Sunday, January 31, 2010

The Biggest Loser Is Right

Oh no! The White House’s healthcare reform agenda is in peril! Massachusetts has given its Senate seat to the Republicans. That nullifies the majority rule the Democrats have had and held over the Republicans. Now they need Republican support in order to move healthcare reform forward. The inanity of all this is not lost on many people. Why is there such a ridiculous and convoluted political maze to make the healthcare system work even a little better? Is healthcare a game to these people? The short answer is yes. Healthcare is a game to these people. And they want to win. Healthcare is in fact a game to most Americans with the exception of those suffering from chronic debilitating diseases. Just look at The Biggest Loser on NBC.

It all started with a well spun idea—take morbidly obese people and put them through a grueling exercise and diet program to help them lose weight. It will empower the obese to take control of their lives! It will bring awareness to the obesity epidemic in America! The first season started out rather benignly. Contestants were tempted with high calorie foods and rewarded with money. Each week the contestants voted off one of two people who lost the least amount of relative weight.

But then America got clever. This was, in fact, a reality show after all. And with a quarter million dollar purse on the line, anything is “fair game”. This includes drinking a gallon of water before the weigh in so the next week you appear to lose an inordinate amount of weight. Or creating alliances with other contestants to systematically vote out the other obese people. You played to win. In the end, you did have to still lose more relative weight, but that was not hard if you got rid of the competition during the show. NBC, of course, loved it. And to help stoke the game play and drama they converted to couples contestants.

In this most recent aired season the show has a contestant accused of throwing the weigh in twice. And tensions between these contestants and the trainers are at an all time high. Also, changes in the show now have immunity challenges where one is “safe” from elimination no matter how much weight they lose—or gain. The advantages do not end there. Now challenge winners can dole out disadvantages such as “no gym for a day”, “2 lbs disadvantage”, and “no elimination vote”. You can imagine the cattiness on the show this season compared to the first season.

So clearly NBC and most of The Biggest Losers viewers believe obesity is a big joke. To them obesity is not a serious health problem. Would they toy with calorie counts and take away exercise regimens of contestants if they thought it was not a joke? The slippery slope would put cancer patients in the obese contestants’ places and take away chemotherapy and radiation therapy, doctors’ visits, and penalize contestants by making them smoke cigarettes. Extreme you say? Not so much if you consider that obesity kills far more people yearly than cancer.

What the show needs to do is to remove the coupling of contestants. Instead of boosting self-esteem and giving moral support, partners create arrogance and trickery. The show also needs to remove any penalties restricting diet and exercise. Those two core factors are what most obese people have a difficult time utilizing. To give and take these key elements is horribly insulting to anyone trying to lose weight. Also, if the essence of the show is weight loss, should not the contestant that loses the most weight win? Then they should automatically eliminate the contestant that loses the least weight each week. That would take care of any contestants throwing the weigh in. Lastly, they need a different way to calculate weight loss. While the percent change of weight calculation is simplistic enough for the public, it is clearly flawed and favors heavier contestants. There should be a factor using the body mass index to help account for that relative difference.

If NBC keeps this show going to way it is now, everything about the show will indeed be the biggest loser. Only not in the witty homonym way they intended.

Sunday, January 24, 2010

Misinformed Opinion

I had some downtime this week and rather than do actual household chores or take care of bodily functions, I decided to read U.S. News. Yes, I might as well have been reading the Valupak coupon circulars for eaves cleaners and landscapers, but I read it anyways. If you do not read U.S. News, it has changed its format recently, and now includes a pro/con opposition of opinions for the question of the week. This week’s question was whether Social Security should apply means testing in order to keep itself viable.

Personally, I think that means testing is a ridiculous way to save Social Security and was likely thought up by a simpleton who only completed algebra and not very easily. Means testing is in theory a way to filter out people who should not need Social Security payments. Those people who continue to pay taxes for Social Security, but never receive Social Security themselves when they come of age. Instead, that saved money would go to people who do depend on Social Security. The reduced drain on the fantastic money pot would also Social Security to stay viable for many more years.

