A lot of the reforms the Gates Foundation has brought about in public education are actually bad. The "Criticism" section in that Wikipedia article doesn't begin to describe it. The best explanation you can easily get is by doing a Google or Wikipedia search for "Diane Ravitch" http://en.wikipedia.org/wiki/Diane_Ravitch and her longest explanation I know of, outside of her books, is her New York Review of Books article.
She refers to Gates as a member of the "billionaire boys club" that is "reforming" education according to some fads that they picked up, which aren't supported by scientific evidence. Ravitch was an assistant secretary of education under GHW Bush and Bill Clinton. She started out believing in charter schools, free market incentives, high-stakes testing, and all the other neocon reforms. But she said that when the data came out, it didn't support those reforms.
The one factor that is most strongly associated with student achievement, according to Ravitch, is family income. So when you reward teachers for raising student test scores, you're mostly rewarding them for having high-income students, and when you fire them for missing the test targets, you're firing them for teaching in poverty schools.
The Gates education reforms depend heavily on high-stakes testing. But according to repeated analyses, the tests they use today to fire "underperforming" teachers are statistically invalid. There was a debate over that in Science magazine last year, in which the author who was defending the tests admitted that they weren't valid, and his argument was that we should continue to use them and try to improve them.
New York City gave all its math and English teachers rankings based on their students' scores in a standardized test (which wasn't scientifically validated), and education commissioner Joel Klein made the results for individual teachers public, despite the risk of unfairly shaming teachers. One fundamental problem is that they don't have enough statistical power to evaluate individual teachers. A science teacher did a standard statistical analysis, and he found out that they had an essentially random distribution. He made the point that every teacher knows that beginning teachers improve a lot from their first to second year (conversely, most teachers agree that they had a lot of trouble in their first year). But yet, when you compare the scores of the teachers in their first year to the same teachers in their second year, the correlation was random. According to these tests, teachers don't improve with experience. It doesn't make sense. And yet, NYC is firing teachers on the basis of these tests.
Financial incentives and bonuses for teachers have been tested in randomized, controlled studies -- and they don't work. Students don't perform any better when their teachers get bonuses for higher test scores. OTOH, it's hard to be a dedicated teacher if you don't know whether you'll have a job in 10 years, your pay is going down because NCLB has destroyed your union, and politicians like Joel Klein attack you, call you incompetent, and humiliate you.
If you needed proof that these reforms aren't working, look at Michelle Rhee's experience in the Washington DC schools system. Her followers were touting her as a genius who was tough on students, got rid of incompetent teachers and principals, and rewarded the master teachers and principals who raised the test scores with generous financial bonuses. They it turned out that the teachers and principles were raising their tests scores by cheating, which was picked up by the internal verification procedures in the tests -- and Rhee knew about it. There have been cheating scandals in high-stakes testing schools around the country. When you fire teachers who don't raise test scores, what do you expect them to do?
Bill Gates and the other "reformers" have turned teaching from a comfortable, respected job where people were paid well but not extravagantly, and motivated by
Hmm. An anthropologist can look at a thigh bone and identify the race of the person it came from.
I don't think modern anthropologists talk about race any more. They talk about "populations."
A DNA sample can also be used to identify the race of a person. I think we're dealing with a little more than skin color here.
DNA sequencing of many populations around the world shows how related different populations are, but the populations don't correspond to 19th-century categories of races.
In medicine, there are a lot of pragmatic associations with race. For example, there is a gene that is moderately widespread in the Caribbean population which makes them especially sensitive to morphine compounds. Sometimes people have violent coughing, and codeine is a standard treatment, but in patients with sensitivity to codeine, a normal dose can cause a life-threatening or fatal overdose with depression of breathing and blood pressure.
So as a physician, if a black Caribbean guy walks into your office with a severe cough, you would be more careful about prescribing codeine.
In principle, if you knew the gene, you could send a DNA sample to a laboratory, but by the time you got the results the problem would be over. (And a lot of times we don't even know whether it's a genetic or environmental effect.)
Sure, racial characteristics are imprecise. You might have a Polynesian who self-identifies as Caribbean, and the racial category would be misleading.
But there are lots of tests and rules in medicine that are equally imprecise.
Now, realize I'm not using the term "race" with the cultural baggage of defining your place on the Great Chain of Being from pond scum to Englishmen.
I'm using it as an easy office test to visually identify people who are more likely than random to be in a certain gene pool.
These guys deserve kudos for drug discovery, but as you say it's a long way from animals to humans. They don't even know whether it's safe in humans. Another big question is, how fast will the parasites develop resistance?
They would be doing pretty well if it turns into another artemisinin http://en.wikipedia.org/wiki/Artemisinin and if it does, they deserve a Lasker too. But even artemisin can't be used as monotherapy, because it can develop resistance.
You may some day have to accept that there is a large number of reasonable, intelligent, and even likable people who completely disagree with your views on government and policy. Just because someone has a political view doesnt mean you know squat about them, their finances, their situation, or their personality.
The Republicans (and conservatives) used to be like that. I used to read the Wall Street Journal editorial page every day just to see a well-argued factually accurate idea that I disagreed with, and sometimes I'd be forced to say, "You know, they're right." But they've gone off the deep end since then. OK, you believe that individuals can make better decisions for themselves than the government can make for them. But what about abortion? Evolution? Prayer in the schools? The war on drugs? Gays? I wish Barry Goldwater were back.
Goodbye to All That: Reflections of a GOP Operative Who Left the Cult Saturday, 03 September 2011 11:09 By Mike Lofgren, Truthout | News Analysis
To be sure, the party, like any political party on earth, has always had its share of crackpots, like Robert K. Dornan or William E. Dannemeyer. But the crackpot outliers of two decades ago have become the vital center today: Steve King, Michele Bachman (now a leading presidential candidate as well), Paul Broun, Patrick McHenry, Virginia Foxx, Louie Gohmert, Allen West. The Congressional directory now reads like a casebook of lunacy.
I could see as early as last November that the Republican Party would use the debt limit vote, an otherwise routine legislative procedure that has been used 87 times since the end of World War II, in order to concoct an entirely artificial fiscal crisis. Then, they would use that fiscal crisis to get what they wanted, by literally holding the US and global economies as hostages.
Everyone knows that in a hostage situation, the reckless and amoral actor has the negotiating upper hand over the cautious and responsible actor because the latter is actually concerned about the life of the hostage, while the former does not care.
Perhaps we could compensate the doctor for that humiliation by having him make a lot of money.
There was a physicians' mutual insurance company several years ago that used a law firm made up of doctors with law degrees. They never settled. They reviewed the case. If the doctor was wrong, they pay up. If the doctor was right, they fight it all the way through a jury trial. That's the way it should be. I wonder if it's an economically viable strategy.
