Pharma pricing, and the secondary market for diabetes test strips

The NY Times has the story on the gray market for diabetes test strips:

The Strange Marketplace for Diabetes Test Strips

"Test strips are a multi-billion-dollar industry. A 2012 study found that among insulin-dependent patients who monitor their blood sugar, strips accounted for nearly one-quarter of pharmacy costs. Today, four manufacturers account for half of global sales.

"In a retail pharmacy, name-brand strips command high prices. But like most goods and services in American health care, that number doesn’t reflect what most people pay.

"The sticker price is the result of behind-the-scenes negotiations between the strips’ manufacturer and insurers. Manufacturers set a high list price and then negotiate to become an insurer’s preferred supplier by offering a hefty rebate.
...
"For a patient testing their blood many times a day, paying for strips out-of-pocket could add up to thousands of dollars a year. Small wonder, then, that a gray market thrives. The middlemen buy extras from people who obtained strips through insurance, at little cost to themselves, and then resell to the less fortunate.

"That was the opportunity that caught Chad Langley’s eye. He and his twin brother launched the website Teststripz.com to solicit test strips from the public for resale. Today they buy strips from roughly 8,000 people; their third-floor office in Reading, Mass., receives around 100 deliveries a day.

"The amount the Langleys pay depends on the brand, expiration date and condition, but the profit margins are reliably high. For example, the brothers will pay $35 plus shipping for a 100-count box of the popular brand Freestyle Lite in mint condition.

"The Langleys sell the box for $60. CVS, by contrast, retails the strips for $164.
...
"While some resellers use websites like Amazon or eBay to market strips directly to consumers, the biggest profits are in returning them to retail pharmacies, which sell them as new and bill the customer’s insurance the full price.
...
“Test strips are basically printed, like in a printing press,” said David Kliff, who publishes a newsletter on diabetes. “It’s not brain surgery.”

"He estimated the typical test strip costs less than a dime to make."

Surrogacy as viewed from Spain (where it is illegal)

Not late-breaking news, but here are some El Pais reports that reflect the ongoing situation in Spain:

Spain struggles with surrogate pregnancy issue
Practice is illegal here but debate rages over whether surrogacy is a right or a form of exploitation

"The Swiss-based International Social Security Association estimates that every year, surrogate mothers give birth to around 20,000 children worldwide. Agencies and parents estimate that between 800 and 1,000 go on to live with Spanish parents, but there are no official figures. There are numbers, however, for international adoptions undertaken by Spaniards, and these have fallen from 5,541 in 2004 to 799 in 2015.

"Yet if the estimates are correct, international surrogacy has overtaken international adoption in popularity. Instead of the international adoption process, which can take up to eight years, it seems that those wanting to be parents are more frequently opting for the quicker route, and paying between €45,000 and € 60,000 in the Ukraine or Russia or up to €120,000 in California – one of 14 American states where the practice is legal.

"Every country has different legislation. Ukraine, for example, only allows heterosexual couples to use surrogates. In Canada, the United Kingdom and Portugal, surrogacy is only allowed in the altruistic sense, meaning the surrogate mother receives no direct economic benefit. And the latter two countries only let nationals use surrogacy. India, a former worldwide power in surrogacy, has vetoed it for foreign couples, and is on the verge of making it illegal for economic profit. Mexico too, particularly the State of Tabasco, has recently restricted surrogacy laws.
...
"“The best solution to avoid abuses is to legislate it. It’s like organ transplants – regulating the legal practice gets rid of organ trafficking,” says Pedro Fuentes, president of a pro-surrogacy parental association that brings together around 400 families, Son Nuestros Hijos. Fuentes is a gynecologist and alongside his husband, he is also the father of a six-year-old boy who was born in California to a surrogate mother. He gets emotional when he tells the story of how he met the surrogate mother and the warm relationship they developed. He said that her own ethics also guided the process, as she had decided to use her body as a surrogate to help a gay couple.

