Truth = an abundance of belief

https://m.youtube.com/watch?v=mRlWwoam9fk&feature=youtu.be

The New Socialists

There are times when I simply stare in disbelief at what I am reading. Today in the New York Times, there was a piece titled "The new socialists" (Link). It was a commentary on the wave of younger politicians, mostly on the local level, following the lead of Bernie Sanders with an unambiguous embrace of socialist policies. The article is written by Corey Robin, a professor of political science at Brooklyn College and the City University of New York Graduate Center. Mr. Robin writes:

Self-identified socialists like Bernie Sanders, Alexandria Ocasio-Cortez and Rashida Tlaib are making inroads into the Democratic Party, which the political analyst Kevin Phillips once called the “second-most enthusiastic capitalist party” in the world. Membership in the Democratic Socialists of America, the largest socialist organization in the country, is skyrocketing,especially among young people.

Mr. Robin delves into the source of the appeal. He goes on write that:

The socialist argument against capitalism isn’t that it makes us poor. It’s that it makes us unfree. 

Socialism means different things to different people. For some, it conjures the Soviet Union and the gulag; for others, Scandinavia and guaranteed income. But neither is the true vision of socialism. What the socialist seeks is freedom.

Under capitalism, we’re forced to enter the market just to live. The libertarian sees the market as synonymous with freedom. But socialists hear “the market” and think of the anxious parent, desperate not to offend the insurance representative on the phone, lest he decree that the policy she paid for doesn’t cover her child’s appendectomy. Under capitalism, we’re forced to submit to the boss. Terrified of getting on his bad side, we bow and scrape, flatter and flirt, or worse — just to get that raise or make sure we don’t get fired.

The socialist argument against capitalism isn’t that it makes us poor. It’s that it makes us unfree. When my well-being depends upon your whim, when the basic needs of life compel submission to the market and subjugation at work, we live not in freedom but in domination. Socialists want to end that domination: to establish freedom from rule by the boss, from the need to smile for the sake of a sale, from the obligation to sell for the sake of survival........
The socialist, by contrast, believes that making things free makes people free.

Say what? Making things free makes people free? However, things are not free and cannot be free. We are inherently dependent upon others for our existence, unless we can take care of all our needs without anyone else's help. That is essentially impossible. Yes we are forced to enter the "market" to live, but remember what markets are. They are places where people are free to enter into voluntary agreements with other like minded people who are free to interact or not. That is the nature of freedom.

What alternatives do we have other than voluntary exchanges or interactions?  The alternatives are limited to no exchanges or forced exchanges. Humans can function at three basic levels; as single individuals, as individuals as part of groups where members participate voluntarily, and part of members of states where the state has the power to coerce its members. Market exchanges are marked by freedom to participate or not. States are defined by their authority to force members to comply. States have the proverbial ability to hold a gun to your head. Socialism highlights state ownership and control.

I believe that in a world that seems to be marked by political gridlock, one of the attractions of Socialism is its promise to use the power of the state to force those who might be viewed as hindering getting things done into complying with those who believe themselves to be right. For those who hold a strong and unwavering vision of being right, this perspective can act as a siren's song. However, one needs to remember that creating pathways increasingly unbridled power will attract those who are most motivated to harness that type of power, and tend to be least constrained by moral scruples that would limit their exercise of power.

It is reasonable to have pointed discussions regarding the failings of market based systems. However, those discussions need to be coupled with honest discussions of failures and catastrophes of unbridled state power. There might be disagreements as to all the particulars of how to define Socialism, but there is agreement that it is at its most basic level, an expansion of state power.

What criteria are important in selecting leaders

As most of you likely realize, I live in Georgia. We are in the midst of a contentious election for governor which has made it on to the national stage. I am not at all happy about by choices. On the Republican side we have Brian Kemp, who out-maneuvered current Lieutenant Governor Casey Cagle for the nomination by out-Trumping him. Don't get me wrong, I was no Casey Cagle fan and I suspect I would be in the same boat if Brian Kemp had lost the primary. However, Kemp prevailed because he sent a xenophobic and gun and chain saw worshiping message to the voters and connected with their inner reptiles. It was simply mean-spirited.

 Just to give him a fair shake, I visited him website. It did not instill any confidence.  It is filled with platitudes but there is little content. He wants to "take a chainsaw" to state regulations. I am all for limited government but there are NO specifics on how this portion of his platform will be implemented. He makes a strong appeal to rural Georgia which I sense is reaching back to the past.

Then there is the Democrat candidate Stacy Abrams. In contrast to Brian Kemp, her website is rich with content describing her proposed agenda. I agree with her on her social agenda and have my disagreements with her on fiscal policy. The cloud that hangs over her is one relating to her personal finances, which she has been completely transparent about. She has over $50K of deferred Federal Taxes and It has been reported and commented on by both state and national press including the New York Times. Today there was an OpEd piece which commented on the Kemp attacks:

This line of attack throws a pernicious political dynamic into high relief. The financial problems of poor and middle-class people are treated as moral failings, while rich people’s debt is either ignored or spun as a sign of intrepid entrepreneurialism.

Reading interviews of Ms. Abrams fill in details which point to her use of financial options available to her to meet the needs of her family, shedding a more positive light on her particular circumstances.  She took on the role of saving her extended family from financial calamity after the convergence of a host of factors. Ms. Abrams is clearly a financial risk taker, which has it upsides and downsides. She is not afraid of personal debt.

I still have to ask the question as to whether it is appropriate for voters to be skeptical of an individual's ability to make good decisions regarding state government finances when they have made perhaps poor decisions with their own? The Times clearly thinks this to be inappropriate. I think it is reasonable to ask what they have learned from their experiences. Ms. Abrams accrued heavy debt to finance her education and has continued to use debt to further her career. She does not regret doing this and does not believe it to be a mistake, yet. Does that approach to debt translate into how she will govern? No matter who she is and where she came from, this is a legitimate question to ask. 

