Sunday, December 27, 2009

Winter Grocery Shopping

Winter is now upon us. With last week’s great snowfall through the eastern seaboard, I got a glimpse of human irrationality. For the two or three days before the weekend weathermen have been predicting at least five to seven inches of snow in most areas. Then as the weekend came closer, that forecast jumped to twelve plus inches. When the snow did finally hit, it ended up being an easy sixteen plus inches. But just as easily and quickly as it came it swept right through, leaving a clear and sunny Sunday. People may have selectively forgotten that fact, but the weathermen also predicted a short-lived snowstorm.

You would like to think that with the accuracy of weather forecasting these days, especially looking only seventy two to ninety six hours ahead and not this ten day voodoo, people would have more faith in the forecast. When I see that a foot of snow is coming my way, I’m preparing to get up early to start shoveling. If I had a snow blower I would get up two hours later, but $500 can buy a lot of Big Macs. However, I also saw that the snowstorm was only going to last a day, so I also knew that I had to shovel once in stopped snowing, lest it melt some and then freeze into an ice rink. What I did not think was that I would be trapped in my house for a week and possibly consider cannibalism like a mountaintop plane crash survivor.

That sentiment is apparently no shared by at least half the public. Mind you, I am talking about the current scenario—a one day large snowfall. Not some four day blizzard marathon. One day of snow. One. And it was on a Saturday. Granted, it was Super Saturday, typically the busiest shopping day of the year, but still, a weekend day. I thought people would be relaxing at home or trying to get out and finish Christmas shopping. And perhaps they did do that. But they also went to grocery stores trying to stock up on milk, bread, and eggs. I know, I know. You think that it is entirely possible that these people were simply shopping for Christmas dinners and Christmas cookies. And I would assure you they were not. There were no components of Christmas dinners in those multitudes of shopping carts I crashed by on Friday. Nor were there bags of chocolate chips or sugar accompanying these kitchen staples. People were out to stock their pantries and refrigerators in case they got snowed in by a one day snow.

Why is it that this mentality exists? I find it very hard to believe that it has trickled over from olden times of war and the Depression. I would believe that people are worried about price gouging after the gasoline fiasco from Hurricane Katrina. Yet you cannot explain the behavior when it was clearly not going to be a blizzard. I think the best explanation for this is the same for the irrational run on banks. All it takes is a few people with unfounded fears to start talking up stocking their pantries and refrigerators. Then that scares more people and more people after that. Soon you have a packed grocery store and no milk on the shelves.

Now me, I was at the grocery store because I planned to make cookies that weekend and just happened to be out of milk, butter, and eggs. Really.

Monday, December 21, 2009

The 'Burbs

I was downstairs in the kitchen today when I happened to look out the window and saw my backyard neighbor Steve outside. He was with three other people, a woman and two men, and they all looked very sad. One of the men was wearing a t-shirt and shorts, not unusual given the unusually warm November afternoon. The other man wore a polo and slacks, while the woman wore a white blouse and black slacks. Each of them took turns patting my neighbor on the back and hugging him. Instantly, I called out to my wife, “Gloria must have died!”

Now obviously I’ve gotten ahead of myself, so perhaps I should start from the beginning. When my wife and I moved into our current house several years ago, one of the first things we noticed was that our backyard neighbors, whom I will call Steve and Gloria, seemed to be very good friends with our next door neighbors, whom I will call Joe and Carrie. We used to see Gloria and Carrie walking back and forth between each other’s houses all the time, knocking on each other’s sliding doors and letting themselves in. They would have outdoor barbeques throughout the summer and hot cocoa in the winter. We met Gloria not long after we had moved in and she told us all about how close she and Carrie were, how their families took vacations together and had dinner all the time. And they seemed to be the best of friends because for the next two years we would always see from our kitchen Gloria walking over the Carrie’s or Carrie walking over to Gloria’s. In retrospect, it seems that Gloria went over to Carrie’s more than the other way around. There were also several other things that seemed to suggest more tension between the two, such as the fact that Gloria did not work while Carrie did. Gloria would spend many a summer day sunbathing in her backyard. Carrie would spend many a summer day mowing the lawn. Given that Gloria and Carrie were likely in their late thirties and were clearly not childhood or even high school friends, you could tell their friendship had an expiration date.

Perhaps a year later my wife and I were in the kitchen and we had a realization. We had not seem Carrie go over to Gloria’s house or vice versa for some time. Was it weeks? Was it months? We surmised the two must have had a falling out. Over what was anyone’s guess. I did remember one day seeing Gloria walking hand in hand with Joe, Carrie’s husband. I didn’t make anything of it at the time, but it came back to me as we pondered this seemingly failed friendship. Not too long after Carrie and Gloria stopped hanging out, we saw Carrie and Joe having drinks with our other next door neighbors, Mark and Cathy. They did not seem to be close before, but now seemed quite chummy. We believed that Carrie and Gloria must definitely have had a fight, and that Carrie had moved on, and Gloria wanted nothing more to do with her backyard neighbors.

A few more months later my wife and I came to another realization—we had not seen Gloria for some time. Where had Gloria gone? What had happened to her? We theorized reasonable possibilities, morose possibilities, and even ludicrous possibilities.

“Maybe she went back home to take care of her sick mother.”

“Maybe she left him and moved back home with her parents.”

“Maybe he killed her and buried her in the backyard mulch line!”

Every once in a while we would look out our kitchen window and into the sitting room of Gloria’s house, as if expecting to see her walk across the room. Steve would come out and mow the lawn every week just like clockwork, but one late spring day we saw him pull up everything in the mulch line. And as the holidays went by, we looked across the yard to see if any decorations had gone up. It wasn’t that men don’t put up decorations, but that men usually don’t put up decorations and especially not if a woman is not around. All of our observations told us that Gloria was not living in that house. This was very concerning. Where does a thirty-something stay at home mother of two children go all of a sudden? We figured Carrie must know, but since we weren’t very close with her we decided it would be rather callous to ask about Gloria.

But then I saw Steve outside very sad with people that must be friends and family also very sad. And everyone including Steve talking on their cell phones every five minutes. This and the fact that Steve had just mowed the lawn yesterday told us that something must have happened to someone close to him. I believed that one of the women was his sister, who seemed to be offering him comfort rather than the other way around, which would make it unlikely that it concerned one of his parents. Though I didn’t see both his children around, without Gloria it also seemed unlikely that it concerned his children. That would only leave Gloria. Something had happened to Gloria.

“Gloria must have died!”

It’s hard to imagine what could have happened to a thirty-something woman who looked healthy enough to sunbathe in her own backyard in a bikini not one year ago, but the list of suspects isn’t very long. I didn’t really know Gloria at all, and I keep thinking I’ll look across the backyard one day and see her walking through her sitting room. Deep down I know I won’t though, and I’ve been reading the obituaries to see if Gloria will show up there. One day I’ll have to ask Carrie what happened to Gloria. Otherwise I’ll be talking the kids treat or treating around the block to Gloria’s house one year to see if she’s there.

Sunday, December 13, 2009

Medicine: SNAFU

Have you ever wondered about the medicines in your medicine cabinet? All those pills that come in different shapes and colors. In tablets and capsules and liquids. Do you ever stop and really think about them? After all, they are in essence chemicals. Synthesized molecules meant to perform certain functions. To a chemist there is pharmacokinetics to be considered. To the public there is only, “what dose will work?” and “what side effects are there?” After all, how complicated is acetaminophen or Tylenol? Or loratadine or Claritin? Most of us learned how to dose these medicines either from our family and friends or by reading the bottle. So what’s the big deal? Apparently, the FDA and bandwagon jumpers would have you believe there is a big deal that concerns your health. And because you are such an ignorant fool, they have to protect you from it.

