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Sunday, September 30, 2012

Online dating as a model for health care outcomes research

I heard an interview with Dan Ariely while listening to CNBC today. He is one of my favorite authors but I was not aware of his work done focusing on online dating services. What struck me about his work and comments was the nature of the critique; online dating services may be of limited value because they collect the wrong data. They collect data that is easily defined and relatively easy to collect such as income, education, height, and weight. Based upon the information presented, users of these services appear to be remarkably superficial in terms of what they value. However, they may be superficial because of the information presented to them.

I was struck by the parallels to current state of outcomes research efforts in  health care. We tend to focus on measures which often are process measures or outcomes measures which are at best proxies to something more important. We use administrative databases because they are the only sources of structured data we might have access to. We do so because in the absence of robust things to measure, we end up collecting data on what we can collect and measuring what is measurable.

Ariely talks about collecting match-making questionnaires on a variety of people, some of whom he liked and others from those he did not care for. He then reviewed the blinded questionnaires and attempted to sort out from these data whether he could discern whether he could tell those which came from the people he had a personal affinity for vs. those he did not click with. He could not. Thus the information collected was not helpful in predicting personal chemistry. In the same sense I would predict that the current state of data collection and analysis used for assessing outcomes and quality will suffer from similar issues. By focusing on what we can measure, we are likely to focus on things that are not particularly important in the delivery of health care.

I think the lesson is not that we should not strive to collect data to drive practice change. We just need to be VERY circumspect about what we strive to collect and how we use it. Our processes focusing on performance improvement also need to be a focus of performance improvement.

Sunday, September 23, 2012

Retirement as an entitlement

I read a story in the newspaper today which highlighted the situation of a 55 year old woman who was having to rethink her retirement strategy. She was concerned that she would not be able to retire at age 65 as she had previously planned but might have to delay this until she was 70 or perhaps longer. It made me think about the whole concept of retirement and what underpins any system that allows people to withdraw from the working world and expect that their physical and material needs to be met. Don't get me wrong. I am looking forward to being able to retire. However, when you step back and look at the actual mechanics of how this can work, a whole series of questions arise.

I have previous written about the development of sedentism of human cultures as nomads settled down to be farmers and the moral dilemmas that grew as a consequence of the changes in human existence. The retirement question is in some sense an outgrowth of this same set of sedentism questions.

When we solely operated as family units, almost involvement was needed to meet the needs of individual members and the group. There was no such thing as retirement. As family members became infirmed, their engagement was limited because they could not bring much to the table. As social systems became more complex, obligations of single individuals to others also became more complex. Some relationships like those binding close family remained in the informal realm while increasingly our relationships to other and the attendant obligations fell increasingly into the legal realm.  However the obligations were defined and enforced, the well being of those involved depended upon the existence of adequate resources to meet essential human needs. There had to be enough food, shelter, fuel, and water for all to survive. Until very recently having a portion of one's life set aside without the requirement to create or gather essential resources was only a pipe dream.

Fast forward to the early 21st century. In the latter half of the 20th century the governments and many large industries in the US and Europe had created an expectation that large segments of their "mature" populations need not be gainfully employed much beyond the fifth decade of life. It must be accepted as a given that there is some point where such an expectation is not sustainable. Could we expect that students upon graduating from school at 18 or 22 years of age could move directly into retirement? The idea is absurd. A working population is an essential requirement to sustain our complex societies, to create and deliver food, to create power and maintain power grids,  to maintain and repair the technologies which support our fragile existence, to deliver health care, to manufacture and distribute all of the consumer goods, and the list goes on. For every person who withdraws from the workforce, that is one less person who can work on the above needs and one more person who will need to have needs met by someone else.

I believe the problem we have is one of disbelief and perception. We have grown up in such a world of plenty that we simply cannot imagine that our individual withdrawal from the workforce could possibly mean that we will have any effect on what is available to meet human needs. Thus, of course we should be able to retire at aged 65. Why not 55 or even 50? Why should I not have access to all this plenty, even if I do not contribute in any material way to its existence? What better entity that government to protect those who cannot protect themselves. Who could have foreseen that extension of those same protections to a larger and not so vulnerable audience would become the perfect tool to win elections.

