Category: Medicine

Charles W. Tidd, Jr., Newtown, Conn.: Your column today
continues to avoid a central issue: a great number of Americans do not
trust the government with their health care. This mistrust is not the
result of television ads by insurance companies but follows from
increasingly frequent routine encounters with the government: waiting
for a passport, figuring out the tax law, having an intelligent
conversation with someone at the DMV, listening to the news – Hurricane
Katrina, the federal prosecutors, the pardons by both Clinton and Bush,
immigration. The list goes on and on.

Why in the world do you want to trust the nation’s health care to the government?  He who pays the piper calls the tune.

I write you because there is no question that our health system
needs to be fixed, but until the issue of public mistrust of government
is addressed, any sort of universal health care will be shunned by many
people.

Paul Krugman:: Do people really distrust the government? I
think we have this program called Medicare, which most people seem to
like. On the other hand, maybe people don’t know that it’s the
government: former Sen. John Breaux was famously accosted by a
constituent demanding that he not let the government get its hands on
Medicare.

Here is the link. 

People like Medicare because it pays some of the bill, while keeping interference in the medical process to an apparent minimum; admittedly non-interference is in part illusory because the indirect effects of Medicare (e.g., it drives up prices) have become enormous.  Almost all government payments of this kind are popular, whether or not the programs are a good use of scarce resources.  People are looking to get something from their costly government, and not necessarily because they trust it.

As Medicare expenditures rise, this illusion of non-interference will become much harder to maintain and indeed Medicare itself may become less popular.  I am always curious to hear — from single-payer proponents — which interest groups they think will have a decisive say over the system, and how those interest groups differ in America vs. Western Europe.  That is one reason why we cannot simply replicate the VA approach writ large, or for that matter the French system.  For a sobering wake-up call, compare the flood defense policies of the Netherlands to, say, Louisiana.

If a woman is a lawyer, or the wife of a lawyer, does she get better treatment?  Lawyers seem to be regarded by doctors as especially litigious patients who should be treated with caution when it comes to risky procedures such as surgery.  The rate of hysterectomy in the general population in Switzerland was 16 percent, whereas among lawyers’ wives it was only 8 percent — among female doctors it was 10 percent.  In general, the less well educated a woman is and the better private insurance she has, the more likely it is that she’ll get a hysterectomy.  Similarly, children in the general population had significantly more tonsillectomies than the children of physicians and lawyers.  Lawyers and their children apparently get better treatment, but here, better means less.

That is from Gerd Gigerenzer’s Gut Feelings: the Intelligence of the Unconscious.  It is a good microeconomics question to ponder the conditions under which a) this is efficient, and b) you would rather be the poorer patient or the non-lawyer than the lawyer. 

…the fraction of Kenyans who are satisfied with their personal health is
the same as the fraction of Britons and higher than the fraction of
Americans.  The US ranks 81st out of 115 countries in the fraction of
people who have confidence in their healthcare system, and has a lower
score than countries such as India, Iran, Malawi, or Sierra Leone.
While the strong relationship between life-satisfaction and income
gives some credence to the measures, the lack of such correlations for
health shows that happiness (or self-reported health) measures cannot
be regarded as useful summary indicators of human welfare in
international comparisons.

That is Angus Deaton, here is more, and here.

Public computer surfaces are reservoirs for methicillin-resistant staphylococci.

The role of computer keyboards used by students of a metropolitan
university as reservoirs of antibiotic-resistant staphylococci was
determined. Putative methicillin (oxacillin)-resistant staphylococci
isolates were identified from keyboard swabs following a combination of
biochemical and genetic analyses. Of 24 keyboards surveyed, 17 were
contaminated with staphylococci that grew in the presence of oxacillin
(2 mg l^-1). Methicillin (oxacillin)-resistant Staphylococcus aureus (MRSA), –S. epidermidis (MRSE) and –S. hominis
(MRSH) were present on two, five and two keyboards, respectively, while
all three staphylococci co-contaminated one keyboard. Furthermore,
these were found to be part of a greater community of
oxacillin-resistant bacteria. Combined with the broad user base common
to public computers, the presence of antibiotic-resistant staphylococci
on keyboard surfaces might impact the transmission and prevalence of
pathogens throughout the community.

