Skip to main content

Regular readers of the MNCC will know that we rarely write about “news” in the world of cancer care, but today I am making a bit of an exception.

An entry published over the weekend in the “Opinionator” blog of the New York Times promoting a “plan to fix cancer care” caught my eye, and I thought after reading the column that the topics covered therein would provide plenty of fodder for our discussion here tonight. It seems especially appropriate given the conversation we had last week at the MNCC.

I’ll summarize the points made by the author, Ezekiel J. Emanuel, after providing a few details of his biography. Emanuel is an MD who has practiced in oncology; he is also a Ph.D. bioethicist and a fellow at the Hastings Center. Currently he holds a position at the NIH and still serves (from what I can tell) as a special adviser to the Director of the OMB on Health Policy. Interestingly, though I’m not sure it pertains to this particular discussion, he is Rahm Emanuel’s oldest brother. Emanuel also had over 20 medical reviewers of this post, including Otis W. Brawley of the American Cancer Society among the other MDs and PhDs listed.

Emanuel opens by asserting that the cost of providing treatment to people with cancer is unsustainable: currently, 0.5 of the U.S. population is under treatment for cancer, for a share of 5% (and growing) of total U. S. health care expenditures in doing so. Then he quickly lists the five major components of his plan with brief descriptions of each.

Number one is shifting from a fee-for-service model to a bundled payment model—that is, setting a flat fee for certain cancers, presumably depending on their stages and treatments. The second is to require insurers to document and report back to the physicians on the costs of the treatments they prescribe, in large part to allow doctors to compare costs and effectiveness. “Armed with better data,” he says, “physicians can learn how to improve care at lower cost.”

“Third,” he continues, “any change in payment methods must be accompanied by rigorous quality monitoring to ensure that there is neither under- nor over-utilization of care.”

The fourth component is to move toward more of a “high touch” model of health care because it can help minimize unnecessary treatment expenditures. This is was not a familiar term to me, but I gather that it is intended to contrast with “high tech,” and here he uses it to recommend more routine interactions between medical providers and patients (though his examples strike me as somewhat oddly chosen).

Fifth and last, he says we need “better incentives for research….[because once] interventions are paid for, the incentive for research disappears.”

He concludes by recommending that

The secretary of health and human services should organize a working group representing Medicare, private insurers, oncologists, quality experts and patients to figure out how to develop these proposals — with no increase in costs — and start implementing them by the end of 2015.
It would probably aid our mutual understanding if you would be so kind as to read the original post, which is quite short, as well as some of the comments that follow it, many of which are well-argued and instructive. I’ll lay out the questions I’d like us to consider after the jump.
Monday Night Cancer Club is a Daily Kos group focused on dealing with cancer, primarily for cancer survivors and caregivers, though clinicians, researchers, and others with a special interest are also welcome. Volunteer diarists post Monday evenings between 7-8 PM ET on topics related to living with cancer, which is very broadly defined to include physical, spiritual, emotional and cognitive aspects. Mindful of the controversies endemic to cancer prevention and treatment, we ask that both diarists and commenters keep an open mind regarding strategies for surviving cancer, whether based in traditional, Eastern, Western, allopathic or other medical practices. This is a club no one wants to join, in truth, and compassion will help us make it through the challenge together.

To discuss a statement like this requires some unpacking of the overall argument. Hence my first question to you would be this: Do you agree with him that the expenditures on treatment for cancer in the U.S. are 1) disproportionately high and 2) not necessarily indicative of good and effective care? On what do you base your own opinion?

Next I would ask us to consider whether that’s indeed the biggest problem about cancer care in the U.S.—namely, an excess of expenditures for little obvious gain in health or prolonged life—or whether there is another set of questions that might take precedence even over this one. I know that meta isn’t everyone’s cup of tea, but here it seems worthwhile to take a sip of it all the same. If the problem isn’t properly framed and understood, then the purported solutions will be even farther away from producing a worthwhile change in the underlying situation.

Then, of course, we can take up each of his proposed “solutions” in relation to the problem as he understands it. Or not! If we think that there are in fact other aspects to be considered that aren’t part of this schema at all.

These are some of my very preliminary responses to each. Some of these are bound to be contentious, which is not necessarily a bad thing. I admit to being a novice in the health care funding field and hope to learn more, and quickly.

1. Fee-for-service might lead to some pernicious results, but does a bundled payment approach work better? Weren’t HMOs discredited in part because the providers had a perverse disincentive to pay less attention to their sickest patients? How would such a system work if we were to be able to move (as I fervently hope) to a single-payer or Medicare-for-all model—easily compatible or a difficult fit?

2. Pushing for cost reports and comparisons reminds me of that famous Atul Gawande essay in the New Yorker a couple of years back, “The Cost Conundrum,” Gawande  argued convincingly that there was no necessary relationship between the amount of money spent on patients’ care and their overall health—that often better results could be obtained with lower-cost and more labor-intensive (read: more medically coordinated and interactive) care. Great essay, even better insight. But who is going to monitor those costs? And to what end, really? Just to reduce them, or to see that better treatment models are implemented?

This also addresses Emanuel’s point #3.

