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Brad F
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Paul In an analysis like you are suggesting, aside from the discount rate and its value, how do you differentiate the well-being a food item, say rice, and a computing device, provide for a rich and poor individual 30 years hence? Essentially, do you really know which has a greater decreasing marginal utility at a particular time for a given class? I would think not for many goods. Brad
I would add that while NYS, my home, has a "unique" Medicaid program, as compared to Georgia, the problems upstate residents face here are more similar to rural Georgia than that of NYC folk. Similarly, the same can be said of Atlanta residents and say, Valdosta. With a majority of US citizens in urban locales, the trade offs are not so clear. The laboratory of democracy calls, and the "let the 50 flowers bloom" slogans certainly have merits. However, scale and efficiency seemed to get lost in the mix when couched in in the warm and fuzzy tones of federalism. I dont want to gloss over the advantages of that approach, but it sometimes seem those (not all) that propose it, dont weigh the trade offs and possibility that on the net net, an "all in" approach may have more heft. However, no one model is a home run. We do have to make a choice though.
As I read above, and listened to something from Health Affairs moments before, the ironic juxtaposition popped out. Its a lovely piece, and you will see what I mean: Its the 7/6 posting. Something to be learned. Brad
Bill I have read this line a number of times, even prior to your post (when Cowen put it online I was initially stymied as well), and for the life of me, cant understand what he means: "Trying to equalize health care consumption hurts the poor, since most feasible policies to do this take away cash from the poor, either directly or through the operation of tax incidence." What does he mean? On your #3 and #4: Suppose you have voting precinct in a town where 90% of the inhabitants live--20% are poor, the rest are middle class plus. Turnout is 80%. 10% of the population, all poor, live in the sticks, and they are unable to vote due to transportation limitations. Suggestion is made to move the polling center towards the 10% of lesser means. As a result, turn out will tank, and in the end, representation of entire town plummets. In this case, trying to fix the problem for the few does more "harm." Is this an analogous screw up to which Cowen refers, mainly, fighting inegalitarian principles, perhaps, harms more than helps? I am not saying I agree or its apples to apples (after all the point is to solve and not just assume permanent dysfxn, like you the sentence you close with), but maybe this is what he is alluding to in his statement? Brad
When I use the term fixed costs, I am referring to the gaps we are usually accustomed to in analyses, ie, have all the fixed costs been taken into account. FOr example, in a preventative intervention, have all the costs to local DOH, etc., been accounted for. Usually not. I assumed that is what you meant by comparing the two examples above--and the implication was that P was more efficient due to scale or other factors. I misunderstood. I get your above point though, and where I/we departed was my inference that T is embedded in the system (you are not--and change is possible), which unfortunately is my linear view of the clinical world (I live there, my bias). Perhaps the authors are seeing it the same way. Their position is, "this stuff is already here and in use, and accepting that, lets look at ICERs."
Paul Point taken, but its not about P vs T, but the broader analysis you are calling for. The fixed costs needed to implement a P program may supersede that of a T--to the point of making it prohibitive. Your post is cautionary and needed, but the issues you raise may not have been lost on the author's. They were contrasting cost-effectiveness only. My point was a QALY is a QALY, and as a metric, has a flattening effect for comparative purposes. The infrastructure required to make them happen is another ball of wax. Brad
Bill I am not following here. If Tx is already embedded in system (the key), and Tx* comes online, yes, it touches fewer lives, but the QALY we are buying off the base is identically priced as the step up in the Px to Px* example. The only difference is the larger investment and the more folks intervened upon in the preventative strategy. Bottom line, that incremental QALY is still costing 10K per person. If you only had a 100K to spend, no matter where you apply it--T vs P, you add 10 QALYs. Brad
Paul Even on vacation, come back for a comment. Check out Mayor Mike (my next door neighbor). Air bags, cigarettes, donuts... You will see what i mean Brad
Bill I get it. However, your assumption in the last paragraph is doctors have the capacity to do the job. They dont: Don Taylor also tweeted this excellent account of docs interpreting the PSA. Outstanding. Brad
Ditto here Bill, always like to check in and see what you are discussing. You have carved out a unique niche, a boutique shop so to speak. I would also add that not only does blogging and commenting get the attention of other like minded folks, it leads to meaningful activities. I am currently putting together a project with not one, but potentially two organizations, and it stems from virtual communication and shared interests. Without these types of channels, it would not have occurred. Brad
Let me sum up your post: "Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime." Yes?
