Another medicine-related post, this time dealing a little less with the abstract numbers that go into medical decisions. Did you know that Norway represents the most MRSA-free country in the world? Neither did I. When you read the article, though, it becomes immediately clear why: less wide-spread, reflexive, knee-jerk use of broad-spectrum antibiotics. Add to that the antibacterial crazy nature of household cleaning products, foams, sprays, soaps, anti-germ surfaces and you get what western society has now: ever-rising numbers of MRSA, VRE, and multi-drug resistant bacterial infections. I find this very interesting how the use of sane government-implemented policies and laws created an atmosphere in Norway that allowed physicians to treat appropriately rather than as a reflex or because a patient asked for antibiotics. What are the chances American politicians might move in a similar direction. Hmm. Zero.

Yes. I’m a pessimist.

Here is some *light* reading for some of the number juggling (or not) that physicians deal with every day with regard to ordering screening exams/tests for their patients. Being a physician, grasping these numbers is difficult. Realizing the difference between sensitivity, specificity, positive predictive value, and negative predictive value was paramount in many of my medical school lectures. Even then, though, the concepts, as shown in the link, are abstract, obtuse, and not easily accounted for in daily decision making.

Human beings taking care of human beings. There is bound to be some imperfection. Now, if only we could invent mammography@ (i.e., a highly sensitive screening test) and mammography* (i.e., a highly specific confirmation test), we’d be better off. Think for a moment why two tests would be needed.

As I have moved further into my career as a physician, I have asked myself a question over and over: what drives people? What is the essence of motivation? While the answer can be made simple and obvious (pleasure, gratification, happiness, reward), motivation is something many of us take for granted on a seemingly-unconscious level: human beings often do not know how or why we seek out certain activities—we just do.

I ask this question to understand myself more than anything. What drives me? Why am I interested in everything from classical music to cumulative doses of x-ray radiation causing increased risk of cancer to open source web browser development to current events to computer nerdery to cycling to ACGME guidelines on the resident 80-hour work week limit to giving forceful, impactful, meaningful presentations to photography? The list goes on and on. These things are pleasureful to me, not necessarily to others. Where I derive satisfaction from parsing my iTunes XML library file, syncing it into a SQL database and analyzing its contents, others probably would not find this fun in the least. (Shima, I’m thinking of you.) This question is deep and is very difficult to answer, yet in the past couple months, I have been asked about this many times: What drives me? What motivates me? Why have I succeeded where others have failed? I will try to answer this here.

Rands In Repose put it best by breaking down why gamers are fixated by the games they play:

We see the world as a very complex but knowable flowchart where there are a finite number of inputs, which cause a similarly finite set of outputs. This impossible flowchart gives us a comfortable illusion of control and an understanding of a chaotic word, but its existence is a handy side effect of a life staring at, deducing, and building systems. It’s also why we love games — they’re just dolled up systems — and the more you understand this fascination with games, the better you’ll be at managing us.

As with all mental excursions with geeks, there’s a well-defined process by which we consume a game, and it goes like this:

• Discovery
• Optimization, Repetition, and Win
• Achievement

This really struck a chord with me and brought me back to all my urology residency interviews I have been on during the last few months: how and why do I participate in so many other non-medical activities and how have I been able to not only dabble in some of these but master them as well? I’m not trying to toot my own horn here, but I’ll tell you my secret. Number one: I have many interests (alluded to above). They vary widely because that variety, for me, is satisfying in and of itself. I can relate to people on many levels and each offers something unique that is not provided elsewhere. In other words, I am stimulated mentally in various ways, not just one. Number two: It is the creative versus the logical. I pursue many activities in different realms so that I can enrich and broaden my knowledge in the hopes that discovery in one area might lead to an innovation in another. This approach necessitates broad interests and has created a positive feedback loop, whereby more interests spur more discovery as my appreciation and depth of knowledge grows.

Take my work for example. As a surgical intern, I have to gather vitals, labs, radiology test results, and more each morning for my patients. This is somewhat time consuming and mindless—save the interpretation! My intern peers do exactly the same thing for their umpteen patients every morning, every day of the week. Rather than simply act as a mindless transcriptionist using the same dumb tools day after day, I stepped back and _thought_ about how I could improve this. The data is all in the computer, I have a computerized list of my patients. Why couldn’t I develop a new tool to bring this data to me automatically formatted each morning. So I did just that, using my computer savvy to create a report of such information. It was fun and I learned new things at the same time. Pushing the envelope is satisfying and I was able to use knowledge from one interest to solve a problem in another. Simple, straight-forward, awesome.