The reality is retirement is a new concept and the selection of the age of 65 was random event based upon the life expectancy over 80 years ago. Promises were made when Social Security was founded that are now actuarial fantasy. Pension systems were created by companies based upon the same bad assumptions. They either figured out how to extricate themselves from those promises or they went bankrupt. How Darwnian!
The legacy of these faulty assumptions is now almost solely the province of governmental entities which are spared the requirements placed upon businesses. Their retirement schemes do not need be actuarially sound, at least in the short run. Is was simple enough to state that those who had reached a certain age were owed some sort of basic support, whether the accounting worked or not. When there were 25+ workers for every retiree, that might have made sense. It does not work so well when the ratio is 3:1 moving to 2:1.

It is not contestable that our population is segmented into those who are working and those who are not. The  question is what portion of our population will be required to work in order to support our population in an acceptable standard of living? It can be argued that this is a question of justice or fairness but that goes only so far when you simply do not have the bodies to get up each morning to accomplish what people need to do in order to have other human needs met. I think we can expect to live longer and to work longer. It is only reasonable.

Saturday, September 22, 2012

A trickle down idea from a rich 1% Democrat

An interview with Leslie Michelson in in today's WSJ. My wife pointed it out to me immediately this morning. She told me, "You need to read this". Mr. Michelson has created a company, Private Health Management, which assists the 1% in navigating the health care system. The mission of this company is to summarized:
Strictly defined, Private Health isn't part of the growing phenomenon known as concierge medicine, where doctors charge a retainer for more face-time and personal attention, and often take their practices off the commercial and government payment grid. Private Health isn't an insurance company either and maintains no contractual or financial relationship with its doctors. "We don't buy access," Mr. Michelson says. A large part of what Private Health does is simply match patients with physicians, which isn't as obvious as it sounds. "People do not know how to choose doctors. It's one of the most important things you can do to promote your own health and that of your loved ones, and it's: 'My friend's cousin's relative went to Dr. Smith, and he was terrific.' Well, how do you know he's terrific?" So Mr. Michelson built a series of proprietary algorithms to distinguish "the few who are the very best" from "the many who are very good," based on "the factors that predict excellence."  
However, I think the key statement comes somewhat later in the interview:
"As the biomedical revolution took off," Mr. Michelson says, "there should have been a counterbalance of somebody taking the position of the general contractor, the manager, and investing in the systems, the technologies and the processes to keep up." But the organization of medicine as an industry didn't change. So the health-care delivery system, to the extent it qualifies as a system, "has no quality control, no integration, no coordination." Doctors "tend to operate in an independent and isolated way, and even specialists who've been treating the same patient for years and years typically never, ever speak to one another."

How true. I think of all the times I try to call another physician, being provided their contact number by our shared patient, only finding myself up against the same barriers patients face when they attempt to call. I patiently wait for the admonishment to call 911 if I am in acute distress followed by the phone tree, prioritizing those who want to pay their bills of schedule appointments for high margin interventions. Often, I end up hitting "0" for the talk to a human option only to be told the office is at lunch or will get back to me when they can. I suspect that my office is the same way (perhaps worse). We end up not talking and hoping for the best. If something goes wrong they will likely reach someone else.

The business plan of Private Health Management is to basically supply an uncovered service to people who can pay for it. In that sense it is similar to concierge care or provision of lasik surgery or botox injections. The bad news it is not covered by insurance. However, the good news is that it is outside the constraints of the present day third party payment system. I would say the trade off is more than worth it if you can come up with the dough.

The sad truth is that despite all of the talk about rewarding coordination of care, there is no explicit and consistent payment of time devoted to such activities within the current payment structure. There may be a few ongoing experiments which are likely to disappear when their grants dry up. If the public were to wait for  the current players in health to development of such a key element of care, it would never happen. As a precondition for development, the mainstream players would insist it develop as part of the current payment system. I am afraid that it would quickly be co opted by those who fare well under the current payment structure which rewards expensive and fragmented care.

