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Sunday, March 1, 2015

The Complacency-Over-reaction Cycle

We had a another series of potential bad snow storms last week. The weather patterns looked eerily similar to last year when we had our famous snowmaggedon. This event resulted in scores of people being marooned on highways for hours, including school children trapped on school buses. This year we were prepared with many school systems closing in anticipation of inclement weather, health systems cancelling patients, and government offices sending people home. What happened was basically nothing. No one complained, yet. The memory of last years debacle was still reasonably fresh in our minds. However, I can confidently predict that this memory will fade and when it fades, we will again become complacent.

I came to realize that this sort of cycle, between over-reaction and complacency is characteristic of virtually all human endeavors. When faced with preparing for the future, do we err on the side of doing too much or too little? It depends upon the circumstances we find ourselves in and the memories we have of recent events. No matter how we act at any given time we run the risk, or perhaps the certainty that we are destined to over- or under reaction at some point and we will be wrong. Furthermore, in retrospect we will look stupid, either preparing for some unlikely eventuality or something which  happened and appeared to be something we should have anticipated. We will be pilloried by the professional Monday morning quarterbacks.

This phenomena courses through basically every aspect of human existence. Look at the news at the recent vaccination controversy. When I was growing up, vaccinations were not questioned. There were not many of them and those which were available targeted diseases where people had actual memory can contact with. Not take the polio vaccine? You had to be absolutely crazy since there were actual people who were you neighbors who were in iron lungs at some recent point in the past. Fast forward 60 years and we are at the top of the curve, with some parents wondering why we would inflict so many shots on our kids for diseases that NEVER happen. Oh, they do happen....

In foreign affairs, we had the greatest generation which navigated us through WWII and the aggression of Nazi Germany. They witnessed the folly of appeasement and the world war that followed. They also witnessed the over-reaction which resulted in deployment of US troops throughout the world over the next 50 years with less definitive and optimal results. Why did we do all this? What were we thinking? We were thinking that the greatest risk was associated with doing too little but experience has informed us that you perhaps can err in either direction. In the near term, what do we do about the local aggressions of Russia and Putin? Is he the next Hitler or a desperate leader of a marginalized and shrinking country?

We will never get it perfectly right. It is not possible. Furthermore, defining whether we got it right or wrong cannot be defined simply by whether the outcome obtained at any given point in time was what we viewed as ideal. The future has yet to happen and when it arrives we can discern whether we have undershot or overshot our desired goals.




Telling graphic


And this:


The reality is we are all feeding at the trough....

King v. Burwell

Sunday morning is when I take time to read the New York Times. My attention was brought to an Op-ed piece entitled "The phoney legal attack on health care". The title of the piece is erroneous on its face. The case is about the ACA, but this imprecise use of terms appears to be indicative of a broader view of language in general which may provide some insight into the perspective on this specific case. The question is whether imprecise words matter or don't they?

As the editorial board explicitly states:
In the long, tangled history of the debate over the Affordable Care Act, no member of Congress ever indicated a belief that the law would work this way. To the contrary, the law explicitly provides for “quality, affordable health care for all Americans.”
Yes, we all know what the intentions of the drafters of the legislation was, but if all that matters is intentions, why go to the bother of drafting anything more? Why not leave it the hands of the legions of well intended people who will ultimately be charged with making the magic happen and we will leave it at their discretion as to how to operationalize this.

The Op-ed piece today was pretty much a hit man piece, basically an indignant diatribe predicated on the assumption that this case could simply not be worthy of any merit and if anyone gave it any degree of greater reflection it would be sign that you  were simply a moron or some tool of right wing fanaticism (or both).  I guess this is what I should expect from the Op-ed page of the Times. It was the Times and it was the Op-Ed page.

Finding a more balanced view became my quest for the morning. It was not particularly easy. However, I did find a piece published in Vox in November 2014 which looked at the arguments which have been presented and will likely be presented  (King v. Burwell). In my reading of this there were two key points about the crafting of the legislation which seemed to be important. First, the way this bill became law, through an unconventional budgetary process, meant that it never went to conference committee where inconsistencies between House and Senate versions get cleaned up. The House version pushed a Federal Exchange while the Senate pushed the state exchanges. The original architects of the bill initially acknowledged that the inconsistencies may have been a product of the path to approval. However, they subsequently backtracked on this clam.