"The association itself has a code of ethics and recommends not trusting “agencies that don’t let you meet the mother, which guarantee results, and which offer package deals saying you won’t have to worry about anything.” Also, they suggest that parents work with a woman who has already given birth. The association certainly makes the case for altruism but it is also open to economic compensation.
...
"The association asks: “When is a women being exploited? When you pay her or when you don’t?”
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Also,
The dark side of Ukraine’s surrogacy boom
Lack of oversight, lax regulations and a failing economy have made the eastern European country one of the most popular destinations to find a surrogate mother
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And here's a story from 2014 with background on the Spanish supreme court's decision not to recognize the child of Spanish parents borne by a California surrogate:
Are you my mother? The Spanish Supreme Court and surrogacy tourism

"The majority of the judges, however, contend that the “best interests” criterion is not the sole factor to be taken into account. Judges should also ponder the State’s interest in preventing the commodification of children and motherhood. But more strikingly, the Supreme Court argues that it is not obvious that it goes in the best interests of the twins to be legally declared as the sons of Ramón and César and not of the surrogate mother. It is striking, in my view, to argue along those lines when the surrogate mother is a woman who has relinquished her motherhood and the intending parents are not only willing to be the parents, but, most importantly, are the “social” fathers."



HT: Stephanie Wang

The Urology Residency Match

Yesterday was Match Day for urologists, a medical specialty that runs its own residency match, in advance of the NRMP.

They write: "This year's Match once again proved urology is a competitive specialty for aspiring young physicians. More than 430 applicants registered for the 2019 SAU/AUA Urology Residency Match. Of those who registered, 90 percent submitted preference lists, competing for a record 339 available positions across the country. When the matching algorithm was processed, 85 percent matched to a vacancy within 136 registered and accredited U.S. training programs, leaving only nine vacancies unmatched."

Here are the statistics from the AUA's web page:

Urology Residency Match Statistics

There are 137 non-military accredited urology residency programs in the United States. (Military programs cannot participate due to government regulations regarding eligibility.) For 2019, 135 non-military accredited urology residency programs in the United States listed 339 positions with 330 vacancies being matched. 389 applicants submitted preference lists netting 59 unmatched applicants. Of the senior medical students in the U.S. applying, 91% percent were matched.

View additional 2019 Urology Residency Match Statistics [pdf]

	Jan 2019	Jan 2018	Jan 2017	Jan 2016	Jan 2015	Jan 2014	Jan 2013
Programs
Positions Offered	339	325	319	295	296	285	279
Positions Filled	330	314	317	294	295	285	279
Positions Open	9	11	2	1	1	0	0
Applicants
Registrations	434	436	477	468	493	534	537
Lists Submitted	389	402	422	417	433	446	434
Ranked by Programs	368	369	385	373	388	420	400
Matched	330	314	317	294	295	285	279
Not Matched	59	88	105	123	138	161	155
Averages and Match Results
Average Applications	71.0	70.0	68.0	65.0	63.0	59.0	53.0
Average Interviews	37.0	11.0	11.0	10.0	10.0	10.0	9.0
Average Offers	14.85	13.78	11.77	11.35	12.23	9.35	8.87
US Seniors Matched	91%	86%	82%	77%	77%	68%	69%
US Graduates Matched	78%	43%	47%	47%	43%	15%	33%
Int'l Graduates Matched	58%	24%	33%	17%	31%	24%	23%
Women Matched	83%	75%	75%	68%	68%	65%	68%

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And here's some process data from the pdf:

HT: Mike Rees

Fifty years of "brain death"

There was a time when death came in threes: neurological, respiratory, and circulatory processes all shut down more or less together, because when a body lost one of these the others inevitably followed very quickly.  But what makes most deceased organ transplantation possible is that respiration and circulation can be maintained on a ventilator after the end of neurological activity, so that organs can remain oxygenated after the brain has died.

The Uniform Determination of Death Act (UDDA) states that an individual who has sustained either:
"an irreversible cessation of circulatory and respiratory functions, or
an irreversible cessation of all functions of the entire brain, including the brain stem, is dead."


A recent Hastings Center Report discusses brain death on the 50th anniversary of its 'birth'.


