Healthcare Facts and Fiction: What the General Public Needs to Understand About Healthcare in America 

Understanding healthcare delivery, pricing, payment and business is a complex dissection. In Part Two of this series we look at drug discovery costs, the FDA and how drugs and medical devices are priced. 

Part Two- Drugs and Devices

Who can forget the tale of Martin Shkreli, Turing Pharmaceuticals and Daraprim? Approved by the FDA in 1953, Daraprim was the anti-parasitic drug used to treat malaria, and toxoplasmosis in all patients and more routinely recently for preventing and treating toxoplasmosis in HIV patients. Shkreli's company Turing Pharmaceuticals obtained the rights to the drug in 2015 and existed as the sole supplier of Daraprim. Turing promptly upped the price from $13.50 per pill to $750 per pill and Shkreli became fodder for then presidential candidates and the poster boy for all that is wrong with pharmaceutical prices, healthcare, and unbridled greed. 

Ah, drugs. America is awash in drugs. We are the most medicated populace on the planet with almost 50% of adults taking at least one prescription medicine in the past month according to the CDC (1).  The Brookings Institute's Hutchins Center (2) reports per capita drug spending at $1112 annually. Pharmaceutical costs continue leading healthcare costs higher to the tune of a 27% spending increase in 2017 (3).  

What discovering and developing new drugs and medical devices costs:

To understand drug costs you need understand the process of drug discovery through FDA approval and marketing. There are five specific steps required to bring any drug to market that spans approximately eight and usually many more years from the first human studies to FDA approval (4):

1. Discovery and Development- A molecule, protein, virus or other biological life form is identified along with its action or potential action in a given disease.

2. Preclinical Research/Phase I- This phase answers the question, "Is the drug safe for humans?"

3. Phase II- Efficacy and safety. Simply, "Does it work and is it safe?"

4. Phase III- Efficacy, safety, and side effects. "What is the best dose for maximizing benefit, minimizing side effects, and what are all the side effects?

5. Post Market Safety Monitoring- monitoring for side effects or therapeutic complications.

The FDA flow chart looks like this:

Keep in mind the entire process is approximately 8 years long in best cases and quite expensive. As in $2.5 billion expensive (5). Certainly this value is variable, but for the most part accurate. Add to that $2,421,495 for the FDA application fee with clinical data and another $304,162 program fee. And that is no guarantee the drug will be approved as approximately only one in ten are granted approval to proceed with sales and marketing. For medical devices the costs are extremely variable and the FDA process is more tortuous, yet much less expensive tolling at less than $1M in fees(6). Regardless, it remains expensive developing and testing a new drug or medical device.

How drugs get from the pharmaceutical company to the patient:

Pharmaceutical companies price their drugs based on many factors including development costs, potential market, competition, and what insurance companies, Medicare and Medicaid will pay. Factoring all variables together helps the drug company arrive at a price known as the list price. 

This is the specific point where drug pricing becomes convoluted. The list price is rarely paid. Insurance companies usually contract a pharmacy benefit management company (PBM) like CVS/Caremark or Express Scripts to handle the pharmaceutical portion of their business as do larger businesses and unions. The PBM negotiates the lower drug prices for the insurance company or business under contract. Here's how it works for a month's supply of Drug A:

Drug A's list price is $100

PBM negotiates the price to $60 and then charges the insurer or company $70 

The insurance company pays the $60 to the PBM but charges the patient a $10 out of pocket co-pay

The insurance company breaks even (cost neutral), The PBM grosses $10 and the patient pays $10 which doesn't sound too bad for the drug in this example. 