Anger, fear, the reptile brain, and electoral success

It appears that it is perpetually election season. For a creature like me who is fundamentally skeptical of the ability of political systems to actually solve problems, I would rather think about almost anything except politics. I realize that my own take on the evolution of politics and the nature of political competition is but a brief flash in the long history of how politics has been conducted in human history stretching back millennia. However, it appears to me that earlier in my lifetime, my perception was that politicians at least tried to appeal to the electorate's ability to reason, at least early in campaigns. Maybe this was an aberration,

This all takes me to thinking about studies over the past 50 years on human decision making. How do we decide what party and candidates to support and what issues to champion? It turns out that we pick candidates an issues much the same way we any other choice, whether that be a pair of shoes, a menu item in a restaurant, or where to buy a house. We are endowed with two decision making machines in our brains which have been described as system 1 and system 2. The former is an evolutionary ancient tool which operates below our threshold of consciousness. It can process huge amounts of information with little or no effort and its readouts are emotional. System 2 is a more recent evolutionary development. It is what we are conscious of. It is slow and plodding, a serial processor, capable of more nuanced thought. It is also a resource hog which can be used only sparingly without exhausting its user.

My observation is that campaigns historically have started by trying to appeal to system 2, but over time as campaigns heat up, they quickly more to strict system 1 appeals. Over most recent years, it appears that all attempts to appeal to system 2 have gone away. It makes sense. Why bother appealing to the rational and thoughtful brain when we all know that the election will be decided by system 1 appeals directed to fear, anxiety, anger, and envy?

Much has been made of Donald Trump's appeal to white rage and anger. I think what made Trump stand out is his immediate dismissal of any need to appeal to the rational side of voters. In that sense he was very efficient in the use of his resources. His success derived from this strategy is very concerning, but also concerning to me is the strategy of his opponents, rejecting his aims but embracing his approach. They match anger with more anger.

My question to my readers (all five of you), is "Is anger a good starting off point for political movement?" I think not. There is no question anger and fear are powerful motivators in politics. They may be able to get you elected but they are terrible motivations when governing. Is it possible for those who get elected by appealing to system 1 can govern using system 2? Perhaps that does not matter when governing becomes a secondary priority.

Medical Pricing Opacity Madness

I blog worth reading
https://johnhcochrane.blogspot.com/2018/07/cross-subsidies-again-hip-replacement.html

This is not going to change from within.

Immigration horribles

We face an avalanche of horrible news regarding immigration and the challenges are not limited to the US. All throughout the world there are people running from violence and poverty to places where there is less violence and poverty. This is not a new story.

I have been trying to track my family history. I had my DNA sequenced and discovered relatives I did not know I had. Their grandmother and my grandfather may have been brother and sister and at least first cousins. They both left Russia in the late 19th and early 20th centuries. It was at a time when the country welcomed immigrants, at least on paper. That all changed after WWI. Until the Great War broke out, there was great demand for labor to support the growing industrial giant that was the US.

My ancestors were escaping the mess that was the Russian Empire and the about to collapse Austro-Hungarian Empire. I am grateful they did. Since that time, humankind has gotten better at moving people around. The great migrations of the late 19th and early 20th centuries was facilitated by the steamship. Fifty years earlier it would have been unthinkable that so many people could have immigrated so far and so fast.

Fast forward a century and we have chaos in South and Central America, in Africa, in the Middle East, and parts Asia.  There is violence, bad government, and poverty. There is also the internet which allows for even the poorest people to know what they might be able to attain and transport of all sorts that allow motivated and intelligent people to migrate. And they are migrating in droves from Africa to Southern Europe, from Central and South America to the US, from Burma to Bangladesh, from North Korea to China.

No one seems to know what can or should be done to deal with these migrations. The pressures of migrations make normally well functioning governments look awful. Put bad leadership in place and they look even worse. However, no matter how bad the leadership might be, we are still left with choices that may make even the best of leadership look bad.

What are our options. At one end of the spectrum we could simply try to close the borders and let no one in. That will not serve our needs in that we need immigrants. Furthermore, we do not have the ability to close the borders, On the other hand, we could simply open the borders and let everyone in. How would that work? We did that 100 years ago but we needed the infusion of immigrants to propel our economy and there were physical limits on how many people could actually get her. What would happen now if we opened the borders to ALL interested parties. Is that really a viable option? How many people would end up entering the country and how would we handle them?

That leaves us with the need to come up with workable rules and the resources to allow some people in and some not. How does that look? I have not heard a single voice out there that has framed this issue within workable limits to immigration .Perhaps this is what they are talking about in terms of comprehensive immigration reform. I did a basic search on the terms "comprehensive Immigration Reform" and there are a number of parties that have issued position papers. It is surprising how little meaningful discussion has made it into the mainstream press.

As noted in the "Catholic Vision of Just Immigration reform (Link)

We do know that policies that indiscriminately separate children from their migrant parents at our national border violate the sacred sovereignty of families. They need to be stopped.

But it’s not enough to condemn the treatment of a mother separated from her child without asking what should happen instead. There have been, unfortunately, too few solutions proposed to address a real problem: how should the identity of family members be verified at the border, to ensure that children are not being trafficked? That issue needs more than moralizing or grandstanding. It needs a real solution.

It’s also not enough to call for an end to family separation at the border without asking what led to this humanitarian crisis, and what kind of reforms will really make a difference.

For that reason, no matter how discouraged they are, Catholics need to lead efforts to develop comprehensive immigration reforms rooted in the principles of justice. Only serious reforms, which create a system that protects security and the right to migrate, will end humanitarian crises at the border, mass detentions and deportations, and the deaths of migrants crossing through the desert.

