department of Health for help in mapping the charges for rehydrating patients in the food poisoning episode. Deploying software normally used to detect Medicaid fraud, a team compiled a chart of what Medicaid and Medicare were billed in six of the cases.

But the department has yet to release the chart. It is under indefinite review, Bill Schwarz, a department spokesman, said, "to ensure confidential information is not compromised."