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Medical device makers for heart like the stent and hip like replacement hips have margins of over 70%. THese and other medical devices may come under pressure from the changes that are anticipatd in the way Medicare reimburses hospitals for these devices, which are largely used by older patients under Medicare coverage. Stocks of these device makers like Boston Scientific, Stryker, and Zimmer, have fallen in recent weeeks

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One in six dollars generated by the U.S. economy goes to pay for health care, almost twice the average for rich countries. It hurts America in many ways; by being a burden on the taxpayer when it comes to Medicare and Medicaid paying for the poor and the elderly, on companies being one reason GM went bankrupt, it eats up federal and state budgets, rising costs make any form of future coverage for all unsustainable, and it robs other priorities such as infrastructure building and other national scale investments. The Economist says that if it had to design a system from scratch, it would go for a system based mostly around publicly funded health care. For the uninsured the solution of an employer mandate is now well accepted, so this is not an issue. What is an issue is how to make the new system affordable? Here the Economist says that whether in stages or in one move, the tax deductability of employer paid health insurance, which is costing the U.S. government $250 billion ayear, has to go. It is necessary to remove this deduction, and its something all interests involved will have to swallow, as other savings are smaller and will not be adequate. The deductability of insurance makes the true cost of insurance transparent, so it supports gold plated insurance. This does not make cost control the pressing priority it needs to be. So the deducatability of employer paid health insurance hurts both ways. The other necessary action is in the area of moving out of the current culture where most doctors work on a fee-for-service basis, where the more tests they prescribe or procedures they perform the greater their incomes. This acts as a perverse incentive, and has aruinous effect in mushrooming health care costs in America. Cutting back on unnecessary tests and procedures, and prescriptions , would save 10% to 30% of health costs says the Economist. And it says this has been proven with the Mayo Clinic in Minnesota and Kaiser Permanente in California showing that cutting back doesn't hurt care and outcomes., so much so that cutting back would occur along with improved outcomes. But Americans with employer paid insurance just take things for granted as its not much out of pocket expense for them. THis creates the lack of a force for controlling costs even as employers are shouldering abigger and bigger burden, and the employee who thinks he is doing fine actually is seeing more of his salary dollars going to pay for his health insurance. In a way the consumers of health care are stuck with the perception that they are not somehow paying for these mushrooming costs and too manytests, procedures and prescriptions. This perception leads them a false sense of comfort with the system they are in, and a fear of something new fanned by the medical lobbies, that any change will impact users negatively. This makes the whole discussion on health care or the process of finding solutions to become an exericize in which terms like "rationing" and "choice" play a distorting role. ...

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Laffer says there is a big gap between the cost of health care and what people actually pay, which keeps cost escalating as there are no pressures from users of services to economize or bring reductions in the prices. But Laffer offers no effective solutions either his patient centred approach to health care reform does not address the problem that employers are paying for health care for the large part and these are not taxed as benefits leaving the employee free to load up on services and ignore the cost, which works just fine for the health care providers who increase revenues and profits- also called cost escalation upto the point now reached where the nation can no longer afford it.

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Leonhardt argues that rationing is rational allocation of limited resources, health care budgets are limited resources even in rich countries like the USA, and if you overpay here you cut somewhere else. Now the cuts that are not noticed he says are in take home pay as employers face increased premiums from insurers. Rationing is taking place all the time with poor health outcomes relative to the cost for poor allocation of resources as survival rate for many diseases are not that much better than other countries. Rationing takes place everyday when patients see doctors only for a few minutes as doctors race to see more patients, and when diseases are not caught early on in the process as doctors do not know their patients well enough. And rationing is taking place as patients simply delay or forego treatments based on the extra cost, or as uninsured get no care. There are so many buzzwords like this thrown around, with doctors, hospitals and insurers and other groups trying to preserve the status quo, even as it is becoming rapidly unaffordable fort the US to be spending so much on health care....

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A plan to postpone a 21% cut in payments to doctors for treating Medicare patients, and instead give a slight payment increase under a House proposal, at a total cost of $245 billion over 10 years, is raising questions about the the impact on the USA budget deficit in coming years. The Congressional Budget Ofice says the House health bill will increase the deficit by $239 billion by 2019. In past years the lawmakers in Congress have postponed the implementation of these cuts, and the administration would like to see this as a separate item and not showing increasing the deficit. The American Medical Association lobbied to have this provision in exchange for its support to the health care plan.

