Drug Pricing in the United States

By Aleicia Zhu

Published 9:03 PM EST, Sat April 10, 2021

Introduction

With the COVID-19 pandemic, the cost of healthcare in the United States has been a surging issue. According to the New York Times, one critically ill patient received a surprise bill for her helicopter lift—it was for $52,112 [1]. As a whole, the US spends 16.9% of its GDP on healthcare, which is more than any other country [2]. Likewise, the costs of drugs and ‘Big Pharma’ have been a recurring motif in what some see as the horror story of American healthcare costs. A single vial of the long-acting insulin Humulin R U-500, for example, can cost $1,487 and on the global market, the US accounts for half of the insulin industry’s profits [3]. Clearly, drug costs can be an issue for American patients, but the extent, policy, and solutions must be examined more closely.  

Results

As stated by the CDC, prescription drugs make up approximately 9.5% of healthcare expenditures [4]. Nevertheless, some groups make efforts to decrease their personal healthcare expenditures on prescription drugs. For the ages 18-64, out-of-pocket costs averaged $6 for generic drugs but $30 for the brand name. Some people in all age groups reported that they did not take their medication or requested a cheaper drug [5, 6]. The over 65 age group, in particular, reported not taking their medications at 4.8% and requesting a cheaper drug at 17.7%. In this same age group, those that were only covered by Medicare were less likely to take their medications as prescribed in contrast to those with private coverage [6]. For the 18-64 age group, the percentage that did not take their medication or requested a cheaper drug declined from 2013 to 2015 and remained stable from 2015 to 2017. Another declining solution used by this group includes alternative therapies, which were most highly utilized by women and the uninsured [5]. Even accounting for higher US incomes, Americans spend 90% more on prescription drugs than Europeans [7].  

Government policy also affects drug costs in the US. Medicare Part D, for instance, was a policy instituted in January 2006 designed to cover some outpatient drug costs and prevent them from increasing. To clarify, Medicare is a government program designed to pay for some of the healthcare costs of people who are 65 and older, have a disability, or have end-stage renal disease [9]. In a study by NBER, they found that the percent of elderly filling prescriptions rose 3% from 2005 to 2007 and out of pocket drug costs declined 15.8%, relative to the near-elderly. The spike in elderly filling prescriptions was mostly in 2006 and actually declined in 2007, though there is still an overall increase [10]. Medicare does use a coverage gap which was, in 2006, paying out of pocket drug costs up to $2250 and after $3600 annually per person. In the $2250 to $3600 range, plans cannot allow the beneficiary to pay more than 25% of the costs of brand name drugs, and some people do have supplementary Medicare advantage plans to pay for this. [11]. Beneficiaries still report financial difficulties, and people report lesser use of both essential and non-essential drugs during the gap. However, people also report that these issues have at least been mitigated from where they once were, though they do experience great confusion from this policy. As for cost to the government, the Congressional Budget Office estimated that the cost of these benefits were $811.5 billion from 2006 to 2017 [12]. Certain advocacy groups believe that this can be reduced by removing the noninterference clause, a segment of the Medicare Modernization Act (which created Medicare Part D) that bans the government from negotiating these drug costs. Not to mention, this receives overall support of 88% of the public. Only private plan sponsors can negotiate these, but supporters claim that the government could have more collective power in driving these expenditures down [13]. The Veterans Affairs system is different, with the government organization owning a network of pharmacies rather than reimbursing privately owned ones. The 1992 Veterans Health Care Act put price ceilings on drugs and the VA is allowed to negotiate, offering themselves steep discounts. Out of all federal purchasers, the VA has the lowest per prescription costs [14]. 

Still, it is important to keep in mind the costs of manufacturing the drugs themselves. Detractors of negotiating down drug costs argue that Americans are subsidizing the healthcare systems of the rest of the world. Without them, pharmaceutical companies would not be able to turn profit and would stop selling the drugs or innovating new ones [15]. Some research indicates that drug development is sensitive to expected future revenues [16]. Drug development is, indeed, expensive. Moreover, pharmaceutical companies need to recoup the costs of failed drugs, not just the ones that make it to market. According to the New England Journal of Medicine, only 11.8% of drugs succeed in obtaining clinical approval [17]. In 2013 dollars, a study in the Journal of Healthcare Economics estimated that the cost of research and development is $2.558 billion [18]. Americans’ drug expenditures are higher, but Americans are also more likely than Europeans to use newer and higher-strength drugs [19].  The $1,487 quoted was for the newer, long-acting Humulin R U-500; Walmart’s ReliOn insulin costs $25 per vial, though it is more inconvenient to use. The Washington Post asserts that pharmaceutical companies spend more on marketing than research and development, but one must be careful to understand that ‘marketing and administration’ were proclaimed to be only marketing. Administration includes almost all costs except R&D and some quality control and maintenance.  