If this function can develop outside of the conventional payment models, what does that mean for how and where treatment happens and where market  power will reside in the future? For those of us who presently are so buried with business that we cannot take on more, why would we be so inclined to fast track some rich 1% who had paid a premium for access to some other rich third party?   The financial relationship is going to end up being much more nuanced.  Furthermore, assuming that entities such as PHM have their own physician teams assisting clients, how does that work when the direct care happens within systems where the PHM physicians are not credentialed and in states where they are not licensed? Maybe the business model, by claiming that they are not in the care delivery business, can circumvent these issues. That could spawn the development of a new opportunity for health care providers to shed their licenses, reinventing themselves as consultants who cannot prescribe or take call, shunting all the grunt and technical work to focused practitioners who wait for business to be shunted from the likes of PHM.

Ultimately, for optimal care the care coordination piece must be embedded locally. Someone needs to be in charge. Someone other than the patient or their family needs to be the general contractor.

Sunday, September 16, 2012

Help prevent blindness

I have learned much by being a dog owner. Today we are celebrating the birthday of our older hound who is the best dog in the world. She is 17 years old today, a remarkable feat for a chocolate lab. They are not supposed to live this long. Her mother died before age 10 and she has outlived everyone in her litter. Before the ravages of age caught up with her she was a remarkable athlete, with the best snout-eye coordination I have ever seen. Her disposition was close to perfect. I have thought about the utility of having her exome sequenced. If there is a genetic basis for such a perfect animal, then we should have this data.

However, she is now 17 years old and as far as we can tell she can still smell but she is virtually blind and completely deaf. She can sense her world only by sniffing it and running into it. Her present state of being does not allow her to see what is coming, except in very narrow circumstances. Even then she finds herself running into things and if we did not put up barriers and guide her, she would end up falling down stairs. Loss of key senses prevents her from anticipating and avoiding hazards.

It is essential for all living beings to have such an ability and to use it wisely. In the same sense, such functionality also extends to entities which are formed by the actions of groups of people. Organizations which are blind to how their actions in the present impact their group in the future are destined to do things which will result in actions which will result in bad consequences. Individuals who belong to organizations have eyes and ears, but these are no the sensory organs which directly guide these entities. These organizations receive feedback in the form of membership numbers, dues, contributions, and recognition. Like living beings these entities require food and ego gratification. Money serves as the fuel that feeds their energy needs and  recognition provides the ego gratification. In a sense, financial tools represent sensory organs for organizations. Money is like the photons which shed light on the structures which an organization has in place to make sure it is viable.

Democratically formed states represent a special form of organizational entity. Where voluntary organizations are completely dependent upon serving their membership, political states are different. If members become blind to the wants and desires of their members or those who provide financial resources, the members will leave and the donors will stop donating. Blindness is a death sentence. In contrast, political entities have the ability to compel people to continue to feed them whether they are blind to their constituent needs or not.
If a private entity cannot meet its payroll needs, the world is generally not so forgiving. The message will be sent, find a way to convince others to voluntarily provide your organization with financial resources you need or cease to exist. A public entity supported by taxes can ignore such signals, at least for a while.

This may have its merits. Government support of basic research is justified based upon the lack of support that would be forthcoming from private sources. This might be true but the issue becomes once the genie is out of the bottle how do political entities create boundaries which they do not cross? How can they say no? Absent the usual financial sensory organs which maintain discipline for private entities, once states start down a given path, how do they know where they are going to end up if they are flying blind?

When my blind dog walks around, she gets feedback whenever she walks into something. I suspect that is a painful experience and she cannot continue because something is in her way. We structure her environment such that we avoid existential threats such as falling down a flight of stairs or walking off a cliff.  How do governments, blindly operating without the usual financial vision avoid existential threats? I am not sure we have an answer to this question.  It is not impossible to deploy the same financial tools to state entities as we apply to private entities.

The barriers to deployment are political. Being or appearing to be blind to financial reality confers a short term political advantage to those running for office. That is actually a very frightening thought in that we now operate in a system that provides leadership with an incentive to be blind. I look at my old blind dog and see what blindness means to her. She has benevolent owners who keep her from walking off a cliff. When our leadership cultivates blindness, who will prevent us from walking off a similar cliff.

