La santé peut-elle être un `marché` ? 01

Index d'articles mis à jour le 05 Octobre 2013
La santé peut-elle être un 'marché' ? 01
➫ 01. Use only as directed - Pro Publica, 20.09.2013
➫ 02. How Many Die from Medical Mistakes in U.S. Hospitals? - Scientific American &
Pro Publica, 20.09.2013
➫ 03. How Factory Farms May Be Killing Us - Alter Net, 17.09.2013
➫ 04. Bitter Pill: Why Medical Bills Are Killing Us - Time, 20.02.2013
➫ 05. Benzodiazépines : une overdose française - Le Monde, 10.01.2013
➫ 06. Dépendance aux antidouleurs opiacés : un fléau venu des Etats-Unis - Rue89,
15.01.2013
➫ 07. Textile : ces vêtements qui nous intoxiquent - Basta!, 29.01.2013
➫ 08. Five Things Your Doctor Should Tell You, But Won't - Mother Jones, 11.02.2013
➫ 09. Des traces de pesticides et de médicaments retrouvées dans des bouteilles
d'eau - Le Monde, 25.03.2013
➫ 10. Des traces de pesticides et de médicaments dans l’eau de bouteille - Rue89, 25.03.2013
➫ 11. Des traces de pesticides et de médicaments dans l'eau en bouteille! - Huffington
Post, 25.03.2013
➫ 12. "La forte demande d'eau en bouteille peut entraîner sa contamination" - Le
Monde, 25.03.2013
➫ 13. Le Mercure & la Santé humaine - Ministère de la Santé du Canada
➫ 14. DSM : quand la psychiatrie fabrique des individus performants et dociles Basta!, 23.05.2013
➫ 15. The $13 Test That Saved My Baby’s Life. Why Isn’t it Required For Every
Newborn? - Pro Publica, 20.09.2013
➫ 16. Prothèses auditives: enquête sur un marché verrouillé - Médiapart, 04.10.2013
➫ 17. Iraqi Birth Defects Covered Up? - Huffington Post, 10.04.2013
1
By Jeff Gerth and T.Christian Miller, ProPublica,
Sept. 20, 2013, 10:00 a.m.
Design & Development: By Krista Kjellman Schmidt, Lena Groeger, Al Shaw
01. Use Only as Directed
During the last decade, more than 1,500 Americans
died after accidentally taking too much of a drug
renowned for its safety: acetaminophen, one of the
nation’s most popular pain relievers.
Acetaminophen – the active ingredient in Tylenol –
is considered safe when taken at recommended
doses. Tens of millions of people use it weekly with
no ill effect. But in larger amounts, especially in
combination with alcohol, the drug can damage or
even destroy the liver.
Davy Baumle, a slender 12-year-old who loved
to ride his dirt bike through the woods of
southern Illinois, died from acetaminophen
poisoning. So did tiny five-month-old Brianna
Hutto. So did Marcus Trunk, a strapping 23year-old construction worker from Philadelphia.
The toll does not have to be so high
The U.S. Food and Drug Administration has
long been aware of studies showing the risks of
acetaminophen – in particular, that the margin
between the amount that helps and the amount
that can cause serious harm is smaller than for
other pain relievers. So, too, has McNeil
Consumer Healthcare, the unit of Johnson &
Johnson that has built Tylenol into a billiondollar brand and the leader in acetaminophen
sales.
Yet federal regulators have delayed or failed to
adopt measures designed to reduce deaths and
injuries from acetaminophen overdose, which
the agency calls a “persistent, important public
health problem.”
The FDA has repeatedly deferred decisions on
consumer protections even when they were
endorsed by the agency’s own advisory
Major Takeaways
1 About 150 Americans die a year by accidentally taking
too much acetaminophen, the active ingredient in Tylenol,
federal data from the CDC shows.
2 Acetaminophen has a narrow safety margin: the dose
that helps is close to the dose that can cause serious
harm, according to the FDA.
3 The FDA has long been aware of studies showing the
risks of acetaminophen. So has the maker of Tylenol,
McNeil Consumer Healthcare, a division of Johnson &
Johnson.
4 Over more than 30 years, the FDA has delayed or
failed to adopt measures designed to reduce deaths and
injuries from acetaminophen. The agency began a
comprehensive review to set safety rules for
acetaminophen in the 1970s, but still has not finished.
5 McNeil, the maker of Tylenol, has taken steps to protect
consumers. But over more than three decades, the
company has repeatedly opposed safety warnings,
dosage restrictions and other measures meant to
safeguard users of the drug.
2
committees, records show.
In 1977, an expert panel convened by the FDA issued urgently worded advice, saying it was
“obligatory” to put a warning on the drug’s label that it could cause “severe liver damage.” After much
debate, the FDA added the warning 32 years later. The panel’s recommendation was part of a
broader review to set safety rules for acetaminophen, which is still not finished.
Four years ago, another FDA panel backed a sweeping new set of proposals to bolster the safety of
over-the-counter acetaminophen. The agency hasn’t implemented them. Just last month, the FDA
blew through another deadline.
Regulators in other developed countries, from Great Britain to Switzerland to New Zealand, have
limited how much acetaminophen consumers can buy at one time or required it to be sold only by
pharmacies. The FDA has placed no such limits on the drug in the U.S. Instead, it has continued to
debate basic safety questions, such as what the maximum recommended daily dose should be.
Safety Delay
(the clock is still ticking)
For its part, McNeil has
taken steps to protect
consumers, most notably
by helping to fund the
development of an
antidote to acetaminophen poisoning that
has saved many lives.
In the 1970s, the Food and Drug Administration appointed an expert
panel to review the safety and efficacy of over-the-counter pain
relievers, including acetaminophen, the active ingredient in Tylenol.
The panel delivered their recommendations on April 5, 1977. At the
time, the FDA estimated it would issue final regulations before the
end of 1978. The agency has still not completed its work. This is how
much time has passed since then. Find out more >>
But over more than three
decades, the company
repeatedly fought
against safety warnings,
dosage restrictions and
other measures meant to
safeguard users of the drug, according to company memos, court records, documents obtained
under the Freedom of Information Act, and interviews with hundreds of regulatory, corporate and
medical officials.
In the 1990s, McNeil tried to create a safer version of acetaminophen, an effort dubbed Project
Protect. But after the initiative failed, the company kept its experiments confidential, even when the
FDA inquired about the feasibility of developing such a drug.
Later, McNeil opposed even a modest government campaign to educate the public about
acetaminophen’s risks, in part because it would harm Tylenol sales.
All the while, it has marketed Tylenol’s safety. Tylenol was the pain reliever “hospitals use most,” one
iconic ad said. The one “recommended by pediatricians,” said another. “Safe, fast pain relief,” its
packages promised.
In written responses to questions for this story, as well as a pre-recorded statement by its vice
president for medical affairs, McNeil said it has always acted to ensure its products were used safely.
“McNeil takes acetaminophen overdose very seriously, which is why we have taken significant steps
over the years to mitigate the risk,” the company wrote. McNeil has engineered safety packaging and
3
spent millions on research, education and poison control centers that advise people who have
overdosed.
The company said that science on acetaminophen had evolved over time and that it had
implemented safety measures accordingly. Most recently, it announced it will soon add red lettering to
the caps of medicine bottles saying they contain acetaminophen and that users should read the label.
In several cases, after FDA advisors recommended the agency enact safety measures over McNeil’s
objections, the company adopted them before the agency forced it to do so. The company then said it
was taking such steps voluntarily. McNeil also stressed that it has always followed FDA regulations.
McNeil objected to the thrust of questions from ProPublica and This American Life, saying they
indicated “a clear bias” in favor of plaintiff’s lawyers who are suing the company.
The company declined to answer questions about individual cases of death or injury. “Our hearts go
out to those who have suffered harm from acetaminophen overdose, and to the families of those who
lost their lives as a result,” McNeil wrote in its statement.
FDA officials said the agency saw the benefits of keeping acetaminophen widely available as
outweighing the “relatively rare” risk of liver damage or death. Some patients cannot tolerate drugs
such as ibuprofen, and for them acetaminophen may be the best option, said one agency official.
Accidental Deaths by Acetaminophen Poisoning
The FDA has bolstered acetaminophen warnings as new science about the drug emerged, the
agency said in a statement.
But FDA officials acknowledged the agency had moved sluggishly to address the mounting toll of liver
damage caused by acetaminophen. They blamed changing research, small budgets, an overworked
staff and a cumbersome process for changing rules for older drugs such as Tylenol slowing them
down.
The agency has greater authority over prescription drugs, and it has already slapped medications
containing acetaminophen with a “black box warning” that says overdosing can lead to “liver
transplant and death.” Paradoxically, the same medicine sold over the counter does not tell patients
that death is a possible side effect.
4
“Among over-the-counter medicines, it’s among our top priorities,” said Dr. Sandy Kweder, one of the
FDA’s top experts on acetaminophen. “It just takes time.”
Many doctors believe in acetaminophen and some medical associations advise patients to take it for
mild to moderate pain or reducing fever. “Given the number of doses given annually, the track record
is incredibly safe,” said Dr. Bill Banner, a pediatrician and the medical director of the Oklahoma
Poison Control Center.
Every over-the-counter pain reliever can cause harm. Even without overdosing, aspirin and ibuprofen
can lead to stomach bleeding. In extremely rare cases, according to the FDA, recommended doses
of ibuprofen and acetaminophen can provoke a skin reaction that can kill.
But the FDA says acetaminophen carries a special risk. About a quarter of Americans routinely take
more over-the-counter pain relief pills of all kinds than they are supposed to, surveys show. That
behavior is "particularly troublesome" for acetaminophen, an FDA report said, because the drug's
narrow safety margin places "a large fraction of users close to a toxic dose in the ordinary course of
use.”
The FDA sets the maximum recommended daily dose of acetaminophen at 4 grams, or eight extra
strength acetaminophen tablets. That maximum applies to both over-the-counter and prescription
drugs with acetaminophen.
Taken over several days, as little as 25 percent above the maximum daily dose – or just two
additional extra strength pills a day – has been reported to cause liver damage, according to the
agency. Taken all at once, a little less than four times the maximum daily dose can cause death. A
comparable figure doesn't exist for ibuprofen, because so few people have died from overdosing on
that drug.
About as many Americans take ibuprofen as take acetaminophen, according to consumer surveys
from the mid-2000s.
The U.S. Centers for Disease Control and Prevention and the American Association of Poison
Control Centers collect data on the number of deaths associated with each drug, but the figures are
incomplete, making comparisons subject to question. McNeil contends the databases do not contain
the information needed to draw conclusions about the relative risks of different medicines. The
company and some epidemiologists maintain that these data sets undercount deaths resulting from
chronic use of naproxen, ibuprofen and similar pain relievers. (More on the numbers can be found
here.)
Still, the data show that acetaminophen is linked to more deaths than any other over-the-counter pain
reliever.
From 2001 to 2010, annual acetaminophen-related deaths amounted to about twice the number
attributed to all other over-the-counter pain relievers combined, according to the poison control data.
In 2010, only 15 deaths were reported for the entire class of pain relievers, both prescription and
over-the-counter, that includes ibuprofen, data from the CDC shows.
That same year, 321 people died from acetaminophen toxicity, according to CDC data. More than half
– 166 – died from accidental overdoses. The rest overdosed deliberately or their intent was unclear.
For the decade 2001 through 2010, the data shows, 1,567 people died from inadvertently taking too
much of the drug.
Acetaminophen overdose sends as many as 78,000 Americans to the emergency room annually and
results in 33,000 hospitalizations a year, federal data shows. Acetaminophen is also the nation’s
5
leading cause of acute liver failure, according to data from an ongoing study funded by the National
Institutes for Health.
Behind these statistics are families upended and traumatized and, in the worst cases, shattered by
loss.
http://www.youtube.com/watch?v=iY0ouwky98g&feature=player_embedded#t=0
Udosha Baumle sits by the gravestone of her son Davy, who died at age 12 of liver failure after taking Maximum Strength
Tylenol Sore Throat. (Melanie Burford for ProPublica)
Just before Christmas 1999, 12-year-old Davy Baumle came down with a sore throat. For a week, his
parents, David and Udosha Baumle, gave him Maximum Strength Tylenol Sore Throat, measuring
out doses of the thick syrup.
But instead of getting better, Davy became listless. On
Christmas Day, he threw up blood.
His father took him to a local emergency room wrapped
in a fuzzy brown blanket. A few days later, the boy was
declared brain dead.
“
They tell you it’s medicine…
They don’t tell you it can kill
you.”
David Baumle, father of
Davy Baumle
The Baumles later sued McNeil, claiming the company
had failed to warn consumers of its product’s lethal
danger.
At trial, they testified they never gave Davy more than the recommended dose, 4 grams per day, or
eight tablespoons. An expert for the company testified that lab work suggested the boy had ingested
more, 6 to 10 grams, over several days.
The difference amounted to as little as 4 tablespoons a day, but the company prevailed, persuading
the jury that the Baumles had not used Tylenol precisely as specified.
David Baumle said he would never have given his son the drug if he knew it was potentially lethal. At
the time, the label simply warned of “serious health consequences” in case of overdose.
“They tell you it’s medicine,” he said. “They don’t tell you it can kill you.”
6
McNeil Consumer Healthcare, maker of Tylenol. Insiders call it
The Fort. (J. Kyle Keener for ProPublica)
Tylenol was born in 1955, when the family-owned
McNeil Laboratories introduced a liquid for children
called Tylenol Elixir.
The drug’s key ingredient, acetaminophen, was
developed in the late 1800s in Germany’s coal tar
industry.
McNeil seized on the drug’s potential after American
research suggested that the medication does not cause
stomach bleeding, as aspirin can. McNeil named the product based on letters in the chemical term for
acetaminophen, N-acetyl-p-aminophenol.
Johnson & Johnson acquired McNeil in 1959, the same year that Tylenol was approved for over-thecounter sales. Soon thereafter, the first adult version of Tylenol rolled off the company’s production
line in Fort Washington, Pa., the site of McNeil’s current headquarters.
Unlike companies that develop prescription drugs, McNeil has no patent on acetaminophen, and so
no right to sell it exclusively. Virtually every drug store stocks generic acetaminophen, usually on the
same shelf as Tylenol. To sell Tylenol at a premium, the company had to persuade customers they
were getting extra value.
Tylenol has had “generic competition for 40 years,” said Ashley McEvoy, then the president of McNeil,
in a webcast interview posted in 2008. “If I look back at what’s garnered success for McNeil, it’s the
enduring value of brands.”
The company aimed its early sales pitches at doctors, according to a company history, working to
persuade them to recommend Tylenol as a safer alternative to aspirin. To this day, the company’s
formula for success hinges on positioning Tylenol as
safer than other painkillers and more trustworthy than
“
generics.
“If I look back at what’s garnered
success
for McNeil, it’s the enduring
Perhaps the most famous chapter in McNeil’s
value of brands.”
corporate history is its response when several people
Ashley McEvoy, former president of
in the Chicago area died in 1982 after taking Tylenol
McNeil, the Johnson & Johnson unit
laced with cyanide.
that makes Tylenol
The mysterious deaths terrorized the country — and
raised questions about the safety of the company’s
products. But in what later became a business school case study, McNeil removed Tylenol from the
market, offered refunds and eventually developed tamper-resistant pills. By the end, it had
transformed a disaster into a public relations coup.
McNeil’s marketing campaigns for its master brand were also skillful, burnishing Tylenol’s image while
usually avoiding claims of absolute safety or zero side effects. One slogan: “The brand of pain
reliever that doctors recommend more than any other.” Another: “Trust TYLENOL. Hospitals do.”
“We never use the word ‘safe’ in our advertising,” said Anthony Temple, McNeil’s longtime medical
director, in a legal case in 1993. “We will say ‘a superior safety profile’ or some language to suggest
its relative safety to other” over-the-counter pain relievers.
7
A History of Advertising
http://www.youtube.com/watch?
v=eDXtq7TL5Vo&feature=player_embedded#t=8
8
Marketing prowess helped turn Tylenol into one of America’s most popular pain relievers. Over the
past decade, McNeil Consumer Healthcare, the unit of Johnson & Johnson that makes Tylenol, has
often spent more than $100 million per year on advertising the drug, according to advertising trade
publications. See ads and commercials from some of the company’s campaigns.
McNeil’s advertising budget for Tylenol has frequently
exceeded $100 million per year: $115 million in 2003,
according to Brandweek; $138 million in 2005,
according to Advertising Age; and $162 million in 2008,
according to Adweek. In 2004, marketing was the
largest department in the company, employing about
150 professionals, McEvoy said in a court deposition.
McNeil’s recent chief executives have often come from
marketing backgrounds. Johnson & Johnson, a
conglomerate of more than 250 companies, does not
even place McNeil into its pharmaceutical division,
which is responsible for prescription drug products.
Instead, the company is part of the consumer division,
along with shampoo, mouthwash and skin care
products.
Johnson & Johnson does not release sales figures for
individual products, but Tylenol is the dominant
acetaminophen brand in the U.S. Although the drug is
available in cheaper generic forms, McNeil accounted
for nearly half of all over-the-counter sales of
acetaminophen, according to a 2010 McNeil
presentation.
Sales of acetaminophen by all companies have also
grown. It became the nation’s most-used drug in the
mid-2000s, according to surveys. In 2009, more than 27
billion doses of acetaminophen were sold in the U.S.,
most over the counter.
One way McNeil has reached ever-more households is
through a marketing strategy known as line extension: targeting market niches by adding products, all
under the halo of the Tylenol brand.
Between 1988 and 2002, the company notified the FDA of plans to introduce 54 different kinds of
packages, ranging from chewable tablets to coated pills, packed into bottles, pouches, cartons and
blister packs.
In the webcast interview, McEvoy, a marketing expert who rose into Johnson & Johnson’s corporate
ranks, called Tylenol “a billion-dollar brand.”
Internally, company officials refer to it simply as “the Brand.”
The liver uses multiple enzyme systems, known as pathways, to process acetaminophen and remove
potentially toxic byproducts produced during metabolism.
In the case of an overdose, these pathways become overwhelmed, allowing the byproducts to build
up to toxic levels, resulting in damage to the liver.
9
The first reports of deaths from acetaminophen emerged in the late 1960s.
How the Liver Processes Acetaminophen
Researchers subsequently learned that when the drug
is broken down in the liver, it produces a potentially
toxic byproduct. In an overdose, the liver can no longer
safely dispose of the byproduct and can fail in a matter
of days, shriveling like a deflated balloon.
The concerns with acetaminophen emerged at a time
when the American system for drug oversight was
undergoing a sea change. Congress had passed a law
in 1962 requiring the FDA to institute more rigorous
testing for new drugs and to review the safety and
efficacy of those already on the market.
In 1972, as part of the review of existing drugs, the
FDA assembled a group of doctors and scientists to
assess painkillers, including acetaminophen. Over five
years, the panel held 50 meetings, heard from scores of
witnesses, and scoured thousands of pages of
research – much of it submitted by drug makers
themselves.
As the panel’s work was going on, one of the world’s
most prestigious medical journals weighed in on
acetaminophen. The London-based Lancet declared in
a 1975 editorial that if the drug “were discovered today
it would not be approved” by British regulators. “It would
certainly never be freely available without prescription.”
The journal’s editorial board called the drug’s apparent safety “deceptive.” They pointed out that “not
much more than the recommended maximum daily dosage” could cause liver damage and that
acetaminophen poisoning was already “one of the commonest causes” of liver failure in Britain.
Relatively few cases of acetaminophen poisoning had been documented in the United States. But an
American study published in 1975 identified four acetaminophen-related deaths in one year in one
city, Denver. The article suggested a reason why so few cases had previously been found: “If you do
not look for something you will not diagnose it.”
McNeil dispatched a top official to meet with one of the study’s authors. The company then gave him
funding to help develop the acetaminophen antidote.
Two years later, in 1977, the FDA’s expert panel delivered its 1,200-page report on pain relievers.
While the committee found that acetaminophen was generally safe when used as directed, it warned
that “some advertising for acetaminophen gives the impression that it is much safer than aspirin.” So
the panelists urged the FDA to add a clear, specific warning to the acetaminophen label.
The language the panel suggested: “Do not exceed recommended dosage because severe liver
damage may occur.” The panel had only advisory power, but it felt so strongly that it told the FDA the
warning was “obligatory.”
10
Committee members wanted to drive home the potentially devastating
consequences of taking too much acetaminophen, said Ninfa Redmond, a
toxicologist who served on the panel.
“We felt very strongly the evidence was conclusive,” Redmond said.
For McNeil, the proposed liver warning put a lot at stake. Just the year
before, Tylenol had become the No. 1 brand in the over-the-counter pain
medication market, according to a company history.
As McNeil prepared its response to the advisory panel’s recommendation,
new reports of harm from the drug emerged.
In September 1977, the Annals of Internal Medicine published articles about patients who suffered
liver damage after taking acetaminophen for an extended period of time at or slightly above
therapeutic doses, underscoring what the Lancet had said about the drug’s narrow margin for error.
That December, McNeil filed a voluminous response to the FDA opposing the recommendation for a
liver warning. It’s not known if the individuals who drafted the company’s filing were aware of the
journal articles, but the company asserted that people who overdosed were “almost invariably” trying
to kill themselves. Indeed, McNeil maintained it had never seen a “documented case” of a person
harmed while taking the drug for medical reasons.
A liver warning “is unnecessary and serves only to confuse and frighten the vast majority of
consumers who use acetaminophen in a rational and appropriate fashion,” the company concluded. It
also wouldn’t help consumers, the company said, because signs of liver damage often don’t emerge
until it’s too late to get help.
McNeil raised another objection: The warning would put it at a competitive disadvantage.
Bayer, one of the world’s largest aspirin makers, had started running advertisements citing
acetaminophen’s potential to harm the liver, based on the advisory panel’s recommendation. “Losses
are already in the millions of dollars,” McNeil stated in its submission to the FDA.
Almost a decade would pass without the FDA coming to any decision. While the label advised
consumers to seek medical assistance if they overdosed, McNeil was able to sell its drug without
warning that it could harm the liver. The agency’s decision was delayed, at least in part, because
regulators extended deadlines to review new research.
Redmond called such additional review unnecessary because the basic facts about the drug were
well-established. She said she was mystified by regulators’ failure to act on the panel’s
11
recommendation. “It’s very surprising, and it’s sad,” she said. “How many people might have died
because of that?”
Finally, in 1988, the FDA announced a “tentative” ruling. The agency agreed a warning was
necessary but said there was no need to specify that the drug could injure the liver.
The agency explained that it didn’t want people who were considering suicide to know what an
overdose could do. And, it said, liver damage didn’t produce telltale symptoms for several days, when
it was often too late for doctors to intervene.
So it mandated a catchall warning: In case of overdose, consumers should seek prompt medical
attention “even if you do not notice any signs or symptoms.”
McNeil had won a reprieve from having to put a phrase on its bottles that company officials believed
scared off buyers: “severe liver damage.” And the FDA would not return to the issue until many, many
years later.
How Much Acetaminophen Are You Taking?
Use this tool to find out which of the drugs in your medicine cabinet contains acetaminophen -- and
how much. Note: A single dose may be more than the amount shown. For example, one pill might
contain 325 mg but the recommended dose might be two pills, or 650 mg. Source: National Library of
Medicine
12
As the FDA’s deliberations over the label crawled on, research began to emerge about the risks of
drinking alcohol and taking acetaminophen — and McNeil took steps to counter the research.
As early as the 1970s, an FDA panel had examined whether to put an alcohol warning on the
acetaminophen label. In 1978, according to an internal McNeil memo, the company had been
13
“successful in convincing” FDA officials “that such a warning was not indicated.” But the issue had not
gone away.
14
According to a corporate memo from February 1986, McNeil had test-marketed
how consumers would interpret different versions of an alcohol warning. No
matter how the warning was phrased, consumers reacted negatively: Most
respondents concluded that drinkers should reduce or discontinue using Tylenol,
even at recommended levels.
The following month, the Annals of Internal Medicine published a study describing
alcoholics who developed liver damage after taking “apparently moderate”
amounts of acetaminophen.
Two weeks after the article’s publication, a McNeil official issued a memo to
Tylenol’s sales force warning representatives to “not initiate discussions with your
physicians” about the danger of mixing alcohol and acetaminophen. A senior
McNeil official would later testify in a deposition that the issue was controversial
and complex. Sales reps, he said, were “not equipped” to discuss it.
Then, in August 1987, a relatively obscure Swedish journal published a study on the dangers of
drinking and taking acetaminophen.
Thomas Gates, then McNeil’s medical director, shot off a memo to the chief executive of Johnson &
Johnson, the president of McNeil and other top officials, laying out a detailed “plan of action” for
“diffusing media interest” in the research and “limiting the extent and duration of the coverage.”
Gates envisioned two possibilities: “Low Level of Publicity (most probable scenario)” and “High Level
of Publicity (worst case scenario).” For the latter, Gates suggested a series of responses: a letterwriting campaign to medical societies, doctors, pharmacists and academics; a coordinated public
relations response with the FDA; even placing on retainer scientists whose research the company
favored.
“If there is another wave of publicity,” Gates warned, “the FDA might be compelled to reconsider the
matter and require a specific warning regarding a possible risk of toxicity in chronic alcohol abusers.”
Gates, long retired from McNeil, was too ill to respond to questions, his wife said.
Ultimately, the Swedish study received little attention.
Gates’ memo summarized cases in the scientific literature over the previous decade that documented
acetaminophen’s risk for drinkers. He wrote that 38 “chronic alcoholics” had reportedly suffered liver
and/or kidney damage while taking acetaminophen. In just over half the cases, users substantially
exceeded dosing limits.
However, there were 18 instances in which they took less than 6 grams a day, not much more than
the 4 grams considered safe, Gates noted.
He stressed that “the amount of acetaminophen ingested is open to question since alcoholics are
notoriously unreliable informants.”
But “if accurate,” he wrote, the amount of acetaminophen that harmed those 18 patients “bring us
uncomfortably close” to the maximum recommended daily dose.
Although McNeil had been preparing for the possibility that the FDA would require an alcohol
warning, it took years before the agency publicly grappled with the issue.
15
In 1993, the FDA convened an advisory panel to look at the risk of mixing alcohol and
acetaminophen. Such panels are made up of outside experts. While the FDA does not have to follow
their recommendations, it usually does.
McNeil argued against the warning, saying the scientific evidence did not justify it and that it would
frighten customers into taking other pain relievers that the company claimed were riskier.
But the panel found that an alcohol warning was warranted. The chairman called the science behind
it “unusually strong and well-supported.”
At the same time, McNeil was seeking FDA approval for a new product, extended release Tylenol.
Because it was a post-1962 drug, the agency could push for a warning with less red tape. It moved to
do so on the new product, raising the possibility that regular Tylenol would have no alcohol warning
but that the time-release product would have one.
After the FDA approved extended release Tylenol with an alcohol alert in 1994, McNeil voluntarily
added the warning to all Tylenol products.
“After careful deliberation and discussion with the FDA, McNeil has made several label changes to
Tylenol over the years — all for the purpose of eliminating potential confusion by consumers and
protecting consumer safety,” the company wrote in response to questions. “A label change does not
mean that a prior label was inadequate, and in fact label changes are an indication that our medical
understanding is evolving.”
Four years after McNeil acted, the FDA required all acetaminophen manufacturers to add an alcohol
alert to their products. People who drank three or more alcoholic drinks every day were advised to
consult their doctors and were warned that liver damage could occur.
“When a company omits a known danger to them that could hurt people, they’re lying to us. I think
that is outrageous.”
The warning label came too late for Antonio Benedi.
Benedi, who worked as a special assistant to President George H.W.
Bush, often drank two or three glasses of wine with dinner. On a Friday in
February 1993, just weeks after Bush left office, Benedi came down with
the flu. Over the next several days, he said, he took Tylenol, never
exceeding the maximum dose.
Benedi said he was careful to read labels. At the time, nothing on his box
of Extra Strength Tylenol warned about the risk of drinking or liver
damage.
Several nights later, he woke up, confused and incoherent. His wife
called an ambulance to rush him to a hospital near their home in the
Virginia suburbs of Washington, D.C.
By the time he arrived, Benedi had slipped into a coma. Tests showed his liver enzyme levels were
high, a sign of organ damage. He had brain swelling, so doctors drilled a hole in his skull to relieve
the pressure.
16
Antonio Benedi was forced to undergo an emergency liver transplant after just a few
days of taking Tylenol. He won an $8.5 million verdict against McNeil, the Johnson &
Johnson division that makes the drug. (Torsten Kjellstrand for ProPublica)
After his third day in a coma, Benedi got a second chance at life.
Doctors declared a young man taken to Benedi’s hospital after a
motorcycle accident to be brain dead, and Benedi received the man’s
liver.
Benedi spent two months in the hospital, more than 200 surgical staples holding his abdomen
together in a raw wound that looked like the Mercedes-Benz symbol.
Almost two decades later, he still suffers from those few days of taking Tylenol. To keep his body from
rejecting his transplanted liver, he had to take powerful medications that eventually destroyed his
kidneys, requiring a kidney transplant.
He sued McNeil. In court, the company argued that a virus had destroyed
his liver and that the warnings on Tylenol’s label were adequate. The jury
found for Benedi, awarding him an $8.5 million judgment in 1994. To this
day, he will have nothing to do with Tylenol — he always tells doctors and
nurses not to give him any.
“I have nothing against corporations. They do a lot of good, employ a lot
of people,” said Benedi. But “when a company omits a known danger to
them that could hurt people, they’re lying to us. I think that is outrageous.”
As Benedi’s case unfolded, McNeil was pressing ahead with a program
dubbed Project Protect to create a safer version of acetaminophen.
But the company kept the program, which has never been reported,
confidential. Even when the government specifically asked for scientific information on developing a
safer acetaminophen, the company didn’t mention its own research.
The concept of such a drug was not new. The 1975 Lancet editorial had called for the development of
a version of acetaminophen that wouldn’t harm the liver. In the United Kingdom, companies had
developed drugs combining acetaminophen with one of its antidotes. But sales never took off — the
drugs were too expensive, the pills were too large, and there were questions about the drugs’ safety.
In the early 1990s, McNeil embarked on a series of experiments to combine acetaminophen with
various protective agents. The effort involved almost 20 different lab and animal studies lasting
several years, according to internal company documents and court records.
As the experiments progressed, however, one official worried that the research could be a doubleedged sword.
A Johnson & Johnson manager based in Europe wrote to Ralph Levi, the head of Project Protect for
McNeil, according to court documents. In his June 1994 note, the manager cautioned that a new,
improved product touched on “a sensitive point,” because the company would be acknowledging that
its existing product “isn’t so safe as we’ve always said before.” Levi has since died, and the court
documents identified the manager only by his first name, Geert.
To help keep Project Protect hidden, the company signed a confidentiality agreement with Rutgers
University, where some of the research was conducted. A key clause: The publicly funded university
17
agreed not to publicize “the identity or interest of McNeil in this area of
technology.” Rutgers said such agreements were standard when researchers
worked with companies.
At least one line of research showed early promise, according to Rutgers
documents, but there’s no public evidence that it or any Project Protect
compound made it beyond laboratory or animal studies.
McNeil’s work remained confidential even after the FDA became interested in
that field of research. In 2006, as part of a larger review of acetaminophen,
the agency solicited information about combining the drug with antidotes.
In response, McNeil submitted a lengthy report citing 51 studies to document the drawbacks of such
combinations. But the company did not mention that it had extensively researched the topic.
FDA officials said McNeil wasn’t required to disclose its research in that response. Asked if the
company had ever told the agency of its project, the FDA did not answer. “Those are the kind of
things that we are always interested in knowing about,” said Kweder, the FDA’s acetaminophen
expert. She added that even “if they didn’t show anything, it’d be useful to us to know if didn’t work
scientifically.”
In response to questions about Project Protect, McNeil acknowledged "research into acetaminophen
overdose antidotes" but did not provide details. The company noted that confidentiality clauses are
standard industry practice. It also said that the firm had complied fully with FDA reporting
requirements.
The company said it halted the research after discovering that the most promising agent “posed a
cardiovascular risk for individuals with a particular genetic defect.” The company did not disclose the
name of the agent.
“Had the research yielded a viable discovery, our intention was to launch a product,” the company
statement said. It continued: “Despite the outcome, we consider this type of research a responsible
action on our part, and are proud of the many scientists who worked on it.”
As McNeil quietly pursued a safer acetaminophen, a bespectacled, bowtied Dallas doctor named Will Lee was pursuing research that would
change the debate about the drug.
In 1997, Lee published a groundbreaking paper in the New England
Journal of Medicine showing that acetaminophen was the leading cause
of acute liver failure at Parkland Memorial hospital in Dallas, despite the
drug’s “apparent overall safety.”
Not to be confused with chronic liver failure, such as that caused by
alcoholism, acute liver failure is a sudden, often fatal condition that affects
about 2,000 Americans each year.
Among 21 patients who had overdosed on acetaminophen accidentally, Lee found, three reported
that they had not exceeded the maximum recommended dose of 4 grams per day. Only seven said
they had taken more than 10 grams.
Following the article, the National Institutes of Health funded a larger study involving many of the
country’s busiest liver transplant centers. Over the next 15 years, Lee, who is currently a professor of
internal medicine at the University of Texas Southwestern Medical Center, confirmed that what he
18
had documented in Dallas was true nationwide: Acetaminophen was the
No. 1 cause of acute liver failure.
Over the years, almost half of the people in the study had overdosed by
accident, Lee found, not by trying to kill themselves. Many of those
patients had other risk factors; about one-fifth drank alcohol frequently.
One finding was downright counterintuitive: People trying to kill themselves
with massive, one-time overdoses were more likely to survive than those
who accidentally took too much.
The reason? The chemical antidote to acetaminophen poisoning that
McNeil helped to develop has a high success rate if administered within
eight hours of an overdose. Those who attempted suicide and later
regretted their action often made it to a hospital in time.
Those who overdosed by accident were often unaware they had been
poisoned. Their symptoms took several days to develop and resembled
those of the flu, for which many of them had taken the drug in the first
place. They were more likely to miss the window for the antidote.
Acetaminophen has “not been recognized as a poison — that’s been part
of the challenge,” Lee said. “It’s just like candy. If four is good, eight must
be better.”
McNeil disputed Lee’s findings, saying they had “serious methodological
weaknesses,” such as relying upon patients to recall the amount of
acetaminophen consumed.
But other researchers came to similar findings. At the Hospital of the
University of Pennsylvania, Dr. Sarah Erush and a colleague found that
half of 46 patients treated for acetaminophen-related liver damage over
four years had overdosed accidentally, not intentionally.
The amount of acetaminophen these patients had ingested was close to
the recommended daily dose of 4 grams.
The median was 6 grams per day — a surprise, because the toxic dose
was thought to be between 10 and 15 grams, Erush said. She also found
that most of these patients had other risk factors, such as chronic alcohol
use.
Although she didn’t publish her research in a peer-reviewed journal, she
presented it to the FDA.
“For almost every patient with accidental exposure, we said, ‘Why did you
take more than the recommended dose?’” Erush said in an interview.
“They said two things: One, the label wasn’t clear, and, two, they always
thought it was a perfectly safe drug.”
McNeil said that it had asked Lee and Erush for patient information in order
to examine their conclusions. Both researchers said they had not provided
McNeil such records, citing patient privacy issues.
19
Lee’s research spurred the FDA to re-examine if the label on over-the-counter acetaminophen should
explicitly warn about the risk of liver damage.
The agency invited a grieving mother to tell her story at a public hearing.
Kate Trunk’s 23-year-old son Marcus had hurt his wrist in 1995 while working on a construction job in
Pennsylvania. Over the next two weeks, he took Tylenol with Codeine and Extra Strength Tylenol. He
started to feel sick and started on Theraflu — apparently not realizing that it, too, contained
acetaminophen.
Soon, Marcus felt bad enough to check himself into a hospital, where he lapsed into a coma. Eight
days after Marcus entered the hospital, Kate and her husband decided to end life support.
“We stayed with him and held him and talked to him and kissed him and petted him,” Trunk said. “He
finally just went. It was total shock, walking around in a daze, not knowing, angry at God, angry at
everything.”
The mystified family did not find out the cause of Marcus’ death until the autopsy came back: liver
failure caused by acetaminophen. The Trunks sued McNeil and settled for an undisclosed amount.
McNeil did not respond to questions about the case.
When the Trunks took their concerns to the FDA hearing, Kate was so
nervous that her husband kept checking her blood pressure. But she
delivered a call to action: She wanted acetaminophen clearly labeled to
warn that the drug could poison and even kill.
“If our son or my husband and I even had an inkling that acetaminophen
toxicity existed, I feel that the outcome of our story would be totally
different,” she said. She ended her testimony by saying that “death is
not an acceptable side effect.”
The committee recommended adding a warning aimed at all users, not
just drinkers, that overdosing can damage the liver.
This time, McNeil gave ground, agreeing with the need for a liver
warning. “We believe with you that the American consumer is smart,
responsible and can self-manage medications,” Dr. Debra Bowen,
McNeil’s vice president of research and development, told the panel.
By 2005, McNeil began placing labels on Tylenol warning that taking too
much could result in “liver damage” for anyone, not just people who
drank alcohol.
In 2009, the FDA imposed stronger language, requiring all over-the-counter acetaminophen products
to warn that overdosing may cause “severe liver damage.”
The FDA’s wording was nearly identical to what its expert panel had recommended 32 years earlier.
Asked about this time lag, the agency replied, “While we acknowledge that there has been some
delay between available scientific information and the translation to labeling instructions for
consumers, FDA has strengthened warnings on the acetaminophen label accordingly as science has
evolved.”