PBMs initially entered the medical arena to contract for better drug prices from manufacturers, reduce insurance spending, thus increasing medicine affordability. As drug prices increased new ways evolved to control costs. Most insurers/PBMs set formularies, which are simply a list of drugs they will reimburse. These formulary lists act as expense choke points. Certain rules may apply such as step therapy where a cheaper medicine must be used first and the patient must fail the therapy before a different (more expensive) drug is reimbursed by the insurer.  Another cost containment strategy is the tiered formulary structure. In a three tiered reimbursement formulary what this means is Tier 1 is the cheapest for the insurer and patient. Think generics and most older drugs. Tier 2 is reimbursed at a lesser amount by insurance and has a higher co-pay for the patient such as older branded drugs. Tier three are usually newer branded drugs and those not on the insurer's formulary with the patient picking up most or all costs. Another pivotal strategy is prior authorization (PA) where the physician submits for and receives permission from the insurer or PBM to prescribe a drug.

Three main issues with these cost containment strategies exist. First, the physician's clinical decision making is now secondary to whatever the insurance/PBM deems appropriate. Sometimes this is good and keeps the doctors thinking of the least expensive solution. Sometimes it flies in the face of the patient's clinical reality versus what insurance/PBM formulary decision makers want. The second issue is the patient has no say what drugs land on their insurance formulary. Last, but not least, is the responsibility for knowing the formulary structure and obtaining prior authorization (PA) rests on the physician and their ancillary office staff. This costs the patient face time with their doctor and costs the doctor's staff time sending and receiving PAs. A brilliant strategy by insurances/PBMs co-opting medical staff for drug price policing. For the medical community it is another overhead expense and time wasting mandated exercise. 

US drug prices vs. the world:

How does the US compare to other countries around the globe? In the first part of this series We mentioned the hepatitis C drug Harvoni costing $70,000 domestically versus $800 in Egypt. According to Reuters US drug prices are generally three times more expensive than England, six times higher than Brazil, and sixteen time greater than India. Why? Most countries negotiate pricing directly with drug companies resulting in better pricing. In 2006 the Medicare Modernization Act (MMA) was implemented after being signed into law three years prior. One of the unique provisos of the MMA prohibited Medicare from negotiating with drug companies for lower prices. Considering Medicare accounts for 30% of $360 billion total US drug spending in 2017, this seems either a gross oversight or is it something more? The 2000 election won by George W. Bush, 36% ($7.29 million) of pharmaceutical giving landed with Democrats vs. 69% ($18.63 million) for Republicans (8). By December 8, 2003 the Medicare Modernization Act was authorized but not yet implemented. Presidential election campaign contributions in 2004 saw 31% go to the Dems against 67% for the Republicans where GWB won his second presidential term. January 1, 2006 MMA was instituted and pharmaceutical companies enjoyed their payoff. At this time only the VA system negotiates pharmaceutical prices directly with companies and individual states may negotiate Medicaid prices only. 

Lastly, the total global pharmaceutical market in 2016 was $1.05 trillion of which $450 billion or roughly 45% is attributed to the US. Let's view this another way: America holds 4.4% of the global population and pays for almost half the World's medications (9).

Drug sales and marketing:

Drug representatives are the visible whipping posts for allegedly helping drive pharmaceutical sales and prices higher. Maybe not. Examining Johnson and Johnson we find these fiscal year 2015 numbers: 

 

     Total Revenue: $71.89 billion

     Advertising Spend: $30.12 million (0.04% of revenue)

     Research and Development Spend: $6.967 billion (9.69% of revenue)

NOTE: According to the corporate 2016 annual report on page 36 the number for Sales, Marketing and Administration is $19.945 billion (27.74% of revenue) (10). Unfortunately the sales and marketing numbers are co-mingled with the administration costs. Understanding a truer cost would delineate the sales and marketing costs alone and specify what areas such as sales, sales, print media advertising, television advertising, and digital advertising the specific spending occurred.

ALSO NOTE: J&J has a consumer division, a medical devices division and a pharma division. 

