Salve Lucrum: The Existential Threat of Greed in US Health Care

Berwick DM.

JAMA. 2023;329(8):629–630.

doi:10.1001/jama.2023.0846

Here is an excerpt:

Particularly costly has been profiteering among insurance companies participating in the Medicare Advantage (MA) program. Originally intended to give Medicare beneficiaries the choice of access to well-managed care at lower cost, MA has mushroomed into a massive program, now about to cover more than 50% of all Medicare beneficiaries and costing far more per beneficiary than traditional Medicare ever has. By gaming Medicare risk codes and the ways in which comparative “benchmarks” are set for expected costs, MA plans have become by far the most profitable branches of large insurance companies. According to some health services research, MA will cost Medicare over $600 billion more in the next 8 years than would have been the case if the same enrollees had remained in traditional Medicare. Opinions differ about whether MA enrollees experience better care and outcomes than those in traditional Medicare, but the weight of evidence is that they do not.

Hospital pricing games are also widespread. Hospitals claim large operating losses, especially in the COVID pandemic period, but large systems sit on balance sheets with tens of billions of dollars in the bank or invested. Hospital prices for the top 37 infused cancer drugs averaged 86.2% higher per unit than in physician offices. A patient was billed $73 800 at the University of Chicago for 2 injections of Lupron depot, a treatment for prostate cancer, a drug available in the UK for $260 a dose. To drive up their own revenues, many hospitals serving wealthy populations take advantage of a federal subsidy program originally intended to reduce drug costs for people with low income.

Recent New York Times investigations have reported on nonprofit hospitals’ reducing and closing services in poor areas while opening new ones in wealthy suburbs and on their use of collection agencies for pursuing payment from patients with low income. The Massachusetts Health Policy Commission reported in 2022 that hospital prices and revenues increased during a decade at almost 4 times the rate of inflation.

Windfall profits also appear in salaries and benefits for many health care executives. Of the 10 highest paid among all corporate executives in the US in 2020, 3 were from Oak Street Health, and salary and benefits included, reportedly, $568 million for the chief executive officer (CEO). Executives in large hospital systems commonly have salaries and benefits of several million dollars a year. Some academic medical centers’ boards allow their CEO to serve for 6-figure stipends and multimillion-dollar stock options on outside company boards, including ones that supply products and services to the medical center.

The info is here.

My summary and warnings are here:

Greed is not good, especially in healthcare. This article outlines the concerning issue of greed pervading the US healthcare system. It argues that prioritizing profit over patient well-being has become widespread, impacting everything from drug companies to hospitals. The author contends that this greed is detrimental to both patients and the healthcare system as a whole. To address this, the article proposes solutions like fostering greater transparency and accountability, along with reevaluating how healthcare is financed.

When Helping Is Risky: The Behavioral and Neurobiological Trade-off of Social and Risk Preferences

Gross, J., Faber, N. S., et al.  (2021).

Psychological Science, 32(11), 1842–1855.

https://doi.org/10.1177/09567976211015942

Abstract

Helping other people can entail risks for the helper. For example, when treating infectious patients, medical volunteers risk their own health. In such situations, decisions to help should depend on the individual’s valuation of others’ well-being (social preferences) and the degree of personal risk the individual finds acceptable (risk preferences). We investigated how these distinct preferences are psychologically and neurobiologically integrated when helping is risky. We used incentivized decision-making tasks (Study 1; N = 292 adults) and manipulated dopamine and norepinephrine levels in the brain by administering methylphenidate, atomoxetine, or a placebo (Study 2; N = 154 adults). We found that social and risk preferences are independent drivers of risky helping. Methylphenidate increased risky helping by selectively altering risk preferences rather than social preferences. Atomoxetine influenced neither risk preferences nor social preferences and did not affect risky helping. This suggests that methylphenidate-altered dopamine concentrations affect helping decisions that entail a risk to the helper.

