March 20th, 2008

How to Solve at Least One Part of the Healthcare Mess: ADAP for All

The presidential elections have once again made our Byzantine healthcare system a regular feature in the news. A recent film also made quite a splash, and though Michael Moore offered no plausible solutions (Cuba? c’mon!), he certainly made me wonder what I’d do if I had two severed fingers that needed to be reattached and only enough money to cover one procedure.

Everywhere, you hear the usual complaints: increasing numbers of uninsured, highly variable (but mostly mediocre) quality of care, “skyrocketing” (interesting how often that adjective is used) costs, misaligned incentives leading to overuse of expensive procedures and medications, greedy insurers denying coverage, and (always) unfavorable comparisons with outcomes in other industrialized countries. Reading the various candidates’ solutions to this quagmire, I get that same heavy-lidded feeling I had in medical school when lecturers tried to “explain” how the immune system works — yes, you have a theory and a lot of nice figures, but could anything so complicated really work? Many of those immunology theories have long since been discarded, and it would not surprise me a bit to see the same happen with the presidential hopefuls’ proposals.

It is with great magnanimity, therefore, that I offer the candidates — free of charge — a model of how to fix one aspect of our healthcare mess, the high cost of prescription drugs.

What we need is an AIDS Drug Assistance Program — ADAP — for everyone, and everything. Yes, ADAPs are far from perfect (4 states had ADAP waiting lists in the last year, some patients can’t get their $2000 viral tropism test paid for), but what they’ve accomplished is truly extraordinary. Some highlights:

  • Provision of HIV-related prescription drugs to low-income people with HIV in all 50 states, the District of Columbia, Puerto Rico, the US Virgin Islands, and Guam. Some states use ADAP funds to provide insurance coverage as well.
  • Each state runs its own ADAP, determining eligibility criteria and coverage — so no one-size-fits-all problem.
  • Funding is derived from an imaginative mixture of federal and state sources.
  • ADAPs participate in the 340B program, enabling them to obtain prescription drugs far below commercial prices.
  • Careful review (and often denial) of medications that have marginal indications for HIV treatment but high cost, such as recombinant growth hormone or erythropoeitin. In other words, cost-containment at its sensible best.

It’s possible (ok, likely) that my rosy view of ADAPs is colored by practicing HIV medicine in Massachusetts, which has one of the more generous ADAP programs in the country. Nonetheless, just think of the typical ADAP beneficiary, and what it would be like caring for him or her without this program — 64% are people of color, 71% are completely uninsured, and over half have an annual income <$9800 (the Federal Poverty Level). Oh yes, more than half are also severely immunosuppressed due to HIV — one could never argue that ADAPs have cherry-picked the “easy” patients.

So go with it, Hillary, Obama, and John — take the best of ADAP, change the name, and make it your plan. Just make sure to leave the real ADAP alone — it’s much too good a program to ruin with national politics.

11 Responses to “How to Solve at Least One Part of the Healthcare Mess: ADAP for All”

  1. David says:

    You propose a National plan that only takes care of the patients in your specialty. This is an amazingly irresponsible, greedy, self centered plan.

    Sorry, but your patients are no more deserving of free drugs than someone else’s cancer patient. If there is any “mess,” it’s because of others like you who chauvinisticly feel they have the only true problem. Wake up — it’s not just about you.

    Using the extreme language “Byzantine healthcare system” and a “healthcare mess” to describe the best medical system in the world indicates that you were influenced by similar lies and distortions in Michael Moore’s movie.

  2. Paul Sax says:

    I think we’re in agreement (at least about some things). I wrote:

    “What we need is an AIDS Drug Assistance Program — ADAP — for everyone, and everything.”

    My point in writing this is that it’s quite something (wonderful, actually) being able to prescribe life-saving therapy for people who need it, regardless of their ability to pay. Sure, it’s an oversimplification — but wouldn’t it be great if something like this existed for other diseases?

  3. Ian MacInnes M.D. says:

    Oh David–I must disagree with your claim that we have the best Health Care system in the world. There are 47 Million people who do not have access to this.
    I have practiced and taught in Scotland, England, Ireland, Saskatchewan, Alberta, Connecticut, and Maine,and can state that the U.S. sadly merits its 37th position, among the Industrial nations, awarded by the World Health Organization.

  4. Anne White MD FRCPC says:

    Provision of HIV-related prescription drugs to low-income people with HIV in all 50 states…….
    Universal Health Care means “universal”. Only providing for low income people puts the middle classes in the position, again,where they are assumed to have enough money (or assets to sell – like a home). I guess they then end up as low income and qualify. I was in Tanzania last year. Bill Gates has it right. EVERYONE gets ARV medications that are needed.
    Having a goal of free medicine to only low income folks is very short sighted. Aim high and you may get most of what you ask for, aim low and that’s what you get- the minimum.
    I agree with Dr MacInnes. I too have practised in several countries with far better access and general quality heathcare than the USA. I find that the people who claim that the USA has the best health care usually have never worked in different systems. They believe the propaganda. With respect to Michael Moore. There is one (American) medical school that now makes all its entry level students watch this film.

