Ahh, yes, the USA. Where more money is spent in the health system, for worse results, than anywhere else in the world.

Now, that's not to say that the system in Australia, the UK, Norway, New Zealand, and other such countries (to cite the ones I'm vaguely familiar with) are fantastic. There are plenty of ways in which they could be improved. But, with their emphasis on preventative care rather than reactive, curative care, they do manage to produce a far better result, at a far lower cost, than the US system does.

Protip for the US political system: "socialism" is not a dirty word. There are some things that are better done by government for the nation as a whole. Health care is one such - by all means have a private system to provide a relief valve, but it should be a sideline, not the main event.

Money isn't always the deciding factor. A few years back several large US hospitals admitted to refusing to perform major surgery on patients who had a high probability of dying because of it... even though they were terminal already. Why? Because if the patients died, it would adversely affect the numbers used by various hospital rating systems, primarily those used for determining malpractice rate.

An acquaintance of mine ran into that. He had some serious heart problems, but other problems made his chance of surviving surgery low. After five expensive trips through testing, evaluation, and rejection, he killed himself. Perhaps not the most logical solution, but despair can make you do that sort of thing.

I very much agree with you. Just in case that wasn't obvious. :)

Wow. I'm so sorry. That's awful.

"Diagnosed in 2008" Well here, he would have been Operated on in 2008 .... Free at point of use. Whether he would still be alive now, is another question, but there would have been a fair chance of catching it BEFORE it metastised. EUWWWWW ...

Meanwhile, the Beatles were right.

Back in the USSA Back in the USS-R

"Well here, he would have been Operated on in 2008 ...."

It's implied that he was: multiple surgeries since 2008. Apparently the hemicolectomy didn't do the trick.

As treatment becomes more and more expensive every society will come to a cutoff point where it cant afford to pay every treatment for everyone.

Even here in Sweden that will happen, and we pay for treatments for a single patient that costs over a million dollars a year that just might slow down his illness (Hunter's disease btw).

I'm not saying that this is wrong and I'm definitely not saying that the way it is done in the US is right, but I think every society no matter what it wants to do will reach its limit.

How should we prioritize then? Who should decide what person is entitled to what treatment?

Yes, but the first operation in the US would probably have cost him, whereas here, it would not .....

And yes, we do have "Healthcare Rationing" - there's even an official body lokking at it: "NICE" _ the National Centre for Clinical Excellence. WHo look at costs of some procedures & most particularly drug-treatments, & decide if they are value-for-money. WHich, needless to say, results in public "political" fights, but at least it IS debated, & it is in the open.

Big difference between USA & here, though in some priorities. We throw money @ children. The US throws money at people in their last year, or even 3 months of life - it is quite noticeable. Also we are (usually) much more relaxed about using Papaver somniferum extratcs & derivatives as painkillers in seriously large quantities, particulalry for people who we know we can't save, but whose last days (or moonths or years) we can make less painful. The US [& "southern" Europe] are very cahry of doing this, to the point of causing untold suffering amongst the dying. Why is this? Rome - or more specifically, the RC church - "suffering is good for you". Bastards.

As treatment becomes more and more expensive every society will come to a cutoff point where it cant afford to pay every treatment for everyone.

Two points.

Sorry, got a little carried-away there. But our current, market-dominated process for developing new medications, is fundamentally broken. Further reading: Bad Pharma by Ben Goldacre. He focusses on the issue of why our clinical trials information process is broken, but things are broken all the way up; for example, there are commercial reasons why, despite our crisis of antibiotic resistance, pharmaceutical companies have little or no financial incentive to develop new antibiotics.

Bluntly: we handed responsibility for developing new treatments to for-profit companies. We then allowed them, by capture of regularity bodies, to raise barriers to entry by new competitors. Finally, we allowed their decisions on what treatments to develop to be governed purely by commercial profit. Unfortunately, it turns out that the most profitable conditions to treat are not the ones we most urgently neat treatments for. Some of the deadliest killer diseases are nevertheless not commercially profitable: they kill mostly poor people, or treatment would likely result in a rapid cure (meaning, less scope for continuing sales), or not enough people suffer from them.

It is to weep.

Important note: NICE rules on whether [expensive] treatments may be purchased by the NHS. They don't rule on whether you can obtain such treatments privately; that's a matter for the medicines regulator (the name of which they changed a few years back; used to be the CSM). If the regulator says "no", it's unsafe; if NICE say "no", it's too expensive and you can still buy it privately (if your pocket is deep enough or you have private medical insurance).

It's not just southern Europe and the USA that are idiots about opiates; most of the Pacific Rim, Africa, South America, and the Middle East have bought into the lunacy. Result: the world's most effective painkillers for terminal illness or extreme injuries (notably diacetyl morphine, aka Heroin™) are unavailable. Madness, utter madness.

(Diamorphine is cheap to make. There is an efficient, rapid antidote available if the prescriber fucks up. It's a better painkiller than morphine, and combines the analgesic effect with an anxiolytic one [like a tranquiliser] and as a side-effect dilates the coronary arteries. That's why you'll find a pre-loaded syringe full of the stuff in the cardiac kit in a British ambulance -- it's the go-to drug for stabilizing an acute myocardial infarction case while they rush the patient to hospital for a stent and anticoagulant treatment.)

Right, I thought you were commenting more on the immediacy of the operation rather than its cost.

The US system also employs at least 10x the number of managers with respect to medical staff that the NHS does.

dirk ARRRGH! And the UK system is itself over-managed, as we all know - there have been a couple of distressing scandals about that surfacing recently (N Staffordshire etc ...)

Stina, I'm now reading "Of Blood and Honey". I'm really enjoying the writing itself, but there are 2 or 3 localisation peeves. Is there a way we can contact each other privately to discuss them, and maybe sort out similar future issues before they get past draft? For example, and on-topic, the cost of Mary Kate having a hospital stay being an issue for their finances would never even occur to Liam.

I ran this past my brother for comment, a molecular biologist at the CSIRO. He wrote, "the sequencing costs seem roughly similar to the cost of sequencing a plant genome for some of our mutants. That cost would mean the genome is being sequenced enough times over to ensure there is a high level of confidence about the sequence quality."

There isn't any profit-mining in the sequencing costs, that is, although he felt the analysis costs were a little overblown.

http://blogs.channel4.com/factcheck/checking-up-on-the-number-of-nhs-managers/2506

Managers are 3.6% of the total NHS workforce.

