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If this were a pill, you’d do anything to get it (washingtonpost.com)
243 points by vellum 1424 days ago | hide | past | web | 142 comments | favorite



One big problem with medicine in this country is that bad hospitals can't just go out of business and be replaced by better ones. If you want to open a new hospital today, there are hearings in which all the crappy existing other hospitals have to say it's okay before you can get a "Certificate Of Need".

So if you had an idea for a new hospital structure that would dramatically improve patient health and cut costs, you wouldn't be allowed to just build it and try it - the existing providers all get a veto.

So we have hospitals that hide all the prices and make MORE money if they screw up and introduce complications, and it's ILLEGAL to drive those idiots out of business with a more customer-responsive system.

It's like if you couldn't open a new coffee shop without permission from Starbucks or a new restaurant without permission from McDonald's. In anything even vaguely resembling a free market, reforms like this wouldn't need to be pushed by a monolithic central bureaucracy - they'd just spread on their own, with old providers rushing to adopt the modern changes for fear of becoming obsolete.

http://en.wikipedia.org/wiki/Certificate_of_need


That may be true, but it misses the point. No single hospital will transform healthcare. The entire structure needs to change - and that's exactly what is happening today.

The trend right now is moving away from hospital-based care and towards an outpatient-based "medical home" model. In the new model, health systems (not necessarily hospital systems) are given bundled payments for managing a set of patients instead of fixed fees for each exam or procedure. This incentivizes health systems to encourage wellness and rewards them for more aggressively treating the sickest patients and keeping them out of the hospital. This is better for everyone, especially the patients.

It turns out that a small percentage of patients with multiple chronic conditions generate much of the cost of our healthcare spending. One way to keep these patients healthy and out of the hospital is to hire companies that specialize in intensive home-based treatment like the company profiled in the article, HQP.

TL;DR The path forward is keeping patients healthy and out of hospitals, not building new ones.


So instead of paying for health insurance if we get sick, the system promises us that we will pay for managed care all the time. Isn't that the promise of HMO? What is different between a "Medical home"? Do we need government action or does Ted Kennedy's 1973 HMO Act provide enough leeway for this kind of managed care?


The new term is Accountable Care Organization (ACO), and don't worry, an ACO is very different from an HMO. In fact, they changed two out of the three letters.

Seriously speaking you are right, this is a risk. I have asked this same question many times to senior folks involved with health reform. I haven't heard a 100% convincing answer, but I'm most of the way there.

Here are the key differences:

1. More MDs, fewer MBAs. HMOs were generally run by insurers (payers) far removed from patients. ACOs are being created primarily by hospital systems and physician groups, sometimes in partnership with a payer (which has more experience managing risk).

2. More/Big data. We have a lot more data, and we've gotten a lot smarter about how to analyze it. So instead of simply rationing care, we can identify and then focus on areas to improve quality and cut costs. Also, the (unsteady) march towards electronic health records (EHRs) should improve this even more.

3. Quality measures. We can leverage data to force providers to compete on quality. See http://www.medicare.gov/hospitalcompare/ for a simple example.

4. Freedom to change plans. In the past, once you had a pre-existing condition you were stuck because no other health plan would accept you. Once plans are prevented from doing this, patients will have the freedom to look elsewhere if they feel their care is being limited.

Update: Added additional info to point 2.


"More MDs, fewer MBAs"

As Bullwinkle said to Rocky, "this time fur sure"

Honestly,

There's little evidence that healthcare is changing for the better and these measures may sound good but in many ways boil down to easter-egging a system broken on much more fundamental levels. You notice the way the mortality rate on the original article's chart was creeping back up, you hear how high-school educated white men experienced a significantly lowered life expectancy in the last ten years?

Of various things in your gilded list, "Quality measures. We can leverage data to force providers to compete on quality". You can use external incentive to increase quality and productivity on something like an automobile assembly line. But turning health care into an assembly line destroys the "human touch" that both helps patients and makes providers self-motivated. There was a study which showed zero gain in health care productivity over some long period of electronic automation. I blame the counter-productiveness of turning things into an assembly-line activity.

Consultants have been slingin' recipes for improved productivity out of managed, controlled, incentivized systems for a long, long time and the disaster has only grown larger. They have made lots of money, they'll continue to make lots of money and transform things for the worse for as long as they can define the problem as being medicine not being run like an automated warehouse. They even make more money failing than warehouse automators make succeeding because they have to reorganize again, and again, and again. Gawd, it's night of the live dead, regulatory-capturing consultants...


The free market offers no incentive to give health services to people who cannot pay for it, or don't know that these services will reduce hospitalization by 33% and costs by 22%.

Basic health care is not McDonald's because your mother does not die prematurely (and miserably, and expensively) for the lack of McDonald's. The core issue is not about some private business being 'customer-responsive' in the vein of Starbucks. You can, today, start private clinics which are more "customer-responsive" (leave a mint on your pillow, etc.) but how are you going to recoup the costs and in particular, how does that benefit the populace in aggregate?


> The free market offers no incentive to give health services to people who cannot pay for it, or don't know that these services will reduce hospitalization by 33% and costs by 22%

Amen to that. The major killers at the turn of the last century were tuberculosis and waterborne diseases, and the free market did nothing to improve living conditions or supply clean water to the urban population then. I am in Portugal right now, where Dr Sousa Martins, a physician who spearheaded the fight against tuberculosis, is considered a saint. Public health is always political issue. It is as true 100 years ago as it is now.


Free market didn't improve living conditions? The supply and demand for more spacious housing and fuel to boil water didn't help things?


For the upper 50%, sure, but the free market failed and generally fails to give the lower 50% of earners access to sufficient resources to do proper sanitation. Treating clean water as a commodity rather than a public utility is a public health disaster. Each household needing expertise and equipment for water purification does not scale.


Define failure in this case. Yes the poor have less than the rich, but so what? What is the cost of clean water today? How much for a fridge?

As it turns out, 99.9% of us households have a fridge (http://www.eia.gov/emeu/recs/appliances/appliances.html). Those weren't really available in 1900, yet I don't remember any huge government subsidy for those (and by keeping your food fresh they prevent diarrhea and improve hygine). I do remember huge, private, factories making them, however.

But even then soap is likely also one of those things that really help prevent deceases through proper sanitation -- yet how poor do you have to be to not be able to afford soap?


> What is the cost of clean water today? How much for a fridge?

A fridge is much more expensive, but it's also much more a luxury. You don't need to refrigerator to avoid diarrhea, it just helps. Pure running water on the other hand is extraordinarily cheap and makes avoiding waterborne illness easy. (Due to the fact that running water is provided by public utilities, not free markets.)

I'm not saying the free market doesn't have a part to play in good hygiene, but trying to rely on the free market for a water supply and food handling regulations has been an unmitigated disaster everywhere it's been tried.


"unmitigated disaster everywhere it's been tried".

England is served by private water companies. Is this a disaster?


Public utilities aren't necessarily public companies. Private companies own and manage the lines, yes, but prices are fixed by the government, and companies are required to supply water to residents, often even in cases of non-payment. Hardly a free market, and definitely what I would call regulated public utilities.


There are many private water systems in the US- I own my own well and septic system, as do all of my neighbors. There are developments nearby that have their own private systems- and it works very well, so I really don't get the unmitigated disaster statement. Perhaps you could share some examples, because that has not been my experience.


No, the free market didn't. People like Sara Josephine Baker did:

http://en.wikipedia.org/wiki/Sara_Josephine_Baker

The free market creates slums. "People are willing to pay for it!" is the phrase that defines the free market. And yes, people are willing to pay to live in slums… when there are no laws, or no enforcement of laws, to protect their interests, because they are powerless, ignorant, undocumented, poor.


>Basic health care is not McDonald's because your mother does not die prematurely (and miserably, and expensively) for the lack of McDonald's

It is indeed important to recognize where health care deviates from known "[market-]solved problems". But you haven't shown an important difference there. While mom doesn't die from lack of McDonald's, she does die from lack of food, and yet no one uses that a reason to make trite remarks about how we can't possibly allow a free market in food.