Anyone can sit at a job and do that job day after day using the same tools. Few seem to delve deeper and ask, “Can this be done more efficiently?” This is innovation. It is fun, it is motivating, it is challenging, and I love it. Original thinking requires thought, poise, gumption, and conscious effort. I’m not just talking about computers, though. Improvement can involve people, organizations, tools, timing, the political process, and more. Too often, I see anonymous people going about their day in mindless manners, simply doing because that’s what they’ve always known and done and have no reason to change it. This passivity appears more and more pervasive in individuals in many aspects of life: political discussion, technological know-how, creative aspiration and expression, scientific knowledge and understanding. I have even seen people spurn others for involvement in such activities.

“You bake?!”

“You write computer programs?!”

“You read about economic policy?!”

“You speak French?!”

Anything outside their comfort zone is disquieting and jarring. I reject this wholeheartedly. Life is not meant to be consumed in neatly-organized cubes that fit squarely next to one another. Life should challenge, encourage inventive thought and discussion, should wake people up and consciously express desires and actions to push society forward. This drives me. And while I have goals, I relish the means to attaining those goals, not simply satisfied to reach them. This is why I would never, ever choose to simply zip forward to the future to see where I end up: I would never know all the bumps and bruises and petabytes of knowledge my brain churned through to get there. That is where we grow. This is where wisdom is born. I aspire to this model, and I encourage others to follow it as well.

My interest in this area and my thoughts on the matter were the inciting agents for refreshing this space, motivating me to change its inherent direction and content. While blogs originated as a medium that is highly self-serving (witness the many narcissistic entries in the archives that pertain solely to this space), they have morphed into something more. The blogs I read aren’t so much blogs as means to discovering new, fun, interesting information. Technical, medical, humorous, insightful. These are descriptors of things I want to learn from and discover. My significant other (Shima!!!) asked me recently where I find all the tantalizing links I send her. I search, I read, I pour over blogs of people I respect. I do it every day like clockwork. I like being up on current events across all the sections of the classic newspaper (local, national, international, business, politics, technology, etc). These are my goals for this space, eschewing the self-deluding nature of the “look-what-I’ve-done” post so common before this one for posts that convey useful, inciting nuggets that can inspire others. I want to share what drives me here with you in the hopes of energizing your inner drive.

Medicare Part D, which passed as part of the “Medicare Modernization Act”:http://en.wikipedia.org/wiki/Medicare_Prescription_Drug%2C_Improvement%2C_and_Modernization_Act in 2003, gives seniors better access to life-saving medications. Although expensive, this program helps older Americans afford prescriptions whose prices have otherwise been increasing at twice the rate of inflation. Something had to be done.

h2. Flawed

Although the primary aims of giving seniors better access to medicines has been achieved, the law itself has two glaring problems.

First, some seniors are left out of any coverage at all in what has become known as the “doughnut hole.” Basically, when someone enrolls in a drug plan in 2007, this person pays a $265 deductible and 25% of total drug costs up to $2,400. After this total $2,400 cost for the year is exceeded (out-of-pocket expenses up to this limit are only $865), the person must pay _all_ drug costs beyond $2,400 up to $5,451. This is a problem because it leaves people that fall into this hole potentially out $3,916. Regardless of income bracket, if you fall into the gap, you have no options but to come up with this sum of money or go without medication.

Second, and equally insidious, is the inclusion of the non-interference clause, which prohibits the Centers for Medicare and Medicaid Services from negotiating drug pricing with pharmaceutical companies. While the non-interference clause does not prohibit private insurance companies that create drug plans from negotiating, the government has clearly been put at a disadvantage—artificially bound to pay higher prices despite buying in bulk for a huge number of seniors across the country. Some have rightly called this the “sweetheart deal.” It basically amounts to a handout to drug manufacturers and an artificial barrier in the marketplace, which is ironic given that Republicans—who normally champion free market principles—were behind slipping it into the final bill despite a majority of Senators (composed of Democrats and Republicans) opposing this clause.

When I first learned about these ludicrous restrictions, I was incensed. No other word better captures how wrong this sort of sly politicking truly is. One can further argue that the money lost from not being able to negotiate created the doughnut hole. Solve one and you can potentially close or eliminate the other completely.

h2. Clear proponents

Enter Senators Wyden (D-OR) and Snowe (R-ME). In a bipartisan effort, they proposed Amendment 3004, which aims to remove the non-interference clause and allow Medicare to negotiate pricing with drug manufacturers directly. The amendment was applied to a larger budget bill.

