Thursday, April 30, 2009
Whistle blowing is always risky,In Great Britain's NHS even worse,nurse looses a lot
See here for what happened to a nurse in England who dared to help let the public know how bad things were at one NHS service about which I have commented before in regard to the issue of how very wrong things can go when quality performance targets dominate the scene.
Monday, April 27, 2009
Two of my favorite medical bloggers seem to disagree regarding CER
When I read a recent blog posting by DB,who postings inspired me to start to blog and with whom I rarely disagree, I was sharpening up my blogging tools to respectfully offer a view counter to his, but as is often the case DrRW beat me to the draw (See here).
Those who oppose or at least have serious doubts about government- run CER are likely not against comparing the effectiveness of various medical treatments ( i.e.. not against CER) but are very skeptical of the ability of a government agency to regularly turn out results that will be free of bias and may also reject the thesis that all drug company sponsored research is biased.
Research can be spun one way or the other-there are so many ways to stack the deck and cook the books that lurk beneath behind the pages of a research project.To believe that a government agency is a) without an agenda and b) incapable of making such an agenda-generated bias operational requires much more faith in the integrity of the government that I summon and seems to ignore what we have learned about how governmental entity really operate versus the high school civics views that describes things in terms of purported aims rather than in real results. A leisurely half hour or so with a discussion of Public Choice theory might disabuse many of the vision of government as a hybrid between Santa Claus and superman.
Dr. RW's final paragraph deserves much consideration:
No one that I know of is objecting to more unbiased data. But CER is not inherently unbiased. Moreover, it is inherently susceptible to design flaws for reasons I pointed out here, with several examples. Bias has more to do with who’s sponsoring the research than the type of research. There’s no reason to think that the government would introduce less bias. In fact, the government policy makers who are pushing CER are explicitly very biased. If you don’t believe me just read the Congressional Budget Office paper which was pushing for CER, which I cited here.
Those who oppose or at least have serious doubts about government- run CER are likely not against comparing the effectiveness of various medical treatments ( i.e.. not against CER) but are very skeptical of the ability of a government agency to regularly turn out results that will be free of bias and may also reject the thesis that all drug company sponsored research is biased.
Research can be spun one way or the other-there are so many ways to stack the deck and cook the books that lurk beneath behind the pages of a research project.To believe that a government agency is a) without an agenda and b) incapable of making such an agenda-generated bias operational requires much more faith in the integrity of the government that I summon and seems to ignore what we have learned about how governmental entity really operate versus the high school civics views that describes things in terms of purported aims rather than in real results. A leisurely half hour or so with a discussion of Public Choice theory might disabuse many of the vision of government as a hybrid between Santa Claus and superman.
Dr. RW's final paragraph deserves much consideration:
No one that I know of is objecting to more unbiased data. But CER is not inherently unbiased. Moreover, it is inherently susceptible to design flaws for reasons I pointed out here, with several examples. Bias has more to do with who’s sponsoring the research than the type of research. There’s no reason to think that the government would introduce less bias. In fact, the government policy makers who are pushing CER are explicitly very biased. If you don’t believe me just read the Congressional Budget Office paper which was pushing for CER, which I cited here.
Thursday, April 23, 2009
Still more thoughts on problems with EMRs and who or what is responsible for the patient
Here is a link to a discussion of more problems with electronic medical records (EMRs) that ties in with the issue of individual versus group responsibility.
The particular case involved a patient at an academic medical center in which
It took three days for the patient's care team to realize that the results entered into his EMR were for a biopsy they did not order of a lesion he did not have. Before the error was recognized, it had caused the patient "tremendous pain and mental anguish."
The author, John Goodman, continues with a theme I have ranted about before, (see here) the increasing lack of individual responsibility for patient care and the replacement with "team care" and computers systems are, of course,increasingly part of the team.
I believe that it is not coincidental that the same ACGME in their 2003 general core competencies statement mentions "systems" or "system" seven times but saw no reason to include the statement quoted above. The authors of the competencies are more concerned with team play, group dynamics,system this and system that, and conserving society's resources and fostering social justice than in inculcating in medical trainees a sense of individual responsibility for their individual patients, which is what I thought it was all about.
The particular case involved a patient at an academic medical center in which
It took three days for the patient's care team to realize that the results entered into his EMR were for a biopsy they did not order of a lesion he did not have. Before the error was recognized, it had caused the patient "tremendous pain and mental anguish."
The author, John Goodman, continues with a theme I have ranted about before, (see here) the increasing lack of individual responsibility for patient care and the replacement with "team care" and computers systems are, of course,increasingly part of the team.
At bottom, the error got as far as it did because of the "medical team" approach - no single person was responsible for this patient's care. Each person relied on the (erroneous) electronic medical record for his view of the whole.
We seem to be replacing personal physician responsibility with "systems".
With so much rhetoric these days about instilling professionalism in medical students and house officers how can individual responsibility be given such short shrift? In 2003 the ACGME eliminated the following statement from their pronouncements:
Physicians must recognize their obligation is not discharged at any given time or any given day.
No, that is not a typo -they eliminated what used to be considered a fundamental principle of the doctor-patient relationship,that the physician is responsible for his patient
I believe that it is not coincidental that the same ACGME in their 2003 general core competencies statement mentions "systems" or "system" seven times but saw no reason to include the statement quoted above. The authors of the competencies are more concerned with team play, group dynamics,system this and system that, and conserving society's resources and fostering social justice than in inculcating in medical trainees a sense of individual responsibility for their individual patients, which is what I thought it was all about.
Earth Day -some cogent counterpoints to the standard green koolaid
The first thing I remember about Earth day were reports of some cases of histoplasmosis in a group of well meaning well-meaners who breathed in a bunch of fungal spores when they set out to clean up their little portions of the earth.
Dr. Don Boudreaux,chairman of the economics department at George Mason University, submits this essay on what he is grateful for on earth day. He sums up his thoughts in this closing paragraph:
I am, in short, thankful for private-property markets that are the main driving force behind these (and many other) anti-pollutants -- a force so powerful that we today enjoy the incredible luxury of being able to worry, should we so choose, about very distant and very speculative forms of environmental problems such as species loss and global warming.
Dr. Mark Perry,economics professor at University of Michigan,wrote this editorial explaining what has driven the cleaning and greening of things since the 1970s birth of Earth Day. (hint it was not Al Gore). He ends his essay with this answer to what has made the earth greener.
Dr. Don Boudreaux,chairman of the economics department at George Mason University, submits this essay on what he is grateful for on earth day. He sums up his thoughts in this closing paragraph:
I am, in short, thankful for private-property markets that are the main driving force behind these (and many other) anti-pollutants -- a force so powerful that we today enjoy the incredible luxury of being able to worry, should we so choose, about very distant and very speculative forms of environmental problems such as species loss and global warming.
