Michael Kalisman MD




Why Everyone Seems to Have Cancer

Sunday, January 5th, 2014

Why Everyone Seems to Have Cancer http://www.nytimes.com/2014/01/05/sunday-review/why-everyone-seems-to-have-cancer.html?nl=todaysheadlines&emc=edit_th_20140105&_r=0 Jillian Tamaki By GEORGE JOHNSON Published: January 4, 2014 EVERY New Year when the government publishes its Report to the Nation on the Status of Cancer, it is followed by a familiar lament. We are losing the war against cancer. Graphic Graphic Declining Lethality Half a century ago, the story goes, a person was far more likely to die from heart disease. Now cancer is on the verge of overtaking it as the No. 1 cause of death. Troubling as this sounds, the comparison is unfair. Cancer is, by far, the harder problem — a condition deeply ingrained in the nature of evolution and multicellular life. Given that obstacle, cancer researchers are fighting and even winning smaller battles: reducing the death toll from childhood cancers and preventing — and sometimes curing — cancers that strike people in their prime. But when it comes to diseases of the elderly, there can be no decisive victory. This is, in the end, a zero-sum game. The rhetoric about the war on cancer implies that with enough money and determination, science might reduce cancer mortality as dramatically as it has with other leading killers — one more notch in medicine’s belt. But what, then, would we die from? Heart disease and cancer are primarily diseases of aging. Fewer people succumbing to one means more people living long enough to die from the other. The newest cancer report, which came out in mid-December, put the best possible face on things. If one accounts for the advancing age of the population — with the graying of the baby boomers, death itself is on the rise — cancer mortality has actually been decreasing bit by bit in recent decades. But the decline has been modest compared with other threats. A graph from the Centers for Disease Control and Prevention tells the story. There are two lines representing the age-adjusted mortality rate from heart disease and from cancer. In 1958 when the diagram begins, the line for heart disease is decisively on top. But it plunges by 68 percent while cancer declines so slowly — by only about 10 percent — that the slope appears far less significant. Measuring from 1990, when tobacco had finished the worst of its damage and cancer deaths were peaking, the difference is somewhat less pronounced: a decline of 44 percent for heart disease and 20 percent for cancer. But as the collision course continues, cancer seems insistent on becoming the one left standing — death’s final resort. (The wild card in the equation is death from complications of Alzheimer’s disease, which has been advancing year after year.) Though not exactly consoling, the fact that we have reached this standoff is a kind of success. A century ago average life expectancy at birth was in the low to mid-50s. Now it is almost 79, and if you make it to 65 you’re likely to live into your mid-80s. The median age of cancer death is 72. We live long enough for it to get us. The diseases that once killed earlier in life — bubonic plague, smallpox, influenza, tuberculosis — were easier obstacles. For each there was a single infectious agent, a precise cause that could be confronted. Even AIDS is being managed more and more as a chronic condition. Progress against heart disease has been slower. But the toll has been steadily reduced, or pushed further into the future, with diet, exercise and medicines that help control blood pressure and cholesterol. When difficulties do arise they can often be treated as mechanical problems — clogged piping, worn-out valves — for which there may be a temporary fix. Because of these interventions, people between 55 and 84 are increasingly more likely to die from cancer than from heart disease. For those who live beyond that age, the tables reverse, with heart disease gaining the upper hand. But year by year, as more failing hearts can be repaired or replaced, cancer has been slowly closing the gap. For the oldest among us, the two killers are fighting to a draw. But there are reasons to believe that cancer will remain the most resistant. It is not so much a disease as a phenomenon, the result of a basic evolutionary compromise. As a body lives and grows, its cells are constantly dividing, copying their DNA — this vast genetic library — and bequeathing it to the daughter cells. They in turn pass it to their own progeny: copies of copies of copies. Along the way, errors inevitably occur. Some are caused by carcinogens but most are random misprints. Over the eons, cells have developed complex mechanisms that identify and correct many of the glitches. But the process is not perfect, nor can it ever be. Mutations are the engine of evolution. Without them we never would have evolved. The trade-off is that every so often a certain combination will give an individual cell too much power. It begins to evolve independently of the rest of the body. Like a new species thriving in an ecosystem, it grows into a cancerous tumor. For that there can be no easy fix. These microscopic rebellions have been happening for at least half a billion years, since the advent of complex multicellular life — collectives of cells that must work together, holding back, as best each can, the natural tendency to proliferate. Those that do not — the cancer cells — are doing, in a Darwinian sense, what they are supposed to do: mutating, evolving and increasing in fitness compared with their neighbors, the better behaved cells of the body. And these are left at a competitive disadvantage, shackled by a compulsion to obey the rules. As people age their cells amass more potentially cancerous mutations. Given a long enough life, cancer will eventually kill you — unless you die first of something else. That would be true even in a world free from carcinogens and equipped with the most powerful medical technology. Graphic Graphic Declining Lethality Faced with this inevitability, there have been encouraging reductions in the death toll from childhood cancer, with mortality falling by more than half since 1975. For older people, some early-stage cancers — those that have not learned to colonize other parts of the body — can be cured with a combination of chemicals, radiation therapy and surgery. Others can be held in check for years, sometimes indefinitely. But the most virulent cancers have evolved such wily subterfuges (a survival instinct of their own) that they usually prevail. Progress is often measured in a few extra months of life. OVER all, the most encouraging gains are coming from prevention. Worldwide, some 15 to 20 percent of cancers are believed to be caused by infectious agents. With improvements in refrigeration and public sanitation, stomach cancer, which is linked to Helicobacter pylori bacteria, has been significantly reduced, especially in more developed parts of the world. Vaccines against human papilloma virus have the potential of nearly eliminating cervical cancer. Where antismoking campaigns are successful, lung cancer, which has accounted for almost 30 percent of cancer deaths in the United States, is steadily diminishing. More progress can be made with improvements in screening and by reducing the incidence of obesity, a metabolic imbalance that, along with diabetes, gives cancer an edge. Surprisingly, only a small percentage of cancers have been traced to the thousands of synthetic chemicals that industry has added to the environment. As regulations are further tightened, cancer rates are being reduced a little more. Most of the progress has been in richer countries. With enough political will the effort can be taken to poorer parts of the world. In the United States, racial disparities in cancer rates must be addressed. But there is a long way to go. For most cancers the only identifiable cause is entropy, the random genetic mutations that are an inevitable part of multicellular life. Advances in the science will continue. For some cancers, new immune system therapies that bolster the body’s own defenses have shown glints of promise. Genomic scans determining a cancer’s precise genetic signature, nano robots that repair and reverse cellular damage — there are always new possibilities to explore. Maybe someday some of us will live to be 200. But barring an elixir for immortality, a body will come to a point where it has outwitted every peril life has thrown at it. And for each added year, more mutations will have accumulated. If the heart holds out, then waiting at the end will be cancer. George Johnson is a former reporter and editor at The New York Times and the author of “The Cancer Chronicles.” A version of this news analysis appears in print on January 5, 2014, on page SR1 of the New York edition with the headline: Why Everyone Seems to Have Cancer. Via: Michael Kalisman, Michael Kalisman md, Cancer, The Cancer Chronicles,Declining Lethality,MichaelkalismanMD@gmail.com

Crazy Pills – mefloquine hydrochloride, brand name Lariam Preventive Drug against Malaria

Thursday, August 8th, 2013

Crazy Pills
F.D.A. Strengthens Warnings on Lariam, an Anti-Malaria Drug (July 30, 2013) (mefloquine hydrochloride, brand name Lariam)
http://www.nytimes.com/2013/08/08/opinion/crazy-pills.html?nl=todaysheadlines&emc=edit_th_20130808&_r=0#

By DAVID STUART MacLEAN

Published: August 7, 2013 8 Comments

CHICAGO — ON Oct. 16, 2002, at 4 p.m., I walked out of my apartment in Secunderabad, India, leaving the door wide open, the lights on and my laptop humming. I don’t remember doing this. I know I did it because the building’s night watchman saw me leave. I woke up the next day in a train station four miles away, with no idea who I was or why I was in India. A policeman found me, and I ended up strapped down, hallucinating in a mental hospital for three days.

F.D.A. Strengthens Warnings on Lariam, an Anti-Malaria Drug (July 30, 2013)

The cause of this incident was drugs. And these drugs had been recommended to me by the Centers for Disease Control and Prevention.

I had been prescribed mefloquine hydrochloride, brand name Lariam, to protect myself from malaria while I was in India on a Fulbright fellowship.

Since Lariam was approved in 1989, it has been clear that a small number of people who take it develop psychiatric symptoms like amnesia, hallucinations, aggression and paranoia, or neurological problems like the loss of balance, dizziness or ringing in the ears. F. Hoffmann LaRoche, the pharmaceutical company that marketed the drug, said only about 1 in 10,000 people were estimated to experience the worst side effects. But in 2001, a randomized double-blind study done in the Netherlands was published, showing that 67 percent of people who took the drug experienced one or more adverse effects, and 6 percent had side effects so severe they required medical attention.

Last week, the Food and Drug Administration finally acknowledged the severity of the neurological and psychiatric side effects and required that mefloquine’s label carry a “black box” warning of them. But this is too little, too late.

There are countless horror stories about the drug’s effects. One example: in 1999, an Ohio man, back from a safari in Zimbabwe, went down to the basement for a gallon of milk and instead put a shotgun to his head and pulled the trigger. Another: in Somalia in 1993, a Canadian soldier beat a Somali prisoner to death and then attempted suicide. “Psycho Tuesday” was the name his regiment had given to the day of the week they took their Lariam.

Lariam is no longer sold under its brand name in the United States, and our military finally caved in to pressure and stopped prescribing it to the majority of its soldiers in 2009. But some are still getting it; lawyers for Staff Sgt. Robert Bales, who has pleaded guilty to killing 16 Afghan civilians in 2012, said he had taken the drug. And the generic version is still the third most prescribed anti-malaria drug here, with about 120,000 prescriptions written in the first half of this year.

Make no mistake: mefloquine does a good job protecting against malaria (and unlike some other anti-malaria drugs, it can be used during pregnancy and has to be taken only weekly). It just works at a significant risk, the full extent of which we’re still discovering.

The new F.D.A. warning advises people taking mefloquine to call their doctor’s office if they experience side effects. Fine advice, except that by the time most people — business travelers, Peace Corps volunteers, students studying abroad — start to notice the side effects, they are thousands of miles away, frequently out of cellphone service.

Most worrying of all, the announcement notes that the drug’s neurological side effects — dizziness, loss of balance or ringing in the ears — may last for years, or even become permanent. I suspect that it’s only a matter of time before that black box tells us that the psychiatric effects may become permanent too.

More than a decade has passed since my last dose of Lariam, and I still experience depression, panic attacks, insomnia and anxiety that were never a part of my life before.

We have a generation of soldiers and travelers with this drug ticking away in their systems. In June of last year, Remington Nevin, a former Army preventive medicine officer and epidemiologist, testified in front of a Senate subcommittee that he was afraid that Lariam “may become the ‘Agent Orange’ of our generation, a toxic legacy that affects our troops and our veterans.”

Science is a journey, but commerce turns it into a destination. Science works by making mistakes and building off those mistakes to make new mistakes and new discoveries. Commerce hates mistakes; mistakes involve liability. A new miracle drug is found and heralded and defended until it destroys enough lives to make it economically inconvenient to those who created it.

Lariam is a drug whose side effects impair the user’s ability to report those side effects (being able to accurately identify feelings of confusion means that you probably aren’t that confused). The side effects leave no visible scars, no objective damage. But if Lariam were a car, if psychological or neurological side effects were as visible as broken bones, it would have been pulled from the market years ago.

It’s a prescription I wish I had left unfilled.

David Stuart MacLean is the author of the forthcoming memoir “The Answer to the Riddle is Me.”

Via:mefloquine hydrochloride, Lariam, Malaria, neurological side effects ,dizziness, loss of balance or ringing in the ears, Michael Kalisman, MichaelKalisman MD, michaelkalismanmd@gmail.com

The Secret Life of Business Class Seats— The Race to Build a Better Business Class—

Sunday, August 4th, 2013

The Race to Build a Better Business Class
http://www.nytimes.com/2013/08/04/business/the-race-to-build-a-better-business-class.html?nl=todaysheadlines&emc=edit_th_20130804
Via: Airlines, Business Class Travel, New Seat Design, Comfort Travel, Delta, Lufthansa, British airways, Singapore airline, Michael Kalisman, Michael Kalisman MD, michaelkalismanmd@gmail.com
The Secret Life of Business Class Seats: Jad Mouawad visits B/E Aerospace to see the technology behind business class seats.
By JAD MOUAWAD
Published: August 3, 2013
IN a confidential test lab in a remote office park near the Frankfurt airport, a small Lufthansa team holed up for five years, refining one of the German airline’s most closely guarded secrets. They called it the V concept.
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Early drawings and a computer rendering of Lufthansa’s new business-class seat
Six feet six inches long and almost two feet wide, the V concept is the German carrier’s latest weapon in the fierce competition among global airlines. It is designed to withstand shocks 16 times the force of gravity and comes with a cozy padded footrest. It is a new business-class seat, and if you are traveling round trip from Frankfurt to New York, it can be yours for about $5,000.
“Business class is where competition really is serious,” says Björn Bosler, the airline’s manager for passenger experience design, business and premium, who led Lufthansa’s team of dozens of seat designers and engineers. Bob Lange, senior vice president, head of market and product strategy at Airbus, the European plane maker, agrees: “There’s an arms race going on among carriers.”
Billions are being spent on research and development, architects, industrial designers and even yacht designers to pack seats with engineering innovations and fancy features. Just fabricating a single business-class seat can cost up to $80,000; custom-made first-class models run $250,000 to $500,000.
Those who fly coach may have had a glimpse of these expenditures as they shuffled past the elaborate reclining, angled, semiprivate accommodations in business and first class on their way to the knee-scraping spaces and overstuffed overhead compartments in the main cabin. Travelers in business and first class may represent 10 to 15 percent of long-haul seats globally, but they account for up to half of the revenue of airlines like Lufthansa or British Airways, says Samuel Engel, a vice president at ICF SH&E, an aviation consulting firm. Carriers vying for the attention of these passengers, who have money or corporate accounts that pay for their travel, are counting on good design to escape the grinding commodity nature of their business.
But there is only so much space inside a plane. As the more lucrative seats expand, the coach section often contracts, with more seats jammed into the same cabin space and more discomfort for coach passengers.
“The seat is one of the few elements that an airline can actually make its own,” says Patricia Bastard, an architect and designer who has worked with Air France on its first-class cabin. “There are very few elements like it inside an airplane. There’s customer service, of course. Maybe there’s a bar. But seats are unique to the airline. Seats are critical.”
Lufthansa, Europe’s largest airline and the world’s fourth largest in terms of passengers, is investing $4 billion to improve its cabins, offer satellite-based Internet and upgrade its onboard entertainment system. But the new business-class seat, which first appeared last year on the company’s new Boeing 747-8 planes, is perhaps the boldest attempt to lure the high-value passenger. The seat research, design, manufacture and installation accounts for roughly a third of that $4 billion investment, says Mr. Bosler — more than a billion dollars. Eleven planes are now outfitted with the new seats, and Lufthansa is expected to install about 7,000 of them on 100 wide-body airplanes by 2015.
Lufthansa’s task — like that of all the big airlines — was to create a special environment for those big-spending travelers within the inflexible boundaries of an aircraft fuselage.
“The challenge was finding a solution that provides all customer benefits but also tries to save as much space as possible and get as many passengers on board as possible,” Mr. Bosler says. “There’s only one way for Lufthansa to make money. It’s with passengers on board.”
THE first airplane business-class sections date to the 1970s, when the seats were like oversize, padded armchairs that could recline about 40 degrees. More comfortable seats for frequent business travelers came with the arrival in the 1990s of planes that could fly nonstop almost anywhere in the world. This new generation of ultralong-range airplanes that could fly for 10 to 14 hours — like the Boeing 777 — meant passengers wanted to be able to get real sleep, not just a fitful, head-snapping catnap

The growth of carriers from the Middle East and Asia also set off a transformation in cabin design. Emirates, for instance, created semienclosed suites for its first-class passengers. It installed showers on its Airbus A380 double-decker planes, as well as large bars behind the business-class cabin where passengers could mingle throughout the flight. Over a short span, passenger expectations changed.
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A small Lufthansa team worked on the design for the seat, called the V concept, for five years.
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Six feet six inches long and almost two feet wide, the seat is designed to withstand shocks 16 times the force of gravity.
“Business class today is what first class used to be 10 or 20 years ago,” says Jacques Pierrejean, a designer based in Paris who helped create the first-class cabin for Emirates.
The business and corporate travel market is by far the most lucrative one for the airlines. Business travelers are expected to spend $273 billion this year on airfares, according to a forecast by the Global Business Travel Association, a 4.3 percent gain from 2012.
“Airlines are rational actors, and where they make their investments tells you where they get their revenues from,” Mr. Engel says. “Despite all the technological advances, and e-mail, and videoconferencing, nothing replaces face-to-face meetings. This is why business travel remains so important. And for business travelers to remain productive, they need to fly relatively comfortably over long distances.”
This growth in business travel has spurred considerable innovation in the front of the plane. But finding the right balance among space, comfort and seat features is tricky. Until about five years ago, the norm was for business seats to provide a lie-flat surface at an angle, what was called a “faux flat,” says Mark Hiller, chief executive of Recaro Aircraft Seating, based in Germany, one of three large seat manufacturers. But frequent fliers complained that they slid down their seats during the flight.
Now airlines are increasingly trying to fit fully flat beds for business class. But these seats require more space, which typically means losing about 10 percent of the business-class seats. British Airways, struggling with trying to fit a 73-inch bed inside the 46 inches separating two seats, came up with a design in which half its passengers sit backward, says Peter Cooke, the airline’s design manager. He calls it “the yin-yang configuration,” and it can pack 56 business seats in just seven rows aboard some Boeing 777s by fitting the broader part of passengers’ anatomy (their shoulders) with the narrowest part of their neighbors’ (their feet). “By far,” he says, “it’s the most space-efficient configuration.”
The downside, obviously, is a basic disruption in the traditional seating arrangement aboard a plane. Travelers face each other, risking awkward eye contact. Mr. Cooke says passengers have become used to this quirk — they accept it on trains — and don’t mind flying backward.
Other formations include a design known as the herringbone, which is used by Virgin Atlantic. Seats are staggered diagonally, allowing tighter spacing between the seats. But it means sleeping passengers’ feet stick out in the aisles.
The latest trend is higher-density seating, now used on Emirates, Swiss and Delta, with slightly shorter beds and narrower seats. The trick here is that when a seat unfolds into a bed, it slides under the armrest of the passenger in front.
“It’s a very demanding environment,” says James Park, a designer based in London who has worked with Singapore Airlines and Cathay Pacific. “A business-class seat has to be a working desk, an entertainment center, a dining facility, and it’s also a bed. It also needs to be comfortable in all those configurations.”
Few of these innovations have occurred on American carriers, which have been locked in a scramble for survival over the last decade. Their business model has amounted to jamming as many people as possible on planes with little money to spare on new designs.
But that is starting to change. Delta, United Airlines and American Airlines have all outlined large investments to install new business-class seats, for international flights and transcontinental legs — from New York to Los Angeles or San Francisco.
“Only a few years ago, all domestic carriers were chasing the commoditization of the business,” says Glen W. Hauenstein, Delta Air Lines’ executive vice president for network planning, revenue management and marketing. “That didn’t work. It was a spiral to the bottom.”