The actual language of the statute (the "four words") are pretty unambiguous that subsidies are linked to section 1311, which describes only state-based exchanges. It does not reference section 1321, which sets up the federal exchanges. Whether that was the intent is dependent on who you ask and when you asked them. However, there is no question as to how the actual law is written.There were all sorts of heated discussions regarding other subsidies during the actual debate before passage. There was reportedly no discussion prior to approval of the bill of the state v. federal exchanges and whether subsidies would be available to to specific state run exchanges only.

There has been all sorts of strident speech regarding the Roberts Court and in particular Justice Roberts relating to this case. First, there has been indignation regarding why they chose to even hear this and whether the plaintiffs had standing. Regarding the latter point, I simply don't have sufficient insight to have an informed opinion on the standing issue. Perhaps at the 11th hour the case will evaporate because of lack of standing. It would be convenient and take the Supreme Court off the hook for now. However, assuming the plaintiffs have standing, it would be hard to imagine that the Court could avoid hearing this case.

I can't help but think of Justice Roberts and how he handled the last challenge to the ACA. Through what best can be characterized and legal gymnastics he converted a mandate to purchase a commercial product into a tax, even though the word tax was not written into the legislation. He went to rather extreme lengths to accommodate the intent of the legislative and executive branches of government. I can't help but assume that this case will bring a similar decision. I cannot imagine that the Roberts Court, and particularly Justice Roberts, wants to have the acute consequences of an unconstitutional ruling on their plate. Furthermore, the legal and linguistic twisting involved in this case is no more convoluted that the previous challenge.

I suspect that in the long run this case will have limited impact because the real impact of the ACA will not be through the public exchanges. These will remain at the margins of the health insurance industry. The big story will be the private exchanges which will likely grow at a much faster rate and will dwarf the public exchanges. The ACA stipulated that subsidies and perhaps tax advantages will accrue to those in the public exchanges. With the explosion of private exchanges and movement of employee health insurance of Fortune 500 companies to these exchanges, there is going to be huge pressure to equalize the tax advantages across these products. It may be that this transition is going to continue and accelerate no matter how the case is decided. US business wants to get out of the provision of health insurance benefits.

One of the great ironies of the ACA is it appears to have spurred the development of private health insurance markets which will disrupt our current employer based model and perhaps inject price sanity into what is an otherwise crazy system. I don't suspect that this was not the intent of those who drafted the legislation but perhaps it will be the salvation of the health insurance market. Those on the far left and far right yearn for a collapse of the ACA so they can push to usher in their respective alternative solutions (single payer v. non-governmental). Will the Supreme's be contemplating all of this when they review King v. Burwell? I suspect so but if they are smart, they will decide on the most narrow of terms.








Sunday, February 15, 2015

The useful functions of vaccine deniers

I was born into a unique generation in the history of mankind. My generation in the US was the first generation which grew up with almost no fears of infectious disease. The polio epidemic, which raged in its worst form immediately prior to my birth, was reigned in by the miracle of the Salk and Sabin vaccines. The antibiotic era began immediately before and one remarkable agent after another was brought to market in my childhood. While there were a number of childhood diseases which I had to weather (measles, mumps, and varicella), the terrifying scourges were for the most part vanquished.

For the next few decades, we became increasingly complacent about vaccination and these diseases which became of interest mostly because of historical interest. The memory of polio, whooping cough, diphtheria, measles, and chickpox became increasingly distant. Yes, if you cut yourself and appeared for acute care you received a tetanus shot, almost like some sort of religious ritual. Throw some salt over your left shoulder or say gesundheit when someone sneezes or coughs. No one gets those diseases anymore, do they?

The general public had increasingly fewer and fewer reference points to judge the need for vaccinations. The generations which experienced infantile paralysis or other less harrowing childhood diseases are dying off and the reality of such diseases have become nothing but distant echos. It is not at all surprising that skeptical voices have emerged. While I believe that these voices as relating to vaccine issues are barking up the wrong tree, I also believe it is important to cultivate skeptical voices. Expert classes tend to become increasingly insulated and self serving over time and the skeptical voices are important to provide feedback from broader, non-expert audiences who ultimately the experts must answer to.

An experiment has been done. The subjects unfortunately were the children of parents who were skeptical of the value of the measles vaccine. The results were the re-emergence of isolated pockets measles. The feedback is if you don't vaccinate your children they are at higher risk of getting sick. The news has been widely broadcasted. There is value in this. One could argue that children should not suffer the consequences of bad judgements of their parents. That however can never be avoided and the risks of striving to use the power of the state to reach those utopian goals will result in much more harm than could ever be perpetrated by the isolated bad judgement of selected parents.

