Tuesday assorted links

Comments

#1 Most likely provided by some websearch analytics. Which begs a question, is being angry by country the point of interest or is it the willingness to express and acknowledge your anger, even subconsciously searching for certain things online?

Also, Canada's angrier than Japan by 1%....I LOLd.

#4 The drone part is way less interesting than the 17 years. That took determination.

#5 Hidden Figures?

#6 Sure. At least until something more convenient comes along.

Spectator Index used to be a great twitter feed, now they publish low quality surveys like this one, where everything turns on the methodology. As the source is Gallup, it might at least be a survey, but most of us probably wonder what it means to answer the question "did you feel angry yesterday" across different cultures. Maybe it's just me, but surely we all feel angry most days. Stuff like this makes my blood boil.

"Maybe it's just me, but surely we all feel angry most days. Stuff like this makes my blood boil."

EE: stasi, know might be a really good time for you to get angry...
stasi: That's my secret EE...I'm always angry.

STASI SMASH!

Actually, it was the Stasi that was smashed by angry East Germans.

"That took determination."

To be on the run or to keep tracking him down instead of calling it a decade and giving up?

> 1

With this thing called the internet you can actually, you know, go to the data source.

It's from interviews.

is not "Prediction markets" just "sports betting" for the academic class?

Sports gamblers are arguably more successful at separating their true beliefs from their mood affiliation.

Trump is being investigated in an impeachment inquiry for cut and dried collusion and we have zero links thus far. Let’s review.

Commenters here have routinely assassinated my character and questioned my sanity because I have repeatedly stated Trump was guilty of conspiracy and obstruction of justice.

Now there is no question. Trump released the transcript. He’s not only guilty of collusion, he’s instigating the collusion and also guilty of extortion. By his own words he’s guilty. He belongs in a prison for 30 years. And will be wearing orange soon, to match his skin tone. Dick and Rat can send him bronzer in prison.

Now that we know the outcome, it’s time to consider the options. It’s clear that the immediate next step for President Warren is to pack the Supreme Court. The only debate here is about the number of judges. I support 15 myself, but others have said 9 is sufficient to render every past Republican appointee irrelevant.

Within 6 months we could have a guaranteed right to welfare, 100% gun confiscations, free housing, free healthcare, and wage equality across fields, position, gender, age and race. What does MR think, 15 or 9 extra judges?

Genuinely insane ramblings

Gotta know how to recognize obvious trolling and sock puppetry in this game. -5 internet points.

6. I could hardly think of a worse way to read a book. Small screen, blue light, lots of animations, plus the distractions that come with looking at a phone. And none of the cool factor that comes with owning a book. I don't think that's going to catch on

2. Almost all of the innovations require consolidation in the industry (EMR, bundled payments, ACOs, etc.). Is that a good thing or a bad thing? Does consolidation mean greater efficiency or higher cost. Consolidation doesn't seem to bother Cowen; indeed, my impression is that with Cowen monopoly is to be praised not scorned. One might recall that during the run-up to ACA "fragmentation" (many small, inefficient providers) was the biggest problem with health care that could be "cured" with consolidation. Well, we've have consolidation on steroids.

#2: pretty good article. The financial incentives were too weak to have much of an impact on patient outcomes, and everybody knew this from the start, but I suspect that there was little else that realistically could have been passed. There'd have been a political price to pay if the incentives had been stronger. The AHA does not want its member hospitals providing services and not getting paid full freight for them.

Also, I suspect that there is a kind of tension between rewarding hospitals for treating patients efficiently and for higher patient satisfaction. Patient satisfaction is for some people going to be a function of 'how much medical care I wanted or expected vs how much I actually received,' which would of course be at odds with the hospital's efficiency goals. These incentives may run in the opposite direction. For example, if you consider how hospital rooms have been evolving in the direction of looking more and more like hotel rooms, I'm sure that helps improve patient satisfaction, but guess who is ultimately picking up a big chunk of the tab for those luxurious hospital room stays? Medicare. Oops.

"I'm sure that helps improve patient satisfaction, but guess who is ultimately picking up a big chunk of the tab for those luxurious hospital room stays? Medicare. Oops."

Hospital rooms cost far, far more than hotel rooms. I expect the slightly better decor is actually trivial.