4. “High touch” vs. “high tech.” Since this wasn’t a familiar concept to me, I went looking, and I found an interesting example of Emanuel’s position on this point from a few years ago. In coverage of a speech he gave to a medical group management meeting in 2009, Emanuel was quoted as saying that “High-touch…means more patient contacts, more proactive monitoring of patients, more data-driven care, more access to physician offices and more coordinated care.” OK, that might be promising, and certainly I can attest to wanting more information (which at this point is probably for me the major outcome from having more interaction with my medical providers). But who pays for these personnel? How will they be trained and deployed effectively? Who will have their interests at heart, rather than supporting the profit-making models that do well by the administrators but not so well by the patients? And again, who minds the shop to see how well this model pans out?

5. The need for “better incentives for research” seems very obvious, and yet again the design and implementation of these improvements seem mysterious. I do not know the dynamics of research funding well enough to comment intelligently, but I also find it frustrating (as did several of you in last week’s comments) that the pace and scope of cancer research still seem so limited.

What do you think of his concluding call to create a national working group to discuss these proposals and come up with a plan to address them? Who do you think should be in this group? Would you want to be on it? What would you want to make sure they address?

EMAIL TO A FRIEND X
Your Email has been sent.
You must add at least one tag to this diary before publishing it.

Add keywords that describe this diary. Separate multiple keywords with commas.
Tagging tips - Search For Tags - Browse For Tags

?

More Tagging tips:

A tag is a way to search for this diary. If someone is searching for "Barack Obama," is this a diary they'd be trying to find?

Use a person's full name, without any title. Senator Obama may become President Obama, and Michelle Obama might run for office.

If your diary covers an election or elected official, use election tags, which are generally the state abbreviation followed by the office. CA-01 is the first district House seat. CA-Sen covers both senate races. NY-GOV covers the New York governor's race.

Tags do not compound: that is, "education reform" is a completely different tag from "education". A tag like "reform" alone is probably not meaningful.

Consider if one or more of these tags fits your diary: Civil Rights, Community, Congress, Culture, Economy, Education, Elections, Energy, Environment, Health Care, International, Labor, Law, Media, Meta, National Security, Science, Transportation, or White House. If your diary is specific to a state, consider adding the state (California, Texas, etc). Keep in mind, though, that there are many wonderful and important diaries that don't fit in any of these tags. Don't worry if yours doesn't.

You can add a private note to this diary when hotlisting it:
Are you sure you want to remove this diary from your hotlist?
Are you sure you want to remove your recommendation? You can only recommend a diary once, so you will not be able to re-recommend it afterwards.
Rescue this diary, and add a note:
Are you sure you want to remove this diary from Rescue?
Choose where to republish this diary. The diary will be added to the queue for that group. Publish it from the queue to make it appear.

You must be a member of a group to use this feature.

Add a quick update to your diary without changing the diary itself:
Are you sure you want to remove this diary?
(The diary will be removed from the site and returned to your drafts for further editing.)
(The diary will be removed.)
Are you sure you want to save these changes to the published diary?

Comment Preferences

  •  Ooops! Sorry to post late again tonight. (27+ / 0-)

    I finished the diary, more or less, then had to take a nap before actually posting it. That nap lasted later than I thought it would.... Guess I should have set myself an alarm. I am still not fully acclimated to the time change, darn it anyway. If the time is different it really ought to be warmer, too.

    Some DKos series & groups worth your while: Black Kos, Native American Netroots, KosAbility, Monday Night Cancer Club. If you'd like to join the Motor City Kossacks, send me a Kosmail.

    by peregrine kate on Mon Mar 25, 2013 at 05:21:00 PM PDT

  •  I couldn't get over my cost of care... (16+ / 0-)

    ...I just got my summary bill from Mount Auburn Hospital. (Cambridge).

    Fallon Community Health Plan paid something approaching $300,000 for my care.  Not the least of which was the Oxalaplatin, at almost $17k per dose.  I also noted a bunch of things I would consider "overruns", in the syringe and saline and other consumables department.  Seems to me that some of that was overpriced, but I digress.

    As far as it being worth it?  Well, ask my wife and young son if they'd prefer to have papa around for a few more years, or monetary savings to our national healthcare costs.  It is all relative.

    But I'm the fortunate one.  Had this happened just six months earlier (before I returned to full employment and benefits)...well, I wouldn't be writing this now, would I?

    •  Both parts of your story are significant. (8+ / 0-)

      That you were able to obtain treatment when not so long ago you might not have, and that it cost so much. I'm glad you're still here, but it is not right that you should feel as though you might not have been. (I'm writing awkwardly--it's the system I'm blaming for its apparent lack of care for all, not you for realizing you had a closer call than you should have.)

      I have not looked up the total cost of my care. I threw up my hands when I realized that the surgery and one night in the hospital (that is, not counting the surgeon's fee or the anesthesiologist's, etc.) cost over $35 K--and that the ins. co. wound up paying only $17 K because of their sweetheart deal with the hospital. My own out of pocket share was minimal because at that time I had great coverage.

      And yet.... Recently I spoke with a social worker at one of the two major cancer centers in town, not the one I use but I don't think it matters much. She said that people will never be turned down for care due to lack of insurance; that they find a way. I do know that that's been true for a couple of people I know personally.