Discussion

On the whole, drug costs in American healthcare are complicated. They are simultaneously a pressing issue in healthcare affordability but also not the greatest issue the US healthcare system faces. For instance, hospital care and clinical services are far more expensive than prescription drugs’ 9.5% of healthcare costs; respectively, they make up 32.7% and 19.9% [4]. Administrative costs are also extremely burdensome, as the US has a labyrinthine system of different private insurers, separate billing codes, Medicare, and Medicaid. In essence, it is a difficult and time-consuming process for physicians and healthcare organizations to get reimbursed. In 1999, administrative costs accounted for 31% of healthcare expenditures in the US, whereas it accounted for 16.7% of Canadian healthcare expenditures. For context, Canada has only one payer—the provincial government—and duplicative private care is illegal. Of course, this single-payer system has its own issues. Wait times are a prominent one in US media. Overall, healthcare reform is an exceedingly complex issue, where every system has its pros and cons.

Americans will, likely, also need to accept certain trade-offs to reduce drug prices. This may include using older or weaker drugs [19]. As with Canada, the government may have to cap or subsidize drug prices instead of paying for them entirely. While physician care and hospital stays have no cost at the point of service, pharmacare still requires payment [20]. Americans will also need to tolerate the taxes to pay for this. While the proposed single-payer system ‘Medicare-for-All’ is popular when not described, support drops from 56% to 37% when told Americans would have to pay more taxes and that it would ban duplicative private care. Some advocates also propose nationalizing the pharmaceutical industry, but it is unclear if Americans are willing to pay the taxes to maintain the same amount of research and development. The Brookings Institute proposes that Europeans pay an extra 20% for drugs make up for it and increase innovation so that they and their global counterparts can benefit [21]. 

Conclusion

American healthcare has been an ever-present issue, from Teddy Roosevelt’s national health insurance to Bernie Sanders’s Medicare-for-All program [22]. On top of that, discussions of ‘Big Pharma’, drug costs, and corporate interests have intertwined with that. Nevertheless, it is important to look into the complexity of the issue. Americans will likely need to have trade-offs if they desire lower healthcare costs, though it does not they should not support reform. These negatives need to be recognized but also balanced against the positives.  

