There's a right way and a wrong way to do things . . .

As I was walking to my car last night I saw a big, beautiful blue helicopter marked "NYPD" land at the Providence heliport, which is near my office. The brilliant thought "WTF?" came to me. It turns out that's how New York City Police Commissioner Raymond Kelly travels -- at least when Marine One is unavailable -- and he was here to give a talk at an institute belonging to my employer.

Sadly, he was unable to speak because protesters shouted and jeered him off the stage. The photograph shows him with Providence Public Safety Commissioner Steven Paré, with whom I serve on the Commissioner of Health's Emergency Medical Services Working Group, and as you can see Steve does not look particularly happy. I wasn't there but I'm not happy either. I have previously expressed my unhappiness about this on Daily Kos and a commenter said there should be a limit to the people the university invites to speak, and how would I feel if they invited Glenn Beck or Rush Limbaugh?

Well, I'd feel just great, actually. Kelly was supposed to give brief remarks and then spend an hour in exchange with the audience. That was a world class opportunity to subject him to something he almost never gets: smart, informed people asking him tough questions and confronting him with the arguments about why his policies are counterproductive, unethical and contrary to the values we Americans claim to believe in. Reporters will never do that, but there were reporters in the room and they would have heard it. Even if they were fair and balanced, they would have had to report what those smart, informed people had to say.

Now that will never happen. Instead all we know is that east coast pointy-headed liberals won't even let the guy talk if they don't agree with him. Well, evidently that's true. It's also sad, and embarrassing, and it isn't smart or well-informed. It's FUAB. That is all.

Bad news?

Apparently so. Specifically, the bad news is that we're living longer. The linked analysis by Pandya et al is concerned specifically with heart disease. This is one area in which medical advances have unquestionably extended life. We haven't reduced the incidence of cardiovascular disease by much, but it doesn't kill people nearly as quickly as it used to. Fortunately, rates of smoking have declined, but the prevalence of obesity and diabetes is increasing. More people with heart disease, living longer, means a lot more people living with heart disease. These authors predict the prevalence will increase from about 11% for men and 8.6% for women today to 14.5% and 10.4%, respectively by 2030. And that will mean an enormous increase in disability, people living with poor quality of life, and of course Medicare spending.

What could be worse than that? If, as many predict, scientists figure out how to slow down the aging process by even just a little bit, say adding 2.2 years to life expectancy, that will be worth $7.1 trillion in benefits over 50 years, if we say a healthy year of life is worth just $100,000. But Medicare costs would increase by $3 trillion per year. (Social Security would go up by about $90 billion, which used to be a lot of money. All of this is in constant 2010 dollars.)

The problem is, are we willing to pay for that? We certainly could pay for it. We live in the wealthiest society ever. And we're all hoping to be in that old category some day. So shouldn't we decide, "This is a good way to spend our money"? Well, it doesn't look that way because rich people would have to pony up. And there seems to be a very strong correlation in this country between wealth and psychopathy.

Running on empty

The Republicans in congress seem to think that the not very functional Healthcare.gov website is their Watergate (since IRSgate, Benghazigate and FastandFuriousgate, among others, haven't panned out). And the corporate media seem to agree! Even John Stewart is piling on. The balky web site proves that the whole concept is unworkable, a trainwreck, and an embarrassment.

Well no. See, here's why this is not going to work as a campaign issue in 2014. They're fixing it. Day by day, they'll fix all the problems and then they will be done, and it will work just fine. And as Rachel Maddow explains via Ed Brayton, Social Security, Medicare and Medicare Part D all got off to rocky starts. Nobody remembers that now, and "Healthcare.gov didn't work right for a few weeks" is not going to be the basis of a a winning campaign in 2014.

People are worried, more substantively, that maybe those healthy young folks who we need to sign up will be discouraged by the crappy web site and we'll end up with adverse selection and a death spiral. Not to worry! The law is written so that we don't need them all to sign up right away. It would be a little bit wonky to explain in detail but basically, there's backup money and reinsurance built in to give us a year or more breathing space on that. Nice if a lot of them come in early, but not essential. Not a panic.