I would like to give one of those "experts" a set of 10 breast films, 5 of which went on to become cancer, 5 of which did not, and ask him to tell which is which. I don't know if you can do that in court, but if the expert witness screws up once, you can refer to it every time he testifies afterwards.
You are correct. Here's an example to prove it. (However, you will notice that even with Medicaid you can't always get treatment.)
Wall Street Journal September 13, 2007
MEDICAL MAZE Legal Loophole Ensnares Breast-Cancer Patients Shirley Loewe Chooses The Wrong Clinic And Starts Long Ordeal
By JOHN CARREYROU
LONGVIEW, Texas -- In June 2003, Shirley Loewe went to Good Shepherd Medical Center here with a softball-size lump in her breast and was diagnosed with a rare form of breast cancer. She didn't know it, but she had just made a big mistake.
Ms. Loewe was uninsured. Under federal law, she could have gotten Medicaid coverage -- and saved herself a lot of hardship -- if she'd gone to a different clinic less than a half-mile away. But by walking through Good Shepherd's doors, Ms. Loewe unwittingly let that opportunity slip and embarked on a four-year journey through the Byzantine U.S. health-care system.
It was an odyssey that would take her to five hospitals, two clinics, two charitable organizations and two nursing homes in two states. She was denied assistance or care at least six times along the way, for reasons that ranged from not being poor enough to not being sick enough.
Knee replacement surgery is a bad example to prove the superiority of the American health care system. It proves the opposite. You shouldn't rush patients into surgery. Canadian doctors say that the long waits are a benefit of their system -- they give people a chance to find out the facts and decide whether the treatment is a good thing.
First of all, most of the people who get knee replacements are in their 60s or 70s, so in the US they get it under Medicare -- single payer health care.
Second, Total knee replacements are the fastest-growing and most expensive surgeries in Medicare. Doctors are rushing patients into knee surgery who shouldn't have it. So this is free-market medical abuse on steroids. (In fact steroids turned out to have some bad outcomes.)
TKR isn't trivial. It's among the most painful procedures in medicine, and if the patient doesn't complete painful physical rehabilitation, the replacement won't work. They usually use Oxycodone for a month or two, but this being the US a lot of surgeons under-dose and leave the patients in pain that drives them to tears (read Jane Brody's account of her own TKR in the New York Times). It's several days in the hospital, a week in a rehabilitation center, a week to a month at home in bed, and 3 to 6 months before you've recovered the function you started with. Then you start to improve, and after 6 months to a year most people can walk and stand again.
But many people don't. About 15% of TKR patients have permanent moderate to severe pain that can't be cured. They're worse off for having the surgery. Some of them get surgery because they're using a cane as a result of their surgery wind up in a wheelchair. What are the risks? Nobody knows for sure because surgeons have been replacing knees without doing good outcome studies. Countries with national health care systems do outcome studies. Denmark is doing a big randomized study, so we should know the outcomes in 10 years.
In Denmark, the current practice is that they don't give TKR until the patient has tried less drastic measures for 6 months and they haven't been adequate. The first step is to lose weight, down to a body mass index of 25 ideally. They also give them exercise/physical rehabilitation and non-steroidal anti-inflammatory drugs. People who are overweight or obese have a worse outcome after surgery, and in some cases, after weight loss, exercise/rehab, and NSAIDs, they don't need surgery after all. Why go through all that pain, bed confinement and risk when you can get the same results without it?
Overtreatment is endemic in US health care. Look at the fastest-growing, largest Medicare expenses besides hip and knee replacement. According to a series of articles in the New England Journal of Medicine, CT scans (another big money-maker for doctors and device companies, a major growing expense for Medicare) are widely overused and a major cause of cancer (about 1/10,000 major CT scans result in an additional cancer, more for CT scans of children). Erythropoietin, a drug that stimulates the growth of red blood cells, was the Medicare/Medicaid's single most expensive drug (=profitable for drug companies and doctors), used in kidney dialysis, and after they finally did the research, it turned out to be actually killing people at the high (profitable) doses they were using. Hormone replacement therapy for post-menopausal women actually turned out to be a major cause of breast cancer in the formulations they were using. There was a significant bump in the breast cancer incidence curve because of these heavily-promoted estrogen drugs.
The Canadian health care system has quality as good as ours, costs them half as much, and the tradeoff is that they do have to wait longer (and sometimes don't get advanced procedures that we get here). They have their flaws. But it's not the backward third-world system that conservatives (Google "Manhattan Institute) would have you believe.
Here's a couple of interesting stories on the Canadian system.
I used to write articles for trade magazines about medical malpractice and product liability. I used to go to legal conferences on medical malpractice and interview lawyers, although I don't have the latest information and I'm recalling some of this from memory. I followed malpractice in JAMA and NEJM. I read the Case Records of the Massachusetts General Hospital, which usually includes a radiology report. So I realize the ambiguity, difficulty and subjectivity of reading a radiology image.
But the malpractice standard isn't the ultimate care. It's a reasonable standard of care. The standard isn't a good outcome. A bad outcome isn't malpractice. If a procedure has a 5% mortality, and the patient knows it and the doctor documented that informed consent in the chart, then death by itself isn't malpractice.
Let's assume an MRI is the standard of care and gives a better outcome for knee surgery. I can understand that a surgeon may have an MRI that he's not satisfied with, and orders a second MRI. But if he has a good recent MRI, I can't understand why he would need a second MRI the day before surgery. You should be able to get lots of experts to testify that a second MRI doesn't improve outcomes, doesn't make the surgery any safer, and isn't necessary. The bad outcome would still have occurred with an MRI.
There were a few articles recently in the NEJM about the overuse of imaging in the context of cancer risk, and I got the impression that a lot of it was unnecessary.
On guidelines -- actually, the defense expert witness says, "the physician followed the guidelines and therefore he was not committing malpractice." The plaintiff expert witness says he was committing malpractice. The judge tells the jury to decide who's right.
Guidelines have many limitations. You don't have guidelines for every procedure. You don't have Grade A evidence for every gudieline. They don't reflect the latest procedure. But they cover the most common procedures.
The court system, and the jury system, is fairly inefficient. A study in the NEJM recently reviewed malpractice judgments and reported the "good news" that 60% of them were decided consistent with the medical record, favoring defense and plaintiff equally. Unfortunately, there were also studies in the NEJM that suggested that the fear of malpractice doesn't lead to better care, as the plaintiffs' lawyers claim.
OTOH, those are the same jurors who are deciding criminal cases, often on the basis of similar medical evidence. The Seventh Amendment guarantees a right to a jury trial, so we can't just take malpractice suits away from jurors.
I don't think there's much room for improvement. Most of the "tort reforms" are efforts to tilt the playing field in favor of the defendant. They want to lower lawyers' fees, eliminate contingency fees, cap pain and suffering, shorten statutes of limitations.