Sanofi is France's largest drug company and also a $40 billion global powerhouse. Their sales and marketing spending is reported at 3.1% of expenditures. When we compare pharmaceutical companies to the tech sector we find a range from 7% at Apple to 53% for Salesforce as seen in the below graphic from Sarah Brady at https://vtldesign.com/digital-marketing/content-marketing-strategy/percent-of-revenue-spent-on-marketing-sales/

From Sarah Brady at https://vtldesign.com/digital-marketing/content-marketing-strategy/percent-of-revenue-spent-on-marketing-sales/

The end result is variable, but this much is understood: the role of drug and device reps is a blip on the pharmaceutical cost radar, the reps bring new information to physicians who are grossly time starved. Lastly, no physician is paid by a pharmaceutical company to prescribe their drug(s). It is absolutely illegal. When looking for collusion and corruption the compass points upstream from physicians to the industrial- political complex. The saying, "Politics makes strange bedfellows," needs amending, "Politics takes on all bedfellows with cash." 

BARRIERS TO SUCCESS

1. The FDA drug and device approval process is slow and expensive. Streamlining the process is essential to decreasing the time and cost

Take away: It is expensive and time consuming to discover and develop new drugs (about $2.5 billion and 8 or more years. 

2. The US is arguably the most medicated country on the planet. 

Take away: Becoming healthier remains essential for each of us to enjoy less medical expenses and greater quality of life.

3. PBMs are an unessential layer of the patient's drug procurement pathway.

Take away: We are seeing the purchase/merger of insurances and PBMs, which should theoretically decrease patient drug costs. Hopefully we will see what streamlining looks like when Jeff Bezos and friends roll out their take on improving healthcare.

4. US patients subsidize global drug prices.

Take away: We can no longer afford to support the world's drug prices as the United States Empire crumbles and the American citizens continue losing economic ground.

5. The connection between congress, POTUS, insurance companies, drug and device companies is rife with quid pro quo relationships.

Take away: Abolish lobbyists. Congress needs to amend Part D to allow Medicare drug price negotiating rights. This is where Warren Buffett can make his influence felt as part of the Bezos, Buffett, Dimon troika. 

The nexus of Washington DC, insurance companies and pharmaceutical companies will be discussed in later segments of Healthcare Facts and Fiction: What the General Public Needs to Understand About Healthcare in America.  

Up next is a rousing romp through a physician's life. What it takes to become a doctor, obtain and maintain the various licenses to practice, rules, regulations, reimbursements, and daily life. Not for the feint hearted reader. 

(1) https://www.cdc.gov/nchs/fastats/drug-use-therapeutic.htm

(2) https://www.brookings.edu/blog/up-front/2017/04/26/the-hutchins-center-explains-prescription-drug-spending/

(3) http://www.ajmc.com/newsroom/americans-used-less-care-in-2016-but-healthcare-costs-still-soared-report-says

(4) https://www.fda.gov/ForPatients/Approvals/Drugs/default.htm

(5) https://www.scientificamerican.com/article/cost-to-develop-new-pharmaceutical-drug-now-exceeds-2-5b/

(6) https://www.fda.gov/ForIndustry/UserFees/MedicalDeviceUserFee/ucm452519.htm

(7) https://www.kff.org/infographic/10-essential-facts-about-medicare-and-prescription-drug-spending/

(8) Big Pharma Political Contributions - Drugsdb.com http://www.drugsdb.com/blog/big-pharma-political-contributions.html#ixzz57b6xuiGL

(9) https://www.statista.com/topics/1719/pharmaceutical-industry/

(10) https://jnj.brightspotcdn.com/88/3f/b666368546bcab9fd520594a6016/2017-0310-ar-bookmarked.pdf

Healthcare Facts and Fiction: What the General Public Needs to Understand About Healthcare in America 

Understanding healthcare delivery, pricing, payment, and business is a complex animal for dissection. As such, we will initially approach healthcare in a general fashion before deeply dissecting this topic in serial fashion. Today is the first in the series.