That 3.6% is up a long way from back in the late 80s, when I worked as a pharmacist; I doubt it was over 1% back then.

From the article: "But, lest you think the NHS is a management-heavy organisation after the claims of politicians, the health think tank the Kings Fund points out in its election 2010 analysis, managers and senior managers only make up 3.6 per cent of the total NHS workforce.

The number of managers and administrators (based on the calculation above) make up 11.7 per cent of NHS staff. Nurses make up 26.2 per cent of the workforce."

So in the first paragraph we have "managers and senior managers only make up 3.6 per cent", and then in the second paragraph we have "managers and administrators ... make up 11.7 per cent".

This seems to prove that old saying about statistics, and shows that the percentage of managers is very dependent on how you define the label "manager".

I would also add (as the significant other of a staff nurse) that one of the huge inefficiencies in the NHS is generated by the trickle down effect of middle-management and admin staff generating the usual kind of job-justifying initiatives that come from an otherwise superfluous position. The extra (and most often pointless) paperwork dumped on the front-line NHS staff that takes away from the time that doctors and nurses have to perform primary-care duties is considerable. I suspect that many management positions in the NHS could be cut, but they have successfully added enough work to the system that unpicking the Gordian knot of paperwork to find out who is really needed would now cost more money than just trundling along as is.

I suspect that many management positions in the NHS could be cut, but they have successfully added enough work to the system that unpicking the Gordian knot of paperwork to find out who is really needed would now cost more money than just trundling along as is.

Correct. And the reason for the administrative creep ...?

There is also the litigation propensity we seem to have imported from the USA.

One word: Yup.

Especially #3, and not just the pure lead time (which should include both time spent training at university, and then also the time it takes to build actual productive usful on-the-job experience, probably another 2 years from my observation) but also the fact that there are only so many new medical professionals minted every year.

And #5 is the huge pain-point that I mentioned for the front-line staff, cause they're the poor buggers that are being forced to provide the performance data on themselves to justify their own jobs (while the mere collection of said data justifies some else's).

Dirk, do you have up to date info on the number of British managers? Last I read, a roughly 2002 or so study said that the % paid for management costs and the like had doubled to 16% because of the evil conservaties internal market shit. It can only have gotten worse since then.

Meanwhile, new labour teed up the ball and the Condems are swinging the 1 wood; the aim is to whack the NHS right into the private sector, with the accompanying excess profits, profit driven deaths, excess management costs and so on.
The majority of the public want to keep a public health service, but the majority of politicians, or at least those in charge of their parties, don't.

Exactly why is unclear. Probably reasons include 1) bribery 2) market worshipping blindness 3) ideology, wait, that's point 2. 4) stupidity.

Isn't point (4) point (2) repeated as well? ;-)

Last year, the newest of the local hospitals went "paperless." A couple of months ago my Dad spent two weeks there as a patient. The only people who weren't shackled to a PC were the janitorial and foodservice staff.

Each time someone came into the room, they were pushing a modified IV stand with a laptop screwed to it. They swept the barcode reader over the band on Dad's wrist, scanned every pill, blanket, or paper cup, then scanned his wristband again when the left. His doctor came in a couple of times; I think he glanced up at Dad once, otherwise, he was working the computer.

Back in the mid'90s I wrote a pharmaceutical tracking package. Ironically, for the corporate overlords who own the hospital Dad was at. As such things tend to do, it expanded into a general patient information system, and as such, crossed the lines of multiple departments. This was before HIPAA; not all departments were computerized, and those that were, were on totally different systems. They didn't even all speak ASCII...

Anyway, at one of the higher-level meetings, I made the point that they were wanting to make the physicians into data-entry operators. Considering what the hospital was paying them, was this a good use of their time? The physician time was billed by the minute, and few of them were computer-literate.

A few quick checks showed that it would save money to hire someone to accompany the physician to handle the computer... which would cost nothing extra, since most of the physicians already had a nurse or secretary following them around already, taking dictation and carrying folders.

It was interesting to see all that went away. If anything, there were more staff around than the last time I was at a hospital, but other than pushing a mop or dinner trolley, all of them were playing "keyboard monkey."

When my significant other started her current staff nurse position there were number of tasks that she was fully trained in and perfectly capable of doing, but not allowed to do because she hadn't yet been trained in the correct data entry processes to record the tasks as done.

Interesting how the topic changed from "it's a wonderful life" to "the horrors of contemporary health systems"...

I suggest you go back and read the entire post rather than just the first 4 lines. Most of it's a rant about the importance of the blank cheque in USian healthcare.

There is a movie called It's A Wonderful Life, which implies that there's more to being a good man that making money. There are similar questions raised in The Best Years of Our Lives.

Ten years ago British hospitals were being fitted with an individual digital TV system. It used Win CE, and had a tiny keyboard, and had internet access, and the talk was that it would give Doctors digital access to the patients notes.

The Doctors don't use it, the internet access is poor with no apparent upgrades, and if I recall right, the system is on its third management company each one charging more for less access.

The last time I was in hospital, one of the junior Doctors was taking photographs on his smartphone and emailing them to the consultant. I can see how an iPad, or some other tablet with that sort of picture taking capacity, could be useful. Likewise for X-rays and other scans, with the right App. But the existing hardware is tied to the patient, and can show pictures, so why isn't it being used. I suppose the management company has set a high price for the deal, so that they don't lose money: I suspect a lot of that cost comes from the past failures to pay off the installation.

It's lousy TV now, 4:3 screen ratio. Broadcast TV in Britain is mostly 16:9.

I get the impression, from too much experience over the last ten years, that the paperwork load has increased to dangerous levels.

OK, so you need to pass on current information between shifts, so that the new nursing staff know what is happening on the ward.

I don't remember it previously needing an hour-long meeting, when you don't see any nursing staff on the ward. That's how it was happening in late 2012.

But the existing hardware is tied to the patient, and can show pictures, so why isn't it being used.

Because it's an extortionate rip-off, mostly targeting the elderly and confused (who don't have smartphones). The phone calls cost more than an out-of-contract mobile, the TV is rubbish and expensive, and the internet access is, IIRC, net-nannied into uselessness. But they've got the hardware installed, so the current franchisees can milk the victims patients' wallets.

I suspect it'll be gone in another few years, next time they have to refurb/redecorate the wards it's installed in.