That was just an obvious example. Substitute "number of sponge baths received from 20-something female nurses per stay" as your patient satisfaction metric, and the principle remains the same.

LOL, will do.

I think I get what you're getting at. The 'luxurious room' in hospital A versus B means you'll be inclined to go to A whenever you have a choice or influence. The actual costs of A and B are going up but not because of the fancy hotel like rooms. The costs, though, are not being driven by fancy accommodations. A similar arrangement, I suspect, happens with colleges.

I am curios what would be strong enough financial incentives to move the needle in your estimation. In 2018 the median operating margin for a hospital was 1.7% (this is down, a lot, from even four years ago). Decreasing reimbursement, across the board, by 1% is not a trivial decrease in the total margin for a hospital, it is dropping the margin by 58%. Even accounting for the fact that this only applies to a subset of revenue, hospitals everywhere have tried to comply to reap the differential.

Your hospital room is cheap. We can, and do, junk everything in it if it becomes too contaminated (e.g. some hideous MDRO sets up shop). Refurbishing the whole place is maybe $10K (building everything from scratch, including the ORs and CT scanners, is maybe $500/sq ft for a new hospital). Given that once we do so, we can let is slide for 5 or 10 years, well you might need to pay an extra dozen bucks a day for the hotel aspect.

No, what drives up healthcare costs are the people. The single biggest line item there are the nurses. Exactly how many patients should your nurse be managing? How many nurses should her manager be managing? Then of course there is RT, Soc, PT, OT, and the rest. Having human contact and services are, by far, the biggest things that improve your Press Ganey, on the flip side they are, by far, the most expensive thing.

If you want cheap(er) healthcare it involves firing people and you spending more time waiting and the people you do see doing less for you. The only way wards make any difference is if they allow you to decrease staffing levels (e.g. Nightingale wards).

The far more common problem are the physicians who graduated from the University of Google College of Medicine or the Well My Sister College of Medicine. When I have a worried mom who wants her kid to get an MRI for an injury that I can quite reasonably manage with a CT and observation I can either acquiesce (and cost the taxpayers a thousand bucks) or I can tell her no. That latter is sure to tank our scores, and we literally use a 1-5 ranking and treat everything below 5 as equivalent for some metrics, but the former is fiendishly expensive when I have 10 of those, or more expensive, cases a day.

I could be wrong, but I have heard of exactly zero hospitals that have said "eff it" and elected to not burn a bunch of provider time trying to get these bounties wherever they have been remotely viable. Certainly we have seen the vast majority of primary care get bought up in a heartbeat by hospital groups just snag the differential between independent and hospital based reimbursement.

"No, what drives up healthcare costs are the people. "

+1, it's all about the number of people.

The US has 18+ million people directly employed in health care out of less than 160 million workers. Over 11% of the work force is employed in healthcare.

Sure is correct. This is why ambulatory surgical centers are cheaper...no overnight stay, no physical/song/play therapists.

I spent 120 days in the hospital last year. The Nurses and other staff helped keep me alive against very long odds. Spending money on health care is a damned fine thing, which is why we do it. It's a good idea to try and be efficient as possible, but the constant pretense that it's just another expense is making me sick. PS. Can someone explain to me why people don't say who they are? And why not just use a number instead of some silly name?

I am very glad to hear you survived your hospitalization and are presumably at least more healthy now.

The question is what percentage of health care spending makes a statistically significant difference in health outcomes.

Yes, there are times when it does. Obviously. But that’s not where the costs accrue. Most healthcare costs have zero value add in terms of health outcomes, but satisfy the customer who pays nothing.

In the real world we let the markets solve for the equilibrium. Unfortunately in a dysfunctional and low trust society it’s a shitshow of drug addicts assaulting patients and giving every moron an MRI for no reason.

Healthcare in a country is a reflection of society. It’s not the policy. It’s a mirror. And the US is terminal.

Silly name...interesting points...

Estimates tend to cluster around 1 part in 4 or 5 of your health outcomes are due to healthcare.

