Doctor Evil

This is extremely disgusting. Doctors in California, who receive payments and other benefits from drug companies, have been prescribing anti-psychotics to kids in foster care -- kids who are not psychotic at all, but who are being drugged into a stupor in lieu of properly addressing their behavioral problems. According to the investigation by the San Jose Mercury News, drug companies spent $14 million from 2010 to 2013 to bribe doctors into making these prescriptions.

According to the investigation, nearly 25% of California foster children age 10-18 were prescribed antipsychotic drugs. I have written about these drugs here before. They are extremely toxic and can cause weight gain, diabetes, and other severe side effects. They are appropriately prescribed only as a fairly desperate measure for people who suffer from psychoses -- schizophrenia and severe bipolar disorder. Some kids were on as many as 8 psychiatric medications; and at most they would be appropriate for fewer than 2% of children. (None, in my opinion. These psychoses are generally not diagnosable until late adolescence and putting any such label on a child, whose brain is still developing, is wrong.)

This is just sick.

This is, or at least may be, a BFD

I have discussed initiatives in the Affordable Care Act that encourage experimentation with new ways of reimbursing health care providers --Accountable Care Organizations being the most noteworthy. These are capitated (i.e. paid a lump sum per year per patient, with some adjustments) multi-specialty provider entities that get bonuses for patient satisfaction and good outcomes and get their pay docked for bad outcomes. But, these are just experiments that will only have a few takers.

But now the Administration has announced a major change in Medicare. By then, 30% of payments will be under ACO-like alternative pay models. A total of 85% of Medicare payments will be tied to outcomes in some way by 2016. Right now, most doctors are paid to do stuff, which means they do too much. They are paid even more if the stuff they do actually harms you and you need more care to fix it. (That happened to me: I underwent a right hemicolectomy, leading to what would be more than a hundred thousand in current dollars, when all I had was diverticulitis.)

We'll see if this really happens, and how well it works. But it's a revolution.

The Lonely Cosmos

Today's musing is a bit off-topic for this blog, but I've been thinking about it, so there.

Now that we're finding rocky planets in the habitable zone of stars by the dozens, meaning there are no doubt billions of them in this galaxy, the presumption is stronger than ever that there is also extraterrestrial life. But, we still have no evidence of technological civilizations other than our own. Many people account for this by supposing that such a phenomenon is very unlikely, or that when civilizations do arise, they don't last very long.

Since we may be on the verge of doing ourselves in, the latter could be so, but on the other hand, a species that managed to steal wisdom from the Gods along with the fire of intelligence might be able to last for billions of years. Why not? But . . .

We have only been dumping radio signals into the deep for a century or so, and pretty soon we may stop. We're no longer communicating by broadcast, but by satellites, which point down, and radio cells which produce very weak signals. I Love Lucy reruns may soon cease to head toward Antares. That is likely the technological evolution of any civilization.

Furthermore, if there are two or more technological civilizations out there that have discovered each other, if they are communicating, it will be by laser, which means we wouldn't see it. Anyway, once they've caught up on any differential knowledge of science and technology, they wouldn't actually have much to talk about. Their esthetics and art would be mutually unintelligible, and they wouldn't have any particular interest in each other's current events and gossip. And no, there's no reason why they would form a galactic federation or anything like that. Under any imaginable technology, it would take centuries to travel between stars; there's no trade, and no tourism.

So yes, they might be out there but no, it's unlikely we'll ever know it.

Return of Bedlam?

I think you'll only be able to read the first 100 words, but that's okay, I'll tell you what Dominic Sisti and friends have to say in the new JAMA.

When I was a youth, we had a wonderful, progressive movement. We were going to end the warehousing of mentally ill people in grim, abusive, totalitarian "hospitals" that were more like dungeons. Instead, we were going to provide them with community based services and housing in the least restrictive possible environment. They were going to be reintegrated and treated like human beings.

So the states emptied out their mental hospitals and then closed them down. In 1955, there were 560,000 people in state mental hospitals. Today, there are 45,000, although the population has doubled. That seemed to save the states a lot of money, so they were happy to do it.

What they were not happy to do, however, was the other half of the proposition: create community housing and supportive services. They noticed the big bucks they saved by closing the snakepit, and they left it at that. As a result, today, half of the people in prison and jail are mentally ill and/or have substance use disorders, and 15% have a diagnosis of psychosis. (The rate is even higher for women.) The ones that aren't locked up with the serial rapists, or in solitary confinement, are often living on the streets or in homeless shelters, getting medical care in emergency departments if at all, and cycling through jail and detox.

