Low hanging fruit in containing health care costs: the case of Lucentis and Avastin.

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.

One of the real gifts of spending this year in Israel is that I can swim every day, thanks to the combination of a small pool in our building (one of the reasons we chose it) and being on leave.  Most mornings, our youngest son swims with me.  Swimming with him is more physically challenging (he loves to race and beats me every time), splashier, much more fun, and somewhat less introspective than it is on my own.  Today though, he stayed in bed with a cold and I was on my own, to swim and to think.  As I swam, I tried to think through an article I am working on about immigrant health and, perhaps inspired by news of the recent Climate March in NYC, I kept remembering an image from South India that has stayed in my mind for many years.   It is of a man at work by the side of a dusty road in the heart of the town where we lived.  He was sitting on a mat, at work fixing an umbrella, with a stack of broken umbrellas on his left and a stack of functional looking umbrellas on his right.  In South India, it is worthwhile to fix umbrellas instead of just throwing them out when they break, and clearly was this man's livelihood.  I think that one of the reasons the image has stayed with me so long is that I saw it shortly before leaving India to return to the United States and to my medical training.  I was struck then and am still struck today by how little is wasted in India and by how badly we do in the United States at valuing not only the material objects we often throw out rather than fix, but also in valuing the energy, industriousness, and creativity of the immigrants we grudgingly admit to our country.  It is not just the umbrellas that I remember, but the man who made a living repairing them.  What could he do with what we waste every day?  

Thinking about the ways in which in this coming new year, we need to waste less not only of material goods

and planetary green space, but of human potential, I thought it would be an interesting challenge to come up with a use for a food I have always intensely disliked, a sort of culinary version of the need to value all of creation.  And, voila, I have actually found a Rosh HaShanah recipe for cauliflower that the boys and I like -- kind of the cauliflower equivalent of junk food.  I hope you will enjoy it with the kavanah with which it is intended, (with apologies to those of you who like cauliflower already to whom this will make no sense).
http://www.joyofkosher.com/recipes/rosemary-roasted-cauliflower/

Of traffic signs and illiteracy

Yesterday marked the end of my first week as solo adult in charge of our household.  In honor of surviving week one with children, apartment, car and sense of humor intact, I thought it would be fun to share a few of the Israeli traffic signs that have made my life just that much more entertaining, and along the way have made me think a bit about real world literacy issues.  In preparation for our time in Israel, I've been working hard on my Hebrew, but all of that time I've focused on understanding and speaking, figuring that they would be so much more important than reading, at least in the beginning.  Interesting logic, as it turns out, since my reading skills are pretty darn basic -- I can sound words out slowly and often can figure our what brief text means if I have time, but show me a paragraph and I panic.  And put that paragraph somewhere important and time sensitive like a traffic sign and wow!  Instant deer-in-the-headlights moment.  Pair that with the interesting Israeli tendency to create traffic signs with paragraphs of text (not always tri-lingual despite what I read in the guidebooks), liberal use of exclamation points, and pictures that only communicate if you know what they mean and you can appreciate the need to either laugh or scream. Of course I can't photograph them while driving, so am missing some of the best ones!

Exactly!

Today marks the end of the first week of school.  Although much of the week, as in American schools, has been dedicated to the business of getting started, figuring out where everyone is going, getting the correct books, and so forth, the teachers have also found time and space to talk about Gaza and the events of the summer.  Haifa is far enough away that the kids here, like our family, experienced events from afar but that does not seem to stop opinions from being strong and highly varied, but the teachers seem able to let them all be heard.  I am impressed with how quickly the school is able to take in new kids, assess their abilities, place them in classes, and begin the process of making them part of a hevre. Although not everything goes smoothly (the boys are still attempting to get copies of the math and science books, for example), the sense that other kids are having the same problems and the humor with which they deal with them seems to make it work.  Having no physics book is a problem.  Having the librarian faced with a line of kids clamoring for books announce that the library is now closed is funny, and a problem for another day.