Most of the health interventions have numbers needed to treat that range from one (e.g. c-section for certain mucked up deliveries) to hundreds (e.g. all comers statin use). Most of us will have a couple of health interventions in our life time on the low end of the scale: appendicitis, emergent c-sections, blood transfusions, epinephrine for anaphylaxis, CAD drugs; but most of us will live at the top end and we will get 30 or more interventions over a lifetime and all but a few will have no effect (e.g. antibiotics, you most likely will get better regardless, but lowering your risk of death from say 4% to 0.04% is generally a good option). Predicting who will benefit is all the rage and the idea behind pretty much all the government healthcare rationing.

The difficulty is that I have the sneaking suspicion that the real savings come from bulk. In the bad old days there were only a couple of pulse oximeters per hospital when they first starting getting used. We could have done a bunch of multi-center trials to figure out exactly when they improve patient survival. Instead we used them on a bunch of patients who did not "need" them and the price has come down to the point that we now hand them out as free schwag at conferences.

As much as MRI gets maligned, and I often one telling patients no, truth is its small potatoes. About 1 in 10 of us will get an MRI any given year on average. So we have about 32,700,000 MRIs any year. Trade data suggest that on average they cost the system $1119 each. All told that works out to around $36.5 billion. That is slightly under 1% of total healthcare costs and it includes every single MRI - the good, the bad, and the ugly.

And lest we forget MRIs do let us minimize costs in other areas. When I give a possible stroke patient an MRI my alternative is often keeping them obs overnight. That is very rarely cheaper. At the end of the day Americans spend about half the time in the hospital of the OECD average.

This is a big deal for us. Our hospital stays are vastly more expensive - we require hospitals to provide vastly more services than everyone else and while MRI scanners are largely fixed in international prices, our labor is vastly more expensive.

More importantly, somewhere 4 days of the average patient's income is coming out of the economy (actually more when you include the employer half of social security and the disruption costs). In the US that translates to pretty close to the price of an MRI.

Now for a lot of stuff the question is not MRI or nothing but MRI vs CT. If anything, we are not using imaging enough. Imaging is getting cheaper every year; the alternatives that require physicians and nurses to warehouse the patient are getting more expensive.

As always, the biggest costs are labor.

I use some silly name for a few reasons:

1. While I have never, nor will ever, reveal PHI here I have no intention of having someone google my name, think that I have, and then raise a time consuming ruckus for me. Being in a field where I need not only do the right the thing, but prove that I did it means that it is worth something to me to avoid the hassle internet outrage.

2. I have had multiple patients that placed on holds who ended up involuntarily committed and were forced to receive psychiatric treatment. They have sense been released, gone off their meds, and have med credible death threats against all the physicians who "imprisoned" them. The number of psychotic individuals who wish me ill is large and I keep off all social media so that they cannot easily find my home or stalk me. I have also been an expert witness for multiple murder trials and again have received death threats. Again I do not wish to make it easy, in the slightest, for my incarcerated patients to find me.

3. I am an outlier minority. I prefer not to have people who will get upset that I refuse to toe professional/racial/veteran lines be able to go over my online venting with a fine tooth comb. It is very helpful to control who knows how heterodox I am about various issues and not have to deal with all of it all the time. It is stimulating to discuss stuff here and I would prefer not to have to worry about what people who read this from real life are going to think.

As far as the number, I don't use one because this is easy, memorable, and slightly self-mocking.

Does this only count people actually providing healthcare (doctors, nurses, therapists, orderlies, etc,). Or does it also count various non-care positions, the medical billers, marketing people, accountants, IT staff, etc? I could be wrong but aicsusoect it's the latter area where employment has exploded.

Could I give you a number? No. But as the article says, the incentives don't seem to have achieved the desired outcomes. Maybe nothing would have worked, but I would just point out that I think you are overstating the impact of labor costs. Currently, they account for roughly 50% of hospital operating costs per this Deloitte survey:

https://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-lshc-deloitte-2017-survey-of-us-health-system-ceos.pdf

Furthermore, that's total labor costs, not direct patient care costs. I would wager that administrative personnel costs are roughly 15-20% of total labor costs (or 7.5-10% of the total operating costs). The real problem with labor costs isn't that they're the only cost, it's that they go up every year, whereas costs of, say, medical devices or supplies probably get cheaper over time as patents expire, manufacturing costs decrease, etc.