Rather, they would recognize that we should leave food production to the market, and simply have the government buy from producers, like we do with food stamps, and then concentrate on making sure that such a system doesn't have bizarre implications for the incentive structure.

>You can, today, start private clinics which are more "customer-responsive" (leave a mint on your pillow, etc.) but how are you going to recoup the costs and in particular, how does that benefit the populace in aggregate?

The problem is that you're not going to get reimbursed by the government, no matter how much better your service is per dollar than the existing recipients of the money. So no, it's not really anything like a fair competition where market incentives bring in new entrants where existing providers suck.

The things is, we are already using a market to provide health care to people unavailable to afford it; it's just that the payer is someone else.

So it's import to examine the process by which that money is given out, and whether it's encouraging waste, or if it has an incentive to economize on care to get the best outcome per dollar. And you don't answer that question by saying "this ain't the market" (because it largely is) or dismiss it by asking how they're going to get paid (because someone is already paying for these services).


> and yet no one uses that a reason to make trite remarks about how we can't possibly allow a free market in food

We do not have a free market in food. Even if you ignore subsidies entirely… Have you not heard of the FDA? Upton Sinclair? Health inspections for restaurants? Requirements to enrich certain food products, pasteurize others?

How about the pet food and baby formula from China (free market!) that was found to have melamine and other poisons in it?

A free market in food results in low quality, unsafe, non-nutritious food. Or things that masquerade as food but aren't. On that note… History will look back at many of our legal "foodstuffs" of today and call them as awful as Radon Water:

http://www.periodictable.com/PopularScience/2004/08/2/index....

Like slums (see my other comment) -- people will pay to live in slums, you know, the free market creates them --- a free market for food provides for a few and poisons the rest. Not unlike the healthcare situation in the US.


> Have you not heard of the FDA? Upton Sinclair?

I'm not going to get into the rest, but it's always worth mentioning that Upton Sinclair's book was a work of fiction. Most of the more disgusting and dangerous scenarios in the book were stuff that he invented to make the book more exciting and make it work better as propaganda. In short, he took dramatic license.

And the FDA has quite likely killed more people than it has saved, and the USDA is essentially a way to subsidize the meatpacking industry by socializing some costs the industry would otherwise have to pay for itself. The net effect of such organizations on safety trends is, at the least, debatable. In the economic literature you often find that the rate of improvement decreases when a new regulatory institution starts managing some metric.


>And the FDA has quite likely killed more people than it has saved,

My immediate reaction is to say you're full of shit. But I'll hold off judgment and see if you can offer any shred of an argument that justifies this statement (not even asking for proof here).


>> And the FDA has quite likely killed more people than it has saved,

> My immediate reaction is to say you're full of shit. But I'll hold off judgment and see if you can offer any shred of an argument that justifies this statement (not even asking for proof here).

The result of the FDA's post-1962 efforts has been to dramatically slow the rate of introduction of new drugs with essentially no effect on the average quality level of the drugs that do get introduced. Some new drugs still get through, but less than half as many per unit time and the FDA approval process delays the use of those drugs and makes them vastly more expensive to develop. These extra delays and higher costs are estimated to have caused, at a minimum, hundreds of thousands of preventable deaths.

Good drugs save lives. Good drug information saves lives. The FDA often finds itself in the business of postponing the use of good drugs and preventing the dissemination of valid drug information. It has a powerful institutional bias towards inaction, but failing to approve good drugs in a timely manner kills people with at least as much certainly as does letting bad ones through.

The notion that the modern FDA on net hurts us more than it helps is a pretty common belief among those economists who have studied the matter. I'd start with this general overview of the issues:

http://www.econlib.org/library/Enc/PharmaceuticalsEconomicsa...

And then browse this site - lots of good stuff there:

http://www.fdareview.org/

Bryan Caplan summarizes the general state of opinion as: "The public thinks the FDA is great. Regular economists think it's pretty good. And economists who specialize in the FDA think it's pretty bad." (source: http://econlog.econlib.org/archives/2005/04/fda_public_econ.... )


Well, you certainly passed my low bar for rationale. I still can't agree though.

Any argument based on statistics is going to be strongly biased against the FDA's current procedure. It is impossible to predict how many deaths were prevented from keeping dangerous drugs off the market, so it is impossible to make a meaningful comparison. Furthermore, a simple utilitarian argument about the net lives saved is not how most people would comprehend the situation. The situation where a drug kills someone will be weighed much more gravely than the situation where a life-saving drug was kept from you because it couldn't be proven effective. So a net-lives-saved calculation simply doesn't capture the intuition that most people have.

Being biased towards conservatism is appropriate at the scale of approving drugs and advertisement towards an entire country. Most people do not have the knowledge (even considering the internet) to appropriately evaluate a drug. I would wager that even doctors are not equipped to make this sort of safety evaluation for their patients. This is exactly the sort of thing that scientists taking a conservative approach should be doing.


Read the links I gave. I wasn't expecting you to be convinced just by what I wrote above.

Before 1962, the FDA was tasked to verify safety but NOT to verify efficacy. Everything you just wrote only argues for that - for keeping drugs off the market that "kill someone" when they take it. It does NOT argue for keeping drugs off the market that we know are safe but can't yet conclusively prove work "better than a placebo" or "better than the standard treatment" in a study.

After 1962, the FDA was tasked with determining efficacy. That is the part where the main problem lies. It turns out that proving that a drug probably doesn't kill people is MUCH easier than proving that a drug "works" at a level better than some metric.

To prove a drug is safe, we have models and processes to calculate the LD50 and verify that people who take it at expected dose levels don't get sick. But to prove it's effective is hard. Hard enough that, in practice, insisting on it it kills hundreds of thousands of people. As one popular example, when the FDA approved beta blockers for use in preventing heart attacks, the FDA's own press release claimed that the newly approved drugs would save 10,000 lives per year, based on the results seen in Europe where the drugs had been in use for the prior decade. Economists look at that and notice that seems to suggest keeping that one class of drug OFF the market in the US after it had been approved in Europe killed on the order of 100,000 people all told. That is a very large death count. The worst death count we've ever seen due to drugs that "slipped through the cracks" prior to 1962 is a few orders of magnitude smaller than that.

> The situation where a drug kills someone will be weighed much more gravely than the situation where a life-saving drug was kept from you because it couldn't be proven effective. So a net-lives-saved calculation simply doesn't capture the intuition that most people have.

That is true, but in this case the "intuition that most people have" is WRONG. By any rational standard, killing a hundred people by preventing them from getting their medicine is MUCH WORSE than killing one person by letting him get his medicine...even if we know who the people affected are in the latter case and not the former. That is approximately the sort of tradeoff we're looking at.

> It is impossible to predict how many deaths were prevented from keeping dangerous drugs off the market, so it is impossible to make a meaningful comparison.

It is difficult, but probably not impossible. One might look at the death rates attributed to medicinal prescription drugs under various regulatory regimes. In the US, you can compare drugs approved pre-1962 versus post-1962 - if the FDA's extra testing in the modern era were really valuable, there should be a bend in that curve in the correct direction (hint: there isn't). One can also compare with other countries that changed their regulatory regimes to be stricter or looser. Sure, you can't get an exact number of deaths, but you can make a plausible estimate. And this calculation WAY favors the FDA approach, due to the "what is seen and what is not seen" factor - people who die from taking a drug show up in newspaper headlines blaming the drug whereas people who die from NOT taking a drug do not show up in newspaper headlines blaming the FDA. :-)

BTW, one simple huge improvement would be to just say that any drug approved for use by some other country's regulatory apparatus could be used here too with a mere "not yet approved by the FDA" warning label.


I read two of the links and skimmed the third. They weren't terribly convincing. You certainly have a point about beta-blockers, there was already a natural experiment being conducted on a mass scale in Europe. If it looked like it was safe and effective, there's no reason why that shouldn't have been used as evidence to expedite the approval process in the US. This isn't an indication that the entire process needs to be overhauled though.