That's nice for doctors, but it's not fair for the patient. Some babies are born with cereberal palsy, and it's not far for an obstetrician to be held liable for his luck of the draw. OTOH, patients are killed or injured because of egregious mistakes or overtreatment, and the cost of compensation gets pretty high. If a doctor does do unnecessary spinal surgery on a 50-year-old man and leaves him paralyzed from the waste down, what's the appropriate compensation for that? 24-hour-a-day attendants for life are pretty expensive.
All developed countries have medical malpratice liability. They seem to spend 2-3% on the liability system, so that seems about right. Estimates of defensive medicine vary, but I think that if you put aside the politically-based estimates and look at the evidence-based estimates, it's under 10%. And I think a lot of that doesn't really protect against malpractice.
My thinking is that the only justified reforms are reforms that bring medical and legal practice into greater conformity with the scientific evidence. That means getting doctors to follow evidence-based medicine and guidelines, and making that a legal s
Interesting link. The AAOS study was a podium session, not a peer-reviewed study. They merely asked the physicians whether they were performing the procedure as defensive medicine, but didn't confirm it. I'd like to know why a procedure would be useful as defensive medicine if it isn't useful for clinical management.
Of course these doctors or their practices are also getting paid for these MRIs. My hypothesis is that they're actually giving unnecessary MRIs just to make money out of it, and when challenged, they justify it by saying it's defensive medicine.
When somebody challenges a doctor on a useless procedure, it sounds a lot better if he says, "defensive medicine," than it does if he says, "I just do a lot of useless procedures because I make a lot of money out of them."
I'd like to see a study designed to tell the difference -- perhaps including a hospital where orthopedists and radiologists are on salary, and not paid by the procedure.
Direct costs of malpractice, which include premiums, damage awards in excess of premiums, and associated litigation costs, represent no more than two percent of health care costs. Thus, tort reforms can have a substantial effect on health care costs only if they affect the amount of healthcare services provided.
Sorry, you must not work in health care.
This is just the malpractice part. What's not in the "1-2%" is what I'll call defensive medicine. I have a colleague who is an orthopedic surgeon. He will not perform surgery on you unless you had an MRI or CT performed the day before. Many, many surgeons do this. And blood work. Update a complete panel. CBC, SMA, drug panel--the whole smash.
It does not matter if you had an MRI last week or your blood tests are two days old.
Why?
He does not want to get sued. You are paying for his defensive medicine.
You might ask "what does having an MRI prevent being sued?" There is a type of patient and a type of lawyer who look for clerical errors and then sue over them--not a negligence outcome. Not having an MRI the day before could be argued as not being the best care.
So what does it really mean? My colleague makes good money being a surgeon and would make less if he had a mark on his insurance record--just or unjust. With the surge in amateur ranking systems this means a lot to a practice.
I call bullshit on this. I just challenged a doctor friend of mine to give me an example of defensive medicine for malpractice purposes that wasn't also good medicine according to the guidelines. He said MRIs. Then he admitted that the hospital is also giving MRIs because they have an MRI machine sitting there that they want to get billing from.
I can't prove it now, but I think hospitals and radiology centers are giving needless MRIs in order to make money out of their MRI machines, and when somebody calls them on it, they say, "We have to do it or we're liable to get sued" as an excuse.
There are guidelines for MRIs. Doctors should follow the guidelines because that's the standard of medicine. If you follow the guidelines, you can go into court, and get a dozen prestigious experts testifying in your defense that you did the right thing, and if the jury believes them, you'll get off. (If you have a stupid jury, you can lose whatever the law says, but following the guidelines is the best you can do.)
If the guidelines say you should have an MRI the day before surgery, then you should have it. If the guidelines say it's not necessary, you shouldn't have it. Same thing with the blood tests, although automated tests are cheap and can pick trends a surgeon should know about.
There is one exception, the Daniel Merenstein PSA case (look it up), where the doctor lost a malpractice case for following the national standard rather than the local standard, but that was because of a law specific to just a few states, and that should be changed, if it hasn't been already.
UK National Health Service pays for fertility treatment.
In the US, it's expensive, so they implant several ova at the time, to make sure at least one of them will be fertilized. Result: When they overshoot, many high-risk twins, and higher-risk triplets, higher infant mortality, higher hospital expenses, worse care.
In the UK they don't worry that much about costs, so they implant one ovum at a time.
Fertility treatments aren't frivolous, because they restore a natural function which most people consider to be important.
Breast implants aren't restoring a natural function.
That goes to his credit. He reviewed the research, came to conclusions, and bit the hand that feeds him.
There's a big difference between
(1) a scientist who is a contrarian who tries to debunk the conventional wisdom and pick fights (and is maybe a pain in the ass sometimes) http://en.wikipedia.org/wiki/Richard_A._Muller and
There was a story in The Guardian which described how the EU laws of extradition are subject to abuse and offer no protection or due process to the person being extradited.
The country with the most extradition requests was Poland, if I recall correctly, and people were extradited for stupid, petty things like a landlord claiming that somebody owed him rent.
In the U.S. people give testimony by international video conference all the time. There was a criminal trial in New York of a rigging company operator who used a cheap, poorly made bearing that failed and caused an accident, and the person from the Chinese company who sold the bearing testified by video.
I think they use video testimony in Guantanamo Bay too.
If the Swedes wanted to get the facts, and see whether there is reason to proceed with a prosecution, they could interview him in London. If it turns out there's no reason to prosecute, they could end it right there. If they decide there is reason to prosecute, then they could call for his extradition. It might not be what they want, but it could end the impasse. Now they'll never interview him.
Let's see what would happen if we applied that principle to other countries. Here's a hypothetical based on an actual incident:
Suppose an American newspaper editor solicited a Chinese scientist to send him data on mining in China -- the kind of data that is routinely disclosed in the U.S. but which is considered a state secret in China.
So China charges the American newspaper editor with espionage and conspiracy to commit espionage. Would the U.S. allow the editor to be extradited? Obviously not. But that's what they seem to want Australia and maybe Sweden to do.
Assange was never in the U.S. None of his disclosures was a crime in the countries he was in. I don't see how Assange committed any crime.
Of course the U.S. claims international jurisdiction all the time, which is essentially "Might makes right." It's a bad precedent when others start doing it to our nationals.
That's a pretty low bar. I can't think of any drug that's more addictive and harmful than tobacco. 400,000 deaths in the U.S. every year, and several million around the world.
Nicotine is arguably the most addicting drug in the world. People who quit nicotine and heroin say nicotine was harder.
There are people who go into their doctors' offices with chronic obstructive pulmonary disease, the doctor tells them that cigarettes will kill them faster, and they still don't stop.
When a doctor tells you you're going to die soon if you don't stop, and you can't stop, that's addicting.