Aleicia Zhu, Youth Medical Journal 2021

References

1. A $52,112 Air Ambulance Ride: Coronavirus Patients Battle Surprise Bills. (2021). The New York Times. https://www.nytimes.com/2020/10/13/upshot/coronavirus-surprise-medical-bills.html
2. ‌U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes? (2020, January 30). Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019
3. ‌“The absurdly high cost of insulin” – as high as $350 a bottle, often 2 bottles per month needed by diabetics. (2016). Natap.org. https://www.natap.org/2019/HIV/052819_02.htm
4. FastStats – Health Expenditures. (2021). https://www.cdc.gov/nchs/fastats/health-expenditures.htm 
5. Products – Data Briefs – Number 332 – February 2019. (2021). https://www.cdc.gov/nchs/products/databriefs/db333.htm
6. Products – Data Briefs – Number 332 – February 2019. (2021). https://www.cdc.gov/nchs/products/databriefs/db335.htm
7. ‌Goldman, D., & Lakdawalla, D. (2018, January 30). The global burden of medical innovation. Brookings. https://www.brookings.edu/research/the-global-burden-of-medical-innovation/#footref-3
8. Products – Data Briefs – Number 332 – February 2019. (2021). https://www.cdc.gov/nchs/products/databriefs/db335.htm
9. ‌How Part D works with other insurance | Medicare. (2021). Medicare.gov. https://www.medicare.gov/drug-coverage-part-d/how-part-d-works-with-other-insurance 
10. Ketcham, J., & Simon, K. (2008). NBER WORKING PAPER SERIES MEDICARE PART D’S EFFECTS ON ELDERLY DRUG COSTS AND UTILIZATION. https://www.nber.org/system/files/working_papers/w14326/w14326.pdf
11. ‌Costs in the coverage gap | Medicare. (2021). Medicare.gov. https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/costs-in-the-coverage-gap
12. ‌Hsu, J. (2008). Medicare Beneficiaries’ Knowledge of Part D Prescription Drug Program Benefits and Responses to Drug Costs. JAMA, 299(16), 1929. https://doi.org/10.1001/jama.299.16.1929 
13. What’s the Latest on Medicare Drug Price Negotiations? (2019, October 17). KFF. https://www.kff.org/medicare/issue-brief/whats-the-latest-on-medicare-drug-price-negotiations/
14. ‌Veterans Health Administration | Health Affairs Brief. (2021). Healthaffairs.org. https://www.healthaffairs.org/do/10.1377/hpb20171008.000174/full/
15. ‌Whitman, E. (2015, September 24). How The US Subsidizes Cheap Drugs For Europe. International Business Times. https://www.ibtimes.com/how-us-subsidizes-cheap-drugs-europe-2112662
16. ‌Dubois, P., de Mouzon, O., Scott‐Morton, F., & Seabright, P. (2015). Market size and pharmaceutical innovation. The RAND Journal of Economics, 46(4), 844–871. https://doi.org/10.1111/1756-2171.12113
17. ‌DiMasi, J. A., Grabowski, H. G., & Hansen, R. W. (2015). The cost of drug development. New England Journal of Medicine, 372(20), 1972-1972. doi:10.1056/nejmc1504317
18. DiMasi, J. A., Grabowski, H. G., & Hansen, R. W. (2016). Innovation in the pharmaceutical industry: New estimates of R&D costs. Journal of Health Economics, 47, 20–33. https://doi.org/10.1016/j.jhealeco.2016.01.012
19. Goldman, D., & Lakdawalla, D. (2018). THE GLOBAL BURDEN OF MEDICAL INNOVATION. University of Southern California. https://healthpolicy.usc.edu/wp-content/uploads/2018/01/01.2018_Global20Burden20of20Medical20Innovation.pdf 
20. The Lancet. (2019). Canada needs universal pharmacare. The Lancet, 394(10207), 1388. https://doi.org/10.1016/s0140-6736(19)32324-4
21. Goldman, D., & Lakdawalla, D. (2018, January 30). The global burden of medical innovation. Brookings; Brookings. https://www.brookings.edu/research/the-global-burden-of-medical-innovation/#footnote-14
22. ‌A Brief History: Universal Health Care Efforts in the US – PNHP. (2018, April 17). PNHP. https://pnhp.org/a-brief-history-universal-health-care-efforts-in-the-us/

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A CRISPR Future

By Aleicia Zhu

Published 1:53 PM EST, Mon February 15, 2021

Introduction

As a doctor, oftentimes you are left disappointed. Sometimes, the patient comes in, gets treatment, and grows healthy once again. Sometimes, however, the doctor is powerless. No matter how many hours they spend studying, working, and researching, they are not gods. They cannot guarantee life. 

With emerging technology, doctors could still have immense power. First, some context. Within psychology, the greatest question is nature vs. nurture. It has raged on over millennia, from the Ancient Greeks to the Enlightenment, finally ending in a not-so-satisfying conclusion. The answer: it is both. Nurture works with nature. The issue is that nurture is malleable while nature is not.

How it Works

So, this is the breakthrough. Over the past decades, insights into this idea have fueled a biotechnology boom. By the early 2000s, the Human Genome Project sequenced the first full human genome. Moreover, the original costs began in the millions. Then, it was the price of a house. Now, it is closer to the price of a TV. In addition to mapping the code of life, the tools to manipulate it arose as well.

Cas9 technology is like a set of amazingly powerful scissors. Derived from a humble bacterium, Cas9 is an enzyme that can be guided to cut specific sites on DNA. It forms part of the CRISPR/Cas9 system. For clarity, CRISPR stands for clusters of regularly interspaced short palindromic repeats. Essentially, they consist of repeating nucleotide sequences along with spacers, snippets of other DNA. In bacteria, this system was used as a defense against viral attacks. Afterward, parts of the viral DNA were assimilated as spacers. The reason is akin to that of why we use vaccines; it helps the bacteria recognize the virus, then attack it with vicious efficiency. Using CRISPR/Cas9, scientists can slice DNA and supply their choice of repair materials. In sum, they have the power to edit genes. 

Uses

With the power to edit genes, the possibilities are endless. Grueling ailments like cancer and Parkinson’s have been found to have genetic links, allowing gene editing to become a possible treatment. Also, there is a tie back to the nature vs. nurture question. Though experience wields its own power, if nature, the basis of being, is changed, the results could be drastic. Then, there is a delve into the darker side. By now, GATTACA is a movie that has assimilated into the repertoire of every science teacher. In it, it depicts the consequences of changing what humans, perhaps, should have not had the power to change. The main character faces discrimination for being unmodified. There, he is labeled a degenerate. Outside of movies, concerns about this have arisen. What of designer babies? Should parents have the power to change their children’s appearance and characteristics? In China, should those twins have been edited? 