  5. Paul Sax says:

    Film Review: I thought “Sicko” was terrific. Entertaining, moving, funny, and (best of all) never boring, the key determinant for me when I go to the movies.

    But when he went to Cuba, he lost me. That whole part of the movie seemed as forced and staged as the earlier parts were heartfelt and genuine.

  6. ashley adams says:

    Your argument for an AIDS Drug Assistance Program is compelling. But it is no more compelling than a TB Drug Assistance Program or a Hep B Drug Assistance Program or a Routine Medical Visit Program, etc. Perhaps big change is best started incrementally — in which case this is a great idea. But the goal should be health care for all forever, no?

  7. Paul Sax says:

    Just proposing we start “small” … with a state-run drug program that covers “everyone, and everything [i.e., all indicated medications].” Once that gets rolling, we can move onto bigger ticket items.

  8. Derek says:

    Getting everyone the prescriptions they need is a good start, yes. I think some of the other commenters missed that point. I grew up in the US, but now live in the UK. I think the NHS is terrific. I, too, recently saw Sicko, and hope that things change in America. I was a beneficiary of ADAP, but the prescription service here is still better than that. Almost every month in the US I had difficulty getting my prescription filled, mostly due to red tape. I’m a conscientious patient, careful of my health and all, yet due to the system would frequently be forced to miss doses. Here, on the other hand, I get my prescriptions delivered quarterly, free of charge, to my home. I never have less than a month’s supply of my much-needed drugs. Over the last two years I’ve been here, I’ve never missed a day’s medication.

  9. Peter says:

    One ugly truth of prolonging the lives of HIV+ patients is that unfortunately they will be able to spread their disease to more people creating more devastation. This is especially true in Aftrica. Several studies (in the USA) have indicated that about 50% of HIV+ men continue to practice unprotected sex. Should we treat these people? OF course. Are they deserving of special status” Absolutely not. HIV is overwhemlingly a disease of lifestyle. I think more health care resources should be spent on prevention and education and less on bailing people out after they have made poor choices. This includes people who have liver issues from excessive drinking, cancer from smoking and other preventable diseases.

    Do you think me heartless? I’d like to think of myself as logical. From evolution we know that when we artificially interfere with natural selection we weaken the gene pool. If we extrapolate what would happen if we saved every person who would otherwise would have died from disease, defect or lifestyle then the future of humanity is a race of very ill people requiring extensive and continuous medical intervention. A balance must be found between saving lifes and spending medical resources with an eye toward what will bebefit the most people in the long run.

