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Monday, October 31, 2016

Do U.S. Physicians make too much money?

"[D]octors in the United States earn an average of more than $250,000 a year, more than twice as much as their counterparts in other wealthy countries."
Really? From "Inequality As Policy: Selective Trade Protectionism Favors Higher Earners" by economist Dean Baker.

My comment below the article:
Notwithstanding your larger point, the average U.S. primary care physician makes more like $170k annually. Glomming up the data by including all of the specialities to arrive at "more than $250,000" is either naive or disingenuous.
Source: Glassdoor. Current as of September 2016.
The full paragraph context from the Dean Baker article:
For the most part, it is impossible for foreign-trained physicians to practice in the United States unless they have completed a residency program in the United States. The number of residency slots, in turn, is strictly limited, as is the number of slots open for foreign medical students. While this is a quite blatantly protectionist restriction, it has persisted largely unquestioned through a long process of trade liberalization that has radically reduced or eliminated most of the barriers on trade in goods. The result is that doctors in the United States earn an average of more than $250,000 a year, more than twice as much as their counterparts in other wealthy countries. This costs the country roughly $100 billion a year in higher medical bills compared to a situation in which U.S. doctors received the same pay as doctors elsewhere. Economists, including trade economists, have largely chosen to ignore the barriers that sustain high professional pay at enormous economic cost.
Baker on Rx:
...In the case of prescription drugs alone, the United States is on path to spend more than $430 billion in 2016 for drugs that would likely cost one-tenth of this amount in the absence of patent and related protections. While we do need mechanisms for financing innovation and creative work, it is almost certainly the case that patent and copyright monopolies as currently structured are not the most efficient route, even if their negative consequences for distribution are quite evident.
OK, we all know that the Pharma lobby continues to effectively protect their members' lavish margins.

More on health care space compensation.

Whether my Primary doc makes $170k annually -- or $250k -- is of nil concern to me in the face of numbers like those. While a salary of $170k is nearly 4 times the median U.S. individual income (~$44.6k), it pales in comparison to many others in the health care space -- not to mention the compensation of celebrity entertainers and athletes.

to wit:
Of the 1,877 CEOs at 2,681 hospitals studied, the average compensation was approximately $600,000 per year, though this varied widely. CEOs of small rural hospitals earned salaries and bonuses of just $118,000 a year, while those at the largest urban teaching hospitals earned on average nearly $1.7 million per year. And some CEOs earn considerably more than that. For example, in a recent year, the CEOs of Northwestern Hospital in Chicago and the University of Pittsburgh Medical Center each earned in excess of $5 million in salary and bonus. - "Why Are Hospital CEOs Paid So Well?"
Let's say you're an industrious PCP. After 4 years of college, 3 years of med school, and 3 years of residency (and a mountain of accrued school loans), you hang out your shingle. Let's say you see 30 pts a day for a total of 48 weeks a year (with 4 weeks given to holidays and other requisite time out of office), and you somehow manage an (unlikely) average reimbursement of $100 per pt encounter.

Your gross revenue, then, would be $720,000 a year.

Deduct rent, utilities, equipment, supplies, marketing, receptionist and MA salaries, insurance (including MedMal), billing service, EMR expenses, etc etc etc...

You'd be damn lucky to pay yourself $170k a year (gross before taxes).

Below, from the 2016 Medicare RVU reimbursement schedule. 

I'm a 99213, a "moderately complex established patient."


Maybe I'm a 99214 by now (all of $79.18), in the wake of my 2015 prostate cancer dx and tx. Irrespective, no wonder my Muir doc has to whip through our semiannual f/up visits.

More on the cost of U.S. health care. Just in via my daily email alerts:
An Open Letter Healthcare.Gov: I Can’t Afford To Be Sick

The other day, I got several letters in the mail. One was from the healthcare marketplace, reminding me that enrollment for 2017 coverage begins on November 1st. The rest were medical bills, some of which are about to go to collections, that I can’t pay for. This isn’t new to me. When I first got sick back in 2010, I wasn’t insured at all. I have so much outstanding medical debt that subsequently went to collections that I’ll probably never be able to get loans for school, a house, a car, or anything else. My credit is under 600, and I don’t think it’s ever actually been over 600. I didn’t even have enough time to build credit — I was only 19 years old when I got sick.