NB: the only islands where it may stay in use are places like the Royal Infirmary at Edinburgh, whose shiny new out-of-city campus is in a valley that features a total lack of 3G service: it's GSM/EDGE at best.

zhochaka @29: Lots of NHS doctors now use tablets to take notes on ward rounds (the benefits are pretty clear), but I don't believe that many hospitals have officially sanctioned their use, or that there is any long term plan to integrate them into any patient record back-end systems. The clip board at the bottom of the bed is still the primary on-the-spot method for patient record keeping and information. On the negative side of utilising new technology, any doctor using his personal smart-device to take pictures of a patient is skating on very thin ice with regards to patient confidentiality.

zhochaka @30: I don't know that "dangerous" is quite the right word -- none of the nursing staff that I know through my wife would worry about paperwork if it was a choice between finishing the writeup or rushing to save a patient's life. I think that it has risen to "idiotic" levels, in that the amount produced cannot possibly be actually read and processed in any meaningful way at this point -- it is paperwork for paperwork's sake. (The handover process is impacted by lots of factors, and varies greatly from shift-to-shift, day-to-day, ward-to-ward -- much of it is vital information exchange, but but not always).

charlie @31: Most NHS staff despise the patient entertainment systems too. They are usually run by external content providers and the charges are also set by these bandits. Not only are they stupidly high, as far as I am aware none of the profit flows back to the hospitals.

I too was confused by this, after reading the complains on the US health system, I was guessing the fund raised would be used to pay the patient's medical bills. But after reading the link, it looks like the fund will be used to sequence his entire genome as a last resort. While this is indeed a wonderful event, I failed to see how this shows the failing of US health care system. Are there other countries where whole genome sequencing is paid by public or private medical insurance?

Are there other countries where whole genome sequencing is paid by public or private medical insurance?

Not yet, but they're talking about it becoming standard practice in the NHS[1] within a decade.

[1] Assuming the Fucking Tories[3] don't succeed in privatizing[2] it.

[2] Not in Scotland they won't, because it's a devolved issue and Scotland is several degrees to the left of England.

[3] Given their current opinion poll standing maybe they should change their party name to "Fucking Tories" and replace their campaign rosette with a dog turd. It certainly couldn't make them any less popular. "Safe in our hands" my ass ...

According to the CMS (a US government agency), it's around 28%, not 50%.

It's 10% in the Netherlands (well, based on the abstract, anyway).

Here is an interesting chart, though. You want T13.3, which puts the UK costs at 28.9% -- on equal footing with the US.

I'm starting to wonder if the whole thing isn't cultural, largely related to our attitudes toward death. I'll bet the UK is more similar to the US in that respect than it is to the Netherlands.

Gah. Swallowed up by the moderation queue due to the linkage.

So, without the links: The CMS puts last-year healthcare costs at 27.9% (1999 figure) of the total lifetime expenditures. The Netherlands seem to be massively lower, at 10% overall and acute care, but just 5% for long-term care.

Then there's the UK: A 2004 study put the figure at 28.9% of total expenditures. A Canada-wide study put that country higher still, at 33%.

I'm starting to wonder if the whole thing isn't cultural, largely related to our attitudes toward death. I'll bet the UK is more similar to the US in that respect than it is to the Netherlands.

All those countries don't use diamorphine for managing pain?

That is appalling. My flabber is well and truly gasted.

Here in Scotland it's even one of the standard options for pain management in maternity wards. So lots of kids (mine included) were born to mothers who were (temporarily) high on smack ;-)

Tablets of various genera are proliferating in medical settings to the extent that uniform coat makers are providing a pocket sized to them in new uniform coats. This saves a lot of time and trouble, since for younger doctors, anyway, the learning curve appears to be a tad faster for laptops/PCs, and the doctor doesn't need a flunky to run it for him or her. Bar codes on wrist bracelets can be read by these tablets, which one hopes will help the occasional Oops, wrong person! problem.

Unfortunately, there is a down side here, in that most hospital systems have suck security (a charming little article about hacking surgically installed medical items was offered to a murder mystery list for our delectation last week). See, sometimes these items have a wireless connection so someone can monitor the results or at least have the computer complain that something isn't right if some bodily functions are out of various tolerances. And sometimes these connections are hackable. Some of the devices are installed defibrillators, while others are insulin pumps. I think anyone with a vivid imagination can manage the rest.

And then the article explained about tire pressure monitors and smart house heating/cooling systems (although I think Arthur C. Clarke was ahead of the curve here; my vague memory offers a story about a Villainous Smart House in Omni Magazine quite some time ago).

Anyway, welcome to the future!

Some things to bear in mind about the NHS:

My personal opinion on which are better long-term is....

Well.

Put it this way: Outside suppliers tend to want to sell boxes and long-term support is expensive to provide........

No system is perfect. However, some are more optimal than others.

Oh, I read the entire post. I just think it's funny that most replies are to the LAST 4 lines of the post.

And I don't mean it as a criticism, just an observation. I also think that health systems need to be criticized, I just wouldn't put the heading "It's a wonderful life" on top of it ;-)

Thanks for that information, Charlie. True, we all have to die sometime. And I'm in favor of making that time as comfortable as possible. So, I agree with you on both points.

Oh, yes. Errors. There are going to be errors. The Mary Kate medical thing is one I've long known about, and I'm pretty sure I already know which ones you'll point out. I've a few contacts to help me steer clear of future errors, but at that time I only had two, and they had their own things going on. I'm always happy to add to my contacts. You can contact me on Twitter and I can pass you my email addy that way. I'm a little leery of tossing it out here.

There is a movie called It's A Wonderful Life, which implies that there's more to being a good man that making money.

Yes. That was the reference I was making. Although, I'd say it says there's more to being a good person than making money.

That's a scary thought. Might I also add that when you've 'news' agencies hacking celeb phones the concept of them doing the same to medical systems isn't that much of a jump. Ah, privacy. I miss you.

What there's no room for irony in your world? ;)

Isn't that something with a lot of iron in it?

So in the first paragraph we have "managers and senior managers only make up 3.6 per cent", and then in the second paragraph we have "managers and administrators ... make up 11.7 per cent".

"Staff" and "workforce" are technical terms, I'm not entirely sure of the difference, except that at my last job I was part of the workforce but not part of the staff.

It's even worse than that.

There's more. Some description in this Vanity Fair article:

http://www.vanityfair.com/culture/2012/12/microcomputers-weapons-smartphone

Ha!

Money shouldn't be the deciding factor? Seriously?

