A few sentences to make your blood boiling in this whopper from Noah Smith:

It’s mostly the providers overcharging you, not the middlemen.

[…] the Kaiser Family Foundation does detailed comparisons between U.S. health care spending and spending in other developed countries. And it has concluded that most of this excess spending comes from providers — from hospitals, pharma companies, doctors, nurses, tech suppliers, and so on.

The actual people charging you an arm and a leg for your care, and putting you at risk of medical bankruptcy, are the providers themselves.

Excessive prices charged by health care providers are overwhelmingly the reason why Americans’ health care costs so cripplingly much.

And to top it off:

Over at Tyler Cowen’s blog, a commenter argues that profit margins are not a good guide to the financial success of a business, and that instead one should look at return on equity (ROE). But if you look at the list of companies with the highest ROE, you see health care providers or suppliers like HCA Healthcare (272%), Cencora (234%), Abbvie (84%), Mckesson (84%), Novo Nordisk (72%), Eli Lilly (59%), Amgen (56%), IDEXX Laboratories (53%), Zoetis (46%), Novartis (44%), Edwards Lifesciences (43%), and so on.

Using “healthcare provider” to mean pharmaceutical companies is at best careless when the article you are writing is directly tied to a murder of a health insurance executive. But what really upsets me is that he is right: physicians, nurses, etc. have allowed themselves to be tied to these behemoths for the promise of what? A steadier paycheck that is less — for the time spent in school and at work — than what a mid-career IT professional earns? Sad. (↬Tyler Cowen)

On my way back from #ASH24 I’ll go back through the abstract book and check out how many cell therapy oral presentations were given by investigators from China. This is the first meeting I’ve attended since 2019 and the difference is striking. Kudos!

PCA maps are the new PET scan, only with zero clinical relevancy instead of at least some. Much more subjective, too! #ASH24

100% of patients developed grade ≥3 neutropenia. “The safety profile was mild” #ASH24

Seeing those PET scans after CAR-T 5–10 years ago was transformative but it has now become superfluous. Yes, yes, that was a nice anecdote, can I now please see some data? #ASH24

United Airlines IAD→SAN flight is full, the person in front of me is talking about sickle cell disease, and I know a good chunk of people on board. I should also be looking at the #ASH24 program instead of writing this but oh well.

And in even bigger news for clinical medicine:

Brian Thompson, the CEO of United Healthcare, was shot and killed by a masked man near a Midtown Manhattan hotel early Wednesday, according to police sources.

United Healthcare is, of course, the Big Bad for-profit healthcare hydra gobbling up hospitals all over the country. On an unrelated note, this seems to have been a hired hit.

Faber est suae quisque fortunae.

Big news for academic medicine yesterday:

Dr. Brian Druker, CEO of the Knight Cancer Institute at Oregon Health & Science University and developer of a drug that revolutionized cancer treatment, said he was stepping down in part because OHSU had “forgotten our mission” and is no longer a place to do cutting-edge research.

The problem with academic medicine is that it is still part of American medicine, and an MD’s worth is measured in RVUs they can generate. This is easier to calculate and cross-compare with non-academic docs, so it wins out over any other activity in an MBA’s spreadsheet.

So, here is a last-minute Hail Marry request that I hope someone will respond to. I run an introductory course on clinical trials at UMBC (BTEC668). Today at 6pm EST we have a patient/caregiver panel where I talk to a few people on why they did or didn’t participate in trials. We may have a last-minute cancelation from a panelist, so if a patient or caregiver has 90 minutes to spare this evening it would be much appreciated! Do email or DM if interested.

The same week Alexey Guzey proposed abolishing the NIH, two more essays popped up:

• Distinguishing the real from invented problems with the NIH, from Sasha Gusev, himself an NIH-funded geneticist
• The NIH Needs Reform: Here are 10 Sensible Suggestions from Joseph Marine, a cardiologist

A few things came to mind:

• You can clearly see the difference in backgrounds. Gusev’s essay is an “insider-y”, show-me-what-we’re-doing-wrong approach. Marine’s is outward-looking-in, dealing more with perception of the NIH.
• Marine makes several immediately actionable proposals which are the policy equivalent of politicians kissing babies but since these days any politician seen kissing a baby would be called a creep (or worse) I suspect that even those modest proposals would become divisive.
• Neither states conclusively what the NIH is for. Is its mission to give out grants? Advance biomedical science? Or help people live longer and/or better? I’d say it’s that last one and that everything else is means to that end.
• So if we see the NIH as a grant-giving machine, I guess we could give it a passing grade. The awardees certainly seem happy! But in the last 30 years we saw several massive public health crisis, from the obesity epidemic to the opioid murders to the bungled response to the pandemic so from that standpoint at least there is room for improvement.
• Gusev’s essay does not at all consider the opportunity cost of the current system. He lists length of grant proposals as an “invented problem” and unironically writes (emphasis mine):

The last NIH proposal I submitted was about ~150 pages which might indeed seem daunting. But only ~12 pages of that was dedicated to science and will be the focus of study section reviewers (and I can also assure you that I wish I had more than 12 pages to work with). The remainder was some combination of budgets, resumes for all of the personnel involved, descriptions of the data and resources, and contractual language between the NIH and my institution. Nearly all of it was handled by experienced grants administrators in my department who can put these documents together in a matter of hours.

• You don’t have to be an expert in probability and statistics to see how this “invented problem” leads to a winner-takes-all system, the winner being a handful of investigators in a handful of institutions. This is an incredible systemic risk that can lead to billions of dollars wasted and set back an entire field of study by decades.
• I want to read something from Adam Mastroianni on the topic of NIH reform.