From the Discussion

From a practical perspective, both methylphenidate (sold under the trade name Ritalin) and atomoxetine (sold under the trade name Strattera) are prescription drugs used to treat attention-deficit/hyperactivity disorder and are regularly used off-label by people who aim to enhance their cognitive performance (Maier et al., 2018). Thus, our results have implications for the ethics of and policy for the use of psychostimulants. Indeed, the Global Drug Survey taken in 2015 and 2017 revealed that 3.2% and 6.6% of respondents, respectively, reported using psychostimulants such as methylphenidate for cognitive enhancement (Maier et al., 2018). Both in the professional ethical debate as well as in the general public, concerns about the medical safety and the fairness of such cognitive enhancements are discussed (Faber et al., 2016). However, our finding that methylphenidate alters helping behavior through increased risk seeking demonstrates that substances aimed at changing cognitive functioning can also influence social behavior. Such “social” side effects of cognitive enhancement (whether deemed positive or negative) are currently unknown to both users and administrators and thus do not receive much attention in the societal debate about psychostimulant use (Faulmüller et al., 2013).

The research is here.

The Most Common Pain Relief Drug in The World Induces Risky Behavior, Study Finds

Peter Dockrill

sciencealert.com

Originally published 18 NOV 21

Acetaminophen, also known as paracetamol and sold widely under the brand names Tylenol and Panadol, also increases risk-taking, according to a study published in 2020 that measured changes in people's behavior when under the influence of the common over-the-counter medication.

"Acetaminophen seems to make people feel less negative emotion when they consider risky activities – they just don't feel as scared," neuroscientist Baldwin Way from The Ohio State University explained last year.

"With nearly 25 percent of the population in the US taking acetaminophen each week, reduced risk perceptions and increased risk-taking could have important effects on society."

The findings add to a recent body of research suggesting that acetaminophen's effects on pain reduction also extend to various psychological processes, lowering people's receptivity to hurt feelings, experiencing reduced empathy, and even blunting cognitive functions.

Similarly, Way's study suggests people's affective ability to perceive and evaluate risks can be impaired when they take acetaminophen. While the effects might be slight, they're definitely worth noting, given acetaminophen is the most common drug ingredient in America, found in over 600 different kinds of over-the-counter and prescription medicines.

(cut)

Overall, however, based on an average of results across the various tests, the team concludes that there is a significant relationship between taking acetaminophen and choosing more risk, even if the observed effect can be slight.

That said, they acknowledge the drug's apparent effects on risk-taking behavior could also be interpreted via other kinds of psychological processes, such as reduced anxiety, perhaps.

The info is here.

Israel Approves Compassionate Use of MDMA to Treat PTSD

Ido Efrati
www.haaretz.com
Originally posted February 10, 2019

MDMA, popularly known as ecstasy, is a drug more commonly associated with raves and nightclubs than a therapist’s office.

Emerging research has shown promising results in using this “party drug” to treat patients suffering from post-traumatic stress disorder, and Israel’s Health Ministry has just approved the use of MDMA to treat dozens of patients.

MDMA is classified in Israel as a “dangerous drug”, recreational use is illegal, and therapeutic use of MDMA has yet to be formally approved and is still in clinical trials.

However, this treatment is deemed as “compassionate use,” which allows drugs that are still in development to be made available to patients outside of a clinical trial due to the lack of effective alternatives.

The info is here.

Precision medicine’s rosy predictions haven’t come true. We need fewer promises and more debate

Michael Joyner and Nigel Paneth
STATnews.com
Originally published February 7, 2019

Here is an excerpt:

While we are occasionally told that we are Luddites or nihilists (generally without much debate of the merits of our position), the most frequent communications we receive have been along the lines of “I agree with you, but can’t speak up publicly for fear of losing my grants, alienating powerful people, or upsetting my dean.” This atmosphere cannot be good for the culture of science.

We are calling for an open debate, in all centers of biomedical research, about the best way forward, and about whether precision medicine is really the most promising avenue for progress. It is time for precision medicine supporters to engage in debate — to go beyond asserting the truism that all individuals are unique, and that the increase in the volume of health data and measurements combined with the decline in the cost of studying the genome constitute sufficient argument for the adoption of the precision medicine program.

Enthusiasts of precision medicine must stop evading the tough questions we raise. The two of us have learned enormously from the free and open exchange of ideas among our small band of dissenters, and we look forward to a vigorous debate engaging an ever-larger fraction of the scientific community.

The info is here.