Saturday, September 8, 2012

Emotional decision making, fear, and muda

There is no question that fear acts as a huge motivational factor for people in general. Our perception of risk is mediated by our emotional and cognitive brains, but the readout of fear tends to be primarily emotional, often leading to irrational decisions, both by individuals and institutions. The logical sequences goes as follows:

1. Bad event happens and instills fear broadly
2. Causality is inferred from coincidental events
3. A broad response is implemented irregardless of any evidence to the contrary, irregardless of evidence supporting effectiveness, and without any mechanisms to assess effectiveness in the future
4.  We are saddled with muda. You might ask what muda is. It is a Japanese term denoted activity denoting activity with no discernible value. It is waste.

In today's WSJ, Simons and Chabris wrote an essay "Do our gadgets really threaten planes?" I have often wondered why we a forced to turn off our electrical devices during takeoff and landing. It was hard to conceive that my kindle reader could conceivably cause a problem but I comply with the requests. I carry some sort of paper alternative to keep me occupied during those windows of time. Simons and Chabris give some historical perspective on these restrictions which turn out to be based upon a few isolated reports of pilots and flight crews who believed that passenger gadgets disrupted navigational and/or flight communication systems. No one has been able to duplicate these observations.

Furthermore, the authors own statistical analysis based upon passenger survey data and compliance with regulations (or lack thereof) really call into question that these particular regulations create any sort of benefit for anyone. It turns out that 40% of passengers did not turn phones off completely, 7% left them on with full WiFi and cellular activity, and 2% pulled what they referred to as a "full Baldwin", continuing to use their phones actively. If their sample is representative, we can assume that personal electronic devices are operational on virtually all flights and we should see some sort of disruption of flight functions if there is a real risk. We have not observed this. Yet the restrictions persist, based upon the precautionary principle. The default mode is to avoid or prohibit activities where there is a perception that some harm may follow, irregardless of evidence or lack thereof.

This article struck a chord because we engage in this type of thinking in medicine. I have touched upon this in a previous blog ( At least part of the problem is our default to the precautionary principle, that no matter how remote the possibility, any scenario where a very bad outcome is at all possible requires some sort of action, even if the action is of unproven benefit. Despite the technological advances in medicine over the pat century, it is my experience that those who practice the healing arts tend not to think of things in quantitative terms. Part of the problem is the lack of actual quantitative data.

An additional aspect is that available data provides a picture which is not so black and white. I have discussed these elements with previous posts. ( Understanding and communicating risks is easy if the choices are stark. Choices are rarely so, but  time constraints tend to drive us to make the choices appear stark, even when they are not. Over time it becomes convenient for us has health care providers to embrace the starkness of the options as well. It simplifies our lives in the short term but we end up is strange and undesirable places because we end up recommending all sorts of wasteful interventions based upon precautionary principles. Over time there are inexorable pressures to implement such interventions under increasing mundane circumstances, often driven by random anecdote or extraordinarily unlikely outcomes. The irony is the process is so gradual and the incentives so perverse that we end up being completely comfortable with trying to defend positions which may appear to be embarrassingly indefensible. I suspect that this may have been the case with physicians whose actions end up crossing legal lines.  (

There are all sorts of estimates as to how much of health care dollars are wasted. Unfortunately, this too is nuanced and not simple arithmetic. Whether what I describe above falls into the bucket of defensive medicine  or something else and whether the influence of such thinking can be quantitative or not is an open question. From my perspective as a practicing physician I perceive this cognitive issue has profound financial impact and this issue cannot be addressed until we can address a cultural divide which needs to be bridged. Practicing physicians tend to be hostile to those who attempt to guide practice based upon quantitative data as evidenced by the reception that the USPSTF receives when they make recommendations that call into question widespread screening practices.

We just can't help ourselves. Our decision making tools still rely on ancient hardware with emotional readouts that were extremely useful to our ancestors down by the watering hole which were essential when we needed to integrate the constellation of data in a hurry and tell us to run like hell. Even physicians who are schooled in numbers and outcomes recognize that this is part of clinical practice and decision making.  ( However, we need to recognize this for what it is and be able to reflect in such a way that we can avoid the worst of the muda created.