Here's a tip for Republican politicians: don't spend your air time making predictions of disaster that aren't going to come true, because reality will happen. Even the people who are getting ticked off now because their catastrophic coverage is being withdrawn will mostly end up happy when they find out they can get much better insurance, for not much more and maybe even cheaper if they qualify for subsidies. Just about everybody else, except for a few rich people like Ted Cruz who have cadillac plans (that will be taxed) will be better off. Even in Alabama! And they won't be communist slaves after all, either.

Once that actually, you know, happens, all the rhetoric of today will be gone the way of the snows of March. I mean, this is  evident to me. What am I missing?

Time Warp

Amanda Marcotte notices what seems to have been oddly under the radar lately, which is the Republican party taking up the cause of banning contraception. It went almost unnoticed that one of their fallback demands in the government shutdown was to eliminate the requirement for contraception coverage in insurance plans. Since 99% of women have used contraception, and only 8% of Americans think it's morally wrong, this does not seem to be a winning cause.

She has some good snark, too:

Clearly, no matter how much hand-waving is going on, many Republicans are trying to demonize contraception, a wildly unpopular position that frankly makes them look like lunatics. But they obviously don’t understand that this is what happens when they threaten to run the government into the ground to keep even a handful of women away from contraception or characterize one as “promiscuous” just because you don’t hate contraception.

Clearly, many Republicans live in a bubble world, constructed of right wing media and Bible-thumping bedroom communities where they get almost no exposure to the fact that some of their ideas are just plain weird. These politicians are supposed to be representatives of the people, but many of them clearly haven’t even considered the possibility that they sound like they’ve been transported here in a time machine from 1963. When I hear some Republican trying to imply that birth control pills are some kind of great controversy in America, I often wonder how their staffers hide the existence of color television from them, much less iPhones and electric cars. The modern world is clearly not the one they’re living in.

Well yeah. It does finally seem to have gotten to the point where their extremism, hypocrisy and detachment from reality are overcoming racial resentments and tribal loyalties to the point where even the Koch brothers' money can't save them. I'd like to think so anyway. Because the alternative, that these refugees from the 12th Century could actually seize state power in the U.S., is unthinkable.

Republicans is Weird

Now they're outraged that Healthcare.gov doesn't work right, demanding the head of Kathleen Sebelius and gearing up for endless hearings and hostile grillings of administration officials.

Am I missing something here? They don't want the website to work. If people sign up for insurance, it will be slavery, communism, and fascism. The only thing standing between us and the destruction of America as we know it is the fact that the web site doesn't work. If they fix it, we'll be living under the iron heel of tyranny like those enslaved Swedes and Canadians.

Well, actually it would be more like the Swiss, who are required by their sadistic overlords to blow giant wooden trumpets while wearing leather short pants with suspenders and expensive watches; and who also get to choose among various private insurance plans with subsidies for lower income people. Yes, it's a horrific vision. We will know that God has truly withdrawn his protection from America if the web site ever works.

The new luddites

The latest blooming meme -- transmitted by some very credible and buttoned-down thinkers, in many cases -- is that this time, the machines are taking our jobs and they aren't coming back. Yeah yeah, the power loom and the harvesting combine put people out of work, but the thereby wealthier economy found other jobs for them to do in the long run. But this time around, the machines aren't just physically powerful and fast, they're getting smart as well. The proposition is that we'll need fundamentally new social and economic structures to keep everybody supplied with an income and meaningful ways to spend their days.

Brad DeLong, no sidewalk raver to say the least, lays it out in telegraphic form. David Atkins sees IBM's Watson replacing oncologists as diagnosticians. I'm not sure that will happen, exactly -- people will still demand that a human make the final decision, I think, even though the human isn't really necessary or even doing anything regarding decision making. But the doctor will need to talk to the patient about Watson's conclusions and their implications. Still, the broader idea that even high level intellectual work is not safe for long seems to hold.