Do psychotropic drugs enhance, or diminish, human agency?

Rami Gabriel
aeon.co
Originally posted September 3, 2018

Here is an excerpt:

Psychological medications such as Xanax, Ritalin and aspirin help to modify undesirable behaviours, thought patterns and the perception of pain. They purport to treat the underlying chemical cause rather than the social, interpersonal or psychodynamic causes of pathology. Self-knowledge gained by introspection and dialogue are no longer our primary means for modifying psychological states. By prescribing such medication, physicians are implicitly admitting that cognitive and behavioural training is insufficient and impractical, and that ‘the brain’, of which nonspecialists have little explicit understanding, is in fact the level where errors occur. Indeed, drugs are reliable and effective because they implement the findings of neuroscience and supplement (or in many cases substitute for) our humanist discourse about self-development and agency. In using such drugs, we become transhuman hybrid beings who build tools into the regulatory plant of the body.

Recreational drugs, on the other hand, are essentially hedonic tools that allow for stress-release and the diminishment of inhibition and sense of responsibility. Avenues of escape are reached through derangement of thought and perception; many find pleasure in this transcendence of quotidian experience and transgression of social norms. There is also a Dionysian, or spiritual, purpose to recreational inebriation, which can enable revelations that enhance intimacy and the emotional need for existential reflection. Here drugs act as portals into spiritual rituals and otherwise restricted metaphysical spaces. The practice of imbibing a sacred substance is as old as ascetic and mindfulness practices but, in our times, drugs are overwhelmingly the most commonly used tool for tending to this element of the human condition.

The info is here.

The So-Called Right to Try Law Gives Patients False Hope

Claudia Wallis
Scientific American
Originally posted in the September 2018 issue

There's no question about it: the new law sounds just great. President Donald Trump, who knows a thing or two about marketing, gushed about its name when he signed the “Right to Try” bill into law on May 30. He was surrounded by patients with incurable diseases, including a second grader with Duchenne muscular dystrophy, who got up from his small wheelchair to hug the president. The law aims to give such patients easier access to experimental drugs by bypassing the Food and Drug Administration.

The crowd-pleasing name and concept are why 40 states had already passed similar laws, although they were largely symbolic until the federal government got onboard. The laws vary but generally say that dying patients may seek from drugmakers any medicine that has passed a phase I trial—a minimal test of safety. “We're going to be saving tremendous numbers of lives,” Trump said. “The current FDA approval process can take many, many years. For countless patients, time is not what they have.”

But the new law won't do what the president claims. Instead it gives false hope to the most vulnerable patients. “This is a right to ask, not a right to try,” says Alison Bateman-House, a medical ethicist at New York University and an expert on the compassionate use of experimental drugs.

The info is here.

Ethics and sport have long been strangers to one another

Kenan Malik
The Guardian
Originally posted March 8, 2018

Here is an excerpt:

Today’s great ethical debate is not about payment but drugs. Last week, the digital, culture, media and sport select committee accused Bradley Wiggins of “crossing the ethical line” for allegedly misusing drugs allowed for medical purposes to enhance performance.

The ethical lines over drug use are, however, as arbitrary and irrational as earlier ones about payment. Drugs are said to be “unnatural” and to provide athletes with an “unfair advantage”. But virtually everything an athlete does, from high-altitude training to high-protein dieting, is unnatural and seeks to gain an advantage.

EPO is a naturally produced hormone that stimulates red blood cell production, so helping endurance athletes. Injections of EPO are banned in sport. Yet Chris Froome is permitted to sleep in a hypoxic chamber, which reduces oxygen in the air, forcing his body to produce more red blood cells. It has the same effect as EPO, is equally unnatural and provides an advantage. Why is one banned but not the other?

The article is here.

Peter Thiel sponsors offshore testing of herpes vaccine, sidestepping U.S. safety rules

Marisa Taylor
Kaiser News
Originally posted August 28, 2017

Here is an excerpt:

“What they’re doing is patently unethical,” said Jonathan Zenilman, chief of Johns Hopkins Bayview Medical Center’s Infectious Diseases Division. “There’s a reason why researchers rely on these protections. People can die.”