This is the reality of the United States healthcare system, and I’m certainly not the only person you know who is struggling with it. Although I pay a paltry $83 premium each month for my marketplace-purchased insurance, many pay far more that that, even with tax credits and subsidies.

I’m actually thankful to have the option of buying insurance through the marketplace at all. It’s the only reason I was able to become self-employed. Prior to being able to partake in it, I was struggling to hang on in the traditional workforce because I needed insurance coverage. I worked purely to get healthcare, and that’s what many people do. But the problems with the U.S. healthcare system and insurance coverage exist regardless of whether you buy it yourself or get it through an employer.

When I worked full time with benefits at a hospital, I was in debt to that hospital because I had had some imaging studies done in the emergency room. It turns out that the radiology department was actually contracted out to a third-party, so it wasn’t even covered by the insurance that hospital employees had. An in-hospital service was out-of-network...
Yeah. Goes to my prior post, no?

Also relevant, with respect to Medicare specifically, from a link I provided a couple of posts back:
Although it’s clear that Medicare will need an infusion of new revenue in the coming years, beneficiaries should not be the piggy bank that saves the program. If LBJ’s vision is to be maintained for the community now and in the future, the community as a whole—taxpayers—must protect it. So far the acceptable solution is to make beneficiaries bear the escalating cost of medical care and thereby shift the burden away from government. But this is the swiftest route toward shredding the social compact that Johnson enunciated back in 1965. The burden of cost containment must fall on providers and others in the health-care industry, not on beneficiaries, who are least able to handle the increasing costs... - Trudy Lieberman in Harpers's, “Don’t Touch My Medicare!” Is the beloved program on its last legs?
"The burden of cost containment must fall on providers..."?
Uh, including those greedy, wealthy $170k/yr PCPs?


Just in. From the always fine EHR Science:
Fixing EHR Usability Requires More Than Doubling-Down on Usability Testing and UCD

The rise of scribes is but one sign that many EHR systems, as currently designed, make clinicians less productive and patient interactions more awkward. The main ways touted by ONC and most observers to address usability issues focus on user-centered design and more comprehensive usability testing. However, can these methods alone actually address clinician complaints? I think not, and the reason is the complexity of the tasks that EHR systems must support.

Unlike simpler information systems such as e-commerce sites, music streaming services, or applications such as word processors, EHR systems are intended to handle a wide-range of data types and support users performing varying sequences of complex tasks. As advanced by ONC and others, EHR systems, in addition to recording and presenting clinical data (i.e., basic paper chart functions), must also assist with clinical decision-making and quality improvement. The bottom-line: It is far easier to create objective usability measures for an e-commerce site than to create similar metrics for a system that can be used by doctors, nurses, dieticians, and respiratory therapists with equal aplomb. Every clinical professional has specific information needs and unique workflows, and complex tasks require sophisticated software systems...
I check Dr. Carter's site every day.


In my email inbox. Education is indeed important...

Spelling class apparently not included.


More to come...

Tuesday, October 25, 2016

Election Day 2016 can't come soon enough

Cheryl and I already voted, by mail-in ballots (and it wasn't for you-know-who). I am so ready for this campaign to be over.

The news getting major play this week.
Obamacare premiums are going up 25 percent. So what happens next?

OBAMACARE PREMIUMS ARE GOING UP 25 PERCENT. SO WHAT HAPPENS NEXT? — HHS on Monday confirmed that benchmark premiums on will dramatically jump next year, re-injecting Obamacare into the political debate just two weeks before the election.
It's the latest bad headline for Obamacare in a series this fall, with major insurers dropping out of the exchanges and Democrats acknowledging the law needs fixes. But the 25 percent rate hike is especially eye-catching: Average prices for the second cheapest silver-level plan — used as the benchmark to determine premium subsidy levels — had increased by just 7.5 percent on average in 2016 and 2 percent in 2015, Pro's Rachana Pradhan reports....
From the HHS release:

Interesting piddly side note. I just got a Humana notice apprising me that my 2017 Medi-Gap high-deductible Plan F Supplemental premium is going up 13.25% relative to the current cost. I'll be paying them $727.08 for the year, -- as a true insurance hedge against something really big, bad, and expensive happening.
Below: the Donald Trump Campaign official health care reform proposal, verbatim as of today:
Healthcare Reform
Since March of 2010, the American people have had to suffer under the incredible economic burden of the Affordable Care Act—Obamacare. This legislation, passed by totally partisan votes in the House and Senate and signed into law by the most divisive and partisan President in American history, has tragically but predictably resulted in runaway costs, websites that don’t work, greater rationing of care, higher premiums, less competition and fewer choices. 

Since March of 2010, the American people have had to suffer under the incredible economic burden of the Affordable Care Act—Obamacare. This legislation, passed by totally partisan votes in the House and Senate and signed into law by the most divisive and partisan President in American history, has tragically but predictably resulted in runaway costs, websites that don’t work, greater rationing of care, higher premiums, less competition and fewer choices. Obamacare has raised the economic uncertainty of every single person residing in this country. As it appears Obamacare is certain to collapse of its own weight, the damage done by the Democrats and President Obama, and abetted by the Supreme Court, will be difficult to repair unless the next President and a Republican congress lead the effort to bring much-needed free market reforms to the healthcare industry. 

But none of these positive reforms can be accomplished without Obamacare repeal. On day one of the Trump Administration, we will ask Congress to immediately deliver a full repeal of Obamacare. 

However, it is not enough to simply repeal this terrible legislation. We will work with Congress to make sure we have a series of reforms ready for implementation that follow free market principles and that will restore economic freedom and certainty to everyone in this country. By following free market principles and working together to create sound public policy that will broaden healthcare access, make healthcare more affordable and improve the quality of the care available to all Americans.
Any reform effort must begin with Congress. Since Obamacare became law, conservative Republicans have been offering reforms that can be delivered individually or as part of more comprehensive reform efforts. In the remaining sections of this policy paper, several reforms will be offered that should be considered by Congress so that on the first day of the Trump Administration, we can start the process of restoring faith in government and economic liberty to the people. 
Congress must act. Our elected representatives in the House and Senate must:
  1. Completely repeal Obamacare. Our elected representatives must eliminate the individual mandate. No person should be required to buy insurance unless he or she wants to. 

  2. Modify existing law that inhibits the sale of healthinsurance across state lines. As long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state. By allowing full competition in this market, insurance costs will go down and consumer satisfaction will go up. 

  3. Allow individuals to fully deduct health insurance premium payments from their tax returns under the current tax system. Businesses are allowed to take these deductions so why wouldn’t Congress allow individuals the same exemptions? As we allow the free market to provide insurance coverage opportunities to companies and individuals, we must also make sure that no one slips through the cracks simply because they cannot afford insurance. We must review basic options for Medicaid and work with states to ensure that those who want healthcare coverage can have it. 

  4. Allow individuals to use Health Savings Accounts (HSAs). Contributions into HSAs should be tax-free and should be allowed to accumulate. These accounts would become part of the estate of the individual and could be passed on to heirs without fear of any death penalty. These plans should be particularly attractive to young people who are healthy and can afford high-deductible insurance plans. These funds can be used by any member of a family without penalty. The flexibility and security provided by HSAs will be of great benefit to all who participate.
  1. Require price transparency from all healthcare providers, especially doctors
    and healthcare organizations like clinics and hospitals. Individuals should be able to shop to find the best prices for procedures, exams or any other medical-related procedure. 

  2. Block-grant Medicaid to the states. Nearly every state already offers benefits beyond what is required in the current Medicaid structure. The state governments know their people best and can manage the administration of Medicaid far better without federal overhead. States will have the incentives to seek out and eliminate fraud, waste and abuse to preserve our precious resources. 