Those of us who make bad decisions (which is all of us sometime) can serve useful functions when the unfortunate circumstances which befall us become apparent to those around us. We can but should not  insulate people from the consequences of their bad decisions. Bad outcomes provide the feedback that tells us that we should not have done specific things. In the case of the parents who make unwise decisions regarding vaccination, we should not be timid about pointing out the errors. However, we also should not deploy tyrannical approaches in an attempt to reign in all sorts of bad judgements. It won't work and it runs the real risk of putting power into the hands of people and entities which want to run peoples lives.

I envision there will always be an ebb and flow when it comes to compliance with vaccination. As we are more successful with vaccine adoption the rates of disease will go down, but over the time the rates of complacency will go up, resulting in lower vaccination rates and resurgence of disease. It should be self correcting except for places such the Swat Valley. It may be unfortunate but the voices of science cannot fight complacency nearly as effectively as the predictable resurgence of disease in a complacent population.

Saturday, January 31, 2015

Title IX hysteria

I am supposed to live in an academic world where we value critical thinking skills. However, I have a growing concern about the clash between the skepticism required for reflective thought and the academic embrace of advocacy driven "scholarship". Nowhere is this more apparent than the recent injection of Title IX fever into college campuses, driven by a zealotus Federal bureaucracy.

Stories about an epidemic of sexual violence on college campuses have peppered the new outlets this past year. There is an industry out there looking for growth opportunities in this realm and some within the industry do not appear to be constrained by any desire to operate driven by fact or truth. One of the more egregious examples centered around the story that came out of the University of Virginia which was reported in Rolling Stone magazine. Whether it represented a complete or partial hoax is not entirely clear but there is no question that many if not most of the story's details were completely implausible.

However, recent initiatives driven by the Federal government have been driven by the impression that there is a huge problem on college campuses which can only be addressed by imposition of new rules driven by the Feds. The leverage they have is through the federalization of higher education funding which allows them to hold virtually all colleges hostage to whatever bureaucratic whim is fashionable in Washington DC.

The data which appears to justify such an overarching reach by the Feds has been called into question. There is a figure thrown around of 1 in 5 women as being a victim of sexual assault. This figure comes from a 2007 survey from the DOJ. Shortly after this study was reported in a story in Slate, a much larger survey done the Justice Department Bureau of Justice Statistics found a rate of 0.6%, substantially lower than the 20% figure previously reported. The former study involved two unnamed public universities while the latter surveyed 90,000 households and 160,000 individuals encompassing a much broader swath of students.

Imagine my surprise when I received an email from my Title IX compliance officer ordering me and all of my colleagues to take a course regarding sexual violence on campus. When the Feds say jump, we say, how high? This enterprise comes directly Whitehouse.gov(Campus assault). Consistent with his activist roots, President Obama does not appear to be troubled by citation of the questionable 1 in 5 statistic. Advocacy is generally not effective when accompanied by any sort of self reflection of self skepticism.

To further my surprise, when I logged into the learning module to "educate" me and bring my into compliance with Title IX training, what statistic was placed immediately front and center? The same 1 in 5 number . I went online and did an internet search for Title IX training materials and what did I find in these as well? The same statistic. If I were grading a presentation by one of my students and I found that they had chosen to highlight a single study which was flawed and ignore information from more robust studies, they would get a failing grade.

 However, I soldiered through the roughly one hour course, clicking through a series of scenarios and questions, picking the "right" answers. The scenarios were ambiguous and the exercise resembled an indoctrination more than an educational activity. The scenarios dealt with perhaps the most complex, difficult, and ambiguous contexts of human interactions; sexual encounters and alcohol. Each one perhaps could serve as a starting point for thoughtful discussions which might go on for an entire semester and PhD ethics thesis. However, in this training session and in final exam, I was called upon to pick the one and only right answer.  I was being put on notice. No input was asked of me and there is essentially no mechanism where I can provide feedback on this. I understand. No feedback is wanted.

