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Saturday, May 21, 2016

I am incedulous that this activuty has not received more attention!

From the Washington Post today(Link). This is an op-ed piece from Nicholas Quinn Rosencranz regarding the Justice Department's settlement with various large banks which included the requirement for donations to various community development groups.
What is less well known is that some of this money — amounting to hundreds of millions of dollars — is designated for “donation” to various “community development” organizations that were neither parties to the case nor victims of the alleged wrongdoing. Investor’s Business Daily has characterized these payments as “political payoffs to Obama constituency groups,” and Congress is now considering banning this practice with the Stop Settlement Slush Funds Act of 2016.
How bizarre!  The constitutional issue is obvious. The settlement represents money paid to the Federal government which is then appropriated to pay another party, without any Congressional approval. What we are seeing as the discretionary portion of the Federal budget essentially disappears is the use of DOJ shakedowns of private entities for cash then used to repay politically connected.

How can we better the world?

Deirdre N. McCloskey published what I consider a spot-on piece today in the WSJ. (Link) It is titled "How the West (and the rest) got rich". It is well worth reading in its entirety and I will almost certainly pick up a copy of her new book, “Bourgeois Equality: How Ideas, Not Capital or Institutions, Enriched the World,” .


I am fascinated by why certain systems work well while other systems do not and I have come to believe that functional complex systems develop not because of intelligent design, but because of innumerable trials resulting in many failures and few successes. Thus the great enrichment is described by Dr. McCloskey. The essay is eloquently written and I thought it useful to highlight some of the most pithy parts.
Nothing like the Great Enrichment of the past two centuries had ever happened before. Doublings of income—mere 100% betterments in the human condition—had happened often, during the glory of Greece and the grandeur of Rome, in Song China and Mughal India. But people soon fell back to the miserable routine of Afghanistan’s income nowadays, $3 or worse. A revolutionary betterment of 10,000%, taking into account everything from canned goods to antidepressants, was out of the question. Until it happened.
Why did it happen? McCloskey goes on to write:
But none of the explanations gets it quite right.
What enriched the modern world wasn’t capital stolen from workers or capital virtuously saved, nor was it institutions for routinely accumulating it. Capital and the rule of law were necessary, of course, but so was a labor force and liquid water and the arrow of time.
What appears to have catalyzed this were ideas and liberty:
The capital became productive because of ideas for betterment—ideas enacted by a country carpenter or a boy telegrapher or a teenage Seattle computer whiz. As Matt Ridley put it in his book “The Rational Optimist” (2010), what happened over the past two centuries is that “ideas started having sex.” The idea of a railroad was a coupling of high-pressure steam engines with cars running on coal-mining rails. The idea for a lawn mower coupled a miniature gasoline engine with a miniature mechanical reaper. And so on, through every imaginable sort of invention. The coupling of ideas in the heads of the common people yielded an explosion of betterments. 
Power hungry statists and control freaks on both the left and right have been suspect of both liberty and change and have repeatedly attempted to vilify commercial interests which have been the drivers of growth and change:
Not everyone was happy with such developments and the ideas behind them. In the 18th century, liberal thinkers such as Voltaire and Benjamin Franklin courageously advocated liberty in trade. By the 1830s and 1840s, a much enlarged intelligentsia, mostly the sons of bourgeois fathers, commenced sneering loftily at the liberties that had enriched their elders and made possible their own leisure. The sons advocated the vigorous use of the state’s monopoly of violence to achieve one or another utopia, soon.
Intellectuals on the political right, for instance, looked back with nostalgia to an imagined Middle Ages, free from the vulgarity of trade, a nonmarket golden age in which rents and hierarchy ruled. Such a conservative and Romantic vision of olden times fit well with the right’s perch in the ruling class. Later in the 19th century, under the influence of a version of science, the right seized upon social Darwinism and eugenics to devalue the liberty and dignity of ordinary people and to elevate the nation’s mission above the mere individual person, recommending colonialism and compulsory sterilization and the cleansing power of war.
On the left, meanwhile, a different cadre of intellectuals developed the illiberal idea that ideas don’t matter. What matters to progress, the left declared, was the unstoppable tide of history, aided by protest or strike or revolution directed at the evil bourgeoisie—such thrilling actions to be led, naturally, by themselves. Later, in European socialism and American Progressivism, the left proposed to defeat bourgeois monopolies in meat and sugar and steel by gathering under regulation or syndicalism or central planning or collectivization all the monopolies into one supreme monopoly called the state.
McCloskey summarizes:
Rep. Thomas Massie, a Republican from Kentucky, had the right idea in what he said to Reason magazine last year: “When people ask, ‘Will our children be better off than we are?’ I reply, ‘Yes, but it’s not going to be due to the politicians, but the engineers.’ ”
I would supplement his remark. It will also come from the businessperson who buys low to sell high, the hairdresser who spots an opportunity for a new shop, the oil roughneck who moves to and from North Dakota with alacrity and all the other commoners who agree to the basic bourgeois deal: Let me seize an opportunity for economic betterment, tested in trade, and I’ll make us all rich.
I agree with McCloskey that political entities may create the necessary framework for betterment but there are limits as to what politics can accomplish. You cannot fix a fine watch movement with a ball peen hammer. Some might argue that enrichment is not a desirable end. I would suspect most of those making those claims do not live in abject poverty.  
 

