Sunday, March 22, 2009
Special Olympics
44 went to California the other day to attend some town meetings that were being staged to help him promote his response to the recession and to pushing his budget proposals. He also found time to appear on the Tonight School with Jay Leno, something he (and other candidates) had done during the campaign. Mr. Leno provided a friendly forum for 44 to discuss his life in the White House and touch on a few topics of interest, like his work to restore calm to the financial markets. The audience was raucously pro-44 from the get-go, paralleling his rock star status seen during the last year. 44 worked without his familiar teleprompter and things seemed to be going well for him. Mr. Leno was a gracious host and didn't ask the kind of tough question one might hear on Face the Nation or Meet the Press, nor was anyone expecting him too.
When the topic turned to life in the White House and 44's love for basketball, Mr. Leno asked if the White House bowling alley might be sacrificed to put in a basketball court. 44 then offered the news that he had been practicing and bowled a 129, "sort of like Special Olympics or something." Mr. Leno laughed, the audience laughed and the conversation went elsewhere.
There was not the hush that occurs when a speaker commits a verbal sin, and in the case of the unrestrained public, a loud scolding voice from an outraged listener. Imagine, if you will, the kind of response had the guest been 43 and he had referred to his successor as a "colored man." Bear in mind that the term "people of color" is perfectly acceptable to audiences where there is a high proportion of leftward leaning listeners. However by substituting a prepositional phrase for an adjective, the first rendition becomes hate language at worst, a sign of unspeakable offensiveness at best.
One can only guess at the kind of reaction taking place backstage, where 44's staff was no doubt watching on a monitor. They are not employed by 44 to be unmindful of errors and one has to believe they were looking for a way to edit out 44's last remark. If there was any attempt to strong arm the Tonight Show staff into removing the Special Olympics reference, it hasn't been made public. Neither 44 nor Leno seemed to think it worthy of corrective action during the show. However, as recounted by the New York Times, during the return trip to Washington on Air Force One, calls were made. The Times' story appeared on page A10 of the March 20 edition and editorial comments were noticeable by their absence.
Nothing more is likely to happen now that apologies to the Kennedy family (the patron saints of the Special Olympics). After all, if Senator Ted can survive the plunge of his car into the waters of Martha's Vineyard from the Chappaquidick Bridge in 1969, leaving Mary Jo Kopechne to drown and go on to receive a Knighthood of the British Empire, what difficulty is there in forgiving 44 for mocking the abilities of the disabled? It was the kind of WASP country club humor that powerful men share when they think they are alone and unobserved by the prying eyes of community watchdogs. The same watchdogs who would grab onto any verbal miscue by a member of the ruling class and shake like a dead rat until it fell apart in their mouths. 44 had merely to order one of his minions to issue the apology and the matter lay as silent as a mummified Egyptian prince.
On one hand it is refreshing to see 44 show that he is, after all, just a human being. On the other, the outrage of the defenders of the public trust has been revealed again to be relative to the political orientation of the speaker, producing a double standard for conduct that is disturbing.
When the topic turned to life in the White House and 44's love for basketball, Mr. Leno asked if the White House bowling alley might be sacrificed to put in a basketball court. 44 then offered the news that he had been practicing and bowled a 129, "sort of like Special Olympics or something." Mr. Leno laughed, the audience laughed and the conversation went elsewhere.
There was not the hush that occurs when a speaker commits a verbal sin, and in the case of the unrestrained public, a loud scolding voice from an outraged listener. Imagine, if you will, the kind of response had the guest been 43 and he had referred to his successor as a "colored man." Bear in mind that the term "people of color" is perfectly acceptable to audiences where there is a high proportion of leftward leaning listeners. However by substituting a prepositional phrase for an adjective, the first rendition becomes hate language at worst, a sign of unspeakable offensiveness at best.