As far as determining efficacy, I prefer this to the alternative. Simply judging rates pre-1962 doesn't really capture the potential for abuse that exists in our current media-saturated lives. Many European countries completely ban drug marketing towards individuals. If the FDA allowed drug makers to market unproven drugs in the US, that would create a huge clusterfuck of false advertising and manipulation. You cannot responsibly advocate both positions.

>By any rational standard, killing a hundred people by preventing them from getting their medicine is MUCH WORSE than killing one person by letting him get his medicine

Yes, using the severely biased statistics that are available. In an environment where proof of efficacy were not required, one can imagine that the drug making business (in the US where direct marketing is allowed) would be even stronger with greater pressure to push drugs on the general population. At scale, deaths rates due to drugs will show up that are impossible to discover using small scale testing. It is known that generic Aspirin kills a hundred or so people a year around the world. More widespread usage of drugs, which is the direct result of what you're proposing, would undoubtedly cause more such cases.


Forget "marketing". Take that out of the equation. I don't care if you ban all marketing to individuals. (Well, I do, but that's an entirely separate argument, and a distraction from this one). The question here is just what drugs can legally be sold or prescribed, regardless of how people learn about them. Currently, "off-label" use is COMPLETELY ACCEPTABLE to the FDA! Once a drug is legal to use, you can use it for any condition at all, not just the condition it was proved efficacious for.

So we already have current widespread use of drugs that haven't been proven efficacious. It doesn't seem to have been a disaster. In fact, widespread use of drugs is one of the few forms of medical intervention that demonstrably makes people more healthy on net. Right now the rule is that it's legal to use drugs if:

(a) they got accidentally grandfathered in due to historical use (eg, aspirin and penicillin would NOT have passed the FDA's current standards), or (b) they were patentable and turned out to be useful enough for treating SOMETHING that it was worth spending on the order of a billion dollars getting SOME use approved, even if it's not the use it's being prescribed for now.

Meanwhile, a drug that is just as effective but isn't patentable or treats a rare enough condition that it's not worth spending a billion dollars to get it through trials in the US...is not legal to prescribe.

Can you honestly justify that contrast?

If a drug has been legal in, say, Denmark, for five or ten years, has seen widespread use, and hasn't caused mass deaths THERE, why can't we just automatically make it legal to use here WITHOUT spending hundreds of millions of dollars redoing the same studies here? Do we think the FDA is somehow smarter and better at its job than its equivalent in every other country in the world?

The FDA faces the wrong incentives. It has no reason to take into account the huge cost of the harm it does, which is a matter of life or death to people with rare or serious diseases. It needs to be fundamentally overhauled or gotten rid of entirely. Yes, there would be costs to letting more people take more drugs...but every serious attempt to estimate it says the benefits would outweigh the costs. If you don't want sick people dying needlessly, you should be opposed to the FDA in its current form. It is an idea whose time has gone.


Here's a much more specific response (from http://www.fdareview.org/harm.shtml):

Gieringer (1985) used data on drug disasters in countries with less-stringent drug regulations than the United States to create a ballpark estimate of the number of lives saved by the extra scrutiny induced by FDA requirements. He then computed a similar ballpark figure for the number of lives lost owing to drug delay:

[T]he benefits of FDA regulation relative to that in foreign countries could reasonably be put at some 5,000 casualties per decade or 10,000 per decade for worst-case scenarios. In comparison, it has been argued above that the cost of FDA delay can be estimated at anywhere from 21,000 to 120,000 lives per decade. . . . Given the uncertainties of the data, these results must be interpreted with caution, although it seems clear that the costs of regulation are substantial when compared to benefits. (196)

In short, that paper estimates the FDA has killed more than twice as many people as it has saved.

The reference: "Gieringer, D. H. 1984. Consumer Choice and FDA Drug Regulation. Ph.D. diss., Department of Engineering-Economic Systems, Stanford University."

Here's another really good (and SHORT) general overview article that should address a lot of your concerns, "Economists Against the FDA" by Daniel B. Klein:

http://www.scu.edu/civilsocietyinstitute/articles/upload/Eco...

When I said that delaying good drugs and good drug information kills, by drug information I meant stuff like this (from the Klein article):

Today men with risk of heart trouble know to take half an aspirin a day. By 1988 it was well established that aspirin greatly reduces the risk of myocardial occlusion. But for years the FDA forbade aspirin makers from advertising that fact (the FDA still significantly restricts advertising about it). The FDA surely killed tens, and quite possibly hundreds, of thousands of Americans by this restriction alone."


Sorry, I didn't see this post earlier. The paper you link to makes some good arguments about the approval process. While I absolutely can't agree that the legal system can effectively screen out dangerous drugs without an oversight agency like the FDA, I can agree that the approval process for drugs to treat acute deadly diseases should be expedited in proportion to the severity of the condition it treats. The problem I see with these arguments is that they're using the worst case scenarios to argue abolishing the agency altogether. Aside from cases of life-saving drugs, the FDA also works to keep drugs and devices to treat non life-threatening or cosmetic cases from being harmful or deadly. An argument that beta-blocker drugs should have been approved faster is not an argument that your typical diet drug should have been. If we can draw a distinction between these cases, I'm more receptive to the arguments you're making.

As far as aspirin for heart attacks goes, I can see the logic in not allowing a drug company to advertise its use for this purpose. Were doctors made aware of this use and were they trained to offer it as medication in appropriate cases? If so, then I think the system worked as it should. If not then there should be a system in place that disseminates such information to doctors and other medical professionals. But allowing drug companies to advertise directly is a massive can of worms. I don't think it should be allowed at all, let alone for "unproven" uses. People are not knowledgeable or responsible enough to evaluate the use of a drug based on uncertain information.


I have read a lot about Upton Sinclair but never heard the criticism that his novel was unrealistic. References?

On the other hand, the inspectors assigned by President Roosevelt at the time…

> Learning about the visit, owners had their workers thoroughly clean the factories prior to the inspection, but [Labor Commissioner Charles P. Neill and social worker James Bronson Reynolds] were still revolted by the conditions. Their oral report to Roosevelt supported much of what Sinclair portrayed in the novel...

And Teddy Roosevelt apparently hated Sinclair, so somehow I trust his employees finding more than I trust you, random hackernewser.

>... excepting the claim of workers falling into rendering vats…

And as for that last bit, is it made up? Surely considering how many workers have accidentally been killed in other "crazy" accidents involving falling-into-stuff (e.g. ammonia/effluent holding tanks), which have been documented, it's not far fetched to believe that in an abusive, unsafe, and unsanitary environment, at least one person has died that way.

So, I'm left with only one conclusion:

You're making stuff up.


> I have read a lot about Upton Sinclair but never heard the criticism that his novel was unrealistic. References?

Try this summary:

http://www.fee.org/the_freeman/detail/of-meat-and-myth

A few paragraphs relevant to what you just wrote:

historians with an ideological axe to grind against the market usually ignore an authoritative 1906 report of the Department of Agriculture’s Bureau of Animal Husbandry. Its investigators provided a point-by-point refutation of the worst of Sinclair’s allegations, some of which they labeled as “willful and deliberate misrepresentations of fact,” “atrocious exaggeration,” and “not at all characteristic.”

Instead, some of these same historians dwell on the Neill-Reynolds Report of the same year because it at least tentatively supported Sinclair. It turns out that neither Neill nor Reynolds had any experience in the meat-packing business and spent a grand total of two and a half weeks in the spring of 1906 investigating and preparing what turned out to be a carelessly written report with predetermined conclusions. Gabriel Kolko, a socialist but nonetheless a historian with a respect for facts, dismisses Sinclair as a propagandist and assails Neill and Reynolds as “two inexperienced Washington bureaucrats who freely admitted they knew nothing” of the meat-packing process. Their own subsequent testimony revealed that they had gone to Chicago with the intention of finding fault with industry practices so as to get a new inspection law passed.

According to the popular myth, there were no government inspectors before Congress acted in response to The Jungle, and the greedy meat packers fought federal inspection all the way. The truth is that not only did government inspection exist, but meat packers themselves supported it and were in the forefront of the effort to extend it so as to ensnare their smaller, unregulated competitors.

