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Slowdown in drug sales growth in USA and Europe. Top seven emerging markets will account for 34% of global sales growth upfrom 7% in 2000. And the USA accounted for 40 to50% of growth in global pharmaceutical sales each year early in this decade, in 2009 the sales in the USA will account for just 9%. Forecasts and figures are from IMS consulting firm. USA sales will rise only 1-2% if at all, while emerging markets will grow by 4.5% to 5.5%. With the economic troubles American consumers are less likely to fill prescriptions and insurers are not covering new drugs and favoring generics. Intense competition among generics drug makers is reducing prices. IMS predicts that the global generic market will grow by 5 to 7% in 2009 to $68 billion, slowing from double digit growth. This is from total sales forecast for pharmaceuticals globally of $830 billion.

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As remedies for the $1.6 trillion federal budget deficit for 2010, which says Hubbard threatens to compromise Americas economic future, set agggressive targets for reducing discretionary spending limiting growth to 2%. Hubbard also wants to see 1% reduction in projected entitlement spending growth for Social Security and Medicare. This can be done progressively, he says, by lowering the growth in spending for middle and upper income households and strengthening the safey net for lower income people. And third he would have a broad based consumption tax to pay for added social spending. Hubbard was adviser to president George W. Bush and is Dean at Columbia Business School.

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How diagnostic tests in portable toolskits, that patients can use themselves, are being developed at low cost in developing countries like China. This creates the kind of care appropriate for poor countries, where patients need something they can afford, and something that does not require repeat visits to doctors offices or clinics. Ustar Biotechnologies is a Chinese startup, that says it has the technology, costs that the founder says "no one can compete with," and affordable prices for poor countries. The sales of such diagnostic test portable devices or kits is expected to soar in coming years. Quimin You, the inventor and founder of Ustar, graduated in North America and worked with multinationals. His proposals for cheap diagnostic technologies were turned down by multinationals, who in their narrow focus saw these thechnologies undermining their existing products. Now Qimin is back in China with a startup that will do this.

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Feldstein says that for the 85% of the people who have healthcare the Obama proposals are not a good deal. The Obama proposals mean higher taxes in the long run to pay for the $1 trillion cost of healthcare for the uninsured group over 10 years. This lower income group has no coverage despite the $300 billion Medicaid program. Feldstein says there surely must be better and less costly ways of getting this lowincome group healthcare. Raising the top income tax rate to 45% from 35%- as a result of letting the Bush tax cuts expire and adding aproposed health surcharge on higher income individuals- would actually lower revenues for the government, as it would change behavior of high income individuals in ways that lower their taxable inome. The result is higher deficits and higher taxes when even without this large deficits are projected for the future. How to slow the rapid growth in healthcare spending? The Obama plan is to cut spending on Medicare. Feldstein sees the govenment's effort aimed at reducing the amount of medical services, as reduced spending comes from fewer services, not reduced payments to providers. Will this result in enough of acost reduction to make the system work. And if the cost reductions are too heavily weighted towards reduced services and not reduced payments to providers would this result in large cuts to services to affect the quality of healthcare for the 85% who are accustomed to a different pattern of healthcare, even though it is structured to allow cost escalation. Feldstein offers no solutions to the problems of cost escalation except to suggest that the Obama plan does not really tackle the cost escalation issues directly with providers, and instead burdens the national finances to an extraordinary degree. And the need for apause and reflection....

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Glaxo's Dr Garnier talks with Jeane Whalen of the WSJ about his work, a lot about his committment to running a company not just for rich countries, that access is a very important word for him and his efforts to make drugs affordable or even free or close to free depending on the country's standard of living, his 24-7 day handling the Avandia issues, and the innovative drug pipeline he has put together over the years.

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The influence of lobbyist on members of Congress just as the Obama administration, having studied the failure of the Clinton submitted healthcare plan try a different strategy of letting Congress come up with a healtcare plan. $133 million was spent in the second quarter alone by healthcare industry lobby interests creating headaches for reform efforts and the Obama administration.

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About 53% of the uninsured Americans disapprove of the Obama health care law, in comparison to 51% of the insured with health care coverage who disapprove of the new law. About 35% of the uninsured say they are likely to pay the penalty for not carrying insurance, and six of ten uninsured say it will make their health better. Overall the approval of the law is at 39% and disapproval at 50% in the Dec. 2013 poll. A striking part of the poll result is that 57% of the uninsured say it will increase their health care costs, compared to 52% of the insured. Only 20% say it will decrease their health care costs. This reflects the lack of serious controls on the surge in healthcare spending in the law. A separate research shows that more of the costs are passed on to users who will pay higher out-of-pocket costs after the law.