Thanks to Monique van Hoek for the pointer.

January entodontist: "You’ll need surgery either right now, or within a few months.  We cut open the gum, clean out the inflammation, and sew your mouth right back up.  Only sometimes do we have to eliminate the tooth."

July 5 entodontic surgeon, 10:31 a.m.: "We can cancel this morning’s surgery, it seems OK for now, just keep an eye on it."

Hail Seth Roberts, hail flaxseed oil!

Dr. Yang didn’t even know that he is a character in a forthcoming book about how to motivate your dentist…

Why not open up a Medical Free Trade Zone in, say, Detroit?  Health care
workers in the zone would not be required to get US visas or licenses,
and any malpractice claims would be resolved in the courts of the
worker’s home country.

That is from the comments.  Of course in principle we could combine this with a single-payer system or other reforms.  That’ll cure those rationing blues and those long waits for hip replacement surgery.  Or you might favor a single-payer system but be willing to do this in the meantime, for the many millions of uninsured, at least some of whom are waiting in agony.  How about it, people?

But let’s make it geographically central, I say Memphis not Detroit.  Or would you feel better if it were a floating pavilion in the Caribbean?  A floating pavilion in the Indian Ocean?  Bangalore?

I have Bangalore at 8510 miles from Falls Church, VA.  Do I hear medical free trade at 8509 miles?  8508?  Can we get the mileage down into triple digits…?

Addendum: Ezra Klein flirts with libertarian anarchism, sort of…

Ezra Klein poses the question:

I’ve never read a compelling explanation of why the nation’s doctors and hospitals haven’t broadly adopted electronic medical records.  It’s not as if they’re allergic to technology.  At this point, cardiovascular care employs every strategy but astral projection to keep our in rhythm.  It’s not as if it wouldn’t be cheaper and easier for them.  The man hours and costs from keeping track of files, printing out labels, finding lost manila folders, and getting sued because the nurse misread the doctor’s handwriting are enormous.  Theoretically, insurers should be pushing on this, but they seem behind the curve, too.  And it’s not as if there aren’t tested programs in use — not only does Europe do electronic records well, but the VA does them beautifully, and they’ve released their primary program, ViSTA, as open source, for free use by anybody.

I can think of four reasons. 

1. Most of the benefits are reaped by the patient, and in the long run.  Today’s suppliers don’t realize these benefits in the form of profits.

2. The United States has relatively weak data protection laws.  Many people don’t want outsiders to know their medical history, and information compilers fear lawsuits if the information leaks out or is hacked.

3. No single provider has an incentive to move first in this game.  Why computerize if no one else has?

4. I haven’t computerized my office (is Alex laughing?), I worry more about surviving until the next day.

The comments over at Ezra’s are excellent.  And if you think that electronic records are the source of vast productivity gains, just have Medicare mandate such a change.  Readers?

Addendum: Here is Arnold Kling.

Overall, I’d like to see no insurance or government programs for most
routine care.  I think a retail medical system would end up looking like
eye care does now, with lots of variety and innovation.  It would also
be more convenient and cheaper.  This type of primary care would
probably be just as effective as what we have now.  If people with
borderline medical conditions visited the doctor more often (because it
was cheap and convenient), care might even be more effective than it is
now.

Here is much more.  The author has spent most of his life in a wheelchair, and he has a great deal of personal experience with the U.S. health care system.

Your body is scanned and monitored by implanted bots; the fight against terrorism made that necessary anyway.  All insurance based on the idea of expense reimbursement is banned.  But if you get sick, they send you some money.  Plain ol’ cash, to spend as you please.  (Off-line we can debate whether this is the government, the private sector, or some mix.) 