Oh, and the fact that to you "it's not far fetched to believe" something does not constitute evidence for it. :-)


ahoyhere wrote:

> Uncited statements from a magazine that a mission to promote free market ideology isn't a very good citation at all.

What do you mean "uncited"? I gave the cite. But since you asked so nicely :-), I found the actual text containing the point-by-point refutation.

Here is the cited report; read it for yourself: http://books.google.com/books?id=xGU-AAAAYAAJ&pg=PA350

The phrases given do indeed appear as described. "willful and deliberate misrepresentations of fact" was in reference to the claim that dead rats and dried rat dung collected on meat that was then swept into the sausage/canning process.

It's interesting reading. The meatpacker rep really seems to know his stuff. Upton Sinclair's claims were indeed evaluated; they didn't hold up.


Uncited statements from a magazine that a mission to promote free market ideology isn't a very good citation at all.

On the other hand, here's President Roosevelt's own speech about the matter:

http://www.theodore-roosevelt.com/images/research/txtspeeche...

"Under existing law the National Government has no power to enforce inspection of the many forms of Prepared meat food products that are daily going from the packing houses into interstate commmerce. Owing to an inadequate apropriation the Department of Agriculture is not even able to place inspectors in all establishments desiring them. The present law prohibits the shipment of uninspected meat to foreign countries, but there is no provision for inspected meats in interstate commerce, and thus the avenues of interstate commerce are left open to traffic in diseased or spoiled meats."

This from the mouth of a President who thought Sinclair was a socialist jackass. So, which source to trust… a first-hand source, who hired the inspectors and commissioned the report, who ran the country and was presumably informed about legal jurisdiction, who thought the original author was a jackass… or a magazine that has its mission statement to promote free market ideology 50 years later?


(HN weirdness - I couldn't "reply" to you a moment ago and now I can. Oh well...I'll recap what I wrote above.)

Here is the report on FEE relied - it was, in my opinion, accurately represented by FEE's summary:

http://books.google.com/books?id=xGU-AAAAYAAJ&pg=PA350

I'm not claiming Upton Sinclair's claims were unrealistic, I'm just claiming they were false. He said stuff that clearly was not true. The stuff about rats and dried rat dung going into the meat: false. The stuff about workers falling into the vat and, again, becoming part of the meat: false.

(there actually was one case one time of somebody falling into the vat, but the body was recovered and buried, not turned into sausage.)

Sinclair clearly invented stuff in order to entertainingly disgust his readers, which makes him an unreliable narrator, not a valid witness.

The fact that the government introduced new inspection laws to reassure the nauseated populace doesn't mean the guy whose lies nauseated them was correct. Nor does the fact that Roosevelt, like any politician, liked taking credit for the laws he signed and making grandiose claims for how much good those laws were likely to do.


> The free market offers no incentive to give health services to people who cannot pay for it

I'm not sure that's strictly true. For one, if the government is paying for those who cannot afford it (through medicare/medicaid, etc.) then there is money to be made, and thus some incentive. Even if its a relatively small amount, some model could be devised to capture the market as a sort of long tail. Much like Amazon has some incentive to sell even the cheapest, niche items.


> The free market offers no incentive to give health services to people who cannot pay for it.

That's why we balanced the market with limited regulations, such as requiring Emergency Departments to treat all patients regardless of their ability to pay. It's also why we established Medicare, Medicaid, and the VHA so providers can get paid for treating patients with limited means.

With the new health reform, it's why we are providing insurance pools so people who do not have benefits through work can benefit by shared risk and still buy health insurance on their own. Health reform also includes an individual mandate to incentivize everyone who can afford it to purchase health insurance.

> these services will reduce hospitalization by 33% and costs by 22%.

> how are you going to recoup the costs and in particular, how does that benefit the populace in aggregate?

You seem to be making contradictory points.


While my mother wouldn't die for lack of McDonalds, she would die, prematurely, painfully (and cheap) for lack of food.

So I don't see how your argument stand.


> The free market offers no incentive to give health services to people who cannot pay for it

Yes, thank you. I've said it many times before - the Free Market cares about your problems to the exact extent that you can Pay for them. Any benefits that happen to flow to the impecunious are incidental (though still nice when they do occur).


> The free market offers no incentive to give health services to people who [...] don't know that these services will reduce hospitalization by 33% and costs by 22%.

Your argument proves too much. You might want to think through the logic in some other area of life. Maybe gas prices at the pump, or candy prices at the supermarket counter. Cheaper and better comparable products DO tend to win over time, do they not?

If X is 22% cheaper (while being better as well) than Y, the people who buy a LOT of this good, whatever it is, have a HUGE incentive to switch. In the case of health care, the big movers would be (a) health insurance companies, (b) other companies that offer health coverage to their employees.

Additionally, of those who buy health coverage or health care directly as individuals there are bound to be some customers who are unusually price sensitive or unusually anal about doing price comparisons. On the margin, THOSE people will switch, and their friends who look to them for guidance will also switch. Just that movement alone might put a company out of business and thereby protect everyone else too, but you also have to think about natural churn. Even if existing customers and existing big companies and existing insurers are all too lazy to switch, as NEW companies and individuals look for their FIRST contract, they'll do a comparison and see that 22% savings.

Last but not least, ignorance is somewhat curable. When X is 22% cheaper to provide (while also better) than Y, X can sell the service for less AND have a higher profit margin...and will use some of those profits (or expected profits) to ADVERTISE. They can TELL the people who "don't know" the stuff that they need to know.

I recommend putting up billboards near the competing hospitals. :-)


Did you read the article? HQP sounds like a great way to start.


This isn't just with hospitals. It basically happens with every aspect of medicine. Insurance, procedures, lab costs, drug costs, etc etc


Looks like the hospitals are using the same techniques as the taxis to keep out the competition.


This reminds me of the health care cost paradox that Atul Gawande wrote about in 2011. In Camden, NJ, one percent of the patients accounted for as much as a third of the city's medical costs. A doctor proposed in a small study that giving these lost causes better care actually reduced costs overall. But good luck convincing politicians to devote more money to cocaine addicts and extremely obese patients.

http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_...


It's not just medical care. Housing follows the same trend[1].

These kinds of studies make me wonder if, politically, we care about cost savings at all.

1. http://www.upenn.edu/pennnews/news/housing-homeless-mentally...


I think we care about cost savings politically, but we don't care about evidence. If someone holds the political belief that cutting public services for the poor saves public money, it's unlikely that any number of studies will change their mind.

Politicians seem to have decent motives, but the system is almost inherently allergic to facts.


I've been watching these issues for a long time and here's the conclusion I've come to:

Americans care far more about people getting "what they deserve," than caring about costs in the long run. Many of the Americans who have the least will still argue against people like them getting "free" things like healthcare -- "I DON'T HAVE HEALTHCARE, LOOK AT ME, I'M FINE". Because they believe those other people don't deserve it. On some level, they believe they don't deserve it either. (In America, land of opportunity, you get what you deserve! So if you don't have it already, you don't deserve it, post ergo propter hoc.)

This also explains why allegedly fiscally conservative Republicans don't support a guaranteed minimum income, because "those people" haven't "earned" it -- no matter that the uncountable costs to society, and the totally countable costs to the government/taxation system, is much greater when people go poor and raise their children in poverty and in slums.

Americans, by and large, are so afraid that one person will get something they don't "deserve" that they'd rather punish them, and everyone else, many times over. The opposite of "Better 10 guilty men go free, than one innocent suffer."

IMO this also explains our ridiculously punitive sentences, instead of simple rehabilitation which is proven to reduce recidivism. "Why would you give them THERAPY? and GYMS? and let them have PUPPIES? THEY'RE SUPPOSED TO BE IN JAIL!" And why so much (much more than you'd think) of the general spirit seems to be against young women who are raped. And on and on. People obviously must be getting what they deserve, or nothing makes sense about their beliefs about themselves, their country, what they've achieved (or not) in their lives, etc.

(I say "Americans" because I've lived for years in another country and traveled all over, and this is far from a universal feeling.)

Puritannical background at work? Perhaps. Certainly not Quaker.