Still, medical devices and supplies are a huge part of the picture. Abbott Labs, for example, didn't build a $126 billion market cap from selling band-aids at a 2% markup. Is there any way to squeeze those administrative costs or non-labor costs? Honestly, I don't know, but it'd be nice to find out.

I would be skeptical that it would be easy to cut those administrative costs. You need people to make sure the services get billed correctly and that the providers get paid. You need people to make sure you have adequate records of all sorts to protect providers from lawsuits, and also to withstand any regulatory or payor audits. You need specialized IT people.

There's a software-as-a-service for everything. Use it so you don't have to grow an entire IT department or an entire admin class for that matter.

Until this illness hit me, I had no experience with hospitals. All I can tell you is how important the people helping you are. Good health care is worth it, and I'm saying that part of the expenses involved are that people who enter the health system know it. It's hard to value it until you need it. I has no idea that you are hoisted around your room until I was there, but the device is really worth it.

HCA essentially does this, to the extent it is possible. I don’t think they really save all that much money doing it. Right now the software isn’t good enough, so you still need the people doing the work, whether or not they work for the provider or a contractor. Also, IT is very expensive and difficult for healthcare, because of the legal and regulatory environment. So far as I know, no one has written software that accounts for the rules about payments and regulatory compliance being “fluid”, to put it nicely. AI isn’t yet that good, and if it were, we’d have Skynet (and self driving cars) already.

We've tried that. Epic made its founder $1.7 billion, and our IT bills are far higher than the ever were before.

A hospital is not an office building. I need my computer to talk to the X-ray machine, the EKG, the bedside ultrasound, the pharmacy, the nurses QR readers, and some of my RFID devices. Oh and the Swan-Ganz that we just floated through the patient's right heart.

When things break I cannot wait until tomorrow. People die. Regardless of if I hire an outside contractor or keep it in house I need onsite service 24/7. When you do hire the contractor, well many times I find that everybody chases the cheapest option (e.g. Epic) and then once you are locked in, prices mysteriously rise. Because again, this ain't an office building. When we have to take the computer system down we only do so after bring in backups for all the essential equipment and then paying overtime for a bunch of extra people to be on hand around 0300. The contractors know this, they know that us kicking them out is literally a billion dollar cost to convert to someone else. Their pricing reflects this.

Hospitals are much more like factories, part of your primary focus is getting the equipment on the floor to work well together. Further, like a factory, we cannot use off the shelf products too often. We pay scads of money for products where better versions exist which are free. E.g. my phone has a nice app that encrypts my emails and lets me email secure photos to the computer system. We pay some utterly unreasonable fee for the system when I can get superior encrypted communications for free. We do that because free doesn't cover our liability if an exploit is found. Paying the overpriced fee for one of the very few vendors is decent business sense because they assume liability.

Regardless of when and where you contract out, you still need people in house to oversee the vendors. Per the courts, due diligence requires in house IT and the "we just bought from reputable vendors" is not sufficient to limit liability.

And this is a common issue. The vast majority of the superfluous admin I would cut, I cannot. It is required by the legal system.

The costs appear to be largely fixed to me. The building and the people have to be paid for and that cost is divided into the bills. But how do you bill?

The prevailing model is the hamburger method. If you eat two hamburgers your bill is twice what it would be if you eat one. As a result there's an incentive to take every nickle and dime and turn it into a ten or twenty ("you had two band aids, that will be $50 please").

The other method is the buffet. You pay to get in and eat what you want. Cost management here is not so bad. If your costs are $100K and you have 1,000 patients then every pays $100. Some people will eat twice as many hamburgers as the others but this will even out.

5. For some reason, this article made me think about Jewish athletes (it is Rosh Hashanah). There's even a Wikipedia List of Jews in Sports. There's actually many in football and baseball, but only three in equestrian. There's no Wikipedia List of Black Women in Economics, although there is a Wikipedia List of Feminist Economists (in alphabetical order). There's only one each in C, D, E, N, O, P, and Y. B and S have the most. John Stuart Mill is on the List (under M) for reasons that puzzle me (although he did favor women's suffrage and argued that the oppression of women was one of the remaining relics of ancient times), as is Lawrence Haddad (his research interests included women's empowerment). Until black women in economics have their own Wikipedia list, I'd choose another occupation if I were a black woman.