Sunday, May 15, 2016

How do we know who is a good doctor?

I am a following "the Incidental Economist" (Link) and Healthcare Triage News. Aaron Carroll blogged on pay for performance programs and wrote a commentary late last year on measuring quality (Link).  There was also an article in today's NYT examining narrow networks and limited access for patients to providers outside of their designated networks (Sorry, we don't take Obamacare - link). What do these items have in common? What they have in common is the need to be able to measure quality. Who care if you are locked into a narrow network if it delivers what you need well? We all sort of lock ourselves into narrow networks when we end up selecting specific physicians to deal with our health care problems.


As I see it, we have a very basic problem in that more often then not, those needing services are really not in a position to discern whether a given physician (or other health care provider) is really good at what we need them to be good at. (When I use the term physician, please view it as a short hand for health care professional delivering a service). Obviously for those physicians who do very specific life saving or function saving targeted interventions, we may be able to sort through who is at the top of the heap v. those at the bottom. Even that can be tricky. A good set of outcomes for an orthopedic surgeon who replaces hips may be due to the fact they are in a position to cherry pick or a less than optimal set may be due to them being the go-to person for difficult cases.


Even more challenging may be within the larger universe of providers who do deliver services where it is difficult to impossible to define what quality is? One can march through the different specialties in medicine and it is the exception rather than the rule that clear criteria can be defined which allows any given person to identify who delivers high quality care.  How does one determine whether a gastroenterologist is good at colonoscopy? Yes, one can look at complication rates but the primary purpose of the exam is not simply to avoid trouble. You can always avoid the complication of the procedure by not doing it. How can one determine if a thorough exam was actually done? Are more biopsies better than fewer? What are the actual deliverables? A similar situation may be relevant for dermatologists? What represents a good skin exam? How can this be measured?  For primary care physicians, what constitutes a good or excellent annual check up? Who is doing the best pelvic exams? Who is the best pathologist? Is it the ones who diagnose the most or the least cancers? How can one discern who are the best pediatricians?
Those with great technical skills may have less than optimal judgement, work ethic, or interpersonal skills. What problems do given physicians within specific specialties actually solve and just how good a job do they do in solving these problems? What information do we have at our disposal to address these issues? We do have the annual best doctors issues for local publications for most major cities. However, the selection process for these is a popularity contest which reminds me of elections for class president when I was in high school. It takes into account essentially no quality data. Furthermore, does any actual quality data linked to a given doctor or other provider reflect the physician competence or other aspects of the team over which they have little control?


It is not an unusual circumstance where I am asked by a friend to make a recommendation for care within my system. I know a number of my colleagues on a personal level but truth be told, I really have very limited insight into what type of physician they actually are. I have basically little or no access to hard numbers in terms of whether they solve the problems of patients who they see. There are exceptions (primarily those who I work with every day)  but for the most part I have not directly and consistently witnessed the bedside manner of most of my colleagues or have clinically significant knowledge regarding the quality of their problem solving skills.


Then move into a domain where people have marginal medical knowledge, experience, and insight and imagine how they make these determinations. They simply are flying blind. Patients and their families can determine if someone spends time with them, listens, and makes an attempt to communicate. These observations are important but may not track with the ability to fix whatever problem that needs to be fixed. The may be especially true when the services delivered are done so for goals which may be realized well in the future. Patients can be very impressed with the quality of a service delivered that they did not actually need. One can generate impressive numbers if one is in the business of delivering preventative care for diseases that never or only rarely happen.


This brings us back to the original question; what can we measure to determine who is the best? Perhaps even more important is what can we measure to determine who is simply good enough? Not everyone can access the best and always spending money to get the best may be a bad investment of someone's scare resources, especially if the stakes are not so high.  How can patients tell if the providers available within their networks will likely be able to meet their basic needs and goals?  I believe the path to being able to address this problem will require inputs from both those delivering care and those receiving care. It will mean looking at both high stakes environments and lower stakes environments. It will unquestionably require that we better define what the specific goals of care are. Service delivery without goals can never fail. As the saying goes if you have no destination anywhere you end up should be fine. Similarly service delivery without measurable goals can also never fail and service delivery where the measurements are not aligned with the patient goals will almost always fail.