      That's of course a good thing. But who knows that in ordinary circumstances? I think most people assume they CAN'T get treatment and so stay away without even asking for help.

      Some DKos series & groups worth your while: Black Kos, Native American Netroots, KosAbility, Monday Night Cancer Club. If you'd like to join the Motor City Kossacks, send me a Kosmail.

      by peregrine kate on Mon Mar 25, 2013 at 06:19:48 PM PDT

      [ Parent ]

  •  When my husband and I were working for (11+ / 0-)

    increased research for a cure for prostate cancer, we figured out that one of the main problems with a cure was a lack of profit incentive. A drug manufacturer is happy treating cancer as a chronic condition rather than a curable illness. There is no profit in wellness.

    And none of these proposals seem to address that issue. They appear to be all about controlling costs by any means but cutting into the profit making nature of cancer treatment. The rest of it, shifting from fee for service to bundled service sounds like rearranging the deck chairs on the Titanic. I'm not sure that would provide any better outcome for the patient.

    We must not confuse dissent with disloyalty - Edward R. Murrow

    by Susan Grigsby on Mon Mar 25, 2013 at 06:15:34 PM PDT

  •  The shift from fee for service (10+ / 0-)

    to bundled care pertains to the whole of health care, not simply cancer care.  The entire health care world is afire with this discussion; it's mostly about medicare reform, but major health care organizations are busy re-organizing the way they deliver care in order to take advantage of these new incentives (which are a big part of the ACA).

    it seems even cancer care is to be considered in this large reorganization of the delivery of care.

    Words can sometimes, in moments of grace, attain the quality of deeds. --Elie Wiesel

    by a gilas girl on Mon Mar 25, 2013 at 06:22:16 PM PDT

    •  Can you say more? Particularly (9+ / 0-)

      in reference to my skepticism that this will indeed be set up in a way to help patients, regardless of the chronic condition they might have?

      Some DKos series & groups worth your while: Black Kos, Native American Netroots, KosAbility, Monday Night Cancer Club. If you'd like to join the Motor City Kossacks, send me a Kosmail.

      by peregrine kate on Mon Mar 25, 2013 at 06:27:32 PM PDT

      [ Parent ]

      •  from where I sit (6+ / 0-)

        it is hard to tell at the moment if this set up really will help patients -- they always SAY that it is about providing better patient care.

        What I know about stems mostly from Medicare patients, which was the primary impetus for this change...at the moment the system is set up to be inefficient and expensive: providers are rewarded simply for high volume of services, which means there's an incentive to over test, prescribe the most expensive procedures, etc, rather than actually provide the care that the patient may need.  The idea is to restructure the entire delivery system so that a provider system (rather than an individual provider) would be responsible for the whole of the patient's care and that the reimbursement would come from the outcome, producing healthier patients would kick-in the greatest financial incentive for the provider system, and would also incentivize more wholistic (including preventative) care.

        That's the theory.  On paper it looks good, because there is a lot that's wrong with how our health care system is organized to provide care (which is, I think what Emanuel is writing about).   The real worry is if it incentivizes systems to simply avoid sick people altogether (which wouldn't directly apply in cancer care, obviously).  In the instances where I have seen this new organizing principle applied to the delivery of care for at risk populations (poor, indigent, non-english speaking patients in large urban health care systems) it does seem to have advantages over the older way of doing things, for one thing it is more "patient-centered", so that it focuses on providing the care that has been demonstrated to work for the conditions that the patients are presented with.  And it focuses on expanding the health care team to include heretofore not recognized members of the care team (like patient care assistants, social workers, etc. who know more about patients lives and circumstances and can coordinate care).  I'm less familiar with how it might apply or what specific changes this kind of re-orientation might fit for cancer patients.

        Sorry.  Still, the idea is to get away from high-end, expensive treatments that aren't backed by an evidence base and deliver more team-based, patient centric care that concentrates on well-established treatment plans that have an evidence base for success.

        That's the theory.  Who knows (yet) about the practice?  

        Words can sometimes, in moments of grace, attain the quality of deeds. --Elie Wiesel

        by a gilas girl on Mon Mar 25, 2013 at 07:44:28 PM PDT

        [ Parent ]

        •  Well that's a bit like the model that is practiced (5+ / 0-)

          in Europe, and other countries and it seems to work great.

          Tracy B Ann - technically that is my signature.

          by ZenTrainer on Mon Mar 25, 2013 at 07:54:46 PM PDT

          [ Parent ]

        •  Thanks for your detailed reply. (5+ / 0-)

          I can see the appeal on paper. And if in practice it produces more patient-centered care, that would certainly be good. That's a shortcoming of cancer care in my experience, and the stories I hear from most people I know who are also dealing with it in one form or another: we're still very much on our own. I can't think of one person I know with cancer who has an advocate or an interpreter of the system and the options that may be available. There's usually very little time included for dialogue or consideration of choices regarding treatment, let alone support for the other aspects of survival that make a big difference.

          Back in the day when I did some (modest) HIV-support work, the innovation was to have case managers be assigned to people to help coordinate care in the multiple dimensions needed. That was a good idea, and it did help people when it was implemented well.