Tom Streithorts, in a compelling essay in the LA Review of Books, puts a positive spin on this as the problem of "post-scarcity economics." But he also considers that the end of scarcity is a big problem. If the economy produces all we need and more with little human effort, your labor -- of whatever sort it may be -- isn't worth anything. We distribute resources now by exchanging them for work, or giving them to rentiers and investors. If labor is worthless, then the 1% will have everything. Of course they won't be able to sell anything, because the rest of us won't have an income. You can see the problem.

The proponents of this claim say it's already happening, that the "natural" level of unemployment is rising. We'll never get back to 4 or 5 percent, and quite possibly we'll bounce off of 7.2% -- already misleadingly low because many people have left the labor force -- and see unemployment going up even as the economy grows. Obviously this is unsustainable, but the problem demands the precise opposite of what the conventional wisdom is saying. People won't just go out and find jobs if you cut off their food stamps and disability and Medicaid. There aren't any, and there won't be any.

I don't know for sure if this is true -- it was the dystopian vision in Vonnegut's novel Player Piano, and other visionaries have been imagining this scenario for a long time. But we need to think this through.

Apparently size does matter . . .

. . . for some people anyway. I have an excellent e-mail spam filter, and it never stops anything that should get through (I don't think, anyway). But, just for the heck of it, the other day I checked my spam folder.

G-mail only keeps the spam for 30 days, but 30 days worth turned out to be thousands of items. Ninety-five percent of which offered to enlarge my privates. One after another after another. Then the twentieth would be touting a penny stock. That was it. I deleted the entire folder and checked by 30 minutes later just to see what was happening. There were already 250 offers for anatomical enhancement.

Obviously, people wouldn't be doing this if it wasn't making them money, and we'd still be seeing Nigerian princes and Viagra if that's what was selling, Ergo, there are a helluva lot of guys out there who feel seriously defective. This could account for the gun culture and pickup trucks jacked up to six feet. Also the invasion of Iraq. In fact, come to think of it, Tom Friedman explained it just that way -- that's why he was for it, because it would make him prouder of his peter. Could this be the key to much of what ails our politics?

Hoisted from my comment . . .

On Charlie Pierce's blog  (which I heartily commend):

Some people here may view what I'm about to say as a bit contrarian, but believe me Paul Krugman agrees with me. Long-term, the cost of Medicare -- and Medicaid, and health care in general, but let's talk about medicare specifically -- is indeed a big problem, and it would be a good idea to start to get handle on it soon. (Conflating this with Social Security is indeed a scam.) Unfortunately, no politician, including BHO, is talking about the true nature of the problem and the needed solutions. No, we don't have to cut benefits, make beneficiaries pay more out of pocket, or even means test it (which would produce trivial revenues/savings). But we do need to a) pay less for drugs and overpaid medical specialists; b) stop doing unnecessary, useless and even harmless procedures (which is what Republicans call "death panels"), which requires basically changing the way we pay for health care; and c) invest more (not less as we are now discussing) in public health, social welfare and environmental protection programs that promote health, prevent disease, and will more than pay for themselves in avoided medical costs. And we need to do more comparative effectiveness and cost effectiveness research so we can figure out how to do all of the above right. That's the discussion we need to be having, but we aren't going near it.

My (unpublished) letter to the NYT

Much to my surprise, they sent me an e-mail saying they were considering publishing this, would I confirm I am the author? But of course they did not.

I am baffled as to why every journalist, including your own headline writer and reporter, are compelled to append the absurd phrase "the God particle" every time they mention the Higgs boson. The Higgs mechanism, Higgs field and Higgs boson have nothing whatever to do with God, an imaginary entity with no relevance to physics. Please stop it.

Reporters seem prone to these ridiculous verbal tics. I have written previously about "James 'Whitey" Bulger" and "Steven 'the Rifleman" Flemmi." Apparently it was illegal simply to print the men's names. Reporters also don't seem to know that they can stop using the word "alleged" after the person is convicted. Actually I don't think they know what it means or why they're supposed to say it in the first place.

Actually I'm being grumpy because I'm so disgusted with them on more substantive grounds. But you already knew that.

The real problem with health care in the U.S.