I think ultimately it has to be. Suppose, for example, that there is a procedure that can save someone's life, but that costs $1 million. Or $10 million. Do you want to say that of course it has to be performed, and we shouldn't even think about the expense? How much cost do you want to add to the health care system, and to the outlays of insurance companies or state medical departments?

Of course, you can say that medical procedures don't cost that much. And they don't—now. But that's because now, we don't provide unlimited funding for medical care, so doctors and hospitals don't think of doing procedures that massively exceed available funding. But if you want to adopt an ethical principle that requires unlimited funding, then that limit seems to be gone. It might even be argued that you've implied an ethical obligation to develop the massively expensive interventions that would use up those unlimited funds—that by not developing them, we are letting money be the deciding factor on what treatments are available.

Of course, such things aren't done, not even by the NHS. It provides health care collectively, but it doesn't have, and can't have, unlimited resources. It decides what care it can afford to provide collectively, but it still decides on the basis of money.

I'm all for people helping other people, and engaging in charity, and showing support for the sfnal community. But neither voluntary gifts, nor market economies, nor tax-funded collective systems have unlimited funds. The collective system shoves the consideration of costs and resources behind the curtain, and tells people to pay no attention to it, but it's still there. The wizard doesn't have magic powers.

Right and wrong. Until we significantly restructure our society (true post-scarcity? Something else?) then money will always be a deciding factor, but for many people in the US system it is the deciding factor -- and that is not how things should be.

As treatment becomes more and more expensive every society will come to a cutoff point where it cant afford to pay every treatment for everyone. Even here in Sweden that will happen, [...]

Hmm, you realise that Sweden (as a whole, per capita) is paying about half as much for its health care compared to what the US does, right? And gets better results for it than the US?

That won't work; I'm not on Twitter!

Charlie (or Moderator Alan, since I know I've got his e-mail already), will one of you forward an e-mail from me to Stina?

[[ Charlie's currently locked inside an aluminium tube, so send it to me ]]

WHS @ 52 Yet people are shocked & horrified if you actually propose this. Example, in the UK, the cost of a human life on the railways is (approx) £10 million. That is, if they can more-or-less-guarantee to save one life a year for a £10^7 outlay, they'll do it. On the Roads? £50 000? Etc ....

Ok, let's back up and restate the question differently.

Should the fact that person1 has 50k in available personal funds and person2 doesn't be the primary deciding factor in which of the 2 gets $procedure?

Should the fact that person1 has 50k to pay for $procedure and asks to have it done be allowed to over-ride the surgeon's medical opinion that it would be highly dangerous to person1 to anaethsetise them for long enough to perform $procedure, and have them bed-ridden for a relatively prolonged (due to age) recovery period? This isn't a hypothetical argument; I've had USians Republicans claim that the answer is "yes".

There's lots of irony in my world, I just didn't detect any in your post :-) IMHO the irony only came later when most of the replies where about how this is NOT a wonderful world.

BTW, what's your new novel about?

Your response doesn't properly address the point, of course money is a factor in any healthcare system and there are organisations tasked with deciding which medicines and devices to purchase and which not to. If there's enough money for 100 treatments that will save 100 people and 10 that will save 10 unless the latter is >10x more likely to happen it makes sense to get the first.

But when most people say money shouldn't be a deciding factor they mean from the perspective of the consumer. No one should have to forego medical treatment because they personally can't afford it.

Ecoonomies of scale also factor into the cost. If we had a planetary unified healthcare system even rare diseases would build up enough of a footprint to be pursued with enough attention.

We already have de facto healthcare outsourcing with medical tourism (People crossing the border to visit the dentist in Tijuana, etc) eventually perhaps telepresence rigs for remote operations, or even the full automated autodocs of sci fi will become available.

UK "medical dramas" are starting to include plotlines involving surgical robotics, so this is probably "bleeding edge" real World technology.

We've a friend who has so far had to have two liver transplants, due to one of those 'one in a million' diseases. Because there are so few people with it (I think his is actually one in ten million) it's pretty well unstudied. Get a larger scale, you might identify a few score with it and work out the problem.

(It might be that genetic sequencing of all the sufferers might turn up some rare mutation. Who knows?)

@52: Suppose, for example, that there is a procedure that can save someone's life, but that costs $1 million.

Here it becomes important to define what you mean by 'saving a life': postponing death for some fixed amount of time, say, five years (after which the patient drops dead); letting the patient live until the life expectancy of their population group; or something in between.

Also, the age (and other circumstances) of the patient start coming into play...

The US Health Care "system" is anarchic. Prices are whatever you can get away with. Pain management is hampered by anti-abuse prosecutions. Pharmacists are allowed to decide for themselves which drugs offend their personal superstitions. If I want to see my GP, it often takes weeks to get an appointment. It is madness, and I am personally sick of it all, especially as I am getting to an age where I'll be needing it more often.

weeks

Same here, for a long time. At least I have an old-time GP (nearing retirement now) who is a real, albeit somewhat outdated, doctor who runs his own practice, not affiliated with anyone. Most people have to settle for "Primary Care Physicians", where you wait a week or more to get a referral to a "specialist", which takes another week or more, who might send you to yet another specialist, at which time you're either recovered or dead without any professional help.

Hospitals and insurance companies screech about "people who use the emergency room as their doctor", but in some places in the USA, that's the only way to get any help in a timely fashion. It's not like you can just go to any doctor you want; most of them want credit checks and referrals from your previous doctor...

But when most people say money shouldn't be a deciding factor they mean from the perspective of the consumer. No one should have to forego medical treatment because they personally can't afford it.

I don't get this comment. There are a lot of transplant "treatments" which easily cost $1 million or more in total. (Total is the key point here. Transplant recipients have a life time of non trivial drug regimens and checkups to deal with.) In the US and I suspect the rest of the world, heart, liver, lung, etc... transplants are mostly constrained by the limited donor pool. If this limit went away would society be expect to pay for every possible transplant? Assuming a the average annual wage of a family group is $50K then it requires over 20 average 1 year incomes to pay for a single transplant.

There's a point where money (or lets call it resources) has to come into play. And in the US no one wants to make the choice. Not even the ones who say they must be made. Because to do so immediately makes you into a cruel heartless thug. (OK there are a few jerks willing to make statements but they are also not limited to R's)

So by not making a choices about how to deal with no infinite resources we get to allow the current system to bumble along.

There is a movie called It's A Wonderful Life, ...

Yes. That was the reference I was making.