One can only guess at the kind of reaction taking place backstage, where 44's staff was no doubt watching on a monitor. They are not employed by 44 to be unmindful of errors and one has to believe they were looking for a way to edit out 44's last remark. If there was any attempt to strong arm the Tonight Show staff into removing the Special Olympics reference, it hasn't been made public. Neither 44 nor Leno seemed to think it worthy of corrective action during the show. However, as recounted by the New York Times, during the return trip to Washington on Air Force One, calls were made. The Times' story appeared on page A10 of the March 20 edition and editorial comments were noticeable by their absence.
Nothing more is likely to happen now that apologies to the Kennedy family (the patron saints of the Special Olympics). After all, if Senator Ted can survive the plunge of his car into the waters of Martha's Vineyard from the Chappaquidick Bridge in 1969, leaving Mary Jo Kopechne to drown and go on to receive a Knighthood of the British Empire, what difficulty is there in forgiving 44 for mocking the abilities of the disabled? It was the kind of WASP country club humor that powerful men share when they think they are alone and unobserved by the prying eyes of community watchdogs. The same watchdogs who would grab onto any verbal miscue by a member of the ruling class and shake like a dead rat until it fell apart in their mouths. 44 had merely to order one of his minions to issue the apology and the matter lay as silent as a mummified Egyptian prince.
On one hand it is refreshing to see 44 show that he is, after all, just a human being. On the other, the outrage of the defenders of the public trust has been revealed again to be relative to the political orientation of the speaker, producing a double standard for conduct that is disturbing.
Tuesday, March 10, 2009
Of stem cells and other myths
Yesterday 44 appeared in a ceremony to sign an order rescinding the ban on federal funding for embryonic stem cell research, in place since 43 stopped government money in 2001. It was the lead story on the CBS Evening News and on many local news shows as well.
As would be predictable from the emotional fervor that holds both sides of the debate, the proponents of funding embryonic stem cell research pulled out all the stops in cheer leading the move. In a non-scientific poll carried out in this blogger's household, the impression created by the coverage of the event was that 43 had, by executive order, blocked stem cell research from taking place in the United States.
The facts are these: embryonic stem cell research has never been banned in the United States. Research using pre-existing cell lines derived from embryonic stem cells has continued to receive federal funding. Nothing has prevented embryonic stem cell research from taking place in other countries or in privately funded labs in the United States. Federal funding using stem cells derived from other sources, like umbilical cord blood, has continued unchanged since 2001.
Why the hoopla? Why the rolling out of the proverbial kid in a wheelchair to herald the change? In part it seems to be a continuation of the desire of many of the previous administration's enemies to dance on its grave. It is also part of an odious tradition carried out by researches to tie their requests for basic science research to feelings of pity for those afflicted with diseases like Alzheimer's, diabetes, cystic fibrosis. The reality is that no clinically significant treatments have arisen from stem cell research, so to show a videotape of the actor Michael J. Fox writhing in distress with his Parkinsonian symptoms and imply that a cure was just around the corner had not 43 "banned" research, is disingenuous at best and cynically manipulative to boot.
As would be predictable from the emotional fervor that holds both sides of the debate, the proponents of funding embryonic stem cell research pulled out all the stops in cheer leading the move. In a non-scientific poll carried out in this blogger's household, the impression created by the coverage of the event was that 43 had, by executive order, blocked stem cell research from taking place in the United States.
The facts are these: embryonic stem cell research has never been banned in the United States. Research using pre-existing cell lines derived from embryonic stem cells has continued to receive federal funding. Nothing has prevented embryonic stem cell research from taking place in other countries or in privately funded labs in the United States. Federal funding using stem cells derived from other sources, like umbilical cord blood, has continued unchanged since 2001.
Why the hoopla? Why the rolling out of the proverbial kid in a wheelchair to herald the change? In part it seems to be a continuation of the desire of many of the previous administration's enemies to dance on its grave. It is also part of an odious tradition carried out by researches to tie their requests for basic science research to feelings of pity for those afflicted with diseases like Alzheimer's, diabetes, cystic fibrosis. The reality is that no clinically significant treatments have arisen from stem cell research, so to show a videotape of the actor Michael J. Fox writhing in distress with his Parkinsonian symptoms and imply that a cure was just around the corner had not 43 "banned" research, is disingenuous at best and cynically manipulative to boot.