Here's a systematic analysis and a plausible tale told by Buz Cooper. In a pistachio shell:

Problem: U.S. spends more than 2X as much on health care as other affluent countries, gets worse health in return.

Buz says: :

1) Well, kinda, but U.S. is more affluent than most, so as a pct. of GDP we only spend 60% more.

My comment: Why does it follow that we should spend more on health care just because we're wealthier, if we aren't getting more for it? We don't eat six meals a day, or go to school for 30 years. If there's a "right" amount of health care we should just buy that much and spend more of our money on something else. But please go on.

 2)  The price of health care inputs is higher in the U.S. than elsewhere. Further correcting for that, we're only buying 31% more.

My comment: This is a good point, up to a point. On the other hand, given your point 1, incomes in the U.S. are higher than elsewhere so we would expect to pay higher salaries to doctors and nurses and EMTs and so on. But, on the other other hand, there's no reason why we should be paying higher prices for drugs and devices; and even in terms of our own general affluence, some medical specialties are definitely overcompensated. But either way yes, it's true that the higher spending doesn't entirely consist of higher consumption.

3)  The remaining 31% can be explained by general inequality. Poor people, of whom we have a lot compared to Europe and Canada, are less healthy and therefore need more health care.

My comment: Now you're talking. We need to spend much more, not less, on social welfare -- making sure that kids are well fed and educated; creating safe urban environments; providing affordable mass transit to connect people with jobs, and educational and cultural opportunities; providing affordable child care so parents can work safe in the knowledge that their children are well cared for; making sure decent housing is affordable for working people. And all that jazz. If we do that, we can get a huge return on our investment -- we'll save money on health care, have a stronger economy, and have healthier happier more fulfilled people. 

So why are we talking about doing the exact opposite? How did this moronic discourse come to rule our politics?

From Habermas to Cervantes

Habermas says that metaphysics is dead, epistemology is on life support, what really matters is epistemology. The philosophy of knowledge can only be pursued as the philosophy of communication. If I convince myself of a truth, and most do not agree with me, of what use is such a truth? Human reality has ineluctable elements, but it also has a huge socially constructed portion. How can we sort out the variety of claims -- of truth per se, or other kinds of validity -- and once have put them in appropriate buckets, how can we evaluate them? And how do we talk with each other about all of this?

I think these are indeed the pressing questions right now. With powerful people inhabiting inconsistent realities, we need to do better than just dismiss those wackos, or murder them, or whatever. We must figure out how to talk with each other. You go, Jurgen!

While Rome burns . . .

Of course, the wingnuts don't believe in the fire even as it scorches their own asses. BMJ today reminds us that antibiotics will stop working for us unless we stop feeding them to livestock. The Brits actually have pretty good policies about this but it doesn't matter because lots of other countries don't and antibiotic resistant pathogens cross international borders as freely as the wind. We might want to do something about this before our kids start dying of staph infections. We might.

Of course, that might actually be merciful if we don't urgently start to deal with climate change. But you know, it's a hoax. Thanks, I feel better now.

This is getting scary

I like to think that I've had a productive research career so far, that the methods I've developed are promising, and that I have a chance in the years I have left to help people take better care of themselves, work more effectively with their physicians, prevent some bad outcomes, and even save us all money in the process. But I've only been able to do this because the American people have valued medical and health services research, and been willing to pay for it. If that isn't true any more, my work is over. I'm not sure what other kind of  job I can get right now, but I need to start thinking about it. That's kind of sad.

Anyway, in case you didn't know it, the work we do is essential if we're going to provide a decent level of Medicare benefits to the growing elderly population in the coming decades. That is a legitimate concern. No, not the spending on food stamps and environmental protection and food safety and veterans benefits and Headstart and diplomacy and highways and bridges and all that stuff that the Republicans have already cut and are demanding to cut further. But the long-term fate of Medicare is a real problem.

But here's the fact: we don't have to limit benefits or make seniors pay more out of pocket or even means test Medicare. (Which maybe sounds like social justice but is a very bad idea politically and would save scarcely any money.) We can get most of the way there by getting more bang for our bucks. Figuring out how to do that is what we do. And we actually understand the problems, unlike the interchangeably ignorant Rand Paul and Paul Ryan.