To prove anything about the net effect, you would need to look at every drug ever approved, disapproved, or not developed due to the FDA process and sum of their net effects.
There certainly are lots of doctors who have carefully followed every drug approved, delayed or not developed over the last few decades. (The FDA almost never rejects a drug; they usually say that more evidence is needed. If a company can't get evidence that the drug works, then they drop the drug because it's a market failure, not because of the FDA.)
I've read articles by those doctors in the medical journals. A cardiologist, for example, doesn't have to look up the drugs. There are cardiologists who have followed every prospective and approved heart drug during a career of 20 or 30 years. They have a pretty good idea of what works and how well it works, based on their own experience and on the clinical trials. They have well-established ways of quantifying the benefits. (Peltzman and the other U. Chicago economists have said that doctors are able to assess the value of new drugs in the marketplace alone, even without the randomized, controlled studies that the FDA requires.)
Look up Steven Nissen's writing, and Marcia Angell's writing. Cardiologists like Steven Nissen point to many FDA-approved drugs over the past decades that have done more harm than good (in terms of lives saved vs. lost), and published the kind of analysis that you describe in the New England Journal of Medicine and elsewhere. He thinks that the number of drugs that had to be withdrawn for safety reasons has increased as a result of the user fees, and that the FDA is approving too many dangerous drugs.
As for drugs in development, the cardiology meetings are full of reports on promising new drugs, and there are lots of cardiologists who follow them from tissue culture to mice to human trials. Nobody is hiding these things. I haven't seen any mainstream doctors complaining that there are promising drugs that aren't being developed, for FDA reasons or any other. That's something that conservative economists say, but it's not something that pharmacists and doctors say.
I can't convince you of this. You just have to go to the medical literature and read the articles yourself. I can't summarize 25 articles for you. And I don't think that would convince you. All I can say is, look at the facts.
As for Krugman, I can't help but think you are trolling by actually googling "the government is so wonderful." Read his articles regularly and you will understand that is the message he is sending, not the exact phrase he is uttering. Yes, it is an overstatement but so is "the market is so wonderful." As a side note, Friedman (and other libertarians), also think the government does (or should do) important things that the market can't do. An environmental example is at ~8:50 into this video: http://www.hoover.org/multimedia/uncommon-knowledge/26936
Yes, it is an overstatement. Krugman is a liberal, not a socialist. Even the socialists and Communists (in China, Cuba, etc.) don't believe that the government can do everything. The issue is whether the U.S. government is too big, and should be starved to death (no exaggeration) as the Wall Street Journal editorial page and Grover Norquist say, or whether it's already smaller than the optimum efficient size. Krugman says that taxes particularly on the rich are lower than they've been in a century, lower than they've been during the times of greatest industrial development, and lower than any other developed country. He says that in the past government has invested in things like the Erie Canal that private operators wouldn't have invested in, that returned their investment many times over, and it would be good for the economy to make more investments like that right now. I agree. If you want more new drugs, increase the budget of the National Institutes of Health (which the Republican congress has reduced, in constant dollars). Don't weaken the FDA safety regulations; that won't raise any incentives for new drugs.
Most drugs aren't life-saving. Even a successful cancer drug like bevacizumab (Avastin) extends life in metastatic colorectal cancer by about 3 months, as I recall. (It costs $100,000 for that treatment, so you're buying life at $400,000 a year.) It's very frustrating to read the New England Journal of Medicine about a successful new drug that only extends median survival from, say, 12 months to 16 months. So people with metastatic colon cancer haven't been dying over 7.3 years for lack of a new drug. They've lost (at best) 3 months.
A lot of the new drugs (like Avastin) have life-threatening adverse affects. For example, there are anti-immune drugs that are used to prevent rejection in kidney transplants. If you don't give enough, the kidney is rejected. If you give too much, the patient can't fight off infections and dies. There's an anti-immune drug for multiple sclerosis that is very effective against multiple sclerosis, but frequently allows a normally dormant virus to activate with an incurable fatal brain infection.
After the Food and Drug Administration Safety and Innovation Act was passed, which allowed pharmaceutical companies to pay user fees to get their drugs approved more quickly, the FDA did approve drugs much faster. However, they also approved a lot of drugs that turned out to kill more people than they saved, like Rosiglitazone and Vioxx.
Most of the doctors who follow this issue, who made FOIA requests and read the internal FDA debates, believe that the FDA approved these dangerous drugs because they were under more pressure to approve new drugs faster. Vioxx is a good example. It wasn't a life-saving drug; it was a treatment for the pain of arthritis, and wasn't any better than competing drugs. They got it to market faster and it killed people.
When we loosen regulations, and pressure the FDA to approve drugs faster, we get more drugs that kill people and we don't get any miracle drugs that save lives.
(Can't blame the Republicans for this. The SIA was a bipartisan bill, BTW, and some Republicans actually opposed it.)
This isn't a randomized controlled trial, It's more like a historical control. But it's the best evidence we've got. And it's better evidence than Peltzman had.
And besides, when we do get a new drug that's really promising, the FDA puts it on a fast track and approves it as quickly as possible -- consistent with careful science. Their average approval time is under 7 months. http://www.fda.gov/forconsumers/byaudience/forpatientadvocates/speedingaccesstoimportantnewtherapies/ucm128291.htm (And I don't know where you got that 7.3 years from. This table says it took 1 year in 1998. You may be counting the entire development time from patent to FDA approval.)
I think economists like Peltzman get things completely wrong because they create a free-market economic model for widgets and plug drugs into their model. I once read a book called Structure of the Chemical Processing Industry. They made the point that products aren't widgets. The pharmaceutical industry has a different structure than the automobile industry. Significantly, most customers don't have enough information to know whether a drug is effective. Significantly, the human (or mouse) body is much more complicated than cars, and there's no predictable way to find new drugs. Significantly, you can spend billions of dollars (as we did with the AIDS vaccine), and get nothing. Significantly, most pharmaceuticals depend on basic research by scientists who usually don't profit directly from the final drug. Significantly, most of that basic research is funded by the government.
Peltzman's theories about how the free market works don't correspond to reality. That's the point in science. You do need specific examples -- empirical evidence.
Speaking for Krugman, he never said, "the government is so wonderful"
Slashdot Mirror
A lot of the reforms the Gates Foundation has brought about in public education are actually bad. The "Criticism" section in that Wikipedia article doesn't begin to describe it. The best explanation you can easily get is by doing a Google or Wikipedia search for "Diane Ravitch" http://en.wikipedia.org/wiki/Diane_Ravitch and her longest explanation I know of, outside of her books, is her New York Review of Books article.
She refers to Gates as a member of the "billionaire boys club" that is "reforming" education according to some fads that they picked up, which aren't supported by scientific evidence. Ravitch was an assistant secretary of education under GHW Bush and Bill Clinton. She started out believing in charter schools, free market incentives, high-stakes testing, and all the other neocon reforms. But she said that when the data came out, it didn't support those reforms.