  3. Remove barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products. Congress will need the courage to step away from the special interests and do what is right for America. Though the pharmaceutical industry is in the private sector, drug companies provide a public service. Allowing consumers access to imported, safe and dependable drugs from overseas will bring more options to consumers.
The reforms outlined above will lower healthcare costs for all Americans. They are simply a place to start. There are other reforms that might be considered if they serve to lower costs, remove uncertainty and provide financial security for all Americans. And we must also take actions in other policy areas to lower healthcare costs and burdens. Enforcing immigration laws, eliminating fraud and waste and energizing our economy will relieve the economic pressures felt by every American. It is the moral responsibility of a nation’s government to do what is best for the people and what is in the interest of securing the future of the nation. 

Providing healthcare to illegal immigrants costs us some $11 billion annually. If we were to simply enforce the current immigration laws and restrict the unbridled granting of visas to this country, we could relieve healthcare cost pressures on state and local governments.

To reduce the number of individuals needing access to programs like Medicaid and Children’s Health Insurance Program we will need to install programs that grow the economy and bring capital and jobs back to America. The best social program has always been a job – and taking care of our economy will go a long way towards reducing our dependence on public health programs. 

Finally, we need to reform our mental health programs and institutions in this country. Families, without the ability to get the information needed to help those who are ailing, are too often not given the tools to help their loved ones. There are promising reforms being developed in Congress that should receive bi-partisan support. 

To reform healthcare in America, we need a President who has the leadership skills, will and courage to engage the American people and convince Congress to do what is best for the country. These straightforward reforms, along with many others I have proposed throughout my campaign, will ensure that together we will Make America Great Again. 
More detail than that which The Donald proffered on the Dr. Oz show. Oh, and The Donald says be sure to get out and vote.

OK: Recall from my prior post? (scroll to the bottom)
"The finest clinical capability on earth is of nil utility if it's increasingly out of reach financially."
BTW, I posted on the Clinton position back in July, here: "The Clinton campaign health care policy position."

I'll have more to say about this shortly, after helping my daughter finish moving.

Until then, how about a song?


And then there's this music, from the Socialist Hellhole of Scandinavia (Sweden, specifically) that crushes all human initiative and creativity (while providing universal health care with excellent outcomes).

We got to see these astonishing young gentlemen live in a club in San Francisco (Slim's). They were even better live. Hard to believe. Google 'Dirty Loops." Unreal.


From The Incidental Economist:
Why the U.S. Still Trails Many Wealthy Nations in Access to Care
Aaron Carroll, MD 

Many are still unhappy with Obamacare.

The main intent of the Affordable Care Act was to expand the safety net (Medicaid), regulate the non-employer-based private insurance market (the insurance exchanges) and help people buy that insurance (subsidies) in order to reduce the number of Americans who are uninsured.

On those metrics, it appears to be succeeding.

First and foremost, Obamacare was about improving access to health care. While it did improve access to insurance, in many, many other ways the United States is falling short. Things are likely to get worse before they get better.

Even with Obamacare, the United States still ranks poorly among comparable countries in insurance coverage. Even in 2016, when the rate of insured is the best it has ever been in the United States, Americans still have a greater percent of the population uninsured than pretty much any other industrialized nation in the world...
From The New Yorker (may be paywalled):
By John Cassidy

It has long been clear that many of the health-insurance companies offering policies through the public exchanges set up under the Affordable Care Act of 2010 were losing money. Some big operators, including Aetna, Humana, and United Health Care, have withdrawn from a number of the exchanges, and those insurers that remain have been indicating their intention to raise prices sharply for 2017. “The reality is the Affordable Care Act is no longer affordable,” Mark Dayton, the Democratic governor of Minnesota, said earlier this month. So it shouldn’t have come as a surprise when the Obama Administration this week formally acknowledged that prices will go up for plans purchased on the exchanges.

But this is an election season, and Donald Trump and other Republicans used Monday’s news as an opportunity to denounce Obamacare as a hopeless failure. “It is blowing up,” Trump told Fox News. “It is out of control. It can’t be saved.” As usual, the G.O.P. candidate was exaggerating greatly.