          I'm not saying that most people with cancer need that level of wrap-around support; fortunately, many people with HIV also don't have the level of difficulty to deal with now that used to be common then. But...it would be better if we were closer to that end of the continuum. And I think that's true for anyone with a serious, chronic and/or life-threatening condition. As it is, it's sink or swim.

          Oh, and don't get me started about evidence-based treatment for cancer. One of the most dismaying realizations of this whole process was my comprehension at last that there is NO consensus among oncologists about the best way to treat my particular cancer and stage. That was a wake-up call indeed.

          Some DKos series & groups worth your while: Black Kos, Native American Netroots, KosAbility, Monday Night Cancer Club. If you'd like to join the Motor City Kossacks, send me a Kosmail.

          by peregrine kate on Mon Mar 25, 2013 at 07:56:08 PM PDT

          [ Parent ]

        •  It is very close to the Kaiser (0+ / 0-)

          system of care that I use currently.  

          What you have described Gilas Girl,  is how Kaiser has organized themselves in California. Everyone who is in their system receives care, no one is denied just because of their condition.  Kaiser participates regularly in treatment trails (especially with cancer patients). The doctors use their internal systems of administration to innovate within the organization and it is integrated into the whole medical community.  

          I may have mentioned before, that my Pulmonologist is working  with a team of doctors to integrate into their own cancer treatment practice the latest lung cancer research regarding genetic markers for Squamous Cell Carcinoma of the Lung. That originating research was just published last Sept. 2012, my Pulmonologist talked in depth with the lead researchers involved February, and they are working to integrate this discovery into the whole system of care already.  (pretty fast response for such a huge bureaucracy if you ask me).

          Life is not a problem to be solved but an adventure to be experienced.

          by DarkHawk98 on Wed Mar 27, 2013 at 04:35:10 PM PDT

          [ Parent ]

  •  I don't know where to turn (10+ / 0-)

    I did have treatment for thyroid cancer last year, but this is a separate problem, not cancer.  I apologise if this is inappropriate, but I am so discouraged.

    I have been fighting with "brain problems" for about 10  years -- trouble speaking (aphasia), and problems with memory and cognitive functions.  A few years ago, my PCP referred me to Mayo, but insurance denied it.  I'm in this cycle of being diagnosed with dementia, then having more tests and I'm not losing intelligence so it's "all in my head," then it's back to dementia.  So my new PCP referred me to a hematologist, who send me to a neurologist that diagnosed dementia again.  But the hematologist doesn't believe that, and referred me to Mayo.  I just found out today that my insurance denied it again -- and says that since they're an HMO, they don't cover outside the network.

    Do I have any options?  My appointment at Mayo is next week, but I think I'm going to have to cancel, and it breaks my heart.  I get a lot of (? ... argh, can't think of a word... ) they give me some breaks at work, but if I get to the point I can't speak, I'll be out of a job.  Not to mention ending up in a nursing home :o(  which I am dreading.  Is there any organisation or place I can go for help with the payment of treatments?

    Thanks.

    •  I am sorry that you have this kind of problem, (7+ / 0-)

      which does seem overwhelming and frightening just to read about it, much less to have it happening to you.

      My first question to you is, what does Mayo itself say about 1) insurance and 2) payment? I'm sure they're accustomed to being considered a treatment center of last resort, so they must encounter these questions frequently. It's possible that they'd enter into a payment plan with you, though that doesn't mean it's feasible, I realize.

      Unfortunately, many organizations that provide financial assistance to people (that is, the few that exist) are based on a diagnosis; I'm sure you've run into that barrier already. But again a savvy social worker at Mayo might be able to help you out with some leads. Or someone at the facility you do get to use locally.

      Good luck. I think it's worth raising this issue in a couple of other groups on Daily Kos: KosAbility on Sundays at 5 PM ET, and WYFP on Saturday evenings (maybe at 8? not sure). Other folks here may weigh in too.

      {{{{{Unknown Quantity}}}}}

      Some DKos series & groups worth your while: Black Kos, Native American Netroots, KosAbility, Monday Night Cancer Club. If you'd like to join the Motor City Kossacks, send me a Kosmail.

      by peregrine kate on Mon Mar 25, 2013 at 07:06:19 PM PDT

      [ Parent ]

      •  Thanks, PKate! (4+ / 0-)

        One of the beneficial side-effects is that I forget to be worried or upset about it most of the time.  I just had gotten emotionally invested in a trip to Mayo, hoping for some answers.  I just learned of the insurance not paying this afternoon.  I'll be calling Mayo and my home clinic tomorrow to see what they suggest.

        If I can remember, I'll check in with KosAbility and WYFP.  Thanks for the suggestions.  And especially for the hugs!

    •  I think you have to get your doctor to go to bat (6+ / 0-)

      for you. Have him or her contact the insurance company.

      I remember my doctor telling me once that the insurance had denied the antidepressant she wanted a patient to take.

      She asked them to put it in writing to relieve her of responsibility if the patient became suicidal on the drug the insurance company did approve. They ended up paying for the one my doctor wanted.

      Can you get a second opinion at a hospital your insurance will pay for?

      Have you asked at Mayo if they have any programs to help with payments?