Even so, GATTACA was made over two decades ago. That Chinese scientist was jailed. Finally, the promised gene-therapy is not yet ready. With risky outcomes and high costs, gene-editing is still not a world-changing phenomenon. It is not a mainstay in hospitals, and more conventional treatment is still the norm. Thus, it is vital to recognize that the invention itself is not the prime break-through. It is the innovations. 

As legislators ponder the ethics, gene-editing technology is still being researched for its applications and improvement. For now, people can discard it as a pipe-dream. Currently, it is too new, untested, and inefficient to be effective. So, out of the doctor’s tool-kit, it stays. People can turn a blind eye to it and also its consequences. However, when it waits, develops, and grows stronger, what can people do then? The ethical consequences will rear again. It could create discrimination, like in GATTACA. It could exacerbate existing class conflict. It could create an irreparable schism in this world. However, if they look at their dying family and friends, and they know that there is something that can be done, will they overlook that? 

Conclusion

Overall, the innovations in gene-editing technology could turn doctors into gods of healing or the facilitators of dystopian nightmares. Either way, it will endow the biological and medical community with immense power. How it will be used, however, is yet to be seen.

References

1. Quakenbush, John. “Human Health Through the Lens of Genomic Data: A Conversation with Professor John Quakenbush.” 2020 Global Health and Leadership Conference, Harvard College Vision, 23 May 2020, Guest Lecture.
2. What is CRISPR-Cas9? (2016, February 2). Your Genome. https://www.yourgenome.org/facts/what-is-crispr-cas9 

A Literature Review of Face Transplants

Introduction

Composite tissue allotransplantation is a microsurgical technique where tissue from a donor is transplanted to a patient. Essentially, it is a combination of transplant and reconstructive surgery. Distinctly, these operations are primarily for quality of life, often in trauma or tumor patients, not necessarily for prolongment. At first, this was completed with hand transplants in France, 1998. However, facial transplantation is a new example and is used for both functional and aesthetic purposes. This technique is still rare, with only 11 human face transplants having been performed between 2005 and 2011. Moreover, these transplants are often partial [1].

In general, facial transplants and composite tissue allotransplantation have had issues with rejection, not dislike solid organ transplants. The immune system is alerted by organ antigens and proceeds to attack it. Most surprisingly, some patients experience split tolerance, in which different tissues from the same donor cause varying responses, possibly due to organ-specific antigens. The first composite tissue allotransplantation corroborated this. The skin of the donor hand was rejected, though the joints were spared. In addition, there are chronic rejection issues with maintaining blood vessels, which progressively narrow as the body rejects the organ. This can lead to thrombosis, then cell death. Infection may contribute to both of the aforementioned issues [2].

Results

Nonetheless, there are solutions. In 2010, a full face transplant was performed on a 30-year-old male with a severe facial deformity from ballistic trauma. Unlike previous transplants, this included all facial units (forehead, nose, eyelids, cheeks, lips and chin). There were no intraoperative complications, but postoperative complications included acute rejection episodes and venous thrombosis. As a result, the immunotherapy treatment needed to be adjusted. Originally, the immunotherapy course consisted of thymoglobulin, prednisone, tacrolimus, and mycophenolate mofetil. The prednisone was tapered, but acute rejection occurred and they required a bolus of prednisone. Additionally, mycophenolate mofetil was replaced with Sirolimus. For the venous thrombosis, the patient’s anastomoses needed to be adjusted. From then on, the patient experienced few psychological issues, which facial transplants can be associated with. [1] 

Another 45-year-old woman received a face transplant after a gunshot wound. Prior to the transplant, the patient experienced social issues, with some strangers screaming and running away when they saw her face. In addition, she had difficulty eating and anosmia. As a result, past psychiatric history included treatment for depression and post-traumatic stress disorder. After treatment, the patient reported receiving more positive affirmations than before. Other factors in bolstering her self-esteem included social assimilation. Family members reaffirmed family ties by finding similarities between the new face and family traits. Notably, this patient reported a strong support system, which was found to be less common in patients with psychological issues [3]. 

Finally, a 28-year-old female qualified for a facial transplant in 2013 for aesthetic, psychological, and medical purposes. Specifically, this patient experiences neurofibromatosis, a genetic disorder causing tumors. The condition caused malformations in facial appearance and quality of life issues. Additionally, they resulted in psychological problems. However, the transplant was soon integrated into the patient’s quality of life [4]. 