While McNeil agreed on the need to warn consumers of acetaminophen’s potential to harm the liver,
it vigorously objected to the FDA’s plans to raise public awareness of that very risk.
20
The FDA's 2004 public service announcement. (FDA)
In 2004, the agency launched a modest public service
advertisement initiative. The slogan: “Why is it important to know
that all these medicines contain acetaminophen? Because too
much can damage your liver.”
A key problem the campaign hoped to address: double dipping, or
overdosing by inadvertently taking more than one medication that
contains acetaminophen.
That risk had grown as McNeil and its competitors expanded the
number of acetaminophen products on drugstore shelves. The
drug was in medications targeted at consumers suffering all
manner of ills, from colds to arthritis aches to insomnia caused by
pain.
The FDA didn’t have a lot of money for the 2004 campaign, just
$20,000, according to an Associated Press story from the time.
During this period, McNeil was spending more than $100 million a year to advertise Tylenol, trade
publications reported.
Nevertheless, McNeil launched an intense and lengthy effort to overhaul the campaign.
The company sent a 79-page complaint demanding that, if left unchanged, the FDA’s educational
campaign would “negatively affect McNeil, the world’s largest marketer of OTC acetaminophen
products.”
Indeed, the complaint said, the FDA should speed up its review “in order to limit the damage that is
being done” by the nascent campaign.
McNeil wanted the FDA to include warnings about other over-the-counter pain relievers, arguing that
they posed risks at least as serious as acetaminophen. The FDA’s initiative, the company contended,
created the false impression that “acetaminophen products are less safe” than other over-the-counter
painkillers and could spur consumers to switch to other pain medicines, resulting in more injuries and
deaths – a frequent McNeil argument.
The FDA’s Steven Galson, then the acting director of the agency’s Center for Drug Evaluation and
Research, disagreed.
Doubling the maximum daily dose of over-the-counter pain killers such as aspirin or ibuprofen “may
slightly increase a person’s risk for bleeding,” in the stomach and gastrointestinal tract, he wrote, but
“it is not even close to the seriousness presented by doubling the dose of acetaminophen,” which can
lead to liver failure.
McNeil took its case all the way to the FDA commissioner, who turned down the company’s final
appeal, saying the agency had “refuted each example to respond to your allegation.”
McNeil did not respond directly to questions about its opposition to the campaign. But it stressed that
it had launched numerous acetaminophen safety education efforts, both on its own and with industry
and government partners. Altogether, McNeil said, these “acetaminophen awareness messages have
been seen over one billion times.”
21
Although the agency had prevailed, its safety initiative fizzled. Major media outlets were reluctant to
run the public health announcements. Magazine publishers told agency officials that they “did not
want to antagonize potential advertisers,” according to an FDA report.
The FDA concluded that its campaign “did not appear to have a significant impact on the problem.”
Indeed, a nationwide poll this year shows that many Americans don’t recognize the risk of double
dipping.
Thirty-five percent of respondents said it was safe to take the maximum recommended dose of Extra
Strength Tylenol with NyQuil, a cold remedy that also contains acetaminophen. The margin of error
was 3.5 percentage points.
Among parents, 35 percent thought it was safe to give a child the maximum dose of Children’s
Tylenol with Children’s Tylenol Plus Multi-Symptom Cold, both of which contain acetaminophen. The
margin of error for the parents’ subgroup was 6.7 percentage points.
In both these examples, mixing the two medicines would not be safe, according to the FDA.
(The survey of 1,003 respondents – conducted by Princeton Survey Research Associates
International and commissioned by ProPublica and This American Life – was completed in March.)
What’s in a Dose?
You may be familiar with
some of these over-thecounter and prescription
drugs, and may have even
taken more than one at the
same time.
Because so many drugs
contain acetaminophen,
people can inadvertently
take more than the
recommended daily limit –
or even hit a dangerous
dose.
Click on a drug to see the
maximum daily dose
recommended on the
label, and how quickly it
adds up in combination
with others (on the website
only).
Click on the drug again to
remove it from the acetaminophen tally. (on the website only).
Please note: This is not meant to be medical advice. Toxic levels vary by individual. Call your doctor if
you think you’ve overdosed, even if you don’t show medical symptoms. Source: National Library of
Medicine
22
With the public education campaign faltering, the FDA regrouped in 2006 and convened a team to
examine the agency’s handling of acetaminophen — including what a former top official described as
“the interactions between the FDA and McNeil over this 30-year history.”
Officials reviewed the science, the reports of deaths and side effects, and the long history of
regulatory delays. The 265-page report that emerged was both a blunt assessment of the drug’s
dangers and a plan for mitigating them.
Officials concluded that deaths from acetaminophen poisoning had risen dramatically over the
decade between 1995 and 2005. They zeroed in on how the drug differed from other over-thecounter pain relievers.
“The 4 gram per day recommended dose is also the maximum safe dose, one that must not be
exceeded, an unusual situation for any drug, particularly an OTC drug, one placing a large fraction of
users close to a toxic dose in the ordinary course of use,” the report said.
Officials proposed more than a dozen solutions, including several aimed at widening the drug’s safety
margin, such as lowering the maximum recommended daily dose and reducing the amount of the
drug in each pill. The report also suggested removing an entire class of pediatric products to reduce
the potential for dosing mix-ups.
Taken together, the proposals constituted a blueprint for sweeping safety reforms.
At the same time, the FDA officials who wrote the report gave a candid assessment of the fierce
resistance they expected from drug makers to certain proposals.
To the notion of lowering the recommended daily dose, the agency expected a “possible industry
challenge.”
To the proposal to decrease the amount of acetaminophen per pill, the report anticipated “possible
industry resistance to costs related to reformulation” and to “possible loss of revenue from elimination
of 500 mg products.”
In June 2009, the agency gathered nearly 40 experts in a Maryland Marriott to weigh in on its
recommendations. Everyone in the room, including executives from McNeil and other companies,
knew the stakes.
Guides to Safe Use
Here are some sites that offer information on how to
safely use acetaminophen. ProPublica does not endorse
any of these sites and is not offering medical advice. If
you have a medical issue, contact a doctor.
Edwin Kuffner, McNeil’s medical director, had
prepared for the meeting by attending some 100
practice sessions with a consulting company
that specialized in readying corporate clients to
speak before the FDA, according to a court
deposition.
Kuffner objected to dropping the daily
recommended dose below 4 grams. For
decades, the company’s labels had advised
users to take no more than 1 gram, or the
equivalent of two Extra Strength Tylenol pills, at
a time. He suggested directing consumers to
take one pill at a time until they felt pain relief,
gradually easing up to a maximum of 4 grams a
day only as necessary. Even though a company document calls this practice “good medicine,” McNeil
has not added this instruction to Tylenol labels.
National Institutes of Health
McNeil
Consumer Health Products Association and others
Mayo Clinic
Food and Drug Administration
23
When it came time to vote, Judith Kramer, a physician and professor of medicine at Duke University,
reminded her fellow panelists of the opportunity before them, noting that attempts to make
acetaminophen safer had foundered for decades.
“There is an elephant in the room that we really should talk about explicitly,” she said. “There are
tremendous cost and commercial implications to some of the recommended changes. These
conditions frequently can overshadow the public health considerations. And I think that we can't let
that happen.”
The panel handed McNeil a defeat, endorsing most of the FDA’s proposals.
But then, the agency’s momentum stalled.
Four years later, the agency has not enacted any of its own suggestions for over-the-counter
acetaminophen.
In fact, the FDA has still not completed the review of the drug that began back in the 1970s, as part of
the agency’s larger mandate to assess the safety and efficacy of older medicines.
In interviews, FDA officials acknowledged that it has taken longer than it should. They blamed a
combination of science and bureaucracy.
Despite 50 years of sales and more than 30,000 published papers, there remain unknowns about
acetaminophen. In a little-publicized 2011 announcement, the FDA acknowledged it was still unable
“to identify precise toxic thresholds and/or specific populations for whom currently recommended
dosages are not safe.”
A Canadian government study found six people had suffered serious liver damage after taking less
than the maximum recommended dose. By contrast, a case report described a man who survived
after ingesting as much as 60 grams all at once. In response to questions, McNeil first wrote in an
email that 8 grams, or double the maximum daily dose, over several days can damage the liver.
Later, when asked to confirm this figure, the company declined to do so. It pointed to data showing
that at least 10 grams a day for at least 2 to 3 days can threaten the liver.
Setting the right dose “has been one of the big challenges for us,” the FDA’s Kweder said. “There is
so much disagreement among experts who are well respected and can present data on where they’d
draw that line.”
Agency officials also said that McNeil has often resisted changes.
McNeil was “more aggressive than most,” a former top FDA official said. “It’s a company that feels
very strongly about the competitive nature of the marketplace.”
McNeil countered: “Our marketing practices are appropriate and align with the regulatory standards
for our industry.”
It also added that the company had a “deep respect for the Food and Drug Administration (FDA) and
its role in establishing and enforcing regulations” and noted that it has voluntarily implemented some
safety measures before the agency required it to do so.
The FDA delays are, at least in part, self-inflicted.
24
The agency said that the procedure it set back in the 1970s for revising rules for older drugs "was not
rapid, but there were many fewer steps to the process that today is long." Indeed, actions that were
supposed to take months have dragged on for years or even decades.
For prescription drugs, the FDA can act more swiftly, and it has limited the amount of acetaminophen
in such medicines.
In 2011, the FDA limited the amount of acetaminophen that can be put in prescription drugs to 325
milligrams per pill, and gave companies until January 2014 to implement the change.
Yet the agency continues to allow the sale of over-the-counter pills that contain up to 650 milligrams
of acetaminophen — twice as much.
Asked why it permits such potent pills to be sold directly to consumers, an FDA official said the
agency “believes there is a benefit to having acetaminophen available.”
In addition to lowering the dose per pill, the FDA slapped prescription acetaminophen with a so-called
black box warning, the agency’s most serious. It states that “acetaminophen has been associated
with cases of acute liver failure, at times resulting in liver transplant and death.”
The label for the over-the-counter version of the drug, taken by far more Americans, mentions neither
of those potential consequences.
The agency’s disparate actions on prescription and over-the-counter acetaminophen have given rise
to glaring inconsistencies.
Tylenol with Codeine No. 3, made by a Johnson & Johnson company, combines acetaminophen with
codeine, which can be bought only with a prescription. Tylenol 3, as it is commonly known, carries a
black box warning about acetaminophen, and each pill contains 300 milligrams, less than the new
limit of 325 milligrams.
By contrast, a single pill of Extra Strength Tylenol — sold at newsstands, gas stations and big-box
retailers across the land — delivers 500 milligrams of acetaminophen. The bottle carries no black box
warning.
Two pills, containing the same medication, made by the same corporation, carrying the same brand
name, regulated by the same agency – but subject to different standards.
While the FDA remains stuck on rules for over-the-counter acetaminophen, McNeil has reversed
course on one major proposal.
Just a month after adamantly opposing dosing reductions at the 2009 advisory committee meeting,
McNeil wrote top FDA officials, offering a plan that recognized the will of the advisory committee.
Although the company had insisted for half a century that 4 grams of medicine per day was the most
appropriate dose for pain relief, the company said it was ready to recommend taking no more than 3
grams a day (or six pills) of its flagship product, Extra Strength Tylenol. The company implemented
the change in 2011.
The move echoed other instances, such as the alcohol warning, in which the company opposed
safety proposals until the FDA signaled its intent. Then the company adopted measures voluntarily as
the agency plodded toward final rules.
“There are still many questions about this drug... It's still killing people.”
25
Kuffner, McNeil's vice president for medical affairs, said in an interview that
the company changed its dosing instructions “after hearing the
discussion” at the 2009 advisory committee. The lower dose is “intended
to increase the margin of safety,” he said.
McNeil hasn’t standardized the new daily dose across all its products,
however. For Tylenol Arthritis Pain, the company’s label puts the daily
limit at 3.9 grams. And the company didn’t change the dose for
customers worldwide. In Canada and other countries, the company still
instructs users of Extra Strength Tylenol that they can take up to 4 grams
a day — eight pills.
Kuffner said the “root causes” of acetaminophen overdose differ from
region to region.
“The safety of consumers in every region is important to us. When you really go back and look at root
causes, some of the root causes weren’t as prevalent as in other regions,” he said. “There are
differences in the prevalence of acetaminophen overdose and liver injury.”
“At the end of the day, when people take 4 grams or 3 grams, both of them are safe doses,” Kuffner
said.
The FDA had said it would issue proposed rules for over-the-counter acetaminophen by the end of
August. But the agency missed that deadline, pushing it back to December.
Dr. Thomas Garvey, a former FDA official and drug industry consultant who has testified against
McNeil in trials, called the amount of time the FDA had taken to reach a final ruling “remarkable and
unusual.”
“There are still many questions about this drug,” Garvey said. “It’s still killing people.”
Many countries restrict sales of acetaminophen, the active ingredient in Tylenol. Countries such as
South Korea, the United Kingdom and Germany limit the amount of pills that can be sold in a
package or where it can be sold. (Lars Klove for ProPublica)
In many other countries, authorities have taken a very different
approach to regulating acetaminophen.
At least 10 other industrialized countries — including Australia,
New Zealand, Germany, Finland, Denmark, Sweden and
Switzerland — have placed some kind of restrictions on the
drug, a 2008 FDA report said. Most limit how much can be sold
at one time or require pharmacies to be the only outlets that
carry it.
Some European countries with strict regulations have remarkably few deaths. Switzerland’s national
toxicology center reported only four deaths due to acetaminophen poisoning from 1998 through
2012. Even accounting for Switzerland’s much smaller population, that’s a fraction of the U.S. toll.
The German government reported four deaths from acetaminophen poisoning in 2010, the same
year the CDC put the American total at 321. The U.S. population is four times that of Germany.
Both Switzerland and Germany limit sales to pharmacies, which sell packages with a maximum of 10
grams, the equivalent of 20 Extra Strength Tylenol pills.
26
In many nations, authorities were focused more on reducing suicides than on preventing accidental
overdoses. In the U.K., for example, acetaminophen had become a common suicide method by the
1990s. The drug was easy to get: In drug stores, it could be purchased in unlimited quantities.
In 1998, the U.K. cracked down on several types of pain relievers, including acetaminophen. At
pharmacies, people could buy the equivalent of only 32 Extra Strength Tylenol pills. At other stores,
they were limited to half that.
Here was a real-world experiment of the effect of restricting acetaminophen. Early studies were
somewhat contradictory, but this year, a large study concluded that the number of deaths linked to
acetaminophen had plunged by 43 percent. In the 11 years since the restrictions took effect, the
researchers estimated, 765 fewer people had committed suicide using the drug.
While the new regulations may have saved lives, they hurt sales. The amount of acetaminophen sold
in the U.K. plunged by 60 percent from 1998 to 2000, according to a study by the FDA. The agency
noted that such restrictions would be more difficult to implement in the U.S. because it has a different
commercial, regulatory and medical culture than Britain and many European countries.
Indeed, here there has been only limited debate about restricting the amount of acetaminophen
consumers can buy.
A proposal to limit package sizes — how many pills could be put in a bottle, for example — was
considered by the advisory panel convened by the FDA in 2009. In a close vote, it failed. Some of the
experts worried that patients suffering from arthritis would be inconvenienced by having to make
repeated trips to buy the drug.
Several committee members said they had struggled with their vote.
27
“I hope the FDA doesn't consider this ‘no’ vote to mean that we support selling 1,000 acetaminophen
tablets in Costco,” said Kramer, the Duke University professor.
Over the past several years, McNeil and Tylenol have suffered a series of body blows related not to
acetaminophen’s risks but to the company’s ability to manufacture its drugs safely. The headlines
might have killed a lesser product, but have only underscored the extraordinary resiliency of the
Brand.
Between 2008 and 2010, federal regulators discovered an array of troubling manufacturing violations
at McNeil’s plants, triggering a series of recalls of Tylenol and other products such as the company’s
Motrin brand of ibuprofen.
For example, to make Tylenol syrup for infants and children, the company used an ingredient that
was possibly contaminated by dangerous bacteria. The company said “a thorough investigation”
showed the bacteria had not reached its medicine. However, the FDA found that McNeil’s tests —
skimming a teaspoon off the top of a container of liquid — were inadequate.
Later, agency investigators also discovered that Tylenol and other products had been contaminated
by tiny bits of cadmium, nickel, chromium, iron and other metals, most likely shavings that fell into the
medicine from machines on the production line.
Again, McNeil officials saw little cause for concern. “We are talking minute particles,” one McNeil
employee told FDA officials. “We are talking contaminants you don’t want to be there!” an inspector
replied, according to previously unreported notes taken by McNeil.
The company itself determined that it had manufactured batches of what the FDA called “super
potent” Infants’ Tylenol with up to 23 percent more acetaminophen than was supposed to be in it. It is
not known if any reached the market.
On April 30, 2010, the FDA issued a formal inspection report with a litany of deficiencies. The same
day, McNeil pulled 136 million bottles of pediatric Tylenol and other medicines off the market.
It was the largest recall in the history of pediatric medicine.
Subsequently, the Department of Justice launched a civil investigation that effectively gave the FDA
power to direct the cleanup of McNeil’s troubled plant in Fort Washington, Pa. The FDA has not tied
any recalled product to individual cases of harm.
Congress hauled in company executives for two public hearings. William C. Weldon, then chairman
and chief executive of Johnson & Johnson, told lawmakers the company had “let the public down” by
not maintaining high quality control standards.
“We are working hard to restore the public’s trust and confidence in Johnson & Johnson and to strive
to ensure that something like this never happens, ever again,” Weldon said.
By the end of 2010, the recalls had cost McNeil approximately $900 million in sales, it reported. Many
Tylenol products vanished from the shelves for months. The company recently acknowledged that it
faces federal investigations related to the recalls; it said it is cooperating with the probes. The
company’s Fort Washington plant remains closed.
Meanwhile, McNeil has faced new court challenges about the risks of its billion-dollar brand.
In the past few years, about 100 lawsuits have been filed, contending that McNeil has failed to
adequately warn the public about the true danger of Tylenol. Most of the lawsuits have been
28
consolidated before a federal judge in Philadelphia. McNeil is fighting the claims, saying its warnings
were adequate. Many of the cases allege that consumers suffered injury or death after taking Tylenol
at or near the maximum recommended daily dose.
After enduring all the negative headlines about its manufacturing plant, getting hit with scores of
lawsuits, and even being removed from some markets for months, Tylenol retains its power as a
brand — a testament to the decades of skillful marketing.
In Johnson & Johnson’s July earnings call, top officials said McNeil’s over-the-counter revenue had
surged by 26 percent. Children’s Tylenol was one of the top two brands in over-the-counter pediatric
pain relief.
And the company’s flagship product? Extra Strength Tylenol had doubled its market share in the first
half of 2013.
Once again, it was America’s No. 1 over-the-counter adult pain medicine.
Additional reporting by Jannis Brühl, Cora Currier, Liz Day, Sergio Hernandez, Olga Pierce, Hanna
Trudo
Related Story: Dose of Confusion
retour à l'index
September 20, 2013
By Marshall Allen and ProPublica
02. How Many Die from Medical
Mistakes in U.S. Hospitals?
An updated estimate says it could be at least 210,000 patients a
year, more than twice the number in a frequently quoted Institute of
Medicine report
ULTIMATE MALPRACTICE: An updated estimate says at least 210,000 patients die from
medical mistakes in U.S. hospitals a year. Image: Flickr/U.S. Naval Forces Central
Command/U.S. Fifth Fleet
It seems that every time researchers estimate how often a medical mistake
contributes to a hospital patient's death, the numbers come out worse.
In 1999, the Institute of Medicine published the famous "To Err Is Human"
report, which dropped a bombshell on the medical community by reporting
that up to 98,000 people a year die because of mistakes in hospitals. The
29
number was initially disputed, but is now widely accepted by doctors and hospital officials 2014 and
quoted ubiquitously in the media.
In 2010, the Office of Inspector General for Health and Human Services said that bad hospital care
contributed to the deaths of 180,000 patients in Medicare alone in a given year.
Now comes a study in the current issue of the Journal of Patient Safety that says the numbers may
be much higher 2014 between 210,000 and 440,000 patients each year who go to the hospital for
care suffer some type of preventable harm that contributes to their death, the study says.
That would make medical errors the third-leading cause of death in America, behind heart disease,
which is the first, and cancer, which is second.
The new estimates were developed by John T. James, a toxicologist at NASA's space center in
Houston who runs an advocacy organization called Patient Safety America. James has also written a
book about the death of his 19-year-old son after what James maintains was negligent hospital care.
Asked about the higher estimates, a spokesman for the American Hospital Association said the group
has more confidence in the IOM's estimate of 98,000 deaths. ProPublica asked three prominent
patient safety researchers to review James' study, however, and all said his methods and findings
were credible.
What's the right number? Nobody knows for sure. There's never been an actual count of how many
patients experience preventable harm. So we're left with approximations, which are imperfect in part
because of inaccuracies in medical records and the reluctance of some providers to report mistakes.
Patient safety experts say measuring the problem is nonetheless important because estimates bring
awareness and research dollars to a major public health problem that persists despite decades of
improvement efforts.
"We need to get a sense of the magnitude of this," James said in an interview.
James based his estimates on the findings of four recent studies that identified preventable harm
suffered by patients 2013 known as "adverse events" in the medical vernacular 2013 using use a
screening method called the Global Trigger Tool, which guides reviewers through medical records,
searching for signs of infection, injury or error. Medical records flagged during the initial screening are
reviewed by a doctor, who determines the extent of the harm.
In the four studies, which examined records of more than 4,200 patients hospitalized between 2002
and 2008, researchers found serious adverse events in as many as 21 percent of cases reviewed
and rates of lethal adverse events as high as 1.4 percent of cases.
By combining the findings and extrapolating across 34 million hospitalizations in 2007, James
concluded that preventable errors contribute to the deaths of 210,000 hospital patients annually.
That is the baseline. The actual number more than doubles, James reasoned, because the trigger
tool doesn't catch errors in which treatment should have been provided but wasn't, because it's
known that medical records are missing some evidence of harm, and because diagnostic errors
aren't captured.
An estimate of 440,000 deaths from care in hospitals "is roughly one-sixth of all deaths that occur in
the United States each year," James wrote in his study. He also cited other research that's shown
hospital reporting systems and peer-review capture only a fraction of patient harm or negligent care.
30
"Perhaps it is time for a national patient bill of rights for hospitalized patients," James wrote. "All
evidence points to the need for much more patient involvement in identifying harmful events and
participating in rigorous follow-up investigations to identify root causes."
Dr. Lucian Leape, a Harvard pediatrician who is referred to the "father of patient safety," was on the
committee that wrote the "To Err Is Human" report. He told ProPublica that he has confidence in the
four studies and the estimate by James.
Members of the Institute of Medicine committee knew at the time that their estimate of medical errors
was low, he said. "It was based on a rather crude method compared to what we do now," Leape said.
Plus, medicine has become much more complex in recent decades, which leads to more mistakes,
he said.
Dr. David Classen, one of the leading developers of the Global Trigger Tool, said the James study is
a sound use of the tool and a "great contribution." He said it's important to update the numbers from
the "To Err Is Human" report because in addition to the obvious suffering, preventable harm leads to
enormous financial costs.
Dr. Marty Makary, a surgeon at The Johns Hopkins Hospital whose book "Unaccountable" calls for
greater transparency in health care, said the James estimate shows that eliminating medical errors
must become a national priority. He said it's also important to increase the awareness of the potential
of unintended consequences when doctors perform procedure and tests. The risk of harm needs to
be factored into conversations with patients, he said.
Leape, Classen and Makary all said it's time to stop citing the 98,000 number.
Still, hospital association spokesman Akin Demehin said the group is sticking with the Institute of
Medicine's estimate. Demehin said the IOM figure is based on a larger sampling of medical charts
and that there's no consensus the Global Trigger Tool can be used to make a nationwide estimate.
He said the tool is better suited for use in individual hospitals.
The AHA is not attempting to come up with its own estimate, Demehin said.
Dr. David Mayer, the vice president of quality and safety at Maryland-based MedStar Health, said
people can make arguments about how many patient deaths are hastened by poor hospital care, but
that's not really the point. All the estimates, even on the low end, expose a crisis, he said.
"Way too many people are being harmed by unintentional medical error," Mayer said, "and it needs to
be corrected."
See how you can help ProPublica investigate patient safety and join our Facebook group on the
topic.
retour à l'index
31
AlterNet / By Tara Lohan
September 17, 2013
03. How Factory Farms May Be
Killing Us
A report from the CDC reveals the grave dangers of antibiotic
resistance and says factory-farmed animals are a big contributor.
Photo Credit: Michael Zysman
What would our healthcare system look like if we couldn’t
perform surgeries, administer chemotherapy, replace joints,
treat diabetes? It would be the end of modern medicine as we
know it. A new report from the Centers for Disease Control
warns we could be headed toward that very future.
Antibiotics revolutionized medicine in the 1940s, saving millions
of lives over the last 70 years. But during that time bacteria
have evolved to become resistant to certain antibiotics. The
more antibiotics we use, the quicker resistance builds up. This has deadly repercussions.
In the report, “ Antibiotic Resistance Threats in the United States, 2013,” the CDC estimates
(conservatively) that 2 million people in the U.S. get antibiotic-resistant infections, and 23,000 die
from them every year.
In addition to the loss of life, it’s also costly.
“In most cases, antibiotic-resistant infections require prolonged and/or costlier treatments, extend
hospital stays, necessitate additional doctor visits and healthcare use, and result in greater disability
and death compared with infections that are easily treatable with antibiotics,” the report states.
“Estimates vary but have ranged as high as $20 billion in excess direct healthcare costs, with
additional costs to society for lost productivity as high as $35 billion a year (2008 dollars).”
One of the biggest culprits is our overuse and misuse of antibiotics in medicine. “Research has
shown that as much as 50% of the time, antibiotics are prescribed when they are not needed or they
are misused (for example, a patient is given the wrong dose),” the report says. “This not only fails to
help patients; it might cause harm. This inappropriate use of antibiotics unnecessarily promotes
antibiotic resistance. Antibiotics are a limited resource. The more that antibiotics are used today, the
less likely they will still be effective in the future.”
But there’s another culprit—our feedlot system of raising animals for meat and dairy in "concentrated
animal feeding operations" (CAFOs).
32
“Antibiotics are also commonly used in food animals to prevent, control, and treat disease, and to
promote the growth of food-producing animals,” says the report.
The report states unequivocally: “The use of antibiotics for promoting growth is not necessary, and
the practice should be phased out.”
This should be a death blow to feedlot operations...if we’re smart. As the report explains: Antibiotics
are widely used in food-producing animals, and according to data published by FDA, there are more
kilograms of antibiotics sold in the United States for food-producing animals than for people. This use
contributes to the emergence of antibiotic-resistant bacteria in food-producing animals. Resistant
bacteria in food-producing animals are of particular concern because these animals serve as carriers.
Our industrial agriculture system produces a whole lot of corn, which we feed to cows and other
livestock, and which does not make for a healthy diet. Throw tens of thousands of those animals
together in a filthy environment of high-stress conditions, poor diet, and growth hormones, and you
have antibiotic use that has grown so much it’s now a threat to human health and modern medicine.
There's a lot at stake. As the report states: Many of the advances in medical treatment—joint
replacements, organ transplants, cancer therapy, and treatment of chronic diseases such as
diabetes, asthma, rheumatoid arthritis—are dependent on the ability to fight infections with
antibiotics. If that ability is lost, the ability to safely offer people many life-saving and life-improving
modern medical advantages will be lost with it.
So, what should we chose? More feedlot meat or more risks to public health and modern medicine?
Tara Lohan, a senior editor at AlterNet, has just launched the new project Hitting Home, chronicling
extreme energy extraction. She is the editor of two books on the global water crisis, including most
recently, Water Matters: Why We Need to Act Now to Save Our Most Critical Resource. Follow her on
Twitter @TaraLohan.
retour à l'index
33
Health Insurance
By Steven Brill
February 20, 2013
04. Bitter Pill: Why Medical Bills Are
Killing Us
Corrections Appended: February 26, 2013
1. Routine Care, Unforgettable Bills
When Sean Recchi, a 42-year-old from Lancaster, Ohio, was
told last March that he had non-Hodgkin’s lymphoma, his wife
Stephanie knew she had to get him to MD Anderson Cancer
Center in Houston. Stephanie’s father had been treated there
10 years earlier, and she and her family credited the doctors
and nurses at MD Anderson with extending his life by at least
eight years.
Because Stephanie and her husband had recently started
their own small technology business, they were unable to buy
comprehensive health insurance. For $469 a month, or about
20% of their income, they had been able to get only a policy
that covered just $2,000 per day of any hospital costs. “We
don’t take that kind of discount insurance,” said the woman at
MD Anderson when Stephanie called to make an
appointment for Sean.
Stephanie was then told by a billing clerk that the estimated cost of Sean’s visit — just to be
examined for six days so a treatment plan could be devised — would be $48,900, due in advance.
Stephanie got her mother to write her a check. “You do anything you can in a situation like that,” she
says. The Recchis flew to Houston, leaving Stephanie’s mother to care for their two teenage children.
About a week later, Stephanie had to ask her mother for $35,000 more so Sean could begin the
treatment the doctors had decided was urgent. His condition had worsened rapidly since he had
arrived in Houston. He was “sweating and shaking with chills and pains,” Stephanie recalls. “He had
a large mass in his chest that was … growing. He was panicked.”
Nonetheless, Sean was held for about 90 minutes in a reception area, she says, because the
hospital could not confirm that the check had cleared. Sean was allowed to see the doctor only after
he advanced MD Anderson $7,500 from his credit card. The hospital says there was nothing unusual
about how Sean was kept waiting. According to MD Anderson communications manager Julie Penne,
“Asking for advance payment for services is a common, if unfortunate, situation that confronts
hospitals all over the United States.”
Sean Recchi
Diagnosed with non-Hodgkin’s lymphoma at age 42. Total cost, in advance, for Sean’s treatment plan
and initial doses of chemotherapy: $83,900. Charges for blood and lab tests amounted to more than
$15,000; with Medicare, they would have cost a few hundred dollars. The total cost, in advance, for
Sean to get his treatment plan and initial doses of chemotherapy was $83,900.
34
CLAUDIA SUSANA FOR TIME
Why?
The first of the 344 lines printed out across eight pages of his hospital bill —
filled with indecipherable numerical codes and acronyms — seemed
innocuous. But it set the tone for all that followed. It read, “1 ACETAMINOPHE
TABS 325 MG.”
The charge was only $1.50, but it was for a generic version of a Tylenol pill.
You can buy 100 of them on Amazon for $1.49 even without a hospital’s
purchasing power.
(In-Depth Video: The Exorbitant Prices of Health Care)
Dozens of midpriced items were embedded with similarly aggressive markups, like $283.00 for a
“CHEST, PA AND LAT 71020.” That’s a simple chest X-ray, for which MD Anderson is routinely paid
$20.44 when it treats a patient on Medicare, the government health care program for the elderly.
Every time a nurse drew blood, a “ROUTINE VENIPUNCTURE” charge of $36.00 appeared,
accompanied by charges of $23 to $78 for each of a dozen or more lab analyses performed on the
blood sample. In all, the charges for blood and other lab tests done on Recchi amounted to more
than $15,000. Had Recchi been old enough for Medicare, MD Anderson would have been paid a few
hundred dollars for all those tests. By law, Medicare’s payments approximate a hospital’s cost of
providing a service, including overhead, equipment and salaries.
On the second page of the bill, the markups got bolder. Recchi was charged $13,702 for “1
RITUXIMAB INJ 660 MG.” That’s an injection of 660 mg of a cancer wonder drug called Rituxan. The
average price paid by all hospitals for this dose is about $4,000, but MD Anderson probably gets a
volume discount that would make its cost $3,000 to $3,500. That means the nonprofit cancer center’s
paid-in-advance markup on Recchi’s lifesaving shot would be about 400%.
When I asked MD Anderson to comment on the charges on Recchi’s bill, the cancer center released
a written statement that said in part, “The issues related to health care finance are complex for
patients, health care providers, payers and government entities alike … MD Anderson’s clinical billing
and collection practices are similar to those of other major hospitals and academic medical centers.”
The hospital’s hard-nosed approach pays off. Although it is officially a nonprofit unit of the University
of Texas, MD Anderson has revenue that exceeds the cost of the world-class care it provides by so
much that its operating profit for the fiscal year 2010, the most recent annual report it filed with the
U.S. Department of Health and Human Services, was $531 million. That’s a profit margin of 26% on
revenue of $2.05 billion, an astounding result for such a service-intensive enterprise.1
The president of MD Anderson is paid like someone running a prosperous business. Ronald
DePinho’s total compensation last year was $1,845,000. That does not count outside earnings
derived from a much publicized waiver he received from the university that, according to the Houston
Chronicle, allows him to maintain unspecified “financial ties with his three principal pharmaceutical
companies.”
(SHARE YOUR THOUGHTS: Are Medical Bills Too High? Tell Us Here)
DePinho’s salary is nearly two and a half times the $750,000 paid to Francisco Cigarroa, the
chancellor of entire University of Texas system, of which MD Anderson is a part. This pay structure is
emblematic of American medical economics and is reflected on campuses across the U.S., where the
president of a hospital or hospital system associated with a university — whether it’s Texas, Stanford,
Duke or Yale — is invariably paid much more than the person in charge of the university.
35
I got the idea for this article when I was visiting Rice University last year. As I was leaving the
campus, which is just outside the central business district of Houston, I noticed a group of glass
skyscrapers about a mile away lighting up the evening sky. The scene looked like Dubai. I was
looking at the Texas Medical Center, a nearly 1,300-acre, 280-building complex of hospitals and
related medical facilities, of which MD Anderson is the lead brand name. Medicine had obviously
become a huge business. In fact, of Houston’s top 10 employers, five are hospitals, including MD
Anderson with 19,000 employees; three, led by ExxonMobil with 14,000 employees, are energy
companies. How did that happen, I wondered. Where’s all that money coming from? And where is it
going? I have spent the past seven months trying to find out by analyzing a variety of bills from
hospitals like MD Anderson, doctors, drug companies and every other player in the American health
care ecosystem.
When you look behind the bills that Sean Recchi and other patients receive, you see nothing rational
— no rhyme or reason — about the costs they faced in a marketplace they enter through no choice of
their own. The only constant is the sticker shock for the patients who are asked to pay.
PHOTOGRAPH BY NICK VEASEY FOR TIME
Gauze Pads: $77
Charge for each of four boxes of sterile gauze pads, as itemized in a
$348,000 bill following a patient’s diagnosis of lung cancer
Yet those who work in the health care industry and those who argue
over health care policy seem inured to the shock. When we debate
health care policy, we seem to jump right to the issue of who should
pay the bills, blowing past what should be the first question: Why
exactly are the bills so high?
What are the reasons, good or bad, that cancer means a half-million- or million-dollar tab? Why
should a trip to the emergency room for chest pains that turn out to be indigestion bring a bill that can
exceed the cost of a semester of college? What makes a single dose of even the most wonderful
wonder drug cost thousands of dollars? Why does simple lab work done during a few days in a
hospital cost more than a car? And what is so different about the medical ecosystem that causes
technology advances to drive bills up instead of down?
(iReport: Tell Us Your Health Care Story)
Recchi’s bill and six others examined line by line for this article offer a closeup window into what
happens when powerless buyers — whether they are people like Recchi or big health-insurance
companies — meet sellers in what is the ultimate seller’s market.
The result is a uniquely American gold rush for those who provide everything from wonder drugs to
canes to high-tech implants to CT scans to hospital bill-coding and collection services. In hundreds of
small and midsize cities across the country — from Stamford, Conn., to Marlton, N.J., to Oklahoma
City — the American health care market has transformed tax-exempt “nonprofit” hospitals into the
towns’ most profitable businesses and largest employers, often presided over by the regions’ most
richly compensated executives. And in our largest cities, the system offers lavish paychecks even to
midlevel hospital managers, like the 14 administrators at New York City’s Memorial Sloan-Kettering
Cancer Center who are paid over $500,000 a year, including six who make over $1 million.
Taken as a whole, these powerful institutions and the bills they churn out dominate the nation’s
economy and put demands on taxpayers to a degree unequaled anywhere else on earth. In the U.S.,
people spend almost 20% of the gross domestic product on health care, compared with about half
36
that in most developed countries. Yet in every measurable way, the results our health care system
produces are no better and often worse than the outcomes in those countries.
According to one of a series of exhaustive studies done by the McKinsey & Co. consulting firm, we
spend more on health care than the next 10 biggest spenders combined: Japan, Germany, France,
China, the U.K., Italy, Canada, Brazil, Spain and Australia. We may be shocked at the $60 billion
price tag for cleaning up after Hurricane Sandy. We spent almost that much last week on health care.
We spend more every year on artificial knees and hips than what Hollywood collects at the box office.
We spend two or three times that much on durable medical devices like canes and wheelchairs, in
part because a heavily lobbied Congress forces Medicare to pay 25% to 75% more for this
equipment than it would cost at Walmart.
The Bureau of Labor Statistics projects that 10 of the 20 occupations that will grow the fastest in the
U.S. by 2020 are related to health care. America’s largest city may be commonly thought of as the
world’s financial-services capital, but of New York’s 18 largest private employers, eight are hospitals
and four are banks. Employing all those people in the cause of curing the sick is, of course, not
anything to be ashamed of. But the drag on our overall economy that comes with taxpayers,
employers and consumers spending so much more than is spent in any other country for the same
product is unsustainable. Health care is eating away at our economy and our treasury.