So is there anyone outside of the US who get's this reference without thinking about it? I suspect in the US most anyone over 30 or 40 will get it immediately. Younger people had too many cable options to have seen it as much at Christmas year year. And outside the US this money may not make much sense given how it's tied hard to the US's image of itself in the 20s, 30s, and 40s.

I'm not sure how you didn't get it as I explained in the post you are replying to that I was talking about the patient having to pay directly for their treatment. Obviously funds aren't infinite and you need an organisation to decide how much of and which treatments to buy but that's not what my comments, and others making similar comments, meant.

To respond to your comment about how much the average family earns: you're being far to limiting in sticking to households. Consider how much revenue can be gained from taxing a business that brings over billion in profit per year.

Whenever I see this movie my main thought is: George got screwed - he should have gotten on the boat while he had the chance.

If hearts, lungs, and livers have no limits on availibility should they be given to anyone who needs one no questions asked? And if not, due to limited medical resources and costs and other factors should a Bill Gates when he is 78 be allowed to pay for a liver transplant, if there's no one younger on the waiting list, out of his own pocket?

I heard you say no.

As to the income issue. Dice it anyway you want. Take the number of households (define as you wish) and divide that into the total economy. Get a number. Now how much of that number goes to health care? And will it ever be large enough to meet all of the possible demand? I say it will not. Maybe for a few years but eventual costs will rise to meet and exceed any number you pick.

George got screwed

This implies it was done to him by others. But he made the choice. I guess you're saying he screwed himself?

Your right, I don't think being able to pay for it on your on means you should get it ahead of anyone else. Limited medical resources should be distributed according to need and benefit, not to the rich first. I find that far more moral. As for Gates he might be able to pay for it but I don't support the idea that those with funds should have to pay either, what they should do is contribute far more in tax.

Again of course there will never be infinite resources. You realise I addressed this in my first post yes?

No one should have to forego medical treatment because they personally can't afford it.

I was keying off this comment.

Again, if BG has the money for a $10 million treatment that no insurance or health care system is willing to pay for are you saying he can't step up and write a check?

I don't have a problem with that no. Not sure why you added the again there because that's not the scenario you presented before.

Ah I see the confusion. Your focusing on the fact that there are treatments that healthcare services won't pay for because they don't give a good return on investment I.e that money could be used better elsewhere.

That's rather against the spirit of the original comment which was against the notion that healthcare is restricted to how much one can pay.

Again with the assumption costs will always rise. Medical technology is as amenable to progress as any other, and I suspect a lot of the cost increases are ideologically driven.

Aside, here's an interesting news item, reminded me of a Vernor Vinge novel

http://www.laboratoryequipment.com/news/2013/01/parkinson%E2%80%99s-treatment-unlocks-creativity

there are treatments that healthcare services won't pay for because they don't give a good return on investment I.e that money could be used better elsewhere.

But this is not open and shut. We have had two big situations in the US where the medical evidence says "we shouldn't be doing thing the way we are doing it". But we continue to do it because the public wants it and threw a fit when this changes were proposed. I'm referring to PSA and breast cancer issues.

They point is if there's a resource that is available why can't someone with lots of money buy said resource if the resource would not otherwise be used?

Money shouldn't be the deciding factor? Seriously?

Yes. Seriously. I don't think you're looking at it the same way I am, however. Ultimately, we all have to die. It's part of life. However, I don't believe that capitalism is the system of choice for health care because I don't believe that profit is what should be mainly on the scale when discussing a person's life. [shrug]

got it! thanks!

My new novel is a secondary world fantasy, late 1700s kind of place. I'm currently smooshing big fat fantasy and mystery together. We'll see how that works out. :)

So is there anyone outside of the US who get's this reference without thinking about it?

Is that a big problem or something? Personally, I don't think so. It's not like it matters if absolutely everyone understands the reference or not. And even so, we have this thing called the internet, don't we?

Just curious. I often wonder how much of our cultural icons make it outside of the country.

I also wonder if Downton Abbey is as big in the UK as it is over here.

No ill will intended.

Heh. And my husband gets really angry because Mr. Potter got away with stealing money from George. So, I always tack on: "And then Mr. Potter was arrested for stealing the $2000. He was found guilty, and died in prison. The end." :)

But this is not open and shut. We have had two big situations in the US where the medical evidence says "we shouldn't be doing thing the way we are doing it". But we continue to do it because the public wants it and threw a fit when this changes were proposed. I'm referring to PSA and breast cancer issues.

I very much disagree that it was the public pitching a fit. I believe it was the insurance companies and big pharma who threw a lot of money at pushing opinions via Feaux News and such. Much like the NRA is behind the media manipulating people into being terrified of 'giving up their guns' the instant anyone mentions a limit of any kind--even a perfectly reasonable one.

Unless you are one of those people who actually believe that corporations are people. [shrug]

I very much disagree that it was the public pitching a fit. I believe it was the insurance companies and big pharma who threw a lot of money at pushing opinions via Feaux News and such.

Well we disagree. I've been around too many people who KNOW what works and those doctors (and insurance companies) are trying to keep the "good" treatments from us regular folks. My mom being one of them.

Facts always loose out to personal stories with these folks.

And I fail to see how cutting back on PSA testing and mammograms doesn't benefit insurance companies.

No ill will intended.

We're cool. Don't worry about it. If someone doesn't understand a reference I make, I'm perfectly fine with explaining. All they have to do is ask. If I think it's important, I'll say more about the reference. Otherwise? Everyone here is capable and intelligent. I'd rather not talk down to people.

And I'm still curious if that movie reference meant anything to the folks here outside of the US.

And I fail to see how cutting back on PSA testing and mammograms doesn't benefit insurance companies.

I agree with you about that statement. But that's the sort of problem I have with our current system. I'm glad that insurance companies have to use 80% of their premiums for medical treatments now. Previously? Not so much.

Maybe we're misunderstanding one another's positions?

The evidence, in very general terms, says we waste money in the US with too much PSA testing and mammograms. So it was proposed that the guidelines be changes to reflect this. Uproar ensues. Guidelines are not changed. Money is wasted.

So the bucket of money that goes to health care doesn't get better allocated and some people don't get treated for other things due to the emotional reaction to an evidence based change.

This is independent of how we fill the bucket. Which, yes, really is a big deal and will have to change in the US. Like it or not.

Well I understood the reference and I'm no expert in old movies. Indeed that film reference is so familiar here in the UK that " Its A Wonderful Life " was parodied in The Telegraphs " Alex " cartoon strip over the Newton-mass holidays as ....