Dr. Mark Perry,economics professor at University of Michigan,wrote this editorial explaining what has driven the cleaning and greening of things since the 1970s birth of Earth Day. (hint it was not Al Gore). He ends his essay with this answer to what has made the earth greener.
.. capitalism has. Through wealth generated by the free market, we have enough resources to move beyond the subsistence economies that damage the environment, enough disposable income to fund clean-up programs, enough wealth to scrub and polish industry.
Only in advanced economies can the technology needed to recycle hazardous waste or to replace dirty coal-fired power plants with cleaner gas or nuclear plants be developed. That technology cannot be produced in centrally planned economies where the profit motive is squelched and lives are marshalled by the state.
There's nothing wrong with setting aside a day to honor the Earth. In fairness, though, it should be complemented by Capitalism Day. It's important that the world be reminded of what has driven the environmental improvements since Earth Day began in 1970.
Wednesday, April 22, 2009
Health Insurance does not equal health care
Worth reading is this commentary by internist Dr. Marc Siegel who cautions that "health insurance does not equal health care".Neither is the promise of a government of universal coverage equal to the actual delivery or ready availability of health care.
Medicare (which some may remember as the government program that promised not to interfere with the physician-patient relationship) has so limited the payment to physicians (particularly primary care physicians) that the promise for medical care for the elderly increasingly is becoming unfulfilled as more and more primary care docs opt out or at least refuse to see new medicare payments. This is government care for just one segment of the population.In Canada the unfulfilled promises can affect everyone or at least those who cannot go south and pay for their care.
A recent Texas Medicare Association survey indicated that only 38% of primary care doctors are accepting new Medicare patients and the situation is worse with Medicaid patients.
Problems finding a physician in Massachusetts affects everyone since they instituted the brilliant plan of getting medical insurance for all by simply passing a law that mandated it.This is the same plan that is now asking for a federal bailout.See here for how that is working out.
There are many interpretations for the cryptic lyrics of the song "Hotel California" which says in part
"...relax, said the night man, We are programmed to receive. You can checkout any time you like, But you can never leave! "
My interpretation is that the hotel provides the trappings or appearance of a service but not the real service. What does your national health service card mean if you have to wait so long for the care that it might not matter or if the shortage of docs gets to the point where little care is available.
Medicare (which some may remember as the government program that promised not to interfere with the physician-patient relationship) has so limited the payment to physicians (particularly primary care physicians) that the promise for medical care for the elderly increasingly is becoming unfulfilled as more and more primary care docs opt out or at least refuse to see new medicare payments. This is government care for just one segment of the population.In Canada the unfulfilled promises can affect everyone or at least those who cannot go south and pay for their care.
A recent Texas Medicare Association survey indicated that only 38% of primary care doctors are accepting new Medicare patients and the situation is worse with Medicaid patients.
Problems finding a physician in Massachusetts affects everyone since they instituted the brilliant plan of getting medical insurance for all by simply passing a law that mandated it.This is the same plan that is now asking for a federal bailout.See here for how that is working out.
There are many interpretations for the cryptic lyrics of the song "Hotel California" which says in part
"...relax, said the night man, We are programmed to receive. You can checkout any time you like, But you can never leave! "
My interpretation is that the hotel provides the trappings or appearance of a service but not the real service. What does your national health service card mean if you have to wait so long for the care that it might not matter or if the shortage of docs gets to the point where little care is available.
Tuesday, April 21, 2009
In Canada health care is a right,wait ,no it isn't?
In Canada, there is universal health care with a single payer and for the most part no opting of the system.Their supreme court ruled that patient rights were been violated because their access to health care was in some instances so delayed that it was no care at all.
Now consider the case of an orthopedic surgeon, Dr. Brian Day who is involved in legal proceedings with the provincial health care entity in British Columbia for accepting payment from a private citizen for medical care. See here for some details and here for details of Dr. Day's lawsuit which seeks to overturn the law in BC that bans private medical care. In this matter the government is arguing that the supreme court ruling does not apply because health care is not a right after all.
Wait,I thought the government of Canada provided medical care for all because of the belief that medical care was a right but now it isn't.
Now consider the case of an orthopedic surgeon, Dr. Brian Day who is involved in legal proceedings with the provincial health care entity in British Columbia for accepting payment from a private citizen for medical care. See here for some details and here for details of Dr. Day's lawsuit which seeks to overturn the law in BC that bans private medical care. In this matter the government is arguing that the supreme court ruling does not apply because health care is not a right after all.
Wait,I thought the government of Canada provided medical care for all because of the belief that medical care was a right but now it isn't.
Sunday, April 19, 2009
More concerns about Government mandated and financed electronic medical records
To reform medical care we are told that we need three things; 1)electronic medical records (EMR), 2)comparative effectiveness research (done by the federal government)(CER) and 3)more efforts at prevention . From these elements we can derive care for all,better quality care and great cost savings.(Why does this remind me of "cheap,fast and good-pick any two"?)
Concerns about the government mandated EMR have been recently expressed regarding the following issues:
1.The Legacy issue
2.The error problem
3.The monopoly problem.
While Dr. Michael O'Connor of the blog The Ether Way eloquently writes (see here) about a more fundamental problem with the EMR, namely that it is,at least in part, a cut-and-paste tool of the administrators and the regulators and not so much of the physicians caring for the patients and as such serves the ends of the first two groups much better than those of the physicians and patients and that physician sometimes resort to "shadow charts" as a work-around to the constraints of the EMR.
Dr. Wes offers this posting about the" Legacy problem" with EMR. This is easily related to by anyone who remembers floppy discs ( remember the kind that were really floppy) and how your current computer does not even have slot for those now. Some may have experienced how various drivers did not work when their new PC was driven by Vista and they were not supported by this new improved Microsoft product.Read the trajectory of frustration ,wasted time and money that is explained in detail on Dr.Wes's entry. As computer systems evoke, incompatibilities arise with older system still in use which can lead to increased costs or partial or complete abandonment of the system.
Another serious matter is discussed in detail on Junkfood Science.See here. The main point is that electronic records can be erroneous (errors creep in from various often unrecognized sources) and those errors can be lethal and good luck getting those changed or even finding out what they say.For a detailed description of just some of what can and does go wrong with electronic medical records, go here for an alarming essay by Dr. S. Silverstein (AKA MednformaticsMD) who has tirelessly been educating the readers of Health Care Renewal about the many problems with medical IT.
Still another issue is raised by a commentary in NEJM about which there is a WSJ article ( see here).Since the stimulus bill gives the government power to define and approve which programs and systems will be used there is the power to create a medical high tech monopoly leaving innovation and corrective improvements out in the cold.
Dr. O'Conner's critique of the EMR should be read in its entirety but here is one good quote.