Delta, for instance, plans to overhaul its entire long-range fleet by next summer, rolling out a new business-class seat on international flights. The company does not have a first-class cabin, focusing instead on business and coach.
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British Airways configures its seats so that half of the passengers sit backward, to fit more seats into business class.
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Etihad Airways has made aisle access a selling point.
“We cater to corporate clients,” Mr. Hauenstein says. “That’s our sweet spot. And few have first-class policies. American corporations are cost-conscious. We’re a lot more socialistic than we think. And we don’t have a lot of oil sheiks or Russian billionaires.”
IN 2007, after reviewing the available business-class seats on the market, Lufthansa decided to design its own. It hired a design firm, PearsonLloyd, a furniture specialist based in London that had developed a first-class seat for Virgin Atlantic.
Lufthansa polled about 3,000 travelers and employees to establish a list of basic requirements for its new seat. Among them: it would have to become a fully flat bed with a minimum length of six feet; provide adequate privacy but still be open to the rest of the cabin; have ample storage space; and provide comfortable sleep. In addition, Lufthansa did not want to lose more than 10 percent of its business seats.
Lufthansa found that passengers put a lower value on having direct access to the aisle than on having a longer, flat bed. The suggestion was surprising. Many airlines like Singapore and Etihad Airways have made aisle access a big selling point — meaning passengers sitting by a window would not have to climb over someone else to get out. But for Lufthansa, bucking this industry trend meant it could fit more seats in a row — six as opposed to just four.
Over the next two years, the airline refined its sketches. It decided the seat would not need wings on the headrest, a feature common in coach to keep the passenger’s head from slipping during sleep, but deemed superfluous in business class where seats recline fully. The massage function on the seat, once viewed as a particularly tempting feature, was also dropped because it was little used. The seat height adjustment was abandoned for the same reason.
By eliminating these features, Lufthansa managed to cut down the number of electric devices that drive the seat’s movements, reducing potential for breakdowns and costly maintenance. Lufthansa also installed an air-cushion system that required less maintenance than foam, which has to be replaced every three to four years.
There were other new features: an ottoman to rest the feet, more storage, a wider screen, and a foldable table that can rotate to allow a passenger to leave a seat even if a meal tray is on it. When the seat turns into a bed, the armrest lowers, providing more sleeping space.
In 2010, halfway through the development program, Lufthansa tested the seat with passengers on a real flight. The seats were in a secret compartment on the airline’s Frankfurt-to-New York daily flight. Over two months, 1,340 passengers tried them. Their comments led to more tweaks: designers added a small separation on a common tray between each pair of seats, so that passengers’ drinks wouldn’t touch.
“All airlines are different. Their clients are different. The body types sometimes are different,” says Luke Pearson, a designer based in London who designed the seat with Lufthansa. The typical Lufthansa business-class passenger is a man in his mid-40s who travels for business every other month. Germans and Americans account for half of Lufthansa’s business passengers.
“Airlines need to know their demographics and what is their culture of travel. Lufthansa have a very good understanding of their clients,” Mr. Pearson says.
The airline says it received more than 3,500 mostly positive comments from passengers during the seat’s first months of service.
Still, while travelers prefer the new Lufthansa seat to its predecessor, the new seat has not won unanimous approval. Some frequent fliers have criticized Lufthansa’s decision not to offer direct aisle access, or the way passengers’ feet converge on the same footrest (although a partition separates them). One reviewer on the Business Traveller Web site said the V-shaped configuration was “nice if you are traveling with someone, but does make you feel a bit more duty-bound to speak to the person next to you if you are on your own, as there is no privacy screen to divide you.”
Another frequent flier offered this faint praise: “The new Lufthansa Business Class is leagues ahead of the old business class. This is due to the fact the Lufthansa had one of the poorer offerings on this class of service.”

When seats in the front of the cabin get more attention, they create a weight problem for the plane as a whole. Airlines, trying to trim weight to cut fuel costs, have sought to balance out heavier seats in the front, in part, by looking for slimmer and lighter seats in coach, ones in which the seat frame is made with high-grade aluminum or carbon composite rather than welded steel. Some connections are even made of titanium. Attention to such detail has become critical: cutting 2.2 pounds can save as much as $800 a year in fuel cost per seat, according to Mr. Hiller, the Recaro executive.
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On one of its seats destined for short-haul domestic flights, Recaro moved the magazine seat pocket away from the knee area to the upper edge of the seat above the tray, providing a couple more inches of space. Bulky foam padding on seat cushions was replaced with mesh, like modern office chairs, and the backrest is about two inches thinner. The seat weighs just 11 kilograms (24 pounds), down from 20 kilograms for previous generations. It is also “prereclined” at a 15-degree angle but cannot be adjusted.
“In our limited space,” says Carole Peytavin, vice president for research and development at Air France,“the question we need to ask is, who is willing to pay for what level of comfort?”
PASSENGERS still pick airlines based on the availability of flights and schedule, says Mr. Lange of Airbus, a former vice president for marketing there. “But the cabin product is now right behind that.”
This is especially true when it comes to business-class clients. “The business case for airlines to renew their business class,” he says, “is driven by their calculus to gain market share.”
Generally speaking, a first-class seat takes up the space of six to eight coach seats and a business-class seat takes up about four coach seats. The same is roughly true for ticket prices: first class is generally more than twice the price of business; business class is usually four times the price of coach.
Mr. Hauenstein of Delta explains that even with fewer seats in its business-class cabin, an airline can make more money. On its Boeing 747-400s, for instance, Delta went from about 65 cradlelike business seats to 48 flat bed seats. Yet while the total count dropped, Mr. Hauenstein says the switch to better seats increased the profitability of its fleet.
The reason lies in a dark science perfected by airlines years ago, known as revenue management. On any given flight, airlines generally try to maximize their profits by selling similar seats at different prices. The basic insight, which American Airlines figured out before others, was that you could make more money selling 100 seats at 100 different fares than offering every seat at the same price.
In business class, there are typically four buckets of prices, ranging from $2,000, for tickets bought far ahead of time, to $6,000 for last-minute walk-ins. If the seat experience is more pleasant, the airline can charge a premium. Delta decided it could sell more of the more expensive fares, and fewer of the less-expensive ones, since business passengers often buy tickets close to the flight date.
“The old cabin was rarely full,” Mr. Hauenstein says. “But if demand exceeds supply, that’s a good way to make money.”
There’s a saying in the airline business that seats are perishable items. If they go unsold on one flight, they cannot be sold anymore. Likewise, the seat itself has a limited life, which airlines and designers say is about seven years. After that, it looks stale. Other airlines come up with something new and exciting. Passengers expect a fresh look.
And so, by the time Lufthansa is done installing all its new seats throughout the fleet, the airline will have to look for a replacement.
“We’ve already started thinking about a new seat,” says Mr. Bosler. Maybe this one will come with a cup holder.
Via: Airlines, Business Class Travel, New Seat Design, Comfort Travel, Delta, Lufthansa, British airways, Singapore airline, Michael Kalisman, Michael Kalisman MD, michaelkalismanmd@gmail.com

Pregnency, Parental Care, Birth,Poatpartum, New Born Medical Care — American Way of Birth, Costliest in the World

Sunday, August 4th, 2013

American Way of Birth, Costliest in the World
http://www.nytimes.com/2013/07/01/health/american-way-of-birth-costliest-in-the-world.html

“I feel like I’m in a used-car lot.” Renée Martin, who, with her husband, is paying for her maternity care out of pocket.

Josh Haner/The New York Times

By ELISABETH ROSENTHAL | Published: June 30, 2013
Published: June 30, 2013

Via: Medical care in US, Health care cost, comparison of Cost of Care in US vs. Europe, Pregnancy, Michael Kalisman, Michael Kalisman MD, michaelkalismanmd@gmail.com

Throughout this article, readers have shared their experiences by responding to questions about their perspective on pregnancy care. Comments are now closed, but you may explore the responses received.
Elisabeth Rosenthal, reporter
Source: Truven Health Analytics
Your Perspective
An average pregnancy costs $37,341.
The charges given here are billed charges – actual amounts paid by an insurance company would be generally less.
YOUR RESPONSE$12,000
Your response is higher than % of other readers’ responses.

ACTUAL COST
Prenatal care
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Your Perspective
What do you think the total cost of a woman’s pregnancy should be, from prenatal checkups through delivery and newborn care?
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Average 2012 Amount Paid for Childbirth
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Renée C. Martin, left, and her husband, Mark Willett. “The economics of this system are a mess,” Ms. Martin said.
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Laura Segall for The New York Times
“Making women choose during labor whether you want to pay $1,000 for an epidural, that didn’t seem right.” Dr. Dean Coonrod, chief of obstetrics and gynecology at Maricopa Medical Center in Phoenix
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Christopher Gregory/The New York Times
“Most insurance companies wouldn’t blink at my bill, but it was absurd.” Dr. Marguerite Duane, who questioned line items on her hospital bill.
LACONIA, N.H. — Seven months pregnant, at a time when most expectant couples are stockpiling diapers and choosing car seats, Renée Martin was struggling with bigger purchases.
At a prenatal class in March, she was told about epidural anesthesia and was given the option of using a birthing tub during labor. To each offer, she had one gnawing question: “How much is that going to cost?”
Though Ms. Martin, 31, and her husband, Mark Willett, are both professionals with health insurance, her current policy does not cover maternity care. So the couple had to approach the nine months that led to the birth of their daughter in May like an extended shopping trip though the American health care bazaar, sorting through an array of maternity services that most often have no clear price and — with no insurer to haggle on their behalf — trying to negotiate discounts from hospitals and doctors.
When she became pregnant, Ms. Martin called her local hospital inquiring about the price of maternity care; the finance office at first said it did not know, and then gave her a range of $4,000 to $45,000. “It was unreal,” Ms. Martin said. “I was like, How could you not know this? You’re a hospital.”
Midway through her pregnancy, she fought for a deep discount on a $935 bill for an ultrasound, arguing that she had already paid a radiologist $256 to read the scan, which took only 20 minutes of a technician’s time using a machine that had been bought years ago. She ended up paying $655. “I feel like I’m in a used-car lot,” said Ms. Martin, a former art gallery manager who is starting graduate school in the fall.
Paying Till It Hurts
Part 1
Colonoscopies Explain Why U.S. Leads the World in Health Expenditures
Like Ms. Martin, plenty of other pregnant women are getting sticker shock in the United States, where charges for delivery have about tripled since 1996, according to an analysis done for The New York Times by Truven Health Analytics. Childbirth in the United States is uniquely expensive, and maternity and newborn care constitute the single biggest category of hospital payouts for most commercial insurers and state Medicaid programs. The cumulative costs of approximately four million annual births is well over $50 billion.
And though maternity care costs far less in other developed countries than it does in the United States, studies show that their citizens do not have less access to care or to high-tech care during pregnancy than Americans.
“It’s not primarily that we get a different bundle of services when we have a baby,” said Gerard Anderson, an economist at the Johns Hopkins School of Public Health who studies international health costs. “It’s that we pay individually for each service and pay more for the services we receive.”
Those payment incentives for providers also mean that American women with normal pregnancies tend to get more of everything, necessary or not, from blood tests to ultrasound scans, said Katy Kozhimannil, a professor at the University of Minnesota School of Public Health who studies the cost of women’s health care.
Financially, they suffer the consequences. In 2011, 62 percent of women in the United States covered by private plans that were not obtained through an employer lacked maternity coverage, like Ms. Martin. But even many women with coverage are feeling the pinch as insurers demand higher co-payments and deductibles and exclude many pregnancy-related services.
From 2004 to 2010, the prices that insurers paid for childbirth — one of the most universal medical encounters — rose 49 percent for vaginal births and 41 percent for Caesarean sections in the United States, with average out-of-pocket costs rising fourfold, according to a recent report by Truven that was commissioned by three health care groups. The average total price charged for pregnancy and newborn care was about $30,000 for a vaginal delivery and $50,000 for a C-section, with commercial insurers paying out an average of $18,329 and $27,866, the report found.
Women with insurance pay out of pocket an average of $3,400, according to a survey by Childbirth Connection, one of the groups behind the maternity costs report. Two decades ago, women typically paid nothing other than a small fee if they opted for a private hospital room or television.
Your Perspective
What aspects of maternity care or its costs were unexpected for you?
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• J Corpus Christi a month ago
My home births, all five of them, each cost less than $1,000. My hospital birth was $13,000, which Medicaid paid for, but we still had a doctor fee of $4,500 that we had to pay out of pocket.
Only in America
In most other developed countries, comprehensive maternity care is free or cheap for all, considered vital to ensuring the health of future generations.
Ireland, for example, guarantees free maternity care at public hospitals, though women can opt for private deliveries for a fee. The average price spent on a normal vaginal delivery tops out at about $4,000 in Switzerland, France and the Netherlands, where charges are limited through a combination of regulation and price setting; mothers pay little of that cost.
The chasm in price is true even though new mothers in France and elsewhere often remain in the hospital for nearly a week to heal and learn to breast-feed, while American women tend to be discharged a day or two after birth, since insurers do not pay costs for anything that is not considered medically necessary.

Your Perspective
If you gave birth outside the United States, what was your experience with medical testing, procedures and costs?
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• Anonymous Windsor a month ago
I gave birth in Germany in 1991 and also delivered twins there in 1993. There were no co-pays for prenatal care or for the deliveries. That’s right, my out-of-pocket cost for pregnancy-related medical services was 0. I was very happy with all the services.
Only in the United States is pregnancy generally billed item by item, a practice that has spiraled in the past decade, doctors say. No item is too small. Charges that 20 years ago were lumped together and covered under the general hospital fee are now broken out, leading to more bills and inflated costs. There are separate fees for the delivery room, the birthing tub and each night in a semiprivate hospital room, typically thousands of dollars. Even removing the placenta can be coded as a separate charge.
Each new test is a new source of revenue, from the hundreds of dollars billed for the simple blood typing required before each delivery to the $20 or so for the splash of gentian violet used as a disinfectant on the umbilical cord (Walgreens’ price per bottle: $2.59). Obstetricians, who used to do routine tests like ultrasounds in their office as part of their flat fee, now charge for the service or farm out such testing to radiologists, whose rates are far higher.
Add up the bills, and the total is startling. “We’ve created incentives that encourage more expensive care, rather than care that is good for the mother,” said Maureen Corry, the executive director of Childbirth Connection.
In almost all other developed countries, hospitals and doctors receive a flat fee for the care of an expectant mother, and while there are guidelines, women have a broad array of choices. “There are no bills, and a hospital doesn’t get paid for doing specific things,” said Charlotte Overgaard, an assistant professor of public health at Aalborg University in Denmark. “If a woman wants acupuncture, an epidural or birth in water, that’s what she’ll get.”
Despite its lavish spending, the United States has one of the highest rates of both infant and maternal death among industrialized nations, although the fact that poor and uninsured women and those whose insurance does not cover childbirth have trouble getting or paying for prenatal care contributes to those figures.
Some social factors drive up the expenses. Mothers are now older than ever before, and therefore more likely to require or request more expensive prenatal testing. And obstetricians face the highest malpractice risks among physicians and pay hundreds of thousands of dollars a year for insurance, fostering a “more is safer” attitude.
But less than 25 percent of America’s high payments for pregnancy typically go to obstetricians, and they often charge a flat fee for their nine months of care, no matter how many visits are needed, said Dr. Robert Palmer, the chairman of the committee for health economics and coding at the American College of Obstetricians and Gynecologists. That fee can range from a high of more than $8,000 for a vaginal delivery in Manhattan to under $4,000 in Denver, according to Fair Health, which collects health care data.
Rather it is the piecemeal way Americans pay for this life event that encourages overtreatment and overspending, said Dr. Kozhimannil, the Minnesota professor. Recent studies have found that more than 30 percent of American women have Caesarean sections or have labor induced with drugs — far higher numbers than those of other developed countries and far above rates that the American College of Obstetricians and Gynecologists considers necessary.
During the course of her relatively uneventful pregnancy, Ms. Martin was charged one by one for lab tests, scans and emergency room visits that were not included in the doctor’s or the hospital’s fee. During her seventh month, she described one week’s experience: “I have high glucose, and I tried to take a three-hour test yesterday and threw up all over the lab. So I’m probably going to get charged for that. And my platelets are low, so I’m going to have to see a hematologist. So I’m going to get charged for that.”
She sighed and put her head in her hands. “Welcome to my world,” she said.
Extras Add Up
Though Ms. Martin has yet to receive her final bills, other couples describe being blindsided by enormous expenses. After discovering that their insurance did not cover pregnancy when the first ultrasound bill was denied last year, Chris Sullivan and his wife, both freelance translators in Pennsylvania, bought a $4,000 pregnancy package from Delaware County Memorial Hospital; a few hospitals around the country are starting to offer such packages to those patients paying themselves.
The couple knew that price did not cover extras like amniocentesis, a test for genetic defects, or an epidural during labor. So when the obstetrician suggested an additional fetal heart scan to check for abnormalities, they were careful to ask about price and got an estimate of $265. Performed by a specialist from the Children’s Hospital of Philadelphia, it took 30 minutes and showed no problems — but generated a bill of $2,775.
“All of a sudden I have a bill that’s as much as I make in a month, and is more than 10 times what I’d been quoted,” Mr. Sullivan said. “I don’t know how I could have been a better consumer, I asked for a quote. Then I get this six-part bill.” After months of disputing the large discrepancy between the estimate and the bill, the hospital honored the estimate.