Part One: Why Amazon, Berkshire Hathaway, and JP Morgan Recently Announced Their Healthcare Experiment.

THE ISSUE

Last week the big reveal from Amazon, Berkshire Hathaway and JP Morgan Chase was announced with maximal fanfare that burned bright in the news cycle for an entire day. This business triumvirate announced their joining forces to create a healthcare company specifically aimed at reducing their respective domestic employee health costs. Currently, these three companies employ greater than 500,000 people in the US and over one million persons globally. With Amazon and Jeff Bezos's reputation for destroying brick and mortar stores, Warren Buffett's inside the beltway access to government and shrewd business moves and Jamie Dimon's financial behemoth stalking Wall Street, one would think great things to come. Outside of the healthcare sector investors sold off a bit on this news. The rest of us shrugged a collective "whatever". We've seen this play before. The powerful, entrenched characters running healthcare have persevered, even more powerful since the ACA passed. Those characters in order of power remain insurance, pharmaceutical, and medical device companies. 

WHO ARE BEZOS, BUFFETT AND DIMON?

"Why these three individuals at this time?" is the seminal question. We know our labyrinthine healthcare is expensive, stuffed with middle men, compliance costs, licensing issues, insurances, and gross overhead expenses few other businesses  endure. Starting with billionaire Jeff Bezos, known as a serious type A personality, retail industry disrupter, and sometimes a vulgar expletive, particularly when he uses the Washington Post as his propaganda mouthpiece or buys Whole Foods and turns it on its head. Yet Bezos is a master of streamlining supply chains, squeezing efficiencies, and reducing overhead by integrating technology and logistics. Oh, and he has been quietly investigating the pharmacy distribution business in several states over the past years making some pharmacy benefit managers (PBMs) a bit nervous.   

Octagenarian Warren Buffett brings his "grandfather  knows best" swagger with sayings like, "The ballooning costs of healthcare act as a hungry tapeworm on the American economy." The billionaire has a cult following amongst his shareholders where his annual open stock meeting plays to tens of thousands who make the pilgrimage to his home town Omaha, Nebraska. More importantly, he has the government's ear where he knows intimately how the system works. His father was a Nebraska senator, so he learned which arms to twist and how hard. His contacts run deep in D.C. 

Another billionaire, Jamie Dimon, chief executive of the largest U.S. bank, JPMorgan Chase & Company rounds out this audacious trio. He brings financial and business transactional clout as well as central banking experience and connections. He served on the BOD of the Federal Reserve Bank of New York. He rounds out an accomplished trio for this gargantuan task.

WHAT ARE THEY ATTEMPTING?

The three companies are forming a new company, “partnering on ways to address health care." From Jeff Bezos, “Hard as it might be, reducing health care’s burden on the economy while improving outcomes for employees and their families would be worth the effort. Success is going to require talented experts, a beginner’s mind, and a long-term orientation.” Sounds far reaching and altruistic. Perhaps. Reducing overhead is not only a smart business strategy, which Amazon has followed religiously, but a necessary one for growth and continual success. 

The smile moment was reading the quote their new company would be “free from profit-making incentives.” From three billionaires this quote seems ingenuous and also unrealistic. Take away the incentive to attain material wealth through hard, smart work and the impetus for success diminishes. We've understood this historically from the original Plymouth Colony embracing a social economic philosophy and nearly perishing to witnessing current day Venezuela. "No profits" begs the question, "How is this system economically sustained?" A question without an answer thus far.

Make no mistake, this new company is about reducing healthcare cost overhead for the respective trio's current business interests. If they can achieve positive results on that scale then look for a national referendum via Amazon, Berkshire, and JPM-Chase utilizing their media power, lobbying networks, political insider relationships, and financial gravitas. Of course they will be integral parts of this system and its profits.