Many EMRs read like Madlibs(for those of you old enough to remember what they are), because they are in fact cut-and-pasted snippets of data from other parts of the EMR, put in place to fulfill some billing documentation requirement or some regulatory imperative. Free text annotation is often discouraged, and frequently impossible to juxtapose next to the appropriate snippet of information in the chart. Some systems make it very difficult to generate any kind of free form documentation, and consequently critical events in the course of a hospitalization are never documented. In most or all hospitals, practitioners have developed a shadow chart that incorporates all of the critical information that practitioners need to know to care for a patient. The existence of these shadow charts has been driven by the hijacking of the medical record for billing and regulatory purposes. The creation of these charts represents additional effort for everyone who directly participates in the care of patients. That such busy people are willing to do this is striking. Little you want to know is in the chart; everything you need to know is in the shadow chart.
I'll admit I had not heard about shadow charts since I have been away from clinical care for a while. Perhaps a reader can inform how widespread this is.
We are told that to reform medical care, billions will be spent to ensure EMRs will cover
everyone's medical records and we can watch as the quality of care is monitored from "this perch" which may well consist of coarse grain and often erroneous data extracted from various EMRs (including the notoriously inaccurate coding information) often excluding the important nuances of the real medical world.
Concerns about the government mandated EMR have been recently expressed regarding the following issues:
1.The Legacy issue
2.The error problem
3.The monopoly problem.
While Dr. Michael O'Connor of the blog The Ether Way eloquently writes (see here) about a more fundamental problem with the EMR, namely that it is,at least in part, a cut-and-paste tool of the administrators and the regulators and not so much of the physicians caring for the patients and as such serves the ends of the first two groups much better than those of the physicians and patients and that physician sometimes resort to "shadow charts" as a work-around to the constraints of the EMR.
Dr. Wes offers this posting about the" Legacy problem" with EMR. This is easily related to by anyone who remembers floppy discs ( remember the kind that were really floppy) and how your current computer does not even have slot for those now. Some may have experienced how various drivers did not work when their new PC was driven by Vista and they were not supported by this new improved Microsoft product.Read the trajectory of frustration ,wasted time and money that is explained in detail on Dr.Wes's entry. As computer systems evoke, incompatibilities arise with older system still in use which can lead to increased costs or partial or complete abandonment of the system.
Another serious matter is discussed in detail on Junkfood Science.See here. The main point is that electronic records can be erroneous (errors creep in from various often unrecognized sources) and those errors can be lethal and good luck getting those changed or even finding out what they say.For a detailed description of just some of what can and does go wrong with electronic medical records, go here for an alarming essay by Dr. S. Silverstein (AKA MednformaticsMD) who has tirelessly been educating the readers of Health Care Renewal about the many problems with medical IT.
Still another issue is raised by a commentary in NEJM about which there is a WSJ article ( see here).Since the stimulus bill gives the government power to define and approve which programs and systems will be used there is the power to create a medical high tech monopoly leaving innovation and corrective improvements out in the cold.
Dr. O'Conner's critique of the EMR should be read in its entirety but here is one good quote.
Many EMRs read like Madlibs(for those of you old enough to remember what they are), because they are in fact cut-and-pasted snippets of data from other parts of the EMR, put in place to fulfill some billing documentation requirement or some regulatory imperative. Free text annotation is often discouraged, and frequently impossible to juxtapose next to the appropriate snippet of information in the chart. Some systems make it very difficult to generate any kind of free form documentation, and consequently critical events in the course of a hospitalization are never documented. In most or all hospitals, practitioners have developed a shadow chart that incorporates all of the critical information that practitioners need to know to care for a patient. The existence of these shadow charts has been driven by the hijacking of the medical record for billing and regulatory purposes. The creation of these charts represents additional effort for everyone who directly participates in the care of patients. That such busy people are willing to do this is striking. Little you want to know is in the chart; everything you need to know is in the shadow chart.
I'll admit I had not heard about shadow charts since I have been away from clinical care for a while. Perhaps a reader can inform how widespread this is.
We are told that to reform medical care, billions will be spent to ensure EMRs will cover
everyone's medical records and we can watch as the quality of care is monitored from "this perch" which may well consist of coarse grain and often erroneous data extracted from various EMRs (including the notoriously inaccurate coding information) often excluding the important nuances of the real medical world.
Tuesday, April 14, 2009
Comparative effectiveness research-more warnings
Those, including several medical bloggers, who seem to have placed more than a little faith in the notion of a government funded and run comparative effectiveness research program (CER) should read the following sobering posting from Health Care Renewal.
The commentary in part expresses concerns about the following recent comments from Governor Sebelius from her congressional hearing for head of HHS.
The author of the Health Care renewal entry is properly alarmed that use of the often garbage type data from EMR have a high likelihood of generating detailed printouts of elaborately presented ( replete with very low p values) results that could be misleading at best and more likely harmful. To expect such " highly uncontrolled" data bases to meaningfully determine if treatment X is better than treatment Y raises unrealistic expectations to a new level.
It seems to me that some pro government CER advocates make two mistakes in their advocacy of the government funded CER.
First, they maintain that we have no or at best very little comparative effectiveness data at all now so the government must provide it. Dr RW in this posting proves that is not the case. A recent example of non-government funded CER is the SYNTAX trial.
Secondly, they conflate the desire to have really good data on what works with the assumption that such will be the product from a government funded CER. Yes,it would be very nice if there were someway to have realms of great CER without bias and without spin but should we really trust a government agency who would somehow be populated by selfless, brilliant, dedicated public servants who would bring no biases to the table and who somehow will be immune to the outside influences that seemed to have plagued every governmental agency ever created and that the output from analysis would not be put to the purpose of limiting government payment for such treatment that they found inferior.
Limiting payment for medical services deemed inferior by data dredging exercises is not what we need to improve medical quality but may well be what government sponsored CER will bring.
The commentary in part expresses concerns about the following recent comments from Governor Sebelius from her congressional hearing for head of HHS.
“The goal,” Sebelius said, “is to provide every American with a safe, secure electronic health record by 2014." The nominee also endorsed efforts to use data gleaned from electronic medical records to conduct “comparative effectiveness research" (the authors bolding)(CER) to provide information on the relative strengths and weaknesses of alternative medical interventions to health providers and consumers.”
The author of the Health Care renewal entry is properly alarmed that use of the often garbage type data from EMR have a high likelihood of generating detailed printouts of elaborately presented ( replete with very low p values) results that could be misleading at best and more likely harmful. To expect such " highly uncontrolled" data bases to meaningfully determine if treatment X is better than treatment Y raises unrealistic expectations to a new level.
It seems to me that some pro government CER advocates make two mistakes in their advocacy of the government funded CER.
First, they maintain that we have no or at best very little comparative effectiveness data at all now so the government must provide it. Dr RW in this posting proves that is not the case. A recent example of non-government funded CER is the SYNTAX trial.
Secondly, they conflate the desire to have really good data on what works with the assumption that such will be the product from a government funded CER. Yes,it would be very nice if there were someway to have realms of great CER without bias and without spin but should we really trust a government agency who would somehow be populated by selfless, brilliant, dedicated public servants who would bring no biases to the table and who somehow will be immune to the outside influences that seemed to have plagued every governmental agency ever created and that the output from analysis would not be put to the purpose of limiting government payment for such treatment that they found inferior.
