A Third Hand Quote, but a Great One

I recently heard Dan Sulmasy give an ethics talk at a conference.  Like me, Dan is a general internist.  In his talk, he quoted a former President of the Society of General Internal Medicine and I thought I’d pass the quote along.
That former President was Nicole Lurie, who now works for the federal government to prepare us for things like health disasters.  She was giving advice to physician researchers who encounter awful situations of social injustice while caring for underprivileged patients.  Her advice:

Don’t get mad. Get data!

Are you surprised that a research geek like me would like that quote?
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On Taxing Rich French People

In another great New Yorker article, Lauren Collins writes about controversy over taxing wealthy people in France, a controversy that has already caused Gerard Depardieu to move to Belgium and/or Russia. At one point in the article, she interviews experts to get their views on whether such taxes are effective in raising revenue. One expert pithily explains:

Yes, it works in practice, but does it work in theory?

That is a question we can ask about much of modern social science!
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The Smell of a Fiscal Crisis

In a wonderful New Yorker article titled “The Hangover,” Nick Paumgarten writes about the strange mix of private and government forces that led to the Spanish fiscal crisis.  In a wonderful sentence, he evokes one such force, the almost invisibility of debt:

It is often hard to perceive an economic crisis. Debt doesn’t look like much. It has no shape or smell. But over time, it leaves a mark.

Quite a mark, indeed. And in my opinion, that stinks!
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Are People from Pennsylvania Sick?

In a 2011 JAMA article, Gil Welch and colleagues looked at how many chronic diseases Medicare enrollees had across different regions of the country.  They came up with the following picture:

This picture may confirm some of your suspicions. For example, elderly in the north are sicker than ones in, say, Arizona or Southern Florida, possibly because they are too sick to move there in retirement.
But Welch’s study points toward another conclusion: doctors in some parts of the country are more inclined to diagnose their patients with lots of illnesses than doctors elsewhere, even taking into account how sick patients are.  They conclude this, in part, because the mortality rate of people with, say, 2 chronic illnesses is lower in parts of the country that hand out lots of diagnoses:

This could mean that doctors in some places hand out too FEW diagnoses. Or that doctors in other areas hand out too MANY. Or that both things are going on.
One thing is clear from this study, however. Before Medicare can consider “pay for performance” schemes, that reward hospitals that achieve good outcomes for their patients, they need not only to adjust for how sick the patients are, but also how stingy the hospital’s doctors are in handing out diagnoses.
 
 
 

Abraham Lincoln on Perspective Taking

I write frequently about the importance of perspective taking in clinician/patient interaction. Seeing the world through other people’s eyes is also a crucial moral and political skill. No surprise then that Abe Lincoln showed great perspective taking abilities. Consider these words, from an 1854 speech on slavery:

I think I have no prejudice against the Southern people. They are just what we would be in their situation.

Would love it if feuding politicians could embrace this wisdom more often today.
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On the Financial Burden of Paying for Medical Care in the US

According to a CDC study, about 1/3 of American families either struggled to pay medical bills in 2011 or outright couldn’t pay them!

Not surprisingly, this problem is especially big for people with limited financial resources:

Just another piece of evidence in favor of something I’ve been talking about lately when giving public lectures: that physicians need to discuss the cost of care with patients before prescribing treatment.
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Do the Obamacare Subsidies Make the Individual Mandate Unnecessary?

Lost in all the confusion about Obamacare is the fact that the law relies on more than just the individual mandate to encourage people to buy health insurance. It also makes health insurance more affordable, especially for people at or below 400% of the federal poverty limit by subsidizing insurance for those folks. So do we even need a mandate or will those subsidies be enough?
First off, it helps to remember that one of the goals of Obamacare is to make sure that people are not priced out of the insurance market once they develop serious chronic illnesses. If an insurance company finds out that a man has prostate cancer, or a woman has coronary artery disease, the company would normally consider those illnesses when estimating how much they need to charge those people for their individual premiums. After all, these people are likely to have more medical expenses then healthier customers. If the price of insurance didn’t reflect their underlying health, that insurance company would be at a competitive disadvantage. But of course this very sensible action by the insurance company would price many such people out of the insurance market… (Read more and view comments at Forbes)

On the Ridiculousness of Hospital Pricing

A recent Time magazine article by Steven Brill has received a lot of attention, for highlighting some of the crazy ways that hospital set their prices. One quote in particular caught my attention. It had to do with what hospitals call the charge master, which is essentially a big list of what they charge for different services. I wrote about the charge master in a previous post, which emphasized the arbitrariness with which these prices are set. But here is a hospital administrator trying to defend the charge master:

“We think the chargemaster is totally fair,” says William Gedge, senior vice president of payer relations at Yale New Haven Health System. “It’s fair because everyone gets the same bill. Even Medicare gets exactly the same charges that this patient got. Of course, we will have different arrangements for how Medicare or an insurance company will not pay some of the charges or discount the charges, but everyone starts from the same place.”

Notice how he switches from defending the charge master, as totally fair because even Medicare gets the same charges that the patients get, to say that of course they make different arrangements for different people. In other words, it is not fair at all. This system can’t last!
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On Not Responding to Anonymous Comments

One of the great pleasures of blogging is reaching new audiences and, better yet, interacting with new people. On the other hand, blogging also puts us bloggers into contact with unpleasant commenters. This unpleasantness has compelled me to establish some guidelines for my own on-line behavior.
First, I strive always to blog, and to comment on other people’s writing, respectfully. I may critique other people’s arguments, I may even criticize certain people’s behavior, but I try to do that respectfully.
Second, when people disagree with me, I am happy to engage in respectful debate with them. But when their disagreements—when their comments to my posts—are disrespectful, I will not respond. At all. Life is too short to spend time debating people who are behaving that way.
Third, I will not respond to anonymous comments. Increasing evidence is showing that anonymity can damage people’s on-line interactions. Internet guru Jaron Lanier calls this “social lasers of cruelty.” If I am willing to post my ideas with my identity clear to everyone, then people commenting on my posts should also be willing to make their identity clear. I expect many people who post nasty comments would do so because they can hide behind anonymity.
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Health Care Under the Ryan Budget

Recently, Congressman Paul Ryan put together another budget balancing proposal. It has received a lot of attention in the news, even though it is as likely to be enacted as is the Senate Democrat alternative– in other words, it won’t be enacted. Nevertheless, for those of you interested in healthcare and healthcare policy, here’s a summary from the Washington Post of what the Ryan plan would mean for different parts of the budget. Medicaid jumps out from this graph, as a program that would take a huge hit.

And there are many government programs that are not reduce significantly under the Ryan plan. Look, for example, at this figure from the Atlantic website.
I have written a lot about the importance of trying to control healthcare costs. But I don’t think it’s fair to disproportionately achieve the savings among the poorest of our citizens, while sparing government programs that deserve at least as much scrutiny as Medicaid.
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PeterUbel