Pharmaceutical companies spend billions on research and development of medications. It exceeds even that spent on marketing, though not by much. As part of the research, different doses are tested, and efficacy, metabolism, and adverse reactions are all tracked, so that a dose that optimizes all three factors can be determined. It is this dose that is ultimately seen on the shelves of your pharmacy. Take Tylenol, for instance. After much testing, it was determined that doses of 325mg was enough to allow treatment of pain. For pain that is more severe, a 500mg dose was also created and marketed as “extra-strength”. In the medical world, as “extra-strength” Tylenol was not always available, 2 regular tabs were used for pain, giving 650mg Tylenol. And for severe fevers, 1000mg, or 2 “extra-strength” tabs were used. Eventually, this practice trickled to the public, and it became commonplace to take 2 regular Tylenol for pain, resulting in 650mg of Tylenol. In the same way, doubling the “extra-strength” dose also became commonplace.

Now fast forward to today. Given some newfound concern over Tylenol toxicity, someone had made it his or her personal mission to bring the dangers of Tylenol to the forefront of medicine. And because of those efforts, the FDA has decided to remove the “extra-strength” dose of 500mg Tylenol from the shelves. It will still be available, but only by prescription. Now what in the world is the point of that? And more importantly, what sort of commentary is that on the American public? If you needed pain control and chose to use Tylenol, and decided to take 500mg because that is what has worked for you in the past, you would find that 500mg is no longer available. Would you then take 325mg of Tylenol? Of course not. You would take two 325mg tablets for a total of 650mg of Tylenol, effectively increasing your ingestion of Tylenol overall. How does that help to prevent toxicity?

Do you remember anything other than a news snippet about Tylenol this year? I don’t. But yet there will be a paucity of “extra-strength” Tylenol at your local store next year. What does that tell you? It tells me that the FDA thinks the American public is composed of 60% morons and 40% idiots. They truly believe that the best and perhaps only way to alter human behavior is to change the environment in which they live. The problem is that people can do simple math and realize that 325mg Tylenol will not cut it for pain control, so the next best thing is to double it. The best way to have handled Tylenol would have been to educate the public about it’s potential for toxicity, so that taking 650mg of Tylenol is not such an easy reflexive decision.

Let’s look at another “mission” for healthcare reform. Take Dennis Quaid. His story was quite popular this year. If you do not remember, his twins received an overdose of heparin after birth in the hospital. It would seem that the nurse either drew up too much heparin solution either by visual error or by calculating the amount incorrectly. (Heparin comes in solution of so many thousands of units per milliliter.) Fortunately, no detrimental effects resulted, but because of it he used his celebrity to “raise awareness” of the dangers of heparin. Now rather than spawning an inservice educational wave across the country about heparin and calculating its dosage correctly, the FDA decided that the potency of heparin should be reduced by 10% in order to reduce toxicity risks.

You can guess what happened next. The FDA issued a statement to patients and healthcare providers that heparin will be made less potent, and that a higher dose of heparin may need to be prescribed in order to maintain therapeutic efficacy. I kid you not. So not only will people still have to titrate the dose of heparin, they will now have to correct for the 10% loss of potency. There will already be some medical errors from miscalculation of heparin. It is a fact of life. But now you are adding another calculation and expecting that it will reduce medical errors. Really? It is far more likely that while you might reduce the adverse outcomes when heparin is actually overdosed (which is not that common), you will introduce far far more adverse events from patients being underdosed with heparin. It takes a really ignorant medically untrained celebrity to come up with that brand of logic.

I am not really sure what the FDA will try to screw up next. Perhaps they will remove the gallon size of milk for fear of calcium intoxication. Or they will cut all table salt with flour in order to better treat and control hypertension. This is standard operating procedure for a government agency, but perhaps best described as SNAFU.

Monday, December 7, 2009

Joys of Shopping

Another holiday has come and gone. Halloween was a burp at the end of October, and Thanksgiving was a blur. And before you have a chance to say “turkey again?” your next-door neighbors have their Christmas trees up and decorated. Or menorah. Or aluminum pole of Festivus. Either way it becomes time to shake off the Thanksgiving dinner coma and go winter-holiday-of-your-choice shopping. And it is a veritable free for all melee come Friday after Thanksgiving. There are so many peculiar nuances to this yearly ritual that aliens to Earth observing us must think we are all raving lunatics.

First, for what is supposed to be one of the greatest days for shopping in the entire year, when shoppers get deep deep bargains while retailers sell lots of merchandise, we have named it Black Friday. Now many believe it is because retailers go from being “in the red” to being “in the black”, but this is certainly the minority theory. It is more likely that the term “Black Friday” was created pejoratively to indicate the madness and chaos that ensues with the disruption of supply and demand by discounts. And the term likely originated in Philadelphia, currently the fattest and rudest city in the United States. Be proud, Philadelphians.

We will either stay up all night or get up at three in the morning to drive to the stores to get the best deals on whatever is up for sale, whether it is a Zsu Zsu pet, a Shop Vac, or HDTV. And the economics of Black Friday are atypical. If retailers are cutting prices by such large margins, you must wonder how they are making a profit. Microeconomics tells us that even though they profit less per item sold, they are selling far more items. So cutting your profit in half but selling three times as many items nets you one and a half times more profit. This then begs the obvious question, if this works for Black Friday, why not use this strategy the entire year? The answer, of course, is that it does not work well for the vast majority of retailers, but for different reasons. One reason is that retailers need the demand for their good to be so ridiculously high that by the time Black Friday comes around, people will go bananas and buy up every last piece of good, including items they really do not need. But if they kept it on sale all year round, demand would fall precipitously because people associate low cost with low quality or novelty and vice versa. (This is one reason why people think goods are expensive at Target even though the prices are some of the lowest. More on this another day.) They will also have too much time to think about buying and end up not buying at all. Another reason is that most of the goods purchased on Black Friday are not as personal items but as gifts. Since people are generally short sighted in terms of their future, they will generally not buy a Christmas gift in April, no matter how much it has been marked down. (This also helps explain Americans’ low savings rate and inability to save adequately for retirement. Again, more on that another day.)

Now the latest development in Black Friday sales is the opening of store at midnight or all night long. This came about after several trampling deaths from people rushing to get items before they sold up. The popular example last year was a trampling death of a Walmart employee. This was not even a raving lunatic shopper but an employee who had to work Black Friday. Could it then be any surprise that we get very little done as a society? Rather than simply behaving as civilized people should, we have to alter the environment in order to achieve a different result. Sound familiar? It is a very American concept. We blame the fast food industry for our obesity, cigarette manufacturers for our lung cancer, and television for our children’s bad behavior.

Now we have CyberMonday, the biggest online shopping day of the year. Far safer for all retailer employees to say the least. But I would bet that if the study was done, CyberMonday would be the least productive day of the year for most businesses. Even though the online stores are open 24/7, inventory is finite, so it’s still first come, first serve. And that leads to a lot of people shopping on company time, even with a lot of companies restricting internet usage.

Me, I will never be out there on Black Friday, fighting for parking spaces, standing in lines, and trying to get the last of whatever is going to be popular for one month before the next fad sweeps through. I will do a little shopping on CyberMonday, if I can find a good deal that includes free shipping. Most of my shopping, however, will be done on the classic busiest shopping day of the year—the Saturday before Christmas—when desperation and embarrassment increase your tolerance for traffic, lines, and every-man-for-himself behavior.

Monday, November 30, 2009

Healthcare Reform-Now With 100 New Opinions!

Here we go again with healthcare reform. Recently the House of Representatives muscled through a healthcare reform bill by a narrow margin using the advantage of a Democratic majority presence. Now the Senate has also used a Democratic majority to narrowly vote to entertain a healthcare bill in coming Senate sessions. Let us be very clear about this. The Senate needed to vote on whether or not to debate the healthcare reform bill. After they debate it they can vote on it. I suppose we should be glad they did not need to vote on whether to vote to debate the bill. We are already a year into the Democrats rule and are still stalled on healthcare reform, though it’s not hard to see why.