Limiting payment for medical services deemed inferior by data dredging exercises is not what we need to improve medical quality but may well be what government sponsored CER will bring.
Monday, April 13, 2009
Medical Home will not be enough, we need the Medical Village
I written before about my skepticism regarding the Medical Home concept.It has been suggested that the home does not go far enough and that a "village "concept should be explored and possibly adopted. Here is one doc's version of how that village concept would be applied to one aspect of medical care. Thanks to Dr. Hal Dall's blog for insightful comments and satire.
Tuesday, April 07, 2009
Statins (or at least one of them) seems to just get better and better
Just as we thought there could not possibly be any more purported benefits of the statin drugs we are treated to still another reason to get on the bandwagon- prevention of venous clots.
At least that is what we are told by more breaking news from the latest paradigm shifting, landmark study, the JUPITER trial. We now learn that in this large , randomized trial of persons whose LDL were less than 130 and their CRP were greater than 2,that there was a 43 % decrease in the incidence of venous thrombotic disease in the rosuvastatin (20 mg) group. See here for the entire article from the NEJM.
Previously I had blogged about the reported benefits of pre-operative statins in terms of fewer deaths,fewer strokes and a lower incidence of atrial fibrillation.
At least that is what we are told by more breaking news from the latest paradigm shifting, landmark study, the JUPITER trial. We now learn that in this large , randomized trial of persons whose LDL were less than 130 and their CRP were greater than 2,that there was a 43 % decrease in the incidence of venous thrombotic disease in the rosuvastatin (20 mg) group. See here for the entire article from the NEJM.
Previously I had blogged about the reported benefits of pre-operative statins in terms of fewer deaths,fewer strokes and a lower incidence of atrial fibrillation.
Monday, April 06, 2009
What the heck could increased variation in red blood cell size have to do with heart disease or mortality?
This article from the Archives of Internal Medicine seems to link a measure of variability in red blood cell (rbc) size with all cause mortality. As the article explains, previously there had several studies that suggested a link between heart disease and RBC size variability as judged by measurement of the RDW by automated blood cell analyzers. (See here for one article linking elevated RDW and adverse clinical outcomes in patients with heart disease). The Archive article examined a large data base for evidence of a similar correlation with all cause mortality and seemed to find one that reached statistical significance.
The RDW is the red cell distribution width which is the standard deviation of red cell width divided by the mean cell width and normally is around 10-15 %. Remember we used to talk about anisocytosis. It may have some limited utility in differentiating iron deficiency anemia from thalassemia with the RDW increased in the former reflecting the fact that in iron deficiency there are two populations of red cells and in thalassemia there is a more homogeneous population of relatively small rbcs. In my experience, it is a by product of automatic blood cell analyzers that most docs ignore, including a couple of hematologist associates I asked about it.
The study authors also wondered how/why RDW seems to correlate with all cause mortality.They investigated the relationship between C reactive protein (CRP) and RDW postulating that somehow inflammation was involved but that did not seem to be the case.
How long will it take for the JUPITER data be dredged to see if statins ( at least rosuvastatin) can lower the RDW?
The RDW is the red cell distribution width which is the standard deviation of red cell width divided by the mean cell width and normally is around 10-15 %. Remember we used to talk about anisocytosis. It may have some limited utility in differentiating iron deficiency anemia from thalassemia with the RDW increased in the former reflecting the fact that in iron deficiency there are two populations of red cells and in thalassemia there is a more homogeneous population of relatively small rbcs. In my experience, it is a by product of automatic blood cell analyzers that most docs ignore, including a couple of hematologist associates I asked about it.
The study authors also wondered how/why RDW seems to correlate with all cause mortality.They investigated the relationship between C reactive protein (CRP) and RDW postulating that somehow inflammation was involved but that did not seem to be the case.
How long will it take for the JUPITER data be dredged to see if statins ( at least rosuvastatin) can lower the RDW?
Thursday, April 02, 2009
Is the Massachusett Universal coverage plan the canary in the mine?
See this article from WSJ online to gather facts about how poorly things are working out in the grand universal health care program for Massachusetts.
Three years into the program (which has been labeled the Bay State bait and switch) the costs have increased far beyond the projections that were part of the program's promises. The budget projection for 2010 is 880 million which is a 42% increase from the 2006 number. (other projections go even higher, see below). They have increased fines for those who can afford insurance but choose to not sign up, also increasing are premiums and penalties for business. A panel has been set up to look at options. It is never good news that a panel has been set to "find solutions". Limiting care is one,limiting profits for insurers is another after premiums and penalties have increased to a point were public outcry becomes too loud.
Proponents had promised universal coverage with lower costs.
Go here for many more details of how badly things have gone as outlined on the Blog Junkfood Science.Here is an except:
By February of this year (2008), the state was asking the Federal government to bail it out ( my bold) and cover half of the program’s costs from 2009 through 2011. According to the Boston Globe, the program will cost taxpayers $1.95 billion this year and is expected to cost $1.35 billion annually by June 2011 — figures that “far outstrip the original plans.” Massachusetts medical authorities, in efforts to keep the program solvent, had approved changes in December to cut payments to doctors and hospitals, reduce choices and benefits for patients, and possibly increase how much patients have to pay.
The WSJ article closes with:
The real lesson of Massachusetts is that reform proponents won't tell Americans the truth about what "universal" coverage really means: Runaway costs followed by price controls and bureaucratic rationing.
At least citizens of Massachusetts have a safety value, something that might not be readily available if the Mass. plan goes national.
We are promised universal health care that will magically be less expensive because of the promised savings of "investments" in medical IT, comparative effectiveness research and preventive medicine.The plan seems to be spend more on health care so we can save more.What could go wrong with that?
Three years into the program (which has been labeled the Bay State bait and switch) the costs have increased far beyond the projections that were part of the program's promises. The budget projection for 2010 is 880 million which is a 42% increase from the 2006 number. (other projections go even higher, see below). They have increased fines for those who can afford insurance but choose to not sign up, also increasing are premiums and penalties for business. A panel has been set up to look at options. It is never good news that a panel has been set to "find solutions". Limiting care is one,limiting profits for insurers is another after premiums and penalties have increased to a point were public outcry becomes too loud.
Proponents had promised universal coverage with lower costs.
Go here for many more details of how badly things have gone as outlined on the Blog Junkfood Science.Here is an except:
By February of this year (2008), the state was asking the Federal government to bail it out ( my bold) and cover half of the program’s costs from 2009 through 2011. According to the Boston Globe, the program will cost taxpayers $1.95 billion this year and is expected to cost $1.35 billion annually by June 2011 — figures that “far outstrip the original plans.” Massachusetts medical authorities, in efforts to keep the program solvent, had approved changes in December to cut payments to doctors and hospitals, reduce choices and benefits for patients, and possibly increase how much patients have to pay.