Don't give up hope. Cities are making progress in HRF and preventive care.


What does HRF stand for?


Why more money? It seems that even more money could be saved by excluding drug adicts and those who are so fat that their fatness interfere with their treatment.


Did you read the article? These people still are treated in emergency care...doctors and emergency medical staff will not ignore someone who needs ER care. Inevitably, most of these patients can't pay, which means the public pays.

But putting extra money into the care of these patients prevents costly ER episodes...a little more money upfront apparently saves money in the long run. But of course, we mostly obsess about what we have to pay upfront


This reminds me of two quotes:

> Those who don't make time for exercise today will have to make time for illness tomorrow.

and

> An apple a day keeps the doctor away.

It's all the same concept - preventative care now keeps you healthy for tomorrow and out of the ER.


From the article ER wasn't the expensive part, it was the months in ICU.

No reason you couldn't identify him there -- granted it would only cut down, not eliminate the costs but it would give a decent motivation to become more healthy.


No, it would not.

People who inject heroin know that injecting heroin is harmful. People who are bariatric patients know that being 500 lbs is considerably risky for their health.

Telling these people that they will have yet another bad thing happen if they continue their existing behaviour has little effect to change their behaviour. There's already a long list of bad things. That's why people who've had their leg chopped off continue to inject heroin in the other leg.


Hmm, maybe just send them directly to an addiction treatment program would work?


Getting a drug addict to medical treatment (and addiction harm reduction measures such as clean needles and prescribed heroin) means that they are avoiding crime to get the money to pay for drugs; they're avoiding spreading various diseases such as HIV, hepatitis, etc (which can all be expensive to treat) and they're at less risk of losing limbs or needing very serious surgery.

It also helps to keep them out of prison.

Even if you hate people who are addicted to drugs and you think they deserve a miserable horrible life you should be persuaded by the fact that modest spending early on prevents large spending -funded by your taxes- later on.


How much more money is saved if they stop?

Look I don't care if they do drugs, but I will argue against wasting more money on them, unless that money is spent on the real problem: getting them out of their drug addiction.


Most of us don't want to live in a society where making bad choices in life (or having bad luck) excludes you from live-saving care.


I wouldn't want to exclude them, I just don't want to spend (even more) money supporting their bad habits. It is a two-way street: they want more money? They have to take that in the form of drug treatment.

The libertarian in me don't want to waste money on them at all but I am not blind to the fact that their life wouldn't have been as miserable as it is if we didn't have a stupid war on drugs.


And since HN tends to lean anti-social: for the objectivists: most of us would don't want to get denied care because we look like a junkie during an emergency.


I think you meant anti-socialist. While HN might or might not lean anti-social, I'm not sure it would have a clear effect on political arguments.


How do you propose, in the middle of a medical emergency, to identify the people who have been excluded with enough speed to deny them expensive care but not harm the chances of saving someone who has not been excluded?


I agree with the general point, but real medical emergencies aren't Grey's Anatomy or ER with people screaming for this or that medication and running down the halls.

You have 4.5 hours to treat someone for a stroke and 6 hours for an MI. Not that you don't have to go quickly, but you also don't have to rush unnecessarily.


There clearly are some medical emergencies that need responses that fast, otherwise I wouldn't see so many ambulances flying by with lights and sirens. Now, maybe there aren't enough of those in the problem category to make a difference in costs. However, even 4-6 hours seems like a pretty short amount of time given that you're going to be trying to identify someone as on a blacklist when they most likely will be trying not to be identified, and measures like requiring ID before treatment will exclude a lot of people not on the blacklist.


You have 4.5 hours to treat someone for a stroke if they teleport to the hospital the second they notice the first symptom. In real life, you often have an hour or four where the patients wait for their weird symptoms to go away again because they don't want to overreact and bother some busy doctor who should be taking care of Serious Emergencies, and then another half hour to get them to the ER, and then you're lucky if they're still in the treatment window at all by the time a doctor sees them.

There's not a lot of running down halls in screaming in real ERs, but there's also no time to, for example, send someone to go home and get the ID the patient forgot in their panic and hurry, to prove they're not blacklisted "no medical treatment" somewhere.


joshgel, I don't know where you live, but in my country, hospitals are publicly rated on their performance in treating MIs with angioplasty within 90 minutes of patient arrival, insured or not.


From the article one of the guys spend months in ICU -- that shit costs a fortune daily.

So it seems reasonable to simply tell him that the next time he comes in he has to be active in a program to improve his general health otherwise he gets booted once he has been positively identified unless he can pay himself.

Anyway it seems that one of the consequences of what the doctor did was that he lost weight and improved his diet -- I would want to see much more focus on that and none at all on the touchy-feeley stuff.


Yep, the other factor the article mentions is the patients "died, reducing their costs permanently". We could just round up the obese and drug addicts and save a whole bunch of money by killing them.

/s


You could have the healthiest country in the world by a huge margin if you just summarily executed anyone who got a serious illness!


This looks like a good approach to health care, and I don't want to be snarky guy, but... Health Quality Partners is about to lose their funding and they get an 8-page glowing article on washingtonpost.com about how great their program is and why it should be continued. It looks like some PR agency is really earning their money.

See, of course, Paul Graham's article on PR agencies: http://www.paulgraham.com/submarine.html

Going back to the subject of the article, I wonder how much this visit program actually costs, and whether it could be direct-marketed to wealthy people with elderly parents. "For $10,000(e.g.) a year, we can reduce your parents' hospitalizations by 33% and help them live independently." Sort of like concierge medicine.


> Going back to the subject of the article, I wonder how much this visit program actually costs, and whether it could be direct-marketed to wealthy people with elderly parents. "For $10,000(e.g.) a year, we can reduce your parents' hospitalizations by 33% and help them live independently." Sort of like concierge medicine.

Better yet, maybe health insurance companies could offer lower rates to chronic patients who enroll in a visit-program. They are the organizations with the most financial incentive to implement these programs.


They absolutely would (and I still don't see why they don't the cost/benefit ratio of paying for that should make sense) but in this case they are talking about the people who have no insurance or whoes bills are paid by the federal tax payers.

And while there are a fair amount of positive things to say about the federal government, prudent financial planning isn't exactly one of them.


Just for clarity, it's an Ezra Klein blog entry, not an article. Obviously Klein is no less susceptible to PR, but this isn't being presented as an unbiased news article. He's an opinion journalist.


Just the same, though: considering how many people are unaware how and why famous bloggers focus on the topics they do, it would be quite an eye-opener for them to learn what led Klein to writing about this topic, and now. In that sense, I consider it somewhat fraudulent (unless he really honestly just discovered all this on his own, which I doubt is within his abilities).


Harsh.

I had a little back-and-forth with Violet Blue a few months ago. She accused some blogger of being egocentric in leading with personal pronouns. I defended said blogger, pointing out I do the same thing all the time, so as to give clues as to my thought process, the genesis of the post, and so on. She shot back a challenge that I should perhaps exhibit OTHER bloggers who do the same thing.

I found it hard to meet that challenge.


I'm not sure I see the relevance.


The relevance is that there is a request for bloggers to reveal every little detail of the process of how they decided on what to write when, and I'm saying that's a very unusual practice.


The similarity isn't applicable. While I see now that my original comment was unclear and overbroad, let me emphasize that I'm not suggesting bloggers do a full "coredump" of their thought processes.

I'm just saying that if a PR agent (or other heavily incentivized group) is directing your attention to a topic (and [in]forming your analysis), while the typical reader would not assume that's how you do it, then you should say so. Same as you would disclose any other conflict of interest.

"I typical form my speech with this pronoun pattern" is not affected by that practice. (edit: and those who criticized you were pretty loopy in doing so, fwiw)


Your "if" is contrafactual -- more precisely the "while" clause is -- for the reasons I illustrated with the story of the pronoun pattern. At least it should be.

Klein surely gets dozens of PR pitches per day, if not hundreds. Of course he's going to be influenced by a few of them. The people who assume otherwise ... well, they may well be too clueless to be his target audience.