  10. The healthcare systems in all developed and many developing nations are in crisis. The problem is not how and to whom and how much insurance payments are being or not being made. The problem is an ever increasing/no upper limit need for expensive high tech medical care! Now this is America’s specialty! We are world leaders in expensive high tech medical care. In fact, according to David Walker, head of the GAO, the 78 million baby boomers going on Medicare in the next 20 years will bankrupt the US Treasury. Bill Clinton is a particularly bad example with his lifelong “bubba diet” and first MI (heart attack) before age 60. And he has had health insurance his entire life. Shame on him!
    Insurance companies stay in business because they are masters at calculating risk. If you live in New Orleans or South Florida are you going to whine that you can’t afford flood insurance? Move way up inland. If your house is on fire and you call State Farm to buy fire insurance, are you going to complain that you got turned down because the fire was considered a “pre-existing” condition? And just try buying earthquake insurance if you’re straddling the San Andreas Fault. As I said, they are masters at calculating risk.
    You see, in the usual sense of the word, health insurance is not insurance, it is considered an “entitlement”. I am an American, and even though I eat like that guy in “Supersize Me”, my BMI is >30, I smoke a pack a day, and the last time I exercised was in grade school, I want health insurance I can afford!!! ‘Cause it’s my birthright. Variations on that scenario are the real cause of the health care “crisis”.
    But wait, I’ve heard other countries have much better systems, so why don’t we learn from them? We’ve all read horror stories of long waits under the British NHS. Where there is socialized medicine, the doctors don’t make much money. So many opt out and take care of Arabs and other rich people. Or come to America. Every AM, Canadian nurses flood across the border to work at (much) higher paying jobs in Michigan and New York. Cuban doctors and nurses don’t mind their low pay. Because of the 50 year embargo, there is not all that much you can buy in Cuba. With Fidel gone, that’s gonna change.
    In America, docs graduate with huge debts, high malpractice insurance rates and expectations of a new Lexus yearly and a grand house in the right neighborhood. Docs have teenagers too. Have you checked the tuition rates for good colleges these days? (50x what I paid in 1951!) Because of this, many doctors don’t accept Medicare, Medicaid and SCHIP. Do you really believe docs are going to accept another low paying government insurance plan that covers all of the currently uninsured? If you do, I have this bridge in Brooklyn I can sell you for a really good price.
    Hearing the politicians in 2008 promising “affordable health insurance for everyone” makes me wonder what they’re all smoking. Do you really think that Big Pharma, Big Health Insurance and Big AMA (whose lobbyists own Congress) are going to go along with socialized medicine for all? If you do, that makes me wonder what you are smoking.
    Employers big and small are dropping health insurance in order to avoid bankruptcy. Hospitals are closing ERs because that’s where the uninsured show up. There aren’t enough nurses, in part because now-a-days many women interested in medicine are becoming doctors! Plus, two large groups don’t go into nursing: men and white people. Many nursing teachers are going to work in the hospitals because the pay is so much higher. We are stealing nurses from every country in the world. Also doctors to work at our VA and charity hospitals and clinics because American docs don’t want to work there. Go to any County or City hospital in America and try to find a medical person who speaks English without an accent. They are good docs, but we’re stealing from the rest of the world.
    Demand for medical services is rising. 90% of Americans eventually reach >140/90 BP. >120/80 (now called “pre-hypertension”) also leads to vascular damage, just not as much or as fast. Most need more than one medication for hypertension and all need to see their doc q6 months for Rx refills. That’s everyday for the rest of their lives. Many with high BP also have high cholesterol. Many of those folks have or will get the Metabolic Syndrome. That adds more pills. A typical senior >60 takes 6-8 prescription meds, few of them reliably even if they can afford them. Decades of taking multiple pills to prevent cardio-vascular and other diseases in most adults add a staggering financial burden to an already cost challenged health care system.
    It gets worse. The pandemic of “diabesity” has now reached our children. The average teenager has pre-hypertension.(see table below) Some have the early stages of type 2 DM. Many of the latter will be on kidney dialysis in their 30’s. Transplantation works poorly in diabetics. Lifespan on dialysis is just a few years. Experts say the answer is 6x instead of 3x weekly dialysis treatments. There aren’t enough docs and technicians and machines to do that even if there was enough money (which there isn’t).
    We have a growing shortage of Primary Care docs. Specialists make more money, have better hours and more prestige. But Primary Care docs are vital to keeping costs down. They are the ones who initiate and monitor pill-based preventive medicine. Sadly after 5 or 10 years of taking multiple pills almost everyone gets sick anyway. Now the specialists take over and the medical costs really skyrocket. A stay in a hospital costs many $1000s/day. The last few years of a senior’s life on Medicare may cost the taxpayers $ millions. As we continue to develop more expensive technology, that cost is only going to rise. And many if not most of their medical problems were completely preventable. It’s best to start as young as possible though.
    Our only hope is that all of us have to start taking much better care of ourselves. In that regard we need a lot of help. The average American has all the will power of a hungry dog with a bowl of hamburger in front of him. So let’s place guards at the doors of every fast food and regular restaurants and all grocers. No one with a BMI > 30 is allowed in. Let’s start rioting. TV news showing angry mobs going around smashing junk food/drink vending machines shows ‘em we mean business! 4th of July could become a vegetarian holiday. Thanksgiving could become a family contest for how little you can eat. Parents start yelling at their kids, “Don’t clean your plate!!” In December you give everyone clothes 1-2 sizes too small as the annual “Christmas Challenge”. Crazy ideas I know but we’ve got to start somewhere.

  11. Peter J Stanton, MS, DC, DABCO says:

    A well thought out rant Dr Bennet.

    I don’t think that taking better care of ourselves will lower costs much. If we do so, we will live longer but also require more care. In addition there is the end of life issue. Even health nuts eventually die and many from long term illnesses costing mega bucks.

    We need to do more research on outcomes. If a procedure or drug does not lower mortality or improve quality of life then lets not pay for it. Recent studies show that for back surgery and knee arthoscopy, most patients are the same upon one year follow up whether they choose surgery or not. Statin use is debatable for most patients.

    We may also have to develop parameters regarding what level of care to render in obviously terminal folks. Is it worth it to perform a hip replacement on a 80 yr old Alzheimers patient? If I have termnal cancer, should we spend 200K to help me live 6 month longer? Here is a really sticky one: Do we spend 500K to help a premie live for 8 yrs after a multiple organ transplant?

    Perhaps it would be best if Americans lived healthy and died quickly.

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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