The WSJ article closes with:
The real lesson of Massachusetts is that reform proponents won't tell Americans the truth about what "universal" coverage really means: Runaway costs followed by price controls and bureaucratic rationing.
At least citizens of Massachusetts have a safety value, something that might not be readily available if the Mass. plan goes national.
We are promised universal health care that will magically be less expensive because of the promised savings of "investments" in medical IT, comparative effectiveness research and preventive medicine.The plan seems to be spend more on health care so we can save more.What could go wrong with that?
Wednesday, April 01, 2009
NHS's hospital from hell showcases performance measures
The British NHS is investigating how things could go so very wrong at one of their hospitals,the Stafford hospital. See here for the newspaper report that puts at least part of the blame on a situation where mindless adhering to quality targets may have caused deaths.
See also here for the story that has this quote:
...So what the government decided to do instead was make hospitals compete on things that mostly weren't related to clinical outcomes; things that could be easily measured, such as the four-hour wait in A&E. If you talk to clinicians, they'll say this has nothing to do with outcomes and doesn't improve the care that patients receive. You can find ways to fiddle the numbers to tick that box, and you can put resources in to try to meet the targets.
At a time when the incredibly bad care that is documented in the two above cited newspapers article was taking place the hospital was getting pretty good grades on its various performance measures.
One such target was "get the patients out of (A&E ) accident and emergency) to the wards in 4 hours.".If you thought there were problems with the U.S. "4-hour pneumonia rule"....
I have blogged before on Goodhart's law which says:
"Once a measure is made a target for the purpose of conducting policy it will loose the information content that would qualify it to play such a role".
While the mindlessness of treating to the quality measure is part of the problem at this NHS hospital there is much more wrong than that .See here for Health Care BS's take on the matter.
See also here for the story that has this quote:
...So what the government decided to do instead was make hospitals compete on things that mostly weren't related to clinical outcomes; things that could be easily measured, such as the four-hour wait in A&E. If you talk to clinicians, they'll say this has nothing to do with outcomes and doesn't improve the care that patients receive. You can find ways to fiddle the numbers to tick that box, and you can put resources in to try to meet the targets.
At a time when the incredibly bad care that is documented in the two above cited newspapers article was taking place the hospital was getting pretty good grades on its various performance measures.
One such target was "get the patients out of (A&E ) accident and emergency) to the wards in 4 hours.".If you thought there were problems with the U.S. "4-hour pneumonia rule"....
I have blogged before on Goodhart's law which says:
"Once a measure is made a target for the purpose of conducting policy it will loose the information content that would qualify it to play such a role".
While the mindlessness of treating to the quality measure is part of the problem at this NHS hospital there is much more wrong than that .See here for Health Care BS's take on the matter.
Monday, March 30, 2009
Should "preventionists" treat the population and real docs treat individuals?
I had not heard the term "preventionist" before reading this excellent entry by Dr. Michal Accad. His thoughtful essay in part delves into a topic that has interested and bothered me for years, the individual versus the collective and in the medical context population health versus individual health.One of my rants on this topic can be found here. (One indicator that you probably have run out anything to say is frequently quoting yourself.)
I quote his final paragraph wherein the term "preventionist" appears, I think tongue in cheek.
... But since population medicine has little to do with individual medicine, and since the application of primary prevention requires no diagnostic skills to identify the subjects of predilection, the advocated intervention need not be practiced in the doctor’s office. I propose that JUPITER’s precepts be promoted in specialized “Centers of Excellence,” public health dispensaries where competent preventionists could directly indoctrinate the public to the many values of the modern wisdom, un-distracted by the chaotic environment of a clinical practice. And thus relieved from the burdens of a task at which they are so woefully “inefficient,” the primary care physician could then return to their humble original calling, the care of a patient with a chief complaint.
The primary care physician increasingly is called upon to to be a preventionist under the threat of being accused of not practicing quality care and not receiving his bribe (aka P4P ).
My favorite P4P quote continues to be:
"He hands you a nickle.He hands you a dime.He asks you with a grin are you having a good time"...Dylan from Maggie's Farm.
Prevention is one of the holy trinity (along with EMRs and quality systems) that will bring the new age of greater health for all, less money spent and really good care for everybody. In terms of the world of the internist, it is the office internist (one variety of the officist) upon whose shoulders falls the obligation to ensure his patients (clients, customers) have been quizzed and then instructed to do whatever they are supposed to do to strive for wellness from submitting to colonoscopies and flossing and using their seat belts.The other sub-species of internist (the hospitalist) can still for the most part manage sick patients leaving the administrative tasks of prevention to his 8-5 office cousins and increasingly to their extenders.
I quote his final paragraph wherein the term "preventionist" appears, I think tongue in cheek.
... But since population medicine has little to do with individual medicine, and since the application of primary prevention requires no diagnostic skills to identify the subjects of predilection, the advocated intervention need not be practiced in the doctor’s office. I propose that JUPITER’s precepts be promoted in specialized “Centers of Excellence,” public health dispensaries where competent preventionists could directly indoctrinate the public to the many values of the modern wisdom, un-distracted by the chaotic environment of a clinical practice. And thus relieved from the burdens of a task at which they are so woefully “inefficient,” the primary care physician could then return to their humble original calling, the care of a patient with a chief complaint.
The primary care physician increasingly is called upon to to be a preventionist under the threat of being accused of not practicing quality care and not receiving his bribe (aka P4P ).
My favorite P4P quote continues to be:
"He hands you a nickle.He hands you a dime.He asks you with a grin are you having a good time"...Dylan from Maggie's Farm.
Prevention is one of the holy trinity (along with EMRs and quality systems) that will bring the new age of greater health for all, less money spent and really good care for everybody. In terms of the world of the internist, it is the office internist (one variety of the officist) upon whose shoulders falls the obligation to ensure his patients (clients, customers) have been quizzed and then instructed to do whatever they are supposed to do to strive for wellness from submitting to colonoscopies and flossing and using their seat belts.The other sub-species of internist (the hospitalist) can still for the most part manage sick patients leaving the administrative tasks of prevention to his 8-5 office cousins and increasingly to their extenders.
Wednesday, March 25, 2009
If you get Universal health care with a single payer you better have a "safety value"
In Great Britain, at least for some, the safety value for the NHS is private health care. In Canada, if you can afford it, the safety value is to leave and get the care in the United States or overseas, perhaps in India.
Here is a reference to comments made by the Director of Trauma at McGill Hospital Centre in regard to the events surrounding the death of Natasha Richardson. He said in part:
"It's impossible for me to comment specifically about her case, but what I could say is ... driving to Mont Tremblant from the city (Montreal) is a 2 1/2-hour trip, and the closest trauma center is in the city. Our system isn't set up for traumas and doesn't match what's available in other Canadian cities, let alone in the States,...