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A new report by Medicare trustees found that the Medicare hospital trust fund would face insolvency by 2029, which is 12 years after the projection made last year. But Medicare's chief actuary questioned this by saying that this assumes cuts in payments to medical providers in the health reform bill would be implemented. Not realistic he says, considering that many doctors would drop out of Medicare causing difficulty for seniors. After 2029 Medicare would be able to pay 85% of the benefits according to this report. Separately the Social Security fund is expected to need a $41 billion cash infusion, with more paid out in benefits, than collected in tax receipts in 2010 and 2011, with this situation getting worse by 2015.

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Serious problem of rapid premium increases for middle class people not eligible for subsidies under the Affordable Care Act. Insurance companies have increased premiums rapidly to pay for the cost of treating people with previous conditions and the uninsured, as well as population with poor health conditions.

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Areas for growth for the Indian drug Industry include the large growing domestic market, the outsourcing by US drug manufacturers, and sales in other developing countries of Asia, Middle East, Latin America and Africa. Analyst estimates are that India will spend $30 billion a year on drugs to improve care for its people in the next 10 years up from $8 billion today. And the distribution network is being developed by drug companies insdie India to reach more people. Also companies like Pfizer plan to double outsourcing of manufacturing drugs from 10% today to 20%.

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The EU's competition commissioner to crackdown on pharmaceutical companies that are delaying the entry of generics drugs with various tactics that are anticompetitive. EU has raided the offices of several marge drug companies and retrieved documents that show this activity was going on. About 5% of medical bills or 3 billion euros coud have been saved from 2000 to 2007, if companies had allowed generics to enter the market earlier and not resorted to these antitcompeitive strategies. Like paying off generics companies or having so many patents on the ingredients of the drug, in one case 1300 patents on one single drug, and then suing the generics companies to tie up the case in the courts.

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The influence of the AMA convened Relative Value Scale Update Committee (RUC) on how the Medicare payments to doctors is shared, and on the growth of the Medicare budget. Concern that the interested party is driving the decision making process. Medicare costs went up by 9% in 2009. Fears that doctors have too much control over the dollars in the $500 billion Medicare program. The tendency to focus on more expensive procedures and short change preventive and less costly care. Medicare spends $60 billion on doctors fees. The older codes remain in place even when costs are reduced, leading to higher costs for the Medicare budget each year. And there is little incentive for doctors in RUC to revise overvalued codes.

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Walk in clinics at drug stores like CVS and stores like Walmart now have the cooperation of hospitals. Hospitals are now affiliated with 25 Walmart clinics. THe Cleveland Clinic has lent its name and backup services to a number of CVS clinics in northeastern Ohio. And the Mayo Clinic is operaing ne Express care clinic at asupermarke in Rochester, Minnesota, and asecond one at ashopping mall. This helps clear emergency rooms of people seeking bsic medical care as for astrep throat or flu. About one thousand clincs are operating in the US at drugstores, supermarkets and big stores since the idea took root 4 years ago. Wal-Mart has partnered with hopitals like the Christus Medical Group in Texas, Aurora Health System in Wisconsin and COxHealth in Missouri to setup clinics. Mayo did so after employees and patients said they wanted more convenient treatment for minor medical problems, so there may be a need here that as not been met. The lower costs at these centers compared to primary care doctors offices or emergency rooms make it possible for them to price lower and meet the needs of the 45 million or so uninsured people in the US, numbers growing as jobless rate increases. They are typically staffed by nurse practitioers or physicians asistants. Dr Herman at Mayo Clinic, who supervises its retail store clinics, says rather than fight this trend primary care doctors should learn from it, and work with hospitals around the country to offer more convenient locations and consumer friendly office hours, including periods of walk-in care with no appointment....