Thursday, September 6, 2012

Defining the health care "right"

This story does not require much comment. A convicted murderer in Massachusetts has successfully won a lawsuit gaining him access to transgender surgery. The judge in the suit wrote:
Judge Wolf, describing his 126-page order as “unprecedented,” said that denying Kosilek the surgery was a violation of the Eighth Amendment’s prohibition on cruel and unusual punishment.
From the standpoint of defining limits on positive rights, this case essentially declares there are none. I simply cannot imagine that this will not be overturned. If this goes to the highest court in the land and is upheld, there is essentially nothing that cannot be successfully sued for in court in the health care arena. What additional medical interventions can those incarcerated with lots of time to think about gaming the system come up with? I can only imagine....

Sunday, September 2, 2012

One man's ideas are another man's ideology

I watched parts of the Republican Convention this week. I caught only a smattering of the speeches but I was struck by the strong focus on the role of private enterprise, self reliance, and the skepticism that the government, particularly the Federal government, is in the position to solve the current challenges faces by the American people. This is in stark contrast to the governing philosophy of the Democratic Party.

These are competing belief systems and it is a completely legitimate question to ask which one is the right approach to support. Unfortunately, within the realm of politics, the road to dominance is generally via demonizing your opponents as opposed to actually challenging their ideas. In Paul Krugman's column yesterday, he called Paul Ryan "at heart a fiscal fraud" ( . This to me suggests that he is akin to Bernie Madoff, fully aware that he is promoting some sort of blatantly dishonest activity as opposed to accepting a different set of beliefs directed toward a common goal of improving the economy.

Similarly, Maureen Dowd wrote today:
That’s why they knocked themselves out producing a convention that was a colossal hoax. They did that for us. Because they care. With exquisite timing, they started caring last Tuesday at 7 p.m., when suddenly the party was chockablock with tender souls in rainbow colors, with strong-minded women and softhearted men, with sentimental rags-to-riches immigrant sagas. We all know Republicans prefer riches-to-riches sagas and rounding up immigrants, if the parasitic scofflaws aren’t sensitive enough to self-deport. That’s why my heart swells to think of the herculean effort the G.O.P. put into pretending its heart bleeds.
Again, there is the implication that no one could actually hold an world view different from Ms. Dowd. The only explanation is that the RNC engaged in some sort of elaborate hoax and deception of the American public.

I was curious to see if other had written previously on distinguishing ideas from ideology, from being principled from having an agenda. I came across a chapter from Louis von Mises book "Human Action" on ideas and specifically the section on world view and ideology ( He provides a conceptual framework for a set of assumptions that I hold, specifically the assumption that we may have different approaches to solving problems but we share the desire to improve our material well being. The issue becomes whose material well being are we talking about and what is the best approach to accomplishing these ends.

The second assumption is:
All other ideologies, in approving of the search for the necessities of life, are forced in some measure to take into account the fact that division of labor is more productive than isolated work. They thus admit the need for social cooperation.
The implication of this assumption is that incentives which affect cooperation are important. He goes on to say:
In fact, for all parties committed to pursuit of the people’s welfare and thus approving social cooperation, questions of social organization and the conduct of social action are not problems of ultimate principles and of world views, but ideological issues. They are technical problems with regard to which some arrangement is always possible. No party would wittingly prefer social disintegration, anarchy, and a return to primitive barbarism to a solution which must be bought at the price of the sacrifice of some ideological points.
While this piece was written more than half a century ago and the terminology has evolved, the themes are consistent:
In the field of society’s economic organization there are the liberals advocating private ownership of the means of production, the socialists advocating public ownership of the means of production, and the interventionists advocating a third system which, they contend, is as far from socialism as it is from capitalism. In the clash of these parties there is again much talk about basic philosophical issues. People speak of true liberty, equality, social justice, the rights of the individual, community, solidarity, and humanitarianism. But each party is intent upon proving by ratiocination and by referring to historical experience that only the system it recommends will make the citizens prosperous and satisfied. They tell the people that realization of their program will raise the standard of living to a higher level than realization of any other party’s program. They insist upon the expediency of their plans and upon their utility. It is obvious that they do not differ from one another with regard to ends but only as to means. They all pretend to aim at the highest material welfare for the majority of citizens.
The accomplishment of improvement of material welfare is described by Mises as (bold is my emphasis):
The problems involved are purely intellectual and must be dealt with as such. It is disastrous to shift them to the moral sphere and to dispose of supporters of opposite ideologies by calling them villains. It is vain to insist that what we are aiming at is good and what our adversaries want is bad. The question to be solved is precisely what is to be considered as good and what as bad. The rigid dogmatism peculiar to religious groups and to Marxism results only in irreconcilable conflict. It condemns beforehand all dissenters as evildoers, it calls into question their good faith, it asks them to surrender unconditionally. No social cooperation is possible where such an attitude prevails.
I highlighted Dowd and Krugman only because the timing of the Republican convention. I am certain that the same behavior will be exhibited when Republican leaning columnists have their chance with the Democratic convention. Those who hold beliefs as to how improve the material well being of others which are different from ones you might believe are not necessarily evil or dishonest. However, from the perspective of exploiting differences in belief systems within the political realm, if is almost always more successful to take such a tack if in order to get elected.