More than two dozen luminaries within the Harvard Law School have come out with a statement protesting their University's new rules regarding title IX. They have the standing and legal scholarship  to do  so. I do not. I know in my heart that continuation in the direction will end badly for most of us. The same people who vetted the online training courses have already shown they are not objective and will not let disparate opinions and data get in the way of furthering their particular lines of advocacy. Yet, they are ones who will be put in charge of adjudicating Title IX issues on campus. They will direct investigations, oversee tribunals, and render decisions.

Colleges and universities are in a similar position to me. They are not in a position to bargain with the Feds. To much money is at stake and there is no foreseeable pathway to success that can be envisioned by confrontation. The risk of losing the income stream driven by fully federalized tuition loans, federal research grants, and federal health care dollars. Monopsony in business has its downside.  

Human interactions are complex. Human sexual relations are the most complex subset of interactions within these interactions. I will be the first to admit we have not yet worked out all the rules on this realm, despite working on them for thousands of years. What the Federal government is trying to do is to create some sort of separate formal review and response structure on college campuses based upon the idea that an urgent need exists. That perceived need is likely based faulty data. The solutions proposed ignore basic concepts of due process and protection of the accused. It seems like such a bad idea. However, very few are in a position to raise our concerns.

Sunday, January 11, 2015

The world is a work in progress

I saw the movie "Imitation game" last night. It is about Alan Turing and his efforts to break the Nazi Enigma code in WWII. It was simply a tragedy of epic proportions that the world lost him at the young age of 41, after he was convicted of solicitation of homosexual sex and forced under court order to take medications which chemically castrated him. Britain at that time considered homosexuality a crime. He committed suicide in the year of my birth.

I remember my first exposure to homosexuals when I was in college. There were a cadre of effeminate men which I did not recall from my high school experience. I may have simply been unaware of this cohort earlier in my schooling. I was rather young and not tuned into these issues. The thought of being attractive to other men was completely alien to my preferences. It had simply never even occurred to me that could be an option at that point in my life. However, I could not consider that homosexuality was a crime at that time, although I think anti-sodomy laws were on the books. They may still be on the books.

This particular cohort at college was almost universally ridiculed among those who I associated with. At that point in time I did not view this with any sort of moral dimension. I perceived this cohort simply as something very strange. I never acted in a way to personally ridicule anyone for their apparent homosexuality. However, I also did not take any action to step up in defense of anyone or call anyone out on their anti-homosexual actions. Knowing what I know now, I could have been more heroic in coming to the defense of those who were identified as being homosexual men. I was simply struggling to find my way at that time.

Roll the clock forward more than forty years. The world is a very different place. I am a very different person or at least I have a very different perspective on my world. I have had the experience of meeting literally thousands of people, both personally and professionally. I have come to realize just how remarkably diverse people are in terms of motivation, responses to incentives, preferences, talents, virtues, and vices. I have come to realize that David Hume was correct in terms of "reason being a slave to passion" and that many if not most of our passions are beyond our choice.

The world is a simpler place when the choices are binary. It makes for simpler law and simpler choices in the personal realm. However, the world is generally not black and white in terms of our choices. The growing acceptance of homosexuality and what could viewed in historical terms  as atypical sexual practices is a product of recent decades in a small subset of human cultures. It may be viewed as part of a longer term trend in human societies of greater acceptance of diversity in general. It is my belief that this is a consequence of greater human affluence in general.

Cultures which live on the edge have less reserves to play with. Mistakes which affect the ability to feed or defend themselves literally can represent existential threats. An almost universal characteristic of human societies has been to hold anyone or anything that is different with great suspicion. Call it the stranger heuristic. The default response to strangers was violence. The default response to almost everything was violence. In a zero sum world which was the world until that past 500 years, that response may have had some survival advantages.

I have had the opportunity to live and experience a world where we can tolerate outliers. In fact, our world may benefit from harnessing the talents of those who we might view initially as strange.  It is not as if we cannot define certain actions as unacceptable. We need to re-examine what we might have viewed as outside the bounds as acceptable. We will not all agree on what is acceptable or not acceptable but we should be very careful about using the coercive power of the state to enforce anything but the most egregious and unacceptable actions. On the flip side, we should also allow leeway to individuals to define their own comfort zones, using social sanctions to provide feedback to those within voluntary social networks. The world is a work in progress.