When do we get to this discussion?

The Danger of The Regulatory State

The regulatory organs of clinical medicine not only hand down and enforce trivial, silly and costly diktats, as a recent blog on this site related, but also impose dangerous constraints on the practice of medicine.  Case in point is the College of American Pathologists (CAP) which acts as the surrogate laboratory inspector for the government.   CAP’s inspection of our academic training program’s “lab,” which consisted of two microscopes, shut down an entire clinic building’s laboratories in a major academic medical center because, as an untrained and uncertified physician, I was performing gram stains.  

I have been doing gram stains since I was taught to perform them 50 years ago in my 7th grade science class; preparing slides is trivial enough that it can be mastered by a 13 year old.  Performing gram stains was a requisite competency in my medical school as it has been for virtually all medical students in the 134 years since Christian Gram published his technique in 1884.   And I have been interpreting them for over thirty years of medical practice.  As an intern thirty years ago when seeing a febrile patient with purulent sputum I would have been severely reprimanded for not having personally done a gram stain and had it available for the attending physician to review.  Now it is a cause for action on the order of the breaching of a Level 4 biohazard unit with commensurately severe disciplinary proceedings to follow for the responsible “untrained” and “uncertified” practitioner.  

Gram stains offers important, often essential and not infrequently time critical information that may not be obtained from culture or at least not obtained in a timely manner. 

1. Gram staining gives immediate results: infectious vs. non-infectious; gram positive vs. gram negative organisms; mycotic vs. bacterial, and does so days before culture results are available.

2. Culture requires viable organisms; gram stain does not.  Gram stain works on bacteria that are alive or dead so where an infectious etiology is suspected but only purulent material with non-viable organisms is available a gram stain can still direct treatment.

3. Gram stains can identify the presence of fastidious infectious organisms, especially fungi, that will not culture out on conventional media such as Sabouraud’s dextrose.  Mycotic infections can be missed or inappropriately ruled out if the results of cultures are accepted as definitive.

4. It is inexpensive: pan-culture for multiple organisms including fungi will run $500-$1000.  Culture may be completely avoided by the gram stain if there is a clear cut clinical correlation; or it can restrict culturing to the class of organisms seen under the scope to determine sensitivity.  

Multiple cases from my inpatient service underwrite these attributes.  In just the six weeks before the CAP inspection threatened disciplinary action against me the cases below relied heavily on my performance and readings:

1.   A 7 day old premature infant in the NICU with KID syndrome, possible sepsis and a localized pustular rash was evaluated; beginning empirical antibiotic treatment would further complicate management of this ventilator dependent baby.  The gram stain showed numerous budding yeast as the sole finding and with the clinicopathologic correlation of the rapid appearance of pustules this indicated candida.  The contemplated systemic antibiotic therapy was avoided and the parents reassured.  Candida was subsequently confirmed by culture but only several days later.

2.   A 44 year old man with HIV, toxoplasmosis, mental status changes and cerebral infiltrates on CT scan presented with multiple fungating nodules thought by infectious disease to be either Kaposi’s sarcoma or T-cell lymphoma.  A gram stain of scant exudate from these lesions showed dense gram positive cocci making the clinical lesions consistent with the rare staph infection botyromycosis.  ID challenged this diagnosis and instructed the primary service to discontinue vancomycin but photos of the gram stain taken with an iPhone convinced them to continue vancomycin before culture subsequently confirmed staph infection as the sole cause of these tumor like nodules.   

3. A 65 year old man post-op for glioblastoma on high dose prednisone with mental status changes presented with a rapidly evolving, acneiform facial rash raising the concern for crytptococcal infection.  A gram stain from pustules showed a dense infiltrate of gram positive cocci (characteristic of Staph epi), gram positive rods (diphteroids characteristic of P. acnes) and round to oval non-budding yeast (characteristic of Pityrosporum), the classic findings of steroid induced acne avoiding both a biopsy and empirical antibiotic therapy for crypto and permitted his discharge from the hospital the next day.

Again, these were just in the previous 6 weeks of one attending encompassing only 6-9 days of actual inpatient service.

A more critical example from our institution was the early diagnosis of a 50 year old man with a high C-spine fracture from an MVA, in the ICU, septic and rapidly deteriorating. A generalized pustular eruption that I gram stained disclosed candidiasis days before blood culture demonstrated candidemia allowing earlier intervention.  And going back in time to when I was expected to perform a gram stain, as a third year resident 30 years ago I evaluated a septic patient transferred in in the middle of the night with multi-organ failure.  Blastomycosis was suspected but empirically giving him amphotericin, the only antimycotic available at that time, risked destroying what was left of his kidneys.  I called blastomycosis on a gram stain from one of the rare pustules on his leg underwriting the necessity of using amphotericin despite the risk.  That diagnosis was subsequently confirmed—but only weeks later by culture.

The exclusion of physicians from performing gram stains has left the microbiology lab techs as the sole authorities on their interpretation. There are many capable lab techs performing and reading gram stains; as noted above preparation and interpretation is typically straightforward as I demonstrated as a 13 year old. But reliance on lab techs should not be taken at face value.  My personal observations from the concurrent processing and interpretation of slides with them discloses significant variations in their capabilities particularly in difficult cases.  Techs follow the guidelines for performance of the procedure which were developed by bacteriologists for uniformly dense specimens skimmed from culture media. This does not account for variations in specimen thickness or content when obtained from necrotic, infected, inflammed or hemorrhagic tissue where variations in the preparation of slides is necessary.

