Archive for September 2009

Theme Thursday: Wild   3 comments

Yesterday’s TT topic was “wild”.

When I was a child, I used to watch Mutual of Omaha’s Wild Kingdom.  I thought that Marlin Perkins was awesome.  Interesting little tidbit about Marlin that I didn’t know (from his Wikipedia page):

Because Walt Disney had fabricated footage of a mass suicide of lemmings in its film White Wilderness,[6] CBC (at that time) journalist Bob McKeown asked Marlin Perkins if he had done the same. Perkins, then in his eighties, “firmly asked for the camera to be turned off, then punched a shocked McKeown in the face.” [7]

As interesting and wild as our world today, for sheer magnitude nothing beats the Late Cretaceous for wildness.  We truly had Sea Monsters living in what is now the central United States.  National Geographic did a special that’s worth watching…

A chunk of the last episode of the BBC series Walking with Dinosaurs: Sea Monsters, showing the Mosasaur (fictitious, obviously, but pretty well done) –

That show has spawned a world tour (which, unfortunately, doesn’t hit Los Angeles).  If you live in Texas, you might still be able to get tickets to one of the later shows.  If you have any adolescent boys in the house, it’s probably a winner.

Posted September 25, 2009 by padraic2112 in Theme Thursday

Existence Statements & Probability   2 comments

Posted September 23, 2009 by padraic2112 in philosophy, science

Only 10%?   5 comments

Really?  Only 10% of the population can get all 12?  Why are we worried so much about high school exit exams?  Apparently adults need to crack open a book or three…

12

How well can you do?

(tip o’ the blogger hat to the Skeptical Teacher)

Posted September 22, 2009 by padraic2112 in science

This Made Me Laugh For About 2 Minutes Today   Leave a comment

From Dr. Free-Ride’s blog:

psychohazard2

This goes a long way to explaining my sense of humor.

Posted September 21, 2009 by padraic2112 in humor, philosophy

Visualizations   4 comments

From Buzzfeed, via Andy… I’d say this is a pretty accurate characterization:

nerd-venn-diagram-9420-1252236207-2

Posted September 17, 2009 by padraic2112 in humor

My Version Of Health Care Reform   4 comments

I’ve talked about this before with various friends and sundry, but I’ve never blogged about it.

The problem with the Health Care debate in this country is that most of the solutions offered are almost as complex as the problem they’re trying to address, or they’re stupidly simple without simultaneously making the overall problem more simple.  This is one case where our system, which has grown and evolved over time, has become unnecessarily complex.  I was finally going to blog about it this week, and then I happened to notice something truly remarkable: Mr. Denniger already wrote itTwice.  Holy tamoly, this is *exactly* what I’ve been saying about health care for *years*.

Note: I’m not particularly certain that my/his idea will immediately correct all the problems with our health care system.  One major problem not addressed, for example, is that the doctor population in this country is hugely rewarded for choosing specialty care as their practice, when what we really need is more general practitioners.  Another is that there is going to be a rather ugly transitional period here, since all medical billing is currently completely insane.  Just two examples.

But this is one case where I do agree fundamentally with conservatives who say that massive infrastructure isn’t what’s required to solve the problem.  Certainly there are issues here, even with Karl’s framework.  It removes medical bankruptcy, which is good.  It ensures that everyone  gets lifesaving care, which is good.  It doesn’t actually solve the long term problem of the free riders, though, since people still won’t get enough insurance, they’ll still go to the emergency room, and it doesn’t really matter if your debt is assigned to the IRS to collect if you’re never going to make enough money to pay it off.

However, it resets the playing field at “not completely, utterly, and overwhelmingly complex to the point of utter insanity”.  It turns insurance companies into true “amortization of risk” companies, which is what they ought to be (note: I’m not convinced that limiting by state is the best long-term solution, but it’s an appropriate place to get started).

It won’t fix everything, but it will certainly remove layers upon layers of obfuscation.