The health care industry seems to have the will and the means to keep it that way. According to the
Center for Responsive Politics, the pharmaceutical and health-care-product industries, combined with
organizations representing doctors, hospitals, nursing homes, health services and HMOs, have spent
$5.36 billion since 1998 on lobbying in Washington. That dwarfs the $1.53 billion spent by the
defense and aerospace industries and the $1.3 billion spent by oil and gas interests over the same
period. That’s right: the health-care-industrial complex spends more than three times what the
military-industrial complex spends in Washington.
When you crunch data compiled by McKinsey and other researchers, the big picture looks like this:
We’re likely to spend $2.8 trillion this year on health care. That $2.8 trillion is likely to be $750 billion,
or 27%, more than we would spend if we spent the same per capita as other developed countries,
even after adjusting for the relatively high per capita income in the U.S. vs. those other countries. Of
the total $2.8 trillion that will be spent on health care, about $800 billion will be paid by the federal
government through the Medicare insurance program for the disabled and those 65 and older and
the Medicaid program, which provides care for the poor. That $800 billion, which keeps rising far
faster than inflation and the gross domestic product, is what’s driving the federal deficit. The other
$2 trillion will be paid mostly by private health-insurance companies and individuals who have no
insurance or who will pay some portion of the bills covered by their insurance. This is what’s
increasingly burdening businesses that pay for their employees’ health insurance and forcing
individuals to pay so much in out-of-pocket expenses.
1. Here and elsewhere I define operating profit as the hospital’s excess of revenue over expenses,
plus the amount it lists on its tax return for depreciation of assets—because depreciation is an
accounting expense, not a cash expense. John Gunn, chief operating officer of Memorial SloanKettering Cancer Center, calls this the “fairest way” of judging a hospital’s financial performance
The original version of this article misidentified William Powers Jr., the president of the
University of Texas system, as the head of the entire system. That is in fact Francisco
Cigarroa, the chancellor of the University of Texas
Breaking these trillions down into real bills going to real patients cuts through the ideological debate
over health care policy. By dissecting the bills that people like Sean Recchi face, we can see exactly
how and why we are overspending, where the money is going and how to get it back. We just have to
follow the money.
37
The $21,000 Heartburn Bill
One night last summer at her home near Stamford, Conn., a 64-year-old former sales clerk whom I’ll
call Janice S. felt chest pains. She was taken four miles by ambulance to the emergency room at
Stamford Hospital, officially a nonprofit institution. After about three hours of tests and some brief
encounters with a doctor, she was told she had indigestion and sent home. That was the good news.
The bad news was the bill: $995 for the ambulance ride, $3,000 for the doctors and $17,000 for the
hospital — in sum, $21,000 for a false alarm.
Out of work for a year, Janice S. had no insurance. Among the hospital’s charges were three
“TROPONIN I” tests for $199.50 each. According to a National Institutes of Health website, a troponin
test “measures the levels of certain proteins in the blood” whose release from the heart is a strong
indicator of a heart attack. Some labs like to have the test done at intervals, so the fact that Janice S.
got three of them is not necessarily an issue. The price is the problem. Stamford Hospital spokesman
Scott Orstad told me that the $199.50 figure for the troponin test was taken from what he called the
hospital’s chargemaster. The chargemaster, I learned, is every hospital’s internal price list. Decades
ago it was a document the size of a phone book; now it’s a massive computer file, thousands of items
long, maintained by every hospital.
Stamford Hospital’s chargemaster assigns prices to everything, including Janice S.’s blood tests. It
would seem to be an important document. However, I quickly found that although every hospital has
a chargemaster, officials treat it as if it were an eccentric uncle living in the attic. Whenever I asked,
they deflected all conversation away from it. They even argued that it is irrelevant. I soon found that
they have good reason to hope that outsiders pay no attention to the chargemaster or the process
that produces it. For there seems to be no process, no rationale, behind the core document that is
the basis for hundreds of billions of dollars in health care bills.
(VIDEO: The Exorbitant Prices of Health Care)
Because she was 64, not 65, Janice S. was not on Medicare. But seeing what Medicare would have
paid Stamford Hospital for the troponin test if she had been a year older shines a bright light on the
role the chargemaster plays in our national medical crisis — and helps us understand the illegitimacy
of that $199.50 charge. That’s because Medicare collects troves of data on what every type of
treatment, test and other service costs hospitals to deliver. Medicare takes seriously the notion that
nonprofit hospitals should be paid for all their costs but actually be nonprofit after their calculation.
Thus, under the law, Medicare is supposed to reimburse hospitals for any given service, factoring in
not only direct costs but also allocated expenses such as overhead, capital expenses, executive
salaries, insurance, differences in regional costs of living and even the education of medical students.
It turns out that Medicare would have paid Stamford $13.94 for each troponin test rather than the
$199.50 Janice S. was charged.
Janice S. was also charged $157.61 for a CBC — the complete blood count that those of us who are
ER aficionados remember George Clooney ordering several times a night. Medicare pays $11.02 for
a CBC in Connecticut. Hospital finance people argue vehemently that Medicare doesn’t pay enough
and that they lose as much as 10% on an average Medicare patient. But even if the Medicare price
should be, say, 10% higher, it’s a long way from $11.02 plus 10% to $157.61. Yes, every hospital
administrator grouses about Medicare’s payment rates — rates that are supervised by a Congress
that is heavily lobbied by the American Hospital Association, which spent $1,859,041 on lobbyists in
2012. But an annual expense report that Stamford Hospital is required to file with the federal
Department of Health and Human Services offers evidence that Medicare’s rates for the services
Janice S. received are on the mark. According to the hospital’s latest filing (covering 2010), its total
expenses for laboratory work (like Janice S.’s blood tests) in the 12 months covered by the report
were $27.5 million. Its total charges were $293.2 million. That means it charged about 11 times its
costs. As we examine other bills, we’ll see that like Medicare patients, the large portion of hospital
patients who have private health insurance also get discounts off the listed chargemaster figures,
38
assuming the hospital and insurance company have negotiated to include the hospital in the insurer’s
network of providers that its customers can use. The insurance discounts are not nearly as steep as
the Medicare markdowns, which means that even the discounted insurance-company rates fuel
profits at these officially nonprofit hospitals. Those profits are further boosted by payments from the
tens of millions of patients who, like the unemployed Janice S., have no insurance or whose
insurance does not apply because the patient has exceeded the coverage limits. These patients are
asked to pay the chargemaster list prices.
If you are confused by the notion that those least able to pay are the ones singled out to pay the
highest rates, welcome to the American medical marketplace.
Test Strips
Patient was charged $18 each for Accu-chek diabetes test strips. Amazon sells boxes of 50 for about
$27, or 55¢ each
Pay No Attention To the Chargemaster
No hospital’s chargemaster prices are consistent with
those of any other hospital, nor do they seem to be
based on anything objective — like cost — that any
hospital executive I spoke with was able to explain.
“They were set in cement a long time ago and just
keep going up almost automatically,” says one hospital
chief financial officer with a shrug.
At Stamford Hospital I got the first of many brush-offs when I asked about the chargemaster rates on
Janice S.’s bill. “Those are not our real rates,” protested hospital spokesman Orstad when I asked
him to make hospital CEO Brian Grissler available to explain Janice S.’s bill, in particular the bloodtest charges. “It’s a list we use internally in certain cases, but most people never pay those prices. I
doubt that Brian [Grissler] has even seen the list in years. So I’m not sure why you care.”
(COMMENT NOW: Are Medical Bills Too High? Tell Us Why)
Orstad also refused to comment on any of the specifics in Janice S.’s bill, including the seemingly
inflated charges for all the lab work. “I’ve told you I don’t think a bill like this is relevant,” he explained.
“Very few people actually pay those rates.”
But Janice S. was asked to pay them. Moreover, the chargemaster rates are relevant, even for those
unlike her who have insurance. Insurers with the most leverage, because they have the most
customers to offer a hospital that needs patients, will try to negotiate prices 30% to 50% above the
Medicare rates rather than discounts off the sky-high chargemaster rates. But insurers are
increasingly losing leverage because hospitals are consolidating by buying doctors’ practices and
even rival hospitals. In that situation — in which the insurer needs the hospital more than the hospital
needs the insurer — the pricing negotiation will be over discounts that work down from the
chargemaster prices rather than up from what Medicare would pay. Getting a 50% or even 60%
discount off the chargemaster price of an item that costs $13 and lists for $199.50 is still no bargain.
“We hate to negotiate off of the chargemaster, but we have to do it a lot now,” says Edward Wardell, a
lawyer for the giant health-insurance provider Aetna Inc.
That so few consumers seem to be aware of the chargemaster demonstrates how well the health
care industry has steered the debate from why bills are so high to who should pay them.
The expensive technology deployed on Janice S. was a bigger factor in her bill than the lab tests. An
“NM MYO REST/SPEC EJCT MOT MUL” was billed at $7,997.54. That’s a stress test using a
39
radioactive dye that is tracked by an X-ray computed tomography, or CT, scan. Medicare would have
paid Stamford $554 for that test.
Janice S. was charged an additional $872.44 just for the dye used in the test. The regular stress test
patients are more familiar with, in which arteries are monitored electronically with an
electrocardiograph, would have cost far less — $1,200 even at the hospital’s chargemaster price.
(Medicare would have paid $96 for it.) And although many doctors view the version using the CT
scan as more thorough, others consider it unnecessary in most cases.
According to Jack Lewin, a cardiologist and former CEO of the American College of Cardiology, “It
depends on the patient, of course, but in most cases you would start with a standard stress test. We
are doing too many of these nuclear tests. It is not being used appropriately … Sometimes a
cardiogram is enough, and you don’t even need the simpler test. But it usually makes sense to give
the patient the simpler one first and then use nuclear for a closer look if there seem to be problems.”
We don’t know the particulars of Janice S.’s condition, so we cannot know why the doctors who
treated her ordered the more expensive test. But the incentives are clear. On the basis of market
prices, Stamford probably paid about $250,000 for the CT equipment in its operating room. It costs
little to operate, so the more it can be used and billed, the quicker the hospital recovers its costs and
begins profiting from its purchase. In addition, the cardiologist in the emergency room gave Janice S.
a separate bill for $600 to read the test results on top of the $342 he charged for examining her.
According to a McKinsey study of the medical marketplace, a typical piece of equipment will pay for
itself in one year if it carries out just 10 to 15 procedures a day. That’s a terrific return on capital
equipment that has an expected life span of seven to 10 years. And it means that after a year, every
scan ordered by a doctor in the Stamford Hospital emergency room would mean pure profit, less
maintenance costs, for the hospital. Plus an extra fee for the doctor.
Another McKinsey report found that health care providers in the U.S. conduct far more CT tests per
capita than those in any other country — 71% more than in Germany, for example, where the
government-run health care system offers none of those incentives for overtesting. We also pay a lot
more for each test, even when it’s Medicare doing the paying. Medicare reimburses hospitals and
clinics an average of four times as much as Germany does for CT scans, according to the data
gathered by McKinsey.
Medicare’s reimbursement formulas for these tests are regulated by Congress. So too are restrictions
on what Medicare can do to limit the use of CT and magnetic resonance imaging (MRI) scans when
they might not be medically necessary. Standing at the ready to make sure Congress keeps
Medicare at bay is, among other groups, the American College of Radiology, which on Nov. 14 ran a
full-page ad in the Capitol Hill–centric newspaper Politico urging Congress to pass the Diagnostic
Imaging Services Access Protection Act. It’s a bill that would block efforts by Medicare to discourage
doctors from ordering multiple CT scans on the same patient by paying them less per test to read
multiple tests of the same patient. (In fact, six of Politico’s 12 pages of ads that day were bought by
medical interests urging Congress to spend or not cut back on one of their products.)
The costs associated with high-tech tests are likely to accelerate. McKinsey found that the more CT
and MRI scanners are out there, the more doctors use them. In 1997 there were fewer than 3,000
machines available, and they completed an average of 3,800 scans per year. By 2006 there were
more than 10,000 in use, and they completed an average of 6,100 per year. According to a study in
the Annals of Emergency Medicine, the use of CT scans in America’s emergency rooms “has more
than quadrupled in recent decades.” As one former emergency-room doctor puts it, “Giving out CT
scans like candy in the ER is the equivalent of putting a 90-year-old grandmother through a pat-down
at the airport: Hey, you never know.”
40
Selling this equipment to hospitals — which has become a key profit center for industrial
conglomerates like General Electric and Siemens — is one of the U.S. economy’s bright spots. I
recently subscribed to an online headhunter’s listings for medical-equipment salesmen and quickly
found an opening in Connecticut that would pay a salary of $85,000 and sales commissions of up to
$95,000 more, plus a car allowance. The only requirement was that applicants have “at least one
year of experience selling some form of capital equipment.”
In all, on the day I signed up for that jobs website, it carried 186 listings for medical-equipment
salespeople just in Connecticut.
2. Medical Technology’s Perverse Economics
Unlike those of almost any other area we can think of, the dynamics of the medical marketplace
seem to be such that the advance of technology has made medical care more expensive, not less.
First, it appears to encourage more procedures and treatment by making them easier and more
convenient. (This is especially true for procedures like arthroscopic surgery.) Second, there is little
patient pushback against higher costs because it seems to (and often does) result in safer, better
care and because the customer getting the treatment is either not going to pay for it or not going to
know the price until after the fact.
Beyond the hospitals’ and doctors’ obvious economic incentives to use the equipment and the
manufacturers’ equally obvious incentives to sell it, there’s a legal incentive at work. Giving Janice S.
a nuclear-imaging test instead of the lower-tech, less expensive stress test was the safer thing to do
— a belt-and-suspenders approach that would let the hospital and doctor say they pulled out all the
stops in case Janice S. died of a heart attack after she was sent home.
“We use the CT scan because it’s a great defense,” says the CEO of another hospital not far from
Stamford. “For example, if anyone has fallen or done anything around their head — hell, if they even
say the word head — we do it to be safe. We can’t be sued for doing too much.”
His rationale speaks to the real cost issue associated with medical-malpractice litigation. It’s not as
much about the verdicts or settlements (or considerable malpractice-insurance premiums) that
hospitals and doctors pay as it is about what they do to avoid being sued. And some no doubt claim
they are ordering more tests to avoid being sued when it is actually an excuse for hiking profits. The
most practical malpractice-reform proposals would not limit awards for victims but would allow
doctors to use what’s called a safe-harbor defense. Under safe harbor, a defendant doctor or hospital
could argue that the care provided was within the bounds of what peers have established as
reasonable under the circumstances. The typical plaintiff argument that doing something more, like a
nuclear-imaging test, might have saved the patient would then be less likely to prevail.
When Obamacare was being debated, Republicans pushed this kind of commonsense malpracticetort reform. But the stranglehold that plaintiffs’ lawyers have traditionally had on Democrats prevailed,
and neither a safe-harbor provision nor any other malpractice reform was included.
(iReport: Tell Us Your Health Care Story)
Nonprofit Profitmakers
To the extent that they defend the chargemaster rates at all, the defense that hospital executives offer
has to do with charity. As John Gunn, chief operating officer of Sloan-Kettering, puts it, “We charge
those rates so that when we get paid by a [wealthy] uninsured person from overseas, it allows us to
serve the poor.”
A closer look at hospital finance suggests two holes in that argument. First, while Sloan-Kettering
does have an aggressive financial-assistance program (something Stamford Hospital lacks), at most
hospitals it’s not a Saudi sheik but the almost poor — those who don’t qualify for Medicaid and don’t
have insurance — who are most often asked to pay those exorbitant chargemaster prices. Second,
41
there is the jaw-dropping difference between those list prices and the hospitals’ costs, which enables
these ostensibly nonprofit institutions to produce high profits even after all the discounts. True, when
the discounts to Medicare and private insurers are applied, hospitals end up being paid a lot less
overall than what is itemized on the original bills. Stamford ends up receiving about 35% of what it
bills, which is the yield for most hospitals. (Sloan-Kettering and MD Anderson, whose great brand
names make them tough negotiators with insurance companies, get about 50%). However, no matter
how steep the discounts, the chargemaster prices are so high and so devoid of any calculation
related to cost that the result is uniquely American: thousands of nonprofit institutions have morphed
into high-profit, high-profile businesses that have the best of both worlds. They have become entities
akin to low-risk, must-have public utilities that nonetheless pay their operators as if they were highrisk entrepreneurs. As with the local electric company, customers must have the product and can’t go
elsewhere to buy it. They are steered to a hospital by their insurance companies or doctors (whose
practices may have a business alliance with the hospital or even be owned by it). Or they end up
there because there isn’t any local competition. But unlike with the electric company, no regulator
caps hospital profits.
Yet hospitals are also beloved local charities.
The result is that in small towns and cities across the country, the local nonprofit hospital may be the
community’s strongest business, typically making tens of millions of dollars a year and paying its
nondoctor administrators six or seven figures. As nonprofits, such hospitals solicit contributions, and
their annual charity dinner, a showcase for their good works, is typically a major civic event. But
charitable gifts are a minor part of their base; Stamford Hospital raised just over 1% of its revenue
from contributions last year. Even after discounts, those $199.50 blood tests and multithousand-dollar
CT scans are what really count.
Thus, according to the latest publicly available tax return it filed with the IRS, for the fiscal year
ending September 2011, Stamford Hospital — in a midsize city serving an unusually high 50% share
of highly discounted Medicare and Medicaid patients — managed an operating profit of $63 million
on revenue actually received (after all the discounts off the chargemaster) of $495 million. That’s a
12.7% operating profit margin, which would be the envy of shareholders of high-service businesses
across other sectors of the economy.
Its nearly half-billion dollars in revenue also makes Stamford Hospital by far the city’s largest
business serving only local residents. In fact, the hospital’s revenue exceeded all money paid to the
city of Stamford in taxes and fees. The hospital is a bigger business than its host city.
There is nothing special about the hospital’s fortunes. Its operating profit margin is about the same as
the average for all nonprofit hospitals, 11.7%, even when those that lose money are included. And
Stamford’s 12.7% was tallied after the hospital paid a slew of high salaries to its management,
including $744,000 to its chief financial officer and $1,860,000 to CEO Grissler.
In fact, when McKinsey, aided by a Bank of America survey, pulled together all hospital financial
reports, it found that the 2,900 nonprofit hospitals across the country, which are exempt from income
taxes, actually end up averaging higher operating profit margins than the 1,000 for-profit hospitals
after the for-profits’ income-tax obligations are deducted. In health care, being nonprofit produces
more profit.
Nonetheless, hospitals like Stamford are able to use their sympathetic nonprofit status to push their
interests. As the debate over deficit-cutting ideas related to health care has heated up, the American
Hospital Association has run daily ads on Mike Allen’s Playbook, a popular Washington tip sheet,
urging that Congress not be allowed to cut hospital payments because that would endanger the
“$39.3 billion” in uncompensated care for the poor that hospitals now provide either through charity
programs or because of patients failing to pay their debts. Based on the formula hospitals use to
42
calculate the cost of this charity care, that amounts to approximately 5% of their total revenue for
2010.
Under Internal Revenue Service rules, nonprofits are not prohibited from taking in more money than
they spend. They just can’t distribute the overage to shareholders — because they don’t have any
shareholders.
So, what do these wealthy nonprofits do with all the profit? In a trend similar to what we’ve seen in
nonprofit colleges and universities — where there has been an arms race of sorts to use rising tuition
to construct buildings and add courses of study — the hospitals improve and expand facilities
(despite the fact that the U.S. has more hospital beds than it can fill), buy more equipment, hire more
people, offer more services, buy rival hospitals and then raise executive salaries because their
operations have gotten so much larger. They keep the upward spiral going by marketing for more
patients, raising prices and pushing harder to collect bill payments. Only with health care, the upward
spiral is easier to sustain. Health care is seen as even more of a necessity than higher education.
And unlike in higher education, in health care there is little price transparency — and far less
competition in any given locale even if there were transparency. Besides, a hospital is typically one of
the community’s larger employers if not the largest, so there is unlikely to be much local complaining
about its burgeoning economic fortunes.
In December, when the New York Times ran a story about how a deficit deal might threaten hospital
payments, Steven Safyer, chief executive of Montefiore Medical Center, a large nonprofit hospital
system in the Bronx, complained, “There is no such thing as a cut to a provider that isn’t a cut to a
beneficiary … This is not crying wolf.”
Actually, Safyer seems to be crying wolf to the tune of about $196.8 million, according to the
hospital’s latest publicly available tax return. That was his hospital’s operating profit, according to its
2010 return. With $2.586 billion in revenue — of which 99.4% came from patient bills and 0.6% from
fundraising events and other charitable contributions — Safyer’s business is more than six times as
large as that of the Bronx’s most famous enterprise, the New York Yankees.
Surely, without cutting services to beneficiaries, Safyer could cut what have to be some of the Bronx’s
better non-Yankee salaries: his own, which was $4,065,000, or those of his chief financial officer
($3,243,000), his executive vice president ($2,220,000) or the head of his dental department
($1,798,000).
Shocked by her bill from Stamford hospital and unable to pay it, Janice S. found a local woman on
the Internet who is part of a growing cottage industry of people who call themselves medical-billing
advocates. They help people read and understand their bills and try to reduce them. “The hospitals
all know the bills are fiction, or at least only a place to start the discussion, so you bargain with them,”
says Katalin Goencz, a former appeals coordinator in a hospital billing department who negotiated
Janice S.’s bills from a home office in Stamford.
Goencz is part of a trade group called the Alliance of Claim Assistant Professionals, which has about
40 members across the country. Another group, Medical Billing Advocates of America, has about 50
members. Each advocate seems to handle 40 to 70 cases a year for the uninsured and those
disputing insurance claims. That would be about 5,000 patients a year out of what must be tens of
millions of Americans facing these issues — which may help explain why 60% of the personal
bankruptcy filings each year are related to medical bills.
“I can pretty much always get it down 30% to 50% simply by saying the patient is ready to pay but will
not pay $300 for a blood test or an X-ray,” says Goencz. “They hand out blood tests and X-rays in
hospitals like bottled water, and they know it.”
43
After weeks of back-and-forth phone calls, for which Goencz charged Janice S. $97 an hour,
Stamford Hospital cut its bill in half. Most of the doctors did about the same, reducing Janice S.’s
overall tab from $21,000 to about $11,000.
But the best the ambulance company would offer Goencz was to let Janice S. pay off its $995 ride in
$25-a-month installments. “The ambulances never negotiate the amount,” says Goencz.
A manager at Stamford Emergency Medical Services, which charged Janice S. $958 for the pickup
plus $9.38 per mile, says that “our rates are all set by the state on a regional basis” and that the
company is independently owned. That’s at odds with a trend toward consolidation that has seen
several private-equity firms making investments in what Wall Street analysts have identified as an
increasingly high-margin business. Overall, ambulance revenues were more than $12 billion last
year, or about 10% higher than Hollywood’s box-office take. It’s not a great deal to pay off $1,000 for
a four-mile ambulance ride on the layaway plan or receive a 50% discount on a $199.50 blood test
that should cost $15, nor is getting half off on a $7,997.54 stress test that was probably all profit and
may not have been necessary. But, says Goencz, “I don’t go over it line by line. I just go for a deal.
The patient usually is shocked by the bill, doesn’t understand any of the language and has bill
collectors all over her by the time they call me. So they’re grateful. Why give them heartache by
telling them they still paid too much for some test or pill?”
SOUND OFF: Are Medical Bills Too High? Tell Us Why
The original version of this article stated that the total annual amount of charity care provided by U.S.
hospitals cost them less than half of 1% of their annual revenue. In fact, the uncompensated care
hospitals provide, either through charity programs or because of patients failing to pay their debts,
amounts to approximately 5% of their total revenue for 2010.
A Slip, a Fall And a $9,400 Bill
The billing advocates aren’t always successful. just ask Emilia Gilbert, a school-bus driver who got
into a fight with a hospital associated with Connecticut’s most venerable nonprofit institution, which
racked up quick profits on multiple CT scans, then refused to compromise at all on its chargemaster
prices. Gilbert, now 66, is still making weekly payments on the bill she got in June 2008 after she
slipped and fell on her face one summer evening in the small yard behind her house in Fairfield,
Conn. Her nose bleeding heavily, she was taken to the emergency room at Bridgeport Hospital.
Along with Greenwich Hospital and the Hospital of St. Raphael in New Haven, Bridgeport Hospital is
now owned by the Yale New Haven Health System, which boasts a variety of gleaming new facilities.
Although Yale University and Yale New Haven are separate entities, Yale–New Haven Hospital is the
teaching hospital for the Yale Medical School, and university representatives, including Yale president
Richard Levin, sit on the Yale New Haven Health System board.
“I was there for maybe six hours, until midnight,” Gilbert recalls, “and most of it was spent waiting. I
saw the resident for maybe 15 minutes, but I got a lot of tests.”
In fact, Gilbert got three CT scans — of her head, her chest and her face. The last one showed a
hairline fracture of her nose. The CT bills alone were $6,538. (Medicare would have paid about $825
for all three.) A doctor charged $261 to read the scans.
Gilbert got the same troponin blood test that Janice S. got — the one Medicare pays $13.94 for and
for which Janice S. was billed $199.50 at Stamford. Gilbert got just one. Bridgeport Hospital charged
20% more than its downstate neighbor: $239.
Also on the bill were items that neither Medicare nor any insurance company would pay anything at
all for: basic instruments and bandages and even the tubing for an IV setup. Under Medicare
regulations and the terms of most insurance contracts, these are supposed to be part of the hospital’s
facility charge, which in this case was $908 for the emergency room.
44
JAVIER SIRVENT FOR TIME
Emilia Gilbert
Slipped and fell in June 2008 and was taken to the emergency room. She is
still paying off the $9,418 bill from that hospital visit in weekly installments.
Her three CT scans cost $6,538. Medicare would have paid about $825 for
all three
Gilbert’s total bill was $9,418.
“We think the chargemaster is totally fair,” says William Gedge, senior vice
president of payer relations at Yale New Haven Health System. “It’s fair
because everyone gets the same bill. Even Medicare gets exactly the same
charges that this patient got. Of course, we will have different arrangements for how Medicare or an
insurance company will not pay some of the charges or discount the charges, but everyone starts
from the same place.” Asked how the chargemaster charge for an item like the troponin test was
calculated, Gedge said he “didn’t know exactly” but would try to find out. He subsequently reported
back that “it’s an historical charge, which takes into account all of our costs for running the hospital.”
Bridgeport Hospital had $420 million in revenue and an operating profit of $52 million in 2010, the
most recent year covered by its federal financial reports. CEO Robert Trefry, who has since left his
post, was listed as having been paid $1.8 million. The CEO of the parent Yale New Haven Health
System, Marna Borgstrom, was paid $2.5 million, which is 58% more than the $1.6 million paid to
Levin, Yale University’s president.
“You really can’t compare the two jobs,” says Yale–New Haven Hospital senior vice president Vincent
Petrini. “Comparing hospitals to universities is like apples and oranges. Running a hospital
organization is much more complicated.” Actually, the four-hospital chain and the university have
about the same operating budget. And it would seem that Levin deals with what most would consider
complicated challenges in overseeing 3,900 faculty members, corralling (and complying with the
terms of) hundreds of millions of dollars in government research grants and presiding over a
$19 billion endowment, not to mention admitting and educating 14,000 students spread across Yale
College and a variety of graduate schools, professional schools and foreign-study outposts. And
surely Levin’s responsibilities are as complicated as those of the CEO of Yale New Haven Health’s
smallest unit — the 184-bed Greenwich Hospital, whose CEO was paid $112,000 more than Levin.
“When I got the bill, I almost had to go back to the hospital,” Gilbert recalls. “I was hyperventilating.”
Contributing to her shock was the fact that although her employer supplied insurance from Cigna,
one of the country’s leading health insurers, Gilbert’s policy was from a Cigna subsidiary called
Starbridge that insures mostly low-wage earners. That made Gilbert one of millions of Americans like
Sean Recchi who are routinely categorized as having health insurance but really don’t have anything
approaching meaningful coverage.
Starbridge covered Gilbert for just $2,500 per hospital visit, leaving her on the hook for about $7,000
of a $9,400 bill. Under Connecticut’s rules (states set their own guidelines for Medicaid, the federalstate program for the poor), Gilbert’s $1,800 a month in earnings was too high for her to qualify for
Medicaid assistance. She was also turned down, she says, when she requested financial assistance
from the hospital. Yale New Haven’s Gedge insists that she never applied to the hospital for aid, and
Gilbert could not supply me with copies of any applications.
In September 2009, after a series of fruitless letters and phone calls from its bill collectors to Gilbert,
the hospital sued her. Gilbert found a medical-billing advocate, Beth Morgan, who analyzed the
charges on the bill and compared them with the discounted rates insurance companies would pay.
45
During two court-required mediation sessions, Bridgeport Hospital’s attorney wouldn’t budge; his
client wanted the bill paid in full, Gilbert and Morgan recall. At the third and final mediation, Gilbert
was offered a 20% discount off the chargemaster fees if she would pay immediately, but she says
she responded that according to what Morgan told her about the bill, it was still too much to pay. “We
probably could have offered more,” Gedge acknowledges. “But in these situations, our bill-collection
attorneys only know the amount we are saying is owed, not whether it is a chargemaster amount or
an amount that is already discounted.”
On July 11, 2011, with the school-bus driver representing herself in Bridgeport superior court, a judge
ruled that Gilbert had to pay all but about $500 of the original charges. (He deducted the superfluous
bills for the basic equipment.) The judge put her on a payment schedule of $20 a week for six years.
For her, the chargemaster prices were all too real.
The One-Day, $87,000 Outpatient Bill
Getting a patient in and out of a hospital the same day seems like a logical way to cut costs.
Outpatients don’t take up hospital rooms or require the expensive 24/7 observation and care that
come with them. That’s why in the 1990s Medicare pushed payment formulas on hospitals that paid
them for whatever ailment they were treating (with more added for documented complications), not
according to the number of days the patient spent in a bed. Insurance companies also pushed
incentives on hospitals to move patients out faster or not admit them for overnight stays in the first
place. Meanwhile, the introduction of procedures like noninvasive laparoscopic surgery helped speed
the shift from inpatient to outpatient.
By 2010, average days spent in the hospital per patient had declined significantly, while outpatient
services had increased even more dramatically. However, the result was not the savings that
reformers had envisioned. It was just the opposite.
Experts estimate that outpatient services are now packed with so much hidden profit that about twothirds of the $750 billion annual U.S. overspending identified by the McKinsey research on health
care comes in payments for outpatient services. That includes work done by physicians, laboratories
and clinics (including diagnostic clinics for CT scans or blood tests) and same-day surgeries and
other hospital treatments like cancer chemotherapy. According to a McKinsey survey, outpatient
emergency-room care averages an operating profit margin of 15% and nonemergency outpatient
care averages 35%. On the other hand, inpatient care has a margin of just 2%. Put simply, inpatient
care at nonprofit hospitals is, in fact, almost nonprofit. Outpatient care is wildly profitable.
“An operating room has fixed costs,” explains one hospital economist. “You get 10% or 20% more
patients in there every day who you don’t have to board overnight, and that goes straight to the
bottom line.”
The 2011 outpatient visit of someone I’ll call Steve H. to Mercy Hospital in Oklahoma City illustrates
those economics. Steve H. had the kind of relatively routine care that patients might expect would be
no big deal: he spent the day at Mercy getting his aching back fixed.
A blue collar worker who was in his 30s at the time and worked at a local retail store, Steve H. had
consulted a specialist at Mercy in the summer of 2011 and was told that a stimulator would have to
be surgically implanted in his back. The good news was that with all the advances of modern
technology, the whole process could be done in a day. (The latest federal filing shows that 63% of
surgeries at Mercy were performed on outpatients.)
Steve H.’s doctor intended to use a RestoreUltra neurostimulator manufactured by Medtronic, a
Minneapolis-based company with $16 billion in annual sales that bills itself as the world’s largest
stand-alone medical-technology company. “RestoreUltra delivers spinal-cord stimulation through one
or more leads selected from a broad portfolio for greater customization of therapy,” Medtronic’s
website promises. I was not able to interview Steve H., but according to Pat Palmer, a medical-billing
46
specialist based in Salem, Va., who consults for the union that provides Steve H.’s health insurance,
Steve H. didn’t ask how much the stimulator would cost because he had $45,181 remaining on the
$60,000 annual payout limit his union-sponsored health-insurance plan imposed. “He figured, How
much could a day at Mercy cost?” Palmer says. “Five thousand? Maybe 10?”
Steve H. was about to run up against a seemingly irrelevant footnote in millions of Americans’
insurance policies: the limit, sometimes annual or sometimes over a lifetime, on what the insurer has
to pay out for a patient’s claims. Under Obamacare, those limits will not be allowed in most healthinsurance policies after 2013. That might help people like Steve H. but is also one of the reasons
premiums are going to skyrocket under Obamacare.
Chest X-Ray
Patient was charged $333. the national rate paid by
Medicare is $23.83
Steve H.’s bill for his day at Mercy contained all the
usual and customary overcharges. One item was
“MARKER SKIN REG TIP RULER” for $3. That’s the
marking pen, presumably reusable, that marked the
place on Steve H.’s back where the incision was to go.
Six lines down, there was “STRAP OR TABLE 8X27 IN” for $31. That’s the strap used to hold Steve
H. onto the operating table. Just below that was “BLNKT WARM UPPER BDY 42268” for $32. That’s
a blanket used to keep surgery patients warm. It is, of course, reusable, and it’s available new on
eBay for $13. Four lines down there’s “GOWN SURG ULTRA XLG 95121” for $39, which is the gown
the surgeon wore. Thirty of them can be bought online for $180. Neither Medicare nor any large
insurance company would pay a hospital separately for those straps or the surgeon’s gown; that’s all
supposed to come with the facility fee paid to the hospital, which in this case was $6,289.
In all, Steve H.’s bill for these basic medical and surgical supplies was $7,882. On top of that was
$1,837 under a category called “Pharmacy General Classification” for items like bacitracin ($108). But
that was the least of Steve H.’s problems.
The big-ticket item for Steve H.’s day at Mercy was the Medtronic stimulator, and that’s where most of
Mercy’s profit was collected during his brief visit. The bill for that was $49,237.
According to the chief financial officer of another hospital, the wholesale list price of the Medtronic
stimulator is “about $19,000.” Because Mercy is part of a major hospital chain, it might pay 5% to
15% less than that. Even assuming Mercy paid $19,000, it would make more than $30,000 selling it
to Steve H., a profit margin of more than 150%. To the extent that I found any consistency among
hospital chargemaster practices, this is one of them: hospitals routinely seem to charge 21⁄2 times
what these expensive implantable devices cost them, which produces that 150% profit margin.
As Steve H. found out when he got his bill, he had exceeded the $45,000 that was left on his
insurance policy’s annual payout limit just with the neurostimulator. And his total bill was $86,951.
After his insurance paid that first $45,000, he still owed more than $40,000, not counting doctors’
bills. (I did not see Steve H.’s doctors’ bills.)
SOUND OFF: Are Medical Bills Too High? Tell Us Why
Mercy Hospital is owned by an organization under the umbrella of the Catholic Church called Sisters
of Mercy. Its mission, as described in its latest filing with the IRS as a tax-exempt charity, is “to carry
out the healing ministry of Jesus by promoting health and wellness.” With a chain of 31 hospitals and
300 clinics across the Midwest, Sisters of Mercy uses a bill-collection firm based in Topeka, Kans.,
called Berlin-Wheeler Inc. Suits against Mercy patients are on file in courts across Oklahoma listing
47
Berlin-Wheeler as the plaintiff. According to its most recent tax return, the Oklahoma City unit of the
Sisters of Mercy hospital chain collected $337 million in revenue for the fiscal year ending June 30,
2011. It had an operating profit of $34 million. And that was after paying 10 executives more than
$300,000 each, including $784,000 to a regional president and $438,000 to the hospital president.
That report doesn’t cover the executives overseeing the chain, called Mercy Health, of which Mercy
in Oklahoma City is a part. The overall chain had $4.28 billion in revenue that year. Its hospital in
Springfield, Mo. (pop. 160,660), had $880.7 million in revenue and an operating profit of $319 million,
according to its federal filing. The incomes of the parent company’s executives appear on other IRS
filings covering various interlocking Mercy nonprofit corporate entities. Mercy president and CEO
Lynn Britton made $1,930,000, and an executive vice president, Myra Aubuchon, was paid
$3.7 million, according to the Mercy filing. In all, seven Mercy Health executives were paid more than
$1 million each. A note at the end of an Ernst & Young audit that is attached to Mercy’s IRS filing
reported that the chain provided charity care worth 3.2% of its revenue in the previous year. However,
the auditors state that the value of that care is based on the charges on all the bills, not the actual
cost to Mercy of providing those services — in other words, the chargemaster value. Assuming that
Mercy’s actual costs are a tenth of these chargemaster values — they’re probably less — all of this
charity care actually cost Mercy about three-tenths of 1% of its revenue, or about $13 million out of
$4.28 billion.
Mercy’s website lists an 18-member media team; one member, Rachel Wright, told me that neither
CEO Britton nor anyone else would be available to answer questions about compensation, the
hospital’s bill-collecting activities through Berlin-Wheeler or Steve H.’s bill, which I had sent her (with
his name and the date of his visit to the hospital redacted to protect his privacy).
PHOTOGRAPH BY NICK VEASEY FOR TIME
Bacitracin: $108
Charge for the common antibiotic ointment that appeared on a patient’s
bill under the hard-to-parse category “Pharmacy General Classification”
Wright said the hospital’s lawyers had decided that discussing Steve H.’s
bill would violate the federal HIPAA law protecting the privacy of patient
medical records. I pointed out that I wanted to ask questions only about
the hospital’s charges for standard items — such as surgical gowns, basic
blood tests, blanket warmers and even medical devices — that had
nothing to do with individual patients. “Everything is particular to an individual patient’s needs,” she
replied. Even a surgical gown? “Yes, even a surgical gown. We cannot discuss this with you. It’s
against the law.” She declined to put me in touch with the hospital’s lawyers to discuss their legal
analysis.