Paul I think the more intriguing discussion relates to whether, in a society where a Paul Starr type option exists (sans mandate), and a "rugged individualist" chooses to go bareback, what then? Harold approaches the tragic case above in ACA default mode (with the mandate, "this would not happen"). Of course, he might be referring to the plight of individuals ONCE they are in a 2014+ Medicaid program--with or without pre-existing coverage. Regardless, I think this is a sensible test case for folks with more conservative or libertarian leanings. Essentially, in the coverage environment you envision--the world of opt out--what do we do with this patient? If the answer is not let them die, its time to rethink plan. Brad
Toggle Commented Apr 5, 2012 on The Rabbit Hole at Something Not Unlike Research
Can we then deduce that when the "if" occurs, Alito would revisit his position? Or, in other words, his beliefs are not rooted Constitutionally, but with the shifting sands of what congress legislates? Also, on Starr, both in print and in interviews, I have never heard him justify how catastrophic care will reconcile into his scheme. For those who opt out and prefer to nickel and dime their minor ailments, no harm, no foul. But ultimately, who pays for the big, unanticipated events--the events that comprise 90+% of what the lock out is attempting to prevent in the first place. It dont add up, and I question the tool as a deterrent if above is what we are looking to prevent. Brad (this is something of mine, very short, that embodies the same): Brad
Paul You made a point I have been waiting to see for some time, mainly, most of the "unfunded" liability of care is not new money entering the system. Its money the government will collect and redistribute. My guess is, the new younger entrants into the market who previously were detached from the insurance marketplace will augment the pot of dollars by a few billion only. Not much juice for the squeeze. Where I do see this effort paying off is setting the foundation for the day ESI and tax advantaged status of premiums goes down. Then, the potential for market collapse is great, and the nature of the discussion changes. In your closing, I guess I would ask, if we envision a system where job lock is eliminated, and individuals are free to move from job to job, state to state, and over a lifetime, AND they keep their plan with whatever health burdens that befall them, what then is an "expected" cost of a plan (what is a risk ban, and how do you stratify risk?). In another words, is an insurance product an all in proposition--understanding some stop-loss is necessary for outliers--and Alito's view is a misperception of optimal risk pooling for society over a lifetime. After all, virtually 100% of us will use HC before we die; if we agree we need insurance, than it is a decades long endeavor. Brad
I think you missed the biggest factor of all. Attribution. If you are speaking of providers, see Table 1 Just look at a chronically ill beneficiary. Who is responsible in the sea of providers? If you are envisioning a future where patients subscribe to integrated systems--a long ways off for nationwide uptake, the system owns the outcomes. Easier to oversee.. However, if mortality, SMRs for inpatients are woefully inadequate, and as outpatients, who knows. Thats tough, probably too high a hurdle to use as meaningful outcome. I am not saying impossible, just real, real hard. Lots of risk adjustment, lots of measurement tools we dont yet have, and registries and databases that are far from complete. Brad
Bill This was a huge issue, and got (and still gets) worldwide attention. Because it is occurring in a minority group (Muslims--and that needs no elaboration) in an ex-colonial power (France), its highly charged. Brad
Really well said Bill, and the best statement on this dust up I have read thus far, and I have read a bunch. If I have come to two conclusions on this matter: 1) There is no right answer. Freedom to exercise your religious beliefs (Douhat, Dionne) vs. public policy (Drum) make for interesting reading, but each side's justification will attract the like minded. For those in the middle, like me, its a coin toss. Call me spineless. 2) In the end, federal dollars come from the same pot, and its all sleight of hand. The church should get what they want in accordance with their beliefs, with some kind of financial pass through or workaround as has been suggested, so those seeking contraception can obtain the same. I do want you to clarify something however--and challenge you a bit. The meaning of "identity," and the controversy in France and burqa veils lets say--literally brings the same type of quagmire into the public square. Would the same editorialist (and you?) take the same position? My point is, "identity" is in the eye of the beholder. Another worm hole... Brad
Paul I enjoyed the post, and wish I had the time to respond more in depth. This is a daunting site (look at the roll): No doubt, you are all too familiar with the difficulties in cost analyses and base assumptions--garbage in, garbage out,etc. Mix that world, with the one in the link. Big headache. I cant disagree with what you have said, but I dont know how to actualize it and make it practical at the bedside, in real time--even with HIT. I recently saw an article, and I should have bookmarked, examining the number of decisions a physician makes in a day. It was enormous, and naturally, as biased as I am, I believe it. We are a long way off from practicing in this vein. Good to discuss, but your vision is more 2020+. Evolution and data quality is too far off. My opinion. Early wins will be VBP and Mcare no pay. Brad