First, the Senate only narrowly voted to allow the bill to be debated. Even with a majority of Democrats, they could barely get all the Democrats to agree that healthcare reform was needed. And as with the House, there are some Democrats that behave more like Republicans. Heck, they call themselves the Blue Dogs in the House! Why not just call yourselves Republicans? This tells you that everyone’s vision of healthcare reform is different. This also means that healthcare in its current state was no one’s vision. It should then follow that whatever form healthcare policy takes will also match no one’s vision. It makes sense that it should not be one person’s vision, but it would be tantamount to trying to create a lion and ending up with a chimera. It should be expected that the Senate will modify the bill to a mindboggling degree, so that everyone’s personal vision can also be inserted. So why waste a week of Senate sessions to only decide to debate the bill? Obviously because not everyone actually wants healthcare reform. That tells you a lot right there.

Second, the Senate healthcare reform bill is different from the House healthcare reform bill that passed a few weeks ago. Why is it different? If the Senate actually passes a bill it will have to go to House to be debated on as well. Which makes you wonder why the House even bothered to develop a healthcare bill in the first place. And all this time the Obama administration has its own plan for healthcare reform but must wait for the Legislative branch to finish its job first. It is quite a wonder that anything is actually accomplished in government.

Third, the House just passed a bill removing the twenty percent Medicare physician reimbursement cuts that were proposed this year. Will the new healthcare policy reinstate it? Has it been compensated for in the new budget? Granted, Medicare is only a part of the overall healthcare bill, but it can be a deal breaking part. Just as the public health insurance option seems to be a deal breaker for many Congressmen. The thing that the government is failing to recognize is that while it can force people to get health insurance and set its own reimbursement rates however it pleases, it cannot ever force people to provide medical care and products. Nor can it force companies to stay in business to provide health insurance. It is a dangerous bluff that will likely be called. If you pass a bill for healthcare reform that saves over a trillion dollars in the next decade you should be happy that it will likely save even more than that because healthcare providers will opt out of government insurances like Medicare, hospitals will close down from poorly reimbursed services, and insurers will close their doors rather than be told how to run their businesses. That means the government will be paying less to fewer healthcare providers, fewer hospitals, and will be the insurer for most Americans. That will save a ton of money. Too bad the actual healthcare will become nonexistent.

The problem with trying to insure everyone is that in order to reduce costs you will need to cut services—office visit time, testing, drugs, and procedures. And no one likes being told what they can or cannot do for their health, especially if it is so important that we need a law for it. In fact, the reverse may actually work better—making people purchase their own insurance and literally letting that drive the market. That means no money, no healthcare. Is that fair you say? Is it any fairer than the disparity in access to food or shelter? We have federal subsidies for that. There could be healthcare stamps. Just as you would not buy filet mignon with food stamps, you would not get a full body CT because you wanted it. But you could still get antibiotics for that pneumonia. Is health insurance that important? Most people care more about their cars than their health. And healthcare is not in the rule of twos—two hours without shelter, two days without water, and two weeks without food. What would it be—two decades without health insurance?

Monday, November 23, 2009

Strike Out!

Hooray! The SEPTA strike is over. For those of you not in the Philadelphia area, SEPTA is the Southeastern Pennsylvania Transportation Authority. It is a primary transportation service for most of the Philadelphia and Philadelphia environs population. In the beginning of this month the workers of SEPTA, whom are unionized as Transport Workers Union Local 234, went on strike at 3 am. Of course, they wanted to strike at 12:01am on Halloween, but did not knowing the wrath of the public if they shut down public transportation during the Phillies World Series attempt. So they waited a few days and then shut down the public transportation to and from Philadelphia, causing widespread inconvenience. This was of course, the whole idea, and it worked, as six days later, a deal was reached to end the strike.

Was it really a deal? For the union, it certainly was a great deal. Let us take a look at what they won. First, they not only retain their pensions, but they get an additional $5000 a year for a $30,000 a year pension payment. Not too bad for a pension plan that is already horribly underfunded. Historically it has been funded by workers contributing a grand total of 2% of their paycheck. Now the workers have to contribute a whopping 3%. What financial hardships they must endure. On top of that, there is no disclosure for the management of the pension fund. They could be investing in alchemy or a Madoff fund for all we know. And the union also won the ability to prevent auditing of the pension fund. That is a gigantic coup. Not only is the public on the hook for the union’s pension payments if it becomes underfunded in the future (which it most certainly will), it is forbidden from looking at the books to see if the money is being handled correctly. Don’t you just love public servant pension plans? They might as well all be invested in the latest fad stock. If it makes money, it makes it big and the fund managers make out like bandits. If it fails, who cares, because Joe Q. Public will pay for it then.

How about healthcare? Are we worried about Obamacare affecting insurance premium rates and having that cost trickle down from the company to us? Do we worry if our businesses will be able to afford to offer healthcare policies? No if we are in TWU Local 234! Not only will they continue to contribute a measly 1% of their paycheck, they will retain all their current benefits and prescription coverage’s and dental. That’s right. They have dental. And they have a PPO, not some gatekeeper HMO tee ball plan. So what does that mean? It means that not only will you have to pay more for health insurance to keep the same coverage or lose coverage to maintain costs, you will have to pay more taxes to pay for the increase in healthcare costs for the union, since they sure are not going to pay for it. And since the money has to come from somewhere, it will come from the public. And do not forget—the contract was signed with SEPTA/Philadelphia/Pennsylvania, so if there is a union healthcare fund deficit, you know from where the money to make up for it will come.

How about salary? With the economy still in somewhat of a slump, many businesses are freezing pay raises. Not SEPTA. They have to pay out an 11.5% pay raise over the next five years. Are these people professional athletes? How many people have five-year contracts with the volatility of the economy these days? Also, there is a $1250 signing bonus for each union worker. Just for renewing their contract. Why even bother with this? Why not just given them free healthcare and reduce the contract by twelve pages of legal parlance? Mayor Nutter of Philadelphia had to go to Harrisburg and plead with the Pennsylvania Capitol for more money so that he could pay past wages earned of city workers and not have to layoff more workers in the near future. But we somehow have $7 million stuffed in the Pennsylvania mattress to payout signing bonuses for striking workers? Of course we do not. It’s coming out of our mattresses through our taxes.

There are many other facets that also show how the TWU Local 234 spanked SEPTA and the public, but are not available to the public. For instance, the layoff clause has been retained, which considering the current contract negotiations, likely covers income for laid off workers for at least six months but probably an entire year. The UAW had clauses of that ridiculous magnitude and look where it is now. It would certainly seem that TWU Local 234 has won the battle, but has it really? And at what cost?

Since the ending of the strike, Pennsylvania legislators have been up in arms about TWU Local 234. And it has spilled over to essentially all public service sector unions. A representative made a specific comment about how the sudden strike left many night shift nurses stranded and unable to get home. The TWU Local will argue that the strike was not sudden, but planned for several months and was even advertised. But really, who puts that sort of information into their daily planner so they can arrange alternative transportation for that day? Really? One might also argue that this particular representative obviously knows a nurse that works night shift—a family member, a friend, or someone close to a powerful campaign contributor. Otherwise, they would likely have used another example based on easy personal acquaintances rather than sit and consider the ramifications of the strike. After all, they are busy politicians. But I digress. The legislators are looking to prohibit the striking of public sector unions, and particularly those of essential services. This is similar to Ronald Reagan’s problem with the air traffic controllers. There is no doubt that it will snowball to include any trade, whether public or private, that the majority of politicians believe is essential on that particular day. And that would be a shame, since nothing would be more karmic than to have a TWU Local 234 member or someone close to a member die after his or her nurses decided to strike because they wanted more money and believed their greedy needs superseded any consequences of their actions. Is that so bad? I wonder how many people did not make it to the hospital to see a loved one in time during the ever important strike.