In some ways, the Affordable Care Act is working as planned. Figures from the Census Bureau show that between the start of 2014, when the major provisions of the law went into effect, and the end of 2015, the percentage of Americans without insurance fell from 14.2 per cent to 9.1 per cent. That drop of 5.1 percentage points is the largest on record. Among groups that the Affordable Care Act particularly targeted, such as poor families and non-elderly adults, the numbers have been even more dramatic.

Since the Affordable Care Act’s expansion of Medicaid, the government insurance program that serves the poor, more than fifteen million Americans have joined its rolls. If Republicans in nineteen states hadn’t refused to go along with the expansion, this number would be considerably higher. Other elements of the law, such as forcing insurers to cover people with preëxisting conditions and allowing young people to stay on the their parents’ plans until the age of twenty-six, have proved enormously popular.

The issue is the publicly-run exchanges, where people who don’t receive health insurance through their jobs can buy plans on an individual basis...
...For people who don’t qualify for subsidies, the costs of buying insurance through the exchanges can be very high. Take a family of four living in Brooklyn and making a hundred thousand dollars a year. Since their income is more than four times the federal poverty threshold, they wouldn’t qualify for any subsidies. On, a Web site that lists the insurance policies offered on the New York state exchange (and others), the cheapest “silver”—that is, mid-level—2017 family plan I could find for such a family was from EmblemHealth, and it cost $1,432.78 a month, or $17,193.36 for the year. The family deductible was $11,600, as was the out-of-pocket maximum.

Figures like these are disturbing. Until policy-holders have covered their deductibles, they have to pay for the full cost of most of the medical services they receive. “I can’t afford to get sick after paying for the health insurance,” Laura Schlett, a forty-four-year-old woman from Brandon, Mississippi, told the Times’s Robert Pear this week. Many people feel the same way...

See my August post "ObamaCare in trouble? Coverage, cost, access problems..." See also my July 2015 review of "ObamaCare is a great mess."

Again, the finest clinical delivery workforce and systems, and the finest clinical science are problematic if access is out of reach financially.


Ian was a recent Health 2.0 Conference Keynoter, recall?

Making a killing under Obamacare: The ACA gets blamed for rising premiums, while insurance companies are reaping massive profits

...While Americans continue to fork out more money, insurers are doing great.

On Thursday, Aetna reported $734 million in profit on $15.8 billion in revenue for the three months ended Sept. 30. The nation’s third-largest health insurer by revenue handily beat Wall Street estimates for the quarter. Chief Financial Officer Shawn M. Guertin cited “solid performance” in its core health insurance business that offset “pressure” from its business under the Affordable Care Act. “Pressure” here refers to the fact that, while Aetna has reaped an ACA windfall, it can’t make money insuring the sicker and costlier undesirables desperately trying to access affordable care by seeking coverage on the ACA exchanges.

Aetna’s earnings report came a week after UnitedHealth reported a 12 percent jump in revenue to $46.3 billion for the three months ended Sept. 30 compared to the same period the previous year. The company collected $36.1 billion in insurance premiums, 11 percent higher than the year-ago quarter, while profits increased 29 percent to $1.98 billion as the company signed up 955,000 more health insurance customers through its employer and individual plans. (Anthem, Cigna and Humana will report their latest quarterly earnings next week.)

Investors are reaping major rewards as well. In the first nine months of the year, UnitedHealth spent $1.1 billion in share repurchases and $1.7 billion in direct dividend cash payments to shareholders, according to its quarterly filing. Between 2012 and 2015, UnitedHealth spent $12.6 billion in buybacks and dividends. Because most revenue for health insurers comes from insurance premiums, any cash doled out to shareholders essentially behaves as a transfer of wealth from a consumer’s health care budget to an investor’s annual capital gains income...

More to come...

Tuesday, October 18, 2016

"Treat the numbers instead of the patient?"

My daily morning online surfing rounds always include the excellent STATnews, where this caught my eye:
Improving health care with the simple act of listening
Vikas Saini, MD
...In medical school, doctors-in-training are taught that 85 percent of a diagnosis comes from a careful history, and another small portion comes from the physical exam. But these days we are so busy testing that it’s easy to miss the subtle — and sometimes not so subtle — indicators of a patient’s health. It’s certainly quicker to order the test, get some numbers, and then treat the numbers instead of the patient.

