Santa and Sanity

Last Saturday, I heard a holiday skit on A Prairie Home Companion® that tickled my funny bone and wrenched my heart. 

It was about how Santa Claus started to suffer from claustrophobia. He was seeking help before Christmas so he could go down chimneys and deliver presents. These few short excerpts will give you some idea of how the story went.

Therapist: "Claustrophobia is very common, Santa Claus. Especially in a chimney environment."

Santa: "Help me over this chimney anxiety. I'm terrified of them. It feels like an MRI machine."

Therapist: "What if instead of a threatening thing—you saw the chimney as a big welcoming hug?"

Santa: "Because it's not." "...it's a long dark hole with hot coals at the end."

Therapist: "Time is up. See you next week. Or wait a minute, no—I'm taking off next week. I'll see you in two weeks."

Santa: "Two weeks and it's all going to be over."

Therapist: "... do the best you can."

Santa: "That's all you can do for me? How about medication?"

Therapist: "Medication isn't recommended when you're operating a sleigh."

Santa: "Please. Give me some meds. Look— (HE SINGS) I'm making a list. I'd sure like some Wellbutrin or Valium. Santa Claus is begging you, please." "...I'm making a list and asking you twice. Some Percocet would be nice."

The skit ended when the next patient, Rudolph, came in for treatment for nasal shame.

I smiled, but then the plight of a friend came to mind. 

For years, he had suffered from depression and other issues, but had reached a contented equilibrium after intermittent counseling and medication. In September, he was let go from his job after decades of dedicated service. Nearly sixty-years-old and suddenly out of work, he suffered an emotional setback. Through COBRA coverage, he picked up health benefits. It was expensive, but he made it happen. Before long,  he reached his lifetime maximum benefit. Now he can no longer afford counseling and medication. Like Santa in the skit, he has to find a way to meet his commitments and get on with his life.

This year, I'm asking Santa to bring us better mental health coverage. Hope he makes it down the chimney.

—Tom DeSanto

Excerpts from A Prairie Home Companion® with Garrison Keillor, "Santa," December 20, 2008. Image from www.quiet-storm.net.

Genomics and Economics

As advances in genomics accelerate, so does the advent of rapid tests that unlock secrets. Sequencing a complete genome has progressed from rarified science to a race to profit. Its possibilities extend from translational research labs to consumer's living rooms. 

As proficiency increases, pricing decreases. And demand soars.    

Gene sequencing promises to revolutionize diagnosis and treatment by spurring the development of new drugs and therapies. According to FierceBiotech, sequencing cost a million dollars in 2007. By mid-2008, the cost dropped to $60,000. One company intends to set the price at $5,000 in 2009. Its CEO considers that the "tipping point." Effective application of sequencing data could cut billions of dollars from the cost of clinical trials and speed results.

At the other end of the scale, a company aspiring to be the "world's trusted source of personal genetic information" offers a $399 home testing kit. It was named TIME Magazine's 2008 Invention of the Year. Now the average joe can discover why he's not so average in his health and ancestry.

The widespread application of genomics is becoming increasingly feasible. Incredible knowledge will be gained. Incredible amounts of money will be made. My hope is that as market forces drive the application of new discoveries, we won't squander the possibilities.

—Tom DeSanto 

Image from 3dscience.com, Zygote Media Group

The Other Healthcare Disparity

Women pay more for health insurance coverage than men do. Conventional wisdom says that childbearing and higher utilization of medical services justify the difference. A recent study by the National Women's Law Center (NWLC) challenges that assertion. 

When all else is equal and maternity benefits are excluded, women still pay more for health insurance coverage. A 40-year-old woman's monthly premiums can range from 4 to 48 percent higher than those paid by a 40-year-old man with identical coverage.  

Within each state, the additional premium cost for women can vary widely. For example, the difference women in Little Rock, Arkansas, pay for the best-selling health plans can range from 13 to 63 percent. If the costs were based solely on gender rating, they would be more consistent. NWLC suspects gender bias.

In the group insurance market, women are better protected from higher costs. However, in the individual insurance market they often face difficulty in finding maternity coverage. If they do, they are subject to exorbitant premiums and/or out-of-pocket costs. Otherwise, they are priced out of health insurance and are relegated to the ranks of the uninsured. Women who need individual coverage tend to work at low-paying jobs and may be heads of households. They need help. Eliminating gender rating could be a first step in the right direction. Maine, Montana and New York already prohibit gender-based rates.

Currently, approximately ten states have some provision for limiting gender rating. Our state-by-state approach to regulating health insurance enables inefficiencies and inequities to continue. As the Obama administration takes on healthcare reform, I would hope for a plan that addresses disparities for all citizens, regardless of socioeconomic status, race—and gender.

—Tom DeSanto

Image from Wikimedia Commons  

Balancing Medicine and Marketing

Recently a friend who works in healthcare marketing told me that she will soon undergo a bilateral knee replacement.

I asked if she would be taking advantage of a recent development, knee implants designed especially for women.

After researching the possibility and discussing it with her surgeon, she found no advantage to the female-specific knee and decided that most likely the whole idea was based more on marketing than on medicine. There's truth in her conclusion. 

Two recent studies showed support for the idea that marketing (specifically the need to sell services and generate revenue) does influence medicine more than we would like to admit.  

A study of 377,000 patients in an HMO in Washington state found that between 1997 and 2006 the number of CT scans doubled and MRI scans per patient tripled. The average cost increased from $229 to $443. Instead of replacing older tests, the new ones were ordered in addition. Why? Better medicine? Protection from litigation? And perhaps the need to generate revenue to pay for all the new equipment.

The CyberKnife delivers radiation with amazing precision. Its first application was to treat inaccessible tumors in the spine and brain. Most recently, it's being promoted as an alternative to the many therapies for prostate cancer. The jury is still out on the effectiveness of treatment. However, we do know that each machine costs around $4 million dollars and urologists can receive approximately $1,200 in Medicare reimbursement for each procedure. "Unfortunately, it often comes down to the money," said Louis Potters, chairman of the American Society for Therapeutic Radiology and Oncology's Health Policy Council. "Prostate cancer is so common that it represents low-hanging fruit in terms of revenue opportunities."

Adoption and proliferation of new technologies is essential to bringing patients greater opportunities for recovery and restored productivity. It is also driven by the real economics required to support the advances.

Medical professionals and marketers alike need to maintain a delicate balance. Quality of care, cost control, hospital/clinic solvency and the overall integrity of America's healthcare system depend on it.

— Tom DeSanto

Sources: Reuters Limited, washingtonpost.com, photo: watership kennel/in knees of a solution