" Alex: It's A Wonderful Crisis "

http://www.telegraph.co.uk/finance/alex/wonderful-crisis/

Downton Abbey is made in this country. It's fairly big, yes.

And we don't have to go looking for a Police Box if we need the Doctor.

It's a Wonderful Life lacks some of the resonance in the UK that it has in the US, but it's still considered a classic movie and most UK citizens would recognise the reference (less so in the younger generation, perhaps).

With pop-culture references, you're usually on safe ground with movies, particularly classic or blockbuster movies -- the cross-pollination between the US and UK is fairly strong. Once you start referencing TV shows, particularly anything made before the 90's, you're into shakier territory; even with recent TV, the transfer is mostly from US to UK, there are very few UK shows that successfully make an impact in the US (Downtown would be a notable exception, and also Doctor Who -- @91: I like the sneaky reference!)

The references to at least ( 80% / 85% / 90% ? ) of the monies collected by medisurance actually, you know, being SPENT ON CARE struck a chord. Until fairly recently, the budget for (schools) education was going up & up, with no perceptible improvement in output - in fact, it was probably getting worse. Until people tumbled to the fact that the money wasn't being spent on & in the schools. It was being reatined by the local authorities on all sorts of politically correct "initiatives", shoring up their educational advisers & fancy schemes. And it wan't just one political party, either ... the start was made by the tories, blaming "profligate, statist Labour" for all this ... until about 5 minutes later, it transpired that tory-controlled areas were doing the exact same scam, just with a diiferent set of political agendas. The backhanders & internal corruption, were, of course, identical, no matter who was in charge.

Sound familar?

UKian - I've heard of IAWL and know what it's about, but have avoided anything more than occasional sitcom episodes that riff off it. In particular, I've never seen the film, at least after i was old enough to remember doing so!

Also, Downton Abbey is big over here but I've never seen that either.

Given their current opinion poll standing maybe they should change their party name to "**ing Tories" and replace their campaign rosette with a dog turd. It certainly couldn't make them any less popular. "Safe in our hands" my ass

Interestingly, Health has now been run by Labour and the SNP in Scotland; the Conservatives haven't had a look-in since 1997. I've got two tales of relevance...

Our esteemed SNP Health Minister has achieved some interesting results regarding the BMA - they've actually walked away from negotiations with her, something they've never done before, even with the Conservatives. An NHS-only consultant friend is unimpressed (more accurately, grinds her teeth and raises her blood pressure when you say "Sturgeon")

As for "targets", last year said Health Minister assured the Scottish Parliament that no, the waiting lists were not being fiddled to meet targets as had been suggested. There had been claims that people were being offered appointments on the other side of the country at 24hrs notice, and when they declined were reclassified as "declining treatment".

Fortunately, the board of Lothian Health decided to commission its own external audit, that revealed that there was some fairly spectacular rigging going on. They'd eventually cut out the "phone up and offer an impossible appointment", the departments concerned had just started reclassing people as having declined treatment, thus resetting their "waiting time" to zero. It's bad news when some staff will only talk to an external auditor in a completely separate building from their boss, after a guarantee of confidentiality, and with a union rep present; toxic management in spades.

Shortly before the sacking, sorry the resignation of the Chief Executive concerned, the Health Minister then released the external report, took credit for its commissioning, and assured the Scottish Parliament that this was an isolated incident, limited to a single Health Board. On the same day that the UK Budget was announced, so obviously there was no desire to lose the story in other news.

Since then, Audit Scotland has started carrying out an audit of the other Health Boards in Scotland. Things aren't looking good on the "it was just Lothian, guv" front. Not good at all. Still, I'm sure that Nicola Sturgeon can bury the announcement on the next Budget Day...

In conclusion, the Conservatives can only be blamed for so much - not that I've ever voted for them, but after fifteen years it's a bit much to lay all the blame at their door. It's also worth noting the reason why the axe was swung in 1979 onwards - it may have been suspiciously profitable to the "right" people, but the country was broke. Interest rates were sky-high; industrial relations and productivity were often a joke. We had limits on the export of currency, and top-end tax rates to make your ears bleed. The Peter Sellers film "I'm All Right Jack" wasn't a comedy, it was a satire (almost a documentary in some firms, AIUI)...

I knew there was a movie called "It's a wonderful life" but first I mistook it for "Life is beautiful" by Roberto Begnini. A friend of mine is a big fan of Frank Capra's movie.

I am pretty sure there is a science fiction short story about some sort of dystopia in which anyone who doesn't agree that it is a wonderful life—the phrase is what sticks—is disappeared. It's one of those things you feel that you ought to be able to recall in more detail, and it feeds into Stina's usage even as that half-ghost of flawed memory.

I expect somebody will tell me what I am thinking of. This is the sort of place where people will know such things.

On Cameron and the Tories, one reason I rather liked the Olympic Opening Ceremony was how much it challenged the political output of that movement. The things it presented as the great of Great Britain were the things that provoke frothing rage amongst the members of the Conservative Party. Things such as the NHS, and the multiculturalism of London. It's one thing for people to say "That's not my sort of music," but in many ways the Conservative Party is in a state of cultural rigor mortis, and has been thrashing futilely in denial since at least the 1920s (aka "the Jazz age").

You look at the explosion of change which the Great War (maybe) triggered, partly because of the women's experience of war work, partly because of the death of about 2% of the total UK population (rough guess, 8% of the male population of marriageable age), partly because of the feeling that the Old Order had cocked-up big-time. The next twenty years saw the General Strike, the Labour Party forming a government, and the Mitford girls (and one of them, now Dowager Duchess of Devonshire, is on record as preferring to take tea with Elvis Presley rather than Adolf Hitler.)

You might think that a Duchess is a natural Tory. I would not be so certain.

zhochaka @ 97 It's by Jerome Bixby & it is actually called "It's a GOOD life" & really, really scary. & @ 98 Labour Party formed well before WWI, in 1900, in fact. The Devonshires always were different. One reason they have survived is that they actually appear to hold to the principal of Noblesse oblige : the military service put in by the husband of the dowager duchess you mention was interesting, to say the least .... He also left the tories to become part of the unfortunately short-lived SDP .... And an earlier Cavendish was, of course the famous but reclusive 18thC scientist, after whom the laboratories in Cambridge are named. Just because you are from a "noble" family does NOT mean tory or reactionary - look up the Previous Duke of Buccleugh, for instance - RNVR in WWII (& joining as an ordinary seaman).... Unfortunately I cannot say the same for my present (legitimate) distant cousins, who have always been Anglican & tory, though they did well in their time - keeping the Spanish out, but the later defeat of Gladstone's Home Rule Bill was NOT an achievement to be proud of!