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The House bill on health care cleared the House Committee on Energy and Commerce with a vote of 31 to 28. Five Democrats joined all 23 Republicans. Compromises were reached with Blue Dog Democrats, centrist Democrats who had concerns about the cost of the health care overhaul. The bill will be taken up again in September after the August recess, when Congress will be faced with the task of recociling the House and Senate versions and reaching common ground on a number of proposals. Some common ground has already been achieved between centris and Blue Dog Democrats and Democratic members who support Obama's proposals. Among the changes on which consensus was reached in the House version: 1. Access Insurers will have to accept all applicants and will not be able to charge higher premiums because of medical history or current illness. All insurers will have to offer a minimum package of benefits, to be defined by the federal government, and nearly all Americans will be required to have insurance. Insurers will have to get prior approval from the government before increasing premiums over a certain amount. About 95% of Americans will be covered this time. The cost will still be approaching $ 1trillion over 10 years. Federal subsidies will be given to those who cannot afford health insurance and Medicaid coverage will be expanded. And the insurance will be made more affordable for the uninsured. Democrats also reached a consensus on creating some sort of government insurance plan or nonprofit cooperative to compete with private insurers. 2. Mobility And under this new plan it will be easier to change jobs as one would retains one's health insurance. This should actually help the job market, and help promote the mobility that is needed, now that jobs are shifting out of sectors like autos to sectors like energy. 3. Cost The Energy and Commerce Committee voted 47 to 11 to set aprocedure for the government to give federal approval of generic versions of expensive biotechnology drugs. By one estimate this saves $9 billion over 10 years. The Democratic proposals from the Energy and Commerce Committee would authorize the Health and Human Services Secretary to negotiate prescription drug prices for Medicare benificiaries. The agreement and consensus among the conservative, liberal and centrist Democrats, and Democrats with ties and connections to the health care industry was reached after intensive negotiations, and adoption of a package of amendments that helped bridge the differences they had. ...

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CEO Ryan at CVS/Caremark. An unassuming man with a sharp focus on things, joined CVS right out of pharmacy school at University of Rhode Island. At 29, CVS owner Stan Goldstein gave him the chance to run pharmacy operations for CVS, then a regional drugstore chain in the eastern USA. Over the years CVS has made a number of successful acquisitions, the latest being the acquisition of Longs Drug store chain on the west coast, and it is now one of the largest chains in the USA. It has nearly 7000 stores and more than 50 million users of its CVS loyalty card in the US. As the pharmaceutical business evolved pharmacy benefit management (PBM's) companies like Caremark, Medco, and Express Scripts, came into being to manage burgeoning prescription costs. PBM's work with companies to save money, by filling recurring prescriptionsin 90 day quantities through the mail at reduced per pill cost. Now drug store chains instead of competing with PBM's are either creating or acquiring these larger PBM's. THe result is that a company like CVS which acquired PBM Caremark in 2007 for $27 billion, now has extensive computerized databases with patients information and drug usage histories. Ryan's clear focus is on these IT records as a distinct advantage, if he can use it to help the Obama administration's efforts to control health costs of chronic diseases like diabetes and arthritis, and back or neck pain, high blood pressure, and others, that end up clogging the hospital system and raising health care costs. By using these IT records to flag when a patient is not compliant or taking his medications and call the patient, Ryan can increase drug sales, get more visits into drugstores if the drugs can also be picked up at CVS stores, and increase sales through ancillary purchases during visits. This is now his strategy. It also includes setting up more clinics at stores and at corporate locations that divert the patient flow for small care like sore throats, flu and the like. As this is the way health care costs can be controlled, Ryan sees himself as helping achieve national goals while keeping CVS in the sales and profit picture for the US, even as health care as we know it goes through a complete transformation that removes the waste and unnecessary cost, and improves effectiveness and health. He sees CVS/Caremark right where it wants to be with its large patient drug database from about 1 billion prescriptions it fills each year, and as the largest single buyer and dispenser of prescription drugs in the country. ...

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Tyler Cowen, Professor of Economics at George Mason University, points out some basic truths about health care as it is practiced today in the USA, and healthcare spending as it stands today. He questions whether starting out with extra spending plans to provide coverage to all will help solve the basic problems facing American health care. Too many tests and diagnostic procedures used by doctors is not aproblem that will be solved by spending more money to cover everyone. And government taking on more spending to cover all will not address all the other major shortcomings of the American way of practicing medicine, like prescribing a battery of tests, that tend to drive up costs, to just mention one of the problems. And it will not address any of the shortcomings in the way Americans take care of their health, diet, exercize and healthy lifestyles. THese are critical to get good health outcomes for the people, and which combined with careful spending of dollars where it will provide the greatest benefit, is the only way the health care solutions can be found....

