Relevant and even prescient commentary on news, politics and the economy.

Coronavirus Treatment Case Report

“First Case of 2019 Novel Coronavirus in the United States” Holshue et al 2020

I quote

Treatment with intravenous remdesivir (a novel nucleotide analogue prodrug in development10,11) was initiated on the evening of day 7, and no adverse events were observed in association with the infusion. Vancomycin was discontinued on the evening of day 7, and cefepime was discontinued on the following day, after serial negative procalcitonin levels and negative nasal PCR testing for methicillin-resistant Staphylococcus aureus.

On hospital day 8 (illness day 12), the patient’s clinical condition improved. Supplemental oxygen was discontinued, and his oxygen saturation values improved to 94 to 96% while he was breathing ambient air. The previous bilateral lower-lobe rales were no longer present. His appetite improved, and he was asymptomatic aside from intermittent dry cough and rhinorrhea. As of January 30, 2020, the patient remains hospitalized. He is afebrile, and all symptoms have resolved with the exception of his cough, which is decreasing in severity.

This suggests that Remdesivir is an effective treatment for Covid 19. I told you so. A guess in Angry Bear March 2 2020 a Case in the New England Journal of Medicine March 5 2020.

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Life in Rome

I am in a city with a curfew (enforced ?) where only pharmacies, supermarkets and those stores where someone from China sells all sorts of household stuff are open. Rome hasn’t reached the dread levels of Wuhan and Milan, but the Italian government is trying to get ahead of the curve.

It is strange and alarming that there is little traffic (it is also impressive that Romans don’t obey the traffic code even when there is little traffic). People are really trying to stay home all the time (I was semi home bound before it was cool).

I have learned about the activities which people consider absolutely necessary. A large fraction of people walking around are walking dogs. Many people are wearing masks (absolutely sold out everywhere) and gloves. I discover there are some things I have to touch. These include an ATM (alarmingly often) and cash.

One striking thing is that people wait outside of the supermarkets and pharmacies. This is a rule that does not have to be enforced — people are scared. Good thing it’s not cold in Rome during March (or February or actually ever at all in the globally warmed year of our lord 2019/2020). This makes me notice the high rates of infection in Iceland and Norway. I guess up there (where I have been in July with a rain coat) the choice is risk of Covid 19 or of frostbite.

The extreme measures (not just ordered but orders which are actually obeyed, by Romans) are impressive because as of the day before yesterday there were only 200 cases in Lazio (region which includes Rome). The fact that one of the cases was governor Zingaretti (also head of the Italian Democratic Party) might have made a difference.

The news spreads even faster than the virus. Down here the health care system is under strain but not overwhelmed (yet) but people read about (and see on TV) reports on how in Lombardy Triage has reaquired it’s original meaning. During World War I, It was red = critical, yellow = serious monitor but not critical, black = doomed. In normal times black now means deceased.

In Lois Armstrong Airport New Orleans during Katrina there were living people with black tags (for will not survive a flight and so will die here). I was appalled. Now in parts of Northern Italy there aren’t enough respirators for patients who would die without one. This is part of why the Italian case fatality rate is high. It is also important that Italians have had low fertility for decades and are old on average.

I guess I haven’t written anything that people don’t know already. I will update when the wave of contagion overwhelms us. I fear that I will be giving readers a hint of future action in their home town.

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Turn Up the Humidity in Your House

This is coming from MEDPAGE TODAY, “Track the U.S. COVID-19 Outbreak in Real Time,” Comments Section (3 comments), March 11, 2020 with regard to  COVID-19

“The mechanism of seasonal effect for seasonal respiratory virus spread is believed to be humidity, not temperature. In New York state which has 220 cases, fomites lose moisture where indoor humidity is low, allowing the lighter particles to stay longer in the aerosol. In Florida and Arizona, with 38 cases, fomites gain moisture and weight from the humid air and fall to the floor faster. Northern Italy, where people wear winter coats in the media reports has dry, heated indoor air, while Southern Italy has humid indoor air.

Humidifying indoor air in schools, stores, churches, etc. may reduce seasonal influenza, respiratory syncytial virus, coronoviruses which produce the common cold, rhinoviruses and Covid-19, Airports, airliners, airport shuttles should be the highest priority. The goal should be humidifying to the level seen in summer without transmitting Legionella.”