A case that illustrates this occured following the CAP injunction when I was ordered to discontinue gram stains. I saw an 18 year old boy hospitalized for multiple large ulcers on his leg that began several months previously after he cut himself at the farm where he lived.  HIs parents consulted infectious disease and multiple cultures including fungal cultures were obtained, all negative for microorganisms.  I performed a touch prep from a biopsy and submitted it to the micro lab for evaluation.  At this point I was prohibited from performing gram stains myself and the prep was read by the lab tech as negative.  I asked to take a look and pointed out multiple large aggregates of yeast that were missed by the otherwise conscientious technician.  Culture was again negative but initiation of itraconazole resolved the ulcers in several weeks confirming the mycotic nature of an otherwise undeterminable fungal species. 

If physicians are not performing, interpreting, teaching and supervising those doing gram stains the results will often result in the above scenario.  For example, virtually every technician I’ve observed places the stained slide on the stage, immediately applies immersion oil, goes straight to 1000x and evaluates several fields, likely what they were taught.   However in a 2 x 1 cm smear of a specimen the evaluation of ten 1000 sq micron fields surveys less than 1% of the sample.  As the case above illustrates low and medium power surveys of a specimen that are not performed by the technician can miss infectious infiltrates.  I have pointed this to our micro lab techs on a number of occasions when concurrently reading slides.  I do not relate this in disciplinary terms but as a teaching opportunity and the techs are universally grateful for such oversight.  But I am one physician—and one who is been told to physically stay out of the main lab.

Regulatory diktats have subcontracted these tests to technicians and physicians have lost this skill and have no incentive to push back and take on such regulatory entities as CAP.  Those are not good reasons for abdicating responsibility and subordinating what should be a physician performed microscopic exam if the clinician desires or where a practitioner is in the best position to make a clinicopathologic correlation from the results. This is especially true in an academic medical center which should be setting the standard.

  

CAP’s injunctions resulting in our suspending performance of gram stains and other advanced physician performed microscopy need to be forcefully challenged.  Moreover, we need to reinstitute training in these techniques.  Gram stain is simpler, more definitive, easier to learn and often critical to the undertaking of acute therapeutic interventions in seriously ill patients—or avoiding undertaking them at all.  If CAP or anyone else doesn't think that’s important—just ask the mother of that premie in the NICU.  

Adding cost without adding value- baked into how we practice and the process measures we use

We recently went through a Joint Commission visit in one health system and mock visits in two other systems. The preparations leading up to these visits are remarkably resource intensive and without question divert resources from other activities which may be more valuable for patient care. We had one particular demand which was both silly and crazy at the same time. For reasons of privacy, we were instructed by our internal reviewer to turn all of our exam chairs such that a patient sitting in the chair could not be identified from the door. No matter that we have installed curtains which are pulled and block the view from an open door. No matter that the rooms were configured where the desk where the provider sits and documents when they are interviewing the patient will now afford the MD/PA a view of the back of the chair. No matter, our work and our opinions are beside the point.

If it were only that the Joint Commission were a bad actor but alas that is not the case. The practice of medicine is riddled with expensive and arbitrary practices which someone thinks might be a good idea and are implemented with limited if any evidence that they actually add value to patients lives. The value that might be added may be dwarfed by the actual cost of delivery.  However, it appears that no additional cost is ever viewed as excessive if it is borne by some other party and/or if the cost can be made sufficiently opaque. I spend my time taking training courses to maintain credentials, courses which impart questionable knowledge and assessed via tests which measure nothing of value pertaining to trivia which is quickly forgotten. On a regular basis, we participate in credentialing processes which remind me of the movie Men in Black. It appears that those involved have had their memories wiped on a regular basis forcing us to repeat steps which have been done over and over again over the course of literally decades.

Within the actual practice, we seem to be blind to the concept of diminishing returns. Any anecdote, no matter how rare or exceptional, can serve as a justification for some intervention which is pushed to be universally applied. The authority to hold people and systems to comply with such mandates tends to be delegated to regulatory entities which become interested primarily in perpetuation of their own existence and use their ability to publicly shame and operationally cripple health care delivery systems to force people and systems to kowtow to their demands, no matter how little value they add to patient care and how much cost is layered on.

There is little incentive to take on such regulatory entities. When you are under scrutiny, you would be crazy to challenge their authority. They hold all of the cards and while they may use such words as "partnership", don't be fooled. When you have finished the review process and met all of the demands, no matter how obscure, irrelevant, or trivial, the incentives drive you and your organization to get back to the work or your core missions. There is no clear pathway to hold the regulatory entities accountable and any effort to shine a light on the absurdity and arbitrariness of their work and rules will almost certainly come back to haunt your organization at the next review cycle.

This again brings to mind the quote from the movie "Bananas" -

Esposito: From this day on, the official language of San Marcos will be Swedish. Silence! In addition to that, all citizens will be required to change their underwear every half-hour. Underwear will be worn on the outside so we can check.

Who should drive cost control efforts in health care?

Ever since I was in medical school almost 40 years ago, we have been talking about the growth of health care expenditures and how the growth rate is unsustainable. Like the proverbial frog in the heated pot, we have adjusted to increasing costs as we approach the boiling point. I believe we are approaching the boiling imminently and payers at all levels are trying to figure out how they can remain solvent while at the same time finance needed health care spending. 

The WSJ published a piece in late March of 2018 highlighting that two major issues are creating financial challenges for state budget, pensions and health care, particularly Medicaid. (WSJ). The result is crowding out of expenditures on virtually all other state functions. The effects of growth in spending diffuse across all levels of payer, public and private. Private insurers are engaged in pitched battles with large and increasingly consolidated health systems over rates while at the same time trying to move costs back to consumers, increasing deductibles and co-pays. It is getting very ugly. We recently experienced a showdown between Piedmont Healthcare and Blue Cross within the Atlanta market which required the Governor to weigh in to get the parties back to the negotiating table.  