"Until black women in economics have their own Wikipedia list, I'd choose another occupation if I were a black woman."

I read that twice trying to turn it into a brain-teaser.

I didn't even read past the first paragraph of 5. Anyone who cites the behavior of a totally anonymous online message board, with no ability to determine how accurate of an extrapolation that is, and can't even determine the distribution of such behavior within the sample itself, as somehow being indicative of an entire profession is an imbecile that puts agenda ahead of even the most basic standards of statistical rigor.

Agree. econjobmarketrumors was/is a message board for a relatively small number of mostly bored and frustrated anonymous grad students. I think it has been mostly cleaned up lately. It's still pretty lively - with a 100 posts an hour sometimes. The AEA political correctness police set up their official monitored EconSpark board as an alternative. Naturally EconSpark is about as lively as a dead car battery.

1. Why does anyone takes this shit seriously?

International comparison surveys that hinge on a single word are always nonsensical, because subtle differences of connotation are lost in translation. Does the foreign word map more closely to "rage" or "fury" or "wrath", or something closer to "resentment" or being "infuriated". And so forth.

Pollsters know that the exact wording of a question can greatly affect the response. This situation is no different.

Just here in the moderately ranked US we have more words and subtle gradations for anger than Eskimos have for snow. There's a whole continuum -- from ticked off, honked off, pissed off, and hacked off to irked, peeved, miffed and the potential powder keg known as disgruntled. And that's just scratching the surface.

The trouble with all the "innovations" in payment are that they are trying to steer healthcare costs by the most asinine way possible. People see large numbers for procedure costs coupled with high pay for physicians and assume the problem must lie at that nexus.

Truth is, the patient behavior trumps anything I could ever do. Smoking and all the rest easily cost us more than any surplus of MRIs ever could. By the numbers, having a spouse at home who can manage simple medical care is such vast savings to healthcare that you would need me to prevent stupendous numbers of infections to come close. Healthcare is much cheaper to deliver the Ozzy and Harriets of the world than to the ever more popular singletons who lack community and have increased risk of substance use issues.

Frankly, establishing these benchmarks run into a perpetual problem - simple metrics are exceedingly easy to game and very hard to meaningfully change. It is also, for many specialties, far easier to pick a better patient population that it is to improve patient care.

The other thing to remember with all this data is that a lot of the change is not going to be coming from the specifics of any given policy. ACOs and the rest are often gimmicks that management, the nurses, or the physicians use to push through change (even if informal cultural things). This gets particularly troublesome when hospitals can opt in or out and when the data shows strong survivorship effects.

Frankly, "healthcare" is going to get more expensive. All the "waste" in the system is there for a reason. Maybe the reason is just venal, but changing it is its own expense. The low hanging fruit was plucked first and there just are very, very things which are actually cheaper to implement going forward. Even when we do find a way to do something cheaper, and there has been a lot of that, we often end up with new things to replace it (e.g. insulin is very cheap, but we are now looking into beta cell transplants and the like) or even more commonly now it is cheap enough to use more (e.g. pulse oximeters went from rarely used to literally becoming a vital sign, the price fell something like 1000 fold, but we now have them on every patient in the hospital).

And at the end of the day, the cheapest patient is always the dead one. If I save your life today, great I just bought the healthcare system at least a couple years of your average healthcare bills.

Hey there, don’t despair. It is still good to be a physician. I would do it over again. I agree that there is very little that we can actually do unless the US overnight wanted to stomach very painful changes.

I agree that prevention is the best healthcare but what is your solution for cost effective treatment when the time comes to need it besides dying as you suggest? Also, why can't prices be posted online like other services?

My solution for cost effective treatment is largely to trust physicians. Every scheme I have ever seen requires us to do things like code illness and if we are going to cheat, we will do so. We are dumping so much time, effort, and political energy into controlling costs that I just don't see a viable return.

Now if we change things at a fundamental level I would do any number of things: repeal HIPAA (you negotiate whatever privacy protection you want, penalties for breech, and then we find an underwriter), allow physicians to own and operate more hospitals, ban the use of international cost comparisons, and charge patients, up front, price differentials based on healthy living habits. Good luck with any of those.