The system is not "set up" for trauma in part because there were no air evac helicopters in that area. As pointed out by others capital investments in the health care system in Canada are costs to the system that cannot be recouped. In the US, the purchase of,for example, an MRI, is also a cost to the hospital or clinic but it can be recouped and typically is a profit center. So hospitals under which system are likely to have MRIs readily available?
It is important to recognize that "universal health care coverage" and "single payer" are not the same thing.
David Henderson of the econlog blog has this to say about the single payer system in Canada:
The essence of "single payer" medicine is that no one other than the government is allowed to pay for medical care. Thus the term "single payer." There are a few exceptions in Canada but, by and large, the more serious the ailment, the more stringent the ban. So, for example, if you want to be treated for cancer in Canada, you can not do so legally and any doctor or hospital that tries to charge you faces serious penalties, up to and including a prison sentence. In that sense, Canadian health care is one of the most totalitarian systems in the industrialized world and is far more extreme than the National Health Service of Britain.
When rationing by waiting turns into health care denied by health care delayed ( as numerous anecdotes or case reports indicate) as occurs in Canada the single payer may in effect work directly counter to the promise of universal care that the single payer system promises. There are many problems of single payer system as a cursory study of the health care in Canada and Great Britain will show, but a single payer system that outlaws private care is, as David Henderson says, about as totalitarian as you can get since your life is in the hands of the state.
Here is a reference to comments made by the Director of Trauma at McGill Hospital Centre in regard to the events surrounding the death of Natasha Richardson. He said in part:
"It's impossible for me to comment specifically about her case, but what I could say is ... driving to Mont Tremblant from the city (Montreal) is a 2 1/2-hour trip, and the closest trauma center is in the city. Our system isn't set up for traumas and doesn't match what's available in other Canadian cities, let alone in the States,...
The system is not "set up" for trauma in part because there were no air evac helicopters in that area. As pointed out by others capital investments in the health care system in Canada are costs to the system that cannot be recouped. In the US, the purchase of,for example, an MRI, is also a cost to the hospital or clinic but it can be recouped and typically is a profit center. So hospitals under which system are likely to have MRIs readily available?
It is important to recognize that "universal health care coverage" and "single payer" are not the same thing.
David Henderson of the econlog blog has this to say about the single payer system in Canada:
The essence of "single payer" medicine is that no one other than the government is allowed to pay for medical care. Thus the term "single payer." There are a few exceptions in Canada but, by and large, the more serious the ailment, the more stringent the ban. So, for example, if you want to be treated for cancer in Canada, you can not do so legally and any doctor or hospital that tries to charge you faces serious penalties, up to and including a prison sentence. In that sense, Canadian health care is one of the most totalitarian systems in the industrialized world and is far more extreme than the National Health Service of Britain.
When rationing by waiting turns into health care denied by health care delayed ( as numerous anecdotes or case reports indicate) as occurs in Canada the single payer may in effect work directly counter to the promise of universal care that the single payer system promises. There are many problems of single payer system as a cursory study of the health care in Canada and Great Britain will show, but a single payer system that outlaws private care is, as David Henderson says, about as totalitarian as you can get since your life is in the hands of the state.
Tuesday, March 24, 2009
Tight glucose control in ICU seems hazardous
In the March 24,2009 on line issue of NEJM the results of the Nice Sugar trial are published and shows that conventional treatment ( target glucose less than 180) as opposed to tight control (defined as 81-108 glucose target) is better. This was a very large trial with over 3000 patients in each arm.
In the tight control group 27.5 % died versus 24.9 % deaths in the conventional treatment group.Severe hypoglycemia (less than 40) occurred in 6. 5 % of the intensive treatment group versus 0.5 % in the conventional treatment group illustrating once more that more insulin may drive the blood sugar too low and be harmful.
Even though meta-analysis have generated conflicting results regarding the efficacy and safety of tight glucose control, both the American Diabetes Association and the American Society of Clinical Endocrinologists have recommended tight control.
The study authors of the NICE trial offered this understatement "Our findings suggest that a goal of normoglycemia for glucose control does not necessarily benefit critically ill patients and may be harmful",
This seems to be another example of the ready, shoot, aim approach to guidelines bringing to mind the ill advised rush to give everyone beta blockers peri-operatively which was probably laid to rest with the publication of the POISE Trial. Let me repeat what I said after that trial was published.
If there is a lesson here it is not just that a large randomized clinical trial gives results opposite to earlier smaller trials-that is a story we have heard more than once before. The lesson is not that expert committees sometimes have to revise their recommendations as new information becomes available.The lesson I think that should be emphasized is that overzealous quality rule writers and enforcers can be a hazard to your health ( and I have said that before). Read Dr. Devereaux's comments regarding how many patients may have been harmed by taking peri operative beta blockers and then wonder how many patients received them simply because premature quality guidelines were in place and physicians were caught up in the rush to treat even though it seems clear now that the evidence for such zealous efforts was inadequate. Dr. DB (AKA Dr. Robert Centor) nailed it when he recently spoke about in this regard " the performance and quality movement which has a 'ready,fire, aim' philosophy".
In the tight control group 27.5 % died versus 24.9 % deaths in the conventional treatment group.Severe hypoglycemia (less than 40) occurred in 6. 5 % of the intensive treatment group versus 0.5 % in the conventional treatment group illustrating once more that more insulin may drive the blood sugar too low and be harmful.
Even though meta-analysis have generated conflicting results regarding the efficacy and safety of tight glucose control, both the American Diabetes Association and the American Society of Clinical Endocrinologists have recommended tight control.
The study authors of the NICE trial offered this understatement "Our findings suggest that a goal of normoglycemia for glucose control does not necessarily benefit critically ill patients and may be harmful",
This seems to be another example of the ready, shoot, aim approach to guidelines bringing to mind the ill advised rush to give everyone beta blockers peri-operatively which was probably laid to rest with the publication of the POISE Trial. Let me repeat what I said after that trial was published.
If there is a lesson here it is not just that a large randomized clinical trial gives results opposite to earlier smaller trials-that is a story we have heard more than once before. The lesson is not that expert committees sometimes have to revise their recommendations as new information becomes available.The lesson I think that should be emphasized is that overzealous quality rule writers and enforcers can be a hazard to your health ( and I have said that before). Read Dr. Devereaux's comments regarding how many patients may have been harmed by taking peri operative beta blockers and then wonder how many patients received them simply because premature quality guidelines were in place and physicians were caught up in the rush to treat even though it seems clear now that the evidence for such zealous efforts was inadequate. Dr. DB (AKA Dr. Robert Centor) nailed it when he recently spoke about in this regard " the performance and quality movement which has a 'ready,fire, aim' philosophy".
The other side of the health Care "debate"
As for as the main stream medical journals (JAMA, NEJM, Annals Internal Medicine) the health care issue is largely already decided with certain conclusions reached and as such now exist beyond debate or refutation. The conclusions are :U.S. health care costs too much, many folks are "denied" access to care and the care is of inferior quality to that received in the other developed countries.