At the same time, CMMS is searching for innovative approaches to effectively deliver health care to its covered populations at lower costs (or at least at slower growth rates). They announced a requests for comments and information on 4/23/18 (CMMS RFI). The RFI throws out a host of ideas, driven by the theme of market based approaches. It is not especially cohesive or cogent. That is not surprising since no one knows the magic formula by which were can consistently do a good job at substantially lower costs. The request is just that: for input from interested parties who can assist them in their goals. 

The responses from the physician community are fairly predictable.  We do not want to act like insurers. We never have and it places us in a very conflicted position. It is essentially impossible to act as advocates for our patients while at the same time function as stewards of system resources. That job is unpalatable and is extremely difficult (perhaps impossible) to do. The AMA has weighed in on this (AMA cost control) and from what I can tell, they take the same tack as politicians who say they will balance budgets by eliminating fraud and abuse without recognizing the underlying structural faults. The amounts saved via the former interventions are rounding errors. The real work requires very fundamental changes in how programs are structured. To take that on means taking on vested interests directly. Professional organizations like the AMA are ill equipped to take these types on jobs on. They function as guilds and are driven by member concerns. 

The Physician community does not want to do the difficult and unpalatable work of driving cost control, acting like insurers, limiting care, and explicitly pushing costs on to patients.  However, we do not want to delegate that job to any other party. We want to be in control. It boils down to whether we as physicians want to lead and exert some degree of control over whatever processes are put in place to try to control costs or whether we present the face of resistance. It is clear to me that CMMS has no real clue as to drive cost savings but I do not think we are particularly constructive in our criticism. We are basically washing our hands of the problem for the simple reason that any solutions we can come up with will either result in transfer of costs to patients (which we believe will result in them balking at payment), decrease in the amount of care activity we are engaged with (with decreased revenue), or decrease the payment per unit of work.  We don't like any of these for obvious reasons but in my opinion, we still should come to terms with whether bending the cost curve is something which is desirable or really essential. If it is, then if not us to deal with it, who then should be empowered to address it? 

Price fixing is not OK when you want to do it but is OK when I want to do it.

The NYT reports a story this morning on attempts of the state of Massachusetts to rein in the growth of spending on prescription drugs. Nothing new or surprising here. Medicaid costs are growing and projections across the board for all states are that if nothing different is done , Medicaid costs will crowd out all other state spending over the next 10-20 years.

The Massachusetts experiment is contingent upon getting a Medicaid waiver from the Feds. Seems reasonable given the basic premise of the waiver concept. Try things in a limited space and if they work, they can be adopted elsewhere. What is difficult to understand is the push back and particularly where the push back is coming from. The AMA, ACP, and the ACS, as well as a number of big pharmaceutical firms (J&J, Merck, Lilly, Teva, and Pfizer)  are pushing back against this proposal.

I get the drug companies resistance. They desire the largest degrees of freedom to push their pricing power. They may say they are motivated by getting the best drugs to patients and that may be true to some extent. We should not be so naive to believe that is their primary motivation. However, the MD professional societies are another matter, especially the AMA. Here you have an organization that is behind the largest price fixing apparatus in a segment of the economy that constitutes nearly 20% of GDP.

The mantra is that such efforts will limit patient access to life saving therapies. However, the ongoing price fixing actions of the AMA have limited patient access to life saving expertise for more than 25 years. We still allow for pharmaceuticals to be priced at various tiers based upon a host of factors but according to the AMA, all expertise is generic and linked to common billing codes which do not account for quality or unique expertise. That is entirely acceptable even though it has devastating effects on access to expertise, especially diagnostic expertise or chronic care management.

In digging deeper into the AMA position, I found this news story from Axios last October. It almost defies comprehension. (Axios Link)

Context: McAneny, an oncologist, made her comments in Chicago at a meeting of the AMA's Relative Value Scale Update Committee, an influential panel known as the RUC. A crowd member asked her if the AMA was "missing an opportunity to throw the weight of our collective influence" behind asking the federal government to negotiate drug prices, which Medicare cannot do by law.  The AMA has been outspoken about rising drug prices and the factors behind them. "There's a lot of places where we can look at significant amounts of waste," McAneny said after calling out pharmacy benefit managers, insurance companies and specialty pharmacies.

However, official AMA policy currently "opposes the use of price controls in any segment of the health care industry, and continues to promote market-based strategies to achieve access to and affordability of health care goods and services." Instead, it backs transparency measures like requiring drug companies to post prices in ads.

Looking ahead: The RUC's main business of examining new payment rates for physician services starts Thursday. Medicare has said it would adopt nearly all of the RUC's recommendations for the upcoming year.

Here we had the AMA President railing against price fixing at the meeting of the AMA RUC, their own price fixing entity.

You can't make this stuff up!!!

A Duke luminary highlighted in Reason magazine...

Reason link

Private equity in health care

Money chases returns. It is a fact of life. As opportunities for returns get squeezed in industries which have been the hunting grounds for private equity, opportunities within health care start to look more attractive. The latest waves have identified physician practices where value can be unlocked by using PE magic. The targets for PE are multiple including anesthesia, ophthalmology, orthopedics, dermatology, dentistry, radiology, pain medicine, behavioral medicine, urology, and even primary care.
Those pushing PE hold it out as a potential savior for physicians, with acquisition meaning they get a pot of money and relief from tasks other than caring for patients. It sounds too good to be true. However, I can't really say for sure how the proponents of PE investment are wrong. I have some hunches. There are apparently certain advantages that PE firms have over other health care entities such as hospitals or health systems. Unlike hospitals and health systems, whose acquisition prices are subject to fair market value (FMV) in order to comply with Stark and Anti-Kickback statutes, private equity firms have no such restrictions. They can form partnerships based on the strategic value of the practice as opposed to FMV. The strategic value may calculated by applying a multiple to a practice’s EBITDA (earnings before interest, taxes, depreciation and amortization). In addition, PE generally has equity and generally much more equity available than health systems or other suitors already involved directly in health care delivery.