The risks are real. Experimental trials with live viruses could lead to infection if not handled properly or produce side effects in those already infected. Genital herpes is caused by two viruses that can trigger outbreaks of painful sores. Many patients have no symptoms, though a small number suffer greatly. The virus is primarily spread through sexual contact, but also can be released through skin.

The push behind the vaccine is as much political as medical. President Trump has vowed to speed up the FDA’s approval of some medicines. FDA Commissioner Scott Gottlieb, who had deep financial ties to the pharmaceutical industry, slammed the FDA before his confirmation for over-prioritizing consumer protection to the detriment of medical innovations.

“This is a test case,” said Bartley Madden, a retired Credit Suisse banker and policy adviser to the conservative Heartland Institute, who is another investor in the vaccine. “The FDA is standing in the way, and Americans are going to hear about this and demand action.”

American researchers are increasingly going offshore to developing countries to conduct clinical trials, citing rising domestic costs. But in order to approve the drug for the U.S. market, the FDA requires that clinical trials involving human participants be reviewed and approved by an IRB or an international equivalent. The IRB can reject research based on safety concerns.

The article is here.

Are You Creeped Out by the Idea of a “Moral Enhancement” Pill?

Vanessa Rampton
Slate.com
Originally posted March 20, 2017

Here is an excerpt:

In its broad outlines, the idea of moral bioenhancement is as follows: Once we understand the biological and genetic influences on moral decision-making and judgments, we can enhance (read: improve) them with drugs, surgery, or other devices. A “morality pill” could shore up self-control, empathy, benevolence, and other desirable characteristics while discouraging tendencies toward violent aggression or racism. As a result, people might be kinder to their families, better members of their communities, and better able to address some of the world’s biggest problems such as global inequality, environmental destruction, and war.

In fact, the attempts of parents, educators, friends, philosophers, and therapists to make people behave better are already getting a boost from biology and technology. Recent studies have shown that neurological and genetic characteristics influence moral decision-making in more or less subtle ways. Some behaviors, like violent aggression, drug abuse and addiction, and the likelihood of committing a crime have been linked to genetic variables as well as specific brain chemicals such as dopamine. Conversely, evidence suggests that our ability to be empathetic, our tolerance of other racial groups, and our sensitivity to fairness all have their roots in biology. Assuming cutting-edge developments in neuroscience and genetics have been touted as able to crack the morality code, the search for a morality pill will only continue apace.

The article is here.

Can Psychedelics Make Us More Moral?

Derek Beres
Big Think
Originally published August 22, 2016

Here is an excerpt:

Could a moral drug enhancement instill empathy in such a person? If so, should it be used? Earp is not ignorant of the ethics of such a drug. Looked at from a broader social perspective instead of an individualist mindset is one important factor. If there’s a possibility that a psychopath could harm members of a society, would such a drug be beneficial, especially if the person desires it? What if they don’t?

Psychopathy is a small but very real instance. What about extending this idea of moral neuroenhancement to people with depression? Anger management issues? Excessive anxiety? This does not imply that a person needs a daily dose. Research has shown that psilocybin has an effect even after one episode...

The article is here.

Adding ages: The fight to cheat death is hotting up

The Economist
Originally published August 13, 2016

Here is an excerpt:

Scientists at the Institute for Ageing Research at the Albert Einstein College of Medicine, in New York, want to mount a trial of metformin in elderly subjects to see whether it delays various maladies (and also death). If that turns out to be the case, it will go a long way to showing that there is a generalised ageing process that can be modulated with drugs. Nir Barzilai, one of the researchers involved, says an important reason to do the trial is to have an indication against which next-generation ageing drugs can be assessed by regulators.

This sort of interest seems to be triggering a change of tone at America’s Food and Drug Administration over whether it might approve an anti-ageing drug. The regulator is thinking about when a broad, and so far unprecedented, claim of anti-ageing might be considered to be supported by the evidence; it is “looking forward to seeing this area of science evolve”. In the dry language of a government agency these are encouraging words.