Posted September 10, 2009 by padraic2112 in politics, Uncategorized

‘Nuff Said   Leave a comment

capmickeyweb

More here.

Posted September 2, 2009 by padraic2112 in humor, noise

Health Care Debate   4 comments

Keith Hennessey wrote a two-part post regarding the current state of the health care debate.  The first post was quite good.  The main point of the post was to refocus the health care debate on the following problem:

“The value decision that underlies most of this debate flows from the question:  Who should decide whether additional medical care is worth the cost?”

From later in the post:

In both examples, one treatment is medically superior and more expensive than the other.  That’s what makes these hard decisions, and better demonstrations of the true tradeoffs, than either Governor Palin’s or President Obama’s examples.

Many chafe at being confronted with these kinds of choices.  They argue that, if we confront these choices, then we need to devote more resources to health care.

The problem is that there is always a resource constraint.  Maybe yours is 10% or 15% higher than mine, or maybe you would redistribute funds from other people to make someone’s pie bigger.  But a bigger pie does not allow you to avoid these tradeoffs.  It just means you confront them at a different cost level.  The question of who gets to decide is unavoidable, no matter where you fall on the policy or political spectrum.

He’s right, and I encourage anybody to read that first post.

I’m really disappointed in this followup post.  I left the following comments in the thread, replicated here since the second one is lengthy.

If enough people choose not to buy the +$400 insurance, it’s no longer +$400 insurance, it’s +$500 or +$1,500 insurance; and conversely if enough people buy the $400 insurance, it’s now +$300 or +$10 insurance (profit considerations non-withstanding).  If the option is between $400 insurance and $10 insurance, statistically healthy people will choose the $10 insurance, to have $390 worth of beer money. And now, the individuals who would have been interested in the $400 insurance are left with a product that sells for $1500. They can’t afford that, so they get some other sort of insurance.

But when they finally get sick, those younger family members who have been paying $10 for their own insurance are often called upon to help pay for the $5 million dollar treatment or watch grandpa die.
Moving insurance decisions to an individual level (particularly when, *as you note*, the general population is not particularly well educated as to medical risks and statistics) means that most people will choose based upon individual risk and individual reward. However, most people in practice are impacted by group risk and group reward; decoupling these is not a simple affair.

My second comment started off perhaps a bit too pointed, but I was hugely frustrated to see a first post that framed a public policy issue in a manner that I thought was excellent, and then almost immediately went off the rails in the second post.

I feel like a guy who walked into a huge banquet hall, saw glittering crystal goblets and brilliantly polished silverware on pristine white linen, sat down on a luxuriously cushioned chair, and was served a twinkie on a cracked plastic plate.

Your previous post did an excellent job of providing a workable foundational framework for constructive discussion on health care.  This post was filled with “I think…”s and “I believe…”s and precious little to provide backing evidence for those beliefs.  You’ve constructed a faith based argument.  That would be fine if we were discussion theology, and at least a credible beginning to a philosophical discussion.  What we’re talking about here is trying to make informed decisions about public policy, and knowing what you think or believe isn’t nearly as interesting as knowing *why*.

>  Governments/insurers/employers have to set up rules that apply to everyone.  People
> are different, and sometimes those rules don’t fit your particular case.

Is this really a particularly worrisome case?  People on Medicare are generally happy with Medicare (from what I recall).  Is this an exception scenario worth serious consideration?

> People have different attitudes toward medical care.  Third parties can’t know those
> preferences or account for them in their decisions.