Sunday, November 15, 2009

How To Strike

There is nothing that brings more smiles to people more than seeing public servants go on strike. It seems that at least twice a year public servants in some sector decide to go on strike. And it is always with the same demands. Money. They want more money. They want higher pay, they want more benefits, they want more paid vacation, and they want more pensions. And for several reasons, they usually get more money. In the past this was not so unusual, especially given that we as a country have only decided to finally raise the minimum wage rate after a few decades. But in this economy? It takes some very large brass ones to do that. And we will see why they feel so secure in going on strike. (Hint: it is not that they have nothing to lose.)

When was the last time you heard of private sector workers going on strike? Difficult to remember, isn’t it? The last time I heard of a private sector strike was four years ago, when hospital support staff went on strike because they wanted—wait for it—more money. And they did get more money. Not as much as they demanded, but then you never ever demand what you want. You always, always demand for much more. That is Rule #1. There will always be a compromise. There has to be. That way both parties keep up the appearance that they have conceded something. It makes their own concession more palatable. But because you always ask for more than you want, your concession is really nothing, and your win is deliciously more enjoyable. And when you demand more money, there is little the other side can do to counter that other than to compromise. After all, they can’t demand more than they want because what they want is to not change anything. Demanding more for them would be to ask you to give past monies back. What a PR nightmare that would become.

And when was the last time you heard of a nonunionized group of workers going on strike? I have never heard of such a thing. That does not mean it has never happened, but certainly it suggests that it has never happened successfully. And that is Rule #2. You must strike only with a union. A union has power because there is power in numbers. This is, in fact, the major power of the union—to be able to have a large number if not a majority of current workers suddenly stop working and halt productive activity on a moment’s notice. That would cripple any large company. It is no wonder then, that Walmart and McDonald’s try so hard to prevent workers from unionizing. Also, a union has an obvious hierarchy and a clear leader and spokesperson. This protects the union because it prevents the possibly of workers getting turned against one another by the other side. Everyone accepts the majority sentiment of the union and a small compromise in their wants for the power of the collective union. There is another strength of the union, and that is securitization of wages during a strike. That means that though you are on strike, you will still get paid through the magical feedbag into which you put your union dues allowing the union to strong arm the company into agreeing to that clause in your contract. If you did not have that security, the war of financial attrition will always favor the company rather than the individual worker, and companies would simply draw out negotiations until the workers could no longer pay their mortgages.

Thinking of all the strikes you have heard about, how many have somehow affected you or someone you know? Probably even odds on that one. The purpose of any strike is to cause chaos and disrupt as much normal flow as possible anywhere. That is Rule #3. You must create chaos and involve as many bystanders as possible. In an imaginary Walmart strike, the stores operations would cease. Revenue would be loss. Management would be sad. But more importantly, customers would not be able to shop at Walmart because it would be chaos in the store—no one to stock or restock merchandise, no one to ring you up, and so on. That would make you mad, and as much as you would like to believe you could be objective about the issues with the strike, you will always blame Walmart at least a little. (Or a lot, since we are talking about Walmart) But what if it is a teacher’s strike? Teachers stop teaching, and children stop learning. But even worse, children now have to be somewhere else, and parents now need to watch them or get babysitters. This then disrupts the parents’ work schedules and income flow for families. This makes the parents mad and they get mad at both the teachers and administration and pressure for a compromise to be made. So the administration is villainized when the teachers intitiate the strike. This is the same with the SEPTA strike. Buses, trains, and other public transportation stop running. Commuters everywhere must scramble to find other ways to get to school, work, and leisure activities. This pisses everyone off. And then the public demand that the city find a way to fix the strike problem because, after all, the city government works for us, the public.

That leads us to Rule #4. Strike only against bosses who have no clear leadership. Now I did oversimplify the power of unions earlier. A union, once created, gains certain rights that protect the workers in the union. One such protection is that against wholesale termination of the workers in a union. This is why Walmart and McDonald’s have been rumored to fire all the employees and shutter stores where employees have attempted to unionize. This makes it doubly easy for civil servants to strike. Not only are they afforded the protection of the union, but the bosses against whom they strike are the most poorly organized, bureaucratically riddled system out there. If you went on strike against a stiffly hierarchal company, you likely would not have a union, so they would more than likely fire you on the spot and have your replacement hired and working before your butt hit the pavement.

But how can you increase your chances of having a successful strike? You must gather public sentiment. That is Rule #5. Fake a nobler cause or pretend you really love your job despite the obvious notion that striking means you are unsatisfied with your job. This means that when the local news crews come to interview you on the picket line, you should say, “ We want to be working and doing a great public service, but those ogres are running the equivalent of a Thai sweatshop in there.” Do not under any circumstance say, “Well, we clearly deserve far more money for the job we do but are too lazy and ignorant to find a better way utilize our talents, so we thought we would just extort the public taxpayer and the game the system to get what we want.”

While these rules have worked well in the past for the majority of strikes, we must not forget the times that it has backfired. The most notable would the air traffic controller strike in 1981. Reagan order the controllers back to work on the premise of national safety and security. The majority of the controllers refused and were subsequently fired by the President. It was a humbling time for unions. If you incorrectly assess your public circumstance, the strike may backfire. Let us take the current the recent teacher’s strike in Pennsylvania. This strike came around the time school started this year. The teachers were asking for—more money. They wanted higher salaries, better pensions, and better health insurance. What they failed to recognize (and especially the social studies and economics teachers) was that the public was still in financial jeopardy. Most people were still down 25% or more on their retirement nest eggs, taking pay cuts or were laid off, and paying higher insurance premiums. And now here come teachers, asking Joe Public to pay more taxes so that their pensions and retirements are secured while his circles their gym toilet. More taxes so that they can pay less for prescription medicines while he has to go to Canada or Mexico for generics. More taxes so they can get a pay raise while he takes a pay cut and works longer hours. Then the teachers have the gall to say to the news cameras, “We really want to be in the classroom teaching, not out here on the picket line.”? Let’s say that while the strike did end, and the teachers got more money, they more than likely did not get what the wanted. More importantly, they will not be able to strike for a while without severe public backlash. At least not until the next financial bubble is growing steadily. The same can be said of the SEPTA strike with the addition that the strike was even more poorly planned because it is heavily dependent on Rule #3. They lost all public sentiment by disrupting already somewhat disrupted work/life balances more. And on top of that, their jobs are not specialized enough to offer them protection. In 1981 the FAA managed to train enough new air traffic controllers to get half the flights back in the air. Think how easy it will be to get new bus drivers.

Monday, November 9, 2009

Can the House Always Win?

The House has passed a health care bill! Let’s celebrate! It only took over a year and won by a very slim margin in a Democrat dominated House, but it passed, so healthcare reform must be around the corner. Right? I said, right? Wrong. It will still be stalled and the system will still be flawed and we will still bitch and moan about it. Why? Because we are flawed at every level from the people utilizing healthcare to the people providing health care to the people moving money for healthcare to the people legislating healthcare. That’s four groups of people debating. If the government and its three groups (White House, Senate, and the House, really, but executive, legislative, and judicial for you hopelessly optimistic in the system) cannot pass most bills easily, imagine how much harder it is with four groups. Let’s look at the four groups.

People utilizing healthcare. Or as some call them, the patients. Nearly everyone falls into this category at one time or another, and so the disharmony among this group is by far the worst. This group will only agree on one thing and one thing only. That the healthcare system is flawed. That’s it. Not even everyone believes that the healthcare system needs a complete overhaul. Those people exist, and Katie Couric or Michael Moore have already found and hounded them. Because not everyone even agrees on what parts of the healthcare system are flawed, there is no agreement on how to fix the system or structure a new one. And not only that, this group of people, while the largest of the four groups, has the least amount of influence over healthcare changes anyways. They have no say as to what goes into a healthcare bill, or how costs are contained, or who will be covered. Sure, they elected the President, and sure, they elected their politicians. But that is where it all ends because they did not elect their politicians’ friends in the healthcare industry. They also did not elect the lobbyists wining and dining their politicians. So what is this group left to do? The only thing they can do is what they already do best. Complain to anyone that will listen, and elect a Democrat when a Republican has failed them and vice versa.