And, returning to my point, it's not common to outline the genesis of any particular opinion column or blog post. I don't really do it, yet I'm closer to doing it than most.


Seriously? You're claiming that most people are aware that writers are choosing their topics (and ideas) because they were fed them that by PR agents?


I'm claiming that most people are aware that PR agents work hard to try to influence us, and that their failure rate isn't 100.00%


Here's a story from atul gawande that has a similar point. http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_...

As far as i can tell , atul is a pretty serious health care journalist so him posting this story tells me it's probably not PR.


The money quote for me was this: “If we scaled what Ken is doing,” Brenner says, “you would probably shut down a third of the hospitals in the country. It’s a disruptive innovation. It just guts the current business model.”

Wouldn't it be better if people never had to go into the hospital in the first place? Aside from the supplemental costs - "surgical complications increase the margin the hospital makes on the patient by 330 percent for the privately insured and 190 percent for Medicare patients." - consider the quality of life issues.

If Medicare is concerned with scaling this program up from a couple thousand people, instead of completely cutting a program which has proven its ability to cut costs AND improve quality of life, why not try it with five or ten thousand people first? If that works, then try it with 20 thousand people, then 50 thousand. If it doesn't scale at that point, then cut it.

Another possible solution is to find a way to eliminate the for-profit hospitals. But Medicare's solution - "It’s pushing providers to band together into accountable care organizations, or ACO, that get a flat fee for all care related to a patient." - sounds destined to fail from the outset to this layman.


Yes. For illnesses like diabetes it's best if you can prevent people getting it, but if they have it it's best if you can help them to avoid getting the complications.

"Diabetic foot" sounds funny, until you realise that it kills people and is a reason for leg amputation. (Prognosis after such amputation wasn't great last time I looked, in about 2004.)

Sending a real person in a car to visit someone at their home sounds intensive, and sounds expensive. Compare it to a tele-medicine device that takes measurements and sends those to a centre somewhere, with people calling over the phone. It's a shame that the evidence base appears to be being ignored. EDIT (after adestefan and ajtaylor commented) -- it feels expensive, but the evidence base is clear that it's not expensive because it works, where as the thing that feels cheap is wasted money because evidence shows it doesn't work. And it's a shame that people in charge appear to be ignoring evidence, and going by 'gut feeling', because it means effective interventions are not happening.

I hope that mentioning the research that a decision is based on becomes more widespread. Even organisations that claim to be evidence based can make odd decisions.


I would agree with you as long as the devices you're referring to are completely automated and rely 0% on the person to do something. My grandmother didn't remember things so well as she got older, so without someone to help her to remember to take her medicine (or that she had indeed taken it) it would have had real implications for her health. As it happened, she had my mother and later my uncle to take the place of the nurse. In my limited experience, the key to seniors is to avoid having to rely on their memory.

As for avoiding complications, I agree with you. The best action is to avoid the disease, and then to avoid the effects of the disease.

As mentioned in the article, sending a person in a car to visit someone is obviously more expensive than a phone call. But the nurse's visit can help to avoid a problem which requires a far more expensive visit to the hospital. That is where the cost savings come into play.


There is something special about having that physical person with you, in your home, talking to you one on one. Yes it's somewhat expensive up front, but the human contact is a major component of what makes this a success.

There is one extra photo in the print edition of this story. It's the nurse, Ms. Graefe, hugging Mr. Bradfield in his kitchen.


Because much of our health needs are mental, and much of mental health is social. Living alone is a chronic debilating condition, akin to diabetes.

Live with your parents, and later live with your kids. Or outsource to home aides.


> Another possible solution is to find a way to eliminate the for-profit hospitals.

Oh God, no. Did you read that incredibly-long and incredibly-powerful healthcare article by Time? Non-profit hospitals are among the worst offenders.

http://www.time.com/time/magazine/article/0,9171,2136864,00.... (subscription)

Some of the most innovative hospitals are actually for-profit. Here's another great article by Atul Gawande comparing Steward Health System, which was founded by Cerberus Capital, to the Cheesecake Factory (but in a good way):

http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_...

> Medicare's solution - "It’s pushing providers to band together into accountable care organizations, or ACO, that get a flat fee for all care related to a patient." - sounds destined to fail from the outset to this layman.

As an entrepreneur, I agree that it's a tragedy that HQP is being abandoned instead of scaled. But ACOs will absolutely have a financial incentive to keep patients out of the hospital and hire companies such as HQP. The problem is that this transition has yet to occur, so HQP is ahead of the market. Hopefully they can find smart investors in the meantime (perhaps this article will help).


I don't doubt that there are excellent for-profit hospitals. Chances are I've even used the services of one. One can find good things coming out of nearly every kind of business if you look hard enough. Please don't take the suggestion as anti-capitalist, because I'm not.

My argument against them is simple: it's very hard to align the two goals of 1) making as much money as possible and 2) providing the best care possible, which in my mind means making their stay as short and inexpensive as possible. Even as a youngish person (late 30's), I don't want to go in the hospital at all and if I do have to go I want to be in and out as soon as it is safe to do so.

The ultimate goal is to keep people as healthy as possible, and to spend the least amount of money to do so. This requires finding the right balancing point, but I'm positive it can be done if the political will exists.


> "I'm positive it can be done if the political will exists."

In your lifetime, what major problem had the political will existed to solve it? As Moldbug says, we have a large government, but not a strong one.


The article suggests that this measure is only opposed by healthcare incumbents, because it threatens their profits.

The comments also show a critical source of opposition that the article doesn't mention: political anger about 'entitlements'.

Many or perhaps even most Americans actually won't agree that it's better if people don't have to go into the hospital in the first place - if they understand that the way of getting that is to offer more care to people at taxpayer expense - even if the expense to taxpayers is actually less.

It's unjust or unfair, you see, because the other guy is getting something for free and his children should be paying for the nurse to come by once a month, not me.

As an ordinary "main street" American, maybe I would rather see him denied that preventive care, even if it means higher costs in the end, in order to avoid the loathsome outcome that I am paying part of his bill. I'd really rather not pay for his emergency care either (and some comments in this thread have suggested the same, that we will save more money by not at all covering people who are at risk), but that's hard to push politically. So we will pay for expensive emergency care, because we don't really have a choice. But we'll be damned if we'll pay for preventive care which doesn't seem urgently necessary.


But isn't eliminating preventative care like shooting yourself in the foot? Or cutting off your nose to spite your face? My parents are in their 60's and definitely complain about the "system" and the entitlements people feel they deserve. But I feel certain that if they were shown the numbers, which showed that giving "free" preventative care at a cost to taxpayers of $x, but would prevent emergency care at $x * 10, they would agree that the preventative approach is better. But as you say, this is a hard sell politically.

All this reminds me of the famous quote from Jerry Maguire: "Show me the money!" Is there anything wrong with pandering to people's base desires, namely "If the government spends less money, we can lower my taxes without implications"?


We already sort of had that in Massachusetts. For hospitals that treated large numbers of free care patients were given flat grants to cover operating costs. ("Free care" covers people too poor for health insurance or to pay for treatment and too young, childless, employed, healthy, etc. for Medicaid.)

However, it is politically unfeasible, because people can't see what the money is being spent on and it was eventually eliminated to "save money". Even though local hospitals had created programs that helped lower costs and provided better care to populations normally ignored.

People care more about punishing poor people than they do about saving taxpayer's money. Otherwise drug testing for medicare recipients wouldn't be a thing.


That quote was the zinger for the article for me too. But electrifying claims like that one should automatically be received with a healthy amount of skepticism; I was disappointed that the author presented the quote bare without any balancing commentary or promise to validate the claim.

If the claim is true it's revolutionary; if it's false or exaggerated, it substantially reduces the credibility of the speaker. In the latter case, this article's credibility would itself be weakened. Hence my disappointment.


Why do people like to use average life expectancy? "Average life expectancy was 45 years old at the turn of the century."

That provides very little information about the distribution of lifetimes and provides a biased view when compared to the 85-year-olds mentioned in the next sentence. Infant/child mortality skews the average a lot. You could have everyone living to 90, if they survive to 5, and still have an average of 45. War and other disasters can also change the average in ways that have little meaning for the medical programs in question.