“The Philippines, Indonesia, Malaysia, Australia, Hong Kong have warmer, more humid air and much less Covid-19. Southern Italy has warmer, more humid indoor air than Northern Italy where indoor air is dry. The photographs in the media from places with the highest rate of Covid-19 spread show people wearing winter jackets.”

“In warm humid climates, fomites absorb water from indoor air and sink to the floor. There is a fine layer of dust everywhere indoors and viral particles attach to charged dust particles.

The mechanism for seasonal respiratory virus transmission is: fomite size in dry heated indoor air promotes viral spread. Larger fomites in humid air fall to the floor and react with charged dust particles.”

fomite definition: objects or materials which are likely to carry infection, such as clothes, utensils, and furniture.

microbiology definition: A fomites (pronounced /ˈfoʊmiːz/) or fomite (/ˈfoʊmaɪt/) is any inanimate object that, when contaminated with or exposed to infectious agents (such as pathogenic bacteria, viruses or fungi), can transfer disease to a new host.

This would include counter tops, etc.

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A Sunday reflection

The BSing of the Red Death: and a K.I.S.S. model for the coronavirus pandemic

Reuters/Ipsos poll this past week found that only 2 in 10 Republicans, vs. 4 in 10 Democrats, say the coronavirus poses an imminent threat to the United States. In keeping with that lack of concern, fewer republicans are taking any steps to prepare, such as washing their hands more frequently.

Anecdotally, from several GOPers in my neighborhood as well as from the proverbial table of old white men at the coffeeshop in the morning, I have overheard conversations all but trumpeting that “coronavirus is a hoax.” I think it was Chris Hayes who has said that Trump is trying to “BS his way through a pandemic.”

This derisive lack of concern reminded me Edgar Allen Poe’s story “The Masque of the Red Death.” In case you’ve forgotten your high school reading, in the story, during a plague known as the Red Death, a masquerade ball is thrown by Prince Prospero for numerous wealthy nobles, as they all hide in an abbey.  Despite this, during the revelry, a mysterious figure – presumably a personification of the Red Death itself – enters and all of the revelers die.

So, how many people might die as a result of Trump’s treating the coronavirus outbreak as a PR and re-election campaign issue, rather than a public health emergency, and when will it likely happen?  Just to give myself some markers, I did what I normally do: try to game this out.

So far, it seems that serious coronavirus cases have been increasing 10-fold every three or four weeks. Put another way, doubling about once a week. If there are currently 10,000 such cases worldwide, including 200 in the US right now (the latter being Pence’s most recent number), how quickly does this spread?

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Novel Coronavirus and Better Unsafe than Sorry

It is possible that a known pharmaceutical called remdesivir inhibits the reproduction of the Covid-19 coronavirus. It inhibits (some) RNA dependendent RNA Polymerases — the type of enzyme the virus uses to replicated its genome and express its genes. It is known that it is a potent inhibitor of the RNA dependendent RNA Polymerases used by the MERS coronavirus

update: here is a good site for Covid-19 data.

So what will be done with remdesivir ? What should be done ? Is what will be done anything like what should be done ?

I think I can guess what will be done. Different groups will work on different projects. Some labs will attempt to produce and purify the Covid-19 RNA dependent RNA polymerase to check if remdesivir inhibits it too. The patent holder, Giliad Science will start a two Phase III trials of remdesivir. Results will be reported and then the FDA will decide whether to approve it for use.

This is good as far as it goes, but I don’t think it goes close to far enough.

I think that aside from the trials, Remdesivir should be given to patients and contacts of patients. It is known to be safe (from the trial which shows that it doesn’t cure Ebola). Also a whole lot of it should be produced starting a month ago.

The first proposal implies changing the law — making an exception to the Food and Drug Act. It also requires some organization without shareholders to bear the liability for side effects (The bill should make the US Federal Government liable). It goes completely against the standard logic that it is against patients’ interests to treat them with unproven drugs. There are two reasons to abandon that logic. First it is unconvincing in general. Second the risk of reacting too slowly to a budding pandemic is huge.

The mass production of Remdesivir is a simpler decision. The risk is a high chance of wasting tens or hundreds of millions of dollars. The risk of business as usual is a small chance of tens of millions of deaths, because drug shortages prevent effective control of the epidemic.