Hiding behind a privacy statute to avoid talking about how it prices surgeons’ gowns may be a
stretch, but Mercy might have a valid legal reason not to discuss what it paid for the Medtronic device
before selling it to Steve H. for $49,237. Pharmaceutical and medical-device companies routinely
insert clauses in their sales contracts prohibiting hospitals from sharing information about what they
pay and the discounts they receive. In January 2012, a report by the federal Government
Accountability Office found that “the lack of price transparency and the substantial variation in
amounts hospitals pay for some IMD [implantable medical devices] raise questions about whether
hospitals are achieving the best prices possible.”
A lack of price transparency was not the only potential market inefficiency the GAO found. “Although
physicians are not involved in price negotiations, they often express strong preferences for certain
manufacturers and models of IMD,” the GAO reported. “To the extent that physicians in the same
48
hospitals have different preferences for IMDs, it may be difficult for the hospital to obtain volume
discounts from particular manufacturers.”
“Doctors have no incentive to buy one kind of hip or other implantable device as a group,” explains
Ezekiel Emanuel, an oncologist and a vice provost of the University of Pennsylvania who was a key
White House adviser when Obamacare was created. “Even in the most innocent of circumstances, it
kills the chance for market efficiencies.”
The circumstances are not always innocent. In 2008, Gregory Demske, an assistant inspector
general at the Department of Health and Human Services, told a Senate committee that “physicians
routinely receive substantial compensation from medical-device companies through stock options,
royalty agreements, consulting agreements, research grants and fellowships.”
The assistant inspector general then revealed startling numbers about the extent of those payments:
“We found that during the years 2002 through 2006, four manufacturers, which controlled almost 75%
of the hip- and knee-replacement market, paid physician consultants over $800 million under the
terms of roughly 6,500 consulting agreements.”
Other doctors, Demske noted, had stretched the conflict of interest beyond consulting fees:
“Additionally, physician ownership of medical-device manufacturers and related businesses appears
to be a growing trend in the medical-device sector … In some cases, physicians could receive
substantial returns while contributing little to the venture beyond the ability to generate business for
the venture.” In 2010, Medtronic, along with several other members of a medical-technology trade
group, began to make the potential conflicts transparent by posting all payments to physicians on a
section of its website called Physician Collaboration. The voluntary move came just before a similar
disclosure regulation promulgated by the Obama Administration went into effect governing any doctor
who receives funds from Medicare or the National Institutes of Health (which would include most
doctors). And the nonprofit public-interest-journalism organization ProPublica has smartly organized
data on doctor payments on its website. The conflicts have not been eliminated, but they are being
aired, albeit on searchable websites rather than through a requirement that doctors disclose them to
patients directly.
But conflicts that may encourage devices to be overprescribed or that lead doctors to prescribe a
more expensive one instead of another are not the core problem in this marketplace. The more
fundamental disconnect is that there is little reason to believe that what Mercy Hospital paid
Medtronic for Steve H.’s device would have had any bearing on what the hospital decided to charge
Steve H. Why would it? He did not know the price in advance.
Besides, studies delving into the economics of the medical marketplace consistently find that a
moderately higher or lower price doesn’t change consumer purchasing decisions much, if at all,
because in health care there is little of the price sensitivity found in conventional marketplaces, even
on the rare occasion that patients know the cost in advance. If you were in pain or in danger of dying,
would you turn down treatment at a price 5% or 20% higher than the price you might have expected
— that is, if you’d had any informed way to know what to expect in the first place, which you didn’t?
The question of how sensitive patients will be to increased prices for medical devices recently came
up in a different context. Aware of the huge profits being accumulated by devicemakers, Obama
Administration officials decided to recapture some of the money by imposing a 2.39% federal excise
tax on the sales of these devices as well as other medical technology such as CT-scan equipment.
The rationale was that getting back some of these generous profits was a fair way to cover some of
the cost of the subsidized, broader insurance coverage provided by Obamacare — insurance that in
some cases will pay for more of the devices. The industry has since geared up in Washington and is
pushing legislation that would repeal the tax. Its main argument is that a 2.39% increase in prices
49
would so reduce sales that it would wipe out a substantial portion of what the industry claims are the
422,000 jobs it supports in a $136 billion industry.
That prediction of doom brought on by this small tax contradicts the reams of studies documenting
consumer price insensitivity in the health care marketplace. It also ignores profit-margin data
collected by McKinsey that demonstrates that devicemakers have an open field in the current medical
ecosystem. A 2011 McKinsey survey for medical-industry clients reported that devicemakers are
superstar performers in a booming medical economy. Medtronic, which performed in the middle of
the group, delivered an amazing compounded annual return of 14.95% to shareholders from 1990 to
2010. That means $100 invested in the company in 1990 was worth $1,622 20 years later. So if the
extra 2.39% would be so disruptive to the market for products like Medtronic’s that it would kill sales,
why would the industry pass it along as a price increase to consumers? It hardly has to, given its
profit margins.
Medtronic spokeswoman Donna Marquad says that for competitive reasons, her company will not
discuss sales figures or the profit on Steve H.’s neurostimulator. But Medtronic’s October 2012
quarterly SEC filing reported that its spine “products and therapies,” which presumably include Steve
H.’s device, “continue to gain broad surgeon acceptance” and that its cost to make all of its products
was 24.9% of what it sells them for.
That’s an unusually high gross profit margin — 75.1% — for a company that manufactures real
physical products. Apple also produces high-end, high-tech products, and its gross margin is 40%. If
the neurostimulator enjoys that company-wide profit margin, it would mean that if Medtronic was paid
$19,000 by Mercy Hospital, Medtronic’s cost was about $4,500 and it made a gross profit of about
$14,500 before expenses for sales, overhead and management — including CEO Omar Ishrak’s
compensation, which was $25 million for the 2012 fiscal year.
Mercy’s Bargain
When Pat Palmer, the medical-billing specialist who advises Steve H.’s union, was given the Mercy
bill to deal with, she prepared a tally of about $4,000 worth of line items that she thought represented
the most egregious charges, such as the surgical gown, the blanket warmer and the marking pen.
She restricted her list to those she thought were plainly not allowable. “I didn’t dispute nearly all of
them,” she says. “Because then they get their backs up.”
The hospital quickly conceded those items. For the remaining $83,000, Palmer invoked a 40%
discount off chargemaster rates that Mercy allows for smaller insurance providers like the union. That
cut the bill to about $50,000, for which the insurance company owed 80%, or about $40,000. That left
Steve H. with a $10,000 bill.
Sean Recchi wasn’t as fortunate. His bill — which included not only the aggressively marked-up
charge of $13,702 for the Rituxan cancer drug but also the usual array of chargemaster fees for
basics like generic Tylenol, blood tests and simple supplies — had one item not found on any other
bill I examined: MD Anderson’s charge of $7 each for “ALCOHOL PREP PAD.” This is a little square
of cotton used to apply alcohol to an injection. A box of 200 can be bought online for $1.91.
We have seen that to the extent that most hospital administrators defend such chargemaster rates at
all, they maintain that they are just starting points for a negotiation. But patients don’t typically know
they are in a negotiation when they enter the hospital, nor do hospitals let them know that. And in any
case, at MD Anderson, the Recchis were made to pay every penny of the chargemaster bill up front
because their insurance was deemed inadequate. That left Penne, the hospital spokeswoman, with
only this defense for the most blatantly abusive charges for items like the alcohol squares: “It is
difficult to compare a retail store charge for a common product with a cancer center that provides the
item as part of its highly specialized and personalized care,” she wrote in an e-mail. Yet the hospital
50
also charges for that “specialized and personalized” care through, among other items, its $1,791-aday room charge.
Before MD Anderson marked up Recchi’s Rituxan to $13,702, the profit taking was equally
aggressive, and equally routine, at the beginning of the supply chain — at the drug company. Rituxan
is a prime product of Biogen Idec, a company with $5.5 billion in annual sales. Its CEO, George
Scangos, was paid $11,331,441 in 2011, a 20% boost over his 2010 income. Rituxan is made and
sold by Biogen Idec in partnership with Genentech, a South San Francisco–based biotechnology
pioneer. Genentech brags about Rituxan on its website, as did Roche, Genentech’s $45 billion
parent, in its latest annual report. And in an Investor Day presentation last September, Roche CEO
Severin Schwann stressed that his company is able to keep prices and margins high because of its
focus on “medically differentiated therapies.” Rituxan, a cancer wonder drug, certainly meets that
test.
SOUND OFF: Are Medical Bills Too High? Tell Us Why
A spokesman at Genentech for the Biogen Idec–Genentech partnership would not say what the drug
cost the companies to make, but according to its latest annual report, Biogen Idec’s cost of sales —
the incremental expense of producing and shipping each of its products compared with what it sells
them for — was only 10%. That’s lower than the incremental cost of sales for most software
companies, and the software companies usually don’t produce anything physical or have to pay to
ship anything.
This would mean that Sean Recchi’s dose of Rituxan cost the Biogen Idec–Genentech partnership as
little as $300 to make, test, package and ship to MD Anderson for $3,000 to $3,500, whereupon the
hospital sold it to Recchi for $13,702.
As 2013 began, Recchi was being treated back in Ohio because he could not pay MD Anderson for
more than his initial treatment. As for the $13,702-a-dose Rituxan, it turns out that Biogen Idec’s
partner Genentech has a charity-access program that Recchi’s Ohio doctor told him about that
enabled him to get those treatments free. “MD Anderson never said a word to us about the
Genentech program,” says Stephanie Recchi. “They just took our money up front.”
Genentech spokeswoman Charlotte Arnold would not disclose how much free Rituxan had been
dispensed to patients like Recchi in the past year, saying only that Genentech has “donated $2.85
billion in free medicine to uninsured patients in the U.S.” since 1985. That seems like a lot until the
numbers are broken down. Arnold says the $2.85 billion is based on what the drugmaker sells the
product for, not what it costs Genentech to make. On the basis of Genentech’s historic costs and
revenue since 1985, that would make the cost of these donations less than 1% of Genentech’s sales
— not something likely to take the sizzle out of CEO Severin’s Investor Day.
Nonetheless, the company provided more financial support than MD Anderson did to Recchi, whose
wife reports that he “is doing great. He’s in remission.”
Penne of MD Anderson stressed that the hospital provides its own financial aid to patients but that
the state legislature restricts the assistance to Texas residents. She also said MD Anderson “makes
every attempt” to inform patients of drug-company charity programs and that 50 of the hospital’s
24,000 inpatients and outpatients, one of whom was from outside Texas, received charitable aid for
Rituxan treatments in 2012.
3. Catastrophic Illness — And the Bills to Match
When medical care becomes a matter of life and death, the money demanded by the health care
ecosystem reaches a wholly different order of magnitude, churning out reams of bills to people who
can’t focus on them, let alone pay them. Soon after he was diagnosed with lung cancer in January
2011, a patient whom I will call Steven D. and his wife Alice knew that they were only buying time.
The crushing question was, How much is time really worth? As Alice, who makes about $40,000 a
51
year running a child-care center in her home, explained, “[Steven] kept saying he wanted every last
minute he could get, no matter what. But I had to be thinking about the cost and how all this debt
would leave me and my daughter.” By the time Steven D. died at his home in Northern California the
following November, he had lived for an additional 11 months. And Alice had collected bills totaling
$902,452. The family’s first bill — for $348,000 — which arrived when Steven got home from the
Seton Medical Center in Daly City, Calif., was full of all the usual chargemaster profit grabs: $18 each
for 88 diabetes-test strips that Amazon sells in boxes of 50 for $27.85; $24 each for 19 niacin pills
that are sold in drugstores for about a nickel apiece. There were also four boxes of sterile gauze pads
for $77 each. None of that was considered part of what was provided in return for Seton’s facility
charge for the intensive-care unit for two days at $13,225 a day, 12 days in the critical unit at $7,315
a day and one day in a standard room (all of which totaled $120,116 over 15 days). There was also
$20,886 for CT scans and $24,251 for lab work. Alice responded to my question about the obvious
overcharges on the bill for items like the diabetes-test strips or the gauze pads much as Mrs. Lincoln,
according to the famous joke, might have had she been asked what she thought of the play. “Are you
kidding?” she said. “I’m dealing with a husband who had just been told he has Stage IV cancer.
That’s all I can focus on … You think I looked at the items on the bills? I just looked at the total.”
Steven and Alice didn’t know that hospital billing people consider the chargemaster to be an opening
bid. That’s because no medical bill ever says, “Give us your best offer.” The couple knew only that the
bill said they had maxed out on the $50,000 payout limit on a UnitedHealthcare policy they had
bought through a community college where Steven had briefly enrolled a year before. “We were in
shock,” Alice recalls. “We looked at the total and couldn’t deal with it. So we just started putting all the
bills in a box. We couldn’t bear to look at them.”
The $50,000 that UnitedHealthcare paid to Seton Medical Center was worth about $80,000 in credits
because any charges covered by the insurer were subject to the discount it had negotiated with
Seton. After that $80,000, Steven and Alice were on their own, not eligible for any more discounts.
Four months into her husband’s illness, Alice by chance got the name of Patricia Stone, a billing
advocate based in Menlo Park, Calif. Stone’s typical clients are middle-class people having trouble
with insurance claims. Stone felt so bad for Steven and Alice — she saw the blizzard of bills Alice
was going to have to sort through — that, says Alice, she “gave us many of her hours,” for which she
usually charges $100, “for free.” Stone was soon able to persuade Seton to write off $297,000 of its
$348,000 bill. Her argument was simple: There was no way the D.’s could pay it now or in the future,
though they would scrape together $3,000 as a show of good faith. With the couple’s $3,000 on top
of the $50,000 paid by the UnitedHealthcare insurance, that $297,000 write-off amounted to an 85%
discount. According to its latest financial report, Seton applies so many discounts and write-offs to its
chargemaster bills that it ends up with only about 18% of the revenue it bills for. That’s an average
82% discount, compared with an average discount of about 65% that I saw at the other hospitals
whose bills were examined — except for the MD Anderson and Sloan-Kettering cancer centers,
which collect about 50% of their chargemaster charges. Seton’s discounting practices may explain
why it is the only hospital whose bills I looked at that actually reported a small operating loss — $5
million — on its last financial report.
Of course, had the D.’s not come across Stone, the incomprehensible but terrifying bills would have
piled up in a box, and the Seton Medical Center bill collectors would not have been kept at bay.
Robert Issai, the CEO of the Daughters of Charity Health System, which owns and runs Seton,
refused through an e-mail from a public relations assistant to respond to requests for a comment on
any aspect of his hospital’s billing or collections policies. Nor would he respond to repeated requests
for a specific comment on the $24 charge for niacin pills, the $18 charge for the diabetes-test strips or
the $77 charge for gauze pads. He also declined to respond when asked, via a follow-up e-mail, if the
hospital thinks that sending patients who have just been told they are terminally ill bills that reflect
chargemaster rates that the hospital doesn’t actually expect to be paid might unduly upset them
during a particularly sensitive time. To begin to deal with all the other bills that kept coming after
Steven’s first stay at Seton, Stone was also able to get him into a special high-risk insurance pool set
52
up by the state of California. It helped but not much. The insurance premium was $1,000 a month,
quite a burden on a family whose income was maybe $3,500 a month. And it had an annual payout
limit of $75,000. The D.’s blew through that in about two months. The bills kept piling up. Sequoia
Hospital — where Steven was an inpatient as well as an outpatient between the end of January and
November following his initial stay at Seton — weighed in with 28 bills, all at chargemaster prices,
including invoices for $99,000, $61,000 and $29,000. Doctor-run outpatient chemotherapy clinics
wanted more than $85,000. One outside lab wanted $11,900.
CT Scans
Patient was charged $6,538 for three ct scans.
Medicare would have paid a total of about $825 for all
three; Stone organized these and other bills into an
elaborate spreadsheet — a ledger documenting how
catastrophic illness in America unleashes its own
mini-GDP.
In July, Stone figured out that Steven and Alice should qualify for Medicaid, which is called Medi-Cal
in California. But there was a catch: Medicaid is the joint federal-state program directed at the poor
that is often spoken of in the same breath as Medicare. Although most of the current national debate
on entitlements is focused on Medicare, when Medicaid’s subsidiary program called Children’s Health
Insurance, or CHIP, is counted, Medicaid actually covers more people: 56.2 million compared with
50.2 million. As Steven and Alice found out, Medicaid is also more vulnerable to cuts and conditions
that limit coverage, probably for the same reason that most politicians and the press don’t pay the
same attention to it that they do to Medicare: its constituents are the poor. The major difference in the
two programs is that while Medicare’s rules are pretty much uniform across state lines, the states set
the key rules for Medicaid because the state finances a big portion of the claims. According to Stone,
Steven and Alice immediately ran into one of those rules. For people even with their modest income,
the D.’s would have to pay $3,000 a month in medical bills before Medi-Cal would kick in. That
amounted to most of Alice’s monthly take-home pay.
Medi-Cal was even willing to go back five months, to February, to cover the couple’s mountain of
bills, but first they had to come up with $15,000. “We didn’t have anything close to that,” recalls Alice.
Stone then convinced Sequoia that if the hospital wanted to see any of the Medi-Cal money
necessary to pay its bills (albeit at the big discount Medi-Cal would take), it should give Steven a
“credit” for $15,000 — in other words, write it off. Sequoia agreed to do that for most of the bills. This
was clearly a maneuver that Steven and Alice never could have navigated on their own. Covering
most of the Sequoia debt was a huge relief, but there were still hundreds of thousands of dollars in
bills left unpaid as Steven approached his end in the fall of 2011. Meantime, the bills kept coming.
“We started talking about the cost of the chemo,” Alice recalls. “It was a source of tension between us
… Finally,” she says, “the doctor told us that the next one scheduled might prolong his life a month,
but it would be really painful. So he gave up.”
By the one-year anniversary of Steven’s death, late last year, Stone had made a slew of deals with
his doctors, clinics and other providers whose services Medi-Cal did not cover. Some, like Seton,
were generous. The home health care nurse ended up working for free in the final days of Steven’s
life, which were over the Thanksgiving weekend. “He was a saint,” says Alice. “He said he was doing
it to become accredited, so he didn’t charge us.”
Others, including some of the doctors, were more hard-nosed, insisting on full payment or offering
minimal discounts. Still others had long since sold the bills to professional debt collectors, who, by
definition, are bounty hunters. Alice and Stone were still hoping Medi-Cal would end up covering
some or most of the debt.
53
As 2012 closed, Alice had paid out about $30,000 of her own money (including the $3,000 to Seton)
and still owed $142,000 — her losses from the fixed poker game that she was forced to play in the
worst of times with the worst of cards. She was still getting letters and calls from bill collectors. “I think
about the $142,000 all the time. It just hangs over my head,” she said in December.
One lesson she has learned, she adds: “I’m never going to remarry. I can’t risk the liability.”2
2. In early February, Alice told TIME that she had recently eliminated “most of” the debt through
proceeds from the sale of a small farm in Oklahoma her husband had inherited and after further
payments from Medi-Cal and a small life-insurance policy
SOUND OFF: Are Medical Bills Too High? Tell Us Why
$132,303: The Lab-Test Cash Machine
As 2012 began, a couple I’ll call Rebecca and Scott S., both in their 50s, seemed to have carved out
a comfortable semiretirement in a suburb near Dallas. Scott had successfully sold his small industrial
business and was working part time advising other industrial companies. Rebecca was running a
small marketing company. On March 4, Scott started having trouble breathing. By dinnertime he was
gasping violently as Rebecca raced him to the emergency room at the University of Texas
Southwestern Medical Center. Both Rebecca and her husband thought he was about to die, Rebecca
recalls. It was not the time to think about the bills that were going to change their lives if Scott
survived, and certainly not the time to imagine, much less worry about, the piles of charges for daily
routine lab tests that would be incurred by any patient in the middle of a long hospital stay. Scott was
in the hospital for 32 days before his pneumonia was brought under control. Rebecca recalls that “on
about the fourth or fifth day, I was sitting around the hospital and bored, so I went down to the
business office just to check that they had all the insurance information.” She remembered that there
was, she says, “some kind of limit on it.”
“Even by then, the bill was over $80,000,” she recalls. “I couldn’t believe it.”
The woman in the business office matter-of-factly gave Rebecca more bad news: Her insurance
policy, from a company called Assurant Health, had an annual payout limit of $200,000. Because of
some prior claims Assurant had processed, the S.’s were well on their way to exceeding the limit.
Just the room-and-board charge at Southwestern was $2,293 a day. And that was before all the real
charges were added. When Scott checked out, his 161-page bill was $474,064. Scott and Rebecca
were told they owed $402,955 after the payment from their insurance policy was deducted. The top
billing categories were $73,376 for Scott’s room; $94,799 for “RESP SERVICES,” which mostly
meant supplying Scott with oxygen and testing his breathing and included multiple charges per day of
$134 for supervising oxygen inhalation, for which Medicare would have paid $17.94; and $108,663
for “SPECIAL DRUGS,” which included mostly not-so-special drugs such as “SODIUM CHLORIDE .
9%.” That’s a standard saline solution probably used intravenously in this case to maintain Scott’s
water and salt levels. (It is also used to wet contact lenses.) You can buy a liter of the hospital version
(bagged for intravenous use) online for $5.16. Scott was charged $84 to $134 for dozens of these
saline solutions.
Then there was the $132,303 charge for “LABORATORY,” which included hundreds of blood and
urine tests ranging from $30 to $333 each, for which Medicare either pays nothing because it is part
of the room fee or pays $7 to $30. Hospital spokesman Russell Rian said that neither Daniel
Podolsky, Texas Southwestern Medical Center’s $1,244,000-a-year president, nor any other
executive would be available to discuss billing practices. “The law does not allow us to talk about how
we bill,” he explained. Through a friend of a friend, Rebecca found Patricia Palmer, the same billing
advocate based in Salem, Va., who worked on Steve H.’s bill in Oklahoma City. Palmer — whose
firm, Medical Recovery Services, now includes her two adult daughters — was a claims processor for
Blue Cross Blue Shield. She got into her current business after she was stunned by the bill her local
54
hospital sent after one of her daughters had to go to the emergency room after an accident. She says
it included items like the shade attached to an examining lamp. She then began looking at bills for
friends as kind of a hobby before deciding to make it a business.
Niacin Tablet
Patient was charged $24 per 500-mg tablet of
niacin. In drugstores, the pills go for about a nickel
each
The best Palmer could do was get Texas
Southwestern Medical to provide a credit that still
left Scott and Rebecca owing $313,000. Palmer
claimed in a detailed appeal that there were also
overcharges totaling $113,000 — not because the prices were too high but because the items she
singled out should not have been charged for at all. These included $5,890 for all of that saline
solution and $65,600 for the management of Scott’s oxygen. These items are supposed to be part of
the hospital’s general room-and-services charge, she argued, so they should not be billed twice.
In fact, Palmer — echoing a constant and convincing refrain I heard from billing advocates across the
country — alleged that the hospital triple-billed for some items used in Scott’s care in the intensivecare unit. “First they charge more than $2,000 a day for the ICU, because it’s an ICU and it has all
this special equipment and personnel,” she says. “Then they charge $1,000 for some kit used in the
ICU to give someone a transfusion or oxygen … And then they charge $50 or $100 for each tool or
bandage or whatever that there is in the kit. That’s triple billing.” Palmer and Rebecca are still
fighting, but the hospital insists that the S.’s owe the $313,000 balance. That doesn’t include what
Rebecca says were “thousands” in doctors’ bills and $70,000 owed to a second hospital after Scott
suffered a relapse. The only offer the hospital has made so far is to cut the bill to $200,000 if it is paid
immediately, or for the full $313,000 to be paid in 24 monthly payments. “How am I supposed to write
a check right now for $200,000?” Rebecca asks. “I have boxes full of notices from bill collectors …
We can’t apply for charity, because we’re kind of well off in terms of assets,” she adds. “We thought
we were set, but now we’re pretty much on the edge.”
Insurance That Isn’t
“People, especially relatively wealthy people, always think they have good insurance until they see
they don’t,” says Palmer. “Most of my clients are middle- or upper-middle-class people with
insurance.”
Scott and Rebecca bought their plan from Assurant, which sells health insurance to small businesses
that will pay only for limited coverage for their employees or to individuals who cannot get insurance
through employers and are not eligible for Medicare or Medicaid. Assurant also sold the Recchis their
plan that paid only $2,000 a day for Sean Recchi’s treatment at MD Anderson. Although the tight
limits on what their policies cover are clearly spelled out in Assurant’s marketing materials and in the
policy documents themselves, it seems that for its customers the appeal of having something called
health insurance for a few hundred dollars a month is far more compelling than comprehending the
details. “Yes, we knew there were some limits,” says Rebecca. “But when you see the limits
expressed in the thousands of dollars, it looks O.K., I guess. Until you have an event.”
Millions of plans have annual payout limits, though the more typical plans purchased by employers
usually set those limits at $500,000 or $750,000 — which can also quickly be consumed by a
catastrophic illness. For that reason, Obamacare prohibited lifetime limits on any policies sold after
the law passed and phases out all annual dollar limits by 2014. That will protect people like Scott and
Rebecca, but it will also make everyone’s premiums dramatically higher, because insurance
companies risk much more when there is no cap on their exposure.
55
PHOTOGRAPH BY NICK VEASEY FOR TIME
Acetaminophen $1.50
Charge for one 325-mg tablet, the first of 344 lines in an eight-page hospital
bill. You can buy 100 tablets on Amazon for $1.49
But Obamacare does little to attack the costs that overwhelmed Scott and
Rebecca. There is nothing, for example, that addresses what may be the
most surprising sinkhole — the seemingly routine blood, urine and other
laboratory tests for which Scott was charged $132,000, or more than $4,000
a day. By my estimates, about $70 billion will be spent in the U.S. on about 7 billion lab tests in 2013.
That’s about $223 a person for 16 tests per person. Cutting the overordering and overpricing could
easily take $25 billion out of that bill. Much of that overordering involves patients like Scott S. who
require prolonged hospital stays. Their tests become a routine, daily cash generator. “When you’re
getting trained as a doctor,” says a physician who was involved in framing health care policy early in
the Obama Administration, “you’re taught to order what’s called ‘morning labs.’ Every day you have a
variety of blood tests and other tests done, not because it’s necessary but because it gives you
something to talk about with the others when you go on rounds. It’s like your version of a news hook
… I bet 60% of the labs are not necessary.”
The country’s largest lab tester is Quest Diagnostics, which reported revenues in 2012 of $7.4 billion.
Quest’s operating income in 2012 was $1.2 billion, about 16.2% of sales.
But that’s hardly the spectacular profit margin we have seen in other sectors of the medical
marketplace. The reason is that the outside companies like Quest, which mostly pick up specimens
from doctors and clinics and deliver test results back to them, are not where the big profits are. The
real money is in health care settings that cut out the middleman — the in-house venues, like the
hospital testing lab run by Southwestern Medical that billed Scott and Rebecca $132,000. In-house
labs account for about 60% of all testing revenue.
Which means that for hospitals, they are vital profit centers. Labs are also increasingly being
maintained by doctors who, as they form group practices with other doctors in their field, finance their
own testing and diagnostic clinics. These labs account for a rapidly growing share of the testing
revenue, and their share is growing rapidly. These in-house labs have no selling costs, and as pricing
surveys repeatedly find, they can charge more because they have a captive consumer base in the
hospitals or group practices. They also have an incentive to order more tests because they’re the
ones profiting from the tests. The Wall Street Journal reported last April that a study in the medical
journal Health Affairs had found that doctors’ urology groups with their own labs “bill the federal
Medicare program for analyzing 72% more prostate tissue samples per biopsy while detecting fewer
cases of cancer than counterparts who send specimens to outside labs.”
If anything, the move toward in-house testing, and with it the incentive to do more of it, is accelerating
the move by doctors to consolidate into practice groups. As one Bronx urologist explains, “The
economics of having your own lab are so alluring.” More important, hospitals are aligning with these
practice groups, in many cases even getting them to sign noncompete clauses requiring that they
steer all patients to the partner hospital. Some hospitals are buying physicians’ practices outright;
54% of physician practices were owned by hospitals in 2012, according to a McKinsey survey, up
from 22% 10 years before. This is primarily a move to increase the hospitals’ leverage in negotiating
with insurers. An expensive by-product is that it brings testing into the hospitals’ high-profit labs.
4. When Taxpayers Pick Up the Tab
Whether it was Emilia Gilbert trying to get out from under $9,418 in bills after her slip and fall or Alice
56
D. vowing never to marry again because of the $142,000 debt from her husband’s losing battle with
cancer, we’ve seen how the medical marketplace misfires when private parties get the bills.
When the taxpayers pick up the tab, most of the dynamics of the marketplace shift dramatically.
In July 2011, an 88-year-old man whom I’ll call Alan A. collapsed from a massive heart attack at his
home outside Philadelphia. He survived, after two weeks in the intensive-care unit of the Virtua
Marlton hospital. Virtua Marlton is part of a four-hospital chain that, in its 2010 federal filing, reported
paying its CEO $3,073,000 and two other executives $1.4 million and $1.7 million from gross revenue
of $633.7 million and an operating profit of $91 million. Alan A. then spent three weeks at a nearby
convalescent-care center.
Medicare made quick work of the $268,227 in bills from the two hospitals, paying just $43,320.
Except for $100 in incidental expenses, Alan A. paid nothing because 100% of inpatient hospital care
is covered by Medicare.
The ManorCare convalescent center, which Alan A. says gave him “good care” in an “O.K. but not
luxurious room,” got paid $11,982 by Medicare for his three-week stay. That is about $571 a day for
all the physical therapy, tests and other services. As with all hospitals in nonemergency situations,
ManorCare does not have to accept Medicare patients and their discounted rates. But it does accept
them. In fact, it welcomes them and encourages doctors to refer them.
Health care providers may grouse about Medicare’s fee schedules, but Medicare’s payments must be
producing profits for ManorCare. It is part of a for-profit chain owned by Carlyle Group, a blue-chip
private-equity firm.
About a decade ago, Alan A. was diagnosed with non-Hodgkin’s lymphoma. He was 78, and his
doctors in southern New Jersey told him there was little they could do. Through a family friend, he got
an appointment with one of the lymphoma specialists at Sloan-Kettering. That doctor told Alan A. he
was willing to try a new chemotherapy regimen on him. The doctor warned, however, that he hadn’t
ever tried the treatment on a man of Alan A.’s age.
SOUND OFF: Are Medical Bills Too High? Tell Us Why
The original version of this article stated that the Assurant Health insurance policy of Rebecca and
Scott S. had an annual pay limit of $100,000. It was $200,000.
The treatment worked. A decade later, Alan A. is still in remission. He now travels to Sloan-Kettering
every six weeks to be examined by the doctor who saved his life and to get a transfusion of
Flebogamma, a drug that bucks up his immune system.
With some minor variations each time, Sloan-Kettering’s typical bill for each visit is the same as or
similar to the $7,346 bill he received during the summer of 2011, which included $340 for a session
with the doctor.
Assuming eight visits (but only four with the doctor), that makes the annual bill $57,408 a year to
keep Alan A. alive. His actual out-of-pocket cost for each session is a fraction of that. For that $7,346
visit, it was about $50.
In some ways, the set of transactions around Alan A.’s Sloan-Kettering care represent the best the
American medical marketplace has to offer. First, obviously, there’s the fact that he is alive after other
doctors gave him up for dead. And then there’s the fact that Alan A., a retired chemist of average
means, was able to get care that might otherwise be reserved for the rich but was available to him
because he had the right insurance.
57
Medicare is the core of that insurance, although Alan A. — as do 90% of those on Medicare — has a
supplemental-insurance policy that kicks in and generally pays 90% of the 20% of costs for doctors
and outpatient care that Medicare does not cover.
Here’s how it all computes for him using that summer 2011 bill as an example.
Not counting the doctor’s separate $340 bill, Sloan-Kettering’s bill for the transfusion is about $7,006.
In addition to a few hundred dollars in miscellaneous items, the two basic Sloan-Kettering charges
are $414 per hour for five hours of nurse time for administering the Flebogamma and a $4,615
charge for the Flebogamma.
According to Alan A., the nurse generally handles three or four patients at a time. That would mean
Sloan-Kettering is billing more than $1,200 an hour for that nurse. When I asked Paul Nelson, SloanKettering’s director of financial planning, about the $414-per-hour charge, he explained that 15% of
these charges is meant to cover overhead and indirect expenses, 20% is meant to be profit that will
cover discounts for Medicare or Medicaid patients, and 65% covers direct expenses. That would still
leave the nurse’s time being valued at about $800 an hour (65% of $1,200), again assuming that just
three patients were billed for the same hour at $414 each. Pressed on that, Nelson conceded that the
profit is higher and is meant to cover other hospital costs like research and capital equipment.
Whatever Sloan-Kettering’s calculations may be, Medicare — whose patients, including Alan A., are
about a third of all Sloan-Kettering patients — buys into none of that math. Its cost-based pricing
formulas yield a price of $302 for everything other than the drug, including those hourly charges for
the nurse and the miscellaneous charges. Medicare pays 80% of that, or $241, leaving Alan A. and
his private insurance company together to pay about $60 more to Sloan-Kettering. Alan A. pays $6,
and his supplemental insurer, Aetna, pays $54.
Bottom line: Sloan-Kettering gets paid $302 by Medicare for about $2,400 worth of its chargemaster
charges, and Alan A. ends up paying $6.
The Cancer Drug Profit Chain
It’s with the bill for the transfusion that the peculiar economics of American medicine take a different
turn, even when Medicare is involved. We have seen that even with big discounts for insurance
companies and bigger discounts for Medicare, the chargemaster prices on everything from room and
board to Tylenol to CT scans are high enough to make hospital costs a leading cause of the
$750 billion Americans overspend each year on health care. We’re now going to see how drug pricing
is a major contributor to the way Americans overpay for medical care.
By law, Medicare has to pay hospitals 6% above what Congress calls the drug company’s “average
sales price,” which is supposedly the average price at which the drugmaker sells the drug to hospitals
and clinics. But Congress does not control what drugmakers charge. The drug companies are free to
set their own prices. This seems fair in a free-market economy, but when the drug is a one-of-a-kind
lifesaving serum, the result is anything but fair.
Applying that formula of average sales price plus the 6% premium, Medicare cuts Sloan-Kettering’s
$4,615 charge for Alan A.’s Flebogamma to $2,123. That’s what the drugmaker tells Medicare the
average sales price is plus 6%. Medicare again pays 80% of that, and Alan A. and his insurer split the
other 20%, 10% for him and 90% for the insurer, which makes Alan A.’s cost $42.50.
In practice, the average sales price does not appear to be a real average. Two other hospitals I asked
reported that after taking into account rebates given by the drug company, they paid an average of
$1,650 for the same dose of Flebogamma, and neither hospital had nearly the leverage in the
cancer-care marketplace that Sloan-Kettering does. One doctor at Sloan-Kettering guessed that it
pays $1,400. “The drug companies give the rebates so that the hospitals will make more on the drug
58
and therefore be encouraged to dispense it,” the doctor explained. (A spokesperson for Medicare
would say only that the average sales price is based “on manufacturers’ data submitted to Medicare
and is meant to include rebates.”)
Nelson, the Sloan-Kettering head of financial planning, said the price his hospital pays for Alan A.’s
dose of Flebogamma is “somewhat higher” than $1,400, but he wasn’t specific, adding that “the
difference between the cost and the charge represents the cost of running our pharmacy — which
includes overhead cost — plus a markup.”
Even assuming Sloan-Kettering’s real price for Flebogamma is “somewhat higher” than $1,400, the
hospital would be making about 50% profit from Medicare’s $2,123 payment. So even Medicare
contributes mightily to hospital profit — and drug-company profit — when it buys drugs.
Flebogamma’s Profit Margin
The Spanish business at the beginning of the Flebogamma supply chain does even better than
Sloan-Kettering.
Made from human plasma, Flebogamma is a sterilized solution that is intended to boost the immune
system. Sloan-Kettering buys it from either Baxter International in the U.S. or, as is more likely in Alan
A.’s case, a Barcelona-based company called Grifols.
In its half-year 2012 shareholders report, Grifols featured a picture of the Flebogamma plasma serum
and its packaging — “produced at the Clayton facility, North Carolina,” according to the caption.
Worldwide sales of all Grifols products were reported as up 15.2%, to $1.62 billion, in the first half of
2012. In the U.S. and Canada, sales were up 20.5%. “Growth in the sales … of the main plasma
derivatives” was highlighted in the report, as was the fact that “the cost per liter of plasma has
fallen.” (Grifols operates 150 donation centers across the U.S. where it pays plasma donors $25
apiece.)
Grifols spokesman Christopher Healey would not discuss what it cost Grifols to produce and ship
Alan A.’s dose, but he did say that the company’s average cost to produce its bioscience products,
Flebogamma included, was approximately 55% of what it sells them for. However, a doctor familiar
with the economics of cancer-care drugs said that plasma products typically have some of the
industry’s higher profit margins. He estimated that the Flebogamma dose for Alan A. — which SloanKettering bought from Grifols for $1,400 or $1,500 and sold to Medicare for $2,135 — “can’t cost
them more than $200 or $300 to collect, process, test and ship.”