It also bugs me when people say "at the turn of the century," since we just recently had one of those but the person is talking about the one previous.

/nitpick


Fin de Ceicle


It's like it's a warm story that we propagate to make us feel great. As if we stand as demi-gods in comparison to the relative cavemen of 200 years ago. The most major accomplishment in respect to longevity appears to be... not letting our young perish. Which is obviously all well and good until this kind of argument is used to validify medicine perhaps beyond its merit.

Forgive the generalizations.


This mistake seems to be getting more and more common.

I use the example of sea turtles - the average lifespan across a clutch of eggs is maybe 1 year - because one out of 100 survives. But the one that survives usually lives for 100+ years. The fact that the life expectancy at hatching is only one year tells you nothing about the distribution.


> Medicare is referring to the newly created Center for Medicare and Medicaid Innovation, which gives the program power to create and expand projects without congressional authorization. This authority could also be used to create projects based on HQP’s lessons. It’s not. Instead, Medicare has created a raft of projects and experiments meant to move the system from fee-for-service toward pay-for-quality — with the hope that if they can get the payment incentives right, then the market will have reason to support programs like HQP.

Yep. As long as the government bureaucrats develop perfect payment incentives, the market will do its job. It's the same story in education. And programming - if you can find the perfect metric for code production (SLOC? function points? story points?) you don't need to do anything else.

But with an imperfect metric, Cambell's Law (http://en.wikipedia.org/wiki/Campbell%27s_law) kicks in.

Want to reduce waiting times? Kick out patients so they die at home. Increase successful surgeries? Tell the doctors to fix a lot of ingrown toenails. Increased lifespan? Make decisions which increase life expectancy, at the expense of quality of life. Or just try to get rid of patients who have poor prospects.

The greatest strength of markets is also their greatest weakness - they are much smarter and more agile than government departments. They can become a malicious literal genie, which optimises whatever the incentives are.


Well there needs to be some sort of artificial incentive if you're going to keep medicine profit-based. The best way to generate profit without those incentives is to keep as many people as sick as possible, because sick people are more profitable than healthy people.


Personally, I like the adage of the Cobra effect to describe similar situations: https://en.wikipedia.org/wiki/Cobra_effect


My grandfather, a physician, made house calls 7 days a week. It was just assumed in those days. When he couldn't drive during WW2 (German refugee = enemy alien) he couldn't be in private practice.

Replacing doctors with nurses in that story is a perfectly sensible modern adaptation. But the house calls are a really good idea.

Not coincidentally, they're a central aspect of the exploding trend toward assisted living.


Please forgive me for going off-topic and for asking a personal question (and please don't answer if it's too personal), but how did the government inform your grandfather that his movement was restricted during WWII? Did he receive some sort of notice from the FBI?

I'm sorry that our government chose to restrict the civil liberties of a very important member of his community during WWII on the basis of his ethnicity.

A cautionary tale for today's America.


Note that the OP's grandfather was not a US citizen, but a refugee from a declared enemy during a time of war. There's a huge difference between the two. That fact that he was even allowed to practice medicine is amazing.


You nailed it. He was early in the immigration process.

In odd bureaucracy, he DID get a doctor's special gas ration anyway. (He had a good institutional job in the Kaiser shipyards.)

Come to think of it, that's another reminder that in those days, medicine --> home visits.


The atomic bomb was built in large part by refugees from a declared enemy during time of war.


Most of the US based scientists were either US citizens (some natural born; others naturalized) or came to the US in the 20s or early 30s. Even then very, very few of these men were German citizens. Fuchs, who was one of the few German refugees, was part of a contingent from the UK. The only reason why Fuchs was even allowed to be a part of the project was because of political pressure outside the project.

This is all documented in exrutiating detail in Rhodes' series on the making if both the atomic and hydrogen bombs.


Was it? The Germans and Austrians involved, for the most part, left for the US years before the war, often by receiving academic positions in neutral or allied countries. Leaving during the war would naturally be treated with greater suspicion.


But those weren't doing house calls and were under guard. :)


According to a new study in the Journal of the American Medical Association, surgical complications increase the margin the hospital makes on the patient by 330 percent for the privately insured and 190 percent for Medicare patients.

This is scary when you consider how good people are at the subconscious mental gymnastics that allow them to justify pursuing their own interests at the expense of others. Either human beings are perfect angels -- inhumanly good, too good for much of human history to have actually happened -- or many people have been tortured and killed for those margins.


How many doctors actually stand to gain by mistreating patients, though? I don't know about the USA, but in my country, most medical care is provided by salaried doctors who are paid the same regardless of the hospital's profit margin.

Now, obviously we do want the hospital to be profitable enough that they don't start firing us, but there's certainly no immediate benefit along the lines of "Well, I don't this guy to get an infection, but I'd make an extra $ 1000 if he did," which I agree would certainly provide skewed incentives. The only thing that happens when my patients get complications is I get to pull more unpaid overtime.


Complication rates are affected by hospital procedures and policies, staffing levels, training, and presumably the pressures that are or aren't put on doctors. All of those are under the control of the administrators who look out for the bottom line. Whether complications make money or cost money surely affects administrators' eagerness to revamp and/or enforce handwashing policies, update training for nurses, keep staffing levels high enough that inexperienced nurses are properly supervised, and put pressure on doctors with high complication rates.

To make it more concrete, there was an article on HN a few years ago suggesting that post-surgical complication rates could be reduced by creating surgery checklists where very basic surgical steps would be checked off as the surgery proceeded: patient identity verified, everything properly sanitized, materials accounted for afterwards, things like that. You would expect a hospital administrator to make a cost-benefit analysis taking into account the cost of researching this idea, creating a trial program, and monitoring compliance and effectiveness. The cost-benefit analysis looks like this: If the program is ineffective, we lose money. If it's effective, we lose even more money. If it's really, really effective, it could screw up the bottom line so much that I lose my bonus or even my job.


We know from studies done around 2003 done by peter provonost that if doctors follow certain checklists while doing an IV(if i recall correctly), reduce the complication rate from 12% to 0%.

Using checklists is still not a common practice among doctors.

What do doctors gain by not using checklists ? freedom, less boredom, maybe feeling of status. Is that the reason ? dunno.


My Taiwanese friends frequently remind me of the historic Chinese practice of a doctor visiting the family regularly to keep health well. The doctor would receive weekly pay only while the family was well; once someone got sick, they stopped getting paid until the doctor helped them recover. This preventative practice reminds me a lot of what my Taiwanese friends speak about.

It seems the age-old cliche "An ounce of prevention is worth a pound of cure" applies here.


That sounds like it could go very badly if you have a mercenary doctor and you come down with an incurable but manageable condition.


By the time you've spent years caring for a family, you probably care about their health for more than just the cash. Not to mention the reputation effects of abandoning sick patients...


Except in the cases of some types of cancer (breast/prostate/liver) where whether you will live or die dices are rolled during the genesis of the cancer and can be influenced little by the treatment. But more than pays about melanoma. It is all about the illness.


I repeatedly post this chart that shows life expectancy stratified by age to HN:

http://www.scientificamerican.com/article.cfm?id=longevity-w...

I learned about this article from another participant's submission to Hacker News.

I happen to be part of a "journal club" with a researcher who studies, among other things, demography of aging, and from him I've learned some startling facts about increases in life expectancy around the world. Girls born since 2000 in the developed world are more likely than not to reach the age of 100, with boys likely to enjoy lifespans almost as long. The article "The Biodemography of Human Ageing" by James Vaupel,

http://www.demographic-challenge.com/files/downloads/2eb51e2...

originally published in the journal Nature in 2010, is a good current reference on the subject. Vaupel is one of the leading scholars on the demography of aging and how to adjust for time trends in life expectancy. His striking finding is "Humans are living longer than ever before. In fact, newborn children in high-income countries can expect to live to more than 100 years. Starting in the mid-1800s, human longevity has increased dramatically and life expectancy is increasing by an average of six hours a day."

http://www.prb.org/Journalists/Webcasts/2010/humanlongevity....