The logic of regulation and policy is first do no harm and better safe than sorry. Safety is not currently possible. A small c conservative approach is also small c crazy.

update:

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Medicare Could Use the VA’s Negotiation Results on Insulins and Other Drugs

VA-Like Negotiations on Insulin Prices Could Save Medicare Billions, MedPage Today, Zeena Nackerdien, February 21, 2020

I am going to dispense with the reasoning dissing the increased pricing of Insulin and go straight to a pricing strategy. Suffice it to say, the various versions developed of Insulin do not justify the pricing increases seen today.

Recently, Philip Longman (“Best Care Anywhere”) was advocating for Medicare pricing for everyone using commercial healthcare insurance. The only problem with this approach is we are not getting to the root cause of increasing prices for pharma, hospital supplies, and hospitals. Kocher and Berwick breached the same topic with their plan to transition from today’s Commercial Healthcare Insurance to Single Payer by reducing insurance premium growth rates – “limit hospital prices to Medicare prices plus 20 percent.” The authors of this particular article (originally in JAMA)  on Medicare advocate using VA Pricing for Insulin.  Further down is a second article taken from JAMA Network (which I have access to) advocating the use of VA pricing for orally-taken drugs also ands using an approved formulary.

Talking about VA pricing for pharmacy after the leap.

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Five Charts, Graphs, Depictions to Help Explain What Voters are Thinking about Health Care – Election 2020

KFF Health Tracking Poll – February 2020: Health Care in the 2020 Election

As SCOTUS decides (this last Friday) whether it will take up he ACA and its constitutionality in Texas v. United States challenging the constitutionality of the 2010 Affordable Care Act (ACA), the
attitude of the public towards it has changed since the 2016 election. The February 2020 KFF Health Tracking Poll finds attitudes towards the ACA hit its highest favorability rating since KFF began tracking opinions ~ ten years ago. The poll finds a clear majority of the public viewing the law favorably (55%), while slightly more than one-third (37%) of the public hold unfavorable views. In my own opinion, much of this change in attitude is the result of the rising patient costs of healthcare due to pricing increases, increased commercial healthcare costs, and the elimination of the CSR subsidies which also impacted people above 400% FPL in income causing many of them to drop healthcare insurance.

Attitudes amongst Republicans have also changed (chart to the left) from 2016 t0 2020 with a greater priority being given to lowering healthcare cost over repealing the ACA. Most Republican voters (84%) hold unfavorable views towards the ACA; however, few offer up the ACA when asked to describe in their own words what about health care is important to their vote. Three percent of Republican voters offer opposition to or repealing the ACA as their top health care issue down from 2016. Twenty-four percent now list healthcare costs as their number one issue.

Attitudes amongst all voters towards the Affordable Care Act during the 2020 presidential election is quite different than how it was in 2016. As always click on the graph to enlarge. Beyond the leap, what is favored.

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Bargaining power, progressive maximalism, and Medicare for All

The HuffPo has reported on a minor dust-up between Bernie Sanders and Alexandria Ocasio-Cortez over the politics of Medicare for All (see here, here, here, also Paul Waldman here).  The tl;dr summary is that AOC suggested that it is good politics for Sanders to insist on MFA, because this will give him more leverage in negotiations over a final bill, but that compromising on a public option is an acceptable outcome that would represent real progress.  Sanders shot back that his bill is already a compromise.  Of course, Sanders’ reply is consistent with AOC’s comments – he may be trying to maximize his bargaining power by pretending to rule out the possibility of further compromise.

My view (here) is that the only significant effect of insisting on MFA will be to make it less likely that the Democratic candidate wins the election.  To be clear, I think that a Democrat who insists on short-run implementation of MFA can win in 2020.  I just think running on MFA will make winning less likely, and that there is no reason to increase the chances of a second Trump term since a second Trump term would be a catastrophe and MFA will not pass no matter what happens in the election.  But AOC suggests one way my theory may be wrong:  perhaps electing a candidate who stakes out a maximalist negotiating position on MFA will help get a stronger reform package through Congress.

This is, unfortunately, wishful thinking.  The hard truth is that progressives will have essentially no bargaining power on the issues that they care about most strongly.  The reason is simple.  To have bargaining power in a negotiation, you need to be willing to walk away from the table and settle for the status quo.  But on the issues they care about most passionately – health care, climate change, etc. – progressives will be the least willing members of Congress to settle for the status quo.  If Congress is trying to decide whether to 1) add a public option to Obamacare or 2) implement full-blown Medicare for All, Sanders and AOC can threaten to oppose the public option all day – but no one will believe them.  Instead, legislation on key progressive priorities will be shaped almost entirely by the need to win over centrists and swing district legislators.  The votes of progressives will be taken for granted, full stop.