This is a daunting task with great risks. Certainly they will threaten and ultimately alienate certain customers of their respective empires as they gin up their new business entity. Just as certain they risk losing some business and profits while remaining beholden to their stock owners. They are not the first business giants to walk this path. AOL, Microsoft, and Intel with their respective leaders have all ventured into this space only to fail. Success depends on overcoming key hurdles like contracting directly with drug companies and eliminating the PBM or the pharmacy middle man to reduce prices and increase efficiencies.

BARRIERS TO SUCCESS

The keys to success are many. Some are simple, but most are horribly complicated. Numerous details are required for this project and success depends on several key pieces:

1. Insurance companies must be brought under control with concrete reimbursement policies. Far too many horror stories of unreasonably denied claims. This will be difficult as United Healthcare's 2017 revenue, "... exceeded $201 billion increasing more than $16 billion year-over-year. Operating cash flows grew to $13.6 billion..." quoting CEO David Wichmann. (His base salary is $1.1 million with $12.3 million total compensation.) Aetna's 2017 revenue was $60 billion with $1.9 billion earnings. (CEO Mark Bertolini made $41 million in 2016 and may walk from Aetna with $500 million if the CVS merger is realized.) 

Take away: health insurance is lucrative with a legislated customer base via ACA. 

2. Medical care needs price transparency. Very few people inside healthcare know what procedures and care cost based on varying insurance reimbursements to providers and healthcare systems. It is a convoluted, confusing, and downright diabolical system like health insurance legislated (aided and abetted) by our friends in government. 

Take away: Warren Buffett knows insurance as GEICO is wholly owned by him through Berkshire-Hathaway. As stated earlier, Warren knows the DC insider shuffle, so if anyone can develop an insurance product for less he can. He can also garner legislative support through various lobbying groups.

3. Drug costs need to decrease. Americans don't realize they subsidize much of the globes' medicines. Country specific pricing is based on GDP wealth and how well individual countries negotiate prices. Why should Harvoni for Hepatitis C cost $70,000 for a treatment course in the US and $800 in Egypt?Americans are no longer "rich" as the middle class faces extinction through high debt, high taxes and fees, minimal savings (CNBC cites 69% of Americans with less than $1000 and 75% with less than $10,000 savings.) and almost non-existent wage increases (calibrated for inflation) over the past forty years. 

Take away: The American consumer is tapped out. Consumer credit card debt is greater than $1,000,000,000,000; student loan debt is greater than $1,300,000,000,000; $8,690,000,000,000 stands in home mortgage debt. 

4. Implement immediate FDA reform. Why are pharmaceuticals leading per capita healthcare spending higher? (According to the 2016 Health Care Cost and Utilization Report that examined the per-person health care spending for employer-sponsored insurance members at from Aetna, Humana, Kaiser, and UnitedHealthcare.) One of the major hurdles is a slow, inefficient FDA. Currently it costs a drug company approximately $2,000,000,000 to develop a drug and get it passed by the FDA. Pharmaceutical manufacturers frequently cite the FDA as a significant portion of this price. This situation also exists for medical devices and the FDA.

Take away: It's the government. Get out of the way.

5. Move healthcare transactions and information to blockchain technology to prevent fraud of all sorts and ensure patient medical record privacy free from hacking.

Take away: Blockchain is the answer for clear transactions and patient privacy.

6. Everyone is free to choose, whether too much food or drink, motorcycle riding without a helmet, no seatbelts, drug use, smoking, and other risky behaviors. No problem. Have at it, but no more expecting healthy people subsidizing your bad choices. It's time to truly subsidize healthy choices and well care. Fortunately we are seeing movement in this area.

Take away: Individuals need pay for their own life decisions. Reward good actions versus financially punishing them. The current government debt and pseudo-socialized healthcare system is economically unsustainable. 