This underscores an inherent issue with moving social problems into a the political realm. We may hold different views as to how the world works based upon differences in belief systems. Many if not most of the differences are based upon some empiric evidence, selectively embraced to support what we believe to be true. When these belief systems reside in the private domain, we are free to embrace what we chose to embrace and reap the rewards or suffer the consequences personally. There may be some spillover effects but as long as those who hold particular belief systems do not capture the coercive power of the state, most individuals will be free to embrace what they hold to be true and have their actions guided by them. There are limits to actions of individuals and for a review of this I recommend Richard Epstein's book, "Simple rules for a compelx world".

Once issues move into the political realm, actions move from individual moral mandates to legal mandates, often imposed on substantial minorities by slim majorities. Particular belief sets and the potential maladaptive consequences fall not only on those who embrace them, but also upon those who want nothing to do with them, but only have them imposed by slim 50.1% to 49.9 majorities. Increasingly, we take the power of the state for granted. We assume that those who are in control of the various levers of government at the local, state, and federal levels are capable of making the life of the average citizen better or worse. What exactly do they have at their disposal which can effect such changes? What empiric evidence is there from the past to support that governmental approaches to problems are effective?

If the effects of state actions were unambiguous and apparent within the time frame of elections, this would not be such an issue. However, within the common election cycle of 2-4 years, assessment of actions within the political realm yield conflicting results. Ideas as to optimal rules and structures are difficult to test at best and assessments as to the wisdom of particular approaches may require decades to become apparent. Short term expediencies required to garner votes may capture the electorate but result in disastrous longer term outcomes. Similarly, vilifying those who disagree with us may be helpful to get elected but is dysfunctional when we need to create institutions which foster cooperation and coordination.

Finally, using the "State" to create optimal incentive structures tends, particularly when there are sharp and legitimate differences between belief systems in regards to which structures to create , does not allow for sufficient diversity of approaches. Political processes, particularly polarized ones,  lead to what I call the "All in" approaches, much like playing poker with only one betting strategy, with every bet being an all in bet. Moving problem solving out of the political realm allows many different agents to act in accord with their individual beliefs, investing their own precious resources. There will be winners and losers, some based upon luck but also many based upon reading the landscape correctly and having the right set of beliefs. I use the term right set of beliefs not in a moral sense but in a functional sense in that their assessment of the environment, human wants, and human nature allowed them to better address human needs and create wealth and resources to re-invest in future successful endeavors.

I believe that political processes are essentially incapable of accomplishing this on a consistent basis and for this reason the role of the state in human affairs needs to be limited. This idea dates back at least to the founding of our Republic. Whether it is true is a legitimate point for discussion. It is not desirable to vilify those those who hold this belief, to always question their motives, to call them frauds or perpetrators or hoaxes, of call them as crazy. It might get you elected but it will not improve the lives of your fellow citizens. We are all dependent on each other to survive and thrive and we can get to a better place when more of us are rowing in the same direction. That will happen when people voluntarily chose their path, not when someone else tries to force them.

Relative vs. Absolute Risk - Great Cartoon!