Christopher Gregory/The New York Times
“Most insurance companies wouldn’t blink at my bill, but it was absurd.” Dr. Marguerite Duane, who questioned line items on her hospital bill.
Mr. Sullivan noted that the couple ended up paying $750 for an epidural, a procedure that has a list price of about $100 in his wife’s native Germany.
Even women with the best insurance can still encounter high prices. After her daughter was born five years ago, Dr. Marguerite Duane, 42, was flabbergasted by the line items on the bills, many for blood tests she said were unnecessary and medicines she never received. She and her husband, Dr. Kenneth Lin, both associate professors of family medicine at Georgetown Medical School, had delivered babies in their early years of practice.
So when she became pregnant again in 2011, she decided to be more assertive about holding down costs. After a routine ultrasound scan at 20 weeks showed a healthy baby, she refused to go back for weekly follow-up scans that the radiologist suggested during the last months of her pregnancy even though medical guidelines do not recommend them. When in the hospital for the delivery of her son Ellis in February, she kept a list of every medicine and every item she received.
Though she delivered Ellis with a midwife 12 minutes after arriving at the hospital and was home the next day, the hospital bill alone was more than $6,000, and her insurance co-payment was about $1,500. Her first two pregnancies, both more than five years ago, were fully covered by federal government insurance because her husband worked for the Agency for Health Care Research and Quality.
“Most insurance companies wouldn’t blink at my bill, but it was absurd — it was the least medical delivery in history,” said Dr. Duane, who is taking a break from practice to stay home with her children. “There were no meds. I had no anesthesia. He was never in the nursery. I even brought my own heating pad. I tried to get an explanation, but there were items like ‘maternity supplies.’ What was that? A diaper?”
Ms. Martin is similarly well positioned to be an expert consumer of health care. She administered the health plan for a large art gallery she managed in Los Angeles before marrying and moving to Vermont in 2011 to enroll in a year of pre-med classes at the University of Vermont. She has a scholarship this fall for a master’s degree program at Vanderbilt University’s Center for Medicine, Health and Society, and then she plans to go on to medical school. Her father-in-law is a pediatrician.
RENÉE MARTIN’S PREGNANCY COSTS

Video by Dave Horn; Photography by Cheryl Senter for the New York Times
Statement after delivery without any discounts; not an official bill:
Hospital charges
$20,257
Obstetrician
4,020
Anesthesiologist
3,278
Drugs
1,125
Bills for prenatal care:
Emergency visit
1,600
Genetic testing
1,500
Ultrasound
1,191
Radiology
520
Hematologist
346
She and her husband, who works for a small music licensing company that does not provide insurance, hoped to start their family during the year they were covered by university insurance in Vermont, she said, but “nature didn’t cooperate.”
Then they moved to the New Hampshire summer resort of Laconia, her husband’s hometown, for a year before she started the grind of medical training. But in New Hampshire, they discovered, health insurance they could buy on the individual market did not cover maternity care without the purchase of an additional “pregnancy rider” for $800 a month. With their limited finances and unsuccessful efforts at conceiving, it seemed an unwise, if not impossible, investment.
Soon after buying insurance coverage without the rider for $450 a month, Ms. Martin discovered she was pregnant. Her elation was quickly undercut by worry.
“We’re not poor. We pay our bills. We have medical insurance. We’re not looking for a handout,” Ms. Martin said, noting that her husband makes too much money for her to qualify for Medicaid or other subsidized programs for low-income women. “The hospital is doing what it can. Our doctors are taking wonderful care of us. But the economics of this system are a mess.”
Not knowing whether the pregnancy would fall at the $4,000 or $45,000 end of the range the hospital cited, the couple had a hard time budgeting their finances or imagining their future. The hospital promised a 30 percent discount on its final bill. “I’m trying not to be stressed, but it’s really stressful,” Ms. Martin said as her due date approached.
Your Perspective
How would you describe the ideal scenario for insurance coverage during pregnancy?
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• Laura Temecula, CA a month ago
Insurance companies should pay for low-cost alternatives with low-risk pregnancies like midwifery care, both in and out of hospital settings. In many countries with better maternal and infant outcomes, midwifery care and nationally-covered health care are the two common themes.
Package Deals
With costs spiraling, some hospitals are starting to offer all-inclusive rates for pregnancy. Maricopa Medical Center, a public hospital in Phoenix, began offering uninsured patients a comprehensive package two years ago. “Making women choose during labor whether you want to pay $1,000 for an epidural, that didn’t seem right,” said Dr. Dean Coonrod, the hospital’s chief of obstetrics and gynecology.
The hospital charges $3,850 for a vaginal delivery, with or without an epidural, and $5,600 for a planned C-section — prices that include standard hospital, doctors’ and testing fees. To set the price, the hospital — which breaks even on maternity care and whose doctors are on salaries — calculated the average payment it gets from all insurers. While Dr. Coonrod said the hospital might lose a bit of money, he saw other benefits in a market where everyone will have insurance in just a few years: mothers tend to feel allegiance to the place they give birth to their babies and might seek other care at Maricopa in the future.

Laura Segall for The New York Times
“Making women choose during labor whether you want to pay $1,000 for an epidural, that didn’t seem right.” Dr. Dean Coonrod, chief of obstetrics and gynecology at Maricopa Medical Center in Phoenix
The Catalyst for Payment Reform, a California policy group, has proposed that all hospitals should offer such bundled prices and that rates should be the same, no matter the type of delivery. It suggests that $8,000 might be a reasonable starting point. But that may be hard to imagine in markets like New York City, where $8,000 is less than many private doctors charge for their fees alone.
One factor that has helped keep costs down in other developed countries is the extensive use of midwives, who perform the bulk of prenatal examinations and even simple deliveries; obstetricians are regarded as specialists who step in only when there is risk or need. Sixty-eight percent of births are attended by a midwife in Britain and 45 percent in the Netherlands, compared with 8 percent in the United States. In Germany, midwives were paid less than $325 for an 11-hour delivery and about $30 for an office visit in 2011.
Dr. Palmer of the American College of Obstetricians and Gynecologists acknowledged the preference for what he called “medicalized” deliveries in the United States, with IVs, anesthesia and a proliferation of costly ultrasounds. He said the organization was working to define standards for the scans.
To control costs in the United States, patients may also have to alter their expectations, including the presence of an obstetrician at every prenatal visit and delivery. “It’s amazing how much patients buy into our tendency to do a lot of tests,” said Eugene Declercq, a professor at Boston University who studies international variations in pregnancy. “We’ve met the problem, and it’s us.”
Starting next year, insurance policies will be required under the Affordable Care Act to include maternity coverage, so no woman should be left paying entirely on her own, like Ms. Martin. But the law is not explicit about what services must be included in that coverage. “Exactly what that means is the crux of the issue,” Dr. Kozhimannil said.
If the high costs of maternity care are not reined in, it could break the bank for many states, which bear the brunt of Medicaid payouts. Medicaid, the federal-state government health insurance program for the poor, pays for more than 40 percent of all births nationally, including more than half of those in Louisiana and Texas. But even Medicaid, whose payments are regarded as so low that many doctors refuse to take patients covered under the program, paid an average of $9,131 for vaginal births and $13,590 for Caesarean deliveries in 2011.
Insured women are still getting the recommended prenatal care, despite rising out-of-pocket costs, according to a recent study. But that does not mean they are not feeling the strain, said Dr. Kozhimannil, the study’s lead author. The average amount of savings among pregnant women in the study was $3,000 to $5,000. “People will find ways to scrape by for medical care for their new baby, but are young mothers taking care of themselves? And what happens when they need to start buying diapers?” she asked. “Something’s got to give.”
Ms. Martin, who busied herself making toys as her due date neared, could not stop fretting about the potential cost of a complicated delivery. “I know that a C-section could ruin us financially,” she said.
On May 25, she had a healthy daughter, Isla Daisy, born by vaginal delivery. Mother and daughter went home two days later.
She and her husband are both overjoyed and tired. And, she said, they are “dreading” the bills, which she estimates will be over $32,000 before negotiations begin. Her labor was induced, which required intense monitoring, and she also had an epidural.
“We’re bracing for it,” she said.
Your Perspective
Is there anything else you would like to share about your experience or expectations for pregnancy care in the United States?
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• MitchP NY a month ago
On our invoice from the hospital we were charged $700 for anesthesia, but no anesthesia services were ever provided to my wife. Because it was “covered” by insurance, and our deductible was what it was regardless, we had no incentive to question the charge.
• nts


This article has been revised to reflect the following correction:
Correction: July 2, 2013
An article on Monday about the high cost of maternity and newborn care in the United States misstated the number of years ago that Dr. Marguerite Duane’s daughter was born. It was five years ago, not seven. The article also misidentified which of Dr. Duane’s sons was born in February. He is Ellis — not Isaac, who is her older son.

Via: Medical care in US, Health care cost, comparison of Cost of Care in US vs. Europe, Pregnancy, Michael Kalisman, Michael Kalisman MD, michaelkalismanmd@gmail.com

Colonoscopies Explain Why U.S. Leads the World in Health Expenditures–The $2.7 Trillion Medical Bill

Sunday, August 4th, 2013

The $2.7 Trillion Medical Bill
Colonoscopies Explain Why U.S. Leads the World in Health Expenditures

http://www.nytimes.com/2013/06/02/health/colonoscopies-explain-why-us-leads-the-world-in-health-expenditures.html

Via: Medical care in US, Health care cost, comparison of Cost of Care in US vs. Europe, Colonoscopy, Michael Kalisman, Michael Kalisman MD, michaelkalismanmd@gmail.com

By ELISABETH ROSENTHAL | Published: June 1, 2013

NETHERLANDS
NEW ZEALAND

SPAIN

SWITZERLAND

CANADA

$319
$6
$7,731
$655
$35
AVG. U.S. PRICE
AVG. U.S. PRICE

AVG. U.S. PRICE

AVG. U.S. PRICE

AVG. U.S. PRICE

$1,121
$124
$40,364
$1,185
$914
M.R.I. scan
Lipitor
Hip replacement
Colonoscopy
Angiogram
Source: 2012 Comparative Price Report by the International Federation of Health Plans. The average prices shown for colonoscopies do not include added fees for sedation by an anesthesiologist, a practice common in the United States, but unusual in the rest of the world. The additional charges can increase the cost significantly.
Published: June 1, 2013
Multimedia
Enlarge This Image

Matthew Ryan Williams for The New York Times
A colonoscopy scope at a Veterans Affairs center in Seattle.
MERRICK, N.Y. — Deirdre Yapalater’s recent colonoscopy at a surgical center near her home here on Long Island went smoothly: she was whisked from pre-op to an operating room where a gastroenterologist, assisted by an anesthesiologist and a nurse, performed the routine cancer screening procedure in less than an hour. The test, which found nothing worrisome, racked up what is likely her most expensive medical bill of the year: $6,385.
That is fairly typical: in Keene, N.H., Matt Meyer’s colonoscopy was billed at $7,563.56. Maggie Christ of Chappaqua, N.Y., received $9,142.84 in bills for the procedure. In Durham, N.C., the charges for Curtiss Devereux came to $19,438, which included a polyp removal. While their insurers negotiated down the price, the final tab for each test was more than $3,500.
“Could that be right?” said Ms. Yapalater, stunned by charges on the statement on her dining room table. Although her insurer covered the procedure and she paid nothing, her health care costs still bite: Her premium payments jumped 10 percent last year, and rising co-payments and deductibles are straining the finances of her middle-class family, with its mission-style house in the suburbs and two S.U.V.’s parked outside. “You keep thinking it’s free,” she said. “We call it free, but of course it’s not.”
In many other developed countries, a basic colonoscopy costs just a few hundred dollars and certainly well under $1,000. That chasm in price helps explain why the United States is far and away the world leader in medical spending, even though numerous studies have concluded that Americans do not get better care.
Whether directly from their wallets or through insurance policies, Americans pay more for almost every interaction with the medical system. They are typically prescribed more expensive procedures and tests than people in other countries, no matter if those nations operate a private or national health system. A list of drug, scan and procedure prices compiled by the International Federation of Health Plans, a global network of health insurers, found that the United States came out the most costly in all 21 categories — and often by a huge margin.
Americans pay, on average, about four times as much for a hip replacement as patients in Switzerland or France and more than three times as much for a Caesarean section as those in New Zealand or Britain. The average price for Nasonex, a common nasal spray for allergies, is $108 in the United States compared with $21 in Spain. The costs of hospital stays here are about triple those in other developed countries, even though they last no longer, according to a recent report by the Commonwealth Fund, a foundation that studies health policy.

Matthew Ryan Williams for The New York Times
A poster illustrating diseases of the digestive system at a doctor’s office.
While the United States medical system is famous for drugs costing hundreds of thousands of dollars and heroic care at the end of life, it turns out that a more significant factor in the nation’s $2.7 trillion annual health care bill may not be the use of extraordinary services, but the high price tag of ordinary ones. “The U.S. just pays providers of health care much more for everything,” said Tom Sackville, chief executive of the health plans federation and a former British health minister.
Colonoscopies offer a compelling case study. They are the most expensive screening test that healthy Americans routinely undergo — and often cost more than childbirth or an appendectomy in most other developed countries. Their numbers have increased manyfold over the last 15 years, with data from the Centers for Disease Control and Prevention suggesting that more than 10 million people get them each year, adding up to more than $10 billion in annual costs.
Largely an office procedure when widespread screening was first recommended, colonoscopies have moved into surgery centers — which were created as a step down from costly hospital care but are now often a lucrative step up from doctors’ examining rooms — where they are billed like a quasi operation. They are often prescribed and performed more frequently than medical guidelines recommend.
The high price paid for colonoscopies mostly results not from top-notch patient care, according to interviews with health care experts and economists, but from business plans seeking to maximize revenue; haggling between hospitals and insurers that have no relation to the actual costs of performing the procedure; and lobbying, marketing and turf battles among specialists that increase patient fees.
While several cheaper and less invasive tests to screen for colon cancer are recommended as equally effective by the federal government’s expert panel on preventive care — and are commonly used in other countries — colonoscopy has become the go-to procedure in the United States. “We’ve defaulted to by far the most expensive option, without much if any data to support it,” said Dr. H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice.
In coming months, The New York Times will look at common procedures, drugs and medical encounters to examine how the economic incentives underlying the fragmented health care market in the United States have driven up costs, putting deep economic strains on consumers and the country.
Hospitals, drug companies, device makers, physicians and other providers can benefit by charging inflated prices, favoring the most costly treatment options and curbing competition that could give patients more, and cheaper, choices. And almost every interaction can be an opportunity to send multiple, often opaque bills with long lists of charges: $100 for the ice pack applied for 10 minutes after a physical therapy session, or $30,000 for the artificial joint implanted in surgery.
The United States spends about 18 percent of its gross domestic product on health care, nearly twice as much as most other developed countries. The Congressional Budget Office has said that if medical costs continue to grow unabated, “total spending on health care would eventually account for all of the country’s economic output.” And it identified federal spending on government health programs as a primary cause of long-term budget deficits.
While the rise in health care spending in the United States has slowed in the past four years — to about 4 percent annually from about 8 percent — it is still expected to rise faster than the gross domestic product. Aging baby boomers and tens of millions of patients newly insured under the Affordable Care Act are likely to add to the burden.
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With health insurance premiums eating up ever more of her flat paycheck, Ms. Yapalater, a customer relations specialist for a small Long Island company, recently decided to forgo physical therapy for an injury sustained during Hurricane Sandy because of high out-of-pocket expenses. She refused a dermatology medication prescribed for her daughter when the pharmacist said the co-payment was $130. “I said, ‘That’s impossible, I have insurance,’ ” Ms. Yapalater recalled. “I called the dermatologist and asked for something cheaper, even if it’s not as good.”
The more than $35,000 annually that Ms. Yapalater and her employer collectively pay in premiums — her share is $15,000 — for her family’s Oxford Freedom Plan would be more than sufficient to cover their medical needs in most other countries. She and her husband, Jeff, 63, a sales and marketing consultant, have three children in their 20s with good jobs. Everyone in the family exercises, and none has had a serious illness.
Like the Yapalaters, many other Americans have habits or traits that arguably could put the nation at the low end of the medical cost spectrum. Patients in the United States make fewer doctors’ visits and have fewer hospital stays than citizens of many other developed countries, according to the Commonwealth Fund report. People in Japan get more CT scans. People in Germany, Switzerland and Britain have more frequent hip replacements. The American population is younger and has fewer smokers than those in most other developed countries. Pushing costs in the other direction, though, is that the United States has relatively high rates of obesity and limited access to routine care for the poor.
A major factor behind the high costs is that the United States, unique among industrialized nations, does not generally regulate or intervene in medical pricing, aside from setting payment rates for Medicare and Medicaid, the government programs for older people and the poor. Many other countries deliver health care on a private fee-for-service basis, as does much of the American health care system, but they set rates as if health care were a public utility or negotiate fees with providers and insurers nationwide, for example.
“In the U.S., we like to consider health care a free market,” said Dr. David Blumenthal, president of the Commonwealth Fund and a former adviser to President Obama. ”But it is a very weird market, riddled with market failures.”
Consider this:
Consumers, the patients, do not see prices until after a service is provided, if they see them at all. And there is little quality data on hospitals and doctors to help determine good value, aside from surveys conducted by popular Web sites and magazines. Patients with insurance pay a tiny fraction of the bill, providing scant disincentive for spending.
Even doctors often do not know the costs of the tests and procedures they prescribe. When Dr. Michael Collins, an internist in East Hartford, Conn., called the hospital that he is affiliated with to price lab tests and a colonoscopy, he could not get an answer. “It’s impossible for me to think about cost,” he said. “If you go to the supermarket and there are no prices, how can you make intelligent decisions?”
Instead, payments are often determined in countless negotiations between a doctor, hospital or pharmacy, and an insurer, with the result often depending on their relative negotiating power. Insurers have limited incentive to bargain forcefully, since they can raise premiums to cover costs.
“It all comes down to market share, and very rarely is anyone looking out for the patient,” said Dr. Jeffrey Rice, the chief executive of Healthcare Blue Book, which tracks commercial insurance payments. “People think it’s like other purchases: that if you pay more you get a better car. But in medicine, it’s not like that.”
A Market Is Born
As the cases of bottled water and energy drinks stacked in the corner of the Yapalaters’ dining room attest, the family is cost conscious — especially since a photography business long owned by the family succumbed eight years ago in the shift to digital imaging. They moved out of Manhattan. They rent out their summer home on Fire Island. They have put off restoring the wallpaper in their dining room.
And yet, Ms. Yapalater recalled, she did not ask her doctors about the cost of her colonoscopy because it was covered by insurance and because “if a doctor says you need it, you don’t ask.” In many other countries, price lists of common procedures are publicly available in every clinic and office. Here, it can be nearly impossible to find out.
The cost of a colonoscopy in the United States varies widely, from place to place,
and even within a city. The map shows the highest amount paid for a colonoscopy
in metropolitan areas, based on an analysis by Healthcare Blue Book.
$2,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$9,000
Play
BILLINGS, MONT.
$5,978
SEATTLE, WASH.
$4,156
SAN FRANCISCO, CALIF.
$4,849
PHOENIX, ARIZ.
$3,464
ORLANDO, FLA.
$5,210
NEW YORK
$8,577
NASHVILLE, TENN.
$2,116
MINNEAPOLIS, MINN.
$4,090
MIAMI, FLA.
$4,514
LOS ANGELES, CALIF.
$5,559
KANSAS CITY, MO.
$3,540
DENVER, COLO.
$4,228
DALLAS, TEX.
$5,902
CHICAGO, ILL.
$4,650
BALTIMORE, MD.
$1,908
AUSTIN, TEX.
$7,471
ATLANTA, GA.
$4,506
The Cost of a
Colonoscopy Varies
Across the Country
Until the last decade or so, colonoscopies were mostly performed in doctors’ office suites and only on patients at high risk for colon cancer, or to seek a diagnosis for intestinal bleeding. But several highly publicized studies by gastroenterologists in 2000 and 2001 found that a colonoscopy detected early cancers and precancerous growths in healthy people.
They did not directly compare screening colonoscopies with far less invasive and cheaper screening methods, including annual tests for blood in the stool or a sigmoidoscopy, which looks at the lower colon where most cancers occur, every five years.
“The idea wasn’t to say these growths would have been missed by the other methods, but people extrapolated to that,” said Dr. Douglas Robertson, of the Department of Veterans Affairs, which is beginning a large trial to compare the tests.
Experts agree that screening for colon cancer is crucial, and a colonoscopy is intuitively appealing because it looks directly at the entire colon and doctors can remove potentially precancerous lesions that might not yet be prone to bleeding. But studies have not clearly shown that a colonoscopy prevents colon cancer or death better than the other screening methods. Indeed, some recent papers suggest that it does not, in part because early lesions may be hard to see in some parts of the colon.
But in 2000, the American College of Gastroenterology anointed colonoscopy as “the preferred strategy” for colon cancer prevention — and America followed.
Katie Couric, who lost her husband to colorectal cancer, had a colonoscopy on television that year, giving rise to what medical journals called the “Katie Couric effect”: prompting patients to demand the test. Gastroenterology groups successfully lobbied Congress to have the procedure covered by Medicare for cancer screening every 10 years, effectively meaning that commercial insurance plans would also have to provide coverage.
Though Medicare negotiates for what are considered frugal prices, its database shows that it paid an average of $531 for a colonoscopy in 2011. But that does not include the payments to anesthesiologists, which could substantially increase the cost. “As long as it’s deemed medically necessary,” said Jonathan Blum, the deputy administrator at the Centers for Medicare and Medicaid Services, “we have to pay for it.”
If the American health care system were a true market, the increased volume of colonoscopies — numbers rose 50 percent from 2003 to 2009 for those with commercial insurance — might have brought down the costs because of economies of scale and more competition. Instead, it became a new business opportunity.
Profits Climb
Just as with real estate, location matters in medicine. Although many procedures can be performed in either a doctor’s office or a separate surgery center, prices generally skyrocket at the special centers, as do profits. That is because insurers will pay an additional “facility fee” to ambulatory surgery centers and hospitals that is intended to cover their higher costs. And anesthesia, more monitoring, a wristband and sometimes preoperative testing, along with their extra costs, are more likely to be added on.
In Mount Kisco, N.Y., Maggie Christ had two colonoscopies two months apart, after her doctor decided it was best to remove a growth that had been discovered during the first procedure. They were performed by the same doctor, with the same sedation. The first, in an outpatient surgery department, was billed at $9,142.84 (insurance paid $5,742.67). The second, in the doctor’s office, was billed at $5,322.76 (insurance eventually paid $2,922.63) because there was no facility fee. “The location was about accommodating the doctor’s schedule,” Ms. Christ said. “Why would an insurance company approve this?”
Deirdre Yapalater’s colonoscopy bill was $6,385