There are cogent arguments to the contrary and those can be found here.
The authors include John Goodman , a Phd in Economics and a prolific author on the subject of health care economics but unlike Uwe Reinhardt is rarely quoted in the big three journals mentioned above. (It seems to help to be on the board of a managed care company to get quoted in JAMA).
Another author is Dr. Robert M Sade. I first heard of Dr. Sade when he published a NEJM article in support of the proposition that health care is not a right. The type of fire storm that his article elicited was not unexpected and included a blistering admonition from the editor of the journal. Dr. Sade, a trained heart surgeon, later left practice and has devoted some of his energies to biomedical ethics and health policy and organ transplantation issues.
Dr. Wes gives his views on the "broken health care system" here.
There are cogent arguments to the contrary and those can be found here.
The authors include John Goodman , a Phd in Economics and a prolific author on the subject of health care economics but unlike Uwe Reinhardt is rarely quoted in the big three journals mentioned above. (It seems to help to be on the board of a managed care company to get quoted in JAMA).
Another author is Dr. Robert M Sade. I first heard of Dr. Sade when he published a NEJM article in support of the proposition that health care is not a right. The type of fire storm that his article elicited was not unexpected and included a blistering admonition from the editor of the journal. Dr. Sade, a trained heart surgeon, later left practice and has devoted some of his energies to biomedical ethics and health policy and organ transplantation issues.
Dr. Wes gives his views on the "broken health care system" here.
Monday, March 23, 2009
The new HFA inhalers may or may not help the environment and drug companies but are the users the forgotten men?
Here is on article discussing the possible cons of the introduction of the HFA inhalers and the outlawing of the older CFC type (except for Maxair).
Some patients complain they do not work as well and more complain about the increased costs and more than a few physicians have spent time educating patients regarding their use and offering reassurance.
If you wonder, as I do, about how much effect the CFC pulmonary inhalers have on ozone depletion and how much good this prohibition will generate, this reference might offer some information and opinion in that regard.
When I wrote about this before I said:
.. I think this is the first time that the FDA [has banned] a medication or group of medications not because they are thought or proven to be harmful to those who use them but because they are thought to possibly harm folks who do not use it. (OK, the purported skin carcinogenic effect of increased sun rays from the purported decrease in ozone layer thickness would affect everyone- even asthmatics.) Since the task of determining harm to medication users has proven much harder that the FDA or anyone ever thought, it is admirable that the FDA will take on an even more difficult task.
I don't have a tracking on the course this regulation took through the regulatory mechanisms and who supported it, but I cannot help but wonder if we are dealing with still another instance of the "Baptists and the Bootleggers". Since there are no generic versions of the HFA inhalers, guess who the bootleggers would be and would the Baptist role be played be the more radical environmentalists?
Some patients complain they do not work as well and more complain about the increased costs and more than a few physicians have spent time educating patients regarding their use and offering reassurance.
If you wonder, as I do, about how much effect the CFC pulmonary inhalers have on ozone depletion and how much good this prohibition will generate, this reference might offer some information and opinion in that regard.
When I wrote about this before I said:
.. I think this is the first time that the FDA [has banned] a medication or group of medications not because they are thought or proven to be harmful to those who use them but because they are thought to possibly harm folks who do not use it. (OK, the purported skin carcinogenic effect of increased sun rays from the purported decrease in ozone layer thickness would affect everyone- even asthmatics.) Since the task of determining harm to medication users has proven much harder that the FDA or anyone ever thought, it is admirable that the FDA will take on an even more difficult task.
I don't have a tracking on the course this regulation took through the regulatory mechanisms and who supported it, but I cannot help but wonder if we are dealing with still another instance of the "Baptists and the Bootleggers". Since there are no generic versions of the HFA inhalers, guess who the bootleggers would be and would the Baptist role be played be the more radical environmentalists?
Friday, March 13, 2009
Wait-Maybe electronic medical records might not save money.
We have been told by President Obama that we cannot fix the economic mess without fixing health care (and education and the environment, for that matter). OK, some of us think that may rank as the non sequitur of the year (decade?) but let us look deeper. Electronic medical records (EMR) has been heralded as one of the ways we can simultaneously improve quality,provide medical care for all and save money. One prominent medical blogger and a fairly well known medical author both suggest that might not be true at least in regard to money part.
KevinMD, see here, offers a interesting take. Hospitals may get more proficient at maximizing coding techniques with computers and therefore increase their share of the medicare and insurance pots and thereby increase costs.With the stimulus plan the government will give money to the hospitals to get the computer systems to code better and get more payments.
Dr. Jerome Groopman whose writings on medical cognitive tricks and traps has now taken on the topic of putative savings from EMR and challenges the often quoted Rand study that claims EMR would save huge amounts of money.See here.The study needs to be analyzed on its own merits as Dr. G. apparently has done but it did not go unnoticed that the study was founded by HP and Xerox, who could be described as interested parties. We all know how the money behind drug studies always raises a red flag and a reflex skepticism of the results but here only now ( at least I can't find other references) does someone make that point with the Rand study.
KevinMD, see here, offers a interesting take. Hospitals may get more proficient at maximizing coding techniques with computers and therefore increase their share of the medicare and insurance pots and thereby increase costs.With the stimulus plan the government will give money to the hospitals to get the computer systems to code better and get more payments.
Dr. Jerome Groopman whose writings on medical cognitive tricks and traps has now taken on the topic of putative savings from EMR and challenges the often quoted Rand study that claims EMR would save huge amounts of money.See here.The study needs to be analyzed on its own merits as Dr. G. apparently has done but it did not go unnoticed that the study was founded by HP and Xerox, who could be described as interested parties. We all know how the money behind drug studies always raises a red flag and a reflex skepticism of the results but here only now ( at least I can't find other references) does someone make that point with the Rand study.
Sunday, March 08, 2009
What does universal health care have to do with the economic mess?
Tell me again why we cannot get out of this economic mess without fixing health care? I have read over twenty putative explanations for why and how we got where we are in one scary recession and so far none of the financial pundits nor card carrying economists have suggested that lack of medical coverage and too high health care costs caused the problem or was even a major contributing cause.
I have read that we had first a housing boom and then a bubble and then a crash whose effects were hyper-amplified beyond most analysts' wildest fears by a situation in which: entities that made loans sold them to others who packaged them in ways few understood, many of the loans were made to people who could not afford them,mortgage based securities (MBS) based in part on bad loan were markedly overvalued by rating companies,financial entities who bought and sold MBSs were dangerously over leveraged and according to one school of economic thought (the Austrian School) a major driving force was the artificially low interest rate driven down by the Federal Reserve system in this country and by other central banks around the world.