People providing healthcare. This is still a large group of people, including not only doctors, but nurses, techs, secretaries, drug company personnel, biomedical manufacturing personnel, and all people working for medical facilities. Though the peripheral people in this group, such as secretaries and hospital valet services may not feel like they are in this group, they are because their financial livelihood is tied to their employer’s financial livelihood. This group is also divided, though not quite as severely as the first. Healthcare has morphed significantly over the decades. The days of prestige and personal fulfillment from practicing medicine are gone. Ninety nine percent of people going into the medical field do not enter the field because they “enjoy helping people”, but because they see the financial stability in a vocation in which they are or could be proficient. And changes to the system will invariably attack that financial stability. But of course, the disharmony comes from many aspects. First, many simply do not understand how they could be affected. There are many nurses and techs, for instance, that do not think their pay could be cut, or benefits stripped, or even jobs laid off. It is an unfortunate ignorance that will be their rude awakening one day. Others are not dependent on their healthcare jobs for financial stability, and so default to their “people utilizing healthcare” stance. Other opposed groups are those between the private practice doctors and the academic doctors, and the old school and the new school. The AMA (American Medical Association) and the Sermo are example of this, as they have differing views on healthcare reform. One thing is certain—half of this group will be very unhappy if healthcare reform hangs the providers out to dry. The question is if they will be unhappy enough to leave and make the question of healthcare reform moot and the question of who will provide healthcare very real.

People moving money for healthcare. I almost called these people the ones who pay for healthcare, and that would have been a gigantic faux pas. This group includes all the insurers as well as the government. While the government is motivated by its need to stem the Medicare and even Medicaid bleed, all other insurers are motivated by their need to make money, and for some, make money for their stockholders. This means that both need to make a profit—the government to stop losing money and keep Medicare viable, and the private insurers to stay in business. The strategies are somewhat different for each one. Medicare will essentially cover anyone with enough work credits in their lifetime and meet certain age or medical condition criteria. It is difficult to be excluded from Medicare. That means that the way to change loss into profit will be to increase revenue with more taxes, or reduce costs by cutting reimbursements, denying some drug coverage and diagnostic testing, and denying more procedures. For private insurers, much of their edge was derived from their ability to deny coverage based on preexisting conditions. This, however, is being targeted by healthcare reform. That means that the private insurers will also need to resort to the same cost cutting techniques the government will use. No longer will they be able to offer more brand name drugs or allow more testing than Medicare because they spend less money on healthier patients. In the insurance world, it is split down the line. Private insurers benefit and profit from the current system. The government and Medicare are bleeding and losing money from the current system. But only one of the two has lobbyists.

The people who legislate on healthcare. These are your politicians. The shifty, unreliable, tunnel visioned egoists you thought were idealists when you elected them. This group has battled over a public option healthcare with a devastatingly enormous amount of wasted time. This group has the most power over healthcare reform but is also the most internally conflicted. They have to listen to the other three groups to determine what to do. And when you are listening to a lot of noise, you end up producing rubbish. The other thing you do when you listen to a lot of noise is daydream and think about what you what to think about, much as a weed smoking teen does in history class. This is how we end up with six thousand little pet projects attached to the healthcare bill. This is also how we end up with a President that has to make the statement, “Now it falls on the United States Senate to take the baton and bring this effort to the finish line on behalf of the American people.” Congratulations to the legislative branch. You’ve forced the President to be your schoolmarm. Apparently, no one has considered passing healthcare reform the same way that Medicare ended up where it is today—by piecemeal. Sure, Medicare started with a band in the 1960s, but there have been many small changes over time. And this way you know exactly with what each shifty politician is taking issue. But then, where is the glory is writing a bill that makes only one change in Medicare? You can’t run for your fifteenth reelection on that feather in your cap.

So what do we have when you add it all up? You have a public made up mostly of people who care only about themselves and not the future or public good. You have healthcare providers that depend on the system they love to hate (frenemies). You have insurers profiting off the public’s medical testing obsession. You have politicians who certainly do not understand the healthcare system any more than most people trying to get their cut of the cash cow that is the healthcare reform process. What does that equal? A perfect example of bureaucracy minus understanding and direction. At this point we would be just as better off if we put the healthcare bill to a national vote and literally let it be decided on the majority of individual votes. That or flip a coin. But I’m sure the politicians would have something to say about which coin is used and who would flip it and where it is flipped and how many times it is flipped…

Friday, October 30, 2009

Swine Whine

Influenza is an epidemic. It always has been. Each year several strains sweep through the globe infecting millions and killing hundreds of thousands. And up until now, we thought we had a small handle on these viruses. But now we have the swine flu, or H1N1, and it has not behaved as the usual influenza viruses usually behave. Because of that, it will cause devastation on many levels.

As a little background, there are three classes of influenza—A, B, and C. Influenza viruses are then classified by two proteins they carry on their outer coat—hemagluttinin and neuraminidase, or H and N. These proteins vary from strain to strain. Thus, you can have an H5N1 influenza virus, an H2N2 virus, and so on and so on. Strains can then further be classified based on their location of origin and year of outbreak. Thus, you can have a B/New Jersey/1977/H2N2 influenza strain. That particular strain does not exist, but you get the point. Influenza viruses also tend to spread in waves over time, much as locusts and cicadas do. It is because of this that we are able to make educated predictions about the coming year’s influenza viruses and create vaccines against them. Thus, vaccines are only effective for the year they are administered, as the strains for the next year are different.

While the swine flu has gotten a tremendous amount of media coverage, which is good for awareness, it has also unfortunately become an epidemic of misunderstanding in itself. To start, the initial scare was the name “swine flu”. Ever since the close overlap of the deadly SARS and avian flu, people have become wary of any disease originating from animals. Now the media uses the correct term of H1N1, but far too late. The term “swine flu” is here to stay. There has also been very few attempts to educate people to the fact the H1N1 is in fact just another influenza virus, and that getting H1N1 is just like getting the flu. What has made people worried is that H1N1 behaves differently than the usual influenza viruses in that it came far earlier than “flu season”, likely will not have a “season” at all, and prefers to attack younger healthier people. But because of the preexisting heightened fear of “swine flu”, all the cases of it seem more extreme and deadly. For example, the regular flu typically attacks the elderly, and so seeing five seniors in the ICU on ventilators is not surprising. But because of the predilection of H1N1 for young people and pregnant women, seeing five pregnant women in the ICU on ventilators is very surprising. Not because it’s the “swine flu”, but because we are not used to seeing five pregnant women in the ICU on ventilators. We misplace our disturbance of the scenario on virulence of H1N1 instead of on the unexpected demographics of the scenario.

H1N1 also seems far deadlier than the regular flu because we are not vaccinated against it as we typically are for the regular flu. Given that “flu season” usually runs from October to February, the vast majority of vaccinations are carried out in October and November. What that does is prevent a substantial number of people from getting the flu, but more importantly, removes the subsequent transmission of the flu by the vaccinated should they have contracted the flu if they were not vaccinated. That is, of course, the true power of vaccination. The H1N1 flu, however, has no true “season”. Thus, there was no lead time for the production of vaccine. That also means that people who contract H1N1 can spread to many more susceptible unvaccinated people, who can then propagate the epidemic. This is also why H1N1 seems deadlier than the regular flu—it has had more lead time to spread exponentially.