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Ms. Yapalater, a trim woman who looks far younger than her 64 years, had two prior colonoscopies in doctor’s offices (one turned up a polyp that required a five-year follow-up instead of the usual 10 years). But for her routine colonoscopy this January, Ms. Yapalater was referred to Dr. Felice Mirsky of Gastroenterology Associates, a group practice in Garden City, N.Y., that performs the procedures at an ambulatory surgery center called the Long Island Center for Digestive Health. The doctors in the gastroenterology practice, which is just down the hall, are owners of the center.
“It was very fancy, with nurses and ORs,” Ms. Yapalater said. “It felt like you were in a hospital.”
That explains the fees. “If you work as a ‘facility,’ you can charge a lot more for the same procedure,” said Dr. Soeren Mattke, a senior scientist at the RAND Corporation. The bills to Ms. Yapalater’s insurer reflected these charges: $1,075 for the gastroenterologist, $2,400 for the anesthesia — and $2,910 for the facility fee.
When popularized in the 1980s, outpatient surgical centers were hailed as a cost-saving innovation because they cut down on expensive hospital stays for minor operations like knee arthroscopy. But the cost savings have been offset as procedures once done in a doctor’s office have filled up the centers, and bills have multiplied.
It is a lucrative migration. The Long Island center was set up with the help of a company based in Pennsylvania called Physicians Endoscopy. On its Web site, the business tells prospective physician partners that they can look forward to “distributions averaging over $1.4 million a year to all owners,” “typically 100 percent return on capital investment within 18 months” and “a return on investment of 500 percent to 2,000 percent over the initial seven years.”
Dr. Leonard Stein, the senior partner in Gastroenterology Associates and medical director of the surgery center, declined to discuss patient fees or the center’s profits, citing privacy issues. But he said the center contracted with insurance companies in the area to minimize patients’ out-of-pocket costs.
In 2009, the last year for which such statistics are available, gastroenterologists performed more procedures in ambulatory surgery centers than specialists in any other field. Once they bought into a center, studies show, the number of procedures they performed rose 27 percent. The specialists earn an average of $433,000 a year, among the highest paid doctors, according to Merritt Hawkins & Associates, a medical staffing firm.
Hospitals and doctors say that critics should not take the high “rack rates” in bills as reflective of the cost of health care because insurers usually pay less. But those rates are the starting point for negotiations with Medicare and private insurers. Those without insurance or with high-deductible plans have little weight to reduce the charges and often face the highest bills. Nassau Anesthesia Associates — the group practice that handled Ms. Yapalater’s sedation — has sued dozens of patients for nonpayment, including Larry Chin, a businessman from Hicksville, N.Y., who said in court that he was then unemployed and uninsured. He was billed $8,675 for anesthesia during cardiac surgery.
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For the same service, the anesthesia group accepted $6,970 from United Healthcare, $5,208.01 from Blue Cross and Blue Shield, $1,605.29 from Medicare and $797.50 from Medicaid. A judge ruled that Mr. Chin should pay $4,252.11.
Ms. Yapalater’s insurer paid $1,568 of the $2,400 anesthesiologist’s charge for her colonoscopy, but many medical experts question why anesthesiologists are involved at all. Colonoscopies do not require general anesthesia — a deep sleep that suppresses breathing and often requires a breathing tube. Instead, they require only “moderate sedation,” generally with a Valium-like drug or a low dose of propofol, an intravenous medicine that takes effect quickly and wears off within minutes. In other countries, such sedative mixes are administered in offices and hospitals by a wide range of doctors and nurses for countless minor procedures, including colonoscopies.
Nonetheless, between 2003 and 2009, the use of an anesthesiologist for colonoscopies in the United States doubled, according to a RAND Corporation study published last year. Payments to anesthesiologists for colonoscopies per patient quadrupled during that period, the researchers found, estimating that ending the practice for healthy patients could save $1.1 billion a year because “studies have shown no benefit” for them, Dr. Mattke said.
But turf battles and lobbying have helped keep anesthesiologists in the room. When propofol won the approval of the Food and Drug Administration in 1989 as an anesthesia drug, it carried a label advising that it “should be administered only by those who are trained in the administration of general anesthesia” because of concerns that too high a dose could depress breathing and blood pressure to a point requiring resuscitation.
Since 2005, the American College of Gastroenterology has repeatedly pressed the F.D.A. to remove or amend the restriction, arguing that gastroenterologists and their nurses are able to safely administer the drug in lower doses as a sedative. But the American Society of Anesthesiologists has aggressively lobbied for keeping the advisory, which so far the F.D.A. has done.
A Food and Drug Administration spokeswoman said that the label did not necessarily require an anesthesiologist and that it was safe for the others to administer propofol if they had appropriate training. But many gastroenterologists fear lawsuits if something goes wrong. If anything, that concern has grown since Michael Jackson died in 2009 after being given propofol, along with at least two other sedatives, without close monitoring.
‘Too Much for Too Little’
The Department of Veterans Affairs, which performs about a quarter-million colonoscopies annually, does not routinely use an anesthesiologist for screening colonoscopies. In Austria, where colonoscopies are also used widely for cancer screening, the procedure is performed, with sedation, in the office by a doctor and a nurse and “is very safe that way,” said Dr. Monika Ferlitsch, a gastroenterologist and professor at the Medical University of Vienna, who directs the national program on quality assurance.
But she noted that gastroenterologists in Austria do have their financial concerns. They are complaining to the government and insurers that they cannot afford to do the 30-minute procedure, with prep time, maintenance of equipment and anesthesia, for the current approved rate — between $200 and $300, all included. “I think the cheapest colonoscopy in the U.S. is about $950,” Dr. Ferlitsch said. “We’d love to get half of that.”
Dr. Cesare Hassan, an Italian gastroenterologist who is the chairman of the Guidelines Committee of the European Society of Gastrointestinal Endoscopy, noted that studies in Europe had estimated that the procedure cost about $400 to $800 to perform, including biopsies and sedation. “The U.S. is paying way too much for too little — it leads to opportunistic colonoscopies,” done for profit rather than health, he said.
Some doctors in the United States are campaigning against the overuse of the procedure, like Dr. James Goodwin, a geriatrician at the University of Texas. He estimates that about a quarter of Medicare patients undergo the screening test more often than recommended, even though the risks of complications, like long recovery times and poor tolerance of sedation, increase for older people. Routine screening is not recommended for all people over 75.
And some large employers have begun fighting back on costs. Three years ago, Safeway realized that it was paying between $848 and $5,984 for a colonoscopy in California and could find no link to the quality of service at those extremes. So the company established an all-inclusive “reference price” it was willing to pay, which it said was set at a level high enough to give employees access to a range of high-quality options. Above that price, employees would have to pay the difference. Safeway chose $1,250, one-third the amount paid for Ms. Yapalater’s procedure — and found plenty of doctors willing to accept the price.
Still, the United States health care industry is nimble at protecting profits. When Aetna tried in 2007 to disallow payment for anesthesiologists delivering propofol during colonoscopies, the insurer backed down after a barrage of attacks from anesthesiologists and endoscopy groups. With Medicare contemplating lowering facility fees for ambulatory surgery centers, experts worry that physician-owners will sell the centers to hospitals, where fees remain higher.
And then there is aggressive marketing. People who do not have insurance or who are covered by Medicaid typically get far less colon cancer screening than they need. But those with insurance are appealing targets.
Nineteen months after Matt Meyer, who owns a saddle-fitting company near Keene, N.H., had his first colonoscopy, he received a certified letter from his gastroenterologist. It began, “Our records show that you are due for a repeat colonoscopy,” and it advised him to schedule an appointment or “allow us to note your reason for not scheduling.” Although his prior test had found a polyp, medical guidelines do not recommend such frequent screening.
“I have great doctors, but the economics is daunting,” Mr. Meyer said in an interview. “A computer-generated letter telling me to come in for a procedure that costs more than $5,000? It was the weirdest thing.”
This article has been revised to reflect the following correction:
Correction: June 9, 2013
An article last Sunday about the high cost of colonoscopies in the United States misstated the year that Michael Jackson died, after which gastroenterologists became more cautious about administering the sedative propofol for fear of lawsuits. It was 2009, not 2010.
This article has been revised to reflect the following correction:
Correction: June 30, 2013
An article on June 2 about the high cost of colonoscopies in the United States, using information provided by the federal government’s Centers for Medicare and Medicaid Services, described the average payment for a colonoscopy incorrectly. The price of $531 does indeed include the payment for the facility fee; those fees are not extra. (As the article correctly noted, the $531 does not include the cost of an anesthesiologist’s services.)

Via: Medical care in US, Health care cost, comparison of Cost of Care in US vs. Europe, Colonoscopy, Michael Kalisman, Michael Kalisman MD, michaelkalismanmd@gmail.com

Hip Replacement- In Need of a New Hip, but Priced Out of the U.S.

Sunday, August 4th, 2013

In Need of a New Hip, but Priced Out of the U.S.

If you have considered a joint replacement, which factors have influenced your decision about whether to have one?

25% of readers named the same factor.
The most common factor was Risks.

Via: Medical care in US, Health care cost, comparison of Cost of Care in US vs. Europe, Hip Replacement, Colonoscopy, Pregnancy, Michael Kalisman, Michael Kalisman MD, michaelkalismanmd@gmail.com

By ELISABETH ROSENTHAL | Published: August 3, 2013

http://www.nytimes.com/2013/08/04/health/for-medical-tourists-simple-math.html?nl=todaysheadlines&emc=edit_th_20130804&_r=0

Published: August 3, 2013

Josh Haner/The New York Times
If you have considered a joint replacement, which factors have influenced your decision about whether to have one?
25% of readers named the same factor.
The most common factor was Risks.
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Josh Haner/The New York Times
Michael Shopenn on Copper Mountain in Colorado in April. Mr. Shopenn, now 67, had his hip replaced at a private hospital in Belgium in 2007.
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Narayan Mahon for The New York Times
Dr. Rory Wright with two hip joint options at the Orthopedic Hospital of Wisconsin.
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Thomas Vanden Driessche for The New York Times
St. Rembert’s, the private hospital in Belgium, where Mr. Shopenn had his hip replaced for $13,666.
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Thomas Vanden Driessche for The New York Times
St. Rembert’s, the private hospital in Belgium, where Mr. Shopenn had his hip replaced for $13,666.
WARSAW, Ind. — Michael Shopenn’s artificial hip was made by a company based in this remote town, a global center of joint manufacturing. But he had to fly to Europe to have it installed.
Mr. Shopenn, 67, an architectural photographer and avid snowboarder, had been in such pain from arthritis that he could not stand long enough to make coffee, let alone work. He had health insurance, but it would not cover a joint replacement because his degenerative disease was related to an old sports injury, thus considered a pre-existing condition.

As you read this article, please share your experiences by responding to the questions that appear. I will write a follow-up article about your responses on Monday, Aug. 5, and they will inspire future articles in this series.
— Elisabeth Rosenthal, Reporter
Desperate to find an affordable solution, he reached out to a sailing buddy with friends at a medical device manufacturer, which arranged to provide his local hospital with an implant at what was described as the “list price” of $13,000, with no markup. But when the hospital’s finance office estimated that the hospital charges would run another $65,000, not including the surgeon’s fee, he knew he had to think outside the box, and outside the country.
“That was a third of my savings at the time,” Mr. Shopenn said recently from the living room of his condo in Boulder, Colo. “It wasn’t happening.”
“Very leery” of going to a developing country like India or Thailand, which both draw so-called medical tourists, he ultimately chose to have his hip replaced in 2007 at a private hospital outside Brussels for $13,660. That price included not only a hip joint, made by Warsaw-based Zimmer Holdings, but also all doctors’ fees, operating room charges, crutches, medicine, a hospital room for five days, a week in rehab and a round-trip ticket from America.
“We have the most expensive health care in the world, but it doesn’t necessarily mean it’s the best,” Mr. Shopenn said. “I’m kind of the poster child for that.”
As the United States struggles to rein in its growing $2.7 trillion health care bill, the cost of medical devices like joint implants, pacemakers and artificial urinary valves offers a cautionary tale. Like many medical products or procedures, they cost far more in the United States than in many other developed countries.
Makers of artificial implants — the biggest single cost of most joint replacement surgeries — have proved particularly adept at commanding inflated prices, according to health economists. Multiple intermediaries then mark up the charges. While Mr. Shopenn was offered an implant in the United States for $13,000, many privately insured patients are billed two to nearly three times that amount.
An artificial hip, however, costs only about $350 to manufacture in the United States, according to Dr. Blair Rhode, an orthopedist and entrepreneur whose company is developing generic implants. In Asia, it costs about $150, though some quality control issues could arise there, he said.
So why are implant list prices so high, and rising by more than 5 percent a year? In the United States, nearly all hip and knee implants — sterilized pieces of tooled metal, plastic or ceramics — are made by five companies, which some economists describe as a cartel. Manufacturers tweak old models and patent the changes as new products, with ever-bigger price tags.
Generic or foreign-made joint implants have been kept out of the United States by trade policy, patents and an expensive Food and Drug Administration approval process that deters start-ups from entering the market. The “companies defend this turf ferociously,” said Dr. Peter M. Cram, a physician at the University of Iowa medical school who studies the costs of health care.
Though the five companies make similar models, each cultivates intense brand loyalty through financial ties to surgeons and the use of a different tool kit and operating system for the installation of its products; orthopedists typically stay with the system they learned on. The thousands of hospitals and clinics that purchase implants try to bargain for deep discounts from manufacturers, but they have limited leverage since each buys a relatively small quantity from any one company.
In addition, device makers typically require doctors’ groups and hospitals to sign nondisclosure agreements about prices, which means institutions do not know what their competitors are paying. This secrecy erodes bargaining power and has allowed a small industry of profit-taking middlemen to flourish: joint implant purchasing consultants, implant billing companies, joint brokers. There are as many as 13 layers of vendors between the physician and the patient for a hip replacement, according to Kate Willhite, a former executive director of the Manitowoc Surgery Center in Wisconsin.
Hospitals and orthopedic clinics typically pay $4,500 to $7,500 for an artificial hip, according to MD Buyline and Orthopedic Network News, which track device pricing. But those numbers balloon with the cost of installation equipment and all the intermediaries’ fees, including an often hefty hospital markup.
That is why the hip implant for Joe Catugno, a patient at the Hospital for Joint Diseases in New York, accounted for nearly $37,000 of his approximately $100,000 hospital bill; Cigna, his insurer, paid close to $70,000 of the charges. At Mills-Peninsula Health Services in San Mateo, Calif., Susan Foley’s artificial knee, which costs about the same as a hip joint, was billed at $26,000 in a total hospital tally of $112,317. The components of Sonja Nelson’s hip at Sacred Heart Hospital in Pensacola, Fla., accounted for $30,581 of her $50,935 hospital bill. Insurers negotiate discounts on those charges, and patients have limited responsibility for the differences.
The basic design of artificial joints has not changed for decades. But increased volume — about one million knee and hip replacements are performed in the United States annually — and competition have not lowered prices, as would typically happen with products like clothes or cars. “There are a bunch of implants that are reasonably similar,” said James C. Robinson, a health economist at the University of California, Berkeley. “That should be great for the consumer, but it isn’t.”
Comparing Two Operations

