Map of life expectancy at birth from Global Education Project.

Thursday, September 24, 2009

Special bonus multi-post

Yesterday I was kind of busy so this post will be enriched with extra vitamins.

First, NEJM today gives you a lot of freebies on health care policy and reform. Scroll down toward the bottom portion of the page to find it all. Arnold Relman is especially good and succinct as he explains the fundamental problem of Provider Induced Demand, which is one of the reasons why health care is not anything like the fictional "free market" they indoctrinate college kids with. We don't know any better, so doctors tell us what we need, and they are paid to do more stuff. A different approach to paying for health care is needed. I've hammered and harped on that a lot here, but Relman is a good explainer. Lots of other good stuff there, including Jacob Hacker on why "cooperatives" are no substitute for the so-called public option. It even has a poll, so go there and freep that poll!

Next, sorry to have to frost your pumpkin, but don't get too excited by the much-ballyhooed HIV vaccine "breakthrough." It's always unseemly when researchers run out and talk to the press before they've been through peer review, and under the circumstances I can't even judge the merits of the trial design. But, assuming it has no methodological flaws and the results mean what they seem to mean, they don't mean much.

The degree of efficacy shown -- reducing the incidence of infection by less than 1/3 -- is very far short of supporting actually using such a vaccine. Actually, just eyeballing it, it's probably marginally significant anyway. And the follow-up is only 3 years. The problem is, if you start giving such a vaccine to people, it will cause many of them to rationalize that they are protected so they can engage in unsafe behavior. It could even be counterproductive. Furthermore this targets strains specifically circulating in Thailand. It might not work on other strains, and even the Thai strains could evolve away from it. Whether this actually raises the likelihood of a truly useful vaccine anytime soon is unclear, but count me as doubtful.

Finally for now, another open door crashed through, this time by creeping socialism. The president of France hired Amartya Sen and Joseph Stiglitz to create a "provocative new study" finding that the widely used Gross Domestic Product is not actually a measure of economic well-being. Since Sen has spent the past 30 years saying that, it's not a big surprise that he said it again. So have a lot of other people, including everybody who isn't sitting on his or her own shoulders. I especially want to acknowledge Hazel Henderson, who gave me her book Creating Alternative Futures in 1978. She used to say that GDP stands for Gross Domestic Problem.

This is another issue I've harped and hammered on here but come on, it's obvious. GDP counts costs and ills as goods. When a hurricane wipes out south Florida, GDP goes up because people have to buy building supplies and hire carpenters. Their houses are gone, but GDP doesn't even notice that. When somebody buys cigarettes, that adds to GDP. When they get cancer, it adds even more because they pay doctors and hospitals and drug companies and ultimately morticians. When one person is paid $40 million in a year and another makes $5/hr., GDP per capita is $20 million, which sounds great, doesn't it? When you pump oil out of the ground, 100% of the price of the oil is added to GDP, but the oil is gone forever -- which GDP again doesn't notice. And on and on and on. Yet when GDP goes up, the corporate media say the economy is healthy. That has always been bullshit, always will be bullshit, and we have always known it. Repeating it doesn't seem to do any good, however. The culture gives it a nod and then forgets all about it.


Bix said...

Just read Relman. And Marcia Angell's article in Huffington:

And Hacker.

It's depressing. Things like "these industries will make more money in the reformed system than they do now," re: insurance and drug companies. I see that in everything I read.

Relman lays out a group-practice alternative similar to what you described in your Utopia Now post. (I suspect Angell's next post will do the same.) It sounds reasonable, but I can't imagine docs taking a salary. Not yet. I think the system will have to hard press clients/patients more for that kind of overhaul. I thought now was the time.

I'm disillusioned by Public Health these days. It's increasingly wound up in what Angell refers to as the medical-industrial complex ... because it relies on things like screenings that just draw people into a web of medical services that they can't afford, and that seem never-ending. You almost want to tell people not to engage the medical system at all.

whisker said...

Thanks, I was going to ask you about the HIV thingy.

Anonymous said...

GDP is, was, built on the idea of the supremacy of the free market and exchanges as being representative. (of what exactly? no matter!)

It was (afaik?) pushed and pushed by the US, as those numbers would make it seem superior. GDP is not a measure of standard of living, as all economists will admit. Or of anything else fathomable or reasonable.

Sarkozy is given to fashionable enthusiams, picking up ideas from advisors. They are usually straight out populist, posturing for the gallery (that is the TV watcher, probably better / differently educated in France than in the US), making a lot of noise to no avail, pushing nationalist ideas... I wouldn’t pay much attention to that.

He has skewered and practically disembowelled the judicial system, with great effect, he can’t bear the independent judiciary, and is working hard to take over the media, he is halfway there. He is a French Berlusconi, if one can grapple with such a concept. Vociferating about how France, its productivity, standard of living, happiness, etc. shouldn’t be measured by an idiotic GDP is just electoral, nationalist grist. Though he is right, of course.

He has also worked hard to begin 'privatizing' the French 'national' health system. So far, he has not been terribly successful, some minor stuff, rising co-payments, a lot of discourse about 'responsibility', the usual....


Cervantes said...

I make no particular endorsement of Sarkozy. As I say, Sen has been saying this for my entire adult life. However, for whatever reason, by commissioning this "study," Sarkozy has succeeded in getting publicity for this important truth.

Anonymous said...

From mainstream media in 09: hard to translate french: absolutely typical, standard, repeated in different venues over and over:


Dans une analyse publiée dans Le Monde du 9 juillet, Cécile Prieur pose directement la question « Le système de santé en voie de privatisation ? ». Elle cite d’abord le discours du président expliquant que les « ressources de la solidarité nationale ne sont pas infinies » et que « les régimes de base ne pourront pas tout financer ». « La solidarité nationale, financée par des prélèvements obligatoires, continuera de remplir sa mission, a annoncé M. Sarkozy. Mais à ses côtés, d’autres formes de protection sont appelées à se développer (...). Je souhaite que soient confiées de nouvelles responsabilités aux organismes complémentaires. »

end quote.

>> Trans of the last part:

National solidarity can no longer finance health care, other forms of ‘protection’ will have to be developed, I hope that new responsibilities will be conferred on other/complementary/different organisms/entities.

Read private insurance.


Anonymous said...

C, sure it is good that Sarko is attempting to knock GDP away, it is great.

At the same time he is doing other things...


Greenwayark said...

Provider Induced Demand is beginning to be felt here in Sweden also. We still have the local Medical Care Center "Vårdcentralen" for primary care. Now with a conservative government we have private primary care centers which seem to be producing Provider Induced Demand. Here the doctors get paid per patient and like about 10 patients an hour. At my gov. run primary care unit I get all the time I need and if anything the dr dosen't refer me to tests if it is not clearely necessary. Both care optione cost the same about 20$ a visit up to about 120$ a year after which it is free. Hope that Obama gets it right!