But now we have a vaccine for H1N1. So can we still make headway in limiting the epidemic? The CDC hopes so, but it may be too little too late as some say. I believe it will stem the epidemic, but not enough to change the way H1N1 is remembered. There are two large limitations with the H1N1 vaccine. First, there is not enough to vaccine the millions that should still be vaccinated. If you cannot vaccinate people, you cannot slow the exponential exposure of people to the virus. Second, because of the recent unsubstantiated scare of autism and MMR vaccines, as well as the painful memory of Guillain-Barre Syndrome in old school flu vaccines, people have convinced themselves not to vaccinate even if the vaccine is available to them. (Guillain-Barre Syndrome is a paralyzing neurologic disorder which occurred because of an autoimmune reaction to the influenza vaccine due to its manufacturing method, which is no longer used to create influenza vaccines) These two problems destroy the very foundation by which vaccination works to prevent an epidemic—prevent the exponential cycle of contracting and spreading the virus.

It gets worse. Just as people believe washing their hands for six seconds is enough (must be fifteen seconds), they also believe that wearing a mask will protect them from H1N1. That mask is the N95 respirator mask. The short story is that the N95 mask was designed to filter the smallest of the smallest particulate matter, keeping harmful organisms from being inhaled by the wearer. It is most commonly used by healthcare workers during treatment of patients with pulmonary tuberculosis. It is now most commonly used during treatment of H1N1 patients to block contraction of the virus. The fact that the mask is able to filter out such small organisms is a credit to its material and construction. But that means a good seal of the mask on the face of the wearer is required to reap that protection. After all, if you put on the mask and it does not sit properly along your cheek, how protected are you then? Because of this, healthcare workers are tested for correct use and fitting of the N95 mask with a taste test. You put on the mask, and then a hood like apparatus. A solution of saccharin or bitter compound is then aerosolized into the hood (so the tester is not subjected to the taste). If you taste the compound, whether it be sweet or bitter, you do not have the N95 mask on correctly. That is how good the N95 mask is at filtering out particulate matter.

Now take this common hospital scenario. You have a patient with H1N1. They are sick enough to be in the hospital. They have lots of family members visiting all the time. And because of the severity of illness they are in the hospital for five to seven days. The questions that is begged is do all these people wear masks when they visit and are they putting the masks on correctly? The answers are yes and no, respectively. The likelihood is slim that they are wearing the masks correctly. After all, the fit test is a time and resource heavy process. Not many healthcare workers are fit tested, so you could count on your third hand how many visitors are fit tested. So they end up using lots of masks over the hospital course of the patient, each at almost two dollars a piece. With the number of H1N1 cases rising, that will be a tremendous cost the hospitals and the healthcare system. And that’s not even the concerning problem. The concerning part is that by donning their incorrectly fitted masks they believe that they are protected from H1N1. You might as well given them aluminum foil hats to keep the aliens from stealing their thoughts.

But vaccination is like a religion. It is resistant to scientific data and logic. You have little chance of convincing people to get vaccinated with fancy diagrams and scary numbers. You need a smooth talking charismatic icon like a celebrity they will follow. It worked for voting, and it would work for vaccination. I can see it now—Rock the Vaccine.

Friday, July 31, 2009

Driving Is Dangerous

Recently, it was reported that very important data was withheld from the American public for six years--data that could have made an enormous impact on life as we know it. The ever so important data? That talking on the phone while driving increases your risk of having an accident. Is this information surprising to anyone? Should this information be surprising to anyone? It really should not be. And yet, people are up in arms about it. Why? Because we could have done something six years ago to prevent countless numbers of accidents and deaths from cell phone related accidents? No. It is because someone withheld information from us. Someone was hiding something from us. And in this day and age, secrets are taboo. We believe there should be complete transparency in everything. The problem is that even when things are made transparent, most people still do not understand it.

Take the recent credit crisis. Without going through the labyrinthine process by which different credit vehicles backfired on banks, let me just say that it was akin to blending loan default risks into investment funds and then hedging on the performance of those funds. Layers on layers of risk on which investors could gamble. Since the economy crashed, there has been an outcry for more transparency in banking. The public wants to know in what their banks are investing their money. And the government has helped to make that happen. But are investors any wiser now? By knowing how CDOs and SIVs are created, are they investing more wisely? Of course not. Nor will they ever invest more wisely. The simple truth of the market is that the majority buy high to try and sell higher. It is called the recency trap. If a stock is going up, you think you can jump in on the way up and still make money, not realizing that you have done no research into the true value of the stock, and also not knowing how long the stock will rise. Ninety percent of investors, if not more, have never even read the annual report of a company in which they have invested. I have only read on half of the stock I buy, and that does not include index and target funds, or course. So, having the components of a investment vehicle available for the investors’ review will hardly affect their investing habits.

This is not to say that the transparency of the financial world is a negative, or that it is even a waste of effort. There are people who certainly can benefit from the new information, which is very complicated. But what if the information is not complicated at all? What if it is completely intuitive? What if it is nutritional information on fast food?

In the last few years, fast food restaurants have begun putting nutritional information on all their menu items. If you want to know how many calories that Big Mac will cost you, you can find it on a pamphlet in McDonald’s. You can also find it on the box in which the Big Mac is served. There would be no denying that the Big Mac will hurt you on so many levels. It is hoped that by allowing people to see how unhealthy much of fast food really is, people will eat less of it and the obesity rate in the United States will decrease. But of course it has not made an impact because the nutrition labels are largely ignored by the majority of people eating fast food. But was that really the problem? Was it really that so many people were deceived so successfully by all the fast food restaurants into thinking that fast food was not unhealthy? Or is the real problem that people either do not care or are too stupid to realize that fast food in unhealthy? I believe the latter is true, and so more transparency offers nothing because you are providing common sense, which is severely lacking. Who does not know that fast food is not good for you? Really, who? Apparently, a lot of people.

This is why all the din over the “withheld” data on the dangers of cell phone use is so utterly ridiculous. Who does not actually believe that talking on a cell phone or texting while driving reduces concentration and increases your risk of an accident? Obviously, a lot of people, since the news is littered with their accident stories. But it is not because someone withheld valuable data that would have made these people decide not to text while driving. They would have texted anyways. It is because many people are just stupid or arrogant or both. Maybe they do not understand that talking on the phone means you concentrate less on driving. Or maybe they believe they have the ability to drive super extra careful while texting because they are in that ninety percent of drivers that believe they are better than average drivers. What it means is that the data that was available six years ago would not have been helpful because it was common sense. If you are having a heated conversation with the person sitting in the passenger seat, you are concentrating less on driving. You are therefore more likely to have an accident. And surprise, no cell phones are involved! Should we do a study on people who talk to passengers while driving? Or course it is more dangerous. We could spend millions to cull the data, but do we really need it? There are now rules that forbid bus drivers from using cell phones or texting. Was that really necessary when we have already have signs that tell passengers not to talk to the driver? And I would bet there were rules before cell phones that told bus drivers not to converse with the passengers. Were we that dense that we could not make the tiny jump in logic relative to cell phones?

The buried data purportedly also showed that hands free sets did not alleviate the risk. Why is anyone surprised by that? This poses a conundrum for many cities and states that have passed cell phone bans while driving, because universally hands free sets have been made legal alternatives. What are they to do? The simplest solution is to repeal the cell phone law and hope that it fades away into the past with other blunders the legislature has made. After all, how was the law enforced? Are there cameras recording people driving while on the phone? You would have to still be on the phone or actively texting after you have pulled over and when the officer finally arrives at your car window. Can an officer ticket someone they see on the phone while driving any more that someone they see driving without a seatbelt? I would bet that subpoenaing cell records for proof would prolong and hinder the legal process. The other solution would be to amend the law to include hands free devices as well--an even harder law to enforce, given the size of the devices these days.

But with most new cars installed with Bluetooth phone hookups and speaker phone capabilities, it becomes as though the person you are talking to is in the car with you. So perhaps we should pass a law banning driving with passengers. Everyone should drive alone. The police can pick off the fools that break the law and use the HOV lane.

Monday, July 27, 2009

Healthcare Reform or Deform?