‘Sticky Pricing’
The American health care market is plagued by such “sticky pricing,” in which prices of products remain high or even increase over time instead of dropping. The list price of a total hip implant increased nearly 300 percent from 1998 to 2011, according to Orthopedic Network News, a newsletter about the industry. That is a result, economists say, of how American medicine generally sets charges: without government regulation or genuine marketplace competition.
“Manufacturers will tell you it’s R&D and liability that makes implants so expensive and that they have the only one like it,” said Dr. Rory Wright, an orthopedist at the Orthopedic Hospital of Wisconsin, a top specialty clinic. “They price this way because they can.”
Zimmer Holdings declined to comment on pricing. But Sheryl Conley, a longtime Zimmer manager who is now the chief executive of OrthoWorx, a local trade group in Warsaw, said that high prices reflected the increasing complexity of the joint implant business, including more advanced materials, new regulatory requirements and the logistics of providing a now huge array of devices. “When I started, there weren’t even left and right knee components,” she said. “It was one size fits all.”
Mr. Shopenn’s Zimmer hip has transformed his life, as did the replacement joint for Mr. Catugno, a TV director; Ms. Foley, a lawyer; and Ms. Nelson, a software development executive. Mr. Shopenn, an exuberant man who maintains a busy work schedule, recently hosted his son’s wedding and spent 26 days last winter teaching snowboarding to disabled people.
His joint implant and surgery in Belgium were priced according to a different logic. Like many other countries, Belgium oversees major medical purchases, approving dozens of different types of implants from a selection of manufacturers, and determining the allowed wholesale price for each of them, for example. That price, which is published, currently averages about $3,000, depending on the model, and can be marked up by about $180 per implant. (The Belgian hospital paid about $4,000 for Mr. Shopenn’s high-end Zimmer implant at a time when American hospitals were paying an average of over $8,000 for the same model.)
“The manufacturers do not have the right to sell an implant at a higher rate,” said Philip Boussauw, director of human resources and administration at St. Rembert’s, the hospital where Mr. Shopenn had his surgery. Nonetheless, he said, there was “a lot of competition” among American joint manufacturers to work with Belgian hospitals. “I’m sure they are making money,” he added.
Dr. Cram, the Iowa health cost expert, points out that joint manufacturers are businesses, operating within the constraints of varying laws and markets.
“Imagine you’re the C.E.O. of Zimmer,” he said. “Why charge $1,000 for the implant in the U.S. when you can charge $14,000? How would you answer to your shareholders?” Expecting device makers “to do otherwise is like asking, ‘Couldn’t Apple just charge $50 for an iPhone?’ because that’s what it costs to make them.”
But do Americans want medical devices priced like smartphones? “That,” Dr. Cram said, “is a different question.”
I’d go to Belgium for surgery at a 90 percent discount in a New York minute!
A Miracle for Many
When joint replacement surgery first became widely used in the 1970s, it was reserved for older patients with crippling pain from arthritis, to offer relief and restore some mobility. But as technology and techniques improved, its use broadened to include younger, less debilitated patients who wanted to maintain an active lifestyle, including vigorous sports or exercise.

Narayan Mahon for The New York Times
Dr. Rory Wright at the Orthopedic Hospital of Wisconsin with two modern hip joint options.
In the first few decades, implants were typically cemented into place. But since the 1980s, many surgeons have used implants made of more sophisticated materials that allow the patient’s own bone to grow in to hold the device in place. For most patients, implants have proved miraculous in improving quality of life, which is why socialized medical systems tend to cover them. Per capita, more hip replacements are done in Britain, Sweden and the Netherlands, for example, than in the United States.
Motivated in part by science and in part by the need to create new markets, joint makers churn out new designs that are patented, priced higher and introduced with free training courses for surgeons. Some use more durable materials so that a patient requiring a hip implant at age 40 or 50 might rely on it longer than the standard 20 years, while other models are streamlined and require smaller incisions.
Zimmer got a big sales bump a few years ago when it began promoting its new “female knee,” a slightly slimmer version of its standard design, in an advertising campaign directed at patients. Hospitals on average pay about $800 more to buy the gender-specific knee implants, according to MD Buyline.
Many doctors say that for most patients, older, standard implants with a successful track record are appropriate. Expensive modifications make no difference for the typical patient, but they drive up prices for all models and have sometimes proved to be deeply flawed, they say.
In the last few years, joint manufacturers have faced lawsuits and have settled claims with patients after new, all-metal implants, which were meant to be more durable than the standard version, had unusually high failure rates. As for those “female knees,” a study featured at the meeting of the American College of Orthopedic Surgeons this year concluded, “While we certainly use the female components frequently in surgery, we don’t detect any objective improvement in clinical outcomes.”
That is why Dr. Scott S. Kelley, an orthopedist affiliated with Duke University Medical Center, generally tries to dissuade patients who request “new, improved” joints. “I tell them: ‘That’s taking a big risk for the potential of a few percentage points of improvement. You wouldn’t invest your retirement account this way.’ ”
The simple fact of the matter is that medicine in this country is a for-profit market segment. The device manufacturers, insurance companies and health care facilities are simply maximizing shareholder value.
A Town’s Lifeblood
The power and profits of the medical device industry are on display here in Warsaw, which has trademarked itself the Orthopedic Capital of the World. Four of the big five joint manufacturers in the world are based in the United States; the other is in Britain. Three of these giants — Zimmer, Biomet and DePuy, a division of Johnson & Johnson — have their headquarters here, a town of 14,000.
An industry that began as a splint-making shop in 1895 has made Warsaw the center of a global multibillion-dollar business. The companies based here produce about 60 percent of the hip and knee devices used in the United States and one-third of the world’s orthopedic sales volume, local officials said. Nearly half the jobs in Kosciusko County, where Warsaw is, are tied to the industry. Residents joke that a mixed marriage is when one spouse works for Zimmer and the other for DePuy.
The industry’s benefits are evident. The county has the lowest unemployment rate in Northern Indiana, and the median family income of $50,000 puts it significantly above the state average. The town boasts lush golf courses and streets lined with spacious homes. The lobby of the elegant City Hall, which is in a restored 1912 bank, features plaques about device manufacturers.
“We eat, sleep and breathe orthopedics,” said Ms. Conley of OrthoWorx, which she said was set up to “plan for the future of the orthopedic industry here.” OrthoWorx’s board of directors includes executives from Biomet and DePuy.
With a high-tech industry as its lifeblood, Ms. Conley said, Warsaw needed to attract engineers and doctors from afar and train local youths for “the business.” It has upgraded the public schools and helped create programs at local colleges in orthopedic regulation and advanced machinist techniques.
Officials at OrthoWorx say the device makers do not discuss “competitive issues” among themselves, including the prices of implants, even as employees stand together watching their children play baseball. Still, it is in everyone’s interest not to undercut the competition. In 2011, all three manufacturers had joint implant sales exceeding $1 billion and spent about only 5 percent of revenues on research and development, compared with 20 percent in the pharmaceutical industry, said Stan Mendenhall, the editor of Orthopedic Network News. They each paid their chief executives over $8 million.
“It’s amazing to think there is $5 billion to $6 billion going through this little place in Northern Indiana,” said Mr. Mendenhall, adding that the recession has meant only single-digit annual revenue growth rather than the double-digit growth of the past.
Device makers have used some of their profits to lobby Congress and to buy brand loyalty. In 2007, joint makers paid $311 million to settle Justice Department accusations that they were paying kickbacks to surgeons who used their devices; Zimmer paid the biggest fine, $169.5 million. That year, nearly 1,000 orthopedists in the United States received a total of about $200 million in payments from joint manufacturers for consulting, royalties and other activities, according to data released as part of the settlement.
Despite that penalty, payments continued, according to a paper published in The Archives of Internal Medicine in 2011. While some of the orthopedists are doing research for the companies, the roles of others is unclear, said Dr. Cram, one of the study’s authors.
Although only a tiny percentage of orthopedists receive payments directly from manufacturers, the web of connections is nonetheless tangled.
Companies “build a personal relationship with the doctor,” said Professor Robinson, the Berkeley economist. “The companies hire sales reps who are good at engineering and good at golf. They bring suitcases into the operating room,” advising which tools might work best among the hundreds they carry, he said. And some studies have shown that operations attended by a company representative are more likely to use more and costlier medical equipment. While some hospitals have banned manufacturers’ representatives from the operating room, or have at least blocked salesmanship there, most have not.
No Gift Shop
There are, of course, a number of factors that explain why Mr. Shopenn’s surgery in Belgium would cost many times more in the United States. In America, fees for hospitals, scans, physical therapy and surgeons are generally far higher. And in Belgium, even private hospitals are more spartan.
When Mr. Shopenn arrived at the hospital, he was taken aback by the contrast with NewYork-Presbyterian Hospital, where his father had been a patient a year before. The New York facility had “comfortable waiting rooms, an elegant lobby and newsstands,” Mr. Shopenn remembered.
But in Belgium, he said, “I was immediately scared because at first I thought, this is really old. The chairs in the waiting rooms were metal, the walls were painted a pale green, there was no gift shop. But then I realized everything was new. It was just functional. There wasn’t much of a nod to comfort because they were there to provide health care.”

St. Rembert’s, the private hospital in Belgium where Mr. Shopenn had his hip replaced for $13,660. Thomas Vanden Driessche for The New York Times
The pricing system in Belgium does not encourage amenities, though the country has among the lowest surgical infection rates in the world — lower than in the United States — and is known for good doctors. While most Belgian physicians and hospitals are in business for themselves, the government sets pricing and limits profits. Hospitals get a fixed daily rate and surgeons receive a fee for each surgery, which are negotiated each year between national medical groups and the state.
While doctors may charge more than the rate, few do so because most patients would refuse to pay it, said Mr. Boussauw, the hospital administrator. Doctors and hospitals must provide estimates. European orthopedists tend to make about half the income of their American counterparts, whose annual income averaged $442,450 in 2011, according to a survey by the Commonwealth Fund, a foundation that studies health policy.
Belgium pays for health care through a mandatory national insurance plan, which requires contributions from employers and workers and pays for 80 percent of each treatment. Except for the poor, patients are generally responsible for the remaining 20 percent of charges, and many get private insurance to cover that portion.
Mr. Shopenn’s surgery, which was uneventful, took place on a Tuesday. On Friday he was transferred for a week to the hospital’s rehabilitation unit, where he was taught exercises to perform once he got home.
Twelve days after his arrival, he paid the hospital’s standard price for hip replacements for foreign patients. Six weeks later he saw an orthopedist in Seattle, where he was living at the time, to remove stitches and take a postoperative X-ray. “He said there was no need for further visits, that the hip looked great, to go out and enjoy myself,” Mr. Shopenn said.
Staying Active
The number of hip replacements has risen sharply in recent years, with much of the growth coming from people younger than 65.
• Show total numbers
• Show proportions
Ages 85++23%Ages 65 to 84+31%Ages 45 to 64+195%Ages 18 to 44+25%0100,000200,000300,000400,000199720042011
Source: Agency for Healthcare Research and Quality
With baby boomers determined to continue skiing, biking and running into their 60s and beyond, economists predict a surge in joint replacement surgeries, and more procedures for younger patients. The number of hip and knee replacements is expected to roughly double between 2010 and 2020, according to Exponent, a scientific consulting firm, and perhaps quadruple by 2030. If insurers paid $36,000 for each surgery, a fairly typical price in the commercial sector, the total cost would be $144 billion, about a sixth of the nation’s military budget last year.
So far, attempts to bring down the price of medical devices have been undercut by the industry.
When Dr. Daniel S. Elliott of the Mayo Clinic decided to continue using an older, cheaper valve to cure incontinence because studies showed that it was just as good as a newer, more expensive model, the manufacturer raised its price.
“If there was a generic, I’d be there tomorrow,” he said.
With artificial joints, cost-trimming efforts have been similarly ineffective. Medicare does not negotiate directly with manufacturers, but offers all-inclusive payments for surgery to hospitals to prompt them to bargain harder for better implant prices. Instead, hospitals complain that acquiring the implant consumes 50 percent to 70 percent of Medicare’s reimbursement, which now averages $12,099, up 25 percent from $9,645 in 1993. Meanwhile, surgeons’ fees have dropped by nearly half.
With the federal government unwilling to intervene directly, some doctors and insurance plans are themselves trying to reduce the costs by mandating preset prices or forcing more competition and transparency.
After concluding that hip replacements billed at $100,000 yielded no better results than less expensive ones, the California Public Employees’ Retirement System, or Calpers, told members that it would pay hospitals $30,000 for a hip or knee replacement, and dozens of hospitals have met that number.
Dr. Wright’s orthopedic hospital near Milwaukee has driven down payments for joints by more than 30 percent by resolving to use only two types of hip implants and requiring blind bids directly from the manufacturers; part of the savings is passed on to patients.
The Affordable Care Act tries to recoup some of the medical device manufacturers’ profits by imposing a 2.3 percent tax on their revenues, effective this year. But Brad Bishop, the executive director of OrthoWorx and a former Zimmer executive, said that the approach would harm an innovative American industry, and that the cost would ultimately be borne by joint replacement patients “whose average age is 67.” He argued that the best way to reduce the cost of joint replacement surgery was to rescind the tax and decrease government interference.
The medical device industry spent nearly $30 million last year on lobbying, according to the Center for Responsive Politics. The Senate moved to repeal the tax, and the House is expected to take it up this fall. The bill’s supporters included both senators from Indiana.
Mr. Shopenn’s new hip worked so well that a few months after returning from Belgium he needed a hernia operation — a result of too much working out at the gym. He was home by 4 p.m. the day of the outpatient surgery, but the bill came to $16,500. Though his insurance company covered the procedure, he called the hospital’s finance department for an explanation.
He remembers in particular a “surreal” discussion with a “very nice” administrator about a $750 bill for a surgical drain, which he called “a piece of plastic in a sealed bag.”
“It was mind-boggling to me that the surgery could possibly cost this much,” he said, “after what I’d just done in Belgium.”

In Need of a New Hip, but Priced Out of the U.S.
By ELISABETH ROSENTHAL | Published: August 3, 2013
Published: August 3, 2013

Josh Haner/The New York Times
Michael Shopenn, who has an artificial hip, on Copper Mountain in Colorado. Joint replacements have grown sharply.
0200,000400,000600,000199720042011KneeHip264,311257,939
Source: Agency for Healthcare Research and Quality
If you have considered a joint replacement, which factors have influenced your decision about whether to have one?
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Risks
Pain
Lifestyle
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25% of readers named the same factor.
The most common factor was Risks.
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Josh Haner/The New York Times
Michael Shopenn on Copper Mountain in Colorado in April. Mr. Shopenn, now 67, had his hip replaced at a private hospital in Belgium in 2007.
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Narayan Mahon for The New York Times
Dr. Rory Wright with two hip joint options at the Orthopedic Hospital of Wisconsin.
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Thomas Vanden Driessche for The New York Times
St. Rembert’s, the private hospital in Belgium, where Mr. Shopenn had his hip replaced for $13,666.
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Thomas Vanden Driessche for The New York Times
St. Rembert’s, the private hospital in Belgium, where Mr. Shopenn had his hip replaced for $13,666.
WARSAW, Ind. — Michael Shopenn’s artificial hip was made by a company based in this remote town, a global center of joint manufacturing. But he had to fly to Europe to have it installed.
Mr. Shopenn, 67, an architectural photographer and avid snowboarder, had been in such pain from arthritis that he could not stand long enough to make coffee, let alone work. He had health insurance, but it would not cover a joint replacement because his degenerative disease was related to an old sports injury, thus considered a pre-existing condition.

As you read this article, please share your experiences by responding to the questions that appear. I will write a follow-up article about your responses on Monday, Aug. 5, and they will inspire future articles in this series.
— Elisabeth Rosenthal, Reporter
Desperate to find an affordable solution, he reached out to a sailing buddy with friends at a medical device manufacturer, which arranged to provide his local hospital with an implant at what was described as the “list price” of $13,000, with no markup. But when the hospital’s finance office estimated that the hospital charges would run another $65,000, not including the surgeon’s fee, he knew he had to think outside the box, and outside the country.
“That was a third of my savings at the time,” Mr. Shopenn said recently from the living room of his condo in Boulder, Colo. “It wasn’t happening.”
“Very leery” of going to a developing country like India or Thailand, which both draw so-called medical tourists, he ultimately chose to have his hip replaced in 2007 at a private hospital outside Brussels for $13,660. That price included not only a hip joint, made by Warsaw-based Zimmer Holdings, but also all doctors’ fees, operating room charges, crutches, medicine, a hospital room for five days, a week in rehab and a round-trip ticket from America.
“We have the most expensive health care in the world, but it doesn’t necessarily mean it’s the best,” Mr. Shopenn said. “I’m kind of the poster child for that.”
As the United States struggles to rein in its growing $2.7 trillion health care bill, the cost of medical devices like joint implants, pacemakers and artificial urinary valves offers a cautionary tale. Like many medical products or procedures, they cost far more in the United States than in many other developed countries.
Makers of artificial implants — the biggest single cost of most joint replacement surgeries — have proved particularly adept at commanding inflated prices, according to health economists. Multiple intermediaries then mark up the charges. While Mr. Shopenn was offered an implant in the United States for $13,000, many privately insured patients are billed two to nearly three times that amount.
An artificial hip, however, costs only about $350 to manufacture in the United States, according to Dr. Blair Rhode, an orthopedist and entrepreneur whose company is developing generic implants. In Asia, it costs about $150, though some quality control issues could arise there, he said.
So why are implant list prices so high, and rising by more than 5 percent a year? In the United States, nearly all hip and knee implants — sterilized pieces of tooled metal, plastic or ceramics — are made by five companies, which some economists describe as a cartel. Manufacturers tweak old models and patent the changes as new products, with ever-bigger price tags.
Generic or foreign-made joint implants have been kept out of the United States by trade policy, patents and an expensive Food and Drug Administration approval process that deters start-ups from entering the market. The “companies defend this turf ferociously,” said Dr. Peter M. Cram, a physician at the University of Iowa medical school who studies the costs of health care.
Though the five companies make similar models, each cultivates intense brand loyalty through financial ties to surgeons and the use of a different tool kit and operating system for the installation of its products; orthopedists typically stay with the system they learned on. The thousands of hospitals and clinics that purchase implants try to bargain for deep discounts from manufacturers, but they have limited leverage since each buys a relatively small quantity from any one company.
In addition, device makers typically require doctors’ groups and hospitals to sign nondisclosure agreements about prices, which means institutions do not know what their competitors are paying. This secrecy erodes bargaining power and has allowed a small industry of profit-taking middlemen to flourish: joint implant purchasing consultants, implant billing companies, joint brokers. There are as many as 13 layers of vendors between the physician and the patient for a hip replacement, according to Kate Willhite, a former executive director of the Manitowoc Surgery Center in Wisconsin.
Hospitals and orthopedic clinics typically pay $4,500 to $7,500 for an artificial hip, according to MD Buyline and Orthopedic Network News, which track device pricing. But those numbers balloon with the cost of installation equipment and all the intermediaries’ fees, including an often hefty hospital markup.
That is why the hip implant for Joe Catugno, a patient at the Hospital for Joint Diseases in New York, accounted for nearly $37,000 of his approximately $100,000 hospital bill; Cigna, his insurer, paid close to $70,000 of the charges. At Mills-Peninsula Health Services in San Mateo, Calif., Susan Foley’s artificial knee, which costs about the same as a hip joint, was billed at $26,000 in a total hospital tally of $112,317. The components of Sonja Nelson’s hip at Sacred Heart Hospital in Pensacola, Fla., accounted for $30,581 of her $50,935 hospital bill. Insurers negotiate discounts on those charges, and patients have limited responsibility for the differences.
The basic design of artificial joints has not changed for decades. But increased volume — about one million knee and hip replacements are performed in the United States annually — and competition have not lowered prices, as would typically happen with products like clothes or cars. “There are a bunch of implants that are reasonably similar,” said James C. Robinson, a health economist at the University of California, Berkeley. “That should be great for the consumer, but it isn’t.”
Comparing Two Operations