Here's a handy backgrounder from the Vera Institute.  (PDF -- the web page is here.) Vera thinks the ACA provides a chance to do something about this, because once people get out of jail, they will now be eligible for Medicaid in many states, and it will be possible to finance more services for them. Maybe, but Medicaid is pretty stingy and these people need a lot. Sisti et al think that for some people, institutional care is the best solution after all. They don't want a return to the bad old days, but large-scale institutions can provide the breadth and depth of services people need most cost-effectively, while guaranteeing good quality shelter, three squares, and social opportunities. It's cheaper than jail and the ER, too.

This isn't for most people with serious and persistent mental illness. Those who can and want to live in community settings should still be given that opportunity. But for some people, it may be right after all.

It can't happen here . . .

. . . but it should. I'm talking about evaluating medical interventions in terms of their costs as well as their benefits. And I do mean monetary costs.

In the UK, the Death Panel is called the National Institute for Health and Care Excellence (NICE -- in the acronym they omit the H). This blog post by Austin Frakt explains how they do it. He doesn't really explain the Incremental Cost Effectiveness Ratio, so I will tell you that in simple terms it's the cost per Quality Adjusted Life Year of a treatment. Here's the definition of a QALY:

A quality-adjusted life-year (QALY) takes into account both the quantity and quality of life generated by health care interventions. It is the arithmetic product of life expectancy and a measure of the quality of the remaining life-years.

The quality adjustment part is probably the most controversial, and I agree that it is somewhat dubious.  However, you do have to think about it in some way because some conditions of life, let's face it, just aren't worth very much. Uh oh! Culture of Death!

Alright, let's posit that human life is infinitely precious and you can't put a price on it. Okay, look right here -- there's an African child dying of malaria. You don't even have to go to Africa. Here's a U.S. citizen who can't afford health care who has uncontrolled hypertension and diabetes, whose life will be shortened by many years. And here is David Koch with his billions. Do you have a problem with that?

Here's the cold, hard truth. Resources are scarce. The amount that it is politically possible to spend on health care, however it's financed and organized, is finite. Within that finite budget, we should allocate our resources to get the best overall result. That means we should not spend huge sums on treatments with small benefits at the cost of inexpensive, more effective treatments. Why? Because human life is precious.

Note that NICE is not actually a death panel in that it does not rule on individual cases. It doesn't say Joe should live and Sally should die. It says that the National Health Service won't pay for a particular drug for a particular indication, for anybody, or perhaps for anybody above a certain age. If you have the dough and you want to buy it on your own, you are free to do so.  This is unavoidable if you are going to provide health care to everybody.

But the way we do it in the U.S. is that we require insurance to pay for any FDA approved treatment, no matter what the cost, no matter how little the benefit. If, however, you can't afford insurance, you will be the one to suffer or die. However, the evaluative institutions established by the Affordable Care Act - the Independent Medicare Payment Advisory Board and the Patient Centered Outcomes Research Institute - are by law forbidden to take cost into account. Because Republicans think it would be immoral to do so. They also think it is immoral to tax rich people to pay for child care and higher education and medical care for low and moderate income people. Sort that out, if you can.

Quick hitter

Something we all should think about this MLK day: J. Edgar Hoover's name is still on the FBI headquarters building. All it would take is a vote of congress to change that.

I'm not an economist, but . . .

I did have to pass a qualifying exam in economics to get my doctorate in social policy, and I read a lot. So . . .

The value of money and who makes a return or a loss on an investment seems like it shouldn't matter for the real world. People can go on making and buying stuff, right? It's just paper. Sadly, no. Money and its various derivatives -- stocks and bonds and more exotic products -- are how trade is organized, and there's a lot that can go wrong.

We have grown accustomed to thinking that inflation is the worst thing that can happen, and of course a quirky sub-culture of the far right has succeeded in making it conventional wisdom that "sound currency" is the only economic goal government should pursue. Not. The global economy now faces the prospect of a ruinous deflation.

Isn't that a good thing? you ask. My savings will be worth more. My wages will go farther. Well, yes, as far as that goes you'll be happy. You already are, paying less for gasoline. But there are many problems.

First, people who borrowed money to invest in, say, drilling for oil and gas, can't pay it back. That means their creditors -- who include pension funds and widows and orphans -- lose their money. They have less to spend. The roughnecks also lose their jobs. As prices fall for other products, this disease spreads. Businesses go bankrupt, and their workers lose their jobs and their investors lose their savings.

Wait, there's more. With prices falling, you're in no hurry to buy. Put off the big purchase, it will just get cheaper. Less demand means a shrinking economy, however, because your spending is somebody else's income. Pretty soon the whole economy is circling the drain.

Will this happen? Is it 1929 all over again? Too soon to say, but that's bad enough.