My beef with the article was not with the “pro” opinion for means testing. After all, there was a “con” opinion following it. My beef was that the author of the “pro” article, a professor of psychology, either put no thought into her piece or is rather ignorant of the nuances of Social Security. And as is true for any manager that tries to micromanage something about which he knows none of the nooks and crannies, things end up as garbage. So it was with this piece. As an aside, U.S. News also could not even manage to find a person trained in economics to write the “pro” piece. Star journalism, U.S. News. Star journalism.

The major argument of this psychology hack was that the rich do not need Social Security, and by expecting it show themselves to be entitled fools destroying the system. She argues that means testing will eliminate payments to these entitled fools while still taking their money. A very Robin Hoodish viewpoint to take. She then makes a feeble attempt to say that people who diligently save should not be prevented from receiving Social Security, but fails to come up with any solution or even a bad brainstorming idea. After reading her piece I secretly wept for any students she has or will come into contact with in her lifetime.

The problem with Social Security most certainly is not that rich people collect it when they should not. Given the current calculations for how much you can receive at retirement, the rich do not soak up much Social Security. They are already outnumbered. Ten percent of the population holds ninety percent of the wealth. Denying those people with not save you much money. It will save money, but only enough to be a band aid because it is not proportional. Making twice as much money does not get you twice the Social Security payment.

The problem with Social Security is its generosity. Social Security payments are based on credits earned for each year you worked and earned enough money. You then need to earn a certain number of credits to qualify to receiver Social Security. Once you have enough credits, you may start collecting payments at retirement. But the kicker is that it carries over to your family! Your family, and a divorced ex-wife is considered family, can also collect benefits if you die or become disabled. And they do not just collect your benefit amount. They can collect upwards of 180% of your Social Security payment for life. For instance, a widow can collect her husband’s Social Security, as can the children. But the family’s net collection is capped at 150% to 180% of the deceased payment. That means that one person’s Social Security payments can be increased and prolonged far beyond his lifespan. What that also means is that a widow, who may also have worked and collected Social Security credits but not enough to match the payments of her spouse, will collect more Social Security at retirement than if her spouse had not died.

We could debate the many nuances and unique couple and family scenarios possible. We could also debate how personal savings rates affect need of Social Security and whether one person’s inability or unwillingness to save for his own future should become the responsibility of the working American public. But the bottom line will always be the same. Social Security, whether or not it is serving or spoiling the greater good, will simply go bankrupt because it is too generous.

Monday, January 18, 2010


Exactly how ridiculous is politics? It is the only profession with its own currency and capital. It began with people simply trying to obtain the best funding, services, goods, or what have you for their constituencies. But as cities became more complex over time, you had to prioritize the needs of your constituency make deals with other politicians to get what your city needed the most. And over time the deals became more complex and involved more people and also coming and possible events. In essence, they became the political equivalent of a mortgage backed security, and were just as difficult to trace and follow. Because of their convolution, they then became easy to abuse. Politicians could use their political capital for personal gain but hide it under the guise of helping their constituency. And that gave rise to political pork.

Political capital and political pork has gotten so bad that you can essentially expect political capital to be traded and some pork to be attached to each and every Congressional bill. You simply cannot expect any politician to act in the best interests of the public. That has led me to my past recommendation to impose term limits on Congressmen. But perhaps that is why President Obama was seen to be a breath of fresh air for the United States government. When talking about pork, President Obama specifically stated that he would veto any bill with pork.