Senator Wyden, on March 15, 2006 stated[1] in very clear language the implications of allowing the government to negotiate prices on the millions of prescriptions being bought for seniors. Apparently, the major bug-a-boo surrounding this legislation (which had a majority of support in the _Republican_ Congress last year!), is the misconception that removal of the non-interference clause would allow HHS to set price controls and a single formulary. Per last year’s amendment co-sponsor, Senator Wyden, this is just not true:

bq. Let me repeat that to the Senate. The bipartisan Snowe-Wyden legislation at line 13 and line 14 includes a bipartisan statutory ban on price setting as an effort to control the cost of medicine. This is about using marketplace forces to hold down the cost of these drugs that are clobbering our older people. [...] I don’t see how anyone can oppose this amendment and, in fact, Secretary Tommy Thompson, the former Secretary of Health and Human Services, said in his last press conference that he just wished he had this authority.

Clearly, this amendment a good thing.

h2. Obfuscation

In response to the debate on Amendment 3004, Senator Grassley (R-IA) states:

bq. First of all, we heard the words “sweetheart deal” for drug companies. If drug companies had their way, they would want no formularies, which is what the Wyden amendment would require. These drug companies would want all drugs covered regardless of cost. So don’t tell me this is a sweetheart deal. If we didn’t have formularies like we would have if the Wyden amendment is adopted, then all drugs would be covered regardless of cost. Then they would not have to compete. But this legislation requires competition building upon the practices that we have used for the Federal employee health plan for 40 years. We patterned this legislation after that because that is what saves money.

bq. …

bq. It is an absurd claim that the Government will not be negotiating with drugmakers comes from the noninterference clause in the Medicare law. The noninterference clause does not prohibit Medicare from negotiating with drugmakers. What it does is it prohibits the Center for Medicare Services from interfering with these negotiations.

bq. To be clear, the noninterference clause is at the heart of the bill’s structure for delivering prescription drug coverage. This clause ensures those savings will result from market competition rather than through Government price fixing.

Where to start? There seem to be three huge problems with Grassley’s fierce language here.

1. His speech starts out nearly incomprehensible, but he seems to interpret negotiation of prices as removing competition from the market. Last I checked, capitalism revolved around negotiation between buyer and seller for a fair market value based on current supply and demand. Tongue in cheek: need we repeat Econ 101, Senator Grassley?

2. He correctly states that in its current form Part D prohibits Medicare from negotiating prices, but allows individual plans to do so. However, anyone who understands basic market principles knows bigger buyers have more clout. Take a look at WalMart[2]. Here lies the core of the argument of those for negotiation: greater efficiencies can be achieved with greater numbers. By allowing Medicare to directly negotiate prices, all medicare beneficiaries are pooled together creating a collectively larger buyer with more clout in the market place.

3. Grassley seems intent on associating removal of the non-interference clause with price fixing. Price fixing and allowing market forces to determine fair prices could not be at further ends of the same spectrum. The rabbit being pulled out of the hat here is named obfuscation.

h2. Deft conclusion

Despite the incoherent rambling of Grassley and the transparent “I’m in your pocket” vote by many Republicans, the “amendment passed”:http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=109&session=2&vote=00050, 54-44, with 2 abstentions. Because it never made it into law, though, the parent bill must have died.

The real kicker arises when people realize that the Pentagon and Veterans Administration both negotiate with drug companies for lower prices given their purchasing power for soldiers and veterans. The Costco phenomenon[3] perfectly parallels the economics at work here: If you buy in bulk, you get more bang for your buck. You wouldn’t walk into a Costco to shop for your family and buy toilet paper one roll at a time. The Pentagon knows this. The VA knows this. Why don’t our elected leaders? In essence, the non-interference clause forces such a restriction on the Department of Human Health and Services (HHS), who manages and administers the Medicare program.

Still, there is hope. On January 12, the House of Representatives “voted to send”:http://clerk.house.gov/cgi-bin/vote.asp?year=2007&rollnumber=23 the Medicare Prescription Drug Price Negotiation Act to the Senate for approval. This time, the legislation is contained within its own bill, and will not suffer at the fate of a doomed budget resolution. Sometime soon, the Senate committee in charge of the bill should submit it for a full floor vote. If and when that does happen and if it passes, it will be up to the President to sign for it.

Pass the word, and contact “your Senators”:http://www.senate.gov just as I have. If your Senator was in the Senate last year, you can see how (s)he voted on this issue by taking a look at “the vote on Amendment 3004″:http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=109&session=2&vote=00050 mentioned above.

fn1. All of these quotes come directly from the “public record of the Senate floor”:http://frwebgate.access.gpo.gov/cgi-bin/getpage.cgi?dbname=2006_record&page=S2165&position=all. The debate on Amendment 3004 starts in the third column.

fn2. While I hate WalMart with a passion, it truly has used its buying power to wrestle market prices lower. There exists no better example.

fn3. While I use the word “phenomenon,” Costco is hardly novel, but some of these East-coasters do not know what it means to purchase in bulk. I borrowed this apt metaphor from Senator Wyden.