Why can't prices be posted online? Largely because we play games. Our list prices are typically obscene because we negotiate with bulk customers (i.e. insurance) to get different rates. We typically increase the prices to some utterly meaningless level so the insurance company can haggle down to something reasonable. We try to hide information from the insurers which means hiding it from the public who barely care anyway.

The other game is that we try not to have sticker shock for the patient. What you cost the system is highly dynamic. If you have complications, or frankly even just behave like an ass, your hospital bill can double. We don't want people getting sticker shock when their bill doubles (sorry, the anesthetic made you express suicidal tendencies and you needed a sitter and an extra night in the hospital) nor to avoid care due to cost concerns.

On the flip side, even for identical patients the costs on our end are exceedingly variable. You come see me with a nice simple GSW. There is a book price for the OR. But if you come it to see me at ohdarkthirty after 12 car pile up on the freeway, chances are I am going to have to call in additional surgeons and techs. This will deplete their hours and for the techs generate some very expensive overtime charges. Or your emergent surgery might bump a merely "urgent" surgery, they develop complications (that's why its "urgent") and now a different patient has an extended ICU stay. And of course we live in this queer little corner of capitalism where we by supplies on markets, but suppliers need government clearance so we inevitably are short weird things (like national shortages of sterile saltwater).

You can run a fixed price hospital, but insurance companies have historically hated them and somebody is carrying a lot of risk. This typically means that the risk holder ends up raking in massive profits, which runs into another major problem with healthcare: people hate large profits in healthcare. For some reason nobody gives a rat's ass if a football player makes unimaginable profits, but if you do that in healthcare the automatic assumption is that you are preying upon the weak. It is no surprise that the few locations that post all their numbers tend to be in ruby red areas politically.

I suspect that even if we all did post our real costs and our real charges, not much would change. At the end of the day we still have TriCare, a health system on par with Austria for size with a line item in the federal budget and no need to play a lot of games that the rest of the American healthcare system has to manage. TriCare is not terribly different in cost than anywhere else. Kaiser, Mayo, and Cleveland Clinic are again all huge players who at best move the needle a few percent. My best guess is that even if you removed all the arcane gunk from the system it would not change much.

So we should follow Lyman Stones advice and remove all marriage penalties from the tax code/welfare state in order to save money on healthcare?

Maybe. We might have people live enough extra time that the savings get consumed by their increased longevity. Depending on how strong some of the feedbacks are you lower the price per QALY from healthcare by a lot, but then have a lot more QALYs to buy. Depending on the effect sizes we could see healthcare get cheaper, or we could see healthcare get more expensive but people live longer.

What I can say for certain is that any reasonably cheap way to move the needle on marriage rates is going to be a phenomenally cheap set of QALYs to buy. If we had to tank some chemotherapy drug, or stop treating some class of drug addict, the cost efficient answer would say do it and get the marriage rate up.

"4. “Chinese police "

Related to 4.

"Hong Kong: First Line of Defence against a Rising Fascist Power"

https://quillette.com/2019/09/28/hong-kong-first-line-of-defence-against-a-rising-fascist-power/

#1: The 22% in the US probably live mostly in Washington, DC. :-)

#5 starts with: Economics is neither a welcoming nor a supportive profession for women. The sentence would still be correct if one left out the two last words.

How does one apply metrics to capture "value", especially in healthcare? By utilizing the moniker of "value", the assumption is that there is a homogenous understanding of ethics and beliefs around both consumer and provider aspects of healthcare, but given the heterogeneity of the US, I don't see how this could be possible.
Value: "we don't want the patient to die, as human life is considered 'valuable'". I guess that could consensus there.

I think that there is a consensus that the government shouldn’t be paying providers to give their patients life threatening infections, when there are many providers who never give those infections to patients (central line infections being the most prominent example).

That's really just a correlative exaggeration. BTW, C Diff is the worst infection, probably most prevalent in hospital settings.

4. Did they punish him by putting the cave dweller in solitary confinement?

#1 It is interesting that Anger stats correlate with average national IQ, on average the higher the IQ the lower the %Angry. If true then none of the citizen will be angry if the average national IQ ≥ 132 :)

PctAngryYesterday = -0.54*IQdb +71.1; #n=20; Rsq=0.309; p=0.01093 * (Sig)

Smart people are all affectless Buddhas and never get POed. Who knew?

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