Discussion

Despite high risk and rejection issues, facial transplant patients appear satisfied with their quality of life. As a result, it is of importance that not only critical procedures are provided for by insurance or the government, but quality of life procedures are beneficial as well. In addition, psychological issues are a genuine concern for face transplants, especially with a body part as personal as the face. However, this level of psychiatric care may need to be extended to other procedures as well, especially ones affecting quality of life as this one does. While the healthcare system is designed to treat illnesses and issues, home life is often outside of its hands. Physicians take a social history to view factors that may impact treatment, but further research must be conducted into the management of resulting psychiatric issues. Based on the case reports, there was prior pharmacological management, but social integration was the greatest contributor to mental health. So, healthcare management research must open up to bolster clinical treatment.

Conclusion

Surgical techniques continue to advance as healthcare aims to both, prolong life and improve it. However, this includes further cooperation between specialties. In this case, that includes transplant surgery, reconstructive surgery, and even psychiatry. The field of composite tissue allotransplantation along with facial transplantation will hopefully continue as a higher case loader is needed to tease out further complications. Nonetheless, past cases have conveyed the ability to ameliorate rejection and psychiatric issues.

Aleicia Zhu, Youth Medical Journal 2020

References

1. Barret, J. P., Gavaldà, J., et al. (2011). Full Face Transplant. Annals of Surgery, 254(2), 252-256. doi:10.1097/sla.0b013e318226a607
2. Swearingen, B., Ravindra, K., Xu, H., Wu, S., Breidenbach, W. C., & Ildstad, S. T. (2008). Science of composite tissue allotransplantation. Transplantation, 86(5), 627–635. https://doi.org/10.1097/TP.0b013e318184ca6a
3. Coffman, K. L., Gordon, C., & Siemionow, M. (2010). Psychological outcomes with face transplantation: Overview and case report. Current Opinion in Organ Transplantation, 1. doi:10.1097/mot.0b013e328337267d
4. Krakowczyk, Łukasz, et al. “Face Transplant in an Advanced Neurofibromatosis Type 1 Patient.” Annals of Transplantation, vol. 22, 2017, pp. 53–57., doi:10.12659/aot.900617.

An Overview of Healthcare Systems: United States, Canada, and Australia

Introduction

With the 2020 US presidential election, there has been much discussion over the healthcare system. From Biden to Trump, each side of the political spectrum has different views on American healthcare and different ideas on reform. Namely, the shift from privatized healthcare to public healthcare, otherwise known as healthcare reform. There has been debate over universal healthcare, retaining the current American system, and abolishing the Affordable Healthcare Act. There have also been accusations that a for-profit healthcare system is detrimental to lower class Americans. Countries such as Canada and Australia are often used as examples of ideal public healthcare systems. However, the two are not identical, even if they are both public. Rather, they have marked differences as well which need to be examined as the United States searches for a new model.

United States

Technically, the US has a two-tier healthcare system. A two-tiered system has both a public and a private option. In the United States, this involves Medicare as the public option for those over the age of 65 and Medicaid for low-income citizens. These are funded by federal and state tax revenue. There is also the Veterans Affairs system, which is similar to the UK. The UK has a single-payer system and healthcare facilities are owned by the government. The providers are government employees. Finally, the most common option is private insurance, which covers 56% of the population. After all, the US, unlike other two-tiered systems like Australia or Germany, does not have a well-supported public option. Medicare and Medicaid have restrictions to be eligible, while public options in other countries do not. Consequently, most people carry private insurance.

  Some detractors state that this system is inefficient. Admittedly, the US spends 17.6% of its Gross Domestic Product (GDP) on healthcare in contrast with Australia’s 9.1% and Canada’s 11.4% expenditure. The US also spends approximately $300 more out-of-pocket per capita on medical care. While both Canada and Australia require a specialist referral from a general practitioner or primary care physician, it differs in the United States as some private insurers permit referrals while others will cover not the visit. Others argue that allowing unnecessary specialist visits is expensive and invasive. In general, US healthcare is more expensive. 

Approximately 27% of Americans report that their healthcare system needs to be completely rebuilt [1]. This is also reflected by physician opinion. In a survey of primary care physicians across the world, US doctors were the most likely to report that they spent substantial time struggling with insurance providers and billing, despite new electronic records. Nearly 60% also reported that their patients had difficulty paying for their health services [2]. To corroborate this, American adults are the most likely to have high medical costs, even with insurance. Thus, patients and physicians can confirm that patients have high healthcare costs that are not fully covered by insurance. Consequently, this becomes a burden on patients.

