Sunday, April 06, 2008

The Ford Pinto as a model for medical care

Remember when Ford’s Pintos were routinely bursting into flame and exploding as the result of very minor collisions?

Remember the outrage when it was learned that Ford was aware of this problem with the gas tanks of those cars, but that they chose to leave them as-is rather than spend a dollar or two per car?

Remember the disbelief that greeted their explanation that they chose this course because their cost-benefit analysis had shown that it was cheaper for Ford to let some cars explode and pay off those lawsuits, rather than to add a couple of dollars to each of the cars?

Well, welcome to the philosophy of modern medicine.

As a case in point, take look at the immunization policy that has been adopted for determining who should receive shots to prevent shingles…

First, you need to know that shingles is due to a reactivation of chicken pox (Varicella zoster) virus that lays dormant in the roots of your spinal nerves for decades, and then emerges to wreak some degree of havoc on your sensory nerves.

If you’ve had chicken pox, you are at major risk for shingles, and the incidence before age 45 is about 1 of 10 getting the disease for both males and females, and after age 45 it is about 1 of 3 for females, and 1 of 4 for males.

Furthermore, HALF of all shingles cases occur in patients younger than 60.

Overall, you clearly have a very good chance of losing in the shingles lottery.

So, what’s in store for you when it happens? Some people get lucky and just have a few months of intense itching followed by weird pain (for me, it felt like I was being chewed on internally), if they catch it in time and take anti-virals and then either anti-convulsants or anti-depressants (both of which often seem to moderate the symptoms somewhat) but all of these drugs have their own side effects. While I was on the anti-convulsant neurontin for more than a year, I found my thinking got quite muddled and I stopped caring about much at all.

Others, though, lose again, and can experience months of agonizing pain that calls for extreme pain meds (like fentanyl, oxycontin, and morphine), and some can even experience blindness, while others can experience itching so severe that they will scratch through bone:

Even having had shingles (twice!), this kind of itching is beyond my comprehension. But perhaps not for my co-worker, who was one of the unlucky: even on massive pain medication, she spent weeks curled into a fetal position, moaning, crying, begging for relief. More than two years later, she still has symptoms, but at least she was not unlucky for a third time; at least she has escaped the worst of it—having pain that is unremitting for years and even decades—but others are not so lucky, and can have their lives completely ruined by years of unspeakable misery.

And yet, the medical establishment has decided to withhold the newly developed and highly effective shingles vaccine (partially paid for by taxpayers like us) from everyone who is younger than 60. Yes, their recommendation, which is what insurance companies base their reimbursement policies on, is that the vaccine “should” only be given to those over 60. Remember, as noted above, half of those who get shingles are younger than 60 (like me and my co-worker…), so a great many people have been, willy-nilly, sentenced to suffer this preventable atrocious disease!

I can only conclude from my research that this is a choice that was made because the health insurance companies do not want to pay the freight for the costly shingles vaccinations ($180 each) for all of their patients. Medicare will pay for those 65 and over, so this leaves only the 60-64 year old cohort to be paid for by the health insurance companies.

But isn’t the big selling point of HMOs and PPOs the superior preventive care that’s given, so that health care costs can be better managed?

Ah, but there’s the rub: a case of shingles doesn’t cost an insurer very much. A few office visits, a few prescriptions, and that’s it. Sure, the patient may be unable to work for years, may require care from family and friends, and may simply end it all through suicide (not that uncommon an outcome of shingles).

None of this ever shows up on the health insurers’ balance sheets, though, so none of this is of any concern to them. The formidable costs—monetary and otherwise—are borne by the patient, the patient’s family, the employer, other insurers (long term care; disability; SSI), but no harm done to the HMO! Obviously, it is far cheaper for the corporation to withhold needed medicine from its patients than to actively prevent the disease! Econ 101!

Ain’t American health care great!

But wait, there’s more! When the manufacturer tested the vaccine, they noted that its efficacy was greatest in the youngest cohort they tested, and then declined in each succeeding cohort. And the age of their youngest cohort was? 60-69 years old. Merck didn’t even test the vaccine on those younger than 60, for some inscrutable reason that I’d love to know about.

Clearly, if the vaccine was more and more effective in each younger cohort, it’s quite possible that it’s even more effective on the next younger group, 50-59 years old, and maybe even more so in folks younger than that, as suggested by simple extrapolation. Sure, there’s no data showing that such extrapolation is valid, but there’s also no evidence that it’s not valid, so why not find out? This seems to be a case of willful ignorance, the motivation for which I have no clue.

The upshot of all this is that it seems I will be requesting the vaccine on my own dime, something I would recommend for anyone who can afford this course. Yes, I am living proof that lightning—shingles—can strike the same person twice, and I have no desire to try for a third bout. The vaccine is “especially recommended” for those who have already had shingles. So even though I supposedly have “great” insurance, I will be paying for this myself. Yea, those corps really do know what they’re doing! And it ain’t health “care.”