The doctor-patient visit is becoming a commodified transaction rather than a collaboration. Clinical life feels more and more like sprinting on a hamster wheel, chasing unproven metrics to get graded on “quality.” It’s no wonder that burnout is exploding among physicians across the country.

The idea that more is better has many Americans going from doctor to doctor to doctor, getting test after test, and becoming increasingly anxious about our health while increasing the cost of health care.

We’ve been told that a big problem with health care is inefficiency and waste. (It is.) We’ve been told that old fashioned doctoring results in huge variations of care. (It does.) We’ve been told that constant electronic nudging will make doctors better. (Maybe.) Doctors are being told they must make their productivity numbers to keep their jobs and prove they are efficient. (Sad but true.)

Pioneering cardiologist and Nobel Peace Prize winner Dr. Bernard Lown has said that the usual rules of efficiency are inverted in medicine. The more time a physician spends with patients, the more efficient he or she becomes. Listening costs next to nothing, and so is infinitely more cost-effective than drugs and devices. Listening promotes healing and causes no harm. In fact, it’s the bedrock of a genuine trusting relationship — something everyone wants from their doctors and nurses. In the tone of voice, in the subtlety of the pattern of pain, in getting the sequence of events right — that’s how a correct diagnosis is made and the person emerges from the patient. If all health care providers listened better, we would save billions of dollars and transform the system. So why don’t we have the time we need to listen?

Because clinicians have been put on a treadmill driven by the pitiless demands of a false concept of efficiency. Money has replaced quality care as the measure of health care. The idolatry of the market is driving a race among hospitals, insurers, and manufacturers to get bigger and bigger.

To fix health care, we need a genuine democratic dialog. To start that, our society needs a massive dose of listening to understand what really matters to patients and communities...
"It’s certainly quicker to order the test, get some numbers, and then treat the numbers instead of the patient."

Goes materially to the central debate surrounding Health IT. Useful here to revisit my prior post "Are structured data the enemy of health care quality?" As I wrote there:
Perhaps optimal "health care quality" requires the open-ended analytical narrative in the progress note, replete with evocative, dx-illuminating metaphors and analogies and elegant turns of phrase in lieu of blunt instrument categorical and ordinal "structured data." That whole elusive "Art of Medicine" thing. The "Spaces Between the Facts comprising 'Big Data'." The slow, contemplative Medicine of "God's Hotel." Listen. look, palpate, empathize...
See also my earlier post "Clinician "burnout." Is HIT a significant factor?"

Another requisite daily stop of mine is "The Incidental Economist: The health services research blog."
Why is improvement in the quality of health care so slow?

In JAMA Internal Medicine, David Levine, Jeffrey Linder, and Bruce Landon look at progress in improving quality of care in the US since 2002. They are not impressed...

I strongly agree that:
  • Measurement in and of itself does little,
  • Incentives won’t always change behaviour, particularly if the cost of change outweighs the value of the incentive, and
  • Quality improvement is accomplished by “health professionals on the front lines in collaboration with their patients.”
But I don’t think these points quite capture why it’s so hard to improve medical quality. I see two reasons why we might have expected change to be faster. First, we expected change to be fast because we looked at dramatic improvements in quality achieved in other industries, such as automobile manufacturing.  Second, other nations deliver care that looks at least as good (or better) than US care, at significantly lower cost. This makes it seem like that there should be low-hanging fruit to harvest, that is, we should be able to make quick changes that move us to a higher quality of care without increasing cost.

Change is hard, in my view, because the fruit is harder to pick than we thought. The fruit is hard to pick in part because delivering health care is not much like making a car...
"...delivering health care is not much like making a car."

Yeah. A standard complaint, that one. Neither is it like aviation, as many QI-skeptic docs grouse. "We're different," goes the common grumpy retort. "Stick your Toyota Production System and pilot checklists where the sun don't shine..."
Auto manufacturing involves highly standardized and intensively automated workflows. Changing how work gets done may require a lot of capital investment. Nevertheless, a numerically-controlled lathe will change what it does when you reprogram it. And you don’t need to worry about the expectations of the steel that the lathe shapes. Medical work is much less standardized. No two patients are the same, biologically, psychologically, or in their social circumstances. Unlike steel, patients have agency that the care system should and must accommodate. All this makes caregiving a matter of craft skills, and care ‘algorithms’ are often more like suggestions. Above all, because they are craftsmen and craftswomen, and not robots, caregivers can be nudged, but they can’t be programmed...