What makes specific specialties attractive are common elements. These include currently fragmented delivery systems, favorable payment environments with strong procedural focus, inclusion of Texas IG)(DDS the menace).

pathology specimen generation, and at least some portion of the business being cash.  Leading this movement was dentistry with a history of corporate dentistry going back more than a decade. There have been what appear to be financial successes but there have also been some spectacular failures including abusive Medicaid clinics investigated by Congress and state authorities(

Of all of the acquisition activities, the one that has captured the most news recently is in the dermatology realm. A recent highlighted article in the NYT (Link) peeled back some of the sausage making involved in making PE investment work, at least in this specialty.

 It has raised a firestorm within the field (Resneck) with the current Chair Elect of the AMA Board of Trustees, Dr. Jack Resneck weighing in. PE firms tend to leverage non-physician clinicians, who are less expensive than physicians, to deliver care, often under limited supervision. This is an especially attractive specialty for PE since there are fewer regulatory burdens involved. Clinics are generally free standing and not burdened with hospital or health system credentialing requirements. A number of dermatologists are cashing out. A number are also raising dire warnings regarding the immediate effects on patient care and the long term effects on the specialty.

This appears to be the start of the wave of consolidation. There are still mountains of cash looking for returns and interest rates are still at historic lows. In the cross hairs are specialties that have bucked the trend toward acquisition by health systems. PE is likely to compete successfully for practices because of the inherent advantages noted above. There are inherent issues which will need to be grappled with, primarily focusing on where capturing efficiencies driven by financial concerns and non-clinicians begins to drive care decisions. In addition, expanded use of non-MD clinicians practicing at "the top of their licenses" will create additional tensions, especially if these changes are deployed in environments where few if any relevant clinical outcomes are measured.

One additional factor which may loom large is how PE influences will play out in an industry where the prices are fixed by administrative mechanisms. The niches within healthcare targeted by PE are specifically the services with the largest profit margins, likely so because they have been mis-priced. In other industries, PE driven expansion in supply will generally drive down prices, creating a feed back loop to discourage additional entry into the field. However, in healthcare, increased supply often drives increased demand, with the pricing controlled by the RUC and Medicare, and private payers simply following their lead.

For those who think that PE entry driving inefficiencies out of the industry will drive down health care costs, guess again. Heavily utilized services which deliver high margins develop interest groups which maintain mispricing by political means. Prices are not set by any sort of market. They are set by the RUC. Be prepared for an explosion of costs as PE driven expansion drives more and more utilization. PE may be good for extracting value from industries but there is reason for skepticism that they will add value to consumers. I believe this pathway may be good for investors in the short term but bad for everyone else.

Informed consents, documentation of encounters, and Larry Nasser

I hate to perseverate about this particular scandal, but the more I think about this situation, the stranger it appears. Dr. Nassar is a doctor and by any standard, his interactions with the gymnasts represent patient encounters. Furthermore, many of these patient encounters were with under aged minors.

I see patients in this age group as well. My encounters happen almost invariably in the presence of some adult guardian. If I do anything to these patients, it is done after informed consent is done. Not always written consent but with explicit permission granted after explaining what I am planning to do and what specifically I hope to accomplish. This is followed by a note in the medical record which documents the events that transpired.

There is a large void in the news reports when it comes down to descriptions of of specific contexts of the assaults perpetrated by Dr. Nassar. The implication is that he touched young girls inappropriately under the guise of treatment.  I don;t work in the sport medicine field and I don't know what their standard workflows and processes are. Do practitioners routinely ask for consent prior to doing manipulations? How do they handle this for minors, especially when the interventions may happen repeatedly and during times when parents are not around? What sort of documentation do they do? Does the documentation acknowledge consent was granted and for what?

I don't know for certain but I suspect that Dr. Nassar and much of the sports medicine world operates in a way which is very different from from the rest of medicine. The rest of medicine is adherent to protocols put in place to protect both practitioners and patients, which also allows for what otherwise represents violation of personal spaces. Are these protocols applied in the realm of sports medicine? It does not appear to be the case. Are there notes written by Dr. Nassar describing each therapeutic intervention, the justification for the intervention, the outcome desired, and subsequent measurement of whether the specific outcome was attained? I do not think so.

Is there evidence that either the gymnast or an adult guardian was fully informed regarding the specifics of the intervention proposed (I am going to do this manipulation requiring me to touch this part of your body), the purpose of the intervention, and the outcome desired. I do not think so.

In my opinion, there are minimum standards which should be required for all doctor (or non-MD clinician) - patient relationships and interventions. These include explicit recognition of patient autonomy, informed consent (not all of which is written informed consent), rigorous protocols for dealing with vulnerable populations (including minor children), and at least a minimum of documentation of intervention deployed which captures the above elements. Furthermore, patients and their adult guardian should have access to all of the medical documentation.  If Dr. Nassar had been required to adhere to these minimum standards, I doubt the events would have transpired.

Larry Nassar and the state of medicine

I read an article in the New York Times this morning about the role of Patrick Fitzgerald as an adviser to Michigan State University (NYT). He was hired by MSU to help them sort out the allegations against Dr. Nassar. It appears that his team did not speak to anyone who placed a complaint but instead focused on senior leadership and other sports medicine doctors.

While there has been lots of coverage in the news about this saga, there has been little written on exactly what Dr. Nassar did which qualified as assault. I believe this is where a problems lies. Physicians are granted some degree of latitude in terms of how we are allowed to interact with  others. We are allowed to ask very personal questions. We are allowed to touch others in ways which no one can do, except those who have very intimate relationships. Each specialty may engage is specific activities which are uniquely delicate and sensitive. Specialists dealing with anatomic areas that may be associated with sexual arousal must tread a fine line.