America no longer exceptional

A long, sad essay in JAMA by Hamilton Moses and friends, which they are actually allowing you, the rabble, to read. In the interest of fiscal responsibility and the fundamental principle, as articulated by Jesus, that nothing government does is good, with the exception of  killing people and blowing stuff up, the U.S. is no longer globally dominant in biomedical research. Yes, we still do about half of it, but NIH funding has been declining steadily in real terms, by 13% since 2004. We'll keep on slipping behind. That also means, of course, that for people like me to get our proposals funded is becoming nearly impossible -- something like 3% of applications are now successful.

Industry has increased its share of research funding, but they obviously go after what's profitable, not what's necessarily most in the public interest. And no, despite what Jesus says, that is not the same thing. Industry is not investing in basic research, but in "me too" drugs that they can patent.

What is worse, from my selfish point of view, is that our investment in health services research is paltry. That's research to get the wonderful new science to actually benefit people, cost-effectively. It's only about 0.2% or 0.3% of national health expenditures, i.e. 1/20th of national research funding. This is very low compared with other industrial sectors, where managers know that technology doesn't implement itself.

Are we going to hear about this in the 2016 campaign, or will it be all about Benghazi and deregulating the banks? I know what I expect.

Low information voters

That's most of us, about most issues. Uwe Reinhardt, eminence gris of health economics,  says no, Jonathan Gruber, voters aren't stupid, but they don't know much. That's because:

• Public policy isn't actually all that easy;
• They don't have time;
• Those with more resources actively mislead.

But you knew that. The problem is that his blog post won't help much, because it's complicated, it take a long time to read, and it's just a blog post, it isn't being pushed at you on Faux News. Oh well.

Go ahead and read it if you want to become a higher information voter, but I will pull out one takeaway, which has to do with tax expenditures. Stephen Brill is going around saying that the taxpayers can't afford the ACA, what with its subsidies for moderate income people and free insurance for the lazy moochers who work at Walmart, but in fact, the government already spends billions on subsidized health insurance for the well-to-do in the form of tax free employer-provided insurance. The tax break is worth much more to the rich than to the poor, which is of course the whole idea. But it's invisible.

Just one nugget among many.

People Are Stupid

I heard Isaac Asimov speak when I was in college and that's how he started his talk. And by the way, it wasn't about science fiction, it was about a progressive vision for the planet.

Anyway, he was right. You may recall that Amber Vinson, the nurse who cared for Ebola patient Thomas Eric Duncan and later contracted the disease herself, visited Cleveland before she became symptomatic, causing mass hysteria. While there, she shopped for a wedding dress at a store called Coming Attractions. The store has been forced to close due to loss of business -- to this day, people are afraid to come in.

That largely speaks for itself, but it's worth remind ourselves once again that the stigma associated with infectious disease often causes more trouble than the disease itself, or at least doesn't help matters and just makes them worse. Ebola is by no means special or unique in this way. Remember the flu pandemic hoax of 2010-2011? Authorities closed schools, people wore masks on the sidewalk, stopped eating in restaurants -- the economic losses were enormous although what we actually had was a milder than usual flu season. Same thing happened with the SARS panic -- nobody would eat in a Chinese restaurant. If you remember the early days of AIDS, they were burning down people's houses and chasing kids out of school.

Of course this always benefits the paranoid party in American politics. Can you guess which one that is?

Can I add anything . . .

. . . to the discussion about the Charlie Hebdo murders?

Maybe a little. Many in the commentariat are opining along the lines that while obviously murder is not the answer, it's wrong to offend people's religious beliefs so don't do it. These include Bill Donohue of a wingnut Catholic organization and others, as discussed here by Jonathan Chait.

I would actually go a bit beyond Chait. Yes, we all have a right to commit blasphemy and the correct response to offense is to talk back, not commit violence. However, you don't have to draw crude and raunchy caricatures in order to offend the pious. All you have to do is aver that their beliefs are false. Religious people demand "respect" for their beliefs -- not for their persons, mind you, which I fully endorse, but for their beliefs.

I don't respect beliefs I consider nonsensical. I'm pretty sure Bill Donohue doesn't think I should respect the beliefs of flat-earthers. I don't know offhand his position on climate change or vaccination, but presumably he thinks I'm allowed to debate those subjects. But why should I respect his nonsensical belief that because a snake convinced a woman to eat a piece of fruit thousands of years ago, we were all tainted by sin until God impregnated a woman with a baby who was also himself and then when the guy grew up had him tortured to death, even though the whole point is he didn't die, thereby removing the taint and allowing people who believe this crap to live in bliss forever while everybody else is eternally tortured?

I don't respect that, it's utterly preposterous, transparently false and internally contradictory. And yes, I'm allowed to say that in public and I'd say it to his face if he were here. So there.

The Tsarnaev trial

As my 4 1/2 long-time readers know, I lived in Boston for some 25 years. I moved away to deepest Connecticut just about a year before the marathon bombing. It deeply affected me, of course, because the bombing tore at the very heart of a community to which I still felt deeply attached. If you're going to commit a terrorist act in Boston, the marathon is probably your best target.