The one factor that is most strongly associated with student achievement, according to Ravitch, is family income. So when you reward teachers for raising student test scores, you're mostly rewarding them for having high-income students, and when you fire them for missing the test targets, you're firing them for teaching in poverty schools.
The Gates education reforms depend heavily on high-stakes testing. But according to repeated analyses, the tests they use today to fire "underperforming" teachers are statistically invalid. There was a debate over that in Science magazine last year, in which the author who was defending the tests admitted that they weren't valid, and his argument was that we should continue to use them and try to improve them.
New York City gave all its math and English teachers rankings based on their students' scores in a standardized test (which wasn't scientifically validated), and education commissioner Joel Klein made the results for individual teachers public, despite the risk of unfairly shaming teachers. One fundamental problem is that they don't have enough statistical power to evaluate individual teachers. A science teacher did a standard statistical analysis, and he found out that they had an essentially random distribution. He made the point that every teacher knows that beginning teachers improve a lot from their first to second year (conversely, most teachers agree that they had a lot of trouble in their first year). But yet, when you compare the scores of the teachers in their first year to the same teachers in their second year, the correlation was random. According to these tests, teachers don't improve with experience. It doesn't make sense. And yet, NYC is firing teachers on the basis of these tests.
Financial incentives and bonuses for teachers have been tested in randomized, controlled studies -- and they don't work. Students don't perform any better when their teachers get bonuses for higher test scores. OTOH, it's hard to be a dedicated teacher if you don't know whether you'll have a job in 10 years, your pay is going down because NCLB has destroyed your union, and politicians like Joel Klein attack you, call you incompetent, and humiliate you.
If you needed proof that these reforms aren't working, look at Michelle Rhee's experience in the Washington DC schools system. Her followers were touting her as a genius who was tough on students, got rid of incompetent teachers and principals, and rewarded the master teachers and principals who raised the test scores with generous financial bonuses. They it turned out that the teachers and principles were raising their tests scores by cheating, which was picked up by the internal verification procedures in the tests -- and Rhee knew about it. There have been cheating scandals in high-stakes testing schools around the country. When you fire teachers who don't raise test scores, what do you expect them to do?
Bill Gates and the other "reformers" have turned teaching from a comfortable, respected job where people were paid well but not extravagantly, and motivated by
Hmm. An anthropologist can look at a thigh bone and identify the race of the person it came from.
I don't think modern anthropologists talk about race any more. They talk about "populations."
A DNA sample can also be used to identify the race of a person. I think we're dealing with a little more than skin color here.
DNA sequencing of many populations around the world shows how related different populations are, but the populations don't correspond to 19th-century categories of races.
In medicine, there are a lot of pragmatic associations with race. For example, there is a gene that is moderately widespread in the Caribbean population which makes them especially sensitive to morphine compounds. Sometimes people have violent coughing, and codeine is a standard treatment, but in patients with sensitivity to codeine, a normal dose can cause a life-threatening or fatal overdose with depression of breathing and blood pressure.
So as a physician, if a black Caribbean guy walks into your office with a severe cough, you would be more careful about prescribing codeine.
In principle, if you knew the gene, you could send a DNA sample to a laboratory, but by the time you got the results the problem would be over. (And a lot of times we don't even know whether it's a genetic or environmental effect.)
Sure, racial characteristics are imprecise. You might have a Polynesian who self-identifies as Caribbean, and the racial category would be misleading.
But there are lots of tests and rules in medicine that are equally imprecise.
Now, realize I'm not using the term "race" with the cultural baggage of defining your place on the Great Chain of Being from pond scum to Englishmen.
I'm using it as an easy office test to visually identify people who are more likely than random to be in a certain gene pool.
Humans are just big mice, right?
These guys deserve kudos for drug discovery, but as you say it's a long way from animals to humans. They don't even know whether it's safe in humans. Another big question is, how fast will the parasites develop resistance?
They would be doing pretty well if it turns into another artemisinin http://en.wikipedia.org/wiki/Artemisinin and if it does, they deserve a Lasker too. But even artemisin can't be used as monotherapy, because it can develop resistance.
And the whales.
I thought Samsung was a supplier to Apple. Is that why the hardware is so similar?
http://xkcd.com/937/ TornadoGuard worked well, except for warning about tornados.
You may some day have to accept that there is a large number of reasonable, intelligent, and even likable people who completely disagree with your views on government and policy. Just because someone has a political view doesnt mean you know squat about them, their finances, their situation, or their personality.
The Republicans (and conservatives) used to be like that. I used to read the Wall Street Journal editorial page every day just to see a well-argued factually accurate idea that I disagreed with, and sometimes I'd be forced to say, "You know, they're right." But they've gone off the deep end since then. OK, you believe that individuals can make better decisions for themselves than the government can make for them. But what about abortion? Evolution? Prayer in the schools? The war on drugs? Gays? I wish Barry Goldwater were back.
http://truth-out.org/index.php?option=com_k2&view=item&id=3079:goodbye-to-all-that-reflections-of-a-gop-operative-who-left-the-cult
Goodbye to All That: Reflections of a GOP Operative Who Left the Cult
Saturday, 03 September 2011 11:09 By Mike Lofgren, Truthout | News Analysis
To be sure, the party, like any political party on earth, has always had its share of crackpots, like Robert K. Dornan or William E. Dannemeyer. But the crackpot outliers of two decades ago have become the vital center today: Steve King, Michele Bachman (now a leading presidential candidate as well), Paul Broun, Patrick McHenry, Virginia Foxx, Louie Gohmert, Allen West. The Congressional directory now reads like a casebook of lunacy.
I could see as early as last November that the Republican Party would use the debt limit vote, an otherwise routine legislative procedure that has been used 87 times since the end of World War II, in order to concoct an entirely artificial fiscal crisis. Then, they would use that fiscal crisis to get what they wanted, by literally holding the US and global economies as hostages.
Everyone knows that in a hostage situation, the reckless and amoral actor has the negotiating upper hand over the cautious and responsible actor because the latter is actually concerned about the life of the hostage, while the former does not care.
Perhaps we could compensate the doctor for that humiliation by having him make a lot of money.
There was a physicians' mutual insurance company several years ago that used a law firm made up of doctors with law degrees. They never settled. They reviewed the case. If the doctor was wrong, they pay up. If the doctor was right, they fight it all the way through a jury trial. That's the way it should be. I wonder if it's an economically viable strategy.
I would like to give one of those "experts" a set of 10 breast films, 5 of which went on to become cancer, 5 of which did not, and ask him to tell which is which. I don't know if you can do that in court, but if the expert witness screws up once, you can refer to it every time he testifies afterwards.
You are correct. Here's an example to prove it. (However, you will notice that even with Medicaid you can't always get treatment.)