      Will your insurance pay for behavioral therapy? Maybe the diagnosis doesn't matter as much as the treatment.

      Tracy B Ann - technically that is my signature.

      by ZenTrainer on Mon Mar 25, 2013 at 07:16:37 PM PDT

      [ Parent ]

      •  Thanks, ZenTrainer! (4+ / 0-)

        The original PCP wrote a letter to the insurance company after they denied this the first time, and they just denied it again.  I will talk with the hematologist to see if he has any suggestions.  I have lost track of how many "opinions" I've had so far - I've been to 4 different places, including Barnes in St Louis, and no one really seems to know what's going on.

        I did get to see a speech therapist for a year or so, and she was a great help because they often work with stroke victims and she had wonderful suggestions about daily coping skills.  When a neuropsych guy said it was due to stress and depression, I went to a therapist that had one session with me (I'd seen her before), and she said it wasn't depression.  Are these what you mean by behavioral therapy?

        Hope this isn't TMI.  I am just feeling down tonight, but I'll go watch a movie and forget about it in a little bit :o)

        Thanks again for your response.

    •  Unknown Q (6+ / 0-)

      I suggest that you call your insurance company and ask for a copy of the denial and what the process is to contest it. Then do it immediately. Ask the hematologist for a letter and supporting medical records, or better yet, enlist the assistance of someone on the staff at the doctor's office who can help you coordinate things between your PCP and the insurance company.

      In the meantime, press them (the insurance co.) about where they would approve of you going. Be as specific as possible on what type of specialist and evaluation is being ordered for you at Mayo, and make your insurance company give you a comparable option that's in-network. Chances are they won't be able to and will give you the authorization you need. Be persistent. Keep a record of every correspondence you have with them, including who you talked to and the date and time. This is always important when dealing with these things, but especially in your case because of your memory issues and the anxiety it's causing.

      Good luck - you can do it, I promise.

      "The answer to violence is even more democracy. Even more humanity." Norwegian Prime Minister Jens Stoltenberg

      by poe on Mon Mar 25, 2013 at 08:27:12 PM PDT

      [ Parent ]

      •  Great advice, poe! Thanks--I wish I could (5+ / 0-)

        hotlist a comment. ;) Huugggs!

        Some DKos series & groups worth your while: Black Kos, Native American Netroots, KosAbility, Monday Night Cancer Club. If you'd like to join the Motor City Kossacks, send me a Kosmail.

        by peregrine kate on Mon Mar 25, 2013 at 08:30:38 PM PDT

        [ Parent ]

        •  Back atcha, my friend (5+ / 0-)

          I'm off to read the article, but I have to say that at a glance I have the same concerns that you and others have raised.

          One thing I can say for sure is that I would most definitely like to be on such a committee. I would practically pay to be on one! While not the biggest part of my job, I deal a fair amount with billing issues, and a lot with insurance companies. It's horrible right now. The people who set the policies and procedures don't know - perhaps don't care to know - what's happening at the point of care. Worse yet, and even more sinister, I suspect it's confusing and unwieldy by design.

          "The answer to violence is even more democracy. Even more humanity." Norwegian Prime Minister Jens Stoltenberg

          by poe on Mon Mar 25, 2013 at 08:43:35 PM PDT

          [ Parent ]

          •  Don't just be (0+ / 0-)

            suspicious, there is no doubt in my mind that the insurance company that Unknown is dealing with is carrying out its actions in the hopes that she will continue to flounder until she goes away, thus saving them the costs of her treatment.  

            If they were in the business of insuring medical care,  they would immediately respond by providing a list of providers who are suitable for her condition.  Alas most health insurance companies appear to be in the business of solely sacrificing patient's health for profits and CEO pay.

            Life is not a problem to be solved but an adventure to be experienced.

            by DarkHawk98 on Wed Mar 27, 2013 at 04:51:09 PM PDT

            [ Parent ]

      •  Oh, poe, I'm nearly in tears. (5+ / 0-)

        I copied your comment and pasted it in email to myself.  Everything has been such an uphill battle for so long, and boy did you hit the nail on the head about the anxiety.  I know you don't know me, nor I you, but your last line awesome and deeply appreciated.  Thank you so much.

      •  Good advice, and have a buddy with you (1+ / 0-)
        Recommended by:
        peregrine kate

        if needed to help you stay on track with the labyrinthine hurdles you may need to follow to get your denial reversed. If you can find a friend to sit with you while you're on the phone they may be able to help you find the information you need when you need it, to make sure the questions you ask are fully answered, and that the information you get is clearly understood. If nothing else...it's moral support...

        PS - please check to see if you've been tested for Lyme, erlichia, or other tick-borne diseases. In chronic untreated cases, the neuro symptoms sound a lot like what you're describing. And if you haven't been tested, talk to your Doc about it, and if they poo-poo it, look for a Lyme literate doctor in your area. Many cases go unnoticed and untreated for years, and by the time it's diagnosed the symptoms include debilitating cardio and neuro ones that often aren't seen as being related to a tick bite that may not have even been felt in the first place!

        Healing blessings to you and everyone at MNCC.