Saturday, January 10, 2015

Needing an industrial revolution in healthcare

I recently finished a Teaching Company course on the Industrial Revolution, taught by Dr. Patrick Allitt. In this course he detailed the development of industrialization of manufacturing over the course of almost 500 years. It is a remarkable story of human ingenuity, technological progress, and extraordinary impact on the human condition. He presents a story of a world not so long ago where human existence was precarious because the tools and systems in place to meet human needs were rudimentary. The remarkable development of industrial technologies in conjunction with effective approaches to motivate and coordinate human activity resulted in a complete transformation of human existence where these tools were deployed.

The progress did not take place in a straight line. There were failures and the achievements made were the product of much tinkering and some planning. The exact outcomes were not necessarily predictable but the themes in retrospect were recurrent. At each step of the way, huge breakthroughs happened when tools were developed that freed humans from manual tasks and automated activities. These breakthroughs were almost always very disruptive of selected industries and populations but the net effects for the broader population were hugely positive. People got more to eat at lower prices as well as better living and working conditions.

Another aspect of this evolution was the ability of the industrial revolution to deliver not only more, but more at a lower price and higher quality. Nowhere is this more evident than in the 20th century where we observed an explosion of increasingly sophisticated consumer goods where after particular product introductions prices would tumble while simultaneously the functionality and quality increased. This includes computers, home appliances, and automobiles. What drove this remarkable expansion of high quality plenty was a combination of science, breakthroughs in human organization, and information systems which could track key elements of cost and quality.

Dr. Allitt tracks all of these elements going back to their origins, which he tracks back to the building and operation of large ships in England. What does this have to do with medicine and biomedical research? Simply that the health care delivery and research relating to health care benefits from the same tools which made the industrial revolution possible. The holy grail for basically any human activity is to get more out of any particular inputs in terms of making human lives better. It has been well documented that, unlike the productivity gains associated with virtually all commercial activities in the US since WWII, health care has shown essentially no productivity gains. As noted by by Kochner, et all in the NEJM (N Engl J Med 2011; 365:1370-1372October 13, 2011DOI: 10.1056/NEJMp1109649):

Of the $2.6 trillion spent in 2010 on health care in the United States, 56% consisted of wages for health care workers. Labor is by far the largest category of expense: health care, as it is designed and delivered today, is very labor-intensive. The 16.4 million U.S. health care employees represented 11.8% of the total employed labor force in 2010. Yet unlike virtually all other sectors of the U.S. economy, health care has experienced no gains over the past 20 years in labor productivity, defined as output per worker (in health care, the “output” is the volume of activity — including all encounters, tests, treatments, and surgeries — per unit of cost). Although it is possible that some gains in quality have been achieved that are not reflected in productivity gains, it's striking that health care is not experiencing anything near the gains achieved in other sectors. At the same time, health care labor is becoming more expensive more quickly than other types of labor. Even through the recession, when wages fell in other sectors, health care wages grew at a compounded annual rate of 3.4% from 2005 to 2010.
 In addition, it is very difficult to demonstrate gains in quality as well. I contend that these two shortfalls are in fact related to the inadequacy in information systems used in health care. When you can't reliably track things, you end up wasting resources and generating poor quality products.

The story in biomedical research is perhaps a bit more nuanced. Biomedical research has revolutionized diagnostics and therapeutics but we are facing issues of diminishing returns. The antibiotic and vaccine revolution deployed in the early to mid 20th century made huge impacts at very modest cost. Arguably the returns of these endeavors dwarfed the costs of development and deployment. We are at a different point now where the cost of new drugs to treat chronic diseases is simply off the charts. Every new decade moves the decimal place over one place. Furthermore, the deliverables for individual researchers is not necessarily something that has an impact on people in the near term. The funding system values a different sort of productivity based upon publications. The explosion of scientific publishing has until recently, not been accompanied by any real change in the mechanics of vetting and review and the problem which has arisen is one of quality control.

However, funding agencies have attempted to develop models to oversee quality and independent entities such as Retraction Watch (http://retractionwatch.com/) have stepped up to inject quality control in the process not adequately addressed with peer review. Not surprisingly there has been an explosion of paper retractions as well as exposees revealing major issues with reproducibility (Nature article). This is very disturbing because what separates science from magic and alchemy is the ability to reproduce results.

What all of these contemporary processes have in common is they are very dependent upon human beings using manual processes and judgement requiring much subjectivity to do their jobs. Furthermore, the products of these efforts cannot be readily and consistently assessed for quality. As long as these remains the case in health care delivery and biomedical research, it will be hard to reap the sort of gains from investment in these sectors when compared to investments made in areas where productivity and quality can be assessed more robustly.