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01:45
‘Sticky Pricing’
The American health care market is plagued by such “sticky pricing,” in which prices of products remain high or even increase over time instead of dropping. The list price of a total hip implant increased nearly 300 percent from 1998 to 2011, according to Orthopedic Network News, a newsletter about the industry. That is a result, economists say, of how American medicine generally sets charges: without government regulation or genuine marketplace competition.
“Manufacturers will tell you it’s R&D and liability that makes implants so expensive and that they have the only one like it,” said Dr. Rory Wright, an orthopedist at the Orthopedic Hospital of Wisconsin, a top specialty clinic. “They price this way because they can.”
Zimmer Holdings declined to comment on pricing. But Sheryl Conley, a longtime Zimmer manager who is now the chief executive of OrthoWorx, a local trade group in Warsaw, said that high prices reflected the increasing complexity of the joint implant business, including more advanced materials, new regulatory requirements and the logistics of providing a now huge array of devices. “When I started, there weren’t even left and right knee components,” she said. “It was one size fits all.”
Mr. Shopenn’s Zimmer hip has transformed his life, as did the replacement joint for Mr. Catugno, a TV director; Ms. Foley, a lawyer; and Ms. Nelson, a software development executive. Mr. Shopenn, an exuberant man who maintains a busy work schedule, recently hosted his son’s wedding and spent 26 days last winter teaching snowboarding to disabled people.
His joint implant and surgery in Belgium were priced according to a different logic. Like many other countries, Belgium oversees major medical purchases, approving dozens of different types of implants from a selection of manufacturers, and determining the allowed wholesale price for each of them, for example. That price, which is published, currently averages about $3,000, depending on the model, and can be marked up by about $180 per implant. (The Belgian hospital paid about $4,000 for Mr. Shopenn’s high-end Zimmer implant at a time when American hospitals were paying an average of over $8,000 for the same model.)
“The manufacturers do not have the right to sell an implant at a higher rate,” said Philip Boussauw, director of human resources and administration at St. Rembert’s, the hospital where Mr. Shopenn had his surgery. Nonetheless, he said, there was “a lot of competition” among American joint manufacturers to work with Belgian hospitals. “I’m sure they are making money,” he added.
Dr. Cram, the Iowa health cost expert, points out that joint manufacturers are businesses, operating within the constraints of varying laws and markets.
“Imagine you’re the C.E.O. of Zimmer,” he said. “Why charge $1,000 for the implant in the U.S. when you can charge $14,000? How would you answer to your shareholders?” Expecting device makers “to do otherwise is like asking, ‘Couldn’t Apple just charge $50 for an iPhone?’ because that’s what it costs to make them.”
But do Americans want medical devices priced like smartphones? “That,” Dr. Cram said, “is a different question.”
Your Perspective
Describe how you would feel about traveling to another country for a procedure or, if you have ever done so, how that care compared with your experience in the U.S.
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Anonymous 21 hours ago
I’d go to Belgium for surgery at a 90 percent discount in a New York minute!
Anonymous 20 hours ago
I would travel to another developed country for this if the cost of doing it at home would ruin my financial situation. Of course I would rather be home around family & friends, and English speaking health providers, but our healthcare system is broken. Even getting heroin on the streets is more transparent in costs then getting a new hip.
Anonymous 20 hours ago
I’ve had dental care in Taiwan. The establishments are like a barber shop with a line of chairs, no appointment required. They look, give you prices for variety of treatments and do it immediately. Good quality and cheap.
Kevin Egan 20 hours ago
I would love to go to Belgium anyway, and if doing it saved me $110,000, that’s kind of a no-brainer. American medical costs would be hilarious if they weren’t a national disgrace that led to actual pain and suffering.
Anne 21 hours ago
My insurance insulates me from the cost of my healthcare, which is part of the problem in the U.S. But if I didn’t have it, I would absolutely go abroad.
Anonymous 21 hours ago
I had my right hip replaced in Mexico. My left hip was replaced in the U.S. My experience in Mexico was far superior to the U.S. regarding the surgeon, price, hospital and rehabilitation.
Anonymous 21 hours ago
I would be very hesitant to travel abroad for a medical procedure. But if I did, I would feel most comfortable going to a country in which I have already spent time and can speak the language.
Anonymous 21 hours ago
I was in an automobile accident in Canada and needed surgery on my leg with full anesthesia and six days hospitalization. i did not have insurance at the time. Cost to me and my family: $250. I was playing competitive soccer six weeks later. That answer your question?
Anonymous 20 hours ago
It is terribly sad and wrong that it’s come to this. If I need expensive medical care that I could get safely with no compromise to my health, I absolutely would carefully consider traveling outside the U.S. But I really shouldn’t have to, should I?
Anonymous 20 hours ago
I’d be concerned about post-op care should anything go wrong, because the doctors live and operate abroad. In what sort of regulatory framework do they operate? What recourses as a foreigner would I have?
Mark McCutchan 20 hours ago
While I’m disappointed that the U.S. health care system has not evolved into providing health care that is best for the patient (as opposed to the hospital or device manufacturer), I welcome the possibility of obtaining affordable health care overseas, with a vacation as a bonus!
R 20 hours ago
I’d be totally fine with it. America is not the “best” anymore. Other people in other countries live healthy, productive lives and are happier for it.
Mark 20 hours ago
The one thing this country understands is competition, and if enough people finally get fed up with unnecessarily paying the highest, most ridiculous health care costs in the world and vote with their feet things will change.
Mai 20 hours ago
Were I to shoulder the burden for the entire cost of procedure and aftercare, I would most certainly consider traveling to another country. While I would be disappointed that such travel would be necessary, one can put up with a fair amount of inconvenience in exchange for a savings of $64,000, like Mr. Shopenn.
Anonymous 20 hours ago
If the success statistics check out and the logistics are easy (i.e. arranged) then I am all for medical tourism. Price does not equate to equality.
A Miracle for Many
When joint replacement surgery first became widely used in the 1970s, it was reserved for older patients with crippling pain from arthritis, to offer relief and restore some mobility. But as technology and techniques improved, its use broadened to include younger, less debilitated patients who wanted to maintain an active lifestyle, including vigorous sports or exercise.

Narayan Mahon for The New York Times
Dr. Rory Wright at the Orthopedic Hospital of Wisconsin with two modern hip joint options.
In the first few decades, implants were typically cemented into place. But since the 1980s, many surgeons have used implants made of more sophisticated materials that allow the patient’s own bone to grow in to hold the device in place. For most patients, implants have proved miraculous in improving quality of life, which is why socialized medical systems tend to cover them. Per capita, more hip replacements are done in Britain, Sweden and the Netherlands, for example, than in the United States.
Motivated in part by science and in part by the need to create new markets, joint makers churn out new designs that are patented, priced higher and introduced with free training courses for surgeons. Some use more durable materials so that a patient requiring a hip implant at age 40 or 50 might rely on it longer than the standard 20 years, while other models are streamlined and require smaller incisions.
Zimmer got a big sales bump a few years ago when it began promoting its new “female knee,” a slightly slimmer version of its standard design, in an advertising campaign directed at patients. Hospitals on average pay about $800 more to buy the gender-specific knee implants, according to MD Buyline.
Many doctors say that for most patients, older, standard implants with a successful track record are appropriate. Expensive modifications make no difference for the typical patient, but they drive up prices for all models and have sometimes proved to be deeply flawed, they say.
In the last few years, joint manufacturers have faced lawsuits and have settled claims with patients after new, all-metal implants, which were meant to be more durable than the standard version, had unusually high failure rates. As for those “female knees,” a study featured at the meeting of the American College of Orthopedic Surgeons this year concluded, “While we certainly use the female components frequently in surgery, we don’t detect any objective improvement in clinical outcomes.”
That is why Dr. Scott S. Kelley, an orthopedist affiliated with Duke University Medical Center, generally tries to dissuade patients who request “new, improved” joints. “I tell them: ‘That’s taking a big risk for the potential of a few percentage points of improvement. You wouldn’t invest your retirement account this way.’ ”
Your Perspective
Can you relate an experience that has led you to feel that the price of American medicine does — or does not — correlate with the quality of care you received?
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Anonymous Martinsburg, WV 18 hours ago
The simple fact of the matter is that medicine in this country is a for-profit market segment. The device manufacturers, insurance companies and health care facilities are simply maximizing shareholder value.
Anonymous West Hills, CA 18 hours ago
There is no correlation. Those who defend the U.S. health care system have a vested interest in the status quo.
Anonymous 19 hours ago
The stats say it all: the U.S. is something like 17th in outcomes but first in cost. The entire system is run by, and for, the providers (doctors, drug companies, hospitals) and not for the patients.
Anonymous 19 hours ago
For a straightforward vaginal delivery of my son, we were charged upwards of $16,000. The quality to cost of health care in the U.S. is completely out of whack with the rest of the developed world and leading emerging economies.
Anonymous 19 hours ago
As a patient advocate and former medical device sales rep, I can tell you with absolute certainty the price of American medicine does not correlate with the quality of care, but price most definitely correlates with the amount of care. No money equals very little care.
John Dowd 20 hours ago
During a recent overnight stay at a major university hospital, I was charged $17 for a tylenol tablet; $34 for the two I took. One can only imagine how I’m being overcharged for anesthesia, more complicated medications and equipment used during the procedure.
Anonymous 20 hours ago
Prescription eyeglasses can’t be worth $900. Asthma medicine can’t cost $1,346 for three months. And dental care can’t be $1,800 to “save” a tooth that lost a 50-year old filling.
Anonymous 20 hours ago
In my experience it does not relate at all, and I am saying this as a patient who is also a physician. Poor accountability and poor organization plague American medicine and do not justify the prices. Neither do overall health outcomes.
Anonymous 21 hours ago
U.S. hospital bills have absolutely no correlation to the quality of care received. Basic blood-work costs over $2,000. A two-hour ER visit in which all I received was an IV for dehydration cost $5,000.
A Town’s Lifeblood
The power and profits of the medical device industry are on display here in Warsaw, which has trademarked itself the Orthopedic Capital of the World. Four of the big five joint manufacturers in the world are based in the United States; the other is in Britain. Three of these giants — Zimmer, Biomet and DePuy, a division of Johnson & Johnson — have their headquarters here, a town of 14,000.
An industry that began as a splint-making shop in 1895 has made Warsaw the center of a global multibillion-dollar business. The companies based here produce about 60 percent of the hip and knee devices used in the United States and one-third of the world’s orthopedic sales volume, local officials said. Nearly half the jobs in Kosciusko County, where Warsaw is, are tied to the industry. Residents joke that a mixed marriage is when one spouse works for Zimmer and the other for DePuy.
The industry’s benefits are evident. The county has the lowest unemployment rate in Northern Indiana, and the median family income of $50,000 puts it significantly above the state average. The town boasts lush golf courses and streets lined with spacious homes. The lobby of the elegant City Hall, which is in a restored 1912 bank, features plaques about device manufacturers.
“We eat, sleep and breathe orthopedics,” said Ms. Conley of OrthoWorx, which she said was set up to “plan for the future of the orthopedic industry here.” OrthoWorx’s board of directors includes executives from Biomet and DePuy.
With a high-tech industry as its lifeblood, Ms. Conley said, Warsaw needed to attract engineers and doctors from afar and train local youths for “the business.” It has upgraded the public schools and helped create programs at local colleges in orthopedic regulation and advanced machinist techniques.
Officials at OrthoWorx say the device makers do not discuss “competitive issues” among themselves, including the prices of implants, even as employees stand together watching their children play baseball. Still, it is in everyone’s interest not to undercut the competition. In 2011, all three manufacturers had joint implant sales exceeding $1 billion and spent about only 5 percent of revenues on research and development, compared with 20 percent in the pharmaceutical industry, said Stan Mendenhall, the editor of Orthopedic Network News. They each paid their chief executives over $8 million.
“It’s amazing to think there is $5 billion to $6 billion going through this little place in Northern Indiana,” said Mr. Mendenhall, adding that the recession has meant only single-digit annual revenue growth rather than the double-digit growth of the past.
Device makers have used some of their profits to lobby Congress and to buy brand loyalty. In 2007, joint makers paid $311 million to settle Justice Department accusations that they were paying kickbacks to surgeons who used their devices; Zimmer paid the biggest fine, $169.5 million. That year, nearly 1,000 orthopedists in the United States received a total of about $200 million in payments from joint manufacturers for consulting, royalties and other activities, according to data released as part of the settlement.
Despite that penalty, payments continued, according to a paper published in The Archives of Internal Medicine in 2011. While some of the orthopedists are doing research for the companies, the roles of others is unclear, said Dr. Cram, one of the study’s authors.
Although only a tiny percentage of orthopedists receive payments directly from manufacturers, the web of connections is nonetheless tangled.
Companies “build a personal relationship with the doctor,” said Professor Robinson, the Berkeley economist. “The companies hire sales reps who are good at engineering and good at golf. They bring suitcases into the operating room,” advising which tools might work best among the hundreds they carry, he said. And some studies have shown that operations attended by a company representative are more likely to use more and costlier medical equipment. While some hospitals have banned manufacturers’ representatives from the operating room, or have at least blocked salesmanship there, most have not.
No Gift Shop
There are, of course, a number of factors that explain why Mr. Shopenn’s surgery in Belgium would cost many times more in the United States. In America, fees for hospitals, scans, physical therapy and surgeons are generally far higher. And in Belgium, even private hospitals are more spartan.
When Mr. Shopenn arrived at the hospital, he was taken aback by the contrast with NewYork-Presbyterian Hospital, where his father had been a patient a year before. The New York facility had “comfortable waiting rooms, an elegant lobby and newsstands,” Mr. Shopenn remembered.
But in Belgium, he said, “I was immediately scared because at first I thought, this is really old. The chairs in the waiting rooms were metal, the walls were painted a pale green, there was no gift shop. But then I realized everything was new. It was just functional. There wasn’t much of a nod to comfort because they were there to provide health care.”