Brain Death at Fifty: Exploring Consensus, Controversy, and Contexts
Robert D. Truog  Nancy Berlinger  Rachel L. Zacharias  Mildred Z. Solomon

Abstract: This special report is published in commemoration of the fiftieth anniversary of the “Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death,” a landmark document that proposed a new way to define death, with implications that advanced the field of organ transplantation. This remarkable success notwithstanding, the concept has raised lasting questions about what it means to be dead. Is death defined in terms of the biological failure of the organism to maintain integrated functioning? Can death be declared on the basis of severe neurological injury even when biological functions remain intact? Is death essentially a social construct that can be defined in different ways, based on human judgment? These issues, and more, are discussed and debated in this report by leading experts in the field, many of whom have been engaged with this topic for decades.
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And here's an article about the report in Forbes (it seems to be in their section on "retirement":-)
What Does "Dead" Mean? The Debate Continues Some 50 Years After Harvard Defined Death.  Robin Seaton Jefferson

“Capron, one of the architects of the UDDA, summarized the situation well in 2001 when he described efforts to determine when death has occurred as both ‘well settled, yet still unresolved.’
**********

The article suggests that we won't have to worry about precise definitions of death once we don't need deceased donors for transplantation any more, but I'm not so sure.  Ventilators help keep people alive while their bodies are struggling, and some will recover.  But if not, there is still often a decision to be made about when to disconnect the ventilator, and make it available for someone who still has a chance of recovery.

Carbon tax with revenue returned through equal lump-sum rebates: open letter

An open letter from many economists, published today as an op-ed in the Wall Street Journal, proposes a carbon tax with the revenue to be returned to taxpayers, as a way to put incentives in place to deal with climate change.
 Here it is in the WSJ: 
Economists’ Statement on Carbon Dividends--Bipartisan agreement on how to combat climate change.

And you can click through to the oped (ungated) and related articles at https://www.clcouncil.org/?mod=article_inline

ECONOMISTS’ STATEMENT ON CARBON DIVIDENDS

27 Nobel laureates, all 4 former Fed Chairs, and 15 former Chairs of the Council of Economic Advisers unite behind carbon dividends as the bipartisan climate solution.

• Wall Street Journal op-ed
• Washington Post
• Axios
• Wall Street Journal article

Organ donation in Germany

Spiegel.de has the story:
Nach langem Abwärtstrend, Zahl der Organspender deutlich gestiegen
(GT: After a long downward trend, the number of organ donors has increased significantly)

"Last year, 955 people left organs for other critically ill patients after their death, as the German Foundation for Organ Transplantation (DSO) announced. That was an increase of nearly 20 percent compared to 2017 with 797 donors and the first major increase since 2010.
...
"a discussion on new organ donation rules has started in parliament across parliamentary boundaries. So far, withdrawals are only allowed with expressly agreed consent, but many postpone the occupation with this topic again and again.

"Spahn is therefore campaigning for a "double contradiction solution" ["doppelte Widerspruchslösung"]. Accordingly, everyone is automatically considered a donor. One should be able to say no to this, otherwise - as a double barrier - relatives would have to be asked. In an open debate in the Bundestag at the end of November broad reservations against such a new regulation became clear.

"Instead, a group led by Greens leader Annalena Baerbock and left-leaning boss Katja Kipping suggests a mandatory recurring query, such as collecting new passports or identity cards - with the option of not yet deciding."
**********

HT: Rosemarie Nagel

Repugnance watch: what to do with a mass-murderer's gun collection?

The NY Times has the story:
A ‘Moral Dilemma’ After Las Vegas Massacre: Sell the Gunman’s Weapons, or Destroy Them

"When the gunman in the Las Vegas mass shooting died, he left behind a hoard of guns and firearm accessories in his two Nevada homes and the hotel suite he used as a perch for his attack.
...
"Now, the main lawyer involved in passing on Mr. Paddock’s nearly $1.4 million estate to the families of the 58 people he slaughtered at an outdoor country music festival is facing a quandary. Should the firearms be sold to raise as much money as possible for the bereaved, or would it be more appropriate to destroy the guns in an emblematic rejection of the kind of violence that Mr. Paddock carried out?
...
"Mr. Paddock died without a will. Lawyers for the victims encouraged Mr. Paddock’s mother — who, under Nevada law, became the heir by default — to give his assets to the estates of the 58 people killed by her son. The mother, Irene Hudson, transferred her right to inherit the estate in March of last year.

"In addition to those killed, hundreds of others were injured in the shooting. However, lawyers say the compensation should go to the loved ones of the dead rather than the injured, saying the money would have greater impact on their lives than if the large number of people hurt in the rampage were also beneficiaries.