This would address cost escalation, boost equity, and eliminate the risk of being bounced by an insurance company, the three core problems cited by Brad DeLong.

The monitors also help us pay wealth-maximizing bonuses for those who get their prostates checked every month.

Larry Kotlikoff has proposed some version of this, minus the scanners and the check-up bonuses.

Keep in mind that standard single-payer plans give the poor, by the standard of their own preferences, far too much health care.  Let’s say a pauper received the same standard of care as a rich man; he would rather have the value in cash instead.  I suspect many of these people would rather have 50 cents in cash than $1 in health care, so right there many of these plans are losing half of their value per dollar spent.

It is described as utopian, read it here, excerpt:

20% Deductible/Out of Pocket Cap: The IRS snarfs
20% of your family economic income and uses it to pay your family
health bills. If your expenses in a year are less than 15% of your
family economic income, the balance is returned to you with your tax
refund check (or stuffed into your IRA).

Single-Payer for the Rest: All family health bills
greater than 20% of your family economic income are paid by the federal
government out of the 5% not returned (and perhaps, someday general
revenues). The main point, after all, is insurance: if you fall
seriously sick, you want right then and there to be treated whether or
not your wallet biopsy is positive.

Sin Taxes: on Tobacco, Gorgonzola, Three-Liter Bottles of
Liquid High-Fructose Corn Syrup, Tanning Clinics (Melanoma), et cetera:
Sin taxes (and, perhaps, someday general revenues) pay for an army of
barefoot doctors and nurses and mobile treatment vans roaming the
country and knocking on doors: Let me examine your prostate. Mind if I
check your refrigerator and tell you how to eat healthier? Have you
exercised today? I’m a Pilates instructor, and we could do a session
now? Are you up on your immunizations? Anybody here have a fever and
need antibiotics? Come on out to the van and I’ll clean your teeth."
The idea is to make the preventive care cheaper-than-free, to insure
that nothing with a high long-run benefit/cost ratio gets left undone
because people would rather get a bigger check the next April to use to
buy an HDTV.

A Lot of Serious Research on Best Public-Health, Chronic-Disease, and Hospital Practices

That’s it. No deduction for employer-paid health expenses. No insurance companies.

There is plenty of further rationale given, do read the whole post.  But I have to say, those rubber gloves have me worried… 

Let’s start with a bang: don’t keep a schedule.

He’s crazy, you say!

I’m totally serious. If you pull it off — and in many structured jobs, you simply can’t — this simple tip alone can make a huge difference in productivity.

By not keeping a schedule, I mean: refuse to commit to meetings, appointments, or activities at any set time in any future day.

As a result, you can always work on whatever is most important or most interesting, at any time.

Want to spend all day writing a research report? Do it!

Want to spend all day coding? Do it!

Want to spend all day at the cafe down the street reading a book on personal productivity? Do it!

When someone emails or calls to say, "Let’s meet on Tuesday at 3", the appropriate response is: "I’m not keeping a schedule for 2007, so I can’t commit to that, but give me a call on Tuesday at 2:45 and if I’m available, I’ll meet with you."

Or, if it’s important, say, "You know what, let’s meet right now."

Clearly this only works if you can get away with it. If you have a structured job, a structured job environment, or you’re a CEO, it will be hard to pull off.

But if you can do it, it’s really liberating, and will lead to far higher productivity than almost any other tactic you can try.

Here is more, all valuable, the pointer is from Michael Blowhard.  Here is Marc’s new blog.

Every night I take two tablespoons, inspired by Seth Roberts, who is up to four and within my sights.  This is not good for my weight but it is very good for my heart, my brain, and my gums.  For most people the value of the dose should be strongly positive.  The Omega-3 ingredient has a scientific consensus in its favor, with no evidence for negative side effects.  Here are Seth’s posts on the topic.

By the way, Seth’s The Shangri-La Diet is now out in paperback.