Friday, March 6, 2009
Health Care "System" abuse
44 is not the first president to advocate reform of the health care "system" in the United States, nor will he be the last. This blogger feels an urge to explore what is meant by the phrase "health care system" as it relates to the practice of medicine. I fear that the term "health care system" (I'll call it HCS hereafter) is roundly abused by nearly all who use the term.
Definitions first: a system is defined in several ways: "A regularly interacting or interdependent group of items forming a unified whole (gravitational, thermodynamic for example)."
Or: "A group of devices or artificial objects or an organization forming a network, especially for distributing something or serving a common purpose."
Finally: "A form of social, economic or political organization or practice."
A HCS, I would argue, should consist of the elements listed in the above definitions. How about this: a group of organizations dedicated to the practice of medicine which form an integrated network to provide those services. There is no distinction in the definition between government and private involvement, nor is there any explicit reference to the financial aspects of such a system. Implicitly a financing mechanism ought to included in the explanation of how the system is sustained.
What other systems are comparable to the HCS and how were they developed and how are they organized? There is, of course, a system of government and laws that were established by the US constitution. Financing of the government is carried out through taxes raised by Congress, as provided in the constitution. The legal system outside of government, meaning the people who work in courts and law offices, contains both public and private elements. Courts, judges, bailiffs and others who work in and around the court system are paid salaries raised by taxes. Attorneys for all other matters, unless they are working pro bono, charge fees based on hours worked. The cost of a legal proceeding to an individual in a civil or criminal matter is born by the person hiring the attorney. The only exception is in criminal matters where the defendant can't afford an attorney and one is appointed. Many lawyers who represent clients seeking financial damages work on a contingency basis: if they win, they share the award. If they lose, they get nothing and do not pass on the costs of arguing the case to the client.
There have no been widespread calls for reform of the legal system, except that it works with extreme deliberation and not with what would be called speed. Lawyers' fees vary considerably from firm to firm and even within a particular firm. An experienced divorce lawyer might charge a client $300 per hour or higher whereas a neophyte or an associate might command half or less for the same unit of work, even though the results are the same. Except for attorneys taking cases on contingency, the end result does not dictate the fee.
Contrast that with people who work in health care. Many work for hourly wages, including physicians who work for institutions. Traditionally, doctors have been paid on a fee for service basis, with room for negotiation. But with the advent of major medical insurance, things started to change. Increasingly, the doctor dealt more with the insurance company rather than directly with the patient. When the US government became involved in a major way as a third party payer, in 1965 with the passage of Medicare by Congress. The doctors of the time signed on gladly, because at first they were guaranteed some payments rather than having to go out and collect on their own from patients. Looking a graph of health care cost inflation versus the overall cost of living, it's easy to see that the two lines were identical until 1965, when the slope of the health care inflation line increased dramatically. Now, 44 years later, the lines are as far apart as ever.
It is the desire to reign in costs that has driven the movement to designate medicine as a system and further to claim that it is "broken." Looking at life expectancy, death rates from major diseases in all age groups, the health of the US has never been better. It is a vast improvement over life in the pre-WWII era, when infectious disease took a heavy toll among the very young and the elderly. One unintended consequence of the inflation of health care costs has been the artificial rise in charges because of discounts demanded by third party payers, both private and government. It works like this: a procedure is billed by a physician or hospital at $100. The third party payer negotiates a rate of 60% of usual charges and pays $60. The next time the provider of services organizes his charges, the price is raised to $120. 60% of that is $72, and so on. Eventually the charge reaches astronomical levels and the individual without insurance is asked to pay the full, non-discounted rate, which leads to an inability to pay bills. People start to forgo health care insurance because the premiums rise higher than the out of pocket costs. A vicious cycle is started.