        •  Oh, very good point about the tick-borne (0+ / 0-)

          diseases. I totally didn't think about that, so I am glad that you did. Thanks, and thanks for the blessings.

          Some DKos series & groups worth your while: Black Kos, Native American Netroots, KosAbility, Monday Night Cancer Club. If you'd like to join the Motor City Kossacks, send me a Kosmail.

          by peregrine kate on Wed Mar 27, 2013 at 09:51:32 AM PDT

          [ Parent ]

  •  Can I have a week to study this and get back to (7+ / 0-)

    you? ;-)

    Without reading any of the suggested material I totally agree with Susan from 29.

    The profit has to be taken out of health care. It's the ethical and economical thing to do.

    And nothing mentioned about other countries who have a better success rate with cancer treatment and research?
    Why reinvent the wheel?

    I would NOT want to be in a group discussing this. 10 minutes in and I would probably jump out the window.

    Tracy B Ann - technically that is my signature.

    by ZenTrainer on Mon Mar 25, 2013 at 06:55:27 PM PDT

    •  Of course! But yes, I think (irony alert) that's (4+ / 0-)

      the real bottom line--the urgency for getting profits out of health care. Right now it's just another mechanism by which the rich are getting richer, and I don't mean to target doctors primarily, though some of them are in that stratospherically wealthy tier. Hospital admins and insurance execs earn obscene amounts of money which never seem to be mentioned as something that should be considered as something to reform.
      Now, it may well be true that as a proportion of health care costs those exorbitant salaries are relatively insignificant. Somehow I doubt it, however; all the bigwigs do get big bucks, and pretty soon the millions do add up.
      The cross-country comparisons would probably be staggering, too.
      Eh, maybe I shouldn't have picked such an easy target. The thing is, Emanuel is absolutely, completely at the heart of the medical establishment, and so his position reveals the limitations of the overall discussion.
      IOW, we're screwed. :P

      Some DKos series & groups worth your while: Black Kos, Native American Netroots, KosAbility, Monday Night Cancer Club. If you'd like to join the Motor City Kossacks, send me a Kosmail.

      by peregrine kate on Mon Mar 25, 2013 at 07:14:49 PM PDT

      [ Parent ]

  •  The Emanuel family is pretty interesting. (3+ / 0-)

    The other brother Ari is a big agent in Hollywood. (Jeremy Pivens plays him on the show Entourage)

    I think he is everyone's agent from Michael Moore to Justin Timberlake.

    From what I have read in the past I have not agreed with Dr. Emanuel 's philosophy of medicine.

    Tracy B Ann - technically that is my signature.

    by ZenTrainer on Mon Mar 25, 2013 at 08:21:24 PM PDT

    •  Yeah, pretty high-powered and ambitious all right. (3+ / 0-)

      I get worn out just reading about them ;) Can't imagine what family gatherings would be like. Probably a good thing that they're all in such different fields, though that probably doesn't reduce the competition by much.
      He hedges his bets a lot--Dr. E. that is. I would agree with him regarding opposition to euthanasia, if the little bit I've read is a fair representation of his position, but for an ethicist he does seem to have a rather bloodless approach. Maybe that's part of the job description.

      Some DKos series & groups worth your while: Black Kos, Native American Netroots, KosAbility, Monday Night Cancer Club. If you'd like to join the Motor City Kossacks, send me a Kosmail.

      by peregrine kate on Mon Mar 25, 2013 at 08:25:48 PM PDT

      [ Parent ]

  •  I am looking at statements and bills (6+ / 0-)

    as they are coming in for Leaves.  I have previously written about thi.

    The cancer was not immediately life-threatening, but the damage to her spine potentially was, and if not directly, the chance of major paralysis was quite real.

    What concerns me about Dr. Emanuel's approach is that it is in isolation - that is, it is dealing with cancer after diagnosis, which is far too often too far downstream from where it could be detected.  The importance of screening - which is not necessarily all THAT expensive as a means of catching cancers in their early, more treatable stages -  does not seem to even enter into his thinking.

    Thus I am skeptical of what he offers because it does not look at the entire picture.

    "We didn't set out to save the world; we set out to wonder how other people are doing and to reflect on how our actions affect other people's hearts." - Pema Chodron

    by teacherken on Mon Mar 25, 2013 at 08:26:32 PM PDT

    •  Quite so re: the focus on post-dx care. (3+ / 0-)

      Screening is important; identifying environmental contributors and then working to eliminate them would be constructive, too.  Basically, it would be better if we could front-load the process so that people could count on getting the interventions they need as early as possible. I don't see any consideration of that in his proposal either.
      Thanks for your comment, Ken. Good to hear that Leaves is doing so much better.

      Some DKos series & groups worth your while: Black Kos, Native American Netroots, KosAbility, Monday Night Cancer Club. If you'd like to join the Motor City Kossacks, send me a Kosmail.

      by peregrine kate on Mon Mar 25, 2013 at 08:34:23 PM PDT

      [ Parent ]

  •  There will be a quilt diary (6+ / 0-)

    tomorrow night for Clytemnestra.  I wanted to post tonight but my draft went poof!  Vanished as I was working on it.

    IMG_2202

    We're quilting Leaves on the Current's quilt now.  