In Spain, as in the rest of the developed world, Grifols’ profit margins on sales are much lower than
they are in the U.S., where it can charge much higher prices. Aware of the leverage that drug
companies — especially those with unique lifesaving products — have on the market, most
developed countries regulate what drugmakers can charge, limiting them to certain profit margins. In
fact, the drugmakers’ securities filings repeatedly warn investors of tighter price controls that could
threaten their high margins — though not in the U.S.
The difference between the regulatory environment in the U.S. and the environment abroad is so
dramatic that McKinsey & Co. researchers reported that overall prescription-drug prices in the U.S.
are “50% higher for comparable products” than in other developed countries. Yet those regulated
profit margins outside the U.S. remain high enough that Grifols, Baxter and other drug companies still
aggressively sell their products there. For example, 37% of Grifols’ sales come from outside North
America.
More than $280 billion will be spent this year on prescription drugs in the U.S. If we paid what other
countries did for the same products, we would save about $94 billion a year. The pharmaceutical
industry’s common explanation for the price difference is that U.S. profits subsidize the research and
59
development of trailblazing drugs that are developed in the U.S. and then marketed around the world.
Apart from the question of whether a country with a health-care-spending crisis should subsidize the
rest of the developed world — not to mention the question of who signed Americans up for that
mission — there’s the fact that the companies’ math doesn’t add up.
According to securities filings of major drug companies, their R&D expenses are generally 15% to
20% of gross revenue. In fact, Grifols spent only 5% on R&D for the first nine months of 2012.
Neither 5% nor 20% is enough to have cut deeply into the pharmaceutical companies’ stellar bottomline net profits. This is not gross profit, which counts only the cost of producing the drug, but the profit
after those R&D expenses are taken into account. Grifols made a 32.3% net operating profit after all
its R&D expenses — as well as sales, management and other expenses — were tallied. In other
words, even counting all the R&D across the entire company, including research for drugs that did not
pan out, Grifols made healthy profits. All the numbers tell one consistent story: Regulating drug prices
the way other countries do would save tens of billions of dollars while still offering profit margins that
would keep encouraging the pharmaceutical companies’ quest for the next great drug.
Handcuffs On Medicare
Our laws do more than prevent the government from restraining prices for drugs the way other
countries do. Federal law also restricts the biggest single buyer — Medicare — from even trying to
negotiate drug prices. As a perpetual gift to the pharmaceutical companies (and an acceptance of
their argument that completely unrestrained prices and profit are necessary to fund the risk taking of
research and development), Congress has continually prohibited the Centers for Medicare and
Medicaid Services (CMS) of the Department of Health and Human Services from negotiating prices
with drugmakers. Instead, Medicare simply has to determine that average sales price and add 6% to
it.
Similarly, when Congress passed Part D of Medicare in 2003, giving seniors coverage for prescription
drugs, Congress prohibited Medicare from negotiating.
Nor can Medicare get involved in deciding that a drug may be a waste of money. In medical circles,
this is known as the comparative-effectiveness debate, which nearly derailed the entire Obamacare
effort in 2009.
Doctors and other health care reformers behind the comparative-effectiveness movement make a
simple argument: Suppose that after exhaustive research, cancer drug A, which costs $300 a dose, is
found to be just as effective as or more effective than drug B, which costs $3,000. Shouldn’t the
person or entity paying the bill, e.g. Medicare, be able to decide that it will pay for drug A but not drug
B? Not according to a law passed by Congress in 2003 that requires Medicare to reimburse patients
(again, at average sales price plus 6%) for any cancer drug approved for use by the Food and Drug
Administration. Most states require insurance companies to do the same thing.
Peter Bach, an epidemiologist at Sloan-Kettering who has also advised several health-policy
organizations, reported in a 2009 New England Journal of Medicine article that Medicare’s spending
on the category dominated by cancer drugs ballooned from $3 billion in 1997 to $11 billion in 2004.
Bach says costs have continued to increase rapidly and must now be more than $20 billion.
With that escalating bill in mind, Bach was among the policy experts pushing for provisions in
Obamacare to establish a Patient-Centered Outcomes Research Institute to expand comparativeeffectiveness research efforts. Through painstaking research, doctors would try to determine the
comparative effectiveness not only of drugs but also of procedures like CT scans.
However, after all the provisions spelling out elaborate research and review processes were
embedded in the draft law, Congress jumped in and added eight provisions that restrict how the
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research can be used. The prime restriction: Findings shall “not be construed as mandates for
practice guidelines, coverage recommendations, payment, or policy recommendations.”
With those 14 words, the work of Bach and his colleagues was undone. And costs remain
unchecked.
SOUND OFF: Are Medical Bills Too High? Tell Us Why
“Medicare could see the research and say, Ah, this drug works better and costs the same or is even
cheaper,” says Gunn, Sloan-Kettering’s chief operating officer. “But they are not allowed to do
anything about it.”
Along with another doomed provision that would have allowed Medicare to pay a fee for doctors’ time
spent counseling terminal patients on end-of-life care (but not on euthanasia), the Obama
Administration’s push for comparative effectiveness is what brought opponents’ cries that the bill was
creating “death panels.” Washington bureaucrats would now be dictating which drugs were worth
giving to which patients and even which patients deserved to live or die, the critics charged.
The loudest voice sounding the death-panel alarm belonged to Betsy McCaughey, former New York
State lieutenant governor and a conservative health-policy advocate. McCaughey, who now runs a
foundation called the Committee to Reduce Infection Deaths, is still fiercely opposed to Medicare’s
making comparative-effectiveness decisions. “There is comparative-effectiveness research being
done in the medical journals all the time, which is fine,” she says. “But it should be used by doctors to
make decisions — not by the Obama bureaucrats at Medicare to make decisions for doctors.”
Bach, the Sloan-Kettering doctor and policy wonk, has become so frustrated with the rising cost of
the drugs he uses that he and some colleagues recently took matters into their own hands. They
reported in an October op-ed in the New York Times that they had decided on their own that they
were no longer going to dispense a colorectal-cancer drug called Zaltrap, which cost an average of
$11,063 per month for treatment. All the research shows, they wrote, that a drug called Avastin, which
cost $5,000 a month, is just as effective. They were taking this stand, they added, because “the
typical new cancer drug coming on the market a decade ago cost about $4,500 per month (in 2012
dollars); since 2010, the median price has been around $10,000. Two of the new cancer drugs cost
more than $35,000 each per month of treatment. The burden of this cost is borne, increasingly, by
patients themselves — and the effects can be devastating.”
The CEO of Sanofi, the company that makes Zaltrap, initially dismissed the article by Bach and his
Sloan-Kettering colleagues, saying they had taken the price of the drug out of context because of
variations in the required dosage. But four weeks later, Sanofi cut its price in half.
Bureaucrats You Can Admire
By the numbers, Medicare looks like a government program run amok. After President Lyndon B.
Johnson signed Medicare into law in 1965, the House Ways and Means Committee predicted that the
program would cost $12 billion in 1990. Its actual cost by then was $110 billion. It is likely to be nearly
$600 billion this year. That’s due to the U.S.’s aging population and the popular program’s expansion
to cover more services, as well as the skyrocketing costs of medical services generally. It’s also
because Medicare’s hands are tied when it comes to negotiating the prices for drugs or durable
medical equipment. But Medicare’s growth is not a matter of those “bureaucrats” that Betsy
McCaughey complains about having gone off the rails in how they operate it.
In fact, seeing the way Alan A.’s bills from Sloan-Kettering were vetted and processed is one of the
more eye-opening and least discouraging aspects of a look inside the world of medical economics.
The process is fast, accurate, customer-friendly and impressively high-tech. And it’s all done quietly
by a team of nonpolitical civil servants in close partnership with the private sector. In fact, despite
61
calls to privatize Medicare by creating a voucher system under which the Medicare population would
get money from the government to buy insurance from private companies, the current Medicare
system is staffed with more people employed by private contractors (8,500) than government workers
(700).
$1.5 Billion A Day
Sloan-Kettering sends Alan A.’s bills to medicare electronically, all elaborately coded according to
Medicare’s rules.
There are two basic kinds of codes for the services billed. The first is a number identifying which of
the 7,000 procedures were performed by a doctor, such as examining a chest X-ray, performing a
heart transplant or conducting an office consultation for a new patient (which costs more than a
consultation with a continuing patient — coded differently — because it typically takes more time). If a
patient presents more complicated challenges, then these basic procedures will be coded differently;
for example, there are two varieties of emergency-room consultations. Adjustments are also made for
variations in the cost of living where the doctor works and for other factors, like whether doctors used
their own office (they’ll get paid more for that) or the hospital. A panel of doctors set up by the
American Medical Association reviews the codes annually and recommends updates to Medicare.
The process can get messy as the doctors fight over which procedures in which specialties take more
time and expertise or are worth relatively more. Medicare typically accepts most of the panel’s
recommendations.
The second kind of code is used to pay the hospital for its services. Again, there are thousands of
codes based on whether the person checked in for brain surgery, an appendectomy or a fainting
spell. To come up with these numbers, Medicare takes the cost reports — including allocations for
everything from overhead to nursing staff to operating-room equipment — that hospitals across the
country are required to file for each type of service and pays an amount equal to the composite
average costs.
The hospital has little incentive to overstate its costs because it’s against the law and because each
hospital gets paid not on the basis of its own claimed costs but on the basis of the average of every
hospital’s costs, with adjustments made for regional cost differences and other local factors. Except
for emergency services, no hospital has to accept Medicare patients and these prices, but they all do.
Similar codes are calculated for laboratory and diagnostic tests like CT scans, ambulance services
and, as we saw with Alan A.’s bill, drugs dispensed.
“When I tell my friends what I do here, it sounds boring, but it’s exciting,” says Diane Kovach, who
works at Medicare’s Maryland campus and whose title is deputy director of the provider billing group.
“We are implementing a program that helps millions and millions of people, and we’re doing it in a
way that makes every one of us proud,” she adds.
Kovach, who has been at Medicare for 21 years, operates some of the gears of a machine that
reviews the more than 3 million bills that come into Medicare every day, figures out the right
payments for each and churns out more than $1.5 billion a day in wire transfers.
STEPHEN VOSS FOR TIME
Jonathan Blum
‘When hospitals say they are losing money on Medicare, my reaction is that
Central Florida is overflowing with Medicare patients and all those hospitals are
expanding and advertising for Medicare patients,’ says Blum, deputy administrator
of the Centers for Medicare and Medicaid Services. ‘Hospitals don’t lose money
when they serve Medicare patients.’
62
The part of that process that Kovach and three colleagues, with whom I spent a morning recently, are
responsible for involves overseeing the writing and vetting of thousands of instructions for coders,
who are also private contractors, employed by HP, General Dynamics and other major technology
companies. The codes they write are supposed to ensure that Medicare pays what it is supposed to
pay and catches anything in a bill that should not be paid.
For example, hundreds of instructions for code changes were needed to address Obamacare’s
requirement that certain preventive-care visits, such as those for colonoscopies or contraceptive
services, no longer be subject to Medicare’s usual outpatient co-pay of 20%. Adding to the
complexity, the benefit is limited to one visit per year for some services, meaning instructions had to
be written to track patient timelines for the codes assigned to those services.
When performing correctly, the codes produce “edits” whenever a bill is submitted with something
awry on it — if a doctor submits two preventive-care colonoscopies for the same patient in the same
year, for example. Depending on the code, an edit will result in the bill’s being sent back with
questions or being rejected with an explanation. It all typically happens without a human being
reading it. “Our goal at the first stage is that no one has to touch the bill,” says Leslie Trazzi, who
focuses on instructions and edits for doctors’ claims.
Alan A.’s bills from Sloan-Kettering are wired to a data center in Shelbyville, Ky., run by a private
company (owned by WellPoint, the insurance company that operates under the Blue Cross and Blue
Shield names in more than a dozen states) that has the contract to process claims originating from
New York and Connecticut. Medicare is paying the company about $323 million over five years —
which, as with the fees of other contractors serving other regions, works out to an average of 84¢ per
claim.
In Shelbyville, Alan A.’s status as a beneficiary is verified, and then the bill is sent electronically to a
data center in Columbia, S.C., operated by another contractor, also a subsidiary of an insurance
company. There, the codes are checked for edits, after which Alan A.’s Sloan-Kettering bill goes
electronically to a data center in Denver, where the payment instructions are prepared and entered
into what Karen Jackson, who supervises Medicare’s outside contractors, says is the largest
accounting ledger in the world. The whole process takes three days — and that long only because
the data is sent in batches.
There are multiple backups to make sure this ruthlessly efficient system isn’t just ruthless. Medicare
keeps track of and publicly reports the percentage of bills processed “clean” — i.e., with no rejected
items — within 30 days. Even the speed with which the contractors answer the widely publicized
consumer phone lines is monitored and reported. The average time to answer a call from a doctor or
other provider is 57.6 seconds, according to Medicare’s records, and the average time to answer one
of the millions of calls from patients is 2 minutes 41 seconds, down from more than eight minutes in
2007. These times might come as a surprise to people who have tried to call a private insurer. That
monitoring process is, in turn, backstopped by a separate ombudsman’s office, which has regional
and national layers.
Beyond that, the members of the House of Representatives and the Senate loom as an additional
535 ombudsmen. “We get calls every day from congressional offices about complaints that a
beneficiary’s claim has been denied,” says Jonathan Blum, the deputy administrator of CMS. As a
result, Blum’s agency has an unusually large congressional liaison staff of 52, most of whom act as
caseworkers trying to resolve these complaints.
All the customer-friendliness adds up to only about 10% of initial Medicare claims’ being denied,
according to Medicare’s latest published Composite Benchmark Metric Report. Of those initial
Medicare denials, only about 20% (2% of total claims) result in complaints or appeals, and the
63
decisions in only about half of those (or 1% of the total) end up being reversed, with the claim being
paid.
The astonishing efficiency, of course, raises the question of whether Medicare is simply funneling
money out the door as fast as it can. Some fraud is inevitable — even a rate of 0.1% is enough to
make headlines when $600 billion is being spent. It’s also possible that people can game the system
without committing outright fraud. But Medicare has multiple layers of protection against fraud that
the insurance companies don’t and perhaps can’t match because they lack Medicare’s scale.
According to Medicare’s Jackson, the contractors are “vigorously monitored for all kinds of metrics”
and required every quarter “to do a lot of data analysis and submit review plans and error-ratereduction plans.”
And then there are the RACs — a wholly separate group of private “recovery audit contractors.”
Established by Congress during the George W. Bush Administration, the RACs, says one hospital
administrator, “drive the doctors and the hospitals and even the Medicare claims processors crazy.”
The RACs’ only job is to review provider bills after they have been paid by Medicare claims
processors and look for system errors, like faulty processing, or errors in the bills as reflected in
doctor or hospital medical records that the RACs have the authority to audit.
The RACs have an incentive that any champion of the private sector would love. They get no up-front
fees but instead are paid a percentage of the money they retrieve. They eat what they kill. According
to Medicare spokeswoman Emma Sandoe, the RAC bounty hunters retrieved $797 million in the
2011 fiscal year, for which they were paid 9% to 12.5% of what they brought in, depending on the
region where they were operating.
This process can “get quite anal,” says the doctor who recently treated me for an ear infection.
Although my doctor is on Park Avenue, she, like 96% of all specialists, accepts Medicare patients
despite the discounted rates it pays, because, she says, “they pay quickly.” However, she recalls
getting bills from Medicare for 21¢ or 85¢ for supposed overpayments.
The DHHS’s inspector general is also on the prowl to protect the Medicare checkbook. It reported
recovering $1.2 billion last year through Medicare and Medicaid audits and investigations (though the
recovered funds had probably been doled out over several fiscal years). The inspector general’s work
is supplemented by a separate, multiagency federal health-care-fraud task force, which brings
criminal charges against fraudsters and issues regular press releases claiming billions more in
recoveries.
(SOUND OFF: Are Medical Bills Too High? Tell Us Why)
This does not mean the system is airtight. If anything, all that recovery activity suggests fallibility,
even as it suggests more buttoned-up operations than those run by private insurers, whose payment
systems are notoriously erratic.
Too Much Health Care?
In a review of other bills of those enrolled in Medicare, a pattern of deep, deep discounting of
chargemaster charges emerged that mirrored how Alan A.’s bills were shrunk down to reality. A
$121,414 Stanford Hospital bill for a 90-year-old California woman who fell and broke her wrist
became $16,949. A $51,445 bill for the three days an ailing 91-year-old spent getting tests and being
sedated in the hospital before dying of old age became $19,242.
Before Medicare went to work, the bill was chock-full of creative chargemaster charges from the
California Pacific Medical Center — part of Sutter Health, a dominant nonprofit Northern California
chain whose CEO made $5,241,305 in 2011.
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Another pattern emerged from a look at these bills: some seniors apparently visit doctors almost
weekly or even daily, for all varieties of ailments. Sure, as patients age they are increasingly in need
of medical care. But at least some of the time, the fact that they pay almost nothing to spend their
days in doctors’ offices must also be a factor, especially if they have the supplemental insurance that
covers most of the 20% not covered by Medicare.
Alan A. is now 89, and the mound of bills and Medicare statements he showed me for 2011 — when
he had his heart attack and continued his treatments at Sloan-Kettering — seemed to add up to
about $350,000, although I could not tell for sure because a few of the smaller ones may have been
duplicates. What is certain — because his insurance company tallied it for him in a year-end
statement — was that his total out-of-pocket expense was $1,139, or less than 0.2% of his overall
medical bills.
Those bills included what seemed to be 33 visits in one year to 11 doctors who had nothing to do with
his recovery from the heart attack or his cancer. In all cases, he was routinely asked to pay almost
nothing: $2.20 for a check of a sinus problem, $1.70 for an eye exam, 33¢ to deal with a bunion.
When he showed me those bills he chuckled.
A comfortable member of the middle class, Alan A. could easily afford the burden of higher co-pays
that would encourage him to use doctors less casually or would at least stick taxpayers with less of
the bill if he wants to get that bunion treated. AARP (formerly the American Association of Retired
Persons) and other liberal entitlement lobbies oppose these types of changes and consistently distort
the arithmetic around them.
But it seems clear that Medicare could save billions of dollars if it required that no Medicare
supplemental-insurance plan for people with certain income or asset levels could result in their
paying less than, say, 10% of a doctor’s bill until they had paid $2,000 or $3,000 out of their pockets
in total bills in a year. (The AARP might oppose this idea for another reason: it gets royalties from
UnitedHealthcare for endorsing United’s supplemental-insurance product.)
Medicare spent more than $6.5 billion last year to pay doctors (even at the discounted Medicare
rates) for the service codes that denote the most basic categories of office visits. By asking people
like Alan A. to pay more than a negligible share, Medicare could recoup $1 billion to $2 billion of
those costs yearly.
Too Much Doctoring?
Another doctor’s bill, for which Alan A.’s share was 19¢, suggests a second apparent flaw in the
system.
This was one of 50 bills from 26 doctors who saw Alan A. at Virtua Marlton hospital or at the
ManorCare convalescent center after his heart attack or read one of his diagnostic tests at the two
facilities. “They paraded in once a day or once every other day, looked at me and poked around a bit
and left,” Alan A. recalls. Other than the doctor in charge of his heart-attack recovery, “I had no idea
who they were until I got these bills. But for a dollar or two, so what?”
The “so what,” of course, is that although Medicare deeply discounted the bills, it — meaning
taxpayers — still paid from $7.48 (for a chest X-ray reading) to $164 for each encounter.
“One of the benefits attending physicians get from many hospitals is the opportunity to cruise the
halls and go into a Medicare patient’s room and rack up a few dollars,” says a doctor who has worked
at several hospitals across the country. “In some places it’s a Monday-morning tradition. You go see
the people who came in over the weekend. There’s always an ostensible reason, but there’s also a
lot of abuse.”
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PHOTOGRAPH BY NICK VEASEY FOR TIME
Sodium Chloride $84
Hospital charge for standard saline solution. Online, a liter bag costs $5.16
When health care wonks focus on this kind of overdoctoring, they complain
(and write endless essays) about what they call the fee-for-service mode,
meaning that doctors mostly get paid for the time they spend treating patients
or ordering and reading tests. Alan A. didn’t care how much time his cancer or
heart doctor spent with him or how many tests he got. He cared only that he got better.
Some private care organizations have made progress in avoiding this overdoctoring by paying
salaries to their physicians and giving them incentives based on patient outcomes. Medicare and
private insurers have yet to find a way to do that with doctors, nor are they likely to, given the current
structure that involves hundreds of thousands of private providers billing them for their services.
In passing Obamacare, Congress enabled Medicare to drive efficiencies in hospital care based on
the notion that good care should be rewarded and the opposite penalized. The primary lever is a
system of penalties Obamacare imposes on hospitals for bad care — a term defined as unacceptable
rates of adverse events, such as infections or injuries during a patient’s hospital stay or readmissions
within a month after discharge. Both kinds of adverse events are more common than you might think:
1 in 5 Medicare patients is readmitted within 30 days, for example. One Medicare report asserts that
“Medicare spent an estimated $4.4 billion in 2009 to care for patients who had been harmed in the
hospital, and readmissions cost Medicare another $26 billion.” The anticipated savings that will be
produced by the threat of these new penalties are what has allowed the Obama Administration to
claim that Obamacare can cut hundreds of billions of dollars from Medicare over the next 10 years
without shortchanging beneficiaries. “These payment penalties are sending a shock through the
system that will drive costs down,” says Blum, the deputy administrator of the Centers for Medicare
and Medicaid Services.
There are lots of other shocks Blum and his colleagues would like to send. However, Congress won’t
allow him to. Chief among them, as we have seen, would be allowing Medicare, the world’s largest
buyer of prescription drugs, to negotiate the prices that it pays for them and to make purchasing
decisions on the basis of comparative effectiveness. But there’s also the cane that Alan A. got after
his heart attack. Medicare paid $21.97 for it. Alan A. could have bought it on Amazon for about $12.
Other than in a few pilot regions that Congress designated in 2011 after a push by the Obama
Administration, Congress has not allowed Medicare to drive down the price of any so-called durable
medical equipment through competitive bidding.
This is more than a matter of the 124,000 canes Medicare reports that it buys every year. It’s about
mail-order diabetic supplies, wheelchairs, home medical beds and personal oxygen supplies too.
Medicare spends about $15 billion annually for these goods.
In the areas of the country where Medicare has been allowed by Congress to conduct a competitivebidding pilot program, the process has produced savings of 40%. But so far, the pilot programs cover
only about 3% of the medical goods seniors typically use. Taking the program nationwide and saving
40% of the entire $15 billion would mean saving $6 billion a year for taxpayers.
The Way Out Of the Sinkhole
“I was driving through central Florida a year or two ago,” says Medicare’s Blum. “And it seemed like
every billboard I saw advertised some hospital with these big shiny buildings or showed some new
wing of a hospital being constructed … So when you tell me that the hospitals say they are losing
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money on Medicare and shifting costs from Medicare patients to other patients, my reaction is that
Central Florida is overflowing with Medicare patients and all those hospitals are expanding and
advertising for Medicare patients. So you can’t tell me they’re losing money … Hospitals don’t lose
money when they serve Medicare patients.”
If that’s the case, I asked, why not just extend the program to everyone and pay for it all by charging
people under 65 the kinds of premiums they would pay to private insurance companies? “That’s not
for me to say,” Blum replied.
In the debate over controlling Medicare costs, politicians from both parties continue to suggest that
Congress raise the age of eligibility for Medicare from 65 to 67. Doing so, they argue, would save the
government tens of billions of dollars a year. So it’s worth noting another detail about the case of
Janice S., which we examined earlier. Had she felt those chest pains and gone to the Stamford
Hospital emergency room a month later, she would have been on Medicare, because she would have
just celebrated her 65th birthday.
If covered by Medicare, Janice S.’s $21,000 bill would have been deeply discounted and, as is
standard, Medicare would have picked up 80% of the reduced cost. The bottom line is that Janice S.
would probably have ended up paying $500 to $600 for her 20% share of her heart-attack scare. And
she would have paid only a fraction of that — maybe $100 — if, like most Medicare beneficiaries, she
had paid for supplemental insurance to cover most of that 20%.
In fact, those numbers would seem to argue for lowering the Medicare age, not raising it — and not
just from Janice S.’s standpoint but also from the taxpayers’ side of the equation. That’s not a liberal
argument for protecting entitlements while the deficit balloons. It’s just a matter of hardheaded
arithmetic.
As currently constituted, Obamacare is going to require people like Janice S. to get private insurance
coverage and will subsidize those who can’t afford it. But the cost of that private insurance — and
therefore those subsidies — will be much higher than if the same people were enrolled in Medicare at
an earlier age. That’s because Medicare buys health care services at much lower rates than any
insurance company. Thus the best way both to lower the deficit and to help save money for people
like Janice S. would seem to be to bring her and other near seniors into the Medicare system before
they reach 65. They could be required to pay premiums based on their incomes, with the poor paying
low premiums and the better off paying what they might have paid a private insurer. Those who can
afford it might also be required to pay a higher proportion of their bills — say, 25% or 30% — rather
than the 20% they’re now required to pay for outpatient bills.
Meanwhile, adding younger people like Janice S. would lower the overall cost per beneficiary to
Medicare and help cut its deficit still more, because younger members are likelier to be healthier.
From Janice S.’s standpoint, whatever premium she would pay for this age-64 Medicare protection
would still be less than what she had been paying under the COBRA plan that she wished she could
have kept after the rules dictated that she be cut off after she lost her job.
The only way this would not work is if 64-year-olds started using health care services they didn’t
need. They might be tempted to, because, as we saw with Alan A., Medicare’s protection is so broad
and supplemental private insurance costs so little that it all but eliminates patients’ obligation to pay
the 20% of outpatient-care costs that Medicare doesn’t cover. To deal with that, a provision could be
added requiring that 64-year-olds taking advantage of Medicare could not buy insurance freeing them
from more than, say, 5% or 10% of their responsibility for the bills, with the percentage set according
to their wealth. It would be a similar, though more stringent, provision of the kind I’ve already
suggested for current Medicare beneficiaries as a way to cut the cost of people overusing benefits.
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If that logic applies to 64-year-olds, then it would seem to apply even more readily to healthier 40year-olds or 18-year-olds. This is the single-payer approach favored by liberals and used by most
developed countries.
Then again, however much hospitals might survive or struggle under that scenario, no doctor could
hope for anything approaching the income he or she deserves (and that will make future doctors
want to practice) if 100% of their patients yielded anything close to the low rates Medicare pays.
SOUND OFF: Are Medical Bills Too High? Tell Us Why
“If you could figure out a way to pay doctors better and separately fund research … adequately, I
could see where a single-payer approach would be the most logical solution,” says Gunn, SloanKettering’s chief operating officer. “It would certainly be a lot more efficient than hospitals like ours
having hundreds of people sitting around filling out dozens of different kinds of bills for dozens of
insurance companies.” Maybe, but the prospect of overhauling our system this way, displacing all the
private insurers and other infrastructure after all these decades, isn’t likely. For there would be one
group of losers — and these losers have lots of clout. They’re the health care providers like hospitals
and CT-scan-equipment makers whose profits — embedded in the bills we have examined — would
be sacrificed. They would suffer because of the lower prices Medicare would pay them when the
patient is 64, compared with what they are able to charge when that patient is either covered by
private insurance or has no insurance at all.
That kind of systemic overhaul not only seems unrealistic but is also packed with all kinds of risk
related to the microproblems of execution and the macro issue of giving government all that power.
Yet while Medicare may not be a realistic systemwide model for reform, the way Medicare works
does demonstrate, by comparison, how the overall health care market doesn’t work.
Unless you are protected by Medicare, the health care market is not a market at all. It’s a crapshoot.
People fare differently according to circumstances they can neither control nor predict. They may
have no insurance. They may have insurance, but their employer chooses their insurance plan and it
may have a payout limit or not cover a drug or treatment they need. They may or may not be old
enough to be on Medicare or, given the different standards of the 50 states, be poor enough to be on
Medicaid. If they’re not protected by Medicare or they’re protected only partly by private insurance
with high co-pays, they have little visibility into pricing, let alone control of it. They have little choice of
hospitals or the services they are billed for, even if they somehow know the prices before they get
billed for the services. They have no idea what their bills mean, and those who maintain the
chargemasters couldn’t explain them if they wanted to. How much of the bills they end up paying may
depend on the generosity of the hospital or on whether they happen to get the help of a billing
advocate. They have no choice of the drugs that they have to buy or the lab tests or CT scans that
they have to get, and they would not know what to do if they did have a choice. They are powerless
buyers in a seller’s market where the only sure thing is the profit of the sellers.
Indeed, the only player in the system that seems to have to balance countervailing interests the way
market players in a real market usually do is Medicare. It has to answer to Congress and the
taxpayers for wasting money, and it has to answer to portions of the same groups for trying to hold on
to money it shouldn’t. Hospitals, drug companies and other suppliers, even the insurance companies,
don’t have those worries.
Moreover, the only players in the private sector who seem to operate efficiently are the private
contractors working — dare I say it? — under the government’s supervision. They’re the Medicare
claims processors that handle claims like Alan A.’s for 84¢ each. With these and all other Medicare
costs added together, Medicare’s total management, administrative and processing expenses are
about $3.8 billion for processing more than a billion claims a year worth $550 billion. That’s an overall
68
administrative and management cost of about two-thirds of 1% of the amount of the claims, or less
than $3.80 per claim. According to its latest SEC filing, Aetna spent $6.9 billion on operating
expenses (including claims processing, accounting, sales and executive management) in 2012.
That’s about $30 for each of the 229 million claims Aetna processed, and it amounts to about 29% of
the $23.7 billion Aetna pays out in claims.
The real issue isn’t whether we have a single payer or multiple payers. It’s whether whoever pays has
a fair chance in a fair market. Congress has given Medicare that power when it comes to dealing with
hospitals and doctors, and we have seen how that works to drive down the prices Medicare pays, just
as we’ve seen what happens when Congress handcuffs Medicare when it comes to evaluating and
buying drugs, medical devices and equipment. Stripping away what is now the sellers’ overwhelming
leverage in dealing with Medicare in those areas and with private payers in all aspects of the market
would inject fairness into the market. We don’t have to scrap our system and aren’t likely to. But we
can reduce the $750 billion that we overspend on health care in the U.S. in part by acknowledging
what other countries have: because the health care market deals in a life-or-death product, it cannot
be left to its own devices.
Put simply, the bills tell us that this is not about interfering in a free market. It’s about facing the reality
that our largest consumer product by far — one-fifth of our economy — does not operate in a free
market.
So how can we fix it?
Changing Our Choices
We should tighten antitrust laws related to hospitals to keep them from becoming so dominant in a
region that insurance companies are helpless in negotiating prices with them. The hospitals’
continuing consolidation of both lab work and doctors’ practices is one reason that trying to cut the
deficit by simply lowering the fees Medicare and Medicaid pay to hospitals will not work. It will only
cause the hospitals to shift the costs to non-Medicare patients in order to maintain profits — which
they will be able to do because of their increasing leverage in their markets over insurers. Insurance
premiums will therefore go up — which in turn will drive the deficit back up, because the subsidies on
insurance premiums that Obamacare will soon offer to those who cannot afford them will have to go
up.
Similarly, we should tax hospital profits at 75% and have a tax surcharge on all nondoctor hospital
salaries that exceed, say, $750,000. Why are high profits at hospitals regarded as a given that we
have to work around? Why shouldn’t those who are profiting the most from a market whose costs are
victimizing everyone else chip in to help? If we recouped 75% of all hospital profits (from nonprofit as
well as for-profit institutions), that would save over $80 billion a year before counting what we would
save on tests that hospitals might not perform if their profit incentives were shaved.
To be sure, this too seems unlikely to happen. Hospitals may be the most politically powerful
institution in any congressional district. They’re usually admired as their community’s most important
charitable institution, and their influential stakeholders run the gamut from equipment makers to drug
companies to doctors to thousands of rank-and-file employees. Then again, if every community paid
more attention to those administrator salaries, to those nonprofits’ profit margins and to charges like
$77 for gauze pads, perhaps the political balance would shift.
We should outlaw the chargemaster. Everyone involved, except a patient who gets a bill based on
one (or worse, gets sued on the basis of one), shrugs off chargemasters as a fiction. So why not
require that they be rewritten to reflect a process that considers actual and thoroughly transparent
costs? After all, hospitals are supposed to be government-sanctioned institutions accountable to the
public. Hospitals love the chargemaster because it gives them a big number to put in front of rich
uninsured patients (typically from outside the U.S.) or, as is more likely, to attach to lawsuits or give to
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bill collectors, establishing a place from which they can negotiate settlements. It’s also a great place
from which to start negotiations with insurance companies, which also love the chargemaster
because they can then make their customers feel good when they get an Explanation of Benefits that
shows the terrific discounts their insurance company won for them.
But for patients, the chargemasters are both the real and the metaphoric essence of the broken
market. They are anything but irrelevant. They’re the source of the poison coursing through the
health care ecosystem.
We should amend patent laws so that makers of wonder drugs would be limited in how they can
exploit the monopoly our patent laws give them. Or we could simply set price limits or profit-margin
caps on these drugs. Why are the drug profit margins treated as another given that we have to work
around to get out of the $750 billion annual overspend, rather than a problem to be solved?
Just bringing these overall profits down to those of the software industry would save billions of
dollars. Reducing drugmakers’ prices to what they get in other developed countries would save over
$90 billion a year. It could save Medicare — meaning the taxpayers — more than $25 billion a year,
or $250 billion over 10 years. Depending on whether that $250 billion is compared with the
Republican or Democratic deficit-cutting proposals, that’s a third or a half of the Medicare cuts now
being talked about.
Similarly, we should tighten what Medicare pays for CT or MRI tests a lot more and even cap what
insurance companies can pay for them. This is a huge contributor to our massive overspending on
outpatient costs. And we should cap profits on lab tests done in-house by hospitals or doctors.
Finally, we should embarrass Democrats into stopping their fight against medical-malpractice reform
and instead provide safe-harbor defenses for doctors so they don’t have to order a CT scan
whenever, as one hospital administrator put it, someone in the emergency room says the word head.
Trial lawyers who make their bread and butter from civil suits have been the Democrats’ biggest
financial backer for decades. Republicans are right when they argue that tort reform is overdue.
Eliminating the rationale or excuse for all the extra doctor exams, lab tests and use of CT scans and
MRIs could cut tens of billions of dollars a year while drastically cutting what hospitals and doctors
spend on malpractice insurance and pass along to patients.
Other options are more tongue in cheek, though they illustrate the absurdity of the hole we have
fallen into. We could limit administrator salaries at hospitals to five or six times what the lowest-paid
licensed physician gets for caring for patients there. That might take care of the self-fulfilling peer
dynamic that Gunn of Sloan-Kettering cited when he explained, “We all use the same compensation
consultants.” Then again, it might unleash a wave of salary increases for junior doctors.
Or we could require drug companies to include a prominent, plain-English notice of the gross profit
margin on the packaging of each drug, as well as the salary of the parent company’s CEO. The same
would have to be posted on the company’s website. If nothing else, it would be a good test of
embarrassment thresholds.
None of these suggestions will come as a revelation to the policy experts who put together
Obamacare or to those before them who pushed health care reform for decades. They know what the
core problem is — lopsided pricing and outsize profits in a market that doesn’t work. Yet there is little
in Obamacare that addresses that core issue or jeopardizes the paydays of those thriving in that
marketplace. In fact, by bringing so many new customers into that market by mandating that they get
health insurance and then providing taxpayer support to pay their insurance premiums, Obamacare
enriches them. That, of course, is why the bill was able to get through Congress.
Obamacare does some good work around the edges of the core problem. It restricts abusive
hospital-bill collecting. It forces insurers to provide explanations of their policies in plain English. It
70
requires a more rigorous appeal process conducted by independent entities when insurance
coverage is denied. These are all positive changes, as is putting the insurance umbrella over tens of
millions more Americans — a historic breakthrough. But none of it is a path to bending the health
care cost curve. Indeed, while Obamacare’s promotion of statewide insurance exchanges may help
distribute health-insurance policies to individuals now frozen out of the market, those exchanges
could raise costs, not lower them. With hospitals consolidating by buying doctors’ practices and
competing hospitals, their leverage over insurance companies is increasing. That’s a trend that will
only be accelerated if there are more insurance companies with less market share competing in a
new exchange market trying to negotiate with a dominant hospital and its doctors. Similarly, higher
insurance premiums — much of them paid by taxpayers through Obamacare’s subsidies for those
who can’t afford insurance but now must buy it — will certainly be the result of three of Obamacare’s
best provisions: the prohibitions on exclusions for pre-existing conditions, the restrictions on co-pays
for preventive care and the end of annual or lifetime payout caps.
Put simply, with Obamacare we’ve changed the rules related to who pays for what, but we haven’t
done much to change the prices we pay.
When you follow the money, you see the choices we’ve made, knowingly or unknowingly.
Over the past few decades, we’ve enriched the labs, drug companies, medical device makers,
hospital administrators and purveyors of CT scans, MRIs, canes and wheelchairs. Meanwhile, we’ve
squeezed the doctors who don’t own their own clinics, don’t work as drug or device consultants or
don’t otherwise game a system that is so gameable. And of course, we’ve squeezed everyone
outside the system who gets stuck with the bills.
We’ve created a secure, prosperous island in an economy that is suffering under the weight of the
riches those on the island extract.
And we’ve allowed those on the island and their lobbyists and allies to control the debate, diverting
us from what Gerard Anderson, a health care economist at the Johns Hopkins Bloomberg School of
Public Health, says is the obvious and only issue: “All the prices are too damn high.”