To the welfare state oriented policy makers and politicians, the "obvious" solution is to turn medical care into a regulated utility like the power company, with rates that are set by commission, not market conditions. Hence their framing of the problem as a "system" that is broken. What is broken is the connection between the real consumer of health care and those who write the checks. True, the consumer pays the bill eventually, but the cost is often disguised as forgoing higher salaries in exchange for the employer buying group rate insurance for employees. By the end of the 20th century, even the deep pockets of employers had been emptied. Continued improvement in medical technology, application of that technology to individuals near the end of life and an insatiable pressure from consumers to be served without any delays with the very best combined to escalate costs. Highly visible spokesmen advocating universal health care coverage pointed to the alleged lower costs of health care in other countries while ignoring the mandatory rationing that delayed or denied care in those countries as well as the very different national demographics that produced higher than expected infant mortality in US urban areas. Comparing that to, for example, a homogeneous population in a north European country made it seem that the US system of financing health care was responsible for the higher mortality numbers.
Over time, by the act of repeating numerous myths in mass media outlets, the proponents of universal health care and a reform of the non-existent "system" for health care set the agenda for what is about to take place in Washington. One of the more pernicious myths that has a life of its own is that US health care is error ridden and causes 100,000 deaths annually because of preventable mistakes. The emphasis is on the alleged preventable nature of these mistakes. The origin of the myth is an observational study published in the venerable NewEngland Journal of Medicine in the mid-1970s. The researchers were attempting to get a handle on the scope of injuries and deaths in hospitals in New York State. They examined all hospital deaths and discharges from a select number of hospitals in the state and asked their investigators, who were all physicians, to flag any deaths that seemed to be related to the medical interventions being performed and any that occurred in patients whose true diagnoses had been delayed either in hospital or before admission. The physicians, being hyper critical of their fellows as is typical when this sort of exercise is carried out, produced a number of deaths deemed "preventable" from the standpoint of there possibly have been earlier intervention in a disease or a procedure carried out that may have caused or hastened a patient's death. This was irrespective of the actual diagnosis. In other words, if a patient was actively dying of an incurable disease and there occurred any complication that hastened the death, for example a catheter infection in a terminal cancer patient, the death was deemed due to medical error. Similarly, if a patient's cancer was diagnosed out of the hospital at any time after the symptoms, however vague, were reported to any physician, that death was counted as a medical error. So the design of the study had a systemic bias in the direction of over-reporting deaths as due to medical error. If a person on the street is asked the meaning of the 100,000 deaths per year statistic, he is likely to believe the deaths all occurred in healthy people who were admitted for elective procedures and died in the hospital. The 100,000 figure was derived by dividing the numbers of deaths per hospital discharge at the particular teaching hospital and multiplying the number by all hospital discharges in New York State. So the bias in hospital selection was added to the bias in case selection. A different study using similar methods but using hospitals in Colorado arrived at an estimate of annual fatalities due to medical errors half that of the first study.
Remember that these were estimates only, using a single teaching hospital in a large urban area. Remember as well that the reviewers were counting fatalities that in many cases would have occurred anyway, albeit a day or two later. In the world of real medicine, the state of Minnesota has been requiring for several years that all hospitals report adverse events, some fatal, some not fatal. The average number of deaths per year has been about 20. This may still be too high, but it is about 1% of the 100,000 nationwide deaths if the numbers are multiplied by 50 states. And what is even more interesting is that in spite of Minnesota hospitals spending large amounts of time and treasure on fixing the problem, the numbers have not gone down, and in some years have increased.
This has gone somewhat far afield from the question of financing HCS, but it serves as a reminder that not all problems as defined by politicians, are problematical. Good statistics on medical errors are important: why, then, do the proponents of universal, government sponsored HCS continue to use statistics that are wildly inaccurate and out of date? A cynic would suggest that the erroneous numbers make a stronger case for changing what in fact does not meet criteria for needing change. The ideologues pushing for socialized medicine need to scare the population into accepting an alternative that will lead to rationing of care and higher overall taxes. So why not engage in some harmless exaggeration? It's worked so far for the climate change lobby in terms of convincing people that the planet is on its death bed, and therefore carbon taxes are the only solution.