I don't know what Dr. Nassar did but I can speculate that he manipulated parts of female anatomy under the guise of "treatment". For the young girls who were placed in his hands, they likely started with the default state of trust. They had some musculo-skeletal problem that Dr. Nassar was charged with diagnosing and treating in order to enhance their gymnastic performance. When Patrick Fitzgerald did his review, he asked a number of Dr. Nassar's peers questions regarding the appropriateness of interventions done and the information he got back from them was the interventions represented standard of care. Yes, taken outside the context of treatment what he did might appear to be quite inappropriate but his colleagues assured investigators that the actions were "not sexual in nature".

The truth is health care providers can do almost anything plausible to a patient under the guise of diagnosis or treatment. In the absence of the ability to measure clinically meaningful outcomes, it is essentially impossible to tell if a given practice is appropriate or not. For the most part, outrageous behaviors can be identified. A dentist does not to fondle breasts in order to remove wisdom teeth. However, there are domains where context defines apparent necessity. Looking for breast cancer does involve manipulating the breast.  This opportunity could be abused by a clinician looking for a titillating experience but it generally provides few opportunities to manipulate the breasts of young girls.

Larry Nassar found himself with the opportunity to manipulate the groins of young girls, all under the guise of treatment of something. The current state of medicine did not readily afford an opportunity to weigh in and say, this is not right. He was afforded the status of an expert and despite the discomfort experienced by literally hundreds of young women, their discomfort could be dismissed by a proclamation that the interventions were "not sexual in nature".  From the perspective of one who is part of the "priesthood", this is a claim which is widely accepted. The public does not understand the complexities involved in medicine. We experts know best given our training and experience. Furthermore, we defer to our colleagues in other sub-specialties, in which we are not experts, and the default is to give them the benefit of the doubt.

One of many weaknesses that is evident is that he could get away with what he did for as long as he did because he was not required to show that the interventions he undertook actually accomplished anything. He was not called upon to measure outcomes. He was afforded expert status with no real data demonstrating that he was an expert in anything.

High cost of the best intentions

I just finished reading John Cogan's book, the High Cost if Good Intentions. This is a comprehensive work examining the history of entitlement programs, starting with pensions for Revolutionary War veterans. The work is fascinating and illuminating and has relevance to our current political and economic environment. The basic tenants of the book are rather simple. Entitlement programs throughout history start out similarly, based upon real needs to specific segments of the population. In the early periods of the Republic, all of these programs were pensions for war veterans; Revolutionary War, War of 1812, and Mexican Wars. They started out as small programs to assist veterans who were injured during their respective service obligations. In each case, the pensions were modified and expanded over time, over decades after the actual service. Furthermore, those deemed worthy of pensions morphed and expanded over time, first to veterans who were not injured during service, then to widows, then to dependents.

After the Civil War, the pool of potential recipients expanded markedly. The pool of pension eligible individuals grew over time with widows and dependent children added. While the original purpose of Civil War pensions was to compensate veterans whose function was impaired as a consequence of service-related injuries, over time criteria were changed which allowed for larger and larger numbers of veterans to qualify for benefits. The Grand Old Army was an extremely effective lobbying force after the Civil War.  Remarkably, there is still one child of a civil war veteran who is collecting pension benefits now.

Early in the republic there were attempts to forward fund pensions for navy veterans. Sailors on active duty could purchase insurance to protect them. Those who opted to participate funded a trust fund to pay for future pensions. However, the trust fund was almost immediately raided by Congress. Furthermore, the Federal government ended up providing pension benefits to sailors who did not opt into paying insurance premiums.

A similar story characterized the Social Security entitlement program. Early trust fund surpluses enticed the Congress to expand pension benefits. Payment increases were almost invariably t imes to happen during election years, often with big bumps in payments hitting October payments right before elections. Buy votes in the present and defer actual payment to later tax payers.

It does not appear to be politically possible to put scale back entitlement benefits once they are deployed and historical experience shows a consistent pattern of expansion with increased payments leveraged to optimize vote capture. The implications for our current political and fiscal environment are stark. Between Social Security, Medicare, and Medicaid, entitlements are growing faster than the economy. Entitlements make up 14% of GDP, dwarfing Defense spending (~3%) and non-defense discretionary spending (~2%).  By 2032 debt service and entitlement spending are projected to consume the entire Federal Budget.

How did this reality come to pass. At each step of the way, the parties lobbying for pensions or other payments were not totally undeserving. Limits set at the onset of any given program always leave some parties just outside the scope of the benefit. It serves as a huge incentive to push for modest expansion. However, the expansion always works as a one way valve, always expanding and always leaving some parties just on the wrong side of some line drawn in the sand.

That which cannot go on for ever won't. Barring some extraordinary change in economic growth, the Federal Government will not be able to meet it's promises. Entitlements are growing at a rate that outstrips overall growth of the economy (538). Pushing tax rates may buy some time, but equally possibly may accelerate the time line to Federal bankruptcy.

The current dysfunction in Washington regardign budgets is directly related to uncontrolled entitlement spending. It is only going to get worse as actual discretionary $'s get scarcer and scarcer; and they will.

System issues v. personal blame

I listen to the banter out of Washington, bickering about "blame" for current events. What it brings to mind are recent discussions within healthcare about blame. Much is dysfunctional about health care but one thing we are moving past is the concept of blame. Historically, when bad outcomes happened the reflex was to look for someone to blame, but the safety and quality movement have begun to change our perspective. We ahve come to realize that while specific individuals may play roles in specific bad outcomes in healthcare, often system issues dwarf the responsibilities of specific people.