Steven Brill @StevenBrill
Brill, the author of Class Warfare: Inside the Fight to Fix America’s Schools, is the founder of
Court TV and the American Lawyer
Read more: http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-killing-us/
#ixzz2Mf8kF6Ap
retour à l'index
71
LE MONDE SCIENCE ET TECHNO
10.01.2013 à 15h32 •
Par Florence Rosier
05. Benzodiazépines : une
overdose française
Il est certains records dont on se passerait. Telle notre consommation nationale de tranquillisants,
somnifères et autres "pilules du bonheur" : nous sommes les champions européens de leur
utilisation. Pour les hypnotiques (somnifères), nous sommes en deuxième position derrière la Suède.
Pour les anxiolytiques (tranquillisants), nous sommes les deuxièmes derrière le Portugal. Pour les
deux réunis, les premiers.
Cette overdose française concerne notamment les benzodiazépines. Ces psychotropes, 22 en tout
sur le marché national, sont indiqués dans le traitement de l'anxiété, des troubles sévères du
sommeil, des épilepsies et des contractures musculaires douloureuses. Un Français sur cinq a
consommé au moins une fois une benzodiazépine en 2010. Plus de 25 millions de personnes ont été
exposées à l'un de ces médicaments entre mi-2006 et mi-2011, note l'Agence nationale de sécurité
du médicament et des produits de santé (ANSM).
Depuis plus de vingt ans, au moins trois rapports ont alerté les pouvoirs publics sur les risques liés à
cet abus. "En 2006, nous faisions, comme dans les précédents rapports, des propositions assez
simples pour améliorer la situation, indique Bernard Bégaud, pharmaco-épidémiologiste de l'Inserm à
l'université de Bordeaux. Rien de notable n'a été fait. Il est difficile de comprendre pourquoi ce
problème de santé publique n'a pas été traité plus tôt comme une priorité."
RISQUE DE DÉMENCE
Les autorités sanitaires, après leur longue léthargie, vont-elles se réveiller ? Un nouveau signal
résonne dans le paysage sanitaire. Aux risques déjà bien connus liés à la consommation de
benzodiazépines s'ajouterait un nouveau risque potentiel de démence due à leur utilisation au long
cours. Le 28 septembre 2012, le laboratoire de Bernard Bégaud publiait dans le British Medical
Journal, avec deux autres équipes bordelaises, une étude indiquant une association statistique entre
la prise prolongée de benzodiazépines et le risque de démence chez les plus de 65 ans. Résultat
aujourd'hui conforté par les données préliminaires - non encore publiées - d'une autre étude
bordelaise, celle de Christophe Tzourio.
Ces deux études viennent de pousser l'ANSM à envoyer un courrier de mise en garde sur ce risque
potentiel à quelque 75 000 médecins généralistes, 2 500 neurologues et 12 000 psychiatres,
rappelant les règles de prescription et de bon usage des benzodiazépines. Pour Dominique
Maraninchi, directeur général de l'ANSM, "la concordance de ces deux études françaises justifie des
actions plus marquées de la part des autorités sanitaires".
Revirement difficile : dès leur lancement dans les années 1960, les benzodiazépines apparaissent
comme des produits miracles, comparées aux barbituriques, très toxiques. Elles procurent une
sécurité d'emploi immédiate. Le psychiatre Patrick Lemoine se souvient qu'"à la faculté de médecine
de Lyon, les "patrons" nous disaient : "les benzodiazépines, c'est tant que vous voulez, aussi
longtemps que vous voulez"".
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Mais cette facilité d'utilisation tourne au piège. Enfermant dans la dépendance les patients qui en
redemandent, les médecins leur en prescrivent toujours plus. "Les benzodiazépines sont des
produits utiles, très utilisés et extrêmement mal utilisés, résume Bernard Bégaud. La moitié des
personnes sous benzodiazépines en France sont traitées hors indications ou hors
recommandations." La durée médiane de traitement par un anxiolytique ou un hypnotique est de sept
mois en France. Mais la durée maximale de prescription recommandée est de douze semaines pour
les anxiolytiques, de quatre pour les hypnotiques. "En maisons de retraite, les benzodiazépines sont
trop souvent prescrites au long cours, dans des troubles du comportement où elles ne sont pas
indiquées", indique Bruno Vellas, responsable du gérontopôle (CHU de Toulouse, Inserm).
SURPRESCRIPTION
La grande majorité (79 %) des primoprescripteurs de benzodiazépines sont des médecins
généralistes. Claude Leicher, médecin généraliste et président su syndicat MG France, en témoigne :
"Depuis une dizaine d'années, nous constatons que la pression dans le monde du travail a
considérablement augmenté du haut en bas de l'échelle sociale. Il n'est pas un jour où nous ne
sommes face à un patient en demande de prise en charge d'un trouble anxio-dépressif. Face à une
telle plainte, deux modes d'intervention sont possibles avant d'envisager un traitement
médicamenteux : l'arrêt de travail ou un accompagnement psychothérapeutique. Mais nous sommes
conscients de cette surprescription de psychotropes et de la nécessité de la maîtriser."
Une enquête menée auprès de médecins généralistes, à Nantes, en 2010-1012, a révélé deux
facteurs intervenant dans cette surprescription de benzodiazépines : "La difficulté d'accompagner le
sevrage pour les généralistes, et leur volonté revendiquée de répondre aux plaintes des patients
dans une logique compassionnelle, explique le professeur Vincent Renard, président du Collège
national des généralistes enseignants. Dans le même temps, ils s'efforcent de diminuer les doses."
Pour Patrick Lemoine, "les médecins français ne sont pas formés à la gestion du refus. Et ils croient
plus à la chimie qu'à des prises en charge physiques ou psychothérapeutiques. Mais la raison
profonde de cette surprescription tient à la non-prise en charge financière des psychothérapies par
les psychologues".
"Il y a en France une frilosité pour parler des inconvénients des benzodiazépines qui frise
l'inconscience, se désole le psychiatre. Le conservatisme de l'Afssaps, aujourd'hui ANSM, est
énorme. L'Afssaps a ainsi été très longue à réagir pour retirer ou restreindre l'utilisation de divers
psychotropes aux effets indésirables importants. Par exemple, le Noctran, un hypnotique associant
trois molécules dont une benzodiazépine, n'a été retiré du marché qu'en octobre 2011. Membre de la
commission de transparence "Sommeil" de l'Afssaps, je m'étais pourtant battu depuis le début des
années 2000 pour son retrait." Il cite d'autres exemples de cet immobilisme, notamment à propos du
Rohypnol, hypnotique exposant à un fort risque de dépendance, de soumission chimique et d'usage
détourné par des toxicomanes.
LA VOIE DE L'ORDONNANCE SÉCURISÉE
Des mesures éparses ont pourtant été prises. En 1991, la durée maximale de prescription a été
limitée pour les anxiolytiques et les hypnotiques. En 2001, elle a été restreinte à quatorze jours pour
le Rohypnol ; en 2010, à douze semaines pour le Rivotril. Cet antiépileptique, surnommé "drogue du
viol", était détourné à des fins de soumission chimique. "Son usage flambait", observe Dominique
Maraninchi. Pour plusieurs benzodiazépines particulièrement détournées par les toxicomanes, la
prescription sur ordonnance sécurisée a été rendue obligatoire. Et en 2012, la prescription du Rivotril
a été restreinte aux neurologues et aux pédiatres.
Il y a eu aussi les recommandations répétées de la Haute Autorité de santé sur le bon usage de ces
molécules maintes fois adressées aux prescripteurs. Avec un effet dérisoire, en regard des enjeux :
les chiffres de l'assurance-maladie montrent, pour 2011, des montants de vente et de
remboursement des benzodiazépines désespérément stables par rapport à 2010 et 2009. "La HAS a
certes émis des recommandations sur le bon usage de ces médicaments. Mais elles sont difficiles à
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mettre en pratique. Face à leurs patients qui réclament des benzodiazépines, les médecins
généralistes restent en difficulté. La réponse doit être collective", estime le professeur Régis Bordet,
neuropharmacologue au CHU de Lille.
En plus du nouveau risque potentiel de démence, les risques liés aux benzodiazépines sont connus
et répertoriés dans le Vidal, bible des médicaments. Interactions médicamenteuses, dépendance,
risque de chutes notamment chez les personnes âgées, pertes de mémoire, troubles cognitif et
comportemental... "Un sevrage brutal peut entraîner une confusion, une épilepsie et des bouffées
délirantes. Certains cas sont mortels", dit Patrick Lemoine. "Ce qui m'inquiète le plus avec les
benzodiazépines, c'est le risque de somnolence au volant, relève le professeur Pierre-Louis Druais,
président du Collège de la médecine générale. En parler est au moins aussi important qu'informer
sur le risque potentiel de démence." Le risque d'accidents de la route sous benzodiazépines apparaît
accru de 20 %, selon une étude française publiée dans PLoS Medicine en 2010.
"Les pouvoirs publics doivent prendre à bras-le-corps l'objectif de diminuer ostensiblement la
consommation de benzodiazépines", affirme Régis Bordet. Mais comme pour les pilules de troisième
génération, Dominique Maraninchi parle de "numéro d'équilibriste". D'où cette impression de
louvoiement ? Un bord tiré pour mettre en garde sur les risques. Un bord pour rassurer sur l'intérêt
de ces molécules, bien utilisées. "Nous devons faire attention aux usagers, justifie le directeur de
l'ANSM. Des millions de personnes sont aujourd'hui sous benzodiazépines. Ce sont aussi de très
bons médicaments, quand ils sont prescrits à bon escient et sur de courtes périodes." Créer un vent
de panique serait nocif. Il ne s'agit pas de causer une flambée d'arrêts de traitement brutaux avec
syndrome de sevrage. Ou des reports massifs vers des psychotropes plus à risque. Ou des refus de
traitement par des patients qui en ont vraiment besoin.
Les autorités se saisiront-elles de ce risque possible de démence pour se mobiliser ? Parmi les
différentes solutions évoquées : faciliter l'accès aux psychothérapies. Des remèdes que la littérature
aurait privilégiés s'ils avaient été disponibles du temps de Baudelaire : "L'angoisse atroce,
despotique,/Sur mon crâne incliné plante son drapeau noir". Sous benzodiazépines au long cours,
que serait devenue la créativité du poète ?
Réservés aux abonnés :
Un risque de démence accru ?
Tempête dans les cerveaux
Plusieurs pistes contre le mésusage
retour à l'index
74
DE L’INTÉRÊT DU CONFLIT
Information sur les lanceurs d'alertes, les
conflits d'intérêts d'experts et une recherche
transparente
06. Dépendance aux
antidouleurs opiacés : un fléau
venu des Etats-Unis
Benjamin Sourice
Journaliste chez Précaire&Militant
Publié le 15/01/2013 à 18h27
Le drapeau américain en pilules (M.a.r.c/Flickr/CC)
L’addiction médicamenteuse aux antalgiques opiacés est devenu
un fléau sanitaire des plus préoccupants pour les autorités
d’Amérique du Nord.
En 2012, 16 500 personnes sont mortes d’une overdose
d’antalgiques opiacés sur le territoire américain, ce qui
représente plus de décès que ceux causés par les surdoses de
cocaïne et d’héroïne réunies.
Les overdoses concernent :
1
dans 20% des cas, des patients suivis par un seul docteur et prenant de faibles doses ;
2
pour 40%, il s’agit de patients suivis mais sur des doses prescrites élevées ;
3
dans 40% des cas, il s’agit d’un usage détourné lié à la toxicomanie.
60% des overdoses adviennent donc dans le cadre d’une consommation d’antidouleur opiacés
prescrites. Cependant, les patients qui deviennent accros s’automédicamentent et augmentent euxmêmes les doses, ce qui les conduit à l’overdose.
Quelque deux millions d’Américains seraient dépendants à ces médicaments indique le Washington
Post qui qualifie ce phénomène d’"épidémie" dans une enquête retentissante, publiée le
31 décembre 2012.
De son coté, le ministère de la Santé canadienne reconnaît qu’"au cours des derniers dix ans, la
surconsommation d’analgésiques opioïdes et la dépendance à ceux-ci sont devenus un problème de
santé publique".
Antidouleur de palier III
Trois médicaments font des ravages dans les territoires nord-américains :
1
l’Oxycontin (oxycodone) ;
2
le Percocet (oxycodone) ;
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3
le Vicodin (hydrocodone).
Le Dr. Xavier Laqueille, responsable du service d’addictologie de l’Hôpital Sainte-Anne à Paris,
explique :
"Ce qui caractérise l’Oxycontin, c’est la puissance de son effet dysleptique, ce qui explique
également son attraction pour les toxicomanes."
Classés par l’Organisation mondiale de la santé (OMS) comme antidouleur de palier III, au même
niveau que les stupéfiants (morphine), ces dérivés opiacés sont délivrés aux Etats-Unis sur simple
ordonnance, aisément falsifiable, et distribués dans toutes les pharmacies du pays sans réel contrôle
des autorités sanitaires.
Normalement prescrits pour soulager les douleurs les plus aiguës (cancers), ces médicaments sont
désormais distribués aux patients pour des maux chroniques de moindre intensité (arthrite, mal de
dos...), relate le Washington Post.
Ces opiacés puissants créent une accoutumance, puis une dépendance en cas de traitement
prolongé ou d’usage détourné, dont le sevrage peut être désagréable pour le patient qui ressentira
des effets de manque (nausée, insomnies...).
Ces médicaments opioïdes peuvent également causer de l’euphorie, ce qui a tendance, chez
certains patients, a entraîner une surconsommation liée à une recherche de bien-être.
Un risque de dépendance connue de longue date par les médecins qui, jusqu’à la fin des années 90,
faisaient preuve d’une certaine "opiophobie".
Evolution de la consommation d’opioïdes aux Etats-Unis (Capture d’écran d’un document du CDC)
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Une dépendance sous-évaluée par les labos
Le Washington Post révèle dans son enquête comment les laboratoires, en particulier Purdue
Pharma, le distributeur de l’Oxycontin depuis 1995, ont manœuvré pour imposer l’idée que ces
antidouleurs "posaient un risque minimum d’addiction".
La presse scientifique a été noyée sous des flots d’études réalisées par les entreprises et signées
par des praticiens de renom selon la pratique des "nègres scientifiques" ( "ghostwriting"). Pour
assurer leur publicité, ces entreprises se sont entourées de personnalités influentes du monde
médical, comme le Pr. Russell Portenoy, spécialiste new-yorkais de la douleur et par ailleurs
conseiller pour l’Agence fédérale américaine des produits alimentaires et médicamenteux (Food and
Drug Administration, FDA).
Le Washington Post révèle également qu’en 2002, huit des dix experts de la FDA chargés d’évaluer
le risque de dépendance avaient des liens d’intérêts avec l’industrie, dont cinq avec Purdue.
Entre 1997 et 2007, la distribution des antidouleurs opiacés va augmenter de 627%, relève une
étude américaine [PDF] de 2011 des Centres fédéraux de contrôle et de prévention des maladies
(CDC). La production actuelle permettrait de fournir "à chaque Américain une dose de 5 mg de
Vicodin toutes les quatre heures pendant un mois", d’après le CDC.
En France, stupéfiants et antalgiques
En France, il existe deux types d’opiacés sur le marché pouvant être prescrits par des médecins
généralistes :
1
les antalgiques ;
2
les traitements de substitution à l’héroïne, comme la méthadone ou le Subutex.
En 2009, deux personnes sont décédées [PDF] sur le territoire français suite à une overdose
d’oxycodone, classé parmi les stupéfiants.
Pour les obtenir, la loi française impose l’utilisation d’ordonnance sécurisée sur les stupéfiants (palier
III), comportant filigrane, numéro de série et identification du patient comme du prescripteur, avec
une limite de validité de 72 heures après la prescription.
Ces substitutifs bon marché sont très recherchés des toxicomanes qui en détournent parfois l’usage
pour alimenter des trafics de rue. Le Dr Laqueille :
"Historiquement, en France, les toxicomanies médicamenteuses sur des antalgiques opiacés
concernent la codéine, avec par exemple le détournement du Néo-codion, ou ceux à base de
morphine, comme le Skenan."
Overdose au Tramadol
Le Tramadol est lui prescrit aux personnes souffrant de pathologies douloureuses. C’est un
antidouleur opiacé intermédiaire (palier II) prescrit notamment en remplacement du Di-Antalvic,
antidouleur non opiacé retiré en 2011 alors que huit millions de Français en consommaient
régulièrement.
L’Agence nationale de sécurité du médicament et des produits de santé (Afssaps devenue ANSM),
qui l’a classé parmi les médicaments à surveiller, a estimé en janvier 2012 que les ventes françaises
de Tramadol avaient augmenté de 30%.
Il peut être détourné comme drogue, notamment dans les pays du tiers monde. En 2010, la
Commission nationale des stupéfiant et des psychotropes relevait sept cas de décès par overdose
de Tramadol en France et une augmentation de l’implication des "substances opiacées licites hors
médicaments de substitution" dans 15,8% des cas d’overdoses enregistrées.
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De plus en plus prescrit, le Tramadol a fait l’objet
d’alertes des praticiens et des autorités sanitaires
pour la dépendance qu’il peut provoquer et les risques
de détournement.
"Dérive des prescriptions"
Le docteur Laqueille reconnaît que "la généralisation
de ces traitements (les analgésiques opioïdes) relève
d’une dérive dans les prescriptions" mais que la
"demande joue un rôle non négligeable".
Spécialiste de la pharmacodépendance du CHU de
Toulouse, la Pr. Anne Roussin avertit [PDF] qu’avec le
Tramadol, une "dépendance" peut s’installer chez des
patients "suite à des prescriptions à but antalgique".
Elle souligne la vulnérabilité de ceux qui, accoutumés,
augmenteraient les doses "parfois à la recherche d’un
bien-être, d’un effet plaisant, euphorisant ou
stimulant". Une mise en garde à prendre avec le plus
grand sérieux aux vues du "pharmageddon"
américain.
LE TRAMADOL
Médicament contenant du Tramadol, vendu sous
les noms de :
– Monoalgic LP
– Zaldiar
– Contramal
– Topalgic
– Biodalgic
– Takadol
– Zamudol
– Dolzam
– Ixprim 37,5 mg/325 mg
– Monocrixo LP 100 mg / 150 mg / 200 mg
– Ultram
– Tramacet 37,5 mg/325 mg
– Ralivia
– Tramium
– Tramacet
– Zumalgic
retour à l'index
CONSOMMATION
PAR NOLWENN WEILER
29 JANVIER 2013
07. Textile : ces vêtements qui
nous intoxiquent
Combien de molécules chimiques dans votre pull, pantalon ou tee-shirt ?
Combien de substances interdites ou jugées dangereuses pour la santé ?
Les 80 milliards de vêtements fabriqués dans le monde chaque année
regorgent de produits chimiques. Pour les rendre si colorés, si brillants, si
faciles à repasser et si bon marché : des perturbateurs endocriniens,
métaux lourds ou nano-matériaux, qui empoisonnent travailleurs du textile
et consommateurs, et se diffusent dans l’environnement. Enquête sur ces
vêtements qui nous rendent malades.
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A l’automne dernier, quelques heures après avoir enfilé une jupe et
un tee-shirt neufs, une fillette de quatre ans a vu des boutons
apparaître sur sa peau, aux endroits de contact avec les
vêtements. Les petits points rouges se sont rapidement étendus au
reste du corps. Son visage s’est mis à gonfler. Le personnel
soignant qui s’est occupé de l’enfant a d’abord soupçonné le
diméthylfumarate (DMFu), un anti-fongique qui avait défrayé la
chronique en 2008 et 2009 suite à l’intoxication d’une centaine de
personnes, via des fauteuils. Le biocide a finalement été mis hors
de cause. Quelle substance a pu provoquer de telles réactions ? Le
choix est malheureusement très vaste.
Nos vêtements regorgent de molécules chimiques, dont certaines très nocives pour la santé. Mais le
secteur de la confection a du mal à s’en passer. Prenons le formaldéhyde : classé dans les
"substances cancérogènes avérées pour l’homme" par le Centre international de recherche sur le
cancer (Circ), il est souvent présent dans les vêtements synthétiques, qu’il contribue à rendre
infroissables, résistants et hydrofuges. Il fixe aussi les colorants : grâce à lui, pulls, jupes, et
chaussettes qui ne décolorent pas à la première lessive. Problème : très volatile, le formaldéhyde
provoque des irritations des yeux et des voies respiratoires, et accroît le risque de pathologies
asthmatiques et de sensibilisations allergiques, même à faible dose.
Des perturbateurs endocriniens en pagaille
Derrière la mention "sans repassage", une autre molécule : les composés perfluorés (PFC), telles
que les fibres téflon. Grâce à ces tensio-actifs, les graisses et l’humidité pénètrent plus difficilement
dans les fibres. Et les vêtements sont plus faciles à nettoyer et à repasser. Ces composés
merveilleux, qui peuplent nos gore-tex sont malheureusement des perturbateurs endocriniens,
provoquant problèmes d’infertilité ou de développement, cancers, déficits immunitaires ou
perturbations du développement neurologique. De nombreux textiles contiennent par ailleurs des
retardateurs de flammes [1]. Pour éviter qu’ils ne prennent feu rapidement, les articles sont traités
avec un mélange de substances, regroupées sous le nom de polybromodiphényléthers (ou PBDE).
Une fois passées dans le corps humain, on retrouve ces substances chimiques persistantes jusque
dans le sang des cordons ombilicaux [2] . Elles altèrent l’attention, la mémoire, l’apprentissage et le
comportement des animaux de laboratoire, même à des doses minimes ! Certaines de ces
substances, présentes dans les vêtements de nuit (mais aussi matelas, fauteuils et rideaux) sont des
perturbateurs endocriniens. Et n’oublions pas les métaux lourds, qui permettent de faire briller les
vêtements et de les teindre efficacement. Ou encore les nano-matériaux, notamment le nano-argent,
qui élimine efficacement les microbes. Et que l’on retrouve dans les chaussettes ou vêtements de
sport, à cause de leurs propriétés anti-tâches et anti-odeurs, alors même que l’on ignore les effets
sanitaires réels de ces nouvelles technologies.
Les travailleurs, premières victimes
Inhalés, ingérés ou passant à travers la peau, ces polluants touchent d’abord les salariés qui
confectionnent les articles textiles. Mais il a aussi des modes indirects d’intoxication, souligne Jerôme
Frignet, chargé de la campagne Detox à Greenpeace : "Une large part des polluants part dans l’eau
au moment du lavage. La fin de vie de ces vêtements — brûlés ou enterrés — entraîne aussi des
relargages de polluants dans l’écosystème."
En Inde, dans la ville de Tirupur, célèbre pour ses teintureries, les ouvriers utilisent des colorants
azoïques (interdits en Europe) ou chlorés. Ils manipulent ces produits et les dissolvent dans l’eau
sans aucune protection. Selon les médecins locaux, rencontrés par Inge Alteméier et Reinhard
Hornung, auteurs du documentaire "Du Poison dans nos vêtements", le nombre de personnes
atteintes de cancer a doublé ces 10 dernières années dans la région. "Les gens souffrent ici de
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cancers des organes internes – reins, estomac, œsophage, col de l’utérus, sein", détaille l’un des
cancérologues.
Deuxième étape toxique : les lieux d’embarquement et de réception des chaussures et vêtements.
Dans les grands ports européens où débarque chaque semaine près d’un million de containers, les
travailleurs respirent des quantités de substances organiques chlorées, destinées à désinfecter la
marchandise et à éradiquer les parasites (champignons, rongeurs,...). A Hambourg, la médecine du
travail a découvert que la moitié des containers en provenance d’Asie contenaient ces substances.
Les mesures de la qualité de l’air des containers sont aléatoires, et non obligatoires. Au Havre, les
douaniers se sont insurgés contre les quantités de vapeur qu’ils respirent en ouvrant les containers.
Pour l’instant, les recommandations se limitent à laisser le container ouvert le temps que les vapeurs
toxiques s’échappent...
370 fois la dose autorisée
Parmi les substances cachées dans nos placards, certaines sont totalement interdites. D’autres ont
un usage règlementé, avec des seuils autorisés – comme le formaldéhyde, les phtalates ou les
métaux lourds. Mais ces seuils sont régulièrement dépassés. Dans une enquête réalisée en 2012 [3],
Greenpeace a trouvé dans des vêtements pour enfants des doses de phtalates 370 fois supérieures
à la norme en vigueur pour les articles destinés aux enfants ! Utilisés pour assouplir les plastiques,
ces perturbateurs endocriniens notoires sont souvent présents sur les dessins, inscriptions et
décorations collés sur les pulls, tee-shirts, casquettes ou pyjamas.
Autre découverte de l’ONG : des éthoxylates de nonylphénol (NPE),
dont la dose pouvait atteindre 45 000 ppm (partie par million), pour
1000 ppm autorisées ! Utilisés comme détergents, les NPE sont
déversés dans les égouts lors du lavage des vêtements. Ils se
décomposent alors en nonylphénol (NP), un sous-produit très
toxique, bio-accumulable et perturbateur endocrinien. Identifiés par
Greenpeace grâce à des contrôles complexes et coûteux, ces
produits passent régulièrement nos frontières incognito. Les contrôles
sont insuffisants, du fait d’un manque de moyens humains et
matériels. D’autant que la présence des toxiques n’apparaît pas sur les étiquettes...
Des coupables jamais inquiétés
Alimenté en France par la Direction générale de la concurrence, de la consommation et de la
répression des fraudes (DGCCRF), le système d’alerte européen Rapex publie chaque semaine un
bilan des produits de consommation dangereux. Dans son rapport 2011, textiles, vêtements et
articles de mode arrivent en tête, avec 27% des notifications, juste devant les jouets (21%), puis les
moteurs (11%). Quand ils apparaissent dans la système Rapex, les articles sont généralement retirés
"par les acteurs économiques eux-mêmes". Qui ne sont pour autant jamais inquiétés.
"Si les produits sont fabriqués en Union européenne, où s’applique la réglementation Reach, un
particulier ou une association qui découvrent des dépassement de seuils de substances chimiques
utilisées peut attaquer la marque, détaille Jérôme Frignet. Mais si le produit est fabriqué hors Union
européenne, comme c’est le cas pour un grand nombre de produits textiles, cette réglementation ne
s’applique pas !" Et "tous les Etats-membres ne signalent pas les articles défectueux", déplore le
Bureau européen des unions de consommateurs (Beuc), qui estime que Rapex "mériterait d’être
renforcé".
Des entreprises qui tiennent à leur image de marque
Le Beuc réclame aussi une vigilance particulière envers les perturbateurs endocriniens. Pour
Greenpeace et le Réseau environnement santé (RES), les demandes sont plus radicales : il faut les
interdire. La délimitation de doses limites (comme le fait souvent la directive européenne Reach [4])
ne vaut pas pour ces substances, estiment les deux organisations.
80
"On reste sur le principe qui dit que "la dose fait l’effet", mais c’est injustifiée pour les perturbateurs
endocriniens", explique Gilles Nalbone, chercheur à l’Inserm et membre du RES. Pour ces produits,
le moment d’exposition est tout aussi important que la dose : "Les périodes de vie in utero étant
particulièrement vulnérables." Pour lui, la réduction globale de l’exposition à ces substances, qui
menacent nos capacités reproductrices, est urgente. Sur cette question, il estime que la France "est
plutôt en avance. Elle a été la première à interdire le bisphénol A par exemple. Et une loi est en
préparation pour généraliser l’interdiction de l’exposition aux perturbateurs endocriniens. Cette façon
de cibler une famille de polluants, c’est tout à fait nouveau".
Les entreprises seront-elles d’accord ? Suite à la campagne Detox menée par Greenpeace à
l’automne, des marques comme Benetton, Mango, Esprit ou Levi’s se sont engagées sur des
échéanciers précis pour éliminer les produits incriminés. "Aucune d’entre elles n’a envie d’apparaître
en tête de gondole de notre prochaine campagne. Leur image de marque est capitale. Et leur cible,
les ados, sont très sensibles aux campagnes lancées sur les réseaux sociaux", explique Jérôme
Frignet de Greenpeace. La marque Zara, premier vendeur de vêtements au monde, a assuré à
Basta ! qu’elle travaille depuis des années dans cette direction. La page dédiée de son site ferait
presque rêver, tant les objectifs sont ambitieux...
Réduire la pression sur les producteurs
Inditex, propriétaire de la marque Zara, "s’engage d’ici 2020 à
encourager un changement systémique, c’est-à-dire social et
politique, pour atteindre l’objectif de "zéro rejet" de substances
dangereuses (dans la chaine de production et dans tout le cycle
de vie des produits) en une génération, ou moins", peut-on y lire.
Comment la marque compte-elle s’y prendre pour financer ces
changements radicaux ?
Osera-t-elle ponctionner son milliard d’euros de bénéfices net (chiffre de 2010), en hausse de plus de
30% en un an ? "Nous jugeons cet engagement crédible", précise Jérôme Frignet. Qui espère que
l’engagement de grandes marques influenceront leurs collègues. Côté grande distribution, où
s’achètent une grande partie des vêtements consommés en France chaque année, silence radio. Ni
Auchan, ni Carrefour n’ont donné suite à nos (nombreuses) sollicitations.
Les grandes marques se savent sous surveillance. Mais elles ont aussi appris à ruser. La technique
hautement toxique du sablage de jeans, qui permet de leur donner ce côté délavé très tendance, est
toujours pratiquée, malgré les promesses, rappelle Nayla Ajaltouni, coordinatrice du collectif "De
l’étique sur l’étiquette". "Le sablage a été interdit en Turquie, où la mobilisation a été rapide et
efficace. Mais il se développe au Bangladesh. Des systèmes de vérifications vraiment performants
sont donc nécessaires." Autre piste : assouplir la demande. "Les donneurs d’ordre ne peuvent pas
ignorer qu’en demandant les mêmes produits, aux mêmes coûts dans les mêmes délais, ils
autorisent implicitement la poursuite de l’utilisation de techniques ou de produits soi-disant interdits."
Repenser nos modes d’habillement
Avoir des vêtements sans dangers implique de renoncer à certains standards. "Vous ne trouverez
pas chez nous de vêtements d’un blanc immaculé, impossible à obtenir sans utilisation massive de
produits chimiques", détaille ainsi Sabrina Cherubini, directrice marketing chez Ekyog, qui travaille
depuis 10 ans sur la construction de filières textiles éthiques et sans produits chimiques. "Pour les
imprimés, nous nous passons de plastisol (qui contient des phtalates, ndlr). Mais la technique que
nous avons sélectionnée suppose trois passages en machine au lieu d’un seul. Nous allongeons
donc les délais pour nos fournisseurs. Et payons trois jours de travail au lieu d’un." Les coûts des
produits textiles proposés par Ekyog ou encore Bleu Forêt (une entreprise située dans les Vosges
qui fabrique des collants et chaussettes) "pourraient diminuer si tout le monde s’y mettait", assure
Sabrina Chérubini.
81
Impossible de poursuivre l’achat effréné d’habits, en les passant simplement en coton bio, et
colorants sans chimie de synthèse. "Si plusieurs milliards de gens voulaient des bluejeans en fibre
naturelle teintée avec des colorants naturels, l’humanité devrait dédier des millions d’hectares à la
culture de l’indigo et du coton uniquement pour satisfaire cette demande – des hectares nécessaires
à l’agriculture", précisent Michael Braungart et William McDonough dans leur ouvrage Cradle to
cradle, recycler à l’infini. "Il faut sans doute repenser nos modes d’habillement, avance Gilles
Nalbone. Nous avons certes des vêtements high tech, en grande quantité et pour pas cher, mais on
en paie le prix fort ensuite, en terme de santé. Évidemment, on touche là à notre modèle de société,
et il y a beaucoup à faire."
Photo : © George Nikitin / Greenpeace et © Ivan Castaneira / Greenpeace
Notes
[1] Voir Les fringues qui tuent, synthèse de l’association Santé environnement France.
[2] Voir Les toxiques en héritage, de Greenpeace, 2005.
[3] L’enquête de Greenpeace a porté sur 20 marques de vêtements, et a inclus des tests sur 141
produits vendus par des enseignes connues et reconnues de la mode, comme Zara, Calvin Klein,
Mango, Tommy Hilfiger ou encore Vero Moda.
[4] Règlement sur l’enregistrement, l’évaluation, et l’autorisation et restriction des produits chimiques.
retour à l'index
ENVIRONMENT
—By Kiera Butler
Monday February 11, 2013 3:01 AM PST
08. Five Things Your Doctor
Should Tell You, But Won't
Hypochondriacs of America, this one's for you.
Illustration by Thomas Fuchs
As a lifelong hypochondriac, I've always been comforted by
the Hippocratic oath. What an excellent idea, having doctors
pledge to put patients first. So I was less than thrilled to learn
that doctors are under increasing pressure—from state
legislatures, industry, and other groups—to break that oath by
withholding key pieces of information from their patients. "We
are very concerned about special interests attempting to
influence our practices," says Valerie Arkoosh, president of
the National Physicians Alliance (NPA).
82
"We've seen state legislatures overreaching a lot with regard to doctor-patient relationship." Here are
five things that—depending on where you live—your doctor could be keeping from you:
1.
Fracking chemicals might be making you sick. Many of the chemicals that oil and gas
companies are pumping into the ground (and groundwater) during the hydrofracking process
are known carcinogens or neurotoxicants. Pennsylvania recently passed a law requiring
companies to disclose the ingredients of proprietary fracking fluids to doctors who can show
that a patient may have been exposed, so long as the doc signs a nondisclosure agreement.
State officials say the info can be shared with patients, but the law itself contains no such
guarantee. "How are you supposed to treat a patient if you can't say why you're treating
them?" Arkoosh asks. "I wouldn't know how to do that."
2.
Your fetus has a serious anomaly. Fourteen states forbid parents from suing doctors who
withheld information that might have caused them to seek an abortion. Proponents argue that
these laws protect the rights of disabled people. As Nancy Barto, a Republican state senator
who championed such a law in Arizona, put it on her blog, "Wrongful life/wrongful birth lawsuits
implicitly endorse the view that the life of a disabled child is worth less than the life of a healthy
child."
3.
The gun in your house may get you shot. Pediatricians routinely ask parents whether they
own guns, since research shows that gun owners and their families are almost twice as likely
to be murdered and 17 times more likely to commit suicide with a gun. But in Florida, the
Firearm Owners' Privacy Act—introduced by conservative legislators and signed into law by
Gov. Rick Scott in 2011—forbids doctors from asking patients whether they own guns. A
federal judge has since ruled most of "Docs vs. Glocks" unconstitutional, but Scott aims to
appeal the decision. Dr. Jerome Paulson, a pediatrician at the Children's National Medical
Center's Child Health Advocacy Institute in Washington, DC, calls the move "absolutely
absurd." Since the connection between guns and injury is clear, he says, "as health
professionals, it's our job to share that information with patients."
4.
There's a cheaper and safer drug than the one I prescribed for you. It's no secret that
pharmaceutical companies push new drugs on doctors. But now they employ data-mining to
do so. For a licensing fee, industry marketers can access the American Medical Association's
database of physicians, which allows sales reps to track down precisely which drugs a doctor
is prescribing. "That's how reps get incentivized—they know what drugs to pitch to what
physicians," Arkoosh says. "Those drugs are always the most expensive drugs. And we don't
have a full understanding of the safety profile of these drugs. Vioxx is exhibit A." (In 2004,
Merck pulled its blockbuster anti-arthritis drug after a study revealed that Vioxx increased
patients' risk of heart attack and stroke; the company has paid out billions of dollars to settle
the resulting lawsuits. Cheap alternative: ibuprofen.) The good news is that Obamacare
requires doctors to disclose in a public database any gift worth more than $10 that they
receive from pharma reps. Until next year, when the provision kicks in, the NPA counsels
doctors to opt out of the AMA database.
5.
Alternative vaccination schedules can sicken your kid. In his popular 2007 tome, The
Vaccine Book: Making the Right Decision for Your Child, pediatrician Robert "Dr. Bob" Sears
(son of the best-selling author Dr. William Sears) encourages parents who are skittish about
shots to reconsider the vaccination schedule recommended by the Centers for Disease
Control and Prevention to decrease the likelihood of a bad reaction. Parents should consider
getting "fewer shots at each infant checkup and spreading the shots out over more time," he
suggests on AskDrSears.com, the online arm of his family's pediatric advice franchise. Online
parent forums are full of posts touting pediatricians amenable to the Sears vaccine schedule.
But Dr. Mary Fallat, chair of the American Academy of Pediatrics' bioethics committee, says
doctors have an ethical duty to warn parents that delaying vaccines will leave kids exposed to
83
disease. If enough of them adopt the Sears schedule, it could weaken our herd immunity to
catastrophic diseases like whooping cough. The kicker? A 2010 study in Pediatrics showed
that adopting an alternative schedule doesn't affect children's long-term outcomes.
KIERA BUTLERSenior Editor
Kiera Butler is a senior editor at Mother Jones. For more of her stories, click here. RSS |
TWITTER
IF YOU LIKED THIS, YOU MIGHT ALSO LIKE...
For Pennsylvania's Doctors, a Gag Order on Fracking Chemicals > A new provision could forbid
the state’s doctors from sharing information with patients exposed to toxic fracking solutions.
Will Pennsylvania Reverse its Gag Order on Fracking Chemicals? > Doctors in the Keystone State
might be able to warn their patients about the hazards of fracking solution after all.
Arizona and Kansas Pursue Laws Letting Docs Hide Information from Women > The bills would
protect doctors who conceal medical information to prevent abortions.
Docs vs. Glocks > Should doctors get fined $10,000 for discussing the health risks of guns with
patients? Florida's governor thinks so.