It is important to remember that the managerialist shit and the madness in the Lothians was setup by new labour following on from the Tories.

I recall when I was still at university 13 years ago or so doing some sort of "Management experience" thing, and one chap who spoke to us was from NHS Lothians, basically saying that the new PFI hospital would have lots fewer beds than the old one, because modern technqiues blah blah. Even as a naieve inexperienced student I was wondering why this made sense given that the percentage of elderly in the population was increasing and oddly enough they tend to need more bed rest before you throw them outside to die of cold.

So, besides being a PFI and therefore by definition expensive and badly setup and more expensive than any other option, it was being run by managers who were caught up in their own little fantasy world. I suppose the key point would be when those in charge of fiddling figures were appointed or trained.

On the topic of the film "It's a wonderful life" I have heard of it and never seen it. My exposure to knowledge of it came first from reading "Readers Digest" back in the 80's and early 90's, and more recently from cultural references by Americans online, usually Americans more than 30 or 40 years old.

"It's bad news when some staff will only talk to an external auditor in a completely separate building from their boss, after a guarantee of confidentiality, and with a union rep present; "

That is typical of large companies. I once made £3000 for a couple of days work sorting out an information management system for a Huge company. The management said it was not working properly and the users (The Workers) were screwing things up.

So I simply asked the people who were using it what the problems were. They told me, and I wrote a report of what was wrong and how it should be fixed (by the original contractor). Everyone happy. All because the workforce and managers were too paranoid to actually talk it out themselves.

"Its a good life". Also a Twilight Zone story http://en.wikipedia.org/wiki/It's_a_Good_Life

It's one of those once read never forgotten short stories that you - that is to say me - always have trouble remembering just when you first read the damn thing but which is so chilling you always remember the plot. ...

" It’s a Good Life " by Jerome Bixby , as is mentioned elsewhere in the thread but this following linked site incorporates the story that has been much reprinted over the years...

http://weirdfictionreview.com/2012/10/creepy-classic-its-a-good-life/

In my opinion the story is well up to the standards of chilliness that you get from one of the M.R. James ghost stories ....

http://www.thin-ghost.org/

This post is bound to be held up for scrutiny by Mods but the extra link is worth the wait.

Some thoughts on the conversation generally.

(1) I think much of the problem is "public private partnership." This is the problem with lots of things. Privatization and Nationalization are both stealing, and quasi private is another word for corrupt.
(2) Regarding all the medical E-paperwork, maybe its growing pains. When old fashioned record keeping was a mature technology everything was fine. Someday everything that happens in a medical setting will be automatically videorecorded from every angle, so that those keyboarding doctors can just become monologue prone. But in the interim period we have clunky. (3) There will always be limits on what can be done. There is a difference between standard health care and cutting edge. For example,there is only one best surgeon in the world, and everybody can't have that surgeon. Somebody has to be operated on by someone just out of medical school who got mediocre grades but got by. I believe all problems are simply because they haven't been mastered yet, and someday we will have Matrix style instant learning. Until then people have to die because the best wasn't available.
(4)When I can't afford to stay alive without bankrupting others I plan to get myself embalmed in vinegar and buried under permafrost. We have a responsiblity to take care of our ill, but I believe they have responsibilities too. (5) "They" say drugs are more expensive in the USA because we are funding development and everybody else gets the benefit of it. Don't know if that's true, certainly other countries do a lot of basic science. I have an acquantance who has a rare illness that there is simply NO research on because there's no money in anything so rare. I wonder how much money would the government ultimately save on health care by funding research (DIRECTLY not through "public private partnerships"). But that would be the government competing, and that's a no-no because the government is incompetent, see? (6) Nobody has mentioned the affordable health care act directly. I think it got watered down so much by political resistance it shot itself in the foot. It might not be worth it, but I hold out hope that it will do some kind of good. Insurance is just such a rip off. (7) Our hosts comments are absolutely spot on and smart. He may know something about this topic. (8) Glad to see you back Stina and to hear you are doing well on a new novel. I submitted a wikipedia article on you to the approving people but nothing came of it, oh well.

So far as I can disentangle the drug mess, it's even more complicated than you might think. I've done it by reading Chemical and Engineering News, and occasionally talking with people in the field.

First off, about 75% of drug costs are salaries. There are a lot of people involved, and they have a lot of expensive degrees and high expectations about how much they deserve to be paid.

In the US, it appears that about one-third of costs are marketing. If I had to cut anywhere, I'd do that. Unfortunately, I believe there was a US Supreme Court ruling a while back saying that it was legal for drug companies to advertise. Unfortunate, that.

As for drug development, there's a lot of basic research all over the world, but primarily in the old First World (US, Europe, Japan).

About 1 in 2,000 to 1 in 10,000 go from promising bench tests to human trials. This winnowing process is called "the valley of death." I don't know the status currently, but a year or two ago, even Big Pharma didn't want to pay for crossing the Valley of Death (to the point of eliminating their own research arms in many cases). It appears that some combination of start ups, venture capital, and non-profit money (such as the Gates Foundation) gets potential drugs through animal trials and so forth to human trials, but this changes year-to-year. I don't know how early stage drug studies are currently funded.

The real expense (and where Big Pharma plays) is running potential drugs through all their human tests. To keep costs down, as many of these tests as possible are performed in the old Third World (especially India). Drug commercialization is truly a global enterprise, with various parts off-shored to keep costs down.

Big Pharma as of about a year ago would basically buy any promising start-up and run the drug through human trials. If it passed the tests (and often they don't), it would hit the market. The cost of this is (AFAIK) currently over US$1,000,000,000 per drug that makes it to market. Divide that by the number of doses they can sell, and you have your drug cost.

My tuppence on the issue is that the biggest problem is that we want safe drugs. Most of that gigantic cost comes from determining whether drugs are safe and effective. If we were willing to roll the dice more (in both categories), costs would go down considerably. Of course, many more people would suffer and die, and our trust in doctors would erode as well.

Absent a desire to have less safe drugs, getting rid of all drug advertising would the next best step in the right direction. For some reason, I expect someone will speak up shortly and explain in detail why this won't work.