    I still need 14 messages for Carol in San Antonio -- please let me know if you would like to include a message on her quilt.  Don't be shy!

    You can order Pootie Pads here until the website is back up. Pooties love them!

    by Sara R on Mon Mar 25, 2013 at 08:27:40 PM PDT

  •  It's time, my dears, for me to call it a night. (5+ / 0-)

    Thank you to everyone who stopped by this evening; it's always good for me to have these discussions. I hope you have enjoyed it too. I will of course check back in the morning for more comments and exchanges.

    Here is the list of proposed diary topics, with potential writers in parentheses:

    Cancer and PTSD
    Cancer and Depression
    Cancer and Anxiety
    Race and Class Disparities in Cancer Survival
    Clinical Trials (murasaki)
    Cancer and Genetic Testing
    Cancer and Environmental "Hot Spots"
    Cancer and Patient Advocates
    Politics of Cancer (ZenTrainer)

    Of course, these are not hard and fast commitments; life happens. But if I've missed anyone, my apologies. Please let me know if one of these, or another topic altogether, piques your interest.

    Next week (4/1) I think I'll be writing about "Bodies in Motion"--that is, the kinds of exercise/fitness regimes, if any, we've pursued.

    Wishing everyone a good and healthy week, along with some more substantial signs of spring!

    Some DKos series & groups worth your while: Black Kos, Native American Netroots, KosAbility, Monday Night Cancer Club. If you'd like to join the Motor City Kossacks, send me a Kosmail.

    by peregrine kate on Mon Mar 25, 2013 at 09:02:47 PM PDT

  •  Night PK. And guess what? It's snowing here (2+ / 0-)

    and it's sticking to the grass. Bloody hell, this is why I moved from MI to TN!

    Tracy B Ann - technically that is my signature.

    by ZenTrainer on Mon Mar 25, 2013 at 09:20:42 PM PDT

  •  Sorry I am late (3+ / 0-)
    Recommended by:
    jesmith2, ZenTrainer, peregrine kate

    My son has a rare form of cancer and his treatments have been ridiculously expensive, but not because they are necessarily "cutting edge."

    To shrink the endocrine tumors, they use a synthetic variant of somatostatin known as Octreotide. The problem is that Novartis owns the patent and renewed the patent by creating a long acting version to replace short-acting self-injections. Treatment using somatostatin analog dates back to the early 80s. Each long-acting dose costs $19,000 (although insurance negotiated price is $12,000), which are administered every 3 weeks. Novartis is the problem because in order to insure a profit margin for the LAR Octreotide in a disease with about 10,000 new cases a year, they jack the price and have not been willing to drop down. Patient advocates have been pushing them for years to do so without success. Their patent is coming to an end and new analogs are coming to market, so the market conditions are about to change. However, it is clear that a big part of our health care cost has gone to pharmaceuticals.

    My first reaction to reading the piece is the fear that "bundled" treatment plans sound too much like a one size fits all mode. Also, it could potentially penalize less common forms of cancer where there is high cost relative to outcomes because of less research and more proprietary monopoly.

    The other thought that comes to mind is that the amount of money we spend on biomedical research in this country is absurdly low. Instead of stupid expensive weapons systems, this is where we should be spending. Ultimately, the cost of care would be lower.

    The profit margins in health care delivery and pharmaceuticals are the problem. Laissez faire capitalism has given us the most expensive and least effective medical care system in the developed world. The failure or unwillingness of our elected officials to address this root cause of cost in our system is disgraceful.

    Finally, I am basic agreement with the "high touch" idea except it does not fit with reality. Most physicians I know do not own their own practices, but rather work in large practices, often in large medical center outpatient care offices. The owners of those practices are forcing them into low touch, high volume care. They are seeing 8-10 patients an hour, with 50 hour per week bill cycle.

    Be radical in your compassion.

    by DWG on Tue Mar 26, 2013 at 02:41:11 AM PDT

    •  Wonderful comment! Though I am sorry about (2+ / 0-)
      Recommended by:
      peregrine kate, DWG

      your son. It would be nice if a few folks like you were in on the national discussion group.

      I have been thinking about patents and medicine a lot lately and wondering about the ethical considerations.

      Tracy B Ann - technically that is my signature.

      by ZenTrainer on Tue Mar 26, 2013 at 05:56:59 AM PDT

      [ Parent ]

    •  I recommend everyone (3+ / 0-)
      Recommended by:
      peregrine kate, DWG, ZenTrainer

      read God's Hotel by Victoria Sweet. The author calls it "slow medicine" but her concept is similar to the "high touch" ideas mentioned in comments above.

      Taking profit out of health care crosses all sorts of political divides and is therefore a multi-generational solution. Fortunately, that process began with the introduction of Medicare some decades ago. The ACA assists in moving the idea along, even if it got watered down in committee.

      We need great leaders who are "radical in their compassion." (Thank you DWG.) Obama is one of these.

      We are on the correct path. The evidence for this is demonstrated by the right wing's maniacal opposition to Medicare and the ACA.

       

      •  Another workshop I went to recently was with (2+ / 0-)
        Recommended by:
        jesmith2, peregrine kate

        my oncologist. He heads the research department for lung cancer at a local hospital here.