Wall Street Journal
September 13, 2007
MEDICAL MAZE
Legal Loophole Ensnares Breast-Cancer Patients
Shirley Loewe Chooses The Wrong Clinic And Starts Long Ordeal
By JOHN CARREYROU
LONGVIEW, Texas -- In June 2003, Shirley Loewe went to Good Shepherd Medical Center here with a softball-size lump in her breast and was diagnosed with a rare form of breast cancer. She didn't know it, but she had just made a big mistake.
Ms. Loewe was uninsured. Under federal law, she could have gotten Medicaid coverage -- and saved herself a lot of hardship -- if she'd gone to a different clinic less than a half-mile away. But by walking through Good Shepherd's doors, Ms. Loewe unwittingly let that opportunity slip and embarked on a four-year journey through the Byzantine U.S. health-care system.
It was an odyssey that would take her to five hospitals, two clinics, two charitable organizations and two nursing homes in two states. She was denied assistance or care at least six times along the way, for reasons that ranged from not being poor enough to not being sick enough.
http://online.wsj.com/article/SB118781024289705455.html
Knee replacement surgery is a bad example to prove the superiority of the American health care system. It proves the opposite. You shouldn't rush patients into surgery. Canadian doctors say that the long waits are a benefit of their system -- they give people a chance to find out the facts and decide whether the treatment is a good thing.
First of all, most of the people who get knee replacements are in their 60s or 70s, so in the US they get it under Medicare -- single payer health care.
Second, Total knee replacements are the fastest-growing and most expensive surgeries in Medicare. Doctors are rushing patients into knee surgery who shouldn't have it. So this is free-market medical abuse on steroids. (In fact steroids turned out to have some bad outcomes.)
TKR isn't trivial. It's among the most painful procedures in medicine, and if the patient doesn't complete painful physical rehabilitation, the replacement won't work. They usually use Oxycodone for a month or two, but this being the US a lot of surgeons under-dose and leave the patients in pain that drives them to tears (read Jane Brody's account of her own TKR in the New York Times). It's several days in the hospital, a week in a rehabilitation center, a week to a month at home in bed, and 3 to 6 months before you've recovered the function you started with. Then you start to improve, and after 6 months to a year most people can walk and stand again.
But many people don't. About 15% of TKR patients have permanent moderate to severe pain that can't be cured. They're worse off for having the surgery. Some of them get surgery because they're using a cane as a result of their surgery wind up in a wheelchair. What are the risks? Nobody knows for sure because surgeons have been replacing knees without doing good outcome studies. Countries with national health care systems do outcome studies. Denmark is doing a big randomized study, so we should know the outcomes in 10 years.
In Denmark, the current practice is that they don't give TKR until the patient has tried less drastic measures for 6 months and they haven't been adequate. The first step is to lose weight, down to a body mass index of 25 ideally. They also give them exercise/physical rehabilitation and non-steroidal anti-inflammatory drugs. People who are overweight or obese have a worse outcome after surgery, and in some cases, after weight loss, exercise/rehab, and NSAIDs, they don't need surgery after all. Why go through all that pain, bed confinement and risk when you can get the same results without it?
Overtreatment is endemic in US health care. Look at the fastest-growing, largest Medicare expenses besides hip and knee replacement. According to a series of articles in the New England Journal of Medicine, CT scans (another big money-maker for doctors and device companies, a major growing expense for Medicare) are widely overused and a major cause of cancer (about 1/10,000 major CT scans result in an additional cancer, more for CT scans of children). Erythropoietin, a drug that stimulates the growth of red blood cells, was the Medicare/Medicaid's single most expensive drug (=profitable for drug companies and doctors), used in kidney dialysis, and after they finally did the research, it turned out to be actually killing people at the high (profitable) doses they were using. Hormone replacement therapy for post-menopausal women actually turned out to be a major cause of breast cancer in the formulations they were using. There was a significant bump in the breast cancer incidence curve because of these heavily-promoted estrogen drugs.
The Canadian health care system has quality as good as ours, costs them half as much, and the tradeoff is that they do have to wait longer (and sometimes don't get advanced procedures that we get here). They have their flaws. But it's not the backward third-world system that conservatives (Google "Manhattan Institute) would have you believe.
Here's a couple of interesting stories on the Canadian system.
I used to write articles for trade magazines about medical malpractice and product liability. I used to go to legal conferences on medical malpractice and interview lawyers, although I don't have the latest information and I'm recalling some of this from memory. I followed malpractice in JAMA and NEJM. I read the Case Records of the Massachusetts General Hospital, which usually includes a radiology report. So I realize the ambiguity, difficulty and subjectivity of reading a radiology image.
But the malpractice standard isn't the ultimate care. It's a reasonable standard of care. The standard isn't a good outcome. A bad outcome isn't malpractice. If a procedure has a 5% mortality, and the patient knows it and the doctor documented that informed consent in the chart, then death by itself isn't malpractice.
Let's assume an MRI is the standard of care and gives a better outcome for knee surgery. I can understand that a surgeon may have an MRI that he's not satisfied with, and orders a second MRI. But if he has a good recent MRI, I can't understand why he would need a second MRI the day before surgery. You should be able to get lots of experts to testify that a second MRI doesn't improve outcomes, doesn't make the surgery any safer, and isn't necessary. The bad outcome would still have occurred with an MRI.
There were a few articles recently in the NEJM about the overuse of imaging in the context of cancer risk, and I got the impression that a lot of it was unnecessary.
On guidelines -- actually, the defense expert witness says, "the physician followed the guidelines and therefore he was not committing malpractice." The plaintiff expert witness says he was committing malpractice. The judge tells the jury to decide who's right.
Guidelines have many limitations. You don't have guidelines for every procedure. You don't have Grade A evidence for every gudieline. They don't reflect the latest procedure. But they cover the most common procedures.
The court system, and the jury system, is fairly inefficient. A study in the NEJM recently reviewed malpractice judgments and reported the "good news" that 60% of them were decided consistent with the medical record, favoring defense and plaintiff equally. Unfortunately, there were also studies in the NEJM that suggested that the fear of malpractice doesn't lead to better care, as the plaintiffs' lawyers claim.
OTOH, those are the same jurors who are deciding criminal cases, often on the basis of similar medical evidence. The Seventh Amendment guarantees a right to a jury trial, so we can't just take malpractice suits away from jurors.
I don't think there's much room for improvement. Most of the "tort reforms" are efforts to tilt the playing field in favor of the defendant. They want to lower lawyers' fees, eliminate contingency fees, cap pain and suffering, shorten statutes of limitations.