Now enter healthcare reform. A bitter battle has and is still brewing over healthcare reform. The public option has already bitten the dust, not because it actually is a bad idea—that would take time to figure out—but because enough politicians either do not like it or are listening to people with money or political capital. Now the entire reform is in dire straits because Senator Kennedy’s seat in the Congress is up for grabs, and a Republican is currently in the lead to take it. If he does, the Democratic party’s majority rule in the Senate will end. To many this is a big deal because it means that Democrats will no longer be able to power whatever Democrat slanted bill through the Senate. And that would put the final nail in the coffin for the healthcare reform bill.

But this is really just a load of crap. The Democratic majority in the Senate has proved minimally helpful in passing bills. And healthcare reform is also the perfect example why the simple fact of having a majority is negated by political capital. While the general theme of the bill is to try and insure up to 30 million more Americans and cut costs over the next decade, multiple smaller issues have cropped up that extend beyond simple party lines. For instance, abortion is a sticking point for many people, both Democrats and Republicans. Many do not want the new healthcare system to pay for abortions and many do. This fractures the Democrat majority. There are clearly ways around this, say by making the abortion issue a state determined matter. That should appease most politicians and preserve the majority rule.

The bigger problem comes when you bring up Medicaid. This is the suggested method of covering the 30 million uninsured. The thing about Medicaid, however, is that it is funded by the states, and unfortunately, very poorly funded by the states. The federal government does help with subsides here and there, but it is still not a lot of money. So you can imagine that when the politicians discovered that healthcare reform would require their states to pay out more over time, they had to make a decision—accept the trade off or not. Most Senators accepted that part of the bill. But Senator Nelson of Nebraska did not. Instead, he decided to play a little game with the Senate and the public’s money. He decided to hold out until every other Democrat had given his support for the bill. Knowing that his party would need all 60 of their own votes to pass the bill, he held out until he became so important that he could asked for just about anything. So he asked that abortion be removed from the bill. And he asked for federal funding of Nebraska’s Medicaid program forever. That’s right. Forever. And he got it.

So that’s our first lesson in politiconomics. There will be many many more lessons on political capital, political supply and demand, and political cost and profit.

Sunday, January 10, 2010

Finite Love

I was at the mall quite a bit over the holidays for obvious reasons—buying gifts I knew people would love an returning all the gifts I hated, and I was watching a lot of families. You had the basic family unit of a married couple. Then you had families with one child, two children, and so on. Then you had your trail mix of families with stepchildren, adopted children, sperm donor children, and clones. But as I watched these families and especially the children, I realized that there was an unavoidable sadness that comes as your family gets larger and larger.

Sure, there is the obvious fact that with more kids you must divide your time between them. After all, parents have no favorite child. Or, at least, in nondysfunctional families they do not. So if you have two children you must spend half your time with one and half with the other. With three children it is one third, with four it is a quarter, and so forth. After all, you do not want to short change a child. This is of course counting your free time only, once sleep, bodily functions, work, spousal time, and eating have been accounted for in a twenty-four hour period.

There is nothing more precious that you can give your child other than your time. It is the one commodity that no one can twist, manipulate, or create beyond what is available. And so if you love your children, why not spend as much time with them as possible? And if you have more than one child, all of whom you love equally, of course, why not spend as much time with each of them as possible? In equal amounts, of course. There can be no other ideal way to parse such a finite commodity. So if you loved your children, you would spend as much time with them as possible. We have all learned from after school specials that nothing else substitutes for this. Thus measurement of time becomes a surrogate for measurement of love.

Now let us take a family with one child. Let us say this child is two years old. And for the sake of simplicity, let us say that the parents will always work the same number of hours a day and sleep the same number of hours of day. We can even say they will go to the bathroom the same number of minutes a day, but you get the point. So for two years this only child has been getting all the time, which we can call 2t. But now the family has a second child. In that second child’s first year of life, he will get 0.5t of time, while the first child gets 0.5t of time. By the time the second child turns two years old, he will have had t of time, while the first child, now four years old, will have had 3t. And when the second child turns four years old, he will have had 2t of time, while the first child, now six years old, will have had 4t. By simple algebra, the second child will always have (age)t/2 of time while the first child will always have (age)t/2 + t of time. The first child will always have had more time spent with the parents.