A comparison of period life expectancy tables and cohort life expectancy tables for men and women in Britain

http://www.ons.gov.uk/ons/rel/lifetables/period-and-cohort-l...

helps make the picture more clear. ("Period life expectancy" is what is usually reported for a whole country. But cohort life expectancy provides a better estimate of future lifespans of young people today,

http://www.time.com/time/specials/packages/article/0,28804,1...

and is still steadily on the rise around the world.) Life expectancy at age 40, at age 60, and at even higher ages is still rising throughout the developed countries of the world.


That chart doesn't support the claim of centenarians becoming the norm, though. It shows that in the last 50 years in the US we've increased the life expectancy of an 80 year old by two years, from 86 to 88. extrapolating that linearly it suggests that children being born today will, if they live to 80 in the 2090s, have a life expectancy then of about 91, so while they may well expect to see the 22nd century dawn they won't generally get to see their hundredth birthday. This is backed up by the UK cohort life expectancy you gave which shows the current cohort life expectancy is still around 91-95, and doesn't extrapolate to predicting hundred-year lifespans even for children born 20 years in the future.


From the Vaupel article:

> If progress in reducing mortality continues at the same pace as it has over the past two centuries, which is a matter of debate, then in countries with high life expediencies most children born since the year 2000 will celebrate their 100th birthday — in the twenty-second century.

Um, color me very skeptical. My guess is there is a lot more disagreement with the startling hypothetical "if progress in reducing mortality continues at the same pace as it has over the past two centuries" then the single reference after "debate" would have you believe. (italics mine)


Atul Gawande wrote about a similar initiative in Camden, NJ, two years ago:

http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_...


Average life expectancy was 45 years old at the turn of the century. You didn’t have 85-year-olds with chronic diseases.

Yes you did. That's like saying there weren't old people a hundred years ago. The reason the average was 45 years is because of the astounding rate of infant mortality (much improved now).


Thank you, I was hoping somebody would have already made this point. Funny thing is, both statements are true; you really didn't have 85-year-olds with chronic diseases. There were 85-year-olds, they just didn't have chronic diseases. The idea that we have them now is due to improved treatment of other diseases ignores tons of epidemiological evidence that says otherwise.


The challenge with health care in the US is that nobody has incentives for reducing health care expenditures. Hospitals get paid when you get sick. Insurance companies see higher margin from reducing administrative costs. Patients are largely uninformed and there are few services out there to help them make lifestyle changes... not to mention that they expect somebody else to pay for it. Employers actually bear most of the non-medicare/medicaid financial risk, but they aren't health experts and have been burned in the past by tele-medicine programs that don't work.

Preventive care programs like the one at HQP are proving that preventive care is effective, but sending a nurse to your home regularly is expensive and I'd question the ROI from doing so, absent some focus on a particular disease. With a solid ROI and some good hard evidence, HQP shouldn't have to rely on CMS to keep them afloat... with some work they would be able to sell their program to payers.

HQP also isn't addressing the systemic issues I mentioned above, so what's especially frustrating about the article is that they bash on ACOs, which is one of the first attempts by CMS to actually align incentives and mend those issues. And frankly, those changes aren't going to be good for hospitals... I'm sure a lot will go out of business as people get healthier and don't need them. This piece of the article in particular makes me question HQP's motives.


In the UK the NHS has district nurses one whose roles is exactly this sort of work and it can make big difference especially where the GP is underperforming. These patients can be unwilling to change GP to a better one (which you can do in the NHS).


Three points were interesting to me:

1) The chart with the blip for the 1918 flu. If we reduce costs by closing facilities, how we cope with the next blip?

2) This is an area ripe for disruption, but regulatory capture seems to prevent this.

3) We should all be spending more time with our elders and noticing these sorts of issues, if for no other reason than it will improve their health.


1) It's not like those facilities are sitting around empty right now. If we close them only by the amount that we reduce the need for them, we'll have about the same reserve capacity.


This reminds me an awful lot of the role of village witch in Terry Pratchette's books. I think we've lost that caretaker role in society because we always assumed it was their children's responsibility. It seems like if capitalism can get something for free, it is assumed to be worthless.


As for going into hospitals making you worse -- I agree from experience. One of my parents went into the hospital for a back procedure, and came back with her mind significantly diminished. She died 8 months later.

The other, in and out of the hospital, eventually died the same week, and one of his complications was MRSA.

Both were at Riverside Methodist Hospital in Columbus, OH, which I gather is a perfectly solid institution.


“The largest group in the top one percent of income in America are physicians.”

It is going to be very challenging to introduce changes that negatively impact a profession with the social respect and the deep pockets physicians have.

It could probably succeed in a countries like Canada, Sweden or Germany, but overcoming entrenched interests in the US and not getting labelled "socialized medicine"[1] in the process is unlikely.

1. Of course it's no more socialized medicine than Medicare, but it's a good way to discredit your opponents.


As of 2008, nearly 59% of US physicians supported national health insurance [1]. Doctors are not the culprit.

1 = http://annals.org/article.aspx?articleid=740467


What do that "national health insurance" look like for physicians? Does it include pay cuts? I'm pretty sure in those 59% of physician's eyes it doesn't.


The answer to that question depends on whether you think physicians lack insight.

I think that most physicians are smart enough to look at the national insurance that already exists (Medicaid & Medicare) and to recognize that their reimbursements would be cut. I think they can balance that against the complexities of the current system and some might be willing to trade somewhat lower pay for the ability to focus on providing care.

20% of health care costs come from physician pay, of which about half goes to the cost of running a practice. Most reformers know that cutting physician pay, while part of almost any plan, is not going to be the most important way to save money.


If pay cuts were accompanied by less annoying insurance infrastructure, I'm sure some doctors would take the pay cuts.


I would expect it is already a reality in some or all of those countries? I know it is in Norway and has been like that for a long time. When the government/taxes pay the health care bills anyway, frequent home visits to reduce expenses are more of a no-brainer.


But in this case, the government is footing the bill. Medicare is "socialized medicine"[1] for the over-65 crowd. As a tax payer, these kinds of articles are exceedingly frustrating.

1. It is (relatively) crappy socialized medicine, though.


If this is as cost-effective as it claims, what's to stop private insurance companies from pushing and covering it? It should theoretically cut their own costs in the long run, right?


I wish some insurance companies could figure out that.

In reality, if they are something like the one I work for, politicking and manager infighting will prevent it - everyone wants the OTHER divisions to lose power, but not their own. My own manager created his own personal software factory (for a freaking country branch), in spite of my belief that it's extremely inefficient for the company as a whole. The shareholders don't care as long as the company makes money.


It seems to me that health insurers are already aligned with the goal of keeping patients from receiving care for acute conditions, so perhaps some of them, being private companies, unencumbered by special interests or government bureaucracy, will adopt systems like the one outlined in this article. Maybe that's a cynical outlook, but since it has been demonstrated that hospitals, being for-profit, are tragically misaligned with maintaining patients' wellness.


The tendency among physicians to be dismissive towards remedies that are procedural in nature reminds me of the tendency of programmers to show disinterest in non-technical solutions to problems.

But as Jeff Atwood reminds us, "The Best Code is No Code At All," and I imagine that physicians could use a similar reminder: "The Best Treatment is No Treatment at All."


Wow. If we can't maintain ways for the cream to rise to the top in the US, we'll continue to become increasingly mediocre.


Well, now we're fighting mental illness at an alarming rate due to many factors - that we could manage better.

I'd like to see the graph of rate of mental illness from the past, to now - and yes, I realize there's a strong argument for that we're better at diagnosing people now, however it just doesn't add up IMHO.


"if this were a pill"


It is about job description. Just put into law that all government money should ensure the best outcomes for the patients and then a lot of things become possible. Give simple and powerful mandate to all health related businesses.


A part of the issue is that it's hard to define "best outcome", you'd have to make sure to not accidentally incentivize drastic short-term procedures like open heart surgery, where the immediate affect is positive (patient hasn't died) but a longer term view would have questioned the care that led the patient to that state in the first place.




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