Healthcare reform has hit yet another hurdle recently. Now Congress will be unable to reach any consensus or pass any bill by the autumn recess in August. They will not even be able to pass a bill saying that they will pass a healthcare bill when they return from recess. There are already so many things wrong with this. The first is why Congress even gets a recess. Does the President get a recess? Why is it that the executive branch is the only branch without a recess? How do things get done during the recess if our government was designed to work with checks and balances? Who is doing the checking and balancing of the executive branch during the recess? Shoe elves that come out of the closet at night? Separate from the issue of healthcare reform, there should be no recess for Congress. Given all the benefits they reap from their position, as well as the infinite reelection possibilities, they should work their asses off for their constituencies. My healthcare premiums will only go up during the recess. Joe the Plumber’s premiums will only go up during the recess. And yet it is not important enough for Congress to stay in session to begin to work on what will no doubt be a lengthy and protracted reform. It literally will take an act of war to bring Congress back to session.

The President has stated that he uses the Cleveland Clinic and the Mayo Clinic (the Minnesota flagship, I believe he is referencing) as models for his ideal healthcare setup. These are places where you get comprehensive care that is structured slightly differently than your ordinary community hospital, or even many of your tertiary care hospitals. You get specialty care from the beginning, and of course, you get the latest and greatest that medicine has to offer. Now who would not want this kind of care? And for everyone who wants that kind of care, who would want to actually pay for it? What the President does not state is that these are also teaching institutions. There are enormous differences between your vanilla hospital and a teaching hospital. Firstly, teaching hospitals do have the latest and greatest medicine have to offer, though community hospitals are not far behind anymore. But because teaching hospitals are supposed to train physicians, they also order and perform far more tests. It does not seem that way on an individual basis, but just five extra tests per patient over a year is a lot of money. Is that really a big deal if you are getting the best medical care, though? I would not think so, if I were the one getting the care. It’s like being at a bar and splitting the bar tab among your friends. It works out great if you are the one drinking the most and sucks when all you’ve had is Miller Lite when everyone is doing shots. Someone is paying for all these extra tests—everyone, regardless of whether or not you are the one getting them done.

The second difference is that teaching hospitals are such large entities that they have physicians on staff. That is to say, the physicians are salaried with bonus potential. Of course there can be private physicians with rounding privileges as well, but at the Mayo and Cleveland Clinics I would bet there are few if any private physicians. This means that physician reimbursement is reduced. Among the specialties in medicine, private physicians earn more than academic/teaching physicians. The ironic exception is the family physician and internist, who do better selling their practices to a hospital. So while it would be nice to a structured comprehensive system like the Mayo Clinic, it would require physician reimbursement to be reduced dramatically, since there far far more private physicians than academic ones. President Obama will not say this because he knows that he will wholly lose the support of physicians around the country. The AMA (American Medical Association) is predominately made up of non-private physicians, and their support of his plan fails to represent the opinion of the bulk of physicians. You may say that physicians make too much money, and I would agree with you if you were referring to twenty years ago, but not for today (see one of my prior posts). The analogous plan would be to create a new system for comprehensive specialized education that results in teacher salaries being cut nearly in half. The teachers would most certainly be outraged. Would the public be any more sympathetic to them than to physicians?

The major source of money loss in healthcare is testing. Everyone agrees on that. The vast disagreement is why there is so much testing. Some say it is because physicians are tricked or bribed into ordering ore tests. Some say it is out of fear of malpractice suits. Some say it is because there is less time to actually talk and examine a patient. And some say it is because physicians have gotten dumber. I think everyone is right. I think much should be done to rein in malpractice suits. Much should also be done to reduce extraneous testing. If it is not curbed, future generations of physicians will be trained into doing the exact things physicians are doing today. But these methods are unlikely to reduce costs because as a broad stroke reform method, it will likely hurt just as many patients as patients it saves from wasting money. There will always be exceptions to the preauthorization rules. And making physicians jump through more hoops will only delay diagnoses and ultimately treatment. It will only add another layer of red tape. What really needs to be done it is reduce the cost of the tests. In medicine, there is dissociation between the test requester and the test administrator. Hospitals that also run labs and imaging studies base much of their rates relative the private rates of freestanding lab and imaging centers. Does it really cost a thousand dollars to run an MRI? Of course it does not. Not even if you factor in the cost of the machine, which is very expensive. Does it cost two hundred dollars to run a basic metabolic panel? Of course it does not. This is where the money in healthcare is predominately going. Physicians in high earning specialties do not make their money from seeing patients and being on call. They make their money in the business of medicine. They own an endoscopy unit. They run a cardiac stress testing laboratory. They make a pittance on the procedure and interpretation of the test, but make a killing on the sale of the tracer, the use of a sterile room, the oxygen that is administered by nasal cannula. This is where the money is. Reducing the costs of tests even ten percent would generate enormous savings. But it is not to be, since it will encroach and confound the President’s position on businesses, especially in the current economic crisis.

Another thing the President stated was that the healthcare that would become available to the uninsured would be the same as that available to Congressmen today. He did mention that the insurance Congressmen enjoy is a tiered system. But he did not elaborate further, and for good reason. Like all insurances, the insurance available to Congressmen is tiered, meaning that you can determine how much coverage you wish to buy. You can decide how much your copays for physician visits will be, how much you pay to have a CT scan, how much you pay per inpatient hospital day, and how much you pay for out of network services. If you want a lower premium, you can accept fifty dollar copays and pay the bulk of out of network services. This is likely what the low income Americans targeted for coverage will get. But if you make good money and have a pension, say, like a Congressman, you can get much better coverage with lower copays, no referral requirements, and third tier medications for fifteen dollars. Suddenly the healthcare reform plan is not so appealing. But if you hide that fact by misleading people into thinking they will have the same coverage as Senator Ted Kennedy, then you can garner tremendous support.

If the President has his way, then the game of chicken will surely begin. There are many physicians who have stated that they simply cannot or will not practice in such an oppressive climate for medicine. So we will see if they are serious. If they are, there will be an even greater shortfall of physicians, especially primary care physicians, to see the fifty million newly insured patients, let alone the existing insured population. Then there really will be savings because there will not be anyone left to order “unnecessary” tests. And even if they do flinch and remain practicing in medicine, there will be fewer and fewer physicians entering medicine such that over time a critical shortfall will still develop. Perhaps in time it may be alleviated by physician extenders such as physician assistants and nurse practitioners, but then they really will not be physician extenders anymore. They will be the primary healthcare providers. And if you believe they have the same training and knowledge as physicians then you have nothing to worry about. But if it turns out they do not, there is going to be a lot of trouble.

Thursday, June 18, 2009

Tune in to UHF-Universal Healthcare Failure

Another President, another stab at healthcare reform. Also another failure at healthcare reform. How do I know this already? I just do. Aside from the glaringly obvious fact that you cannot provide universal healthcare or even almost universal healthcare for people who do not all care enough about their health, you also cannot force providers of healthcare to provide their services for free.

Let's look at the proposals. Obama wants physicians to curb excessive tests performed out of defensive medicine. What a fantastic idea! I'm sure that physicians would like to order fewer tests that they have to interpret and explain to patients. Especially if those tests do little to help diagnose the patient. Now I will admit that there are many physicians out there who now order lots of test because they are simply dumb physicians. Someone had to be at the bottom of the class. But overall I still believe that excess testing is the result of fear of litigation. Is the test to confirm a clinical diagnosis? Is confirmation really needed or really does it look better in a juryroom of nonphysicians that a tangible "test" was done with results in black on a white paper? If something goes wrong, what will be more accepted in a courtroom to the lay public--test results that have ranges and positive/negative values or a physician's clinical judgement? I'll put five bajillion dollars on the prior. You want to cut costs from testing? Then accept that clinical diagnoses are indeed valid. Don't trust the physicians to make good clinical diagnoses? Then don't get medical care.