The math need not seem complicated. What it tells us is that because the first child was an only child to begin with, he got all the time while he was an only child. This is something that the second child will never have. Thus, the parents will never be able to have spend the same amount of time with the second child as they did with the first. You can extend that to the third child, who will get less time than the first two because there will never be a time when he gets all or even half the time as the first two children did. Does this then mean that the more children you have the less you love them?

Obviously not, but it is a disturbing concept. You may say that work hours may change. For the children’s sake it would have to go down. You can’t really sleep less because who is spending time with their children at two in the morning? There is, however, a limit to this idea. When the children get older, new children may actually get relatively more time. Few teenagers want or need their parents time to the same degree as when they were six. So if you had children eight or more years apart, you would not have to feel you were shortchanging them your love. Fortunately, children have no frame of reference for comparison to know that you have spent less time with them than their older siblings. Well, until they learn algebra, at least.

Sunday, January 3, 2010

Bundle Me Up

Hooray! Bundling is coming! The answer to all our problems! No more shall we be charged excessively for medical care! Now doctors will finally have an incentive to cure patients as quickly as possible. How could this possibly be a bad thing? How?

What in the world is bundling, you say? Bundling as it refers to healthcare in general is when you offer one price for a general treatment. It is similar to construction and contract work with a major difference. Let’s say you hire a contractor to refinish your basement. He comes by, looks over the basement, and gives you an estimate. You make a deal and sign a contract. But when he starts taking down the old drywall, he discovers mold. Now he will have to seal the foundation cracks and lay new insulation and drywall. It will take him longer and he will need more materials. And of course this will cost you a lot more. But your contract was for a refinished basement, you say? Unfortunately, your contract did not cover mold and foundation work, even though it is needed to accomplish the final goal of a refinished basement.

Bundling in healthcare is just like that, only the contract does cover just about everything that is needed to accomplish the final goal. Imagine if that were true in contracting. We need to rebuild the foundation and so we need to rebuild the entire house to refinish the basement? You got it at no extra cost. That is how it is in medicine. If you get admitted for pneumonia, there is a net reimbursement for that, calculated by oxymoronic government geniuses. That reimbursement is split up between the hospital, doctors, and everyone else involved in the admission. Need to stay in the hospital longer because you are improving more slowly than most people with pneumonia? No problem for you. The hospital and doctors, however, will not get paid for those extra days because the money will have been spent.

That is not the spirit that bundling is trying to capture. Imagine another scenario where you are in the hospital for appendicitis. You get an appendectomy. But then you develop a hospital acquired urinary tract infection. Or a hospital acquired pneumonia. These things do happen, and are not unexpected. There are people, however, that believe they should never happen. Period. And because of that belief, there is a move to deny payment for any treatment or tests done due to a hospital acquire infection. And if they have it their way, any hospital acquired anything, save a regrown limb on an amputee. The spirit of bundling in that sense is reasonable. If your contractor breaks a window while bringing two by fours into your house, you should not be responsible for the cost of the new window or the labor to install it.

What are the consequences of bundling, then? There are two obvious outcomes. The first is that you will have doctors that will continue to treat you for no more money even as your case gets more complex. The second is that you will have doctors who will do only enough to get you seemingly better so they do not end up working for free. But even in the first scenario you will have problems because the hospital will not be able to eat the costs of hospitalization beyond doctor’s fees for very long if they are not getting paid for it. And there are movements to deny payment for subsequent hospitalization if they are for identical causes. For patients this would certainly be a good thing. We can throw around terms like “accountability associated reimbursement” and “standardizing healthcare”. The public will eat it up. It sounds as though everyone will get equal care. No more worrying about whether you have a good doctor or not, or if you are at good hospital or not. Who needs a doctor to run an algorithm? We can use cheaper nurse practitioners. And if people would give up their bias of having people with a medical background run the algorithm, we could even train a monkey to run it.