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Epic Systems of Verona, Wisconsin, is one of the companies engaged in digitizing health records. It has helped develop records for 40 million patients in hospital systems such as Cedars-Sinai Medical Center in Los Angeles, Kaiser Permanente, the Cleveland Clinic, and John Hopkins Medicine in Baltimore and the Weill Cornell Physicians Organization of New York. Epic provides the software, the IT systems, the training and support. Epic is one of the pioneers in this, having been in the business for 30 years. About 40% of primary care doctors in the U.S. and 25% of hospitals use electronic patient records. The Federal government has provided $2.7 billion in funding from $27 billion of Stimulus funds assigned for the purpose of conversion to electronic medical records. This is likely to speed up the conversion. Other providers are Cerner, Allscripts, Meditech, Siemens Healthcare, G.E. Healthcare, and IBM. Epic Systems is considered the defacto standard in the industry for medical schools and some of the major hospital systems in the country. New contracts are leading to a major expansion of Epic Systems which employs 5100 people. Epic plans to hire an additional 1000 people. Revenue for the privately owned company are estimated at $1.2 billion, a 45% increase over the prior year. Epic is expected to have 127 million patients under medical records by mid 2013. To get the feedback essential for such a large conversion, CEO Faulkner relies on feedback from 250,000 doctors who use the Epic systems software, and on nurses and doctors from Epic who visit customer's sites to see first hand how it works and what needs improvement. Judith Faulkner started Epic more than 30 years ago. A project for the Psychiatry department led to other projects after she graduated in computer science from the University of Wisconsin. Epic continues to attract programmers to Wisconsin by making the Epic campus a fun environment and a great place to work. ...

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Doctors face a 21% cut in the amount of Medicare payments for treating seniors having Medicare, though this cut will be delayed till 2011 under legislation in Congress. This issue goes back to 1997, when a budget law set spending targets, and stated that if they were exceeded formulas to reduce doctors payments would go into effect. The formulas seriously cut into doctor payments by Medicare in 2002, so the formula was put off. The result of this is that the cuts based on the formula now amount to 21%. The cuts are not expected to go through, but at the same time Congress has an headache on its hands with the growing deficit. In the Senate there is opposition to a $120 billion bill to extend long term unemployment benefits which lapsed in June 2010, for tax breaks, and other expenses. Senators want to pare down the bill's price tag, as $80 billon of this is unfunded and will be added to the budget deficit. For a primary care doctor in Washington state, Medicare pays about $95 compared to private insurers payment of $129, and a plan for state workers that pays $140....

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The basic problems facing American health care. Douglas Elmendorf , head of the Congressional Budget Office, says none of the bills he has seen make the fundamental changes needed in how medical care is delivered and paid for. The big issue is the unwilingness of different interests to accept serious changes. THe NYT says the long run solution to the problem of rising costs is to move away from the fee-for-service system that pays hospitals and doctors for each additional service they provide and into anew system that is organized around ways that encourage low-cost and high quality healthcare. The difficulty is that the long run may be too far, considering the seriousness of the crisis. Elmendor also suggests taxing employer provided health benefits, as this will discourage the excessive use of medical care. As the NYT says this is politically risky, even though it believes this may be a way to the new system which has to discourage the use of health care in the manner it is conducted now, with too many tests being conducted. A new system requires an enlightened approach on the part of each interest group in the face of a crisis, and the failure to do that may only end up retaining some of the worst aspects of the old system just mentioned that drive up costs and make universal health care unaffordable....

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The publisher of the Wall Street Journal, Dow Jones & Co., is working to overturn a court injunction that prevents the public from seeing the Medicare billing records of individual doctors. Dow Jones & Co., filed court papers in January 2011, to overturn the court injunction. The American Medical Association has fought to keep secret the amounts of money individual doctors get paid by Medicare. The AMA filed a lawsuit against the government to keep secret these Medicare records, on the grounds of privacy rights, and won a court ruling in 1979. This court ruling still stands. The position of Dow Jones in its efforts to change this situation, is that giving the public access to the records is essential to the monitoring of so large a public expense as Medicare. These records would then be available to state medical boards, nonprofit organizations, universities and newspapers who can act as watchdogs over the $500 billion Medicare program. Such transparency and monitoring is an essential feature for the proper functioning of such programs and to prevent misuse of public money. For a program like Medicare, fraud and waste has enormous implications, as it adds to the spiralling cost of healthcare and to the unsustainable budget deficits. In one of the largest cases so far, the FBI, Justice Department, 700 state, federal and local agents, worked together to charge 114 defendents nationwide with Medicare fraud in February 2011. A senior law enforcemet official says Medicare fraud is so rampant, "there's no way in hell you can prosecute your way out of this problem, no way." He says the the answer is more effective monitoring of the money that goes out. And a key part of that is transparency and public access to how the money in Medicare is spent, what individual doctors and healthcare providers are getting paid by Medicare. The lack of this transparency for a program the size of Medicare can only lead to a lack of monitoring as the Dow Jones suit asserts, and make it difficult for the government to check abuses in the way money goes out. At a time when teachers and public workers and seniors are expected to make their share of the sacrifices to fix the budget deficits, it is incomprehensible that money should then be allowed to go out of the Medicare system through fraud and waste, because of a lack of transparency....