The fact that measuring what is expedient has ended up not getting us to where we want to be should not come as a surprise and should not prompt us reject striving for measuring outcomes. For us to sink more and more money into an industry which has dismal quality control is simply not an option.

Tuesday, April 26, 2016

Intergrative health and CAM- delivering what people want as opposed to what we think they need

I colleague sent me a link to a blog from the British Medical Journal written by Timothy Caulfield entitled "The straw men of integrated health". Link


In this blog Tim Caulfield pretty much completely debunks the defenses proffered for CAMs in general However, it may not really matter because Mr. Caulfield perhaps misses the point. Mr. Caulfield, whose most recent book "Is Gwyneth Paltrow wrong about everything", believes we are mislead by celebrity and deceived by pseudo-science. He is probably right about the science but he is misled but what the actual deliverables are.


His book appears to be written to target people like me. (I have not yet read it but probably will). I use my plodding and non-reptilian brain to  sort through evidence and make plodding and thoughtful decisions. However, the target for his blog and book are people who make decisions to randomly avoid gluten and do cleanses because it makes them feel good about themselves. They could give a rip about any double blind control trials. They do a veggie purge which gives them a terribly satisfying sense of control and they feel great, at least for a while.


Human brains are complicated things and emotions are even more complex. The scientific basis of medicine and the deliverables in the health care realm used to be hard stops, literally. We intervened so that people would not die. It is a relatively easily measured endpoint and snake oils and witchcraft did not move the needle much. When modern antibiotics and modern acute care techniques came on the scene, these interventions quickly rendered less effective (or not effective) approaches to the dustbin of history.


We now have moved into a totally different realm of health care deliverables. People have the luxury of taking living for granted and have moved on to feeling good, feeling in control,  and worrying about the future. We in the scientific realm have not moved the needle much regarding making people happy. There are entrepreneurial sorts who peddle all sorts of compounds which some people crave and make them "happy" albeit for a brief period of time. There also are all sorts of downsides to many of these compounds.


Much of the population is either depressed, insecure, anxious, worried, or somewhat unfulfilled. This is a huge market and nature, abhorring any sort of vacuum, fills this will any number of people with a host of interventions. Some are activities (running, swimming, Lladro collecting, civil war reenactment, mission trips to Haiti), some are spiritual endeavors (praying, meditation, chanting), some appear to be deviant (cross dressing, pedophilia), and others dance around medical interventions. Many seem to make people feel better. None really make any scientific sense.


However, this is not a scientific issue, at least at this point. Perhaps at some point in time someone may be able to connect the dots and demonstrate how any particular activity or behavior makes a given person feel good. We are not likely close to that now.


I guess my point is Gwyneth Paltrow and the CAM crowd should not drape their decisions with the mantle of scientific legitimacy. However, the scientific community should stop telling people what they should or should not do to make them feel good about themselves.


This also has implications regarding what is defined as health care and what insurance pays for. In his Atlantic piece, he dove deeply into the movement of healthcare from addressing acute illnesses to addressing lifestyle concerns and risks of future disease link. The insertion of CAM into this discussion is a natural evolution of this trend. Will we end up requiring payment for CAM by third party payers?





Sunday, April 17, 2016

Shorting health care

Within the world of finance, people and organizations can make very bad bets and invest huge sums of money in very bad investments. Look at the 2008 housing bubble collapse. Massive sums of money went into building homes for people who could not afford them. Certain very astute investors saw the mismatch and placed bets against where most of the money was going. As the movie "The Big Short" showed, they were viewed initially as crazy and then as visionary. They ultimately served an important function in redirecting investment away from poor investments.


Within health care, we are also investing huge sums of money into a variety of investments. I am not talking about specific stocks or equipment but instead I am referring to our investments of specific clinical care delivery activities with the idea that these investments will result in better health returns for individual patients. For example, does the investment of time, money, and effort on every patient over age 50 years of age getting an annual physical have any real tangible return on this investment? If not, why is this investment of resources not like buying penny stocks? My question is, how can I short the annual physical?

The imperfections of simplicity and the perils of complexity

I know I am not alone in yearning for a simpler world at times. The latest point of contention revolves around "bathroom" laws.


Each of us operates in the world by simplifying many decisions. If we had to reflect deeply about every decision we make, we would become paralyzed and use huge amounts of scarce resources to do what would ideally be done with minimal conscious effort. Central to many of our decisions and routine interactions are the concepts of sex and gender. For the sake of simply being able to function, we have historically adopted simplified rules to facilitate interactions between people, including men and women. However, there is nothing inherently simple about any of this. Don't let anyone convince you to the contrary.