Another proposal is to tax healthcare benefits and use that slush money to fund healthcare for the uninsured. Now that's a Harrison Bergeronian approach if I ever saw one. Why not tax gym memberships and use that money to pay for gastric bypass surgery for the obese? Or tax vegetables to pay for smoking cessation billboards. We'll call it a Virtue Tax. Because there are obviously way way more virtuous people in America than sinful people, so I'm sure there'll be trillions of dollars rasied by this tactic. People for some reason also believe that offering healthcare to the uninsured means offering them fantastic healthcare that covers brand name drugs, specialist visits without referrals, and nonstandard of care procedures. It doesn't. The "healthcare" that the uninsured will get it access to a primary care physician (PCP) who won't be able to spend more than ten minutes a visit with them because they have to see the other six thousand newly poorly insured (NPI) as well and get paid by the government in Zimbabwe dollars. The NPIs won't even have decent prescription coverage and will only be able to get medication that was brought to market before 1975. More likely than not, the NPIs will look more like a hybrid of medical assistance and Medicaid patients. And because they will still be the worst covered, they will still have the highest morbidity and mortality with respect to health issues.

A third proposal is to cut hospital as well as physician reimbursement up to 30% in order to stem to rising cost of healthcare. We will address hospitals and physicians separately. Hospitals are almost always teetering on being in the red, if not living in the red. Few hospitals are in the black, and the ones that are happen to be in wealthy cities. Not a surprise since wealthy people have GOOD insurance that pays the provider adequately for services rendered. Also, in wealthier cities there are fewer uninsured or poorly insured that access the hospital services, which offer little to no reimbursement for services rendered. And hospitals cannot turn away uninsured or poorly insured patients. Unlike regular private businesses, which can refuse to to do business with a patron (for the most part), hospitals must treat every patient that enters the emergency room. And if they need admission, they are admitted. You can imagine the ensuing cash flow drain on the hospital for services, tests, medications that will essentially never be paid. Which means the costs of services, tests, medications need to go up so that money can be reclaimed when someone with better insurance actually pays their bill. So if we cut reimbursements, that will effectively also cap or prohibit raising prices for services. The NPIs and their throwaway insurance will not pay even close to what the utilized services cost, and the hospital will hemorrhage money like a ruptured aortic aneurysm. Hospitals will close and--well, you can make up your own ending to that story.

Now what about cutting physician reimbursements? In the short term it will save quite a bit of money. In the long term it will devastate healthcare. Why? How long does it take to become a physician? Four years of medical school and at least three years of residency. You add more years for different specialties, but at least seven more years after college, sometimes ten or more. And what do medical students get paid for four years? Nothing. They pay high tuition fees. What do residents and fellows get paid during training? Perhaps fifty thousand on average these days. And they have to pay back college and medical school loans or capitalize the interest on those loans. Meanwhile, college graduate Joe U. goes into business and starts climbing the corporate ladder. Joe U. is already earning a higher salary, getting 401k benefits, starting to save more at an earlier age because he can, and has fewer loans to repay. Over seven years (perhaps more) that adds up to a pretty penny. Now you want physicians to not only be paid less, but you won't let them deduct school loans because they "make too much". With that landscape even fewer people will want to become physicians. Who will treat the NPI then? Physician extenders, of course. At least that's what Governor Rendell and his wife (a nurse practitioner) want you to believe. I have nothing against physician extenders. But that's what they are--physician extenders. If you want to have a nurse practitioner or a physician's assistant treat you today, what they do is overseen and signed off on by a physician. In the future when there are fewer physicians, who will oversee the physician extenders? And if you want to give the NPs and PAs more autonomy, I also have no problem with that. Just make sure they have the same liability with the same malpractice insurance costs as physicians. Many politicians like to allude to the increased use of physician extenders but are mysteriously absent when asked to make a written statement that NP/PA training is equivalent to MD/DO training. Why not use more teaching assistants in the school if you cannot afford more teachers? What's the big deal, anyways? There are some teachers that simply get paid too much and a teaching assistant can deliver pretty much the same curriculum, right? You don't have a problem with your child learning from a teaching assistant instead a teacher, do you? People home school, so how much training do you really need to teach? As long as your child passes the equivalency tests it's fine. As long as you are alive at the end of the calendar year you're fine.

The fallacy is that everyone deserves healthcare. Healthcare is a privilege, not a right. If you decide to smoke four packs a day and booze it up every weekend, you do not deserve a forty thousand dollar coronary bypass operation when you have your heart attack at the age of forty seven. It is unfortunate that money is inexorably tied to healthcare, where many poor people who deserve healthcare cannot afford it, and many rich people who do not deserve healthcare abuse it. Is there a solution to the current healthcare crisis? Likely not a good one, unfortunately. But gains can still be made. Consideration should be given to allowing tax deductions on school loan interest for all income levels, especially if we are serious about education being important. Consideration also should be given to the government producing generic medications. It's a big business that not only generates revenue against the deficit, but also allows the government to reduce costs by pushing generics in its health insurance plan. It already controls the formulary at the Veterans Administration Hospitals, and veterans do not have any worse outcomes than the public. The other fallacy is that if you make healthcare/health insurance affordable, everyone will but it. Obviously not true because the President is leaning towards forcing everyone to "opt in" to insurance. We had to force everyone to get car insurance. And we are population that will wash our cars every Saturday but never get our cholestrol or blood pressure checked. Perhaps health insurance should be tied to auto insurance. The slogans wouldn't even have to change. You'll still "be in good hands".

Tuesday, May 26, 2009

Quantum Pregnancy

I admit it. I am a Trekkie. I have always loved Star Trek with all the science fiction it oozed in every episode. However, I am probably not a true Trekkie relative to most of the Trekkies out there, but relative to the rest of the public I am a Trekkie nonetheless. A gray zone Trekkie, if you will. But that is besides the point. This is simply to explain why I have thought of this current posting, since in retrospect it is an odd thought.

One of the basic tenets of science fiction is that of space travel. And with space travel comes many special problems, such as the aging space traveler, time travel, and black holes. The one constant in all these scenarios is the speed of light. The laws of physics tell us that nothing can go faster than the speed of light in a vacuum. (I say vacuum because you can slow light down in certain substances.) And because light at comprised of photons can have different spins (like electrons), light carries information. The corollary then is that information cannot travel faster than the speed of light. Information in the most basic sense being on/off or 1/0 or yes/no. You can also split a photon into a pair of photons with a laser. This results in two photons that are entangled, or joined in their quantum properties. Since photons have spin, the entangled photons will have opposite spins. When the photon is initially split into entangled photons, there is no way of knowing which way either resultant photon is spinning. You only know that they are spinning in opposite directions. But if you were to measure the spin of one of these entangled photons, its counterpart would instantaneously adopt the opposite spin of the photon whose spin you just measured. And it does not matter where the photons are in relation to one another because there are entangled in a quantum sense. So if they were ten feet apart, checking the spin of one photon instantly decides the spin of its entangled pair ten feet away. If they were a light year apart, the same instantaneous effect would occur. By that logic, you could imagine how information could be transmitted faster than the speed of light.

What if this was true for finding out the sex of a baby? For the first four months you have no idea the sex of the baby. But then comes the day when you can find out the sex if you want. Up to that point, it could be a boy or a girl. We like to believe that the sex is already determined because the chromosomes decided that at the time of conception. But there really is no way of proving that theory no matter how much logical and scientific sense it makes. It is just as likely for there to be an alternate universe with a "quantum" paired pregnant female or a "quantum" paired pregnant female on the other side of the Earth or across town, and finding out the sex of one baby determines the sex of the paired baby. This would a corollary to the theory that everyone has an evil twin somewhere. But then the problem is that you'll never know if you are the one "determining" the sex of the baby or simply finding out the sex because your paired pregnant counterpart has already "determined" the sex of her baby.

You would have to somehow find your paired pregnant counterpart first...