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The Congressional Budget Office's Elmendorf says without spending cuts in payments to doctors and hospitals and other providers, providing coverage to the unisured will put the nation deeper into debt. Popular measures such as increasing preventative care, expanding medical records and rewarding doctors for choosing treatments that improve cost and quality have potential but its not proven how much the savings from this would be. The administration and the White House Budget Director, Peter Orszag, say they are in agreement with the CBO that something needs to be done to seriously reduce costs, reducing payments for Medicare and Medicaid to doctors and hospitals, and making other changes.

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The public option as anecessary step for effective cost control in healthcare in the USA. The potential for higher healthcare costs in the future gutting the whole effort to provide universal health care if there isn't the money to pay for it. Which means that if the public option brings costs down its anessential part of any healthcare program that is sustainable years from now. Krugman calls for audacity from the President.

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The American Medical Association came out against the public option in President Obama's health care reform plan. The outpouring of comments on this article show that public opinion today seriously questions the actions of the AMA, and think that this is not in the best interests of the nation. Its the kind of outpouring of criticism that GM's old management received from readers fed up with the management of the Detroit automakers, before the GM bankruptcy. Out of the 26 most read or recommended comments on this article shown on the link to the article in the NYT, 25 were strongly critical of the AMA's position on health care, none were in favor, and one was critical of the insurance companies. The 25 that were strongly critical had a total of reader recommends of 6539 readers when they were totalled up for all 25 comments. Some of these comments were strongly critical and explained at length why. Some were from doctors who disassociated themselves from the AMA. One suggested that the American College of Physicians also represented doctors, and the AMA represented only one group of mostly older doctors who are against any change. The financial crisis and the election of a new President, the changes in the country since the last failed reform effort in 1993, the new mood of the country as it changes to its more frugal past, a new generation of doctors and a new generation of young people coming to the fore, all may mean that things are no longer the same, and actually very different. Are the people running the AMA, like the people who were running GM a short time ago, not able to see how they are perceived by the public? ...

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To overcome resistance on Capitol Hill Obama takes his proposals for health care to the states and back to the grassroots support that got him elected. He will hold atown hall meeting in Virginia on health care. Obama advisor Axelrod says the main thing is to show what widespread support Obama's proposals have across the country. As ameans to this Obama's main political group Organizing for America will swing into action in the weeks ahead.Obama is talking to governors, Democrat Christine Gregoire of Washington, and Republican Michael ROunds of SOuth Dakota,

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The Institute of Medicine releases areport of the 100 health topics that should get high priority, as the Obama adinistration proceeds with a plan to $1.1 billion to compare the effectivenesss of treatments. Some of these areas for research are prostate cancer treatments, a surgical procedure called ablation, and others.

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The NYT editorial says budget reconciliation should kick in if by a certain date in the fall bipartisan agreement is not reached. With budget reconciliation, the term for a expedited processs, health care legislation can pass by a simple majority vote. NYT says bipartisan agreement is a good thing, but more important is effective health care reform. And there is little evidence of Republican cooperation so far on any issue.

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WSJ's CEO council advocates a goal of 10% electric cars by 2020 and upto 50% of the fleet by 2030. Other top priorities of the CEO's from Google, Intel, Time-Warner, Fedex and other companies at a recent 1 day conference were obesity, a stimulus program in excess of $300 billion, and restarting the Doha round of talks for global trade.

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With 10.3 million workers unemployed according to the Bureau of Labor Statistics, and this includes 2.8 million added this year so far in 2008. Most of the people who lost their jobs also lost their health benefits. This increases the urgency for the Obama administration to come up with action in the health care area as the ranks of the uninsured will grow in 2009.

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The Senate FInance Committee's $829 billion bill, would cut by $113 billion money for America's Health Insurance Plans over ten years, specifically Medicare Advantage, reducing insurer profits. The AHIP is responding with aad campaign to seniors to fight this setting up aconfrontation with the Obama adminsitration.

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Comparative effectiveness research will be conducted to evaluate what is the best treatment for any ailment or disease or health problem under the $1.1 billion allocated for this in the Stimulus Plan. What are the alternative methods of treatment, what is the effectiveness of each treatment, what are the comparative costs and so on. Is it better to treat neck pain with surgery or acombination ofphysical therapy, exercize and medications? If there is ablockage of arteries in the lower leg and leg pain, how does drugs and watchful waiting compare with surgery? For chronic heart failure how does home monitoring of blood pressure and weight and exercise in addition to medications provide an alternative route as opposed to just medications. Dr Fisher of Dartmouth Medical School cites these as examples of questions that can be asked in comparitive effectiveness research. The money will be available to the Health and Human Services Department and will be used over several years. About 15 federal employees will form a council to coordinate the research and advise President Obama and Congress on how to use the money. In 2007 the US spent $2.2 trillion, or 16% of GDP, on health care, and the Congressional Budget Office says it will grow to 25% of GDP at the rate its growing by 2025 if left to its own devices. ...