For the most part, this is why the bill includes the now-infamous (not really) “death panels”, so that doctors can inform patients as to health outcomes for grave illnesses, and people can express those preferences.  Beyond a matter of preference, there is the in-practice question of “preferences” diverging from the standard of care.  Certainly some people will want to refuse vaccinations, for example.  Do we allow them to do so as a matter of routine?  What about during an epidemic?  Can we state that there are times when the preferences of the individual are not germane?  When?  If not, why not?  And if we allow people to opt-out of care decisions, what happens when the consequences occur?  Do we refuse treatment to un-vaccinated children who get measles?  Do we treat head injuries to people who ride motorcycles and don’t wear helmets?  Do we provide cancer treatment to smokers?  On the other side, do we give every conceivable test to hypochondriacs?  Do we give liver transplants to people with terminal cancer?  Do we give hyperconcerned parents antibiotics for their child’s ear infection, when there is little demonstrated medical value?  Your position conveniently allows you to duck answering these questions directly, if we give more decision-making power to the individual, but the consequences to the public policy are still going to be there.

> The cost-benefit decision depends on the cost and the resources available.  Using Friday’s
> example 1, you might choose the Skele-Gro if it were $500, but reject it at a cost of $5,000.

Yes, but not all medical decisions can be made on utility theory.  Moreover, we can’t expect health care providers to have audit capability over patients’ financial records at the time of admission.  If a doctor says one treatment for my daughter’s life-threatening disease will cost $50,000 with an 90% chance of success and one will cost $250,000 with a 93% chance, how does the doctor know I have the other $200K?  Are you suggesting removing medical cost related bankruptcy?  How does the hospital recoup those costs without passing them on to the other consumers, if it turns out the patient can’t pay?

> In addition to whatever resource constraint exists, third parties have other pressures on
> their decisions, and other incentives.  A government bureaucrat has rules and laws he
> has to follow, deadlines, and time and workload pressures.  He also faces political
> pressure from Congress and medical treatment interest groups (hospitals, nursing
> homes, doctors, nurses, drug and device manufacturers, …)  These pressures make
> his cost-benefit decision on your behalf different from your own.

True, but possibly not really relevant, and correctable.  We have an existing, ongoing case study (again) in Medicare to show how often this occurs.  How bad is it?  You believe it is bad… why?  What studies lead you to believe that the workload in Medicare leads to bad outcomes, generally?

The same is true with the status quo.  In your proposed model, you’ll have individuals making partially informed medical decisions based largely upon price tag.  I’m unconvinced that the average person is going to make a cost-benefit decision that will generally be within a narrower neighborhood of “the correct” decision than medically advised bureaucrats.  Moreover, I haven’t seen any proposed model that includes some bureaucrat’s signature to proceed with a treatment.  Researchers come up with treatments.  NIH grants fund their efficacy.  Medicare decides to cover the treatment (or not) based upon that efficacy (certainly, political pressure can be applied here, I’m seriously unconvinced it’s anywhere near epidemic proportions).  Private insurers generally follow.  Practitioners execute treatments as part of their professional judgment.  If a doctor has a pattern of treatments that don’t match the general population of doctors, audits are performed.

> Government bureaucracies are slow to adapt to changes in medical practices and markets.

In comparison to what?  (I’ll go ahead and grant you “markets’; medical practices are an entirely different story).  What are you proposing as a model for creating a standard of care?  “Whatever the patient wants”?  How will you have reasonable tort reform if a patient decides that a green tea enema or crystal therapy will cure his currently operable early stage cancer and then he dies of it later?  How can a doctor reasonably defend herself from a malpractice suit if there is no standard of care?

Moreover, *people are just generally bad at risk assessment*.  This is basic security and psychology research.  People will generally underestimate the amount of insurance they need to cover medical costs, just like they underestimate how much they need for retirement (volumes of citations available upon request).  When they fail to have the insurance to cover their costs, the two possible choices are: do nothing and let them suffer the consequences, or provide treatment and absorb the cost, spreading it out among the other people who seek care.  They become free riders, or dead bodies.  How do you propose to resolve this dilemma, which seems to be an inherent weakness in your proposed model?

There’s a bunch of hard questions above.  I don’t pretend to know offhand the right answers to all of them (or even most)… but I certainly would have liked any one of them to have been mentioned.

Posted September 2, 2009 by padraic2112 in politics, rants