If one plows through a lucid and laboriously documented academic discussion by Marcus Brunnermeier from Princeton's economic department you will be treated to a discussion of how he suggests the housing bubble was made possible by cheap credit supplied both by a surplus of foreign ( mainly Asian) money looking for a good return on investment and an expansionary Federal Reserve Policy,of lowered lending standards ,of major changes in the banking system (i.e. going from loan and keep , to loan and sell off the loans), of various actions by banks to establish a "shadow banking"system involving off balance sheet investment vehicles exposing them to liquidity risk, of investments entities relying more and more on a borrow short and loan long arrangement . In short he describes elements of the events that took place as a mortgage crisis was amplified into a severe finanacial crisis.
If medical costs and folks without medical insurance played a role in any of this he and every other economists and financial analysts and pundits who has written about it really missed the boat.
Yet, we told by the new administration that we cannot get out of this financial mess without fixing the health care system. We are told that for recovery we will have to simultaneously cut medical care costs and ensure that everyone has medical care and improve quality of care. Of course, there are good arguments to the point that we do spend a lot of medical care and thoughtful people have a legitimate concern that some folks do not have health insurance and that there is a great deal that needs fixing but what do those concerns have to do with a housing bubble,burst, and mortgage crisis amplified into a financial crisis and why is a health care fix a necessary part of recovery?
Dr. Krauthammer hammered away at what he describes as Obama's glaring non-sequiturs in his Washington Post commentary dated 3/6/2009 entitle "The great Non-sequitur"
President Obama has asserted that the mess we are in relates to the country failing to obtain universal health care, green energy and better education. Dr. Krauthammer gives us this quote from the President's speech in which we are seemingly finally told why the real reasons of why we are where we are now:
"Our economy did not fall into decline overnight," he averred. Indeed, it all began before the housing crisis. What did we do wrong? We are paying for past sins in three principal areas: energy, health care and education -- importing too much oil and not finding new sources of energy (as in the Arctic National Wildlife Refuge and the Outer Continental Shelf?), not reforming health care, and tolerating too many bad schools.
Krauthammer says in reply:
.. the list of causes of the collapse of the financial system does not include the absence of universal health care, let alone of computerized medical records. Nor the absence of an industry-killing cap-and-trade carbon levy. Nor the lack of college graduates. Indeed, one could perversely make the case that, if anything, the proliferation of overeducated, Gucci-wearing, smart-ass MBAs inventing ever more sophisticated and opaque mathematical models and debt instruments helped get us into this credit catastrophe. .......
Clever politics, but intellectually dishonest to the core. Health, education and energy -- worthy and weighty as they may be -- are not the cause of our financial collapse. And they are not the cure. The fraudulent claim that they are both cause and cure is the rhetorical device by which an ambitious president intends to enact the most radical agenda of social transformation seen in our lifetime.
Whether on not you agree with Dr.K's characterization of what Mr. Obama's agenda really is, it is very hard to accept the claim that fixing his big three initiative is necessary for the economic repair.To be fair I have to recuse myself regarding expressing an opinion on the carbon cap and trade issue,I have not researched that enough to justify comment but if the lack of a universal health care plan in this country is a cause of the economic downturn, it must be the best keep secret on the century. Should not Great Britain have been spared the economic turmoil since they have had a universal health coverage system in place for years?
I have read that we had first a housing boom and then a bubble and then a crash whose effects were hyper-amplified beyond most analysts' wildest fears by a situation in which: entities that made loans sold them to others who packaged them in ways few understood, many of the loans were made to people who could not afford them,mortgage based securities (MBS) based in part on bad loan were markedly overvalued by rating companies,financial entities who bought and sold MBSs were dangerously over leveraged and according to one school of economic thought (the Austrian School) a major driving force was the artificially low interest rate driven down by the Federal Reserve system in this country and by other central banks around the world.
If one plows through a lucid and laboriously documented academic discussion by Marcus Brunnermeier from Princeton's economic department you will be treated to a discussion of how he suggests the housing bubble was made possible by cheap credit supplied both by a surplus of foreign ( mainly Asian) money looking for a good return on investment and an expansionary Federal Reserve Policy,of lowered lending standards ,of major changes in the banking system (i.e. going from loan and keep , to loan and sell off the loans), of various actions by banks to establish a "shadow banking"system involving off balance sheet investment vehicles exposing them to liquidity risk, of investments entities relying more and more on a borrow short and loan long arrangement . In short he describes elements of the events that took place as a mortgage crisis was amplified into a severe finanacial crisis.
If medical costs and folks without medical insurance played a role in any of this he and every other economists and financial analysts and pundits who has written about it really missed the boat.
Yet, we told by the new administration that we cannot get out of this financial mess without fixing the health care system. We are told that for recovery we will have to simultaneously cut medical care costs and ensure that everyone has medical care and improve quality of care. Of course, there are good arguments to the point that we do spend a lot of medical care and thoughtful people have a legitimate concern that some folks do not have health insurance and that there is a great deal that needs fixing but what do those concerns have to do with a housing bubble,burst, and mortgage crisis amplified into a financial crisis and why is a health care fix a necessary part of recovery?
Dr. Krauthammer hammered away at what he describes as Obama's glaring non-sequiturs in his Washington Post commentary dated 3/6/2009 entitle "The great Non-sequitur"
President Obama has asserted that the mess we are in relates to the country failing to obtain universal health care, green energy and better education. Dr. Krauthammer gives us this quote from the President's speech in which we are seemingly finally told why the real reasons of why we are where we are now:
"Our economy did not fall into decline overnight," he averred. Indeed, it all began before the housing crisis. What did we do wrong? We are paying for past sins in three principal areas: energy, health care and education -- importing too much oil and not finding new sources of energy (as in the Arctic National Wildlife Refuge and the Outer Continental Shelf?), not reforming health care, and tolerating too many bad schools.
Krauthammer says in reply:
.. the list of causes of the collapse of the financial system does not include the absence of universal health care, let alone of computerized medical records. Nor the absence of an industry-killing cap-and-trade carbon levy. Nor the lack of college graduates. Indeed, one could perversely make the case that, if anything, the proliferation of overeducated, Gucci-wearing, smart-ass MBAs inventing ever more sophisticated and opaque mathematical models and debt instruments helped get us into this credit catastrophe. .......
Clever politics, but intellectually dishonest to the core. Health, education and energy -- worthy and weighty as they may be -- are not the cause of our financial collapse. And they are not the cure. The fraudulent claim that they are both cause and cure is the rhetorical device by which an ambitious president intends to enact the most radical agenda of social transformation seen in our lifetime.
Whether on not you agree with Dr.K's characterization of what Mr. Obama's agenda really is, it is very hard to accept the claim that fixing his big three initiative is necessary for the economic repair.To be fair I have to recuse myself regarding expressing an opinion on the carbon cap and trade issue,I have not researched that enough to justify comment but if the lack of a universal health care plan in this country is a cause of the economic downturn, it must be the best keep secret on the century. Should not Great Britain have been spared the economic turmoil since they have had a universal health coverage system in place for years?
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