It isn't just a sporting event. It isn't even principally a sporting event. That's just an excuse. It's really Boston's one special day, like July 4 for the United States, your wedding anniversary for your marriage, Christmas for Christians. (I guess it would have to be Darwin Day for me but we don't really have anything comparable.) It's a holiday in exactly one city, and people head downtown by the millions to stand together in a completely muddled mix of every ethnicity and class and cheer on everybody, the leaders and the sorriest stragglers. You can't drive either, you have to take the T.

Those guys lived in Cambridge, which is essentially part of Boston, and they knew what they were doing. Was it as evil as invading Iraq? Well, it was evil on  a far smaller scale but it was all the evil within their power to achieve. But I do have to ask, what is the point of the trial?

Tsarnaev's lawyers offered to plead guilty, which would mean maybe 60 years or more locked in a cage by himself for a now young man, who would only leave feet first. Once he disappeared into federal Administrative Maximum Facility in Florence, Colorado (presumably) he would be forgotten.

Is that insufficient vengeance and insufficient demonstration of society's repugnance? Apparently, because now the Department of Justice is going to give him several weeks on the front page, an elaborate public presentation of his life and character, and should he actually receive the death penalty, reappearance on the front page from time to time over many years as his appeals wind through the courts. All this for the chance to snuff him in 10 years or so. To what purpose? Beats me.

More you didn't know about the ACA

Yes, it's Socialism-Fascism-Muslimism-Freedom Destroying-Anti-American-Communist-Atheism, but it also, in addition to getting millions of people health insurance, makes health care better. And a lot of the ways it does that are apparently a secret, at least if you rely on the corporate media for your information.

Did you know that the ACA requires private health plans to cover all the services that have received an A or a B rating from the U.S. Preventive Services Task Force? An A rating means "The USPSTF recommends the service. There is high certainty that the net benefit is substantial," and a B rating means "The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial." In other words, they've studied the issue deeply and concluded that the thing is worth doing. Oh yeah, these services have to offered without patient cost-sharing.

Now, in many cases, these services would actually reduce health care spending in the long run. (Not necessarily -- something can be worth doing even if it actually costs money, but we'll deal with that another time.) An example is smoking cessation interventions -- counseling, nicotine replacement, and other pharmaceutical treatments. These aren't magic bullets, but they do raise quit rates.

Via Tim McAfee et al in the new JAMA (subscription only, alas), when Massachusetts added smoking cessation services to its Medicaid program in 2006, the smoking rate among beneficiaries fell from 38% to 28%, hospitalizations for myocardial infarction fell by nearly half, and there were $3.12 in savings for every dollar spent. (Land, et al, here )

So okay, you may ask, this being so, why don't all insurers already do this? Why do we need a law? Don't they want to save money? Well, here's the problem . . .

The savings will only be realized over a considerable period of time, but the money is spent now. By the time you don't have that heart attack or lung cancer, you won't be in that insurer's plan any more. In fact you'll probably be on Medicare, but even if not, there's a lot of turnover among enrollees. In a single payer system, you don't have this problem, but we do here in the U.S. of A. Only by passing a law requiring that insurers offer these services can the social benefit be realized. (And all insurers will actually benefit in the end -- what we have here is a version of the "free rider" problem.)

There are other goodies in the ACA. We'll get to them.

Yeah, I harp on this

The headline on every news site today is still the crash of AirAsia Flight QZ8501 on Sunday. Yep, for 5 whole days that's been the most important event on the planet. It's even more important than the 92 people who die in motor vehicle crashes in the U.S. every day, which means that the deaths of 162 people are infinitely more important than the deaths of, we can surmise, about 460 people in the same 5 days, and those are even Murricans, since CNN isn't reporting on them at all.

Al Qaeda just had to somehow or other bomb airplanes in flight, hence the shoe bomber and the undie bomber, even though it's much easier to put a suitcase bomb in the security line at the airport. But that just wouldn't be as satisfying, it seems.

And there isn't even any policy rationale for this asymmetrical attention.  The rate of motor vehicle fatalities per capita has been declining in the U.S. since 1972, but it's still much safer to fly in a commercial airliner than it is to ride in a car.

There is a whole academic industry devoted to the psychology of risk perception, but it can only partly explain this. A catastrophic event, in which a large number of people are killed, gets our attention much more than a large number of smaller events, even if they add up to a worse total. But the news media go bananas over a private plane crash in which one or two people are killed, or a runway mishap in which a few people or even nobody is killed. Furthermore, a train crash in which 162 people were killed wouldn't get nearly as much coverage. And airplanes are no longer novel, though they are somewhat less a routine part of most people's lives than a Ford Focus.

You explain it to me.