If John Deere opened an outpost in Chile or Russia lets say: Do they: 1) pay higher labor costs to hire from a smaller work pool of non-smokers (? reduces profits--and you can always fire the sick smoker and hire another healthier one) 2) internalize a cessation program and hire all-comers at lower labor costs (wider pool of applicants) 3) Hire all comers and demand the govt pay for cessation programs How does an American profit maximizing entity behave? On another front, do you feel smoking is a protected lifestyle choice? Brad
Truth be told, I set myself up for your absolutely correct response. I was actually thinking of this when I wrote my post: This is emblematic of "status quo" unfortunately, and my intent, while harming a few, was to send a greater economic message. Living just south of Harlem, believe me, the Newport ads and permissiveness of this habit are front and center. I want the gentler interventions, believe me, but the political will is absent. Even in my own state, time and time again, the deciders fall short. My response was visceral and rational. Maybe not the best combo. Brad
Paul While I cant say I am completely comfortable with the policy, I can live with it. The same way we tax tobacco--its regressive as folks of lesser means take up the habit in greater numbers. One justification is its impact as a negative deterrent for future smokers. By the same means, if more companies adopt this policy, might it have a similar effect? Putting it bluntly, shorter term pain for some, longer term gain for many others? The landscape will be such that smoking acts as an obstacle for job ascertainment. Granted, this might impact a sliver of indivduals negatively, but the alternative is the status quo. Will a policy like this, if widely adopted, allow greater number of folks to take the fight back to big tobacco at a lesser cost, with less effort? The states have stalled it appears, although some pockets of success (NYC) break through with herculean efforts. On that latter count, difficult to scale. I understand that companies are not attempting to wage a war with the tobacco companies--they are looking out for #1--but it certainly is a "positive" externality.. Brad
Bill, Three points: 1) Given most clinical instruments are developed by academics or folks working for institutions accepting govt dollars, the involvement of public funding is virtually assured. The finer points of how one deduces salary underwriting is beyond me, but one wonders whether 5, 10, or 30% of public dollar contribution changes "ownership," or not. 2) Inertia plays a role re: your example of CBCL above. Interestingly, clinicians are inculcated with the use of UptoDate and ePocrates. Most folks are familiar with the tools or at least the brands. Even when institutions offer free alternatives, some better, migration is slow. Its the first one out of the gate theory. Once your hooked... My guess is the issue, while important in the piece, will resemble illegal MP3 downloading. Clinicians speak the language of MMSE, so for the greater good, we justify poaching. I am not saying its right, but there is always an altruistic tinge if activity involves patient care--thus, we "steal" with a clean conscience. It will continue, to the detriment of the creators--better or worse. Great pick up and thanks for posting this. I am making a mental note. Brad
Bill P4P may not be used, but measurements exist, yes? I see the studies utilizing x-border outcomes in most mainstream journal (hips, PNA, MI care, etc). If thats the case: 1) Are Canadian providers driven by slightly different motivations than US docs, ie, cartoon does not apply up north? 2) Canadian providers, if surveyed--and perhaps they have been, would express low morale as it relates to pay and rewards, compared to their bling ridden neighbors below? What do you think? Brad
He is of the free market vintage, and most of his WSJ pieces are critical of FDA and other regulatory oversight. He would opt to "leave it to the markets." Perhaps it is overly critical to state he would vaporize the USPTF, but its safe to assume the agency he envisions, as opposed to the one we do, are vastly different. The word "defang" comes to mind. :) Brad
Bill Additional comments. First, on payers having to provide coverage for A and B grade evidence; second, an unforeseen positive exeternality for MCOs: If the USPTF did not exist--which is what Scott advocates (a world without this body), "A or B evidence" would be strong enough to stand on its own via forces of academic community and professional societies--MCO's would cover anyway. Can you imaging an insurer not paying for treatment validated in a high quality RCT? He has been critical of handling of Avastin payment coverage. Surely, if it extended lives, who would scream the loudest if insurer "x" refused to pay? That would not happen in a USPTF world. Additionally, he does not discuss those services that get a C or D. Thats cloud cover for payer denial, and a benefit to the commercial world (read quarterly earnings). They can blame uncle sam for "us not paying." Convenient of him to leave those factoids out. Brad