A symptom of this is a phenomenon known as “medical tourism”. On one hand, citizens from developing countries travel  to the US to access better expertise with the latest r technology. Conversely, American citizens also travel to less developed areas where costs may be as low as 10% of prices in the US. Naturally, this occurs with elective procedures, especially cosmetic ones. Elective procedures can still be life-saving. However, they can be scheduled, allowing them to complete these procedures overseas at a lower cost. Emergent procedures must be done immediately and, as a result, cannot be done in a foreign country. So, medical tourism does not ameliorate the costs of emergent procedures [3]. 

Canada

Canada is a single-payer system, where the sole option is the regionally administered public insurance program. Hospitals are often, though not always, public and are considered government property. Their healthcare professionals are considered government employees. There are private practices and hospitals, but they are all compensated by the government. This government compensation is funded by province and federal revenue. There are, however, services that are not covered by the government, such as vision or dental services. Approximately 67% of the population purchases private coverage for these needs. 

An accusation against this single-payer system is that the wait times are substantially longer than private healthcare systems, such as the one in the US. 41% of Canadian adults report that they have waited at least 2 months to see a specialist. In comparison, 9% of American adults report that they have waited at least 2 months to see a specialist. On the other hand, only 15% of Canadians experienced cost as a barrier to access, in comparison to the US’s 33% [1]. Consequently, the Canadian healthcare system is a trade-off between access and wait times. Canadian healthcare is more accessible to lower-income patients due to lower costs, though they must wait longer to receive this treatment than American patients.

The lack of commercialization in Canada also reflects the disposition of patients. In America, there have been assertions that this payment for care has led to patients behaving more like customizers. Patients can demand unnecessary and invasive care. In a study done on cancer patients, Canadian care was less aggressive than in the US. This may be due to the American patients desire for care even when it is futile, because they feel as if they are entitled to this care provided they will pay for it. Other than cancer treatment, some American physicians report that their patients are more demanding of certain services and substances, like opioids. They also report that using patient satisfaction metrics to measure standards of  care pressures them into giving opioids and other unnecessary treatments [4]. Canadians do pursue “medical tourism” for economic reasons, though it is almost solely for cosmetic procedures and other procedures not covered by the government [3]. 

Australia

Australia has a two-tier healthcare system, with both public and private options. Unlike the US however, the public option is universal. There is no income or age requirement and is funded by general tax revenue and earmarked income tax. Like Canada, there are services that are not covered, such as dental or vision services. On top of that, some citizens choose to use the private option. Approximately half the population purchases coverage for uncovered services and private hospitals. Nonetheless, the government negotiates with pharmaceutical companies to lower costs [1]. The Australian government also subsidizes 80% of out-of-pocket costs if it exceeds 1,033 USD. 

Similar to Canada, 60% of primary care physicians report that their patients face longer wait times to see specialists [2]. In a study conducted at the Townsville Hospital in Australia, the original health system sent  referrals, then triaged them. However, this ended in long waitlists unless the condition was critical. A solution devised by Townsville Hospital was then to reduce and update referrals. A follow-up letter was sent to patients who had waited longer than 2 years, requesting that they either: 1) take no action if they felt their referral was no longer necessary or 1) visit their general practitioner (a primary care physician in the United States) to update the referral [5]. 

In other cases, patients were willing to pay the premium of private care in exchange for faster treatment.With the presence of a private option, once again, care is more “customer service”-focused. Approximately 60% of US and Australian physicians use patient satisfaction metrics. In Canada, this figure is only 15% [2]. 

Conclusion

Each healthcare system is different, with varying strengths and weaknesses. With the impending US election, it is vital that the American voters understand the nuances of each and how it affects Americans, specifically in the COVID-19 pandemic. A contraindication is that this article does not cover every healthcare system available. While healthcare is variable and every country differs in its  policies these nuances are opaque to many healthcare professionals, let alone the general public. Nonetheless, people must be educated before they vote. A democracy cannot function without an educated public that knows what is best for themselves and society as a whole. These decisions affect millions of citizens and must not be taken lightly.

Aleicia Zhu, Youth Medical Journal 2020

References

[1] The Commonwealth Fund. (2012). International Profiles of Health Care Systems. The Commonwealth Fund. www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2012_nov_1645_squires_intl_profiles_hlt_care_systems_2012.pdf. 

[2] Schoen, Cathy, et al. (2012). A Survey of Primary Care Doctors in Ten COuntries Shows Progress in Use of Health Information Technology, Less in Other Areas. Health Affairs, 13(12). www.healthaffairs.org/doi/full/10.1377/hlthaff.2012.0884.