How ALEC Helps Companies Keep Fracking Ingredients Secret > The nonprofit famous for
supporting "Stand Your Ground" also aids drilling companies in protecting their trade secrets.
retour à l'index
Le Monde.fr avec AFP
25.03.2013 à 08h36
09. Des traces de pesticides et de
médicaments retrouvées dans des
bouteilles d'eau
Une étude de 60 Millions de consommateurs et de la
fondation France Libertés a révélé lundi la présence de
traces de pesticides et de médicaments, dont un pour traiter
le cancer du sein, dans environ 20 % des eaux en bouteille,
sans toutefois remettre en cause leur potabilité.
"A court terme, il n'y a absolument aucun problème de
qualité. Ces eaux sont parfaitement buvables, insiste le
rédacteur en chef de 60 Millions de consommateurs, Thomas
Laurenceau. On est dans l'ordre de l'ultra-trace, du millième de micron, c'est vraiment minuscule."
L'enquête "ne met absolument pas en cause l'honnêteté des embouteilleurs", mais interroge la
contamination de l'environnement par les pratiques humaines, ajoute-t-il. "Il y a inquiétude sur la
84
qualité de la ressource globale", résume M. Laurenceau, qui appelle, avec France Libertés, à "la
remise à plat des normes de qualité" prenant en compte les nouveaux polluants.
L'analyse a porté sur 47 bouteilles d'eau, trois bonbonnes d'eau et une dizaine d'échantillons d'eau
du robinet prélevés dans trois départements. Sur les bouteilles d'eau étudiées – portant sur
l'ensemble du marché –, 37 ne présentaient aucune trace des 85 molécules recherchées. Dix en
revanche contenaient des résidus de médicaments et pesticides.
"ANALYSES À GRANDE ÉCHELLE"
"La grande surprise", écrit 60 Millions de consommateurs, est la présence de tamoxifène, hormone
de synthèse utilisée dans le traitement du cancer du sein, dans la Mont Roucous, Saint Yorre,
Salvetat, Saint Armand (Du Clos de l'abbaye) et Carrefour Discount (Céline Cristaline). La teneur est
"infime", mais c'est "suffisant pour qu'on s'interroge sur la pureté originelle imposée par la
règlementation des eaux minérales", souligne le magazine, qui précise avoir procédé deux fois à
l'analyse des échantillons après contestation de la part des embouteilleurs des premiers résultats et
de la méthodologie employée, accusée de produire de "faux positifs".
"La seconde analyse a confirmé cette présence, sans que nous soyons en mesure d'en expliquer
l'origine, ajoute encore 60 Millions de consommateurs. L'affaire est suffisamment sérieuse pour qu'on
lance des analyses à plus grande échelle."
Du buflomédil et du naftidrofuryl, des vasodilitateurs, ont été également détectés dans l'Hepar pour le
premier et dans la Saint Armand pour le second. Par ailleurs, des traces d'atrazine et
d'hydroxyatrazine, des désherbants pourtant interdits en 2001 mais très persistants, ont été trouvées
dans la Vittel (Grande source), la Volvic (Clairvic), la Cora (Saint-Pierre) et la Cristaline (Louise).
"POTENTIELS EFFETS COCKTAIL"
"Ce qu'on en retire, ce n'est pas de dire que telle marque est plus risquée qu'une autre. Il n'y a pas
les bons et les mauvais. Sur l'ensemble des marques, il y a un problème, poursuit M. Laurenceau.
Les embouteilleurs sont extrêmement prudents, mais ça interpelle de voir qu'il peut y avoir [des
micropolluants], même si c'est infinitésimal, qui ne devraient pas être là."
Et l'eau du robinet ? Sur 10 prélèvements, huit contiennent une à quatre molécules sur les 85
recherchées, principalement des pesticides, mais aussi des résidus de médicaments dont, à
nouveau, du tamoxifène décelé notamment en milieu urbain (Rennes et Limoges).
Enfin, sur les trois bonbonnes, des traces de diéthylphtalate ont été trouvées dans l'Obio, et de
bisphénol A, d'atrazine et de retardateur de flamme dans la Culligan Val-de-Marne. "Si tous les
micropolluants sont ici présents en très faibles teneurs, leur variété interroge sur les potentiels effets
cocktail", souligne 60 Millions de consommateurs.
Le magazine et France Libertés, qui ont lancé en 2011 l'"Initiative transparence santé", ont publié en
mars une carte de la qualité de l'eau potable en France, montrant que les seuils limites en polluants
étaient dépassés dans près de 420 communes grâce à des dérogations, sans risque sanitaire
immédiat.
À LIRE SUR 60MILLIONS-MAG.COM
retour à l'index
85
25/03/2013 à 11h06
Signalé par Elsa Ferreira
10. Des traces de pesticides et de
médicaments dans l’eau de
bouteille
L’eau de bouteille n’est pas si pure. Sur 47 échantillons d’eau minérale, 10 d’entre eux présentent
des traces de médicaments et de pesticides, révèle une enquête de 60 millions de consommateurs
en association avec France Liberté.
Leur présence ne remet pas en cause la qualité de l’eau – les quantités décelées relevant du
"millième de micron" –, insiste le rédacteur en chef du magazine, Thomas Laurenceau. Mais les
résultats soulèvent la question de la contamination de l’environnement du fait de l’activité humaine.
"L’eau que nous buvons aujourd’hui, au robinet ou en bouteille, est de bonne qualité. Mais si nous ne
faisons rien, cela risque de ne pas durer."
Traitement contre le cancer du sein
Parmi les pesticides décelés, l’atrazine et l’hydroxyatrazine, des désherbants pourtant interdit depuis
2001. Ils ont été trouvés dans les bouteilles de Vittel (Grande source), Volvic (Clairvic), Cora (SaintPierre), et Cristaline (Louise). "Comment est-ce possible ?", s’interroge Emmanuel Poilane, le
président de France Liberté, dans une tribune sur le Huffington Post : "Il nous faut prendre en compte
la réalité du temps de l’eau qui n’est pas le temps de l’homme. Les activités humaines aujourd’hui
vont perturber la qualité de l’eau pour les décennies à venir et c’est dangereux."
Dans 10 % des échantillons – dans les bouteilles de Mont Roucous, Saint Yorre, Salvetat, Saint
Armand (Du Clos de l’abbaye) et Carrefour Discount (Céline Cristaline) –, le laboratoire a relevé des
traces de tamoxifène, une hormone de synthèse utilisée dans le traitement du cancer du sein. Ils ont
également découvert des vasodilatateurs, le buflomédil et le naftidrofuryl.
Les embouteilleurs ont contesté ces résultats. 60 millions de consommateurs a donc renouvelé les
tests et les a confirmé, "même s’il demeure impossible, à ce niveau d’analyse, d’écarter totalement
l’éventualité d’une contamination extérieure", précise Thomas Laurenceau.
Concernant l’eau du robinet, 8 échantillons sur 10 contiennent au moins un des polluants
recherchés.
25 mars 2013 à 08:40
Par AFP
retour à l'index
86
Publication: 25/03/2013 05:00
11. Des traces de pesticides et
de médicaments dans l'eau en
bouteille!
Une tribune d’Emmanuel Poilâne, directeur de France Libertés,
publiée ce matin sur le Huffington Post
Emmanuel Poilane
Directeur de France Libertés- Fondation Danielle Mitterrand
En janvier dernier, France Libertés et 60 millions de
consommateurs rendaient publique la carte des
dérogations en cours aux normes de qualité de l’eau
potable, dans le cadre de l’Opération Transparence
sur le prix et la qualité de l’eau en France.
Parallèlement, des analyses ont été réalisées sur la
composition de l’eau du robinet dans trois
départements essentiellement ruraux et sur les eaux
en bouteille et en bonbonnes pour une cinquantaine
de marques.
Aujourd’hui, les résultats tombent. Ils sont surprenants.
Les analyses effectuées révèlent la présence de pesticides et de résidus de médicaments dans l’eau
du robinet de quelques communes étudiées…et dans certaines eaux en bouteilles.
Une eau pas si pure…
Contrairement à ce que l’on peut penser, les eaux en bouteille ne sont pas épargnées par l’impact
des activités humaines. Je vous invite à découvrir, dans le numéro d’avril de 60 millions de
consommateurs, la liste des eaux en bouteille dans lesquelles 85 polluants ont été recherchés au
cours de l’étude menée par 60 millions de consommateurs et France Libertés dans le cadre de
l’opération transparence.
Alors que certaines entreprises, produisant des eaux en bouteille, mettent la pureté de l’eau au
centre de leur stratégie de marque, en réalité, cela ne s’avère pas tout à fait exact et est même
inquiétant du point de vue de la qualité de la ressource en eau de notre pays à long terme.
87
Certes, les doses de polluants détectées sont très faibles mais la simple présence d’ultra-traces de
médicaments ou de pesticides doit nous sensibiliser à la protection de la ressource en eau.
Des traces d’atrazine ont été trouvées dans l’eau du robinet et dans certaines bouteilles d’eau alors
que ce produit est interdit en France depuis 2003. 10 ans ! Comment est ce possible ? Outre les
multiples causes de pollution de la ressource en eau, il nous faut prendre en compte la réalité du
temps de l’eau qui n’est pas le temps de l’homme. Les activités humaines aujourd’hui vont perturber
la qualité de l’eau pour les décennies à venir et c’est dangereux.
La nécessité de réflexion sur la ressource en eau
Il ne s’agit donc pas de remettre en cause la potabilité de l’eau aujourd’hui mais d’attirer l’attention
sur la protection de la ressource en eau pour l’avenir. La question qui se pose est la suivante :
comment faire pour empêcher la pollution de cette ressource si fragile ?
En France, le curatif prime trop souvent sur le préventif, Le traitement des eaux est renforcé avant sa
distribution au lieu de soigner le mal à la source. Cela conduit à négliger les conséquences
environnementales et sanitaires et à occulter la qualité de la ressource en eau. De plus, cette
approche curative entraîne des coûts élevés du prix du service de l’eau et nous éloigne de la
perspective d’un accès à l’eau pour tous.
Il est nécessaire de repenser nos pratiques et nous interroger sur l’avenir de la ressource en eau.
Cela passe par le renforcement des réglementations pour un meilleur contrôle de l’eau, une meilleure
transparence de sa composition et par la révision de nos politiques agricoles afin de réduire les rejets
de pesticides et de nitrates.
En tant qu’usagers, citoyens et consommateurs, nous devons exiger que les pouvoirs publics et les
distributeurs d’eau mènent des analyses plus poussées sur la composition de l’eau pour connaitre la
réalité et trouver des solutions pérennes de protection de la ressource. Aujourd’hui, nous ignorons
les conséquences, dans le temps, d’un tel cocktail de polluants. Evitons que l’eau que nous buvons
devienne une bombe à retardement pour notre pays.
Il est grand temps de traiter le problème à la source afin de garantir à tous l’accès à une eau potable
de qualité. France Libertés et 60 millions de consommateurs lance un manifeste pour l’eau potable.
➪ Du tamoxifène (hormone de
synthèse utilisée dans le
traitement du cancer du sein) a
été retrouvé dans la Mont
R o u c o u s , S a i n t Yo r r e ,
Salvetat, Saint Armand (Du
Clos de l'abbaye) et Carrefour Discount (Céline Cristaline).
➪ Des traces d'atrazine et d'hydroxyatrazine, des désherbants interdits ont été trouvées dans la
Vittel (Grande source), la Volvic (Clairvic), la Cora (Saint-Pierre) et la Cristaline (Louise) rapporte
Le Monde.
➪ Du buflomédil a été détecté dans l'Hepar.
➪ Du naftidrofuryl, a été détecté dans la Saint Armand
retour à l'index
88
Le Monde.fr
25.03.2013
Audrey Garric
12. "La forte demande d'eau en
bouteille peut entraîner sa
contamination"
ENTRETIEN. L'annonce est aussi surprenante
qu'inquiétante : une bouteille d'eau sur cinq présente
des traces de pesticides et de médicaments, dont un
produit prescrit pour traiter le cancer du sein.
C'est ce qu'a révélé, lundi 25 mars, une enquête de la
revue 60 Millions de consommateurs et de la fondation
France Libertés.
Lire : Des traces de pesticides et de médicaments dans des bouteilles d'eau
Comment cette pollution d'eau souterraine, supposée à l'abri de toute contamination, est-elle
possible ? Jean Carré, hydrogéologue et directeur adjoint du département santé, environnement et
travail de l'Ecole des hautes études en santé publique, estime qu'une souillure est notamment
possible lorsque les forages d'eau sont exploités au maximum, "ce qui peut créer une dépression et
donc un transfert de polluants d'un réservoir à l'autre".
L'eau en bouteille est-elle moins susceptible d'être contaminée que l'eau du robinet ?
Jean Carré : Toutes les eaux que nous buvons ont la même origine : l'eau de pluie. Seuls diffèrent le
circuit et la profondeur des nappes. L'eau du robinet vient à la fois de nappes souterraines et d'eaux
de surface. A Paris, par exemple, l'origine est mixte, tandis qu'en région parisienne, il s'agit
essentiellement d'eau de surface. Ces eaux sont donc exposées aux rejets de certains
micropolluants par l'agriculture, les industries ou les stations d'épuration.
Parmi les eaux en bouteille, strictement réglementées en Europe, les eaux dites de source sont des
eaux naturellement propres à la consommation humaine. Les seuls traitements qu'il est permis de
leur appliquer, afin d'éliminer des éléments instables comme le gaz ou le fer, sont l'aération, la
décantation et la filtration. Les eaux minérales naturelles, quant à elles, sont des eaux de source
possédant des propriétés particulières : elles ont des teneurs en minéraux et en oligo-éléments
susceptibles de leur conférer des vertus thérapeutiques, et leur composition est stable dans le temps.
Elles sont exclusivement souterraines et circulent dans des systèmes de roche complexes, à des
profondeurs allant de plusieurs centaines de mètres à plus d'un kilomètre.
Ces eaux sont captives – c'est-à-dire protégées entre deux couches de terrain imperméable –, mais
sur une partie de leur trajet seulement. Ensuite, elles reviennent à la surface et peuvent se mélanger
à des eaux superficielles. Ces eaux doivent donc être prélevées à une certaine profondeur (entre
quelques dizaines et quelques centaines de mètres) et selon des techniques de captage
particulières, qui prévoient notamment que leur pression soit supérieure à celle des eaux de surface.
De quelle façon les eaux en bouteille peuvent-elles être polluées ?
89
Elles peuvent être contaminées au moment du mélange avec les eaux superficielles, en raison de
nappes mal protégées – en cas d'infiltrations dans certains terrains – mais aussi à cause du mode
d'exploitation.
En raison de la forte demande d'eau en bouteille, les forages sont en effet exploités au maximum. On
pompe de l'eau plus loin que par le passé, ce qui peut créer une dépression et donc un transfert de
polluants d'un réservoir à l'autre. Tout dépend donc de la quantité d'eau pompée et de la profondeur
à laquelle se situent les forages.
Etes-vous surpris par le chiffre d'une bouteille sur cinq polluée par des résidus de pesticides
et de médicaments ?
Il n'est pas surprenant de trouver des traces de pesticides dans les eaux minérales naturelles, dans
la mesure où les sources se trouvent souvent dans des régions agricoles. Surtout, la circulation de
l'eau se fait à une lenteur telle dans les roches que l'on peut y retrouver des produits interdits depuis
douze ans, tels que de l'atrazine, résidu d'un pesticide.
Les traces de médicaments retrouvées dans des eaux souterraines sont, elles, bien plus
surprenantes. Ce qui est étonnant, c'est que les huit marques d'eau en bouteille épinglées par l'étude
de 60 Millions de consommateurs diffèrent grandement en ce qui concerne leurs milieux,
environnements et terrains géologiques.
La Mont-Roucous est ainsi puisée dans des granits du centre de la France et la Salvetat dans les
calcaires de la montagne Noire, dans des zones isolées, tandis que la Saint-Amand vient d'une vaste
nappe qui traverse plusieurs départements, et la Saint-Yorre provient des formations sédimentaires
profondes de l'Allier. Comment un même produit, le tamoxifène [une hormone de synthèse utilisée
dans le traitement du cancer du sein], peut-il se retrouver dans les eaux de territoires aussi variés ?
Ces résultats doivent toutefois être analysés avec précaution : les résidus observés le sont à des
niveaux extrêmement bas, avec une marge d'incertitude forte.
Les normes et contrôles des autorités sanitaires sont-ils suffisants pour détecter la présence
de ces micropolluants dans l'eau ?
L'eau est l'un des produits les plus contrôlés en ce qui concerne les pesticides. On en mange ainsi
bien plus qu'on n'en boit. Par contre, il n'existe pas de norme en matière de résidus de médicaments.
Mais leur valeur s'avère être inférieure à celles des pesticides, entre cent et mille fois moins.
retour à l'index
13. Le Mercure & la Santé
humaine
90
Votre santé et vous
Sur cette page :
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Enjeu
Contexte
Sources de mercure
Effets sur la santé de l'exposition au mercure
Risques d'intoxication au mercure
Réduire vos risques
Rôle du gouvernement du Canada
Pour en savoir plus...
Enjeu
Bien que le mercure émane naturellement des rochers, du sol et des volcans, les activités
humaines ont augmenté son niveau dans l'atmosphère. La population canadienne court le
risque d'être exposée à du mercure provenant de nombreuses sources, notamment la
nourriture et les amalgames dentaires.
Contexte
On utilise le mercure dans divers procédés industriels et produits commercialisés. Depuis les
années 70, les préoccupations environnementales donnent lieu à une baisse de l'utilisation et
du traitement du mercure dans le monde.
Le mercure existe sous trois formes :
•
le mercure élémentaire - élément liquide argenté, brillant et volatil qui dégage une
vapeur incolore et inodore à la température de la pièce;
•
le mercure inorganique - élément formé lorsque le mercure élémentaire est combiné à
d'autres éléments comme le soufre, le chlore ou l'oxygène afin de créer des composés
connus sous le nom de sels de mercure;
•
le mercure organique - composés, comme le méthylmercure, formés lorsque le
mercure élémentaire est combiné à du carbone.
Le mercure est une source de contamination mondiale, étant donné qu'il est toxique, qu'il ne
se décompose pas dans l'environnement et qu'il peut s'accumuler dans les organismes
vivants. Dans sa forme vaporeuse élémentaire, le mercure peut être porté par le vent sur de
longues distances et demeurer dans l'atmosphère pendant de longues périodes.
Le mercure peut se transformer dans l'environnement. Certains types de bactéries et de
champignons ont par exemple la faculté de donner au mercure sa forme la plus toxique, le
méthylmercure. Le méthylmercure tend à s'accumuler, jusqu'à un certain point, dans tous les
poissons, mais plus particulièrement dans les prédateurs comme le requin, l'espadon,
certaines espèces de thon (généralement vendues à l'état frais ou surgelé), l'escolar, le
voilier et l'hoplostète orange, ainsi que dans les mammifères marins. Les poissons d'eau
douce prédateurs comme le brochet, l'achigan et le doré jaune peuvent également contenir
des niveaux élevés de méthylmercure. Comme le poisson constitue aussi une excellente
source de protéines de qualité et d'acides gras oméga-3 et qu'il est faible en gras saturés, il
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faut soigneusement prendre en considération les bienfaits et les risques liés à sa
consommation.
Sources de mercure
Toutes les formes de mercure proviennent d'une gamme de sources naturelles comme les
volcans, le sol, les évents marins, les zones géologiques riches en mercure et les feux de
forêts, sans oublier les lacs, les rivières et les océans. Toutefois, les activités humaines ont
augmenté la quantité de mercure dans l'environnement de plusieurs façons, notamment par
divers procédés de combustion et procédés industriels comme la production d'énergie au
charbon, l'extraction et la fonte de minerais métalliques ainsi que l'incinération des déchets.
Le mercure peut également provenir de la lixiviation des sols inondés aux nouveaux
emplacements de barrages hydroélectriques ou dans toute zone inondée. Ce procédé est
susceptible d'accroître les niveaux de mercure dans la chaîne alimentaire aquatique en eau
douce à ces endroits.
Des produits comme les piles miniatures, les tubes fluorescents, les thermomètres, les
thermostats, les commutateurs et les relais, les baromètres ainsi que les amalgames
dentaires peuvent contenir du mercure; néanmoins, il existe des solutions de rechange
exemptes de mercure dans la plupart des cas. Le mercure est également utilisé en très faible
concentration dans certains produits homéopathiques. Mais lorsqu'on l'utilise selon les
normes de fabrication réglementées, le mercure contenu dans les produits homéopathiques
est considéré comme inoffensif. Le mercure est également utilisé dans la médecine
traditionnelle un peu partout dans le monde. Le fait de jeter ces produits peut causer des
fuites de mercure à partir des sites d'enfouissement ou des déchets incinérés et accroître la
quantité de mercure dans l'environnement.
En raison de la toxicité et des effets du mercure sur la santé humaine et environnementale,
même de petits renversements de mercure doivent être tenus pour dangereux et nettoyés
avec prudence. Le mercure élémentaire liquide, qu'on retrouve communément dans les
thermomètres, les thermostats et les baromètres ménagers, forme rapidement une vapeur
toxique, incolore et inodore lorsqu'il se répand. Si elle est inhalée, la vapeur est vite absorbée
par les poumons. Les enfants sont particulièrement à risque puisque les vapeurs du mercure,
plus lourdes que l'air, persistent souvent près du sol où les petits rampent et jouent. Votre
représentant de santé publique pourra vous donner de plus amples renseignements sur la
façon de nettoyer les petits renversements de mercure.
Effets sur la santé de l'exposition au mercure
Les effets sur la santé de l'exposition au mercure dépendent de la forme chimique dans
laquelle l'élément se trouve (élémentaire, inorganique ou organique), de la voie d'exposition
(inhalation, ingestion ou contact cutané) et du niveau d'exposition. Les vapeurs de mercure
élémentaire liquide et le méthylmercure sont absorbés plus facilement que les sels de
mercure inorganique et peuvent, de ce fait, être plus nocifs. Il importe de réduire, dans la
mesure du possible, son exposition à toute forme de mercure.
Mercure élémentaire
Les effets sur la santé du mercure élémentaire dépendent de la durée et du type d'exposition.
Si, par exemple, une personne avalait du mercure élémentaire liquide provenant d'un
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thermomètre brisé, l'absorption par le corps serait limitée. En revanche, l'inhalation des
vapeurs de mercure émanant de ce thermomètre brisé faciliterait l'absorption et pourrait
occasionner des problèmes de santé. Des concentrations élevées de vapeur de mercure
peuvent causer des lésions à la bouche, aux voies respiratoires et aux poumons et sont
susceptibles de provoquer la mort par insuffisance respiratoire. L'exposition à long terme à
de faibles concentrations peut provoquer des symptômes analogues à ceux provoqués par le
méthylmercure.
Composés inorganiques du mercure
Le mercure inorganique peut provoquer de l'insuffisance rénale et des lésions gastrointestinales. Les sels de mercure sont irritants et peuvent provoquer des cloques et des
ulcères sur les lèvres et la langue. Les éruptions cutanées, la transpiration excessive,
l'irritabilité, la fibrillation musculaire, la faiblesse et l'hypertension artérielle sont autant de
symptômes de l'exposition à des niveaux élevés de composés inorganiques du mercure.
Composés organiques du mercure (comme le méthylmercure)
Le mercure peut se transformer dans l'environnement. Le méthylmercure tend à s'accumuler,
jusqu'à un certain point, dans tous les poissons, mais plus particulièrement dans les
prédateurs susmentionnés. L'absorption du méthylmercure se fait d'abord par le tube digestif
pour ensuite se répandre dans le reste du corps. L'élément toxique pénètre facilement dans
le cerveau, où il peut demeurer pendant une longue période. Chez la femme enceinte, il peut
traverser le placenta et s'accumuler dans le cerveau et les tissus du foetus. L'enfant peut
également être contaminé au méthylmercure par ingestion de lait maternel.
Le système nerveux en développement d'un enfant est particulièrement sensible au
méthylmercure. Les effets varient selon le niveau d'exposition; ils peuvent se manifester par
une baisse du QI, des retards moteurs et verbaux, un manque de coordination, des
problèmes de cécité ou encore des crises d'épilepsie. Chez les adultes, les effets d'une
exposition importante se remarquent par des changements de personnalité, des
tremblements, des troubles visuels, des problèmes de surdité, la perte de coordination
musculaire et de sensation, des troubles de la mémoire, des déficiences intellectuelles et
même le décès.
Risques d'intoxication au mercure
En général, les Canadiens et Canadiennes ne risquent pas de s'intoxiquer au mercure.
Toutefois, les gens qui sont exposés à des niveaux élevés de mercure peuvent connaître des
ennuis de santé allant de l'éruption cutanée à l'anomalie congénitale, voire le décès dans les
cas d'empoisonnement extrêmes.
Les gens qui consomment quotidiennement de grandes quantités de poisson, de
mammifères marins et de gibier accroissent leurs risques. Le foetus en développement et les
enfants dont les mères ont consommé énormément de poisson et de mammifères marins
durant leur grossesse sont les plus susceptibles d'éprouver des ennuis de santé. Cependant,
l'exposition au méthylmercure par la consommation de poisson est généralement si faible
qu'il est difficile d'en mesurer les effets indésirables possibles sur la santé, et ce, même à
l'aide d'appareils ultrasensibles permettant d'analyser les changements dans les aptitudes
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cognitives. Les avantages nutritionnels de la consommation de poisson peuvent
contrebalancer de tels effets sur la santé. Les enfants, qui tendent à porter les choses à leur
bouche, risquent d'augmenter leur ingestion de mercure par les sols et les objets contaminés.
Dans des régions comme l'Arctique, le régime alimentaire traditionnel peut consister, à
certains moments de l'année, en des quantités importantes de poisson ou de mammifères
marins. Il importe toutefois de considérer les risques éventuels versus les nombreux
avantages nutritifs et socioculturels d'une alimentation de ce genre.
Les gens qui se préoccupent de l'exposition au mercure peuvent fournir des échantillons de
cheveux, de sang ou d'urine chez le médecin ou dans une clinique médicale pour qu'on
procède à des analyses.
Réduire les risques
Le mercure élémentaire contenu dans les amalgames dentaires ne constitue généralement
pas un risque pour la santé. Il existe, cependant, un petit nombre de gens qui affichent une
hypersensibilité au mercure. Bien que les responsables de Santé Canada ne recommandent
pas le remplacement des amalgames dentaires au mercure, ils suggèrent toutefois
l'utilisation de produits exempts de mercure lorsqu'une obturation doit être réparée.
Les femmes enceintes, les personnes allergiques au mercure et celles qui souffrent de
malaises rénaux devraient éviter les amalgames au mercure. Dans la mesure du possible, il
faudrait aussi éviter de les faire extraire durant la grossesse en raison du risque d'exposition
aux vapeurs de mercure. S'il y a lieu, les obturations sur la première dentition des petits
devraient être faites avec des matériaux qui ne contiennent pas de mercure.
Il est recommandé de suivre les conseils de Santé Canada en matière de consommation de
poisson pour profiter pleinement des bienfaits de cet aliment tout en contrôlant l'exposition au
mercure. Les poissons prédateurs comme le requin, l'espadon, le thon frais ou surgelé,
l'escolar, le voilier et l'hoplostète orange enregistrent toutefois des niveaux de mercure plus
élevés que les autres espèces et ne devraient être consommés qu'à l'occasion. Certains
groupes (notamment les jeunes enfants et les femmes enceintes ou qui prévoient le devenir)
devraient limiter leur consommation de thon blanc en conserve. Cette recommandation ne
s'applique toutefois pas aux autres types de poissons vendus au détail. Le Guide alimentaire
canadien donne des exemples de choix sains en matière de poisson. Pour obtenir des liens
vers les consignes de consommation de Santé Canada, consultez la section Pour en savoir
plus.
Si vous consommez le fruit de la pêche récréative dans les eaux de votre région, consultez le
gouvernement de la province ou du territoire pour obtenir de plus amples renseignements sur
le sujet.
Rôle du gouvernement du Canada
Le gouvernement du Canada oeuvre actuellement dans un certain nombre de secteurs afin
de réduire l'utilisation et l'émission de mercure dans l'environnement. En 2000, le Conseil
canadien des ministres de l'environnement a établi plusieurs normes à travers le pays dans
le but d'abaisser les niveaux de mercure dans l'environnement. Ces normes visent certains
produits contenant du mercure et les émissions de mercure provenant d'industries
sélectionnées. Le gouvernement a également contribué à la mise en place du Programme de
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lutte contre les contaminants dans le Nord et du Programme national sur les contaminants de
l'environnement chez les Premières nations.
En outre, Santé Canada établit et applique des restrictions quant à la présence de mercure
dans les produits homéopathiques, les produits traditionnels et les autres types de produits
de santé naturels finis. Santé Canada établit également des normes scientifiques applicables
au mercure dans le poisson vendu au détail et émet des avis sur la consommation de ces
poissons. L'Agence canadienne d'inspection des aliments met en pratique les normes de
Santé Canada sur le mercure dans les poissons vendus au détail.
Bien que le Canada compte poursuivre la réduction des niveaux de mercure, il doit être
appuyé dans ses efforts. Une bonne partie du mercure qui se dépose dans les lacs et le sol
canadiens provient d'autres pays. Chef de file à l'échelle régionale et internationale en ce qui
touche la réduction des niveaux de mercure dans l'environnement mondial, le Canada
travaille en collaboration avec les États-Unis et le Mexique, par l'intermédiaire de la
Commission nord-américaine de coopération environnementale, pour s'attaquer aux
questions relatives au mercure dans le cadre du Plan d'action régional nord-américain sur le
mercure.
Pour en savoir plus
Consultez les sections suivants de Santé Canada :
Le mercure présent dans le poisson Consigne de consommation à l'égard du mercure
présent dans le poisson : Choisir en toute connaissance de cause
Bien manger avec le Guide alimentaire canadien
Grossesse en santé
L'innocuité des amalgames dentaires
Programme national sur les contaminants de l'environnement chez les Premières nations
Le mercure - Votre santé et l'environnement Outil de ressources
Vous pouvez également consulter les sections suivants d'Environnement Canada :
Le mercure dans l'environnement
Le mercure dans l'environnement -
Avis en matière de consommation de poisson
Nettoyer les déversements mineurs de mercure
Pour obtenir des renseignements supplémentaires, consultez le site suivant :
Programme des Nations Unies pour l'environnement
Des articles complémentaires sur les questions de santé et de sécurité se retrouvent sur le
site de Votre santé et vous
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Vous pouvez aussi composer le 1-866-225-0709 ou le 1-800-267-1245 (sans frais) pour les
malentendants.
Dernière mise à jour : novembre 2008
Version initiale : octobre 2004
© Sa Majesté la Reine du Chef du Canada, représentée par le ministre de la Santé,
Mise à jour : Novembre 2008
Partager
Avis importants sur les hyperliens et la Loi sur les langues officielles.
retour à l'index
MÉDECINE
PAR LAURA RAIM
23 MAI 2013
14. DSM : quand la psychiatrie
fabrique des individus
performants et dociles
Sommes-nous tous fous ? C’est ce que laisserait supposer la
nouvelle version du DSM, la bible des psychiatres recensant
troubles mentaux et comportements "anormaux". Plus on compte
de malades, plus le marché de l’industrie pharmaceutique s’élargit.
Surtout, le DSM apparaît comme un moyen de faire rentrer dans la
norme ceux qui seraient jugés "déviants" – une part de plus en plus
grande de la population. Ces "mal ajustés" de notre société
orientée vers la rentabilité économique, où l’individu se doit d’être
performant et adaptable. Enquête sur un processus de
normalisation qui, sous couvert de médicalisation, façonne les
individus.
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Vous êtes timide ? Peut-être souffrez-vous de "phobie sociale". Votre
tristesse passagère, liée à un événement douloureux comme la perte d’un
proche, n’est-elle pas plutôt une dépression ? Le territoire du pathologique
semble s’étendre sans fin. Ces troubles psychiatriques sont recensées par
le "DSM-5", cinquième version du catalogue des affections mentales,
ouvrage de référence des psychiatres, sorti le 19 mai. Avec son lot de
"nouveautés". Rares sont ceux qui ne se reconnaîtront pas dans l’un des
400 troubles répertoriés ! Avec ses critères toujours plus larges et ses seuils
toujours plus bas, le DSM fabriquerait des maladies mentales et pousserait
à la consommation de psychotropes, estiment ses détracteurs.
Alors que la première version du "Manuel diagnostique et statistique des troubles
mentaux" (Diagnostic and statistical manual of mental disorders - DSM), publié en 1952, ne recensait
qu’une centaine d’affections, son contenu n’a cessé d’enfler au fil des révisions, tous les vingt ans.
Ses détracteurs pointent le risque de "médicaliser" à outrance des comportements finalement
normaux. Selon la version antérieure, le DSM-4 (sorti en 1994), la moitié de la population des ÉtatsUnis pouvait être considérée comme souffrant de troubles mentaux, estime l’historien Christopher
Lane. 38 % des Européens souffrirait de désordre mental [1] ! Pourquoi une telle inflation ? Sommesnous en train de tous devenir fous ?
Les critiques du DSM mettent en avant la responsabilité des laboratoires pharmaceutiques. Ces
firmes chercheraient à étendre le "marché des troubles". Et ont noué à partir des années 80 des liens
étroits avec les psychiatres influents, à commencer par les rédacteurs du DSM : 70% des auteurs ont
ainsi déclaré avoir des rapports financiers avec les labos [2]. Les ventes d’antidépresseurs et de
neuroleptiques aux États-Unis représentent 24 milliards de dollars. En France, elles ont été
multipliées par sept en deux décennies, et représentaient plus d’un demi milliard d’euros au début
des années 2000. Au-delà des conflits d’intérêts, cette "pathologisation du normal" révèle bien
d’autres choses. Avant d’être un outil de diagnostic de maladies mentales, le DSM ne serait-il pas
plutôt un dispositif de normalisation des conduites, dans une société orientée vers la rentabilité
économique ?
Rentrer dans la norme
Dans ce répertoire des affections mentales, il est davantage question de comportement que de
souffrance. Un choix revendiqué par les auteurs : "Pour être le plus objectif possible et s’assurer
qu’un même patient aurait le même diagnostic qu’il soit à Paris, New York ou Tokyo, l’Association des
psychiatres américains (APA) a décidé d’écarter toute théorie explicative, source de dissensus parmi
les différents courants de la pensée psychiatrique, et de rester au niveau de l’observable, sur lequel
tout le monde peut-être d’accord. Or l’observable, c’est le comportement", explique le psychiatre
Patrick Landman [3]. Président du collectif Stop DSM, il s’oppose depuis trois ans à la "pensée
unique DSM". Se contenter d’observer les comportements pour établir un diagnostic permet
d’échapper aux biais culturels, moraux ou théoriques des différents cliniciens. Mais cette
standardisation se fait au prix d’une grande simplification de la complexité des problèmes rencontrés
en psychiatrie.
L’abondance des troubles du comportement et de la personnalité dans le DSM "est emblématique
d’une psychiatrie qui se préoccupe moins de la vie psychique des gens que de leur comportement",
ajoute le psychiatre Olivier Labouret [4]. Un comportement qui doit avant tout être conforme à la
norme. "Il n’est pas anodin que le DSM n’emploie pas le mot "maladie", qui renvoie à la souffrance
ou à la plainte émanant du patient, mais le mot "trouble", qui est la mesure extérieure d’une déviation
de la norme, souligne le psychiatre. Le trouble, c’est ce qui gêne, ce qui dérange".
Quand l’homosexualité était une "affection mentale"
Ces normes développées par la psychiatrie n’ont pas attendu les versions successives du DSM pour
se manifester. Dans son cours au Collège de France sur les "anormaux", le philosophe Michel
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Foucault expliquait comment à partir du milieu du XIXe siècle, la
psychiatrie commence à faire l’impasse sur le pathologique, la
maladie, pour se concentrer sur "l’anormal" : la psychiatrie a "lâché
à la fois le délire, l’aliénation mentale, la référence à la vérité, et puis
la maladie, explique le philosophe.
Ce qu’elle prend en compte maintenant, c’est le comportement, ce
sont ses déviations, ses anomalies". Sa référence devient la norme
sociale. Avec ce paradoxe : la psychiatrie exerce son pouvoir
médical non plus sur la maladie, mais sur l’anormal.
Une analyse qui rejoint celle de l’antipsychiatrie américaine. Pour le professeur de psychiatrie
Thomas Szasz, les "maladies mentales" ne sont que des "mythes" servant à médicaliser les
comportements jugés indésirables ou immoraux au sein de la société [5]. "Le sort de l’homosexualité,
inclus puis exclu du DSM au gré de l’évolution des mentalités aux États-Unis, illustre à quel point le
manuel reflète moins l’état d’une recherche scientifique sur les maladies que les normes de
"l’acceptable" d’une époque", rappelle le philosophe Steeves Demazeux, auteur de Qu’est-ce que le
DSM ?.
Traquer les "déviants" ?
Tous les comportements ne subissent pas le même traitement. "Si vous parlez à Dieu, vous êtes en
train de prier, si Dieu vous parle, vous êtes schizophrène", écrivait ainsi Thomas Szasz. Et des
"paraphilies" (pour ne pas dire "perversions"), telles que le masochisme et le fétichisme, demeurent
dans la catégorie des "troubles sexuels", témoignant de la culture puritaine américaine dans laquelle
baignent les auteurs, et à laquelle la population est invitée à se conformer. La psychiatrie, qui détecte
et désigne les déviants à l’époque moderne, ne ferait selon Szasz que remplacer l’Inquisition qui
traquait les sorcières au Moyen-Age. Les inquisiteurs avaient pour guide le Malleus Maleficarum, les
psychiatres… le DSM.
