This morning's New York Times carries a wonderful illustration of one of the cardinal differences between the culture of healthcare in Israel and that in the US. Katie Thomas and Rachel Abrams detail the odd history of Lucentis and Avastin, both effective drugs for macular degeneration, but with the difference that Lucentis costs $2000 per dose compared to $50 for Avastin. Despite this massive difference in cost and multiple studies showing no clinical advantage for Lucentis over Avastin, many ophthalmologists, particularly those receiving industry payments, continue to prescribe Lucentis. The cost to the Medicare program: an extra $1 billion per year. Medicare, of course, has been barred by Congress from negotiating drug prices. Pharmaceutical representatives quoted in the story express their belief in the importance of the ability of each physician to choose which drug to prescribe free from interference based on cost.
In Israel, each year the national health system reviews the basket of covered health services including medications. In 2009, the committee charged with this work considered the evidence and refused to cover Lucentis on the grounds that it had no advantages over Avastin, which was already available. Such a decision making process does not exist in the US for patients covered by Medicare or other fee for service plans, although it does exist within HMOs. This means that there is no national body in the US to review the pros and cons of medications and decide which have benefit that justifies their cost. Ostensibly this is because we in the US highly value physician autonomy and the ability of each physician to choose the best treatment for an individual patient, as well as because we oppose any kind of rationing. Yet that $1 billion we spend yearly is ultimately a decision about rationing something -- if not medical care, then schools, food stamps, or some other piece of the budget. And of cource Lucentis is just one medication, one piece of the larger health care puzzle.
Speaking with Israeli physicians about the drug basket approach, it's clear to me that these are very difficult decisions, but ones that are made attempting to weigh the pros and cons of each item with the overall goal of improving the health of the population. Decisions in the US might be easier, given the much high overall level of spending, but still few of us would choose to spend a billion dollars without any expectation of benefit.
Monday, December 8, 2014
Monday, September 22, 2014
Thinking about the ways in which in this coming new year, we need to waste less not only of material goods
Monday, September 8, 2014
Friday, September 5, 2014
Amid dealing with figuring out the details of daily life, I've continued trying to learn more about health and healthcare here. This past weekend, Itai was able to explain to me a bit about conditions for foreign workers, since much of my work in healthcare in the US has been around access to care for immigrants. As in the US, foreign workers provide most of the home health care here (among other occupations) but unlike the US where they are one of the groups least likely to have health insurance, in Israel their employers are required to provide them with insurance. One of the things that fascinates me about Israel's health system is the fact that it has kept costs stable at about 8% of GDP for the past 2 decades while costs in the US have skyrocketed. As I wrote in my last post, health outcomes including life expectancy continue to improve in Israel and exceed those of the US. Every resident of the country, whether a citizen, foreign worker, or temporary residents like our family on sabbatical must have health insurance, but that insurance is easy to obtain and remarkably affordable. Part of the reason this system works is that overall costs for healthcare have been kept remarkably low through strict governmental regulation. See Health Affairs for a detailed explanation. 90% of Israelis say they are satisfied or very satisfied with their health plan compared to about 87% in the US (including only those who have insurance).
Thursday, August 28, 2014
Speaking of Zeke, for those interested in following his photographic journeys, he has started a blog as well. It's a bit like taking a lovely stroll with him, although without some of the hotter, dustier parts and with the ability to rest and sip something cool.
In between checking news reports and trying to maintain a sense of normalcy, I've also begun trying to understand public health conditions here, beginning with the lens of health disparities since that is the focus of my knowledge base of health in the US. We've watched the events in Ferguson from a distance and reading about disparities here in Israel between Arab and Jewish populations reminds me acutely of similar and often more marked disparities back home between African-American and white populations. Comparing the numbers with those in the US is really quite striking. Continuing to try to understand these issues, hopefully with the help of some contacts in the public health community here.
2.7 per 1000 births among Israeli Jews
6.8 per 1000 births among Israeli Arabs
5.5 per 1000 births among US Whites
12.8 per 1000 births among US Blacks
Children living in poverty
24% among Israeli Jews
66% among Israeli Arabs
13% among US Whites
38% among US Blacks
Monday, August 18, 2014
http://www.everydaymaven.com/2012/mujaddara-burghul/ for what looks like a good version (apologies for not trying it before posting, but it's hot!). After we ate, the owner sat and talked with us for an hour or so, telling us all about his family, the Druze history in Dalyat el Carmel, the history of the Druze and Muslims, and so forth. An unforgettable trip.