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Of the people asked the question "what issue do you see as the most important for health care" 44% in a NBC/WSJ poll said they considered Cost as the biggest issue, and 37% said that they considered the Uninsured as the biggest issue, 11% said quality of care was the biggest issue. The President is focussing on cost as he develops the health care plan. He is also saying that to provide health care for all and cover the uninsured without controlling costs would break the bank. Another thing that the White House shows it has learned from previous failed attempts, is that it is doing this with an open Health Care Forum with participation of different sides in the health care discussion. Clinton's effort in 1993 ran into problems because it was developed secretively, and without much discussion, and little effort to get different people's views. The previous attempt also waited too long after the election, and this time the President is moving quickly when he enjoys large popular support. Its also true now that there is serious concern especially in this downturn of what a threat spiralling costs of health care are becoming to the future prosperity of the American people. This time the leaders in Congress are setting an aggressive schedule to get health care palns legislation on the floor by June and get a floor vote in August 2009....

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Copies with slight changes to extend drug life with new brand names- Clarinex for Claritin, Nexium for Prilosec, Paliperidone for Risperdal being the latest in this new marketing strategy of drug companies to extend the life and sales of a successful drug. The drug companies try to market the copy drug as a significant improvement, which is what J&J is doing with Paliperidone. Experts are skeptical. Pricing of the generic versions of Risperdal or its copy will be much less expensive. Cost is a sensitive issue. About 15% of Risperdal's $1.35 billion sales were from Medicaid, generic substitutions offer potentially large savings. Meantime J&J did not do clinical tests between Risperdal and Paliperidone, the tests with 1600 patients compared Risperdal with a sugar pill. A psychiatry Professor at Duke and another professor at NYU are skeptical of J&J claims for Paliperidone. United Health shows savings of $150 million by using generics instead of Nexium, so managed care payors will tread carefully....

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The National Childhood Vaccine Injury Compensation Program protects vaccine makers from much of the litigation risk faced by pharmaceutical manufacturers. It limits compensation for death to $250,000. This special vaccines court is called Office of Special Masters at the U.S. Court of Federal Claims. This may be one reason for Pfizer's willingness to pay $68 billion for Wyeth which is amaker of childhood vaccines. Vaccines will generate $21.5 billion in sales by 2012, according to Sanofi-Aventis. Vaccines are biologic products that can't be copied. Wyeth's Prevnar is designed to protect children against 7 strains of pneumococcal disease. It has sales of $2.7 billion projected to grow to $5.5 billion in 2015 according to Sanford C. Bernstein & Co. Vaccines have driven huge reductions in childhood diseases, and the Act is designed to potect makers of vaccines, who suffered from excessive litigation in the 1980's.

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As Indian pharmaceutical industry sees drug testing in India as an opportunity, conditions for obtaining the best results are being established by taking necessary steps. With ashortage of experienced people to run drug trials, Indian government has stepped up training, setting up partnerships with the U.S. FDA, Health Canada, the World Health Organization, and other similiar organizations, The emphasis should be on credible dat and the safety of subjects says A.K. Pradhan, India's Assistant Drug Controller. After the death of an infant in a Wyeth Pharmaceuticals drug testing effort, the Drug Controller of India though supportive of Wyeth has raised certain issues that Wyeth is addressing.

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Walgreens is changing its growth model to add the business of Health and Wellness buying two companies I-trax Inc. and Whole Health Management which run 350 health centres at corporate offices. Pharmacies will be added to these centres. Its targeting 7600 office sites with 1000 or more employees that could use a health-care center. Its competitors CVS and Walmart are going into managing employer drug benefit programs, with Walmart's selling point being reducing costs of paying for prescriptions for employers.

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President Obama has 63% job approval rating in a New York Times/CBS News poll. His backing is among Democrats and independents alike which is very useful for Obama.But the poll shows more American having faith in the President than in the handling of specific issues. He gets good approval on foreign policy initiatives at 59%, but in the handling of the Auto bankruptcy, or of health care his ratings are below his personal ratings as President. A majority of those polled were concerned about the rising budget deficits. BUt his ratings among Republicans has fallen from 44% in February to 23%. Republicans were viewed favorably by only 285 of those polled, the lowest ever.