Here are a couple of examples from the new JAMA. They're very wonky, and I think you'll be stopped at the abstract anyway, which is probably a blessing. Lewis Lipsitz discusses the so-called 3-Night rule, and Steven Landers discusses the future of Medicare home health benefits.

The 3-Night rule is that in order to qualify for care in a Skilled Nursing Facility (SNF), you first have to spend 3 nights in the hospital. Back when the rule was created, it usually took that long for proper assessment and stabilization of whatever acute episode the person had suffered. The rule was intended to make sure people didn't receive skilled nursing care, which is quite expensive, unnecessarily. But, nowadays, it's often the case that somebody come into the ED and they can quickly receive whatever acute services they need and could be immediately sent on to a SNF without even being admitted. However, if that happens, Medicare won't cover the bills in the SNF, which few families can afford. What often happens is that doctors end up keeping people for three nights, just so they'll qualify, but hospital care is even more expensive than SNF care. Also, being in the hospital is bad for you, especially if you're old and frail.

So why not just bag the rule? Well, a funny thing can happen. If people who are in a nursing home but not receiving skilled nursing care, the nursing home gets a relatively low reimbursement. If the person has some sort of a setback, the facility can decide to start charging the SNF rate even if the person doesn't really need skilled nursing care. If they have to send them to the hospital instead, and get a doctor's authorization, they can't get away with that. The result is that waiving the 3-Night rule so far has not consistently demonstrated cost savings. But, if you structure payment and regulation correctly, you could indeed get both cost savings and better experiences and outcomes for patients. It takes policy wonks to figure out how to do this correctly, and well-designed trials and data analysis to prove what works and what doesn't.

There are similar issues with home care: how to get people the services they need, that can keep them at home and out of the hospital or nursing home, without overpaying or inviting fraud. If we can figure out how to do these things correctly, along with many other challenges, we can make Medicare much more sustainable while taking better care of people. But that takes a) investment up front and b) honesty and wisdom from politicians who prefer to exploit fears about Medicare to scare people into voting against their own interests. I'm talking to you Paul Ryan.

Remember Reality?

Most people seem to have forgotten all about that concept but I haven't, and I happen to know that reality bites. Here's Michael Tomasky discussing the debt limit, including a warning that has already come true: that Republicans will start claiming that hitting the debt limit will be harmless, or even, in the case of the yoyo interviewed at the link, beneficial.

They're already claiming that the government shutdown is harmless, except when they're complaining about the specific government services that have been suspended, for some mysterious reason having nothing to do with their refusing to fund them. But listen up folks: when we hit the debt limit, one of two things will happen. Either the U.S. stops paying interest on debt, in which case financial markets will devolve into chaos; or it stops mailing out Social Security checks and Medicare reimbursements, in which case we will plunge into an economic depression and people will starve and stuff like that.

Third possibility: Obama takes advantage of one of the options he has for ignoring the debt limit (platinum coin, constitution requires payment of government obligations), whereupon the House impeaches him and sues in federal court and the government remains in total chaos until January of 2015; meanwhile the shutdown continues and we go into a second Great Depression anyway.

This will happen. Their denying it in advance won't change anything. Do they really not understand that?

Doctor Doofus

There's nothing I can do, and nothing original I can say about the collapse of our republic, I'll just outsource to Timothy Egan then move on to my regular blogging agenda. Or rather, I will say this. It is really depressing to think that there are horrid communities in this country, full of racist, ignorant, cruel and repulsive people who would actually vote for the malignant clowns who run the Republican party. I will make sure never to visit such places.

Now, on to Stayin' Alive. In spite of 20 years or more of serious efforts to improve the quality of medical care and to rein in overdiagnosis, overtreatment and just plain wrong treatment, all sorts of news today that shows we are failing. First, I believe I have written before about low back pain. Most of the time it resolves on its own after a while; there is no benefit to commonly performed surgical procedures, nor to ordering MRI or other imaging procedures on routine presentation, and definitely more harm than benefit to prescribing narcotics. Ordinary over-the-counter pain relievers, maybe physical therapy, and just waiting are the right course unless there are other symptoms indicating a possible serious problem.