[3] Horowitz, M.D., et al. (2007). Medical Tourism: Globalization of the Healthcare Marketplace. MedGenMed, 9(4), 33.

[4] Ho, T.H., et al. (2011). Trends in the Aggressiveness of End-of-Life Cancer Care in the Universal Health Care System of Ontario, Canada. Journal of Clinical Oncology, 29(12). dx.doi.org/10.1200%2FJCO.2010.31.9897. 

[5] Stainkey, L.A., Seidl, I.A., Johnson, A.J. et al. (2010). The challenge of long waiting lists: how we implemented a GP referral system for non-urgent specialist’ appointments at an Australian public hospital. BMC Health Serv Res, 10, 303. doi.org/10.1186/1472-6963-10-303. 

An Outlook Into Society and Medicine Through A Neurological Disease

Cause, Symptoms, and Diagnosis

Anti-NMDAR encephalitis is a rare neurological autoimmune disease that can cause severe symptoms [1]. In brief, autoimmune disorders can be simplified as the immune system attacking the body [2]. For this disorder, the immune system has created antibodies against the NMDA receptors, which are responsible for learning, judgment, and autonomic activities like breathing or swallowing. Still, the cause is unknown [3].However, anti-NMDAR encephalitis appears linked to tumors, especially ovarian tumors [4]. In addition, cases appear to occur after a viral infection, especially herpes simplex virus [5]. `

For neurological symptoms, this can include unconscious movement, memory issues, and damage to cognition. However, psychiatric symptoms are more clear from onset. Consequently, anti-NMDAR is often misdiagnosed as a psychiatric disorder. These severe symptoms include paranoia, delusions, and psychosis [1]. Recovery can range from months to years but has improved with the development of immunotherapies [3]. 

Typically, physicians will recognize these symptoms first and then order testing. This involves testing the blood serum or cerebral spinal fluid for NMDAR antibodies [1]. Besides that, additional testing can be done to detect symptoms. This usually includes tumor imaging, an MRI, or an electroencephalogram (EEG) [3]. Still, first-line doctors like emergency physicians or primary care providers often misdiagnose anti-NMDAR encephalitis as a psychiatric disorder because of its symptoms. Its strong prevalence in women, as approximately 80% of patients are female, also causes misdiagnoses. There is no clear marker, so physicians must be familiar with the myriad of symptoms involved in order to identify it [5].

Figure 1. The MRI of a male with anti-NMDA receptor encephalitis, his MRI after treatment, and the MRI of a health volunteer [4].

Treatment and Prognosis

Patients with the best prognosis have typically had a tumor removed, are young, or have a low concentration of antibodies in their blood serum or cerebral spinal fluid. This usually results in substantial improvement. Conversely, patients who did not have a tumor typically have worse outcomes [5]. The length of recovery can range from months to years, depending on severity and treatment. Early diagnosis and treatment is directly correlated with improved outcomes [3]. However, anti-NMDAR encephalitis is frequently misdiagnosed due to the preponderance of severe psychiatric symptoms. This can hinder a patient’s recovery [5]. Other than removing the tumor, patients can receive steroids or immunosuppressants to weaken the antibodies that are attacking the body [1]. After receiving treatment, outcomes are acceptable. The symptoms subside in the order that they occurred, typically beginning with the most severe issues. Still, some patients continue to experience memory and cognition issues. In the worst of cases, anti-NMDAR encephalitis is lethal, killing approximately 6% of patients[4]. 

A Dark History for Women

From Ancient Greece, hysteria has been a common diagnosis for women experiencing psychiatric issues, essentially attributing their issues to their gender. However, some scientists propose that there is a logical explanation for this misdiagnosis. Specifically, that explanation is anti-NMDAR encephalitis. This disease predominantly affects women and also causes severe psychiatric symptoms.

Additionally, the removal of ovarian tumors is one of the most effective treatments for the disease [6]. From antiquity, a treatment for hysteria and other health issues in women has been sterilization by removal of the reproductive organs. In removing the reproductive organs, tumors are also excised. One such operation was created by the surgeon Robert Battey, and he referred to it as the “normal ovariotomy”. Originally, this was to treat menstrual disorders and other symptoms. Later on, it was used to treat psychiatric and neurological disorders in women, often without their consent. Even so, surgeons and their communities accepted this, because the patients generally improved. [7]. 