That's nice for doctors, but it's not fair for the patient. Some babies are born with cereberal palsy, and it's not far for an obstetrician to be held liable for his luck of the draw. OTOH, patients are killed or injured because of egregious mistakes or overtreatment, and the cost of compensation gets pretty high. If a doctor does do unnecessary spinal surgery on a 50-year-old man and leaves him paralyzed from the waste down, what's the appropriate compensation for that? 24-hour-a-day attendants for life are pretty expensive.
All developed countries have medical malpratice liability. They seem to spend 2-3% on the liability system, so that seems about right. Estimates of defensive medicine vary, but I think that if you put aside the politically-based estimates and look at the evidence-based estimates, it's under 10%. And I think a lot of that doesn't really protect against malpractice.
My thinking is that the only justified reforms are reforms that bring medical and legal practice into greater conformity with the scientific evidence. That means getting doctors to follow evidence-based medicine and guidelines, and making that a legal s
Interesting link. The AAOS study was a podium session, not a peer-reviewed study. They merely asked the physicians whether they were performing the procedure as defensive medicine, but didn't confirm it. I'd like to know why a procedure would be useful as defensive medicine if it isn't useful for clinical management.
Of course these doctors or their practices are also getting paid for these MRIs. My hypothesis is that they're actually giving unnecessary MRIs just to make money out of it, and when challenged, they justify it by saying it's defensive medicine.
When somebody challenges a doctor on a useless procedure, it sounds a lot better if he says, "defensive medicine," than it does if he says, "I just do a lot of useless procedures because I make a lot of money out of them."
I'd like to see a study designed to tell the difference -- perhaps including a hospital where orthopedists and radiologists are on salary, and not paid by the procedure.
As KevinMD himself said, the costs of defensive medicine are probably overstated http://www.kevinmd.com/blog/2010/09/defensive-medicine-saves-money-physicians.html
Especially the claims made by Newt Gingrich's organization.
Direct costs of malpractice, which include premiums, damage awards in excess of premiums, and associated litigation costs, represent no more than two percent of health care costs. Thus, tort reforms can have a substantial effect on health care costs only if they affect the amount of healthcare services provided.
Sorry, you must not work in health care.
This is just the malpractice part. What's not in the "1-2%" is what I'll call defensive medicine.
I have a colleague who is an orthopedic surgeon. He will not perform surgery on you unless you had an MRI or CT performed the day before. Many, many surgeons do this. And blood work. Update a complete panel. CBC, SMA, drug panel--the whole smash.
It does not matter if you had an MRI last week or your blood tests are two days old.
Why?
He does not want to get sued. You are paying for his defensive medicine.
You might ask "what does having an MRI prevent being sued?" There is a type of patient and a type of lawyer who look for clerical errors and then sue over them--not a negligence outcome. Not having an MRI the day before could be argued as not being the best care.
So what does it really mean? My colleague makes good money being a surgeon and would make less if he had a mark on his insurance record--just or unjust. With the surge in amateur ranking systems this means a lot to a practice.
I call bullshit on this. I just challenged a doctor friend of mine to give me an example of defensive medicine for malpractice purposes that wasn't also good medicine according to the guidelines. He said MRIs. Then he admitted that the hospital is also giving MRIs because they have an MRI machine sitting there that they want to get billing from.
I can't prove it now, but I think hospitals and radiology centers are giving needless MRIs in order to make money out of their MRI machines, and when somebody calls them on it, they say, "We have to do it or we're liable to get sued" as an excuse.
There are guidelines for MRIs. Doctors should follow the guidelines because that's the standard of medicine. If you follow the guidelines, you can go into court, and get a dozen prestigious experts testifying in your defense that you did the right thing, and if the jury believes them, you'll get off. (If you have a stupid jury, you can lose whatever the law says, but following the guidelines is the best you can do.)
If the guidelines say you should have an MRI the day before surgery, then you should have it. If the guidelines say it's not necessary, you shouldn't have it. Same thing with the blood tests, although automated tests are cheap and can pick trends a surgeon should know about.
There is one exception, the Daniel Merenstein PSA case (look it up), where the doctor lost a malpractice case for following the national standard rather than the local standard, but that was because of a law specific to just a few states, and that should be changed, if it hasn't been already.
UK National Health Service pays for fertility treatment.
In the US, it's expensive, so they implant several ova at the time, to make sure at least one of them will be fertilized. Result: When they overshoot, many high-risk twins, and higher-risk triplets, higher infant mortality, higher hospital expenses, worse care.
In the UK they don't worry that much about costs, so they implant one ovum at a time.
Fertility treatments aren't frivolous, because they restore a natural function which most people consider to be important.
Breast implants aren't restoring a natural function.
That goes to his credit. He reviewed the research, came to conclusions, and bit the hand that feeds him.
There's a big difference between
(1) a scientist who is a contrarian who tries to debunk the conventional wisdom and pick fights (and is maybe a pain in the ass sometimes) http://en.wikipedia.org/wiki/Richard_A._Muller and
(2) a scientist who is a hired gun and makes a case for whoever is paying the bill. http://en.wikipedia.org/wiki/Steve_Milloy#Links_to_tobacco_industry
There was a story in The Guardian which described how the EU laws of extradition are subject to abuse and offer no protection or due process to the person being extradited.
The country with the most extradition requests was Poland, if I recall correctly, and people were extradited for stupid, petty things like a landlord claiming that somebody owed him rent.
In the U.S. people give testimony by international video conference all the time. There was a criminal trial in New York of a rigging company operator who used a cheap, poorly made bearing that failed and caused an accident, and the person from the Chinese company who sold the bearing testified by video.
I think they use video testimony in Guantanamo Bay too.
If the Swedes wanted to get the facts, and see whether there is reason to proceed with a prosecution, they could interview him in London. If it turns out there's no reason to prosecute, they could end it right there. If they decide there is reason to prosecute, then they could call for his extradition. It might not be what they want, but it could end the impasse. Now they'll never interview him.
Let's see what would happen if we applied that principle to other countries. Here's a hypothetical based on an actual incident:
Suppose an American newspaper editor solicited a Chinese scientist to send him data on mining in China -- the kind of data that is routinely disclosed in the U.S. but which is considered a state secret in China.
So China charges the American newspaper editor with espionage and conspiracy to commit espionage. Would the U.S. allow the editor to be extradited? Obviously not. But that's what they seem to want Australia and maybe Sweden to do.
Assange was never in the U.S. None of his disclosures was a crime in the countries he was in. I don't see how Assange committed any crime.
Of course the U.S. claims international jurisdiction all the time, which is essentially "Might makes right." It's a bad precedent when others start doing it to our nationals.
No, no! The Zionist lobby is actually an elaborate scheme by horny IDF soldiers to schtupp stupid Jewish girls from Great Neck and Los Angeles. http://www.jewlicious.com/2011/02/the-unofficial-guide-to-sex-on-birthright-israel/
That's a pretty low bar. I can't think of any drug that's more addictive and harmful than tobacco. 400,000 deaths in the U.S. every year, and several million around the world.