If an unregulated diet can do the trick, why does the world need drugs? Three reasons. One is that taking a few pills a day will be easier for most than subsisting on low-calorie muffins and salad. A second is that companies can make money making pills and will compete to create them. A third is that pills may work better than diets. Dr Barzilai, who is in the pill camp, points out that CR works less well in primates than other mammals, and that people with low body-mass indices, a natural condition for those restricting their calories, are in general more likely to die. Those who do well on CR, he says, are likely to be a subset benefiting from the right genetic make-up. His hope is that a range of targeted therapies might allow everyone to get the benefits.

The article is here.

Moral enhancements 2

By Michelle Ciurria
Moral Responsibility Blog
Originally published June 4, 2016

Here is an excerpt:

Here, I want to consider whether intended moral enhancements – those intended to induce pro-moral effects – can, somewhat paradoxically, undermine responsibility. I say ‘intended’ because, as we saw, moral interventions can have unintended (even counter-moral) consequences. This can happen for any number of reasons: the intervener can be wrong about what morality requires (imagine a Nazi intervener thinking that anti-Semitism is a pro-moral trait); the intervention can malfunction over time; the intervention can produce traits that are moral in one context but counter-moral in another (which seems likely, given that traits are highly context-sensitive, as I mentioned earlier); and so on – I won’t give a complete list. Even extant psychoactive drugs – which can count as a type of passive intervention – typically come with adverse side-effects; but the risk of unintended side-effects for futuristic interventions of a moral nature is substantially greater and more worrisome, because the technology is new, it operates on complicated cognitive structures, and it specifically operates on those structures constitutive of a person’s moral personality. Since intended moral interventions do not always produce their intended effects (pro-moral effects), I’ll discuss these interventions under two guises: interventions that go as planned and induce pro-moral traits (effective cases), and interventions that go awry (ineffective cases). I’ll also focus on the most controversial case of passive intervention: involuntary intervention, without informed consent.

The blog post is here.

Former FDA Commissioner Charged in RICO Lawsuit

The Alliance For Human Research Protection

A Federal Lawsuit charges Dr. Margaret Hamburg, former Commissioner of the Food and Drug Administration (FDA) with conspiracy, racketeering & colluding to conceal deadly drug dangers – under the federal Racketeer Influenced and Corrupt Organizations law (RICO) law. The amended RICO lawsuit was filed on April 11, 2016 in the U.S. District Court in Washington DC on behalf of eight plaintiffs who claim they have suffered severe harm by ingesting the drug, Levaquin whose deadly risks were concealed to protect financial interests.

The drug is one of the controversial group of antibiotics, including  Levaquin, Cipro, Avelox and other fluoroquinolones. Public Citizen petitioned the FDA in 1996 and again in 2006, to issue Black Box warnings for tendon rupture and tendinitis. Had warnings been issued, the death toll from Levaquin– reputedly more than 5,000 — and the tens of thousands who were debilitated with life-threatening diseases would likely have been averted.

The article is here.

Arizona again tries to illegally import execution drug

By Michael Kiefer
The Arizona Republic
Originally published October 23, 2015

The Arizona Department of Corrections paid nearly $27,000 to import from overseas an illegal drug for executions by lethal injection, but federal officials stopped the shipment at the airport.

According to heavily redacted documents obtained by The Arizona Republic, the Corrections Department contracted to purchase 1,000 vials of the anesthetic sodium thiopental. And although the seller's name and information are blacked out on the documents, an offer to sell the drug to Arizona is virtually identical to an unredacted offer sent to corrections officials in Nebraska from a pharmaceutical supplier in India.

The article is here.

What happened when Portugal decriminalised drugs

The Economist
Originally published June 11, 2015

Economist Films: For 20 years The Economist has led calls for a rethink on drug prohibition. This film looks at new approaches to drugs policy, from Portugal to Colorado. “Drugs: War or Store?” kicks off our new “Global Compass” series, examining novel approaches to policy problems.

Economist Films is a new venture that expresses The Economist’s globally curious outlook in the form of short, mind-stretching documentaries.

Ethics of Money in Medicine

By Danielle Ofri
Physician, Writer, Editor


Here is an excerpt:

But this is just one example of unethical allocation of money in medicine. Much ado was rightly made last year when Medicare data showed a few doctors with unsavory and maybe illegal billing practices.  But for all the complaints about doctors’ salaries driving up healthcare costs, hardly anyone made a peep when that same data revealed that it is the salaries of the administrators and executives that are tipping the scales.