I will not argue that specific people are acting in ways which aggravate current dysfunctions in Washington, not the least of which is our current A...hole in chief. However, he is not alone in being immature (although he takes it to new lows). I would argue that he is a problem but he is not THE major problem. Budget dysfunction predated him. 

I was thinking about this issue for the past few days and low and behold Peter Suderman wrote a spot on piece in the NYT today regarding just this (Suderman NYT). We are now experiencing the consequence of poorly conceived legislative process (40 years old) coupled with shrinking discretionary dollars which has created an increasingly partisan environment driving a culture of brinkmanship.

Blame games will get us nowhere except for a spiral downward.  We need to grasp and embrace an understanding that  no single person or party can be blamed for our current state. Congress, past and present is to blame. The Presidents, past and present are to blame. The American people, past and present are to blame. We elected everyone in Washington and embraced expectations of Washington that are unattainable.

We can change who represents us but that will not get us much meaningful change unless we fix system issues which are the primary drivers of dysfunction. 

Federal budget gridlock

Here we go again. Budget gridlock. Federal Shutdown. Finger pointing. Who is to blame for the current state of affairs?

I believe a bit of historical context is needed. Between fiscal year 1977 and fiscal year 2015, Congress only passed all twelve regular appropriations bills on time in four years - fiscal years 1977, 1989, 1995, and 1997. Between 1976 and 2013, there were 18 times where funding was interrupted because of the inability to pass budgets or continuing resolutions. Government shutdowns occurred after 1980 as a consequence of rulings by then Attorney General Benjamin Civiletti subsequently requiring the Federal government to scale back services without actual appropriations (ref). The budgeting process is completely broken down. We may want to assign proximate blame for the most current shutdown but whatever argument is put forth, it is essentially meaningless in the larger sense.

The discretionary budget represents less than $0.30 on every dollar spent at the Federal level. Congress has essentially no control over more than 70% of Federal spending. While it may seem counter-intuitive, as the discretionary spending constricts, the incentives to play brinkmanship games appears to increase. With less money available to work out compromises, there are incentives to switch from win-win negotiations to winner takes all. And it is only going to get more pronounced as mandatory spending consumes more and more of the Federal Budget. By 2030, government shut downs will be meaningless since discretionary spending will be all be gone away. 

I am concerned that this shutdown may last a while precisely because no one seems to think it will and because Donald Trump is in a position to not back down. Furthermore, much of the government will continue to function (Vox). He does not really care if it blows up the Republican Party.  I will make a prediction. Like all predictions, it could be way off. I believe this will go on for weeks. The DACA issue and immigration were core stances for Trump. He will cater to his base. He has no reason to back down. 

The complex and evolving relationship

I read the Op-Ed piece in the NYT by Daphne Merkin titled "We say #MeToo. Privately we have misgivings" (NYT). It got me thinking. One characteristic of humans is we really have to work hard to understand historical context and time frames. We have existed in social groups for perhaps 100,000 years, and in larger complex groups for perhaps not more than 10,000 years, since the dawn of agriculture. Our current organizational structures have essentially just appeared over the course of not more than 500 years.

The relationships of men and women have undergone marked changes in recent decades and most of us within the US have little or no concept of how men and women related throughout the overwhelming majority of the course of human history. This relationship is nuanced and extraordinarily complex. Human societies have been grappling with this relationship since the dawn of human history. It cannot be boiled down to one idea or simple rules. However, the fate of humans depends upon how this relationship plays out. Men and women need to interact in a very personal, intimate, and vulnerable way or additional humans will not be made. Yes there are exceptions to this (in vitro fertilization and artificial insemination), but these are rare exceptions, not the rule and they have only been available for the equivalent of an historical blink of an eye.

The drives which motivate humans to mate are powerful and complex and have in some sense bedeviled societies for millennium. Rules were adopted with manage the risks. We look back upon many of these rules as being brutal, oppressive, and archaic, which they are given our present circumstances.  We need to remember that for most of human existence, our ancestors eked out their existence in a world of terrible violence driven by scarce resources. Mixed into this were sexual drives and competition for mates. Some rules worked better than other in terms of fostering success of social groups. It is reasonable to assume that the rules which made it to near contemporary times likely fostered additional social cohesiveness and moderated internal violence.

Fast forward to the past 100 years where there has been an extraordinary revolution in terms of the roles and status of women. No longer is there a huge advantage to size and aggressiveness of men. The industrial and communication revolutions have allowed women to compete for positions of leadership and authority on the basis of merit unlike any other time in history. However, we are still left with the legacy of who we are, complex social creatures whose procreation depends upon almost incomprehensible sexual motivations. Furthermore, sexual drives are to a great degree asymmetric and manifest differently in the two sexes. I understand there are overlapping distributions.

What this translates to is despite the changing roles and incredible changes in the overt trappings of society, we are left with the fate of humans being dependent upon the same personal, vulnerable, and private interactions our ancestors had to deal with. Intimate interactions still happen in private. The paths taken by couples to embark on the journey from casually meeting to intimate encounters has no single guidebook currently. (Older societies did simply this with mates being chosen by parents. We have for the most part discarded this convention). Each individual in the market for a mate needs to somehow successfully signal and then act when they believe they receive signals back. How people signal and what are acceptable signals is context, time, culture, and individual dependent. Some people can get away with certain approaches that others cannot.

This is not a topic handled by the formal educational system, something we should likely be grateful for. However, it leads to an almost infinite myriad of strategies which people use to attract partners. Which ones have historically been acceptable or are currently acceptable or will be acceptable is obviously evolving. No matter where these mores move toward, they will always need to address the reality that what drives these relationships are not rational and when they play out it places parties in vulnerable positions in private. There is no other realm of human existence that will provide a greater challenge to laws and social mores.

There is no EASY button. Beware of the hedgehogs who sell one simple approach.  Good systems will have failures.