44 is letting his policy wonks do the wet work of eliminating the opposition on this one. If enough people have been scared by the shibboleths of medical errors and money wasted by insurance companies, they may well win the day and clamp the manacles of over-regulation on what is now the best health care on the planet, system or not.
Definitions first: a system is defined in several ways: "A regularly interacting or interdependent group of items forming a unified whole (gravitational, thermodynamic for example)."
Or: "A group of devices or artificial objects or an organization forming a network, especially for distributing something or serving a common purpose."
Finally: "A form of social, economic or political organization or practice."
A HCS, I would argue, should consist of the elements listed in the above definitions. How about this: a group of organizations dedicated to the practice of medicine which form an integrated network to provide those services. There is no distinction in the definition between government and private involvement, nor is there any explicit reference to the financial aspects of such a system. Implicitly a financing mechanism ought to included in the explanation of how the system is sustained.
What other systems are comparable to the HCS and how were they developed and how are they organized? There is, of course, a system of government and laws that were established by the US constitution. Financing of the government is carried out through taxes raised by Congress, as provided in the constitution. The legal system outside of government, meaning the people who work in courts and law offices, contains both public and private elements. Courts, judges, bailiffs and others who work in and around the court system are paid salaries raised by taxes. Attorneys for all other matters, unless they are working pro bono, charge fees based on hours worked. The cost of a legal proceeding to an individual in a civil or criminal matter is born by the person hiring the attorney. The only exception is in criminal matters where the defendant can't afford an attorney and one is appointed. Many lawyers who represent clients seeking financial damages work on a contingency basis: if they win, they share the award. If they lose, they get nothing and do not pass on the costs of arguing the case to the client.
There have no been widespread calls for reform of the legal system, except that it works with extreme deliberation and not with what would be called speed. Lawyers' fees vary considerably from firm to firm and even within a particular firm. An experienced divorce lawyer might charge a client $300 per hour or higher whereas a neophyte or an associate might command half or less for the same unit of work, even though the results are the same. Except for attorneys taking cases on contingency, the end result does not dictate the fee.
Contrast that with people who work in health care. Many work for hourly wages, including physicians who work for institutions. Traditionally, doctors have been paid on a fee for service basis, with room for negotiation. But with the advent of major medical insurance, things started to change. Increasingly, the doctor dealt more with the insurance company rather than directly with the patient. When the US government became involved in a major way as a third party payer, in 1965 with the passage of Medicare by Congress. The doctors of the time signed on gladly, because at first they were guaranteed some payments rather than having to go out and collect on their own from patients. Looking a graph of health care cost inflation versus the overall cost of living, it's easy to see that the two lines were identical until 1965, when the slope of the health care inflation line increased dramatically. Now, 44 years later, the lines are as far apart as ever.
It is the desire to reign in costs that has driven the movement to designate medicine as a system and further to claim that it is "broken." Looking at life expectancy, death rates from major diseases in all age groups, the health of the US has never been better. It is a vast improvement over life in the pre-WWII era, when infectious disease took a heavy toll among the very young and the elderly. One unintended consequence of the inflation of health care costs has been the artificial rise in charges because of discounts demanded by third party payers, both private and government. It works like this: a procedure is billed by a physician or hospital at $100. The third party payer negotiates a rate of 60% of usual charges and pays $60. The next time the provider of services organizes his charges, the price is raised to $120. 60% of that is $72, and so on. Eventually the charge reaches astronomical levels and the individual without insurance is asked to pay the full, non-discounted rate, which leads to an inability to pay bills. People start to forgo health care insurance because the premiums rise higher than the out of pocket costs. A vicious cycle is started.