7. Motivating the individual remains elusive if there is little or no incentive (See number six above). Patient compliance remains a huge factor in sickness and wellness. Think of the diabetic that doesn't watch carb intake, is overweight, doesn't take their meds. Ditto for the patient with heart disease who still smokes, is sedentary, and takes their medication wantonly. Anything given away for free or nearly free loses its value. 

Take away: Work at keeping yourself healthy and you will decrease your healthcare costs. It's like turning a light off in a room when not in use to decrease your electric costs.

Next issue we will autopsy pharmaceutical and device costs in our system. 

Comments? Email Sid at issueautopsy@blogspot.com

The end of week happy story. After all, everyone needs a smile.

Frankie the Miracle Cat

There are dog people and there are cat people. Cat owners are staunchly cat and sometimes anti-dog. Comments like, "My cat is smarter than a dog and can take care of herself. I don't need to spend as much time caring for her as you do taking care of your dumb dog." Dog people are, well...dogmatic, "My dog is interactive, kind and smart. You don't see any helper cats out there." Now anyone who knows my wife, myself and our three dogs understands we are both animal and dog people. Definitely dog people.

It was a morning cold, dark and wet, a typical season changing October day with rain, sleet, and the occasional snow flake portending winter's arrival. The type of day where it is better staying in than going out. Work forced my wife out in this miserable weather. She departed for work and as routine I watched for the vehicle exiting our driveway to the road. Not seeing that mundane, yet essential event my phone lit up indicating her incoming call. "Will you come out here?" she queried. Certainly not surprised and by now conditioned to so many unplanned events I scurried outside. 

Unsure of the situation I popped out the garage door and rounded the corner quickly. My wife stood halfway between the car and me with a small light colored object in both hands. "She was under the car and followed me. Can you take her?" The fuzzball was a kitten. With no choice, I replied the only way possible, a simple, "Yes." I put the kitten down only to witness her scramble after my wife walking back to her car. Running after the little dynamo I scooped her up, commenting, "She seems to have bonded to you." My wife smiled, "I'm not sure what we should do with her." Translation: "Think we might keep her?"

"I'm in trouble. I know what happens next," I thought anticipating another rescue animal. "Let's see what happens and I will take her to the shelter later if she is still around."

The kitten's boney body easily fit into my two hands. Clearly she needed food so I placed her outside the back door, retrieved some dog food, and fed her (I know, dog food, but I remain fiercely protective of my sardines to this day.). By that time another kitten, same type coloring but slightly larger arrived for the handout. I placed the food for their eager appetites and went inside planning to recheck on them in fifteen or so minutes. After a short time I rechecked the kittens. They were gone. Honestly, I was not too upset. What would we do with a cat and three dogs including one that kills cats on sight (She has good reason but that is another story.)? Plus there were multiple out buildings including an old barn. "Plenty of shelter," I reasoned. 

After an hour my conscience tap danced on my reason. I felt guilty. My wife was under the premise I would take this animal to the shelter and now I couldn't find the kitten. The weather changed for the worse as a biting wind added to the cold, damp day when I went outside looking for the kitten first circling the house slowly, then the barn, then some of the other buildings. No luck. Wilbur Bud our chocolate lab who has a great nose accompanied me as I repeated this process four times that day with the same results. I even added canine reinforcement with KT our other chocolate lab who can retrieve admirably also. Each time we came up empty my conscience stomped my rationale hard, "When you have a chance to do something good or helpful, don't wait." 

The arrival of my wife that Friday evening and the day's cat search recap left us both scratching our heads as to the kitten's whereabouts. Bringing in the dogs prior to bedtime, my wife ventured onto the back deck. All three dogs entered first then she followed with the kitten in her arms. "Where did you find her"? I asked as surprised as she with this development. "She walked up the steps when I was calling the dogs," she held the purring kitten proudly. We were both smitten with this sweet little rascal spurring our diligent work making her a box to sleep and stay warm in the garage where we could assure her safety. "What do we feed her?" I asked. "We have milk and can get food in the morning," my wife answered. 