        All of his slides mentioned something about anxiety and stress, as a factor causing cancer or as a side effect of having cancer etc.

        I asked why, if that is so, anti-anxiety meds aren't given out with each diagnosis.

        Someone else answered that there was just a new decision on a slight change in medical model diagnosis. That was that any patient being diagnosed with cancer needs to be referred to someone to assess their mental and emotional status.

        This at least gets us over to the "right brain' folks who  use the "high touch" methods as a matter of course.

        Tracy B Ann - technically that is my signature.

        by ZenTrainer on Tue Mar 26, 2013 at 08:15:19 AM PDT

        [ Parent ]

        •  Very interesting. Yes, I personally believe (3+ / 0-)
          Recommended by:
          jesmith2, ZenTrainer, DarkHawk98

          stress played a role in my own cancer. (I'm not willing to make a generalization here, or to cite a particular percentage of stress's contribution to my condition.)

          Thing is, what does it mean to have someone "assess" a cancer patient's mental and emotional status? Is there going to be some support provided--free or nearly so--and would that support also be compatible with the patient's own beliefs? It's a good idea but could use some flexibility.

          For the record, I did see a clinical social worker who is part of the oncology team at the hospital for a few months, the first six months or so post dx. She was a nice woman, and generally helpful, but I stopped going to see her for two major reasons. One was that I figured out that the case notes that she was taking about me were part of my medical history with oncology, and I wasn't pleased about that. (They already have enough trouble with being accurate about my medical history.) The other was that after I had the metastases to my lungs, she was ready to start talking with me about end-of-life issues and hospice. No way was I interested in going there. No way. Then and now, I needed to give it my best shot, not fold my tents and give up.

          Some DKos series & groups worth your while: Black Kos, Native American Netroots, KosAbility, Monday Night Cancer Club. If you'd like to join the Motor City Kossacks, send me a Kosmail.

          by peregrine kate on Tue Mar 26, 2013 at 06:34:35 PM PDT

          [ Parent ]

      •  Looks like an excellent book, jesmith2. (0+ / 0-)

        I will have to pick it up soon. Thanks for mentioning it.
        Reminds me it's about time again for another diary on cancer books to recommend.

        Some DKos series & groups worth your while: Black Kos, Native American Netroots, KosAbility, Monday Night Cancer Club. If you'd like to join the Motor City Kossacks, send me a Kosmail.

        by peregrine kate on Tue Mar 26, 2013 at 06:38:19 PM PDT

        [ Parent ]

    •  Thanks, DWG, for stopping by no matter when. (0+ / 0-)

      (Sometimes these discussions do persist for a couple of days.)

      I assume that your son will be on this medication indefinitely? Thank goodness that coverage caps will soon be ended.

      Big Pharma is definitely responsible for a great portion of the health care cost climb in the U.S. There's been relatively little attention paid to that reality, but it persists.

      I agree with your other points as well. We have deeply distorted priorities for research and other social expenditures in this country, and the lack of controls on health care profits is shameful.

      Your observation about most doctors being captured in effect by larger systems is also an important one, something that most outside of the system don't realize at all (and thus can't appreciate the impact of it).

      I hope that your son's health holds steady, at least, and improves in the best case. Good to see you here.

      Some DKos series & groups worth your while: Black Kos, Native American Netroots, KosAbility, Monday Night Cancer Club. If you'd like to join the Motor City Kossacks, send me a Kosmail.

      by peregrine kate on Tue Mar 26, 2013 at 06:43:58 PM PDT

      [ Parent ]

  •  There is also the larger issue of care vs cure. (1+ / 0-)
    Recommended by:
    peregrine kate

    Much more money to be made treating cancer than curing.

    Tracy B Ann - technically that is my signature.

    by ZenTrainer on Tue Mar 26, 2013 at 05:58:45 AM PDT

  •  Zeke Emanuel makes some good points BUT (1+ / 0-)
    Recommended by:
    DarkHawk98

    Remember, he's the one in the Obama WH who was virulently opposed to the Public Option and campaigned relentlessly against it, behind the scenes of course.

    I noted this rather small article has numerous co-authors.  I suspect the article reflects their POV more than it does Emanuel's.

    It's a very good article that raises many good points about what's wrong with our current system of both cancer care and cancer research and drug development.  I certainly encourage any cancer survivors to get involved in advocating for changes to the system.

    It is an old strategy of tyrants to delude their victims into fighting their battles for them. FDR

    by Betty Pinson on Thu Mar 28, 2013 at 12:12:22 PM PDT

    •  You know, I had forgotten that point. (0+ / 0-)

      I posted the article as a prompt for discussion, which turns out to have worked pretty well. But I am very sorry to hear that he worked against all of our best interests; that turns me against him as almost nothing else would.
      We all do need to get involved. Our lives depend on it.

      Some DKos series & groups worth your while: Black Kos, Native American Netroots, KosAbility, Monday Night Cancer Club. If you'd like to join the Motor City Kossacks, send me a Kosmail.

      by peregrine kate on Mon Apr 01, 2013 at 08:36:47 PM PDT

      [ Parent ]

Subscribe or Donate to support Daily Kos.

Click here for the mobile view of the site