To the welfare state oriented policy makers and politicians, the "obvious" solution is to turn medical care into a regulated utility like the power company, with rates that are set by commission, not market conditions. Hence their framing of the problem as a "system" that is broken. What is broken is the connection between the real consumer of health care and those who write the checks. True, the consumer pays the bill eventually, but the cost is often disguised as forgoing higher salaries in exchange for the employer buying group rate insurance for employees. By the end of the 20th century, even the deep pockets of employers had been emptied. Continued improvement in medical technology, application of that technology to individuals near the end of life and an insatiable pressure from consumers to be served without any delays with the very best combined to escalate costs. Highly visible spokesmen advocating universal health care coverage pointed to the alleged lower costs of health care in other countries while ignoring the mandatory rationing that delayed or denied care in those countries as well as the very different national demographics that produced higher than expected infant mortality in US urban areas. Comparing that to, for example, a homogeneous population in a north European country made it seem that the US system of financing health care was responsible for the higher mortality numbers.
Over time, by the act of repeating numerous myths in mass media outlets, the proponents of universal health care and a reform of the non-existent "system" for health care set the agenda for what is about to take place in Washington. One of the more pernicious myths that has a life of its own is that US health care is error ridden and causes 100,000 deaths annually because of preventable mistakes. The emphasis is on the alleged preventable nature of these mistakes. The origin of the myth is an observational study published in the venerable NewEngland Journal of Medicine in the mid-1970s. The researchers were attempting to get a handle on the scope of injuries and deaths in hospitals in New York State. They examined all hospital deaths and discharges from a select number of hospitals in the state and asked their investigators, who were all physicians, to flag any deaths that seemed to be related to the medical interventions being performed and any that occurred in patients whose true diagnoses had been delayed either in hospital or before admission. The physicians, being hyper critical of their fellows as is typical when this sort of exercise is carried out, produced a number of deaths deemed "preventable" from the standpoint of there possibly have been earlier intervention in a disease or a procedure carried out that may have caused or hastened a patient's death. This was irrespective of the actual diagnosis. In other words, if a patient was actively dying of an incurable disease and there occurred any complication that hastened the death, for example a catheter infection in a terminal cancer patient, the death was deemed due to medical error. Similarly, if a patient's cancer was diagnosed out of the hospital at any time after the symptoms, however vague, were reported to any physician, that death was counted as a medical error. So the design of the study had a systemic bias in the direction of over-reporting deaths as due to medical error. If a person on the street is asked the meaning of the 100,000 deaths per year statistic, he is likely to believe the deaths all occurred in healthy people who were admitted for elective procedures and died in the hospital. The 100,000 figure was derived by dividing the numbers of deaths per hospital discharge at the particular teaching hospital and multiplying the number by all hospital discharges in New York State. So the bias in hospital selection was added to the bias in case selection. A different study using similar methods but using hospitals in Colorado arrived at an estimate of annual fatalities due to medical errors half that of the first study.
Remember that these were estimates only, using a single teaching hospital in a large urban area. Remember as well that the reviewers were counting fatalities that in many cases would have occurred anyway, albeit a day or two later. In the world of real medicine, the state of Minnesota has been requiring for several years that all hospitals report adverse events, some fatal, some not fatal. The average number of deaths per year has been about 20. This may still be too high, but it is about 1% of the 100,000 nationwide deaths if the numbers are multiplied by 50 states. And what is even more interesting is that in spite of Minnesota hospitals spending large amounts of time and treasure on fixing the problem, the numbers have not gone down, and in some years have increased.
This has gone somewhat far afield from the question of financing HCS, but it serves as a reminder that not all problems as defined by politicians, are problematical. Good statistics on medical errors are important: why, then, do the proponents of universal, government sponsored HCS continue to use statistics that are wildly inaccurate and out of date? A cynic would suggest that the erroneous numbers make a stronger case for changing what in fact does not meet criteria for needing change. The ideologues pushing for socialized medicine need to scare the population into accepting an alternative that will lead to rationing of care and higher overall taxes. So why not engage in some harmless exaggeration? It's worked so far for the climate change lobby in terms of convincing people that the planet is on its death bed, and therefore carbon taxes are the only solution.
44 is letting his policy wonks do the wet work of eliminating the opposition on this one. If enough people have been scared by the shibboleths of medical errors and money wasted by insurance companies, they may well win the day and clamp the manacles of over-regulation on what is now the best health care on the planet, system or not.
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