Nicotine is arguably the most addicting drug in the world. People who quit nicotine and heroin say nicotine was harder.
There are people who go into their doctors' offices with chronic obstructive pulmonary disease, the doctor tells them that cigarettes will kill them faster, and they still don't stop.
When a doctor tells you you're going to die soon if you don't stop, and you can't stop, that's addicting.
1. Send fake tweet
2. Buy oil stocks after they go down
3. Sell them after they go up again
4. PROFIT!
To prove anything about the net effect, you would need to look at every drug ever approved, disapproved, or not developed due to the FDA process and sum of their net effects.
There certainly are lots of doctors who have carefully followed every drug approved, delayed or not developed over the last few decades. (The FDA almost never rejects a drug; they usually say that more evidence is needed. If a company can't get evidence that the drug works, then they drop the drug because it's a market failure, not because of the FDA.)
I've read articles by those doctors in the medical journals. A cardiologist, for example, doesn't have to look up the drugs. There are cardiologists who have followed every prospective and approved heart drug during a career of 20 or 30 years. They have a pretty good idea of what works and how well it works, based on their own experience and on the clinical trials. They have well-established ways of quantifying the benefits. (Peltzman and the other U. Chicago economists have said that doctors are able to assess the value of new drugs in the marketplace alone, even without the randomized, controlled studies that the FDA requires.)
Look up Steven Nissen's writing, and Marcia Angell's writing. Cardiologists like Steven Nissen point to many FDA-approved drugs over the past decades that have done more harm than good (in terms of lives saved vs. lost), and published the kind of analysis that you describe in the New England Journal of Medicine and elsewhere. He thinks that the number of drugs that had to be withdrawn for safety reasons has increased as a result of the user fees, and that the FDA is approving too many dangerous drugs.
As for drugs in development, the cardiology meetings are full of reports on promising new drugs, and there are lots of cardiologists who follow them from tissue culture to mice to human trials. Nobody is hiding these things. I haven't seen any mainstream doctors complaining that there are promising drugs that aren't being developed, for FDA reasons or any other. That's something that conservative economists say, but it's not something that pharmacists and doctors say.
I can't convince you of this. You just have to go to the medical literature and read the articles yourself. I can't summarize 25 articles for you. And I don't think that would convince you. All I can say is, look at the facts.
As for Krugman, I can't help but think you are trolling by actually googling "the government is so wonderful." Read his articles regularly and you will understand that is the message he is sending, not the exact phrase he is uttering. Yes, it is an overstatement but so is "the market is so wonderful." As a side note, Friedman (and other libertarians), also think the government does (or should do) important things that the market can't do. An environmental example is at ~8:50 into this video: http://www.hoover.org/multimedia/uncommon-knowledge/26936
Yes, it is an overstatement. Krugman is a liberal, not a socialist. Even the socialists and Communists (in China, Cuba, etc.) don't believe that the government can do everything. The issue is whether the U.S. government is too big, and should be starved to death (no exaggeration) as the Wall Street Journal editorial page and Grover Norquist say, or whether it's already smaller than the optimum efficient size. Krugman says that taxes particularly on the rich are lower than they've been in a century, lower than they've been during the times of greatest industrial development, and lower than any other developed country. He says that in the past government has invested in things like the Erie Canal that private operators wouldn't have invested in, that returned their investment many times over, and it would be good for the economy to make more investments like that right now. I agree. If you want more new drugs, increase the budget of the National Institutes of Health (which the Republican congress has reduced, in constant dollars). Don't weaken the FDA safety regulations; that won't raise any incentives for new drugs.
Nope. There's a third option.
Most drugs aren't life-saving. Even a successful cancer drug like bevacizumab (Avastin) extends life in metastatic colorectal cancer by about 3 months, as I recall. (It costs $100,000 for that treatment, so you're buying life at $400,000 a year.) It's very frustrating to read the New England Journal of Medicine about a successful new drug that only extends median survival from, say, 12 months to 16 months. So people with metastatic colon cancer haven't been dying over 7.3 years for lack of a new drug. They've lost (at best) 3 months.
A lot of the new drugs (like Avastin) have life-threatening adverse affects. For example, there are anti-immune drugs that are used to prevent rejection in kidney transplants. If you don't give enough, the kidney is rejected. If you give too much, the patient can't fight off infections and dies. There's an anti-immune drug for multiple sclerosis that is very effective against multiple sclerosis, but frequently allows a normally dormant virus to activate with an incurable fatal brain infection.
After the Food and Drug Administration Safety and Innovation Act was passed, which allowed pharmaceutical companies to pay user fees to get their drugs approved more quickly, the FDA did approve drugs much faster. However, they also approved a lot of drugs that turned out to kill more people than they saved, like Rosiglitazone and Vioxx.
Most of the doctors who follow this issue, who made FOIA requests and read the internal FDA debates, believe that the FDA approved these dangerous drugs because they were under more pressure to approve new drugs faster. Vioxx is a good example. It wasn't a life-saving drug; it was a treatment for the pain of arthritis, and wasn't any better than competing drugs. They got it to market faster and it killed people.
When we loosen regulations, and pressure the FDA to approve drugs faster, we get more drugs that kill people and we don't get any miracle drugs that save lives.
(Can't blame the Republicans for this. The SIA was a bipartisan bill, BTW, and some Republicans actually opposed it.)
This isn't a randomized controlled trial, It's more like a historical control. But it's the best evidence we've got. And it's better evidence than Peltzman had.
And besides, when we do get a new drug that's really promising, the FDA puts it on a fast track and approves it as quickly as possible -- consistent with careful science. Their average approval time is under 7 months. http://www.fda.gov/forconsumers/byaudience/forpatientadvocates/speedingaccesstoimportantnewtherapies/ucm128291.htm (And I don't know where you got that 7.3 years from. This table says it took 1 year in 1998. You may be counting the entire development time from patent to FDA approval.)
I think economists like Peltzman get things completely wrong because they create a free-market economic model for widgets and plug drugs into their model. I once read a book called Structure of the Chemical Processing Industry. They made the point that products aren't widgets. The pharmaceutical industry has a different structure than the automobile industry. Significantly, most customers don't have enough information to know whether a drug is effective. Significantly, the human (or mouse) body is much more complicated than cars, and there's no predictable way to find new drugs. Significantly, you can spend billions of dollars (as we did with the AIDS vaccine), and get nothing. Significantly, most pharmaceuticals depend on basic research by scientists who usually don't profit directly from the final drug. Significantly, most of that basic research is funded by the government.
Peltzman's theories about how the free market works don't correspond to reality. That's the point in science. You do need specific examples -- empirical evidence.
Speaking for Krugman, he never said, "the government is so wonderful"
They're biological products. Blood is a biological product regulated by the FDA.