Of course, it is possible to argue that “insisting” on Medicare for All may help a bit at the margins.  Perhaps.  But in addition to its electoral costs, focusing on maximalist positions has two serious drawbacks.  First, the language of progressive maximalism is not persuasive to people who are not already progressive.  Second, staking out “tough” positions diverts the attention of progressives from the really critical task of designing policies that can attract support from their more moderate colleagues.  In the case of climate legislation, I will argue that these issues are of overwhelming importance.

I suspect that both AOC and Sanders know all this.  AOC’s comments suggest she understands the importance of compromise and incremental progress and is willing to provide leadership on this issue.  This is a hopeful sign – leadership by elected progressives will be critical to building a more strategic and effective brand of progressive politics in the United States.  But – as Sanders’ reaction shows – we have a long way to go.

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Bronze ACA Plans are Terrible. Bronze plans are often the best Choice

Andrew Sprung writes about the ACA. I read him quite often as his posts are expert analysis of the ACA and healthcare.  Mostly recently this commentary was posted by Andrew on the benefits of getting a Bronze plan as opposed to a Gold plan if facing large out of pocket expenses (premiums + deductibles).

“XPOSTFACTOID”   Mostly about the ACA: Obamacare to Trumpcare.

Bronze plans are terrible. Bronze plans are often the best choice.

In discussion of the ACA marketplace (and health insurance generally), deductibles are often used as a stand-in for out-of-pocket costs. Now here cometh David Anderson to remind us that a plan’s maximum out-of-pocket cost (MOOP) can be just as important — and that the MOOP often does not particularly correspond to metal level.

The highest allowable MOOP at all metal levels is $8,150 (a travesty by international rich country standards). Here is David’s mapping of the range of MOOP for gold plans in HealthCare.gov states. Dark green is $2,500 MOOP; dark red is $8,150.

As David points out, bronze plans will be a better deal for anyone who knows they’ll hit the out-of-pocket max. As he’s pointed out elsewhere (and in passing here), it takes a lot more spending to hit the high max in a gold plan — say, $30,000 — than in a bronze plan. That’s because once you meet your deductible (likely to be relatively low in a gold plan with high MOOP), a high percentage of ensuing costs will be covered in a gold plan until the MOOP is reached, at which point coverage goes to 100% for ensuing costs (if you stay in network).

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Surprise Billing To Be Resolved in February 2020 to be Enacted in 2022

I had wondered why the Senate (Schumer) had backed off on legislation controlling surprise billing. It turns out there is a House bill also and I am sure they are going back and forth on this. Recently, two bills have emerged in the House and one from the Senate. Medscape, “House Committees Advance Bills to Address Surprise Billing.”

Of course if Congress’s butt was on the line, a solution would have been found quickly and enacted in 2020. At the end, see which one I would back.

The House Ways and Means Committee bill passed by a voice vote bipartisan bill. It seeks to establish more use of third-party negotiators ( arbitration) for settling certain disputes about payment for out-of-network care. This bill has the support of the American Hospital Association and the American College of Emergency Physicians. The American Medical Association also praised the committee’s reliance on mediation for disputes on bills.

The House Education and Labor Committee advanced a hybrid proposal seeking to use established prices in local markets to resolve many disputes about out-of-network bills. Key to this bill is the use of arbitration above a certain cost. Bills greater than $750 or in the case of air ambulance services $25,000; clinicians and insurers could turn to arbitration for an independent dispute resolution. House Education and Labor passed this bill in a 32-13 mixed vote with some Republicans and Democrats opposing and in favor.

The latest Senate Health, Education, Labor and Pensions (HELP) Committee of legislative proposals also addresses surprise medical billing. The HELP bill called for mandating that insurers reimburse out-of-network costs on the basis of their own median rates for in-network providers.

The Education and Labor Committee bill is estimated to save $24 billion, the Senate HELPS bill is estimated to save $25 billion, and the Ways and Means’ bill would save almost $18 billion  all over 10 years. It is suggested the greater use of arbitration in the Ways and Means’ bill will result in less savings.

Read on about the private equity involved and providers.

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