Nor did anyone so much as hiccup when it was reported that $455 million dollars was spent on TV ads since the Affordable Care Act was enacted, more than 90% of which was devoted to trying to destroy the ACA. We are so jaded about CEO salaries and the money swamp of politics that we hardly are hardly bothered when we see these statistics.

When I read about the $400 million was spent on TV ads to prevent uninsured Americans from getting health insurance, I was frankly disgusted. If people with deep pockets are really interested in improving our healthcare system there are far better ways to use that money. That handsome sum could have put several thousand nurses in clinics or schools. It could have sponsored medical school for 2000 students from underserved communities.  Heck, it could have purchase 6 million albuterol inhalers and handed them out. But no, the money was squandered on TV advertisements.

The entire article is here.

Ethics and the Enhanced Soldier of the Near Future

By Dave Shunk
Military Review
January-February 2015

Here are two excerpts:

The soldier of the future likely will be enhanced through neuroscience, biotechnology, nanotechnology, genetics, and drugs. According to Patrick Lin, writing in The Atlantic about the ethics of enhancing soldiers, “Soldier enhancements, through biological or technological augmentation of human capabilities, reduce warfighter risk by providing tactical advantages over the enemy.” Lin describes efforts to develop a “super-soldier” who can perform more like
a machine.

(cut)

New ethical challenges are arising from the technological developments in stem cells, genetics,
neurosciences, robotics, and information technology.  Lawrence Hinman of the Center for Ethics in
Science and Technology, University of San Diego, reports that “these developments have created ethical vacuums, situations in which our technology has outstripped our ethical framework.” This statement, although made in 2008, remains true. In fact, current military references to enhanced soldiers are very limited.

The entire article is here.

Brief depression questionnaires could lead to unnecessary antidepressant prescriptions

University of California School of Medicine - Davis
Press Release
Originally released September 2, 3014

Short questionnaires used to identify patients at risk for depression are linked with antidepressant medications being prescribed when they may not be needed, according to new research from UC Davis Health System published in the September-October issue of the Journal of the American Board of Family Medicine.

Known as “brief depression symptom measures,” the self-administered questionnaires are used in primary care settings to determine the frequency and severity of depression symptoms among patients. Several questionnaires have been developed to help reduce untreated depression, a serious mental illness that can jeopardize relationships, employment and quality of life and increase the risks of heart disease, drug abuse and suicide.

The UC Davis team was concerned that the questionnaires might lead to prescriptions for antidepressant medication being given to those who aren’t depressed. Antidepressants are effective in treating moderate-to-severe depression but can have significant side effects, including sexual dysfunction, sedation and anxiety. They also have to be taken over several months to be effective.


“It is important to treat depression, but equally important to make sure those who get treatment actually need it,” said Anthony Jerant, professor of family and community medicine at UC Davis and lead author of the study.

The entire pressor is here.

The link to the study is in a blue hyperlink above.  The conclusion of the research is as follows:

Conclusions: These exploratory findings suggest administration of brief depression symptom measures, particularly the PHQ-9, may be associated with depression diagnosis and antidepressant recommendation and prescription among patients unlikely to have major depression. If these findings are confirmed, researchers should investigate the balance of benefits and risks (eg, overdiagnosis of depression and overtreatment with antidepressants) associated with use of a brief symptom measure.

Cognitive enhancement, legalising opium, and cognitive biases

By Joao Fabiano
Practical Ethics Blog
Originally published November 18, 2014

Suppose you want to enhance your cognition. A scientist hands you two drugs. Drug X has at least 19 controlled studies on the healthy individual showing it is effective, and while a handful of studies report a slight increase in blood pressure, another dozen conclude it is safe and non-addictive. Drug Y is also effective, but it increases mortality, has addiction potential and withdrawal symptoms. Which one do you choose? Great. Before you reach out for Drug X, the scientist warns you, “I should add, however, that Drug Y has been used by certain primitive communities for centuries, while Drug X has not.” Which one do you choose? Should this information have any bearing on your choice? I don’t think so. You probably conclude that primitive societies do all sort of crazy things and you would be better off with actual, double-blind, controlled studies.

The entire blog post is here.