Next day we purchased cat rudiments such as food, litter box, and litter. As we set up the litter box the seminal dog person question emerged, "How do they know to use this?" asked my wife. In typical "I'm not concerned" style I answered, "I don't know, they just do. We'll set it in the bathroom and see what happens. Easy clean up if I'm wrong." Not finished she asked, "What do we name her?" My solution was quick, "Look at her blue eyes. Old Blue Eyes. Let's call her Frankie." 

Just when we thought it was clear sailing we discovered Frankie harbored worms and not the kind you fish with. She also had a chunk out of her right front paw and no claw at that toe, another smaller piece from her nose, emaciated, and now oozing sero-sanguinous fluid from the corners of her mouth where small hematomas newly emerged. Initially we attributed this drainage to a lost tooth and opted for a "wait and see" strategy. We spent another nasty, wet fall day inside taking turns holding Frankie incorporating her into the "pack". The dogs were fine, even Sophia the cat killer. Always intuitive, she seemed to sense Frankie's infirmity, or maybe she didn't loath cats anymore, or maybe she smelled our scent on the animal and felt our angst. 

Zero dark thirty Sunday morning and the sero-sanguinous drainage was now a dark, bloody, five or six cubic centimeter non-coagulated puddle in front of Frankie's cat bed in the bathroom. She lay listless, not purring when touched. "She's bleeding now," my frustrated wife stated. "She's dying," I softly lamented. My wife was already finding the emergency vet as I peered at her. Amazing how fast she can work an iPhone. She trundled the cat, I warmed the truck and we headed off praying this little animal, this kitten we fell in love with so quickly, would live. 

We knew Frankie had a coagulopathy, a blood clotting disorder. But what caused this? Apparently she ingested one of the older anticoagulant rat poisons placed many moons ago either by eating an animal that ingested that compound or eating the poison bait itself. "So what are our choices with her care?" my wife asked the vet. "Well her CBC is borderline transfusion need. It's a bit tenuous now. We should keep her. How far do You want us to go?" Knowing this type situation intimately we both answered, "No heroics. What is reasonable and prudent." Needless to say Frankie stayed at the emergency animal hospital. where the vet techs dropper fed her hourly racing to fluid replace the animal and keep up with the blood loss. Vitamin K every four hours was given to reverse the anticoagulant similar to what we do with people on coumadin who require reversal. "You may call me anytime to see how she is doing," the vet offered. 

What an ugly ride home. "It will be miraculous if she lives," I prepped my wife. "Miracles happen," she confidently retorted. We waited. We worried. We prayed for the little bugger. How did she wiggle her way into our lives so quickly? She showed up at our door, we took her in and assumed responsibility for her care. It was expensive (Don't ask.), impractical, and downright inconvenient. Yet here we were, absolutely concerned for this critter. That afternoon we called the vet for an update. The situation remained bleak. A second call that evening brought a slight momentum turn in Frankie's life battle. The instructions were to pick her up tomorrow morning as there was nothing more the vet could do. By 6:30 am the next morning she looked a bit better, was no longer exsanguinating from her mouth and was not as listless as twenty-four hours prior. I carefully carried Frankie to the car in her cat bed with instructions for more vitamin K administration and also checking her stools for evidence her deworming succeeded. 

Today Old Blue Eyes thrives with our pooches. Actually, she acts rather canine like. Frankie comes when called by name. When the dogs are commanded to sit as a group she will lie down near them. She despises being alone and seeks out human companionship, is quite verbal and loves a belly rub. She is gentle, sweet, entertaining. The dogs and she get along famously. Sophia is known to sniff at her, tail wagging, enjoying her little sister. Wilbur Bud and she are fast friends while KT wonders what the fuss is about. My wife and I now are dog and cat people. We also decided Frankie was truly our 'Miracle Cat" and Christmas gift this year. After all, one miracle so many centuries past deserves another one today.