St. Rembert’s, the private hospital in Belgium where Mr. Shopenn had his hip replaced for $13,660. Thomas Vanden Driessche for The New York Times
The pricing system in Belgium does not encourage amenities, though the country has among the lowest surgical infection rates in the world — lower than in the United States — and is known for good doctors. While most Belgian physicians and hospitals are in business for themselves, the government sets pricing and limits profits. Hospitals get a fixed daily rate and surgeons receive a fee for each surgery, which are negotiated each year between national medical groups and the state.
While doctors may charge more than the rate, few do so because most patients would refuse to pay it, said Mr. Boussauw, the hospital administrator. Doctors and hospitals must provide estimates. European orthopedists tend to make about half the income of their American counterparts, whose annual income averaged $442,450 in 2011, according to a survey by the Commonwealth Fund, a foundation that studies health policy.
Belgium pays for health care through a mandatory national insurance plan, which requires contributions from employers and workers and pays for 80 percent of each treatment. Except for the poor, patients are generally responsible for the remaining 20 percent of charges, and many get private insurance to cover that portion.
Mr. Shopenn’s surgery, which was uneventful, took place on a Tuesday. On Friday he was transferred for a week to the hospital’s rehabilitation unit, where he was taught exercises to perform once he got home.
Twelve days after his arrival, he paid the hospital’s standard price for hip replacements for foreign patients. Six weeks later he saw an orthopedist in Seattle, where he was living at the time, to remove stitches and take a postoperative X-ray. “He said there was no need for further visits, that the hip looked great, to go out and enjoy myself,” Mr. Shopenn said.
Staying Active
The number of hip replacements has risen sharply in recent years, with much of the growth coming from people younger than 65.
Show total numbers
Show proportions
Ages 85++23%Ages 65 to 84+31%Ages 45 to 64+195%Ages 18 to 44+25%0100,000200,000300,000400,000199720042011
Source: Agency for Healthcare Research and Quality
With baby boomers determined to continue skiing, biking and running into their 60s and beyond, economists predict a surge in joint replacement surgeries, and more procedures for younger patients. The number of hip and knee replacements is expected to roughly double between 2010 and 2020, according to Exponent, a scientific consulting firm, and perhaps quadruple by 2030. If insurers paid $36,000 for each surgery, a fairly typical price in the commercial sector, the total cost would be $144 billion, about a sixth of the nation’s military budget last year.
So far, attempts to bring down the price of medical devices have been undercut by the industry.
When Dr. Daniel S. Elliott of the Mayo Clinic decided to continue using an older, cheaper valve to cure incontinence because studies showed that it was just as good as a newer, more expensive model, the manufacturer raised its price.
“If there was a generic, I’d be there tomorrow,” he said.
With artificial joints, cost-trimming efforts have been similarly ineffective. Medicare does not negotiate directly with manufacturers, but offers all-inclusive payments for surgery to hospitals to prompt them to bargain harder for better implant prices. Instead, hospitals complain that acquiring the implant consumes 50 percent to 70 percent of Medicare’s reimbursement, which now averages $12,099, up 25 percent from $9,645 in 1993. Meanwhile, surgeons’ fees have dropped by nearly half.
With the federal government unwilling to intervene directly, some doctors and insurance plans are themselves trying to reduce the costs by mandating preset prices or forcing more competition and transparency.
After concluding that hip replacements billed at $100,000 yielded no better results than less expensive ones, the California Public Employees’ Retirement System, or Calpers, told members that it would pay hospitals $30,000 for a hip or knee replacement, and dozens of hospitals have met that number.
Dr. Wright’s orthopedic hospital near Milwaukee has driven down payments for joints by more than 30 percent by resolving to use only two types of hip implants and requiring blind bids directly from the manufacturers; part of the savings is passed on to patients.
The Affordable Care Act tries to recoup some of the medical device manufacturers’ profits by imposing a 2.3 percent tax on their revenues, effective this year. But Brad Bishop, the executive director of OrthoWorx and a former Zimmer executive, said that the approach would harm an innovative American industry, and that the cost would ultimately be borne by joint replacement patients “whose average age is 67.” He argued that the best way to reduce the cost of joint replacement surgery was to rescind the tax and decrease government interference.
The medical device industry spent nearly $30 million last year on lobbying, according to the Center for Responsive Politics. The Senate moved to repeal the tax, and the House is expected to take it up this fall. The bill’s supporters included both senators from Indiana.
Mr. Shopenn’s new hip worked so well that a few months after returning from Belgium he needed a hernia operation — a result of too much working out at the gym. He was home by 4 p.m. the day of the outpatient surgery, but the bill came to $16,500. Though his insurance company covered the procedure, he called the hospital’s finance department for an explanation.
He remembers in particular a “surreal” discussion with a “very nice” administrator about a $750 bill for a surgical drain, which he called “a piece of plastic in a sealed bag.”
“It was mind-boggling to me that the surgery could possibly cost this much,” he said, “after what I’d just done in Belgium.”
Your Perspective
Is there anything else you would like to share about your reaction to this article and how the cost of a joint replacement or another medical procedure has affected you?
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Anonymous 20 hours ago
For all the people who said they would travel to a foreign country for surgery, have they thought about what they would do if they have a complication after they get home? What if they need to be re-operated on? How easy do they think it will be to find a surgeon who is willing to fix another surgeon’s mess?
Anonymous 20 hours ago
It strikes me that the system that created this imbalance in American medical costs is unsustainable. But this is what it costs to create the American way of life, in which some people make $8 million, and others make $10 an hour, all depending on how good their lobbying is.
Eric Smith 20 hours ago
One of the perennially struggling airlines could make a lot of money by just setting aside a few flights a day for medical tourists. Make arrangements with overseas hospitals and insurance companies, put a doctor and a few nurses on board instead of stewardesses, then charge a big premium for putting it all together.
JCM 21 hours ago
Once the U.S. government is allowed to negotiate the price it pays for prescription drugs, implants, and other medical devices and services, the prices will drop dramatically. This is an issue that requires sufficient backbone on the part of Congress to pass a law.
Orrin Schwab 21 hours ago
The entire healthcare industry needs to be rebuilt in the image of vastly superior foreign models. In the long term, we have no other alternative, other than national bankruptcy.
Anonymous 19 hours ago
The obvious solution to the American problem, if we are not going to have a universal system, is to mandate real competition. Care providers, from manufacturers to hospitals, need to be made to provide prices.
Anonymous 20 hours ago
Given the noble history of medicine there is a natural inhibition to speak harshly about what is wrong with doctors and hospitals and health care, but now is the time to overcome any reticence and to speak the truth.
Anonymous 20 hours ago
This is so depressing. The health care system, like its government, seems to have become totally divorced from the people. I probably will need a hip replacement. I know where it will not be done.
Anonymous 19 hours ago
This is an eye-opening article. It inspires me, a candidate for medical school and a business student, to explore patient-friendly low cost and high yielding solutions that can be marketed to hospitals in order to give both patients and hospitals more affordable choices.
bill deep river 18 hours ago
America used to be the envy of the world. Now America is like a bad economic dream where the rich spend millions and the middle class and poor, scrape by. People complain about big government but look at what big business has done to us.
Anonymous 19 hours ago
It is not logical that a country which so highly touts fair trade and open competition continues to allow artificial barriers to exist. It makes everything we were taught in U.S. schools sound farcical.
Anonymous 18 hours ago
The article makes you wonder why the United States has not developed a public utility model for health care services. Medicare sets pricing, and it has the best cost containment track record of any insurer.
Philip A. Hanrahan, MD Charlotte, NC 18 hours ago
I am a physician in Charlotte, N.C. and I also had a hip replacement last year. My orthopedist was paid $2,361.23 by insurance and the assisting orthopedist was paid $330.58. The hospital got $27,264.00. I was back to work 8 days after the surgery. I have had no complications. I don’t begrudge any of these payments, and I think leaving the US to get health care is insane.
Damon clarksville 16 hours ago
Imagine if car buying was done this way. We would be up in arms complaining that we are getting fleeced by the car companies. Shouldn’t the current medical system we have should be structured similarly? We should have the right to comparison shop and transparency in pricing so one can make smart health care decisions.


A version of this article appeared in print on August 4, 2013, on page A1 of the New York edition with the headline: For Medical Tourists, Simple Math.

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Patricia Prague 20 minutes ago
Seven years ago, I had a hip implant in Prague, where I live, and paid a few hundred dollars extra for an “above standard” hip (titanium ceramic). Under Czech insurance, this was my only out of pocket cost. Ten days in hospital, same for rehab, and no paperwork! Excellent surgeon and nurses. Hospital (Motol) clean, quiet. Foreigners who speak English and don`t speak Czech can probably arrange similar care, and perhaps have it done cheaper here, if with fewer bells and whistles, than in Belgium. What is going on in the US is shameful, if not insane.
Chris Minneapolis an hour ago
This notion that more expensive means better is crazy. Moreover, the arrogance (or ignorance) of thinking only the US can properly perform these procedures is ruining our healthcare system. I wouldn’t hesitate to go to another country.
Anonymous Chromo, CO 30 minutes ago
I just had hip replacement surgery in the US. My 5.5 hour trip home after spending a week in Denver was difficult. I couldn’t imagine the return trip from Europe; or the potential to hurt/damage the surgically repaired hip during the trip. Wonder how they managed the hip precautions during the flight (no bending over 90 degrees for 90 days is one that comes to mind)?
Anonymous Wake Forest an hour ago
I never have any elective procedures, health checkups done in the US if I can help it. Besides the high cost of health care there is the added frustration of getting appointments that sometimes require you to wait for weeks if not months. Recently, I had high quality dental work (German trained dentists) done for a reasonable price in Istanbul, Turkey. I was in Turkey for a 10 day vacation. It was a walk in dental clinic and my dental work including implants took 3 days to complete.
Anonymous Ann Arbor an hour ago
I would travel to get the procedure. In my case, the hospital and the provider woul end up making all the money and I would be left holding the bag on my huge $20K deductible. The high deductible was the only way I could afford any insurance.
Lynne Knudsen Easthampton, MA 37 minutes ago
WhenI was in Honduras, many years ago, I had dental work done by a wonderful local dentist which cost me a fraction of the costs here. Now, Medicare & my good insurance cover most of my medical expenses so I would probably try to stay home before exploring the possibilities of going overseas.
Anonymous San Francisco 35 minutes ago
I’m in the middle of looking for referrals. A little scared, but determined.
pjr Anchorage 35 minutes ago
I would travel for a needed surgery verses having to come out of pocket for an overpriced surgery. I live in Alaska and the cost of exams and surgeries are already more expensive than say Seattle or other area of the lower 48. Blue Cross already will let us travel for certain procedures that are overly costly in Alaska. I hate going to the doctor because of the ridiculous costs.
DJA Pelican Rapids, MN 30 minutes ago
Thanks for the information…I don’t need it yet, but can tell that knee replacement will be necessary in the future if I want to continue canoe country trips into my 80’s!
Dennis Jud Portsmouth, NH 30 minutes ago
Our healthcare system is clearly broken. I am a cruising sailor needing a simple inguinal hernia repair. My hospital estimated it at $13,300; another at $23,000. A good friend got his done recently in Panama for $2000 at a very good hospital. This is a 45 minute laparoscopic, day-surgery procedure. I did some research and found a hospital in Toronto that specializes in hernia repairs, has a much better long term success rate that any in the US. The procedure will cost around $5,000, including a four night stay in the hospital, all meals and physical therapy.
Monica Rosenbloom Larkspur 28 minutes ago
A friend contracted pneumonia while vacationing in Thailand. Her traveling companion took her to a hospital in Bangkok where she stayed two nights and received excellent care. She gave her insurance information to the hospital and flew home. A couple of weeks later her insurer received the bill: $800. Of course, pneumonia must be treated immediately, so travel isn’t an option, but I compare my father’s 4 days of hospitalization for pneumonia in California: $50K+.
Johan Antwerp 28 minutes ago
Traveling to another country to get the medical care you should receive in your own country is not a sustainable solution. Healthcare should be a basic right for all.
Anonymous Lindenhurst NY 27 minutes ago
I would go if I needed a knee or hip replacement. I went to Canada to have hernia surgery and was very pleased with the outcomes. It was less than the cost in the U.S and they don’t use the mesh. They just tie the muscle tissue. A simple solution costing much less than the procedure done in the U.S.
Tony Savannah 24 minutes ago
My wife had both hips replaced in Berlin 2008 & 2009 … care included 30 days at a country-side post-op rehab facility (each time … ). Out-of-pocket = $00.00. (Caveat: I was working for a German firm and had German health insurance.) Care/facilities were second-to-none.
Frank Niering Buckfastleigh, Devon an hour ago
The issue does not arise with me as, in the UK, where the National Health Service funds all new hips, knees, and most other medical procedures as well. I know of few, if any, problems associated with the many operations with which I am familiar.
Anonymous Naples Florida an hour ago
The problem in this country is simple, have you ever met a poor Doctor. They are all making lots of money. And I would travel to another country for an operation. , except maybe Mexico.
Brian Altman MD Louisville 35 minutes ago
Nice Article Elizabeth, but I am an orthopedic surgeon who has been implanting total knees for twenty years and my non concierge insurance mandated surgeons fee has steadily decreased from $4000 to about $1200 – and that included taking care of ALL complications and follow up visits for 90 post op days. About 10-15% of joint replacement surgeries don’t go ‘as planned” and need “revising.” How much would that cost with a foreign implant preformed by a surgeon on the other side of the planet? Brian Altman MD baltmanmd@gmail.com brian.r.altman@us.army.mil
John Brookes San Antonio 35 minutes ago
It wouldn’t bother me a bit. Some Texans travel to Mexico for dental work, which is far less expensive there. You would think Medicare and/or insurance companies would jump at the chance to send people elsewhere to save money. I was prescribed a cervical traction unit. I had to buy it from a Medicare approved supplier for lots more money than it was on Amazon. Ever wonder what would happen if we made insurance companies and hospitals non-profit organizations? BTW take a look at Consumer’s Reports most recent report on surgical hospital facilities….it’s appalling.
Anonymous Atlanta 35 minutes ago
I would certainly consider all my options, including costs, and would not rule out have the procedure done in another country.
Mrs. S. Schechter New York 34 minutes ago
At one time I never would have entertained the thought but, now I think I would. That would be after, of course, extensive research. Some things in this country just should not have a ” The Sky Is The Limit ” price tag. I believe in capitalisim all the way, not greed. I also believe in fair competition not cartels.
Anonymous Tallahassee, FL 34 minutes ago
In the past 25 years, I have had seven knee surgeries, including total replacement of each knee, and revisions. The costs ranged from $68,000 to $135,000. My private major medical policy paid for all of them, but that policy costs me more than $20,000 annually. Our medical system is corrupt. Yes, I’m willing to go to another country.
Anonymous Charlevoix 34 minutes ago
We are a capitalist country and, by that fact, are entitled to charge whatever the law allows for anything which includes life sustaining health interventions. Morally, this is indefensible on all levels. I am happy, Mr. Shopenn found a way around our system and also happy Ms.Foley was able to pay the American asking price. To a great many of us, however, these are not options because of limited resources. Living in the greatest country on earth? I don’t think so.
Anonymous Philadelphia 33 minutes ago
I’ve been a health care professional for over 30 years, spent much of that time as an administrator at a facility that performed several hundred joint replacements per year. Seeing how it works from the inside, between the joint replacement suppliers, physicans and insurances companies convied me we are getting fleeced. Everyone involved in the process is making a lot of money with no incentive to change how things work to be more economical and less expensive for the consumer. Trying to change this is like touching the third rail.
Jacquie Carbondale 32 minutes ago
I had right hip replacement surgery last year in the U.S. The costs are still dribbling in. It’s sort of like an ‘ala carte’ situation. Instead of trying to make it possible for folks to have the coverage to pay for health care, how about trying to bring those costs down. The average # of middlemen between surgeon and patient at 13 tells us where the $$ goes.
Coigne New York 30 minutes ago
The American medical industry feeds on illness. I would certainly go to a more advanced European country for treatment.
Lou H Burnt Hills an hour ago
I would feel great doing it. Why perpetuate an over-priced, low quality medical-industrial complex like the one in the US? Healthcare regulation needs to be enhanced in the US if they don’t want to slip into 3rd world status at Platinum prices.
Ruth (will do) NYC 40 minutes ago
If I needed the work on my ailing Knee, I’d definitely go over seas. Maybe to Spain where my son has a home.
beth fort lauderdale 39 minutes ago
If the need arose, I would go to another country for an orthopedic surgery in a heartbeat. As a taxpayer and consumer increasingly exploited in so many facets of my life by monopolistic enterprises and a complicit government, I am gratified to know that other countries are willing to treat me far more fairly than my own.
Anonymous Edgewater 39 minutes ago
I would go to another country for a procedure if the need arises. I refuse to pay this obscene healthcare industry in this country who takes us and our sufferings as hostages for their greed and profit.
John Elmira 38 minutes ago
Perfectly acceptable but concerned abot post operative problems once returned to the US.
Alan T. Hot Springs Village 37 minutes ago
The option to travel abroad is extremely appealing. With most goods purchased by US consumers made, installed and packaged in the worldwide market place it is reasonable to expect American consumers to go outside our borders for medical services. This approach is consistent with market driven capitalism and consumerism.
Peter Rosenwald San Paulo 36 minutes ago
I’m an American living in Brazil. 7 years ago I was advised I needed a pacemaker and asked a friend, an eminent US cardiac surgeon whether I should have the operation in the US or Brazil. He answered that the pacemaker would be the same and the medical standard in Brazil at Sao Paulo’s best hospitals were as high or higher than in the US. Total cost of the operation, the pacemaker and all follow-up was US$ 26,500, less than half what it would cost in the US. The experience was perfect with kind, efficient and expert care.
Barbara Wright Willimantic, CT 34 minutes ago
No problem! Any concerns about quality of care, language, etc., would be more than offset by my disgust for the American system. The entire range of medical care, from insurance, devices and drugs to doctors’ interventions and hospital stays, should be non-profit and completely transparent, with no shareholders, reasonably paid executives, and no motivation to gouge the patient — or the patient’s insurer.
Anonymous Brooklyn an hour ago
The article demonstrates that on a global scale there is choice and competition.
Ronniejean Irvin Oakton, va an hour ago
There’s a lot of follow up after knee replacement. and sometimes things go wrong. It happens. Back to Belgium??? What orthopedist will look after you here when you had surgery there? So why isn’t there a class action suit to get these prices in line?
Sheila NYC 44 minutes ago
I have done this – one excellent hip resurfacing in Birmingham England 2001 and another in India in 2004 & wrote about my experience in 2005. We are not patients in the U.S. – we are profit centers. I would avoid ever getting any care at all in the U.S. if I could. We have SO MUCH to learn about how superior, cheaper care is delivered abroad, but Americans continue to be inveigled by the propaganda machines.
Anonymous Ormond Beach 44 minutes ago
I would not hesitate for a second to go to Belgium for any medical procedure. When are we in the US going to face up to the cost of our out-of-control medical costs? When we all do what this story says is so easy?
Robert Cohen Winder, Georgia 44 minutes ago
Sad in that it would seem to make some catch 22 sense for the nation to officially export its Medicare surgical patients too. I broke pelvis, and Medicare apparently covered the bulk of my excellent Athens region hospital’s billing, which was approximately $80,000. Milton Friedman and Tom Friedman economic theory of mutual advantage and globalization has been perversely if not absurdly affirmed.
Philip Melbourne 44 minutes ago
I live in Australia. Between private health cover and the national scheme costs are reined in. I have not had an implant and have not been hospitalised in years. My last hospital stay was a week, with tests scans and treatment. The total out-of pocket was about $AUD400. I have on-going medication that costs about $AUD 22 per month, for four prescriptions. American medicine sounds like the biggest racket since religion and politics.
Maria Ann Arbor 43 minutes ago
After reading this article, I will certainly consider traveling abroad, and do a lot of price-comparison research, should I ever need an expensive procedure. As it stands now, I tend to avoid doctors, tests, and the like because of my lousy insurance. I want the extra money I have to be used for my child, not my middle-aged aches and pains. It’s getting very third-worldish here in the USA, owing to our failed government and out-of-control lobbying groups. Maybe time to consider moving elsewhere….
Anonymous New York 42 minutes ago
I have had a knee replacement and a hip replacement both experiences were costly. I would travel abroad for a further medical care as I have been advised I still need more surgery. Besides the medical costs there are collateral costs such as equipment , post op Rehab and care. These factors financially impact the patient,s income And insurance coverage. I am glad to know that I must investigate other options because I literally cannot afford more surgery in the present state of surgerical cost in America
Anonymous Not Available 42 minutes ago
My wife and I spend four months a year in Thailand and have all of our medical done there. The costs are very reasonable, the service is very friendly and professional, many ti9mes we can get in to see a specialist without an appointment and we are not in constant fear of having our insurance cut off in the US for actually having gone to a doctor. What a concept!
Susan Fort Collins 41 minutes ago
Would definitely do this especially if the costs are so much lower. I know people in the US who have health insurance, but cannot afford knee surgery who are living in pain each day. This is an atrocity.
JFS Pittsburgh 40 minutes ago
It worked well for my husband’s boss’s wife (two hips, different years, India). And I don’t think US healthcare providers will take cost seriously (or the US professional classes take the problem of outsourcing seriously) until it happens to them, too. So yes, I’d do it, in protest, whether or not I have health care, until such time as we get an effective, efficient single-payer system in the USA.
Marti Washington DC 40 minutes ago
I’d be concerned about doing it and what the “recovery” would be like, but it has been “on my radar” that medical tourism is NOT out of the question.
Sharon Atlanta 39 minutes ago
. I have dual citizenship and live between Israel and the US. . Israel has socialized medicine and as a resident I pay about 25$ a month there and $100 in the US.for medicare ..both are mandatory. As a registered nurse, it is unacceptable that in the US, care is so costly. I am pleased to have been a small part of getting Obama Care started . I am healthy..having had only an appendectomy in Israel–but NO ONE came from the billing office or sent me a bill . With only medicare, I hope Obama Care will run smoothly.
joannie St.Helena an hour ago
I would absolutely go to another country for that type of procedure if I found such savings!
Susan Moore Coatesville an hour ago
I’m a retired BSN, worked most of my career in Academic Hospitals of high repute. I’d leave town for a joint replacement without a doubt. I’d LOVE an excuse to visit Belgium
Ayshford New York an hour ago
After watching Maggie Smith’s wonderful take on overseas care in “The Best Exotic Marigold Hotel” who wouldn’t? But seriously, of course I would.
Anonymous Wilmington,DE an hour ago
Foreign taxpayers (paying at a much higher rate than US) will be paying MY bill. No, I will pay with my insurance at home.
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Via: Medical care in US, Health care cost, comparison of Cost of Care in US vs. Europe, Hip Replacement, Colonoscopy, Pregnancy, Michael Kalisman, Michael Kalisman MD, michaelkalismanmd@gmail.com