Sans doute les normes d’une époque ont-elles toujours
influencé le partage des eaux entre le normal et le
pathologique. Mais cette influence a longtemps été
cantonnée en arrière-plan. Le DSM-3 franchit un cap dans
les années 80 en faisant de ces normes les critères directs
et explicites de chaque trouble. Un exemple : "Avec le
DSM-5, il faut avoir moins de trois accès de colère par
semaine pour être un enfant "normal", explique Patrick
Landman. Les autres – ceux qui dévient de cette norme –
seront désormais étiquetés "trouble de dérégulation
d’humeur explosive" ! Et pourront être "normalisés" par des
médicaments. En prenant par exemple de la ritaline, cette
molécule à base d’amphétamines consommée à haute dose aux États-Unis, pour améliorer la
concentration des écoliers. Près de huit millions d’enfants et d’adolescents américains de 3 à 20 ans
prennent des antidépresseurs ou des calmants. Le DSM non seulement reflète les normes sociales
du moment, mais les renforce en les transformant en normes médicales.
Le "bon fonctionnement de l’individu", un enjeu économique
Un des critères d’une grande partie des troubles – que ce soit la schizophrénie, l’hyperactivité ou le
trouble des conduites – est l’"altération significative du fonctionnement social ou professionnel". Le
choix des termes n’est pas innocent : la "fonction" d’un organe, d’un appareil ou d’un outil se rapporte
toujours à une totalité subordonnante. On parle ainsi du bon ou du mauvais fonctionnement du foie
ou du rein relativement à l’organisme. Parler de la "fonction" ou du "bon fonctionnement" de l’individu
trahit le fait que celui-ci n’est pas une fin en soi. L’individu doit "fonctionner" correctement dans
l’entité qui le subordonne : l’entreprise, l‘école, la société. C’est cela que l’Échelle d’évaluation
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globale du fonctionnement (EGF) du DSM-4 (datant de 1994) se propose de mesurer. Êtes-vous au
"top" de votre "fonctionnement social, professionnel ou scolaire". Ou celui-ci subit-il une "altération
importante" ou "légère" ? Si vous êtes "intéressé et impliqué dans une grande variété d’activités,
socialement efficace, en général satisfait de la vie", vous avez des chances d’obtenir une note de 90
sur une échelle allant de 0 à 100...
Et votre "fonctionnement social" intéresse au plus haut point votre pays. Car pour les États, c’est leur
puissance économique qui est en jeu : "L’Union européenne évalue entre 3 et 4 % du PIB les coûts
directs et indirects de la mauvaise santé mentale sur l’économie", indique en 2009 le rapport du
Conseil d’analyse stratégique sur la santé mentale. Invalidité, accidents du travail, absentéisme,
baisse de la productivité... Autant d’impacts de la santé psychologique des travailleurs sur
l’économie. Le rapport évoque les "nouveaux impératifs de prévention des formes de détresse
psychologique et de promotion de la santé mentale positive ou optimale.". Concrètement ? Il s’agit
d’investir dans "le capital humain" des personnes, en dotant "chaque jeune d’un capital personnel",
dès la petite enfance. Objectif : que chacun développe très tôt les "compétences clés en matière de
santé mentale". Des "aptitudes qui se révèlent in fine plus adaptées aux demandes du marché du
travail", explique le Conseil d’analyse stratégique...
Le travailleur idéal : performant, invulnérable et sûr de lui
Et pour cause : l’Organisation mondiale de la Santé (OMS) définit en 1993 ces compétences
psychosociales comme "la capacité d’une personne à répondre avec efficacité aux exigences et aux
épreuves de la vie quotidienne". Autrement dit, "être capable de s’adapter aux contraintes sans
jamais questionner le bien-fondé ou la justice de la situation, voilà ce qui est attendu de quelqu’un de
"normal", résume Olivier Labouret. Le DSM reflète l’idéal transhumaniste de l’homme que l’on peut
programmer et améliorer pour qu’il soit compétitif sur le marché du travail".
Les patients les mieux "notés" sur l’Échelle d’évaluation globale du fonctionnement du DSM ont "un
niveau supérieur de fonctionnement dans une grande variété d’activités" et ne sont "jamais débordés
par les problèmes rencontrés". A la plus grande satisfaction de leur employeur ! "L’homme idéal
sous-jacent du DSM est performant, invulnérable et sûr de lui", poursuit le psychiatre. En cela, le
DSM traduit une conception évolutionniste de la psychologie : seul l’individu "vulnérable" ou "fragile"
n’arrive pas à s’adapter à la réalité socio-économique, puisque la majorité semble y arriver."
La psychiatrie au service de la productivité ?
Ce normativisme social au service de la productivité économique n’est pas nouveau. Mais la "bible
des psychiatres" applique et renforce les normes, de manière systématique et globale. Ses effets
sont repérables dans toutes les institutions, bien au-delà de l’hôpital. Aux États-Unis et en Australie,
les mutuelles, les tribunaux et les écoles s’y réfèrent pour étayer leurs décisions. Et les
gouvernements mènent des politiques de santé publique ciblant des "catégories DSM" de la
population.
En France, si le manuel n’a pas encore force de loi, sa présence s’intensifie. "On utilise en France
surtout la classification de l’OMS, la Classification internationale des maladies (CIM). Mais celle-ci est
quasiment calquée sur le DSM, que la Haute autorité de Santé reconnaît déjà officiellement
d’ailleurs, explique Patrick Landman. Le DSM est enseigné dès les premières années de médecine.
Tous les généralistes y sont donc formés. "Quant au champ de la recherche, on ne peut pas publier
un article si l’on n’utilise pas les codes du DSM. Et les laboratoires, qui financent les formations postuniversitaires, ne jurent que par lui."
La violence du système néo-libéral occultée
Bon nombre de souffrances, difficultés, émotions, traits de caractère ou préférences sexuelles, se
retrouvent inscrits dans le DSM, alors qu’ils ne devraient pas relever du champ médical. La grande
majorité des praticiens et des patients ne songent pas à questionner le statut de ces "troubles" ainsi
officialisés. Ni à remettre en cause les normes sociales qui ont présidé à la formation de ces
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catégories. Ce sont toujours les êtres humains qui, "inadaptés",
souffriraient de "dysfonctionnements". Ils sont invités à identifier
leurs troubles et recourir à un traitement qui leur permettra de
rapidement redevenir "fonctionnels"…
Notamment sur le marché du travail. Une violence symbolique du
système néolibéral, qui se dénie comme telle, du fait de son
déplacement dans le champ psychologique et médical, déplore
Olivier Labouret. "La pression normative écrasante qui en résulte,
désormais occultée, empêche toute possibilité de comprendre et
de réformer l’ordre du monde".
Nous sommes désormais non plus malades, mais "mal ajustés". Un mot de la psychologie moderne,
utilisé plus que tout autre, estime Martin Luther King en 1963 : "Certainement, nous voulons tous
éviter une vie mal ajustée , admet-il. Mais il y a certaines choses dans notre pays et dans le monde
auxquelles je suis fier d’être mal ajusté (…). Je n’ai pas l’intention de m’ajuster un jour à la
ségrégation et à la discrimination. Je n’ai pas l’intention de m’ajuster à la bigoterie religieuse. Je n’ai
pas l’intention de m’ajuster à des conditions économiques qui prennent les produits de première
nécessité du plus grand nombre pour donner des produits de luxe au petit nombre".
Laura Raim
Illustrations : © Rodho pour Basta !
Notes
[1] Étude de 2011 publiée dans la revue European Neuropsychopharmacology
[2] Lire notamment Jean-Claude St-Onge, Tous fous ?, Ed. Ecosociété, 2013.
[3] Auteur de Tristesse business. Le scandale du DSM 5, éd. Max Milo, 2013.
[4] Auteur de l’ouvrage Le nouvel ordre psychiatrique, éd. Erès, 2012
[5] Son raisonnement est le suivant : pour qu’il y ait maladie, il faut qu’il y ait lésion. De deux choses
l’une : soit il y a lésion du cerveau, il s’agit alors d’une maladie du cerveau (même si elle perturbe le
comportement, comme l’épilepsie) et non pas de l’esprit. Soit il y a une souffrance mentale mais pas
de lésion, alors il ne s’agit pas de maladie.
Nos dossiers :
•
Menaces sur la santé publique
Lire aussi :
•
Une minute de silence pour les suicides liés au travail
•
Fabrice Nicolino : "Tant qu’il y aura des abattoirs, il y aura des champs de bataille"
•
Suicides à France Télécom : hypocrisie sur toute la ligne
Réagir à cet article
1 - De polechomage | 12:47 | 23 mai 2013 |
Je suis tout à fait d’accord avec votre critique de la norme et de la performance en psychiatrie.
Toutefois vos citations de Thomas Szasz sont affligeantes dans la mesure où il semble considérer
toutes les maladies mentales comme non existantes. Un schizophrène ne fait pas forcément
qu’entendre Dieu, il peut par exemple lui obéir et se tuer (50% des schizophrènes meurent par
suicide au cours de leurs délires). La schizophrénie est une maladie sérieuse qui met en danger la
vie du malade, il est stupide de la nier, et à défaut de pouvoir la guérir (elle guérit au bout de 10 ans
dans 30% des cas mais sans qu’on ne sache comment) il faut la soigner. Maintenant, je connais bien
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le problème, un schizophrène sous médicament est jugé par son médecin par sa conformité à la
norme : on lui demande d’être "autonome", de vivre dans son appartement si possible, d’avoir un
travail, etc... Une personne non diagnostiquée par quelque maladie que ce soit et qui sort de la
norme, ce sera tout au plus un excentrique, un schizophrène ne peut être excentrique, il est
forcément malade, et son comportement déviant, les médecins veulent le supprimer. Aucune
originalité ne lui est tolérée sans qu’elle soit jugée pathologique. Voilà d’après moi le problème donc,
il faut bien soigner les vrais malades, mais laisser tranquille les originaux, malades ou non. Il ne
s’agit pas, comme Thomas Szasz, de nier le problème de la schizophrénie et de laisser mourir les
schizophrènes de leut maladie.
De Eric | 21:51 | 23 mai 2013 |
"Ce n’est pas un gage de bonne santé que d’être bien intégré dans une société profondément
malade." Jiddu Krishnamurti
Tous les psychiatres qui ne méprisent pas le DSM sont des dégénérés, produits d’une société
dégénérée.
2 - De Lionel | 00:10 | 24 mai 2013 |
On pourrait aussi aborder la question sous des angles différents, par exemple dire que l’étendue des
"anormalités" du DSM5 est une alarme signalant une montée fulgurante des maladies mentales dans
nos sociétés néolibérales.
Et ce n’est pas une théorie, tous les psychologues et psychiatres ne s’occupant pas que d’établir des
ordonnances sont unanimes, de plus en plus de gens se plaignent de souffrances psychiques.
L’estimation des taux moyens de ces troubles ( qui ne sont pas encore des syndromes ) dans les
sociétés traditionnelles est de l’ordre de 6 % d’une population touchée.
Dans les années 98-2000 la fourchette des grandes métropoles se situait dans les 16 %.
En 2005 une étude parlait de 22 à 25 % dans les pays industrialisés et une autre étude récente dont
j’ignore si elle est crédible parle de près de 40 % pour l’Europe !
Ces chiffres sont très parlants et amènent non plus uniquement à se positionner en faveur d’une
personne en souffrance mais de connaître les origines de la souffrance qui sont clairement à mettre
en parallèle avec les dérives d’un système moribond, déculturant, déstructurant, individualisant à
outrance, effaçant toute trace de racine et d’identification.
Une société qu’il faut nommer : le capitalisme néolibéral qui fabrique de la folie à la chaîne.
Alors oui, Big-Pharma est forcément en cause, mais si l’on parlait un peu des causes du mal ?
Les cancers aussi explosent, cherche-t-on à interdire les pesticides ou les substances nocives des
produits domestiques ?
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by Michael Grabell
ProPublica, Sep. 21, 2013, 5:10 p.m.
15. The $13 Test That Saved My
Baby’s Life. Why Isn’t it Required
For Every Newborn?
Dozens of babies die every year because hospitals do not perform
a simple test that detects congenital heart defects. Seventeen
states have yet to require the exam for newborns.
(Dave Herholz, Flickr)
On July 10, my wife gave birth to a seemingly healthy baby
boy with slate-blue eyes and peach-fuzz hair. The pregnancy
was without complications. The delivery itself lasted all of 12
minutes. After a couple of days at Greenwich Hospital in
Connecticut, we were packing up when a pediatric cardiologist
came into the room.
We would not be going home, she told us. Our son had a
narrowing of the aorta and would have to be transferred to the
neonatal intensive care unit at NewYork-Presbyterian Hospital at Columbia, where he would need
heart surgery.
It turned out that our son was among the first in Connecticut whose lives
may have been saved by a new state law that requires all newborns to
be screened for congenital heart defects.
It was just by chance that we were in Connecticut to begin with. We live
in New York, where such tests will not be required until next year. But
our doctors were affiliated with a hospital just over the border, where
the law took effect Jan. 1.
As we later learned, congenital heart problems are the most common
type of birth defect in the United States. The Centers for Disease
Control and Prevention estimate that about one in 555 newborns have
a critical congenital heart defect that usually requires surgery in the first
year of life.
More Resources:
Which States Require This
Screening?
American Academy of
Pediatrics legislation
tracker
Newborn Foundation
screening progress
map
Many cases are caught in prenatal ultrasounds or routine newborn
exams. But as many as 1,500 babies leave American hospitals each year
with undetected critical congenital heart defects, the C.D.C. has estimated.
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Typically, these babies turn blue and struggle to breathe within the first few weeks of life. They are
taken to hospitals, often in poor condition, making it harder to operate on them. By then, they may
have suffered significant damage to the heart or brain. Researchers estimate that dozens of babies
die each year because of undiagnosed heart problems.
The new screening is recommended by the United States Department of Health and Human
Services, the American Heart Association and the American Academy of Pediatrics. Yet more than a
dozen states — including populous ones like Massachusetts, Pennsylvania, Florida, Georgia,
Wisconsin and Washington — do not yet require it.
The patchy adoption of the heart screening, known as the pulse oximetry test, highlights larger
questions about public health and why good ideas in medicine take so long to spread and when we
should legislate clinical practice.
Newborns are already screened for hearing loss and dozens of disorders using blood drawn from the
heel. The heart test is even less invasive: light sensors attached to the hand and foot measure
oxygen levels in the baby’s blood. This can cost as little as 52 cents per child.
Our son’s heart defect was a coarctation of the aorta, a narrowing of the body’s largest artery. This
made it difficult for blood to reach the lower part of his body, which meant that the left side of his heart
had to pump harder.
In the hospital, though, he appeared completely healthy and normal because of an extra vessel that
newborns have to help blood flow in utero. But that vessel closes shortly after birth, sometimes
revealing hidden heart problems only after parents bring their babies home.
Depending on the heart defect, the onset of symptoms can be sudden.
This is what happened to Samantha Lyn Stone, who was born in Suffern, N.Y., in 2002. A photograph
taken the day before she died shows a wide-eyed baby girl lying next to a stuffed giraffe. The next
morning, her mother, Patti, told me, she was wiping Samantha’s face when she heard a gurgle from
the baby’s chest.
Before her eyes, Samantha was turning blue. Blood began to spill from her mouth. Ms. Stone dialed
911, and minutes later, a doctor who heard the call over a radio was there performing CPR.
Samantha went to one hospital and was flown to another.
But the damage was irreparable. Samantha had gone 45 minutes without oxygen: She lapsed into a
coma and died six days later.
It wasn’t until several years later that Ms. Stone learned about the pulse oximetry test. “This could
have saved my daughter,” she told me. “There is no parent that should ever have to go through what
I went through.”
Pulse oximetry is not a costly, exotic procedure. Most hospitals already have oximeters and use them
to monitor infants who suffer complications. You can buy one at Walmart for $29.88.
A recent study in New Jersey, the first state to implement the screening, estimated that the test cost
$13.50 in equipment costs and nursing time. If hospitals use reusable sensors similar to those found
on blood-pressure cuffs, the test could cost roughly fifty cents.
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As medical technology advances, few screenings will be so cheap or simple. Recent years have seen
controversy over prostate cancer and mammography screenings. Medical ethicists have to weigh the
costs of each program and the agony caused by a false positive against the lives saved.
But with pulse oximetry, the false positive rate is less than 0.2 percent — lower than is seen for
screenings newborns already get. The follow-up test is usually a noninvasive echocardiogram, or an
ultrasound of the heart. A federal advisory committee came down in favor — three years ago.
“There’s really no question, scientifically, this is a good idea,” said Darshak Sanghavi, a pediatric
cardiologist and a fellow at the Brookings Institution. “The issue is, how do we change culture?”
Opposition has taken two forms. One is from doctors who believe policy makers shouldn’t interfere
with how medical professionals do their jobs. The other is from smaller hospitals, which worry about
access to echocardiograms and the costs of unnecessary transfers.
These concerns can be addressed fairly easily. Nurses in New Jersey and elsewhere have been able
to work the test into their normal routines. A rural hospital should already have a protocol to transfer a
newborn in serious condition. If Alaska can do it, less remote states can, too.
But this is not simply a rural health care problem. Cardiologists and neonatologists I’ve spoken with
said they knew of hospitals in New York City, Boston and metropolitan Atlanta that weren’t screening
newborns for heart defects.
“It’s completely the luck of the draw of where you deliver,” said Annamarie Saarinen, who has pushed
for the screening since her daughter narrowly avoided leaving the hospital with an undetected heart
defect.
Fortunately, our son’s condition was also caught and corrected. The only lasting effects are a threeinch scar on his side and checkups with a cardiologist. He will live a normal life. He will be able to
play sports and climb things he’s not supposed to.
Shouldn’t every baby have that chance?
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04 OCTOBRE 2013
PAR MICHAËL HAJDENBERG
16. Prothèses auditives: enquête
sur un marché verrouillé
Les malentendants souffrent, les audioprothésistes prospèrent.
Seuls 20 % des 6 millions de malentendants sont appareillés. Les
tarifs pratiqués par les audioprothésistes et leur volonté de
maintenir leur monopole enfoncent les populations les plus fragiles
dans l'isolement. La Direction de la concurrence enquête.
Le diagnostic est clair, mais le remède se fait plus qu’attendre. La France compte environ 6 millions
de malentendants, pour seulement un gros million de porteurs de prothèses auditives. Alors que
96 % des personnes qui voient mal portent des lunettes, moins de 20 % des malentendants qui
devraient être appareillés le sont. Une problématique de santé publique majeure que n’a pas
manqué de relever la Cour des comptes dans son rapport sur la sécurité sociale publié le 17
septembre.
En cause : le coût financier de l’appareillage. Pointés du doigt : les audioprothésistes, qui dégagent
des marges à faire pâlir d’envie n’importe quelle profession médicale, et qui font tout pour conserver
leur monopole. À tel point que, selon nos informations, la DGCCRF (Direction générale de la
concurrence la consommation et de la répression des fraudes) a ouvert une enquête sur les
pratiques anti-commerciales des syndicats qui représentent la profession.
La cause mériterait pourtant mieux qu’une bataille de commerçants. Selon la Cour des comptes, la
moitié des plus de 55 ans souffrent d’un trouble de l’audition. Or, "alors qu’on pourrait s’attendre à
une tendance significative à la baisse du prix des audioprothèses, le niveau des prix demeure élevé".
Pour le moins.
En moyenne, il faut compter 1 535 euros pour chaque oreille (l’appareil + le suivi). À l’âge adulte, le
remboursement par la sécurité sociale s’élève à 199 euros par oreille. Comme le constate la Cour,
"ne représentant qu’un enjeu financier très secondaire (114 millions d’euros par an), l’Assurance
maladie obligatoire s’est complètement désintéressée de ce domaine" ; ce qui constitue "un grave
échec au regard des principes mêmes qui la fondent".
Les organismes d’assurance maladie complémentaire
remboursent en moyenne 30 % du prix, et encore : les actifs sont
mieux protégés, alors que les problèmes de surdité surviennent
généralement à l’âge de la retraite. L’appareil de base et les
soins sont gratuits pour les bénéficiaires de la CMU (Couverture
maladie universel). Mais le minimum vieillesse est légèrement
au-dessus du seuil de la CMU, ce qui fait que les retraités n’en
bénéficient pas, sauf exception.
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Le reste à charge pour le client est donc de l’ordre de 60 % du prix selon une étude de la DREES
(Direction de la recherche des études de l’évaluation et des statistiques) et celle du HCAAM (Haut
conseil pour l'avenir de l'assurance maladie) de juillet, pour ceux qui bénéficient d'une mutuelle. Soit
900 euros de chaque côté en moyenne. Pour les petites et moyennes retraites, se soigner les
oreilles coûte un bras.
Ce qui n’a pas l’air d’émouvoir particulièrement les audioprothésistes : selon la Cour des comptes,
"en l’absence – fréquente – de prescription précise de la part du médecin, un audioprothésiste peut
conseiller préférentiellement un produit haut de gamme, ce qui expliquerait qu’en France, à plus de
90 %, ce sont les audioprothèses relevant de la classe la plus chère qui sont vendues".
Bien sûr, les tarifs ne sont pas la seule raison d’un taux d’appareillage faible en comparaison des
pays anglo-saxons. D'abord, l'appareillage n'est pas adapté à l'ensemble des malentendants, mais
probablement à environ la moitié d'entre eux. Surtout, l’obstacle psychologique est majeur. Michèle
Delaunay, ministre déléguée en charge des personnes âgées et de l’autonomie, a d’ailleurs déjà
estimé qu’il faudrait commencer par changer le nom de l’équipement : dans l’optique, on parle de
lunettes ; pas de prothèse pour les yeux. Sans compter que les lunettes peuvent être un accessoire
de mode, que personne n’a honte de porter. Il en va tout autrement des prothèses auditives, aussi
miniaturisées soient-elles.
Les conséquences sont nombreuses : isolement social, repli sur soi, hausse des risques de chutes et
de dépression… Mais rien n’y fait : au lieu de s’appareiller entre 60 et 65 ans, à l’âge où il devient
souvent plus difficile de distinguer les sons aigus par exemple dans des brasseries ou des lieux de
rassemblement (les voix d’enfants et de femmes notamment), les Français attendent en moyenne 10
ans de plus. Quand ils s’équipent.
"Je vois presque tous les jours – encore ce matin – des gens qui aimeraient s’appareiller mais qui
n’en ont pas les moyens, explique Christian Dubreuil, professeur en ORL au centre hospitalier Lyon
Sud. Je n’ose même plus le leur proposer. Alors on leur conseille un Senheiser, un petit casque
audio qui coûte 10 fois moins cher, qu’on trouve dans les magasins d’électro-ménager, et qui leur
permettra de régler leur propre volume pour regarder la télévision."
Le professeur Dubreuil enrage de voir ces personnes qui "ne sortent plus, s’isolent, ne comprennent
plus rien". Il ne décolère surtout pas contre les audioprothésistes dont il détaille "les marges
énormes".
Dans son rapport, la Cour des comptes cite des études qui font état d’un coefficient multiplicateur de
3 à 3,5 sur le prix d’achat, "soit une marge brute de 2 500 euros pour une paire d’oreilles haut de
gamme, les plus vendues". Le calcul est rapide : "La vente d’un équipement par jour suffirait au
distributeur pour être rentable."
"Dans le monde de la santé, de telles marges sont choquantes"
Le prix comprend la vente de l’appareil, mais aussi le suivi, c’est-à-dire les consultations ultérieures
pendant 5 ou 6 ans, la durée de vie d’un appareil. Sauf que pour le professeur Dubreuil, ces marges
sont parfaitement injustifiées. "Même avec un patient qui aurait besoin de revenir 10 fois la première
année, c’est colossale. D’autant que faire les réglages, de nos jours, est extrêmement rapide."
Les audioprothésistes ont un bac + 3. À peine sortis de l’école, ils gagnent souvent au moins 3 000
euros euros net par mois. "Mais les audioprothésistes expérimentés qui travaillent sur cinq ou six
magasins peuvent gagner vraiment beaucoup beaucoup plus d’argent. Alors qu'à la différence des
médecins, des avocats ou encore des architectes, ils n’ont de responsabilité ni civile ni pénale :
quand cela ne marche pas, c’est de la faute de l’oreille."
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Marc Chauveau, auteur du guide de l’audition, a fait ses propres calculs et arrive à un tarif moyen
horaire de 165 euros. Une "anomalie" en comparaison des autres professions paramédicales.
"Surtout que la valeur ajoutée de l'audioprothésiste pour le réglage est souvent dérisoire. Appareiller
deux oreilles (dont les pertes sont sensiblement identiques) ne demande que 10 % de travail en plus
alors que cela permet aux audio de doubler leur marge."
Sans entrer dans ces détails, Jacques Schlosser, président de Surdi 13, une association qui
regroupe des personnes malentendantes, s’offusque également : "Qu’un commerçant se fasse une
marge de 1 à 4 dans le commerce, ça arrive. Mais là on est dans le monde de la santé, c’est
choquant. Et les audioprothésistes font tout pour ne pas avoir à partager le gâteau."
Alain Afflelou, pas vraiment un débutant, en fait actuellement l’expérience, comme Optical Center,
Leclerc ou Audio 2000 avant lui. En 2011, il a voulu lancer pour l’écoute l’équivalent de son offre
tchin-tchin pour les yeux : une "oreille" offerte pour une achetée. Avec un avantage de taille : son
réseau existe déjà, il suffit d’y placer des "corners" (espaces dédiés à l’audition au sein de centres
d’optique).
Le médiatique discounter espérait ouvrir 150 centres en un an. Il en est à 70. Alain Afflelou, qui se dit
lui-même diplômé d’audioprothèse et appareillé, explique qu’il n’avait pas mesuré les obstacles
auxquels il se heurterait et surtout l’un d’entre eux : le manque d’audioprothésistes. Seules cinq
écoles existent actuellement en France, qui forment environ 150 nouveaux praticiens chaque année.
"Si on pouvait ouvrir d’autres écoles, cela débloquerait le marché, peste Alain Afflelou. Les
audioprothésistes sont une denrée rare, payée très cher, 5 000 euros en moyenne. Du coup, on
ouvre cinq centres par mois alors qu’on pourrait en ouvrir 40."
Officiellement, ce sont les ministères de la santé et de l’enseignement supérieur qui décident de
l’ouverture de nouveaux instituts de formation. Mais le lobby des audioprothésistes ne l’entend pas
de cette oreille, et pèse de tout son poids. Une (petite) école de 15 places vient de voir le jour à
Cahors. Une autre devrait suivre l’an prochain à Bordeaux. Mais les nouvelles ouvertures se font au
compte-gouttes.
La surdité source d’absurdité ? Sûr de lui, Luis Godhino, président de l’Unsaf, défend le travail des
audioprothésistes : entendre de manière satisfaisante demande du temps, les premiers jours sont
difficiles, il faut ajuster selon le ressenti du patient. "Les gens passent plusieurs heures dans nos
magasins, et viennent plusieurs fois. Tous les audioprothésistes ne font pas fortune. Seuls les
meilleurs travaillent bien, qui y passent le temps nécessaire. Les 25 % qui marchent le mieux font
60 % de l’activité."
Luis Godhino conteste aussi le fait que la clientèle soit presque systématiquement orientée vers les
appareils les plus chers, qui par ailleurs sont réellement de meilleure qualité. Et il nie la pénurie
décrite par Alain Afflelou. "Il n’y a pas de problème d’offre. Regardez dans l’optique : le trop-plein de
professionnels n’a pas permis de faire baisser les prix. Par ailleurs, l’offre d’Afflelou ne peut pas tenir.
Les gens sortent en croyant avoir fait une bonne affaire, mais ça ne peut pas marcher : le suivi en
pâtira. Seulement on n’a pas le recul aujourd’hui pour le savoir. Il faudra attendre trois ans pour en
faire le constat." Sans compter que les "corners" ne réuniraient pas les conditions nécessaires aux
réglages les plus fins.
Alain Afflelou conteste ces analyses. Et assure que même avec son offre à prix réduits, il fait encore
60 % de marge. "Ça aussi, c’est faux, rétorque Godhino. Ce n’est juste pas possible."
Une rente soigneusement préservée
L’Unsaf se bat sur un autre front. Car outre les discounters, de jeunes entrepreneurs qui ont fait
l’analyse d’un marché bien trop cher, tentent de se faire une place au soleil avec un "assistant
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d’écoute". L’entreprise Sonalto fait une analyse simple du marché : les audioprothèses coûtent trop
cher, et il est possible de vendre des appareils préréglés, moins pointus techniquement, mais
susceptibles d’améliorer le quotidien de nombreux malentendants.
"Les audioprothésistes proposent aux gens du sur-mesure, nous du standard", explique Maxence
Petit, l’un des fondateurs de l’entreprise, qui commercialise le produit 300 euros. "On se compare
aux lunettes loupes pour la vue quand elles sont apparues il y a une vingtaine d’années."
Aux États-Unis, ce type d’appareils préréglés commence à percer sérieusement. Mais en France, les
audioprothésistes veillent. Alors que Sonalto commençait à distribuer son produit dans des
pharmacies, il s’est pris en pleine figure la contre-attaque judiciaire de l’Unsaf et du Synea (Syndicat
national des entreprises de l’audition). Ces deux syndicats considèrent qu’il s’agit d’une prothèse
déguisée, et que seuls des audioprothésistes ont le droit de commercialiser ce type de produits en
vertu de l’article L.4361-1 du Code de la santé publique.
L'assistant d'écoute "Octave" de la société Sonalto
La procédure est en cours. Mais les syndicats ont réussi à assécher
ces entrepreneurs, qui disent avoir déjà dû dépenser 300 000 euros
de frais d’avocats. "Ils nous mènent une guerre d’usure. On a dû
licencier deux personnes sur cinq. On est au bord de la rupture
avant même que notre produit ait vraiment eu sa chance", s’offusque
Maxence Petit.
Le syndicat a envoyé des courriers presque menaçants aux
pharmaciens qui commercialisaient le produit, déposé plainte contre l’un d’entre eux pour exercice
illégal de la profession d’audioprothésiste, fait pression auprès de l’Ordre des pharmaciens et tenté
d’intimider la société de distribution du produit Visiomed.
Autant de pratiques potentiellement "anticoncurrentielles" et possiblement contraires à l’article L.
420-1 du code du commerce, qui ont fait tiquer la DGCCRF (Direction générale de la concurrence,
de la consommation et de la répression des fraudes), au point de déclencher une enquête. La guerre
menée à Sonalto est d’autant plus surprenante que des assistants d’écoute de toutes sortes existent
déjà, vendus sur Internet.
Seulement, si un tel produit était vendu dans les quelque 22 000 pharmacies françaises, la menace
serait tout autre. "Vous croyez qu’ils nous font peur ? demande Luis Godhino. Ce n’est vraiment pas
une question financière. C’est une question de santé. On fait ces démarches car ils vont décevoir les
gens. La surdité est un vrai handicap. Or ils ne respectent pas la réglementation."
Dans ce cas, pourquoi ne pas les laisser échouer ? Après tout, si le produit n’est pas bon, il ne se
vendra pas. "Oui, mais ils font une communication de dingue. S'ils avaient fait ça en douce, on les
aurait laissés se planter en douce. Mais là, ils dévalorisent l’image des audioprothésistes. Ils nous
descendent de façon agressive pour dire qu’ils vont sauver les gens qui n’ont pas les moyens de
s’appareiller. On ne l’accepte pas."
Sonalto attend depuis deux ans une décision claire de l’ANSM, l’agence du médicament, afin de
savoir s’il est classé comme dispositif médical ou non. La décision aura des conséquences sur la
distribution du produit. L'ANSM explique qu'après plusieurs positionnements différents du produit, sa
notice et la communication sur sa finalité ou non médicale sont encore à l'étude.
En attendant, les malentendants s’impatientent. Une chose est sûre : déficit oblige, l’Assurance
maladie ne prendra pas mieux en charge le coût des audioprothèses, même si le fait que des millions
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de personnes s’enfoncent dans la dépendance représente un coût majeur pour la société à moyen
terme.
Au ministère des personnes âgées, on dit la ministre "préoccupée par le sujet" et on reconnaît "un
besoin de régulation". Au ministère de la santé, on évoque seulement la proposition de loi du député
(PS) Bruno Le Roux sur les réseaux de soins, qui doit être examinée à l'assemblée avant fin
novembre et qui autoriserait les mutuelles à adapter leurs remboursements selon que le
professionnel de santé appartient ou non à un réseau de soins. Avec un impact attendu sur les
prix puisque les complémentaires peuvent sélectionner les distributeurs et les produits, et négocier
dans ce cadre les prix et prestations qui sont faites à leurs assurés.
D’autres solutions existent, évoquées par les différents acteurs du dossier : dissocier la vente des
appareils et la prestation, tarifer la prestation à l’acte et non plus de façon forfaitaire, multiplier le
nombre d’étudiants, limiter les entraves au marché… Des associations souhaitent surtout depuis des
années qu’un tarif obligatoire soit fixé pour certaines prothèses sélectionnées, ce qui reviendrait à
plafonner le prix. Sensibles aux arguments des audioprothésistes, les pouvoirs publics n’ont pour
l’instant pas pris en compte ces demandes. Il n’est pire sourd que celui qui ne veut pas entendre.
retour à l'index
April 10, 2013
17. Iraqi Birth Defects Covered
Up?
by Jeena Shah, cooperating attorney with the Center for Constitutional Rights, which helped to
launch the Right to Heal initiative.
This week, one of the world's most renowned and respected medical journals, The Lancet, joined the
chorus of epidemiologists challenging the credibility of a recently-released report by the World Health
Organization (WHO) and the Iraqi Health Ministry.
The report contradicts consistent reporting of high rates of birth defects in Iraq following the U.S.
invasion in 2003. The WHO's defense of the study despite the critiques from many corners raises
questions as to the independence of the international body tasked with monitoring and addressing
public health crises around the globe.
Doctors across Iraq report that cancer rates, birth defects, and other environmental health problems
have skyrocketed since 2003. In the words of Dr. Mozhgan Savabieasfahani, an environmental
toxicologist based in Michigan who has been studying the rise in congenital birth defects in Iraq since
the 2003 U.S. invasion, "Iraq is poisoned."
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Toxic Munitions
Among the toxic munitions used by the U.S. military, depleted uranium, also known as "DU," is known
to lead to cancer and genetic defects from exposure to its radiation and carcinogenic chemical
properties. Scientific studies also strongly suggest that DU can interfere with the pre-natal
development of a fetus.
The U.S. military first used DU in Iraq in the 1991 Gulf War. Official statistics from the Iraqi
government indicate that by 1995, 800 out of 100,000 Iraqis were suffering from cancer as compared
to before the war when the rate was 40 out of 100,000. A 2001 study by the U.S. government of
21,000 veterans who had served in the Gulf War found an increased rate of miscarriages, and of
those who gave birth, two to three times greater likelihood of birth defects.
Despite strong evidence of the lasting damage DU can cause, the U.S. once again used it as a
weapon following its 2003 invasion and, according to a Pentagon spokesperson, took no
responsibility to clean up DU-impacted areas in Iraq.
Birth Defects Reported throughout Iraq
Iraqi doctors have borne witness to the horrifying consequences. Dr. Samira Alani, a pediatrician at
Fallujah General Hospital, reported that as of the end of 2011, she had personally logged 699 cases
of birth defects since October 2009, amounting to an alarming rate of 14.7 per cent of all babies born
there. An investigation conducted by the Federation of Workers' Councils and Unions in Iraq found
that many of the children born with defects die soon after birth but others survive with deformities so
rare they have not been given a medical name.
In the district of Haweeja, where it is believed that DU munitions may have been stored or tested by
the U.S. military, surveys undertaken by the Organization of Women's Freedom in Iraq indicate that
one-quarter of newborns are suffering from disabilities. Villages suffering from the highest rates of
birth defects and cancer are those immediately down-wind of a U.S. training base.
Report Inconsistencies
Beginning in May 2012, the Iraqi Ministry of Health joined with the WHO to study the prevalence of
birth defects in Iraq. While the study was completed by early October 2012, it was nearly a year
before a report was released. Scientists, health professionals, and human rights advocates from
across the globe questioned the delay, particularly as disturbing information about the study and its
conclusions began leaking out. Hans von Sponeck, former assistant secretary general of the United
Nations and senior UN humanitarian official in Iraq, stated that "The US government sought to
prevent WHO from surveying areas in southern Iraq where depleted uranium had been used and
caused serious health and environmental dangers." Previously, a high-ranking official at the Iraqi
Ministry of Health spoke publicly of the "damning evidence that there has been a rise in birth defects
and cancers [in Iraq]," particularly in areas where toxic munitions, such as DU, were used by U.S.
and U.K. forces.
So when the published report instead concluded that Iraq is facing no unusually high rate of birth
defects, epidemiologists took a closer look at the study's methodology and found significant flaws enough to undermine the credibility of the report's conclusions.
As a part of the Right to Heal initiative, Iraqis and U.S. veterans exposed to some of the same toxic
munitions have joined together to demand further study to be funded by the U.S. government of the
environmental and health impact the U.S. war has had on Iraqi and U.S. veteran communities. This
study is needed in order to remediate toxic sites and provide proper treatment to those still suffering,
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which should be an obligation of the United States as reparations for the lasting toll of its war on Iraq.
The WHO's failure to support a rigorous and honest assessment of the suffering of Iraqi families is a
travesty and yet another injustice to the Iraqi people. The international community, networked
together and with the mounting concerns of voices like The Lancet, will make sure the truth comes to
light.
retour à l'index
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