Well, Mafi et al in JAMA Internal Medicine (I think you'll get stopped at the abstract, but I have the magic cookie) find that from 1999 to 2010, mistreatment of low back pain increased in the U.S.

Nonsteroidal anti-inflammatory drug or acetaminophen use per visit decreased from 36.9%in 1999-2000 to 24.5%in 2009-2010 (unadjusted P < .001). In contrast, narcotic use increased from 19.3%to 29.1% (P < .001). Although physical therapy referrals remained unchanged at approximately 20%, physician referrals increased from 6.8%to 14.0%(P < .001). The number of radiographs remained stable at approximately 17%, whereas the number of computed tomograms or magnetic resonance images increased from 7.2%to 11.3%during the study period (P < .001).

Meanwhile, futile treatment of critically ill patients continues more or less unabated; doctors continue to prescribe antibiotics for upper respiratory tract infections which is a) generally useless and b) actually harmful to patients and c) harmful to all of society; and, in BMJ, we learn that most trials of cancer screening don't even bother to assess harms, which says a lot about the underlying psychology of physicians and clinical researchers. Obviously, if you only study potential benefits and ignore potential harms, you'll end up doing a lot of stuff you shouldn't do.

I almost despair, at times. Patients also think that more is necessarily better, and of course this fundamental misunderstanding contaminates our politics as well. No, efforts to reduce overdiagnosis and overtreatment are not "death panels." They are life panels. Reducing waste and harm in medical care is the only way to make the whole enterprise sustainable, affordable, and available to everybody and at the same time, it means better outcomes and healthier people.

And to hell with Republicans.

Pahhhhhtttyyy!

In case you didn't know, it's NHL opening night and the Canadiens are at home. You can't even imagine what's going on here. There's a huge plaza in the middle of Rue Ste. Catherine with an open air concert space, which is featuring a free Kings of Leon Concert and 150 booths selling beer and booze. I mean it is absolutely bugfucking insane. I hung out with it for a while then it was just too much.

Believe me, Boston would never try this for opening night of baseball or football. You'd have a guaranteed riot with overturned and torched cars, serial sexual assaults, and mass tazerings and rubber bullets. Here, it's loud for sure, but non-violent. They can do it. We can't.

American Exceptionalism

What I could say of the conference is multiple and various, but one important theme is that the Europeans and Canadians here think we're completely nucking futz. To whit . . .

I attended a talk yesterday in which the investigator reported on surveying cancer patients about out of pocket costs. How much could they pay, how much did they pay, how was it affecting them financially and emotionally, yadda yadda yadda. As you might expect, the answers are not so much, more than they had, and disastrously. (Average cost: $600/mo. Top cost: tens of thousands of dollars a month. Average education: grade 12.)

A guy from Germany or the Netherlands or someplace -- you know, one of those totalitarian dungeons -- said basically WTF? In my country, in all of Europe, nobody who has cancer pays a penny. The speaker was nonplussed. What, you don't even have a copay? No no, the guy said. We might have a conversation over whether it's still worth it if the person is going to die anyway, but of course they don't have to pay. Why should they? They have cancer for heaven's sake!

Makes sense to me. Back in the U -- S-- S-- A one thing the confluence of government shutdown and opening of health insurance exchanges has accomplished is that it has forced the corporate media, against their will, to explain what's going on. Err, okay, the idea is that if you don't have health insurance and you haven't been able to get it because you couldn't afford it or you are disqualified by your diagnosis of pinky spasm, now you can get online and find good, cheap health insurance. Therefore you and your children and grandchildren are no longer free. Or something. Meanwhile people are having their regular doctor appointments and the doctor is telling Granny, no, there isn't any death panel and your Medicare is just the same as ever, except now your prescription drug coverage is better. Even if the doctor is a teabagger, what else is he gonna say? There isn't anything else.

So as far as I can tell this can't end well for Ted Cruz. But I don't prognosticate. We'll see.