The rules are not perfect and they are evolving over time. Using the simple binary sex/gender model, we have had a very difficult time trying to sort this out as human society has changed markedly over the past 100 years. Moving to a much more nuanced view of sex/gender/sexual preference results in a geometric increase of complexity overlaid on an already complex domain of human interaction.


What we are talking about is defining acceptable rules of human engagement. Even under the best of circumstances, this is extremely difficult and will always be fraught with what seems like less than desirable outcomes. This has also been a moving target.  What I find remarkable about this discussion is how certain parties can be so sure of their positions. We have only recently been medically and surgically intervening to "transform" selected individuals from one gender to another. We have been trying for thousands of years to refine the rules of engagement between man and women and we are still flailing to some degree. There is clearly less than perfect consensus looking out across the world in general and this is based upon a simple binary model (man and woman).


When we inject this new complexity into the sex/gender world, whatever routine we have used to simplify our dealings with sex/gender issues is disrupted. What will replace it? I have no idea. What are the rules of engagement? Again, I have no idea. What rules which have used historically will also work in the new world? I don't know.


This is important but it is not simple. It is not a black and white issue. Desegregation in some respects was much easier to deal with. It actually simplified the rules and removed distinctions where no distinctions were needed. The rules of engagement do not need to be contingent upon the color on someone's skin. Relations between men and women require rules of engagement which are inherently different, at least in great part because of the biology of sexual attraction.


It might be argued that the different rules of engagement are really not dependent upon gender or sexual phenotype but sexual orientation. That might have some element of truth but we have used sexual phenotype as a proxy for this for a very long time for the simple reason is it is a simple and generalizable (but not perfect) rule. Even with this simplification the rules are very complex (VERY COMPLEX). In my opinion (and it is just an opinion), it is not realistic to expect rapid, widespread adoption of new rules governing interactions between sexes/genders to happen without a great deal of discussion and contention. It is not fair or constructive to the parties involved to vilify everyone with opinions which may differ from your own.


Step one....listen

Sunday, March 20, 2016

Uterus transplants and other interventions extending capabilities to those not born with them

The Cleveland clinic's most recent attempt to do a cadaveric uterine transplant did not meet with the desired endpoint. The uterus had to be removed because complications (Link). This was brought to my attention in a blog piece from the MD Whistleblower (Link). He raises some interesting questions but I think his questions should also touch upon implications in a much broader clinical and ethical realm. The circumstances of the transplant were the patient who received the transplant was born without a womb. As it turns out, there are many humans who are born without wombs, approximately half  to be specific.


The Cleveland Clinic experiment seems like a bad idea at multiple levels. It is not as if no other options existed for this specific person. For the transplanted womb option to work, they had to go through the in vitro fertilization anyway meaning those eggs could have been implanted in a surrogate who did not need to take a host of immunosuppressive drugs for the entirety of the pregnancy. Frankly, I do not see how any IRB could approve this protocol. It places the person getting the uterus at great risk and places an unborn child at great risk, all of which is completely unnecessary for generating a child. Yes, it is a clinical trial but I simply cannot see how these types of risks can be justified. It appears to be reckless in my opinion.


The ability or inability to carry a child because of having or not having a uterus is one of basically an infinite set of human functional differences which exist because of inborn or acquired differences. The question I want to pose is what portion of these differences constitute fair game for correction via some sort of medical intervention? What sort of interventions should we strive to develop and which ones of these should be the target of investment of public dollars? As we move inexorably toward a world which defines access and payment for health care as a universal right, what of the inevitable desires of people to use the health care system to enhance functionality beyond what they were born with? Does that too represent an inherent human right?


Think of all the differences in inborn or acquired traits which could become fair game. I am not so tall and always thought it would be great to be taller, much taller. The fact that I am "vertically challenged" likely has had all sorts of impact on what success and failures I have encountered in life. Simple physical attractiveness (perhaps not so simple) has huge functional implications which has major impact on where people end up in the world. At his point height and physical attractiveness are already amenable to some form of rectification. Imagine all of the possibilities for enhancements that other interventions could impact.


Should this be within the realm of heath care delivery? We already have bleed through in terms of training and missions. Physicians trained in plastic surgery and increasingly other fields such as dermatology, are trained as physicians but have moved into realms very distinct from taking care of people with actual illness and sickness. Once we validate the mission to take people who are not sick by any typical definition of disease, and push the mission to create functionality that people were not born with, we are doing something very different. Before we open this Pandora's Box, we should be very intentional about understanding where it will take us.