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The health care system is designed to encourage procedure based specialist practices and discourages the patient understanding education and monitoring that occurs with a well designed preventive family physician practice. As a result a patient only spends 30 minutes ayear on average with family physician compared to one hour in other developed nations. In the USA there has been a steady decline in the level and quality and extent of family care and the close one on one rapport with well trained family physicians who enjoyed their work and understood their patients and kept up with their health conditions and provided good and regular advice on these conditions. There is no money in this care as a result first you provide an environment where a whole range of medical conditions can flourish and expand, and then you hit them with a whole series of tests to rule out specific medical conditions. It is a perfect way to expand the testing and let testing flourish, so it would appear that if someone had wanted to start with a goal of letting testing proliferate unhindered then this would be the perfect way to design it. ...

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The worst flaw in the health care bill says the Economist is that "fee for service" and doctors billing for each test done continues as before.The whole idea of medical services based on medical necessity and value for money has been left out of the billsin Congress. Alan Meltzer also pointed this out in his discussion of the deficits and debt over the next decade; that the 25% reduction in medical expenditures does not look anywhere closer to reality, worsening the deficits. This is also the view expressed in the discussion of health care reform in the November 2, 2009, issue of Business Week. Never mind said BW that the doctors and hospitals account for one third of medical expenditures and there is waste in Medicare spending. Congress said BW has made no changes in the "fee-for-service" system of medical care that has inflated medical costs, by paying doctors for the volume of services delivered and not the quality of services delivered.

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The Economist cites the Dartmouth Atlas Project which shows differences in cost across the country for health outcomes and spending involving Medicare. It cost $5000 per person in Salem, Oregon in 2006, $8000 in San Francisco, and more than $16,000 in Miami, with outcomes for health tending to be better in places where the costs were lower. This is one of the statistics that Peter Orszag of the Congressional Budget Office uses to come up with his estimate of 30% waste in health care spending in the United States. Prof. Skinner at Dartmouth and Prof. Garber at Stanford point out that of most health systems around the world the American system is "uniquely inefficient" and wasteful. The Economist cites information that the American system is twice as costly per person for healthcare than the Swedish system, and that it costs twice as much in Minnesota as in Miami. A poll done for the Economist shows 52% of the people in the UA are dissatified with the quality of care, 40% think the system needs fundamental change, and 29% think that it should be fundamentally rebuilt. The lack of uniform coverage is also causing turmoil in the system. About 49 million are uninsured, and a quarter or more are able to buy insurance and do not buy it because it is so costly, has exclusions and coverage is inadequate. But these people also end up in the emergency rooms along with the indigent costing the whole system tens of billion of dollars for costly late interventions that could have been avoided with preventive care early on. With the economic crisis and rise in joblessness, the dire condition of state and local budgets, the situation has probably drastically worsened, and the system near breakdown. ...

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The inflated costs for spinal surgeries at some hospitals in California. How surgeons, doctors, consultants, distributors and hospitals operated in a flawed system to make revenue gains through overbilling, and focus on increasing the number of surgeries performed.

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The US is facing a new pattern of demographic changes and their impact on Medicare and Social Security programs. The number of people on Medicare will grow in 2 decades, 2010- 2030, from 47 million to 80 million for Medicare, and from 44 million to 73 million for Social Security, according to this estimate. The workforce will grow more slowly and the tax base wiill shrink accordingly during this period. This pending worker-pensioner imbalance and the jump in the cost of the bill for Medicare and Medicaid, as well as the federal health benefit for poor people, create a major problem for the US. At the same time the group of people over 65 will rise in these 2 decades from 17% of the voting age population to 26%. This group and the people who expect to soon join this group will resist any changes to Medicare or Social Security programs, making it that much harder for the political process to tackle these issues to make the programs sustainable in the long run.

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As Obama faces the situation FDR faced, between political popularity after election in 1932, and loss of some political capital in the first year by 1933, and a lot depends on political will and courage. He has to execute and implement plans for efficient government spending that builds jobs to replace those lost, and to use the investments in really productive ways including projects that provide returns for years into the future. As David Axelrod points out in the Frank Rich column in the NYT, people sometimes live in a parallel universe, which may be completely at odds with what the rest of the country caught in the economic currents of layoffs and collapsing businesses is thinking.