Additionally, other scientists speculate that anti-NMDAR encephalitis is responsible for historical reports of “demonic possession”.  One of the symptoms are sudden, “jerking” movements of the limbs that are entirely unconscious. In addition, a common psychiatric symptom is paranoid delusions of danger. This appears congruent with descriptions of possession. Once again, because anti-NMDAR encephalitis patients are primarily women, it may have led to the misconception that this gender is weaker and therefore more susceptible to the supernatural or witchcraft [8].

Modern Social Implications

Anti-NMDAR encephalitis is a newly discovered disease, only described in 2007 by Dr. Josep Dalmau at the University of Pennsylvania [9]. Because of its severe symptoms and historical linkage, this led to introspection into the role of women in healthcare. 

Much has changed since Battey’s ovariectomies, but women continue to experience issues in medicine. From the perspective of a patient, some women fail to receive psychiatric treatment, because these issues are considered “normal” for their gender. For anti-NMDAR encephalitis in particular, neurologists voice concerns that their patients cannot receive treatment or will be misdiagnosed with a psychiatric disorder. Some diagnoses include insanity or psychosis, whose treatment still includes electroconvulsive therapy. In essence, patients with those misdiagnoses would receive improper care. Rapid diagnosis and treatment are especially important in recovery, but this is hindered by gender issues [8].

One woman voiced her story in the 2012 novel Brain on Fire: My Month of Madness. The author and career journalist, Susannah Cahalan, contracted anti-NMDAR encephalitis only three years after it was discovered. At the time, her doctor estimated that only ten percent were correctly diagnosed. In her personal stories, Cahalan’s doctors grossly misdiagnosed her, ranging from “parties to much” to bipolar disorder. After a few months and the onset of severe neurological symptoms, she was finally diagnosed with anti-NMDAR encephalitis. Her best-selling novel and subsequent has made anti-NMDAR encephalitis one of the more famous neurological diseases. Now, diagnosis is often faster and treatment has improved [10].

Final Words

Anti-NMDAR encephalitis has an innate link between science, medicine, the media, and society. Specifically, it outlines the path of a disease, from its discovery in science, applications in medicine, coverage by the media, then perception in society. The concern for women and their mental health has not stopped, but it has been ameliorated in the case of anti-NMDAR encephalitis, where patients can get diagnosed quickly enough to have an optimal prognosis. Nonetheless, it is vital that the healthcare industry utilizes the media effectively to advocate for its patients.

References

[1] Anti-NMDAR Encephalitis. Perelman School of Medicine. https://www.med.upenn.edu/autoimmuneneurology/nmdar-encephalitis.html.

[2] Irani, Sarosh and John Radcliffe. NMDAR Antibody Encephalitis. Encephalitis Society. https://www.encephalitis.info/nmdar-antibody-encephalitis.

[3] What is Anti-NMDA Receptor Encephalitis?. The Anti-NMDA Receptor Encephalitis Foundation. https://www.antinmdafoundation.org/the-illness/what-is-anti-nmda-receptor-encephalitis/. 

[4]  Hughes, Ethan G., et al. (2010). Cellular and Synaptic Mechanisms of Anti-NMDA Receptor Encephalitis. Journal of Neuroscience. 30. https://dx.doi.org/10.1523%2FJNEUROSCI.0167-10.2010 

[5] Chanaka, Amugoda, et al. (2019). Anti-NMDAR Encephalitis: Higher Suspicious Needed for Earlier Diagnosis. Hindawi. https://doi.org/10.1155/2019/7476254 

[6] Pollak, Thomas A. (2013). Hysteria, hysterectomy, and anti-NMDA receptor encephalitis: a modern perspective on an infamous chapter in medicine. British Medical Journal. 346. https://doi.org/10.1136/bmj.f3756 

[7] Komagamine, Tomoko, et al. (2019). Battey’s operation as a treatment for hysteria: a review of a series of cases in the nineteenth century. History of Psychiatry. 55-66. https://doi.org/10.1177/0957154×19877145 

[8] Radecki, Ryan P. (2019). Demonic Possession or Autoantibody-Mediated Encephalitis?. ACEP Now. https://www.acepnow.com/article/demonic-possession-or-autoantibody-mediated-encephalitis/. 

[9] Dalmau, Josep. (2007). Paraneoplastic anti–N‐methyl‐D ‐aspartate receptor encephalitis associated with ovarian teratoma. Annals of Neurology. 25-36. https://dx.doi.org/10.1002%2Fana.21050 

[10] Cahalan, Susannah. (2012). Brain on Fire: My Month of Madness. Simon and Schuster. 

Aleicia Zhu, Youth Medical Journal 2020