Or madame Vastra, Jenny and of course Strax

Para 3 - I'm picking a "mature drug" deliberately here.

UK - Tv advertised brand name Ibuprofen costs ~£2-00 for 16 tablets: Generic with no advertising costs £0.50 to £1-00 for 16 depending on exact brand and shop. I'd say you may be under-estimating the costs of a drugs "marketting" budget.

Possibly. But what you're actually demonstrating is the apparent added value resulting from that marketing campaign. In a rational economic situation the vendors would not spend more on the marketing than they expect to get back from added gross profit on sales, but rational economic behaviour is the economist's equivalent of the spherical cow.

So, they might be getting back 1000% more than the marketing is costing, or they might get back 10% more, or some other value. We really can't tell just from the price difference.

It also wouldn't surprise me if the makers of Neurofen (the branded one) were to be running both the branded and unbranded versions off their production line. Why should they ignore the generic market when they have production already in place that can exploit it?

This also ignores that the branded Neurofen is probably more effective despite being chemically identical to the generic. The placebo effect is remarkably strong, and one thing that triggers it is apparent extra investment in the treatment.

That's sometimes true, but at least for me, I see something like that as paying vast sums to finance the advertising campaign.

Of course, a plain text mesage saying "$NewCharlesStrossNovel is now available" is more likely to get me to a bookshop than a full page advert saying "$NewGameofThrones_Novel is now available" is. And the facts of them being guest bloggers here sold me Kari and Stina's novels.

It also wouldn't surprise me if the makers of Neurofen (the branded one) were to be running both the branded and unbranded versions off their production line. Why should they ignore the generic market when they have production already in place that can exploit it?

This also ignores that the branded Neurofen is probably more effective despite being chemically identical to the generic. The placebo effect is remarkably strong, and one thing that triggers it is apparent extra investment in the treatment.

Bellinghman @108: True and true for the above. Again drawing from the experiences my significant other as a registered nurse, branded and unbranded are indeed chemically identical and often produced off the same production line. The unbranded version of over-the-counter meds are usually what is dispensed in NHS hospitals (for obvious reasons), and the placebo effect is reinforced further in these circumstances; many patients automatically believe the doses they receive in hospital are stronger, and respond accordingly.

I don't remember making a Downton Abbey reference. Did I?

Not a story I'm familiar with, but I like the association.

Thanks, Dirk. I thought it sounded like a Twilight Zone kind of story.

(8) Glad to see you back Stina and to hear you are doing well on a new novel. I submitted a wikipedia article on you to the approving people but nothing came of it, oh well.

Really? Thanks! Did they give you a reason why? I'm curious because I see entries on authors with far less published in Wikipedia. (They're older and male, of course.)

Last time I was in the States, a few years back, I often saw prime-time early evening TV ads for prescription drugs on the main national channels (NBC, CBS etc.). They were common, sometimes two or three in a single commercial break. This doesn't happen in the UK and, I suspect, in most of the EU. Prescription drug marketing is done to doctors and others in the business, not to Joe Public.

There is also a delusion among many US folks that it is the only country that does any drug research and development work, ditto for all medical research and treatments and the Rest Of The World relies totally on the generosity of the much-put-upon American public in matters medical. This leads to a belief that drugs are cheaper elsewhere because the US pharmaceutical companies are somehow forced to sell them at a loss there and furthermore they make up those losses by overcharging their US customers.

Unfortunately, I believe there was a US Supreme Court ruling a while back saying that it was legal for drug companies to advertise. Unfortunate, that.

OMG, this. The bulk of the ads on American TV these days are for giant trucks, fast food, or drugs--more often? Drugs. The change over the past few years has been so drastic that when my best friend (an ex-American who lives in London) visited she couldn't believe what she was seeing. It's appalling. I have to wonder what's the point? I mean, it's not as if we can prescribe the drug for ourselves. I know I've never asked my doctor for a drug advertised on television. Never.They also throw free samples at doctors as if they were candy. An ex-friend of mine is in pharmaceutical sales, and wow, the money she makes. She's a sales person. Their marketing budget has got to be crazy. So, pardon me while I call bullshit.

Not that I'm aware of, but I've never watched Downton Abbey.

My point was that it's sometimes possible to understand "pop culture" references without having listened to/read/seen the referenced material.

Um, yeah. So your company just spent a billion dollar developing a drug, you're pwned by stockholders (excuse me, you represent a publicly held company), and you're not going to run a big advertising campaign to get the word out?

That can't be good for keeping your job, unless you like assuming responsibility for not meeting investors' unrealistic expectations. After all, those unrealistic investors are trying desperately to amass enough money to afford the drugs they'll need at the end of life...

That's what was so unfortunate about the Supreme Court's ruling. It's legally valid, first amendment stuff, but at the same time, it's a net negative for everyone except subcontractors to the drug marketing companies. Drug costs have gone up 30-50% simply to cover marketing, doctors now get pestered with patients self-diagnosing and demanding drugs, despite the evidence (the latest? Testosterone shots for aging Boomers and Gen-Xers to get their rage on, never mind the side effects), and drug marketing goes from a rather genteel inform-the-professionals job to the obscene Red Queen drag race we have now.

Worse, perhaps, any drug that can't be advertised doesn't get developed. Testosterone doping shots get funded (even though it's a minor health issue for all but a very few), malaria pills and targeted antibiotics do not. Stupid.

I don't remember making a Downton Abbey reference. Did I?

I did that. Wondering if DA was as popular back where made in the UK as here. Part of the is IAWL well known in the EU commentary.

It also wouldn't surprise me if the makers of Neurofen (the branded one) were to be running both the branded and unbranded versions off their production line. Why should they ignore the generic market when they have production already in place that can exploit it?

Of course. Grocery stores and food makers/packagers have been doing this for years in the US.

Back to drugs, Wal-Mart, Target, various drug store chains, etc... have their own private labels for various over the counter drugs. Walmart's is called Equate. Never dug deep but given the packaging, pill shapes, dosages, etc... you have to assume they are made by one of the big names. And as a part of the deal they likely give the big name a better shelf slot than all the other names. It is this kind of thing that drives the mom and pop folks out of business. They just don't have access to a house brand like the big chains.

HP and Stapes got into a big fight a few years back over Staples' generic ink and toner brands. It was settled by HP becoming Staples' lead brand for such and Staples still has their generic brand but it is now never directly compared to the HP brands. Everyone is is at the back of the bus.

Everyone ELSE is ...