In very large institutions, that is exactly what will happen. Care will become standardized. Protocols will be written. Many many protocols. So many, in fact, that it will make the government look like a two year old deciding what to eat. People will be diagnosed based on the constellation of reported symptoms and basic labs and imaging and then fed into a treatment algorithm. These protocols will be based on the average patient—average length of stay, average number of comorbid conditions, most likely diagnoses, and so on. And this will work just fine—for the average person. What if you are not the average person? What if you actually have lung cancer that is manifesting as a productive cough? Chances will be more likely that it will be missed with bundling. And what if you do get diagnosed and get admitted with pneumonia because of chemotherapy? Should you expect that your case will be treated differently than the college kid with walking pneumonia? The answer is yes, you should expect it, and it will be in the beginning. But as these cases accumulate over time and the doctors continue to care for them with little reimbursement because of bundling, the hospital will also begin to bleed money because of little reimbursement. Most hospitals are already in the red more often than not, and this will make it worse. Eventually, either the doctors will stop working or the hospital will shut down. I bet the latter will happen first. Then care will be completely standardized—no care whatsoever. What a great big bundle of joy reform will bring us.

Friday, January 1, 2010

Twenty Ten

Goodbye 2009. Hello 2010! There are going to be so many changes for 2010. New trends will be starting, and old habits will have to die hard. For the last decade we have certainly taken a lot of things for granted, but now it is time for our rude awakening.

The most annoying change that I foresee is the confusion and subsequent frustration with writing the date. For practically the last two generations there was little confusion in the way dates were written, even given that Americans write dates counter intuitively using a month/day/year convention. You might as well say the time is 52:11. It clearly makes more logical sense to write the date as day/month/year, in logical time duration order, as it is done in Europe. But for a country that still uses avoirdupois weight units it is not surprising. But beyond that anomaly, the problem will arise with confusion of the year 2010 as “10” and the tenth day of the month as “10”. Thus, “1/10” may mean January 10th or January 2010. We did not have this problem in 2009, since the convention is to write January 9th as “1/9”, and January 2009 as “1/09”. Does that mean I will have to write “1/2010”? How very annoying.

People will also be setting New Year’s resolutions. Most of them will involve weight loss. It’s never a good commentary on society when that many Americans are trying to lose weight. But it could be worse—the most common resolution could be to try and be nicer to others. What would that tell you about America?

Me, I don’t think I’ll set any new year’s resolutions. It is not that I have no resolutions to make, just that I really do not see the point in New Year’s resolutions. If you have such a problem that is adversely affecting your life, you should make changes when you discover the problem, not weeks or months later because it is time to buy a new kitten calendar. Take obesity. If you know you are overweight, and you know it is not how you want to be, you should begin to work on your weight the moment you have that epiphany. If that occurs in May, why would you wait seven months to make that change? You would only be unhappy for an additional seven months with nothing gained. Or if you come to the conclusion that you need to save more money, why wait to start saving? Given the power of compound interest, your money would grow far more the earlier you started.

And most resolutions are broken or forgotten before the first spring thaw. It is not difficult to see why, considering that there is little to no significance to the start date for the resolution. People are far more likely to successfully quit smoking after a tobacco related health scare than after a new year’s resolution. It’s obvious to see why—there is no personal connection to January 1st for most people. You might as well throw a dart on a calendar.

One change that I am curious to see is the change in New Year’s glasses. Thus far, we have enjoyed double zero years, making New Year’s glasses easy to conceptualize—one zero for each eye. When 2011 comes around, though, I will bet there will be a change to headbands or necklaces. Or at best monocles. Otherwise you end up with a square made of two 1’s for one eye and that just does not look right.

So goodbye 2009! Or more accurately, goodbye fiscal year 2009! Perhaps one day we will throw New School Year’s parties as well.