New Radiation Therapy Prolongs Prostate Cancer Survival

Thursday, July 18th, 2013

New Radiation Therapy Prolongs Prostate Cancer Survival

Bayer Healthcare Pharmaceuticals, via Pr NewswireTrials have shown that a new radiation therapy, called Xofigo, can extend the lives of men with the most advanced form of prostate cancer.
A new radiation therapy can extend the lives of men with the most advanced form of prostate cancer, a large new study has found.

http://well.blogs.nytimes.com/2013/07/17/new-radiation-therapy-prolongs-prostate-cancer-survival/?ref=health

By ANAHAD O’CONNOR
Bayer Healthcare Pharmaceuticals, via Pr NewswireTrials have shown that a new radiation therapy, called Xofigo, can extend the lives of men with the most advanced form of prostate cancer.
A new radiation therapy can extend the lives of men with the most advanced form of prostate cancer, a large new study has found.
The treatment is an isotope of radium that zeroes in on cancer cells that have spread to bones. The radium, which mimics calcium, binds with minerals in a patient’s bones, where it delivers radiation that destroys cancer cells without inflicting as much damage to surrounding tissues as older radiation therapies.
The study, published in The New England Journal of Medicine, involved a large group of men with late-stage prostate cancer who were expected to live less than a year. Those who were given the drug, however, saw their median survival time increase to nearly 15 months, a “substantial 30 percent improvement,” said Dr. Chris Parker, the lead author of the new study and a consultant clinical oncologist at the Royal Marsden Hospital and the Institute of Cancer Research, both in London.
Men given the drug also experienced fewer adverse effects, like bone pain and muscle weakness.
The drug was approved by the Food and Drug Administration in May and is sold under the brand name Xofigo. The agency reviewed the drug under a fast-track priority program, approving it three months ahead of schedule.
The drug’s mechanism is not specific to prostate cancers. In clinical trials it has also shown promise in treating bone metastases resulting from breast cancer. And it is likely to help in treating bone metastases caused by other cancers as well, said Dr. Robert Dreicer, a prostate cancer specialist and the chairman of the Cleveland Clinic’s department of solid tumor oncology, who was not involved in the new research.
“I think this is a big deal,” said Dr. Dreicer said. “It’s not a home run, but it’s a nice advance.”
Prostate cancer is the second leading cause of cancer deaths among men in the United States. Every year, nearly 30,000 men die from the disease, and almost a quarter of a million new cases are diagnosed.
The cancer is usually treated with radiation or an operation that removes the prostate gland, followed by drugs that suppress the hormone testosterone, which can stimulate the growth of prostate tumors.
In many men, however, the disease eventually spreads and reaches a point where hormone therapy no longer keeps it in check. Most of the deaths from prostate cancer occur when the disease has spread to the bone.
“About 90 percent of men with advanced prostate cancer have bone metastases, and there has certainly been an unmet need for an effective treatment,” Dr. Parker said.
The new drug contains radium 223, which targets bone and emits alpha particles that are far more massive and energetic than the beta particles emitted by older radioimmunotherapies like strontium. Once in the bone, the heavier alpha particles do not stray as far as the lighter beta particles, which makes them less toxic to bone marrow, Dr. Parker said.
In the new study, Dr. Parker and his colleagues recruited more than 900 men in 19 countries who had hormone-resistant prostate cancer that had spread to their bones but not to other organs. Such men typically live for two or three years, but by the time they entered the study their disease had already progressed for some time.
The men were randomly assigned to receive either placebo or a monthly injection of Xofigo. In those who received it, the drug increased the median survival time from about 11 months to nearly 15. Dr. Parker said that in the real world, the drug could be used even earlier.
“If the drug were used earlier and the 30 percent benefit maintained,” he said, “it would give a longer absolute benefit.”
Drugs for advanced prostate cancer are typically expensive, costing tens of thousands of dollars for a single course of treatment. Xofigo is no different. A course of treatment, administered over roughly six months, costs $69,000. A spokeswoman for the drug’s developers, Bayer and its partner Algeta, said Medicare and most commercial insurers were likely to cover the drug.
In an editorial that accompanied the study, two leading radiation oncologists at the University of Pennsylvania noted that Xofigo could be used to complement other fairly new drugs that prolong survival in the late stages of the disease.
VIA: prostate Cancer, Radiation, Xofigo, Bayer and its partner Algeta, isotope of radium, Bone Metastasis, Michael Kalisman, Michael kalisman MD, michaelkalismanmd@gmail.com

Health Plan Cost for New Yorkers Set to Fall 50%

Thursday, July 18th, 2013

Health Plan Cost for New Yorkers Set to Fall 50%

By RONI CARYN RABIN and REED ABELSON

Individuals buying health insurance on their own will see their premiums tumble next year in New York State as changes under the federal health care law take effect, Gov. Andrew M. Cuomo announced on Wednesday.

State insurance regulators say they have approved rates for 2014 that are at least 50 percent lower on average than those currently available in New York. Beginning in October, individuals in New York City who now pay $1,000 a month or more for coverage will be able to shop for health insurance for as little as $308 monthly. With federal subsidies, the cost will be even lower.

Supporters of the new health care law, the Affordable Care Act, credited the drop in rates to the online purchasing exchanges the law created, which they say are spurring competition among insurers that are anticipating an influx of new customers. The law requires that an exchange be started in every state.

“Health insurance has suddenly become affordable in New York,” said Elisabeth Benjamin, vice president for health initiatives with the Community Service Society of New York. “It’s not bargain-basement prices, but we’re going from Bergdorf’s to Filene’s here.”

“The extraordinary decline in New York’s insurance rates for individual consumers demonstrates the profound promise of the Affordable Care Act,” she added.

Administration officials, long confronted by Republicans and other critics of President Obama’s signature law, were quick to add New York to the list of states that appear to be successfully carrying out the law and setting up exchanges.

“We’re seeing in New York what we’ve seen in other states like California and Oregon — that competition and transparency in the marketplaces are leading to affordable and new choices for families,” said Joanne Peters, a spokeswoman for the Department of Health and Human Services.

The new premium rates do not affect a majority of New Yorkers, who receive insurance through their employers, only those who must purchase it on their own. Because the cost of individual coverage has soared, only 17,000 New Yorkers currently buy insurance on their own. About 2.6 million are uninsured in New York State.

State officials estimate as many as 615,000 individuals will buy health insurance on their own in the first few years the health law is in effect. In addition to lower premiums, about three-quarters of those people will be eligible for the subsidies available to lower-income individuals.

“New York’s health benefits exchange will offer the type of real competition that helps drive down health insurance costs for consumers and businesses,” said Mr. Cuomo.

The plans to be offered on the exchanges all meet certain basic requirements, as laid out in the law, but are in four categories from most generous to least: platinum, gold, silver and bronze. An individual with annual income of $17,000 will pay about $55 a month for a silver plan, state regulators said. A person with a $20,000 income will pay about $85 a month for a silver plan, while someone earning $25,000 will pay about $145 a month for a silver plan.

The least expensive plans, some offered by newcomers to the market, may not offer wide access to hospitals and doctors, experts said.

While the rates will fall over all, apples-to-apples comparisons are impossible from this year to next because all of the plans are essentially new insurance products.

The rates for small businesses, which are considerably lower than for individuals, will not fall as precipitously. But small businesses will be eligible for tax credits, and the exchanges will make it easier for them to select a plan. Roughly 15,000 plans are available today to small businesses, and choosing among them is particularly challenging.

“Where New York previously had a dizzying array of thousands upon thousands of plans, small businesses will now be able to truly comparison-shop for the best prices,” said Benjamin M. Lawsky, the state’s top financial regulator.

Officials at the state Department of Financial Services say they have approved 17 insurers to sell individual coverage through the New York exchange, including eight that are just entering the state’s commercial market. Many of these are insurers specializing in Medicaid plans that cater to low-income individuals.

North Shore-LIJ Health System, the large hospital system on Long Island, intends to offer a health plan for individuals as well as businesses for the first time. Some of the state’s best-known insurers, UnitedHealth Group and WellPoint, are also expected to participate. Insurers may decline to participate after they receive approval for their rates, but this is unlikely.

For years, New York has represented much that can go wrong with insurance markets. The state required insurers to cover everyone regardless of pre-existing conditions, but did not require everyone to purchase insurance — a feature of the new health care law — and did not offer generous subsidies so people could afford coverage.

With no ability to persuade the young and the healthy to buy policies, the state’s premiums have long been among the highest in the nation. “If there was any state that the A.C.A. could bring rates down, it was New York,” said Timothy Jost, a law professor at Washington and Lee University who closely follows the federal law.

Mr. Jost and other policy experts say the new health exchanges appear to be creating sufficient competition, particularly in states that have embraced the exchanges and are trying to create a marketplace that allows consumers to shop easily.

“That’s a very different dynamic for these companies, and it’s prodding them to be more aggressive and competitive in their pricing,” said Sabrina Corlette, a professor at Georgetown University’s Center on Health Insurance Reform.

But some consumers may still find the prices and plans disappointing. Jerry Ball, 46, who owns a recycling business in Queens, said the cost of covering his family increased so rapidly in the last few years that he had to scale back their coverage. Still, he pays nearly $18,000 a year for a high-deductible policy for a family of three.

He said he would be reluctant to part ways with his insurer, Oxford, and was disappointed that even the least expensive Oxford plan being offered next year would cost about as much as he pays now.

With another plan, he said: “Will I be able to maintain my doctors? I’m concerned that some of the better doctors aren’t going to take health insurance.”

He acknowledged that the new law would allow him for the first time to easily switch plans, but it is still hard for him to believe it guarantees coverage for pre-existing conditions. “I have to be careful. I can’t be denied coverage, right?” he asked.

Via: Health care cost, coverage, pre-existing conditions, Health Insurance, Michael Kalisman, Michael Kalisman MD, Michaelkalismanmd@gmail.com

Dementia’s Signs May Come Early

Thursday, July 18th, 2013

Dementia’s Signs May Come Early
http://www.nytimes.com/2013/07/18/health/looking-for-early-signs-of-dementia.html?pagewanted=1&_r=0&hp

By PAM BELLUCK
A Lapse or a Loss?
As people age, virtually everyone experiences lapses
in memory and attention. But some memory
changes are not considered a reflection of normal aging.
This list may help distinguish between what is normal
aging and what could be more worrisome.

Normal Aging
• Walking into a room and forgetting why you entered.
• Having trouble retrieving the names of unfamiliar people.
• A change in memory compared with young adulthood.
• Memory changes similar to others of the same age.

Abnormal Aging
• Getting lost in familiar surroundings.
• Having difficulty remembering important details of recent events.
• Having difficulty following the plot of a television program or book because of memory.
• Memory changes that are worse than others of the same age.
The man complained of memory problems but seemed perfectly normal. No specialist he visited detected any decline.
“He insisted that things were changing, but he aced all of our tests,” said Rebecca Amariglio, a neuropsychologist at Brigham and Women’s Hospital in Boston. But about seven years later, he began showing symptoms of dementia. Dr. Amariglio now believes he had recognized a cognitive change so subtle “he was the only one who could identify it.”
Patients like this have long been called “the worried well,” said Creighton Phelps, acting chief of the dementias of aging branch of the National Institute on Aging. “People would complain, and we didn’t really think it was very valid to take that into account.”
But now, scientists are finding that some people with such complaints may in fact be detecting early harbingers of Alzheimer’s.
Studies presented Wednesday at an Alzheimer’s Association conference in Boston showed that people with some types of cognitive concerns were more likely to have Alzheimer’s pathology in their brains, and to develop dementia later. Research presented by Dr. Amariglio, for example, found that people with more concerns about memory and organizing ability were more likely to have amyloid, a key Alzheimer’s-related protein, in their brains.
And, in a significant shift highlighted at the conference, leading Alzheimer’s researchers are identifying a new category called “subjective cognitive decline,” which is people’s own sense that their memory and thinking skills are slipping even before others have noticed.
“The whole field now is moving to this area, and saying ‘Hey, maybe there is something to this, and maybe we should pay attention to these people,’ ” said Dr. Ronald C. Petersen, chairman of the advisory panel to the federal government’s new National Alzheimer’s Project.
Dr. Petersen, director of the Mayo Clinic’s Alzheimer’s center, said preliminary results of a Mayo study of healthy older adults in Minnesota suggested something similar.
“Lo and behold, those who had a concern about their memory in fact had more likelihood” of later developing mild cognitive impairment, an early phase of dementia, he said. He said study participants with memory concerns were 56 percent more likely to be given a diagnosis of such impairment, even when results were adjusted for factors like education, genetic risk and psychiatric issues like anxiety and depression.
“These people are sensing something, and there’s some biological signals that correlate,” Dr. Petersen said. “I think it’s real.”
Experts emphasize that many people with such complaints will not develop dementia. Some memory decline reflects normal aging, they say, and some concerns reflect psychological angst. People who forget what they wanted in the kitchen or the names of relatively unfamiliar people are probably aging normally. People who forget important details of recent events, get lost in familiar places or lose track of book or television plots may not be, especially if they have more problems than others their age.
And much remains unknown about subjective concerns. In some studies, like Dr. Amariglio’s, highly educated people noticed changes more readily, but in other studies, less educated people did. Some studies suggest people who worry more about memory deficits have more dementia risk, but it is unclear if the worry reflects the changes they sense or if worrying itself increases risk. People with family histories of dementia could be reporting problems simply because they know about the disease and its genetic component. And, while a study presented Wednesday found slight correlations between subjective concerns and the highest-risk genetic mutation, ApoE4, that relationship remains unclear.
Experts are not yet suggesting doctors regularly screen people for “subjective cognitive decline” because much more research is needed and no effective dementia treatment now exists.
Dr. Richard Caselli, a neurology professor at the Mayo Clinic in Arizona, said that when patients cited cognitive problems, he ruled out “reversible things,” but did not recommend testing for Alzheimer’s because “if we do a scan and say, ‘Hey, we found some amyloid in your brain,’ there’s really nothing you can do.”
But subjective screening has value now for clinical trials, experts say, because it can help pinpoint people at higher risk for dementia to better determine if treatments can delay or prevent Alzheimer’s.
Major studies like the Alzheimer’s Disease Neuroimaging Initiative are adding subjective memory complaint categories. So will an important trial to see if an anti-amyloid drug can prevent dementia in cognitively normal people with amyloid in their brains.
“People have been interested in this subjective concern for a long time, but we didn’t have a way to say is this normal,” said Dr. Reisa Sperling, who runs Brigham and Women’s Alzheimer’s program and is helping lead the coming anti-amyloid study.
Not long ago, most experts considered subjective concerns unmeasurable or related to depression or anxiety. Frank Jessen, a researcher at the German Center for Neurodegenerative Diseases, said his first study on the topic, submitted to journals around 2004, “got rejected everywhere,” but in 2012, the same study with more years of data was accepted by Neurology, a major journal.
In November, a working group of leading experts was formed, headed by Dr. Jessen. The name “subjective cognitive decline” was chosen after some debate, with some experts preferring other terms.
Dr. Jessen said in diseases from arthritis to Parkinson’s, people often feel something is wrong before others notice. In most phases of dementia, family members and friends see deficits, but the disease has usually stolen the person’s ability to recognize them. But at the subjective phase, studies suggest family members may miss problems; the person may feel his mind working harder, but he still functions well.
One of Dr. Caselli’s patients, Roger Siegel, 84, has noticed problems for at least five years, and said he now remembers about 30 percent of what he would like to, and has trouble concentrating. “I take a shower and wonder did I wash that leg,” he said. In books, “many times I forget which character is which.”
Recently, he bought six packages of pie filling instead of one “because I asked somebody where would I find it and the answer was Aisle 6, so I wrote down 6, but by the time I got to the aisle, I picked up six of the thing.”
Neither his wife nor Dr. Caselli perceive these difficulties.
“I know I’m losing my mind,” Mr. Siegel said, “but according to Caselli, I’m fine.”
Dr. Caselli said Mr. Siegel has “been saying he is declining for years,” and was given a diagnosis at another clinic of mild cognitive impairment three years ago “based on his subjective complaints, when he had no evidence of decline and I told him so.”
But recently fine-grained cognitive measures showed he had “slight decline on his tests, and so may possibly be at a very early stage of a very slowly progressive degenerative syndrome,” Dr. Caselli said.
The working group aims to develop standardized subjective cognitive tests so when treatments become available doctors can eventually use them as a “cheap and noninvasive” way to help identify people at greater risk, said Dr. Petersen. “We can’t do M.R.I.s and scanning on everyone,” he said.
Current tests range from an eight-page assessment in Dr. Amariglio’s research to one question included in a broader University of Kentucky study of dementia. But Richard Kryscio, a biostatistician and study leader, said those reporting memory changes since their last visit were 2.8 times as likely to develop mild cognitive impairment or dementia years later, and autopsies of participants who died found more Alzheimer’s plaques and tangles in people with subjective cognitive concerns.
Experts say the goal is a test identifying which subjective concerns are potentially worrisome, since not all are.
Sharon Atkinson-Mallory, 70, of Belmont, Mass., a participant in Dr. Amariglio’s study of people without symptoms, said she had occasional trouble putting names to faces and remembering why she entered a room. But Ms. Atkinson-Mallory, a psychotherapist, maintains a practice, exercises, pursues a genealogy hobby, and considers her issues similar to those of others her age.
Carol Miller, 61, of Rochester, Minn., part of the Mayo Clinic’s study of cognitively healthy adults, seems more concerned. A registered nurse who retired after being laid off a few years ago, she has forgotten cardiovascular and neurological vocabulary that once “I would recall very easily,” she said. “I don’t trust myself as a safe R.N. because I don’t have the knowledge anymore.”
When shopping for blueberry filling for her daughter’s birthday cake, she twice reached the checkout counter having forgotten it. And twice she has left the stove on. “I could’ve burned the house down,” she said. “That was scary, like ‘Wow, what’s the deal there?’ ”
Still, she said, “so far they tell me I’m normal.”

Via: Dementia, Alzheimer, Memory Loss, cognitive impairment , amyloid, Alzheimer’s-related protein, Michael Kalisman, Michael Kalisman MD, michaelkalismanmd@gmail.com

The Voice Foundation Symposium May 29-June 2, 2013

Wednesday, June 12th, 2013

The Voice Foundation Symposium and Board Listing

Via:Michael Kalisman MD, Michael Kalisman, Symposium Program, The Voice Foundation