Last Shabbat, we stayed with GJC alumni Hila, Itai, Nadav and Roni in Jerusalem and in addition to a wonderful visit with them, were able to be at the bar mitzvah of Adam Bonn-Yavneh, grandson of Chana  Bonn.  Adam's davenning and dvar were amazing but I think my favorite part were the calls first from his mother Jessie to Adam and then later from Adam to Jessie of l'at l'at (slower, slower).  Such a treat to be part of such a warm, loving community celebration!  This Shabbat the boys and I are going to try to find Or Hadash, a reform congregation about 3 km from our apartment.  Everything here is either up a steep hill, down a steep hill, or both, so hoping we find it on the first try.

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).

In this morning's tentative calm after 2 months of fighting, we woke up to hope for the end of the conflict, but also to the reality of its aftermath.  With the violence and political posturing, we have seen an increase in antisemitism abroad and in tensions between Israel's Arab and Jewish populations as well, often breaking out in violent acts within Israel's cities.  This morning's paper carried an article about Israel's President Rivlin work to address this latter issue, describing "the rising voices of hatred, hotheadedness and racism in Israeli society, particularly between Arab and Jewish citizens of Israel."  Israel still faces tremendous challenges to build a viable path forward with Gaza that does not simply create conditions for another war in 2 or 3 years time.  A part of this work, would seem to be finding a path to justice and understanding internally between peoples who once lived side by side amicably.  I am glad to be living in Haifa, with its tradition as a joint Jewish-Arab city during this time of both challenge and possibility.  As we talk with both Arab and Jewish city residents, I've been impressed by the uniformly positive reaction to both Adam and Zeke planning to study Arabic this year.

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.

Infant mortality

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

Beginnings

We've been in Israel for almost a week now, and having promised myself that I would do some writing while we are on sabbatical in Haifa this year, it seems time to start.  For the last few days, our time has been consumed with the business of setting up household:  figuring out where to buy groceries, how to sign our kids up for school, how to actually move the car we are renting out of the parking garage (far from obvious), and where to buy a birthday cake for our youngest son's 14th birthday. This last taught us that one of the wonderful things about Haifa is that it is Israel's bakery capital, with more per-capita bakeries (not a commonly used statistic, but one that seems to matter to our family) than anywhere else in the country.   The other thing I've noticed on the food front is that fruits and vegetables are surprisingly affordable for a desert country. Cucumbers cost about 75 cents per pound, tomatoes about the same.  From what I've been able to find out so far, much of this relates to investment in technological resources to make farming of these crops affordable, fascinating in light of their much higher relative cost in the US and the lack of investment in this sector at home.  This is an area I want to understand better.  Certainly just looking around the streets in Haifa, people are almost all thin.  Not a scientifically valid measure, but striking.

Everything seems to take longer than I think possible, largely because most businesses seem not to be listed on the internet, and in the absence of any other system, we are finding things by wandering the streets, looking for what we need and asking in various shops.  Because of this, when we sat down to figure out how to get health insurance for our family yesterday, we expected it to be very complex to figure out and require the same multiple visits to various offices that it has taken to enroll our boys in school (actually we've only managed to enroll one of them so far, with an appointment on Thursday -- visit #4 -- in hopes of enrolling the other).  We have US insurance through the end of August, so wanted to make sure there wouldn't be a gap.  Fascinatingly, one brief phone call later, we all have health insurance starting immediately and costing about 1/8th what our plan costs in the US.  Oh, and no co-pays instead of the 50% "co-insurance" we pay up to a cap of $5000 in the states.  I got an email later the same day with my insurance card as a PDF and the 24 hour toll-free number to call if I need help finding a doctor.  Really.  Israel has a private insurance system, but with very stringent governmental regulation.  I'm sure there are lots of flaws in the system that one could point out, but I'm still amazed.

Our other adventure yesterday was a visit to Dalyat el Carmel, a Druze village near Haifa.  We had a good time wandering through shops, finding a finjan for me to make my coffee in as well as a bakery with about 25 kinds of baklava.  Very, very happy boys.  Then we stopped for lunch at a restaurant near where we parked our car, where we had amazing homemade Druze food (homemade because the owner's house is next to the shaded porch where the restaurant sits).  He was unfazed by our request for vegetarian food, and brought out dish after dish of delicious lentils, stuffed grape leaves, stuffed cabbage, hummus, falafel, and mujadara.  This last is a Druze version of a dish that's made up of lentils, bulgar (rice in the Lebanese version), carmelized onions, and spices -- amazingly good!  I'm going to try making it as soon as it gets cool enough to imagine turning on the stove -- see:  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.