My hope is that the problem is that improvement in the quality of health care is slow because we are still on the left hand side of the [logistic S] curve, and change will speed up in the future. Or, perhaps, we will eventually figure out how medical care can be automated.
"Or, perhaps, we will eventually figure out how medical care can be automated."

Lordy. Recall my earlier post "The future of health care? "Flawlessly run by AI-enabled robots, and 'essentially' free?"


also apropos of "health care quality." Yet another daily stop, Science Based Medicine. Just ran into citation of this book.

Downloaded. Just as I'm finishing up Robert Cialdini's intriguing "Pre-suasion." Dr. Rawlins' book also goes to "waste" and "poor quality" in health care. I'm instantly reminded of all the absurd crap I had to wade through during my daughter's terminal cancer illness.

Also on deck, relatedly, some other stuff I'm looking at.

LOL. e.g., as reported by Eric Pfeiffer:
...Self-help is a $10 billion industry. People are hungry to form new habits; it’s the age of behavioral psychology meets the productivity zeitgeist, and whether your techniques are peer-reviewed or merely placebo, they’re certainly sellable. (Amen’s take on what counts as “tested”: “The best way to evaluate these techniques is to try simple things and measure where you notice improvement.”) [Jim] Kwik often fields personal questions from his audiences, offering what he calls a “personal trainer for your brain.” Soft-spoken and geeky, he conducts his webinars in front of a giant Iron Man mural while wearing a T-shirt with a picture of a brain over the tagline, “There is no app for that.” His online classes and seminars run around $400; some clients pay upward of $10,000 per person for in-person coaching, either one-on-one or in small groups... ["Is Jim Kwik the Next Lumosity or Just the Next Fad?"]

I got an email from Robin Farmanfarmaian the other day.
Dear Friends,

My friend Jim Kwik is hosting a gathering I wish the entire world could attend: the Superhero Brain Summit.

It will be one of the best events of the year, completely dedicated to optimizing the supercomputer between our ears that controls everything from your health to happiness and influence to income.

Jim usually charges $2,000 for a ticket to attend this...

But since I was a speaker, I can invite my network to get free online insider access today.

Inside you'll get access to topics including memory improvement, speed-reading, optimal brain diet, creativity, mindfulness, work productivity, sleep, and more.

Reserve your spot to attend this Superhero Brain training

If you don’t know Jim, his clients include the likes of Elon Musk to entertainers like Will Smith as well as other top entrepreneurs and entertainers.

Jim has arranged one of the most amazing lineup of speakers:

Dr. Mark Hyman, 10x New York Times Bestselling Author. Director of the Cleveland Clinic Center for Functional Medicine. Superpower of ULTRA-MIND.

Dr. Daniel & Tana Amen, New York Times Bestselling Authors. Creators of the Amen Clinics, the leader in brain optimization. Superpower of BRAIN HEALTH.

Jim Kwik, Founder of Kwik Learning. Superpower of MEMORY & SPEED-READING.

Dave Asprey, New York Times Bestselling Author. Founder of Bulletproof Coffee. Superpower of BRAIN BIOHACKS.

Shannon Lee, Daughter of Bruce Lee, shares her father’s approach to deep learning. Superpower of MASTERY.

Jack Canfield, Co-Author of the Chicken Soup for the Soul series with one billion books in print. Superpower of FOCUSED MINDSET.

Shawn Stevenson, Nutrition Expert. Bestselling Author. Superpower of SLEEP.

Keith Ferrazzi, New York Times Bestselling Author and world’s foremost expert on professional relationship development. Superpower of CONNECTION.

And tons more!
Here's the video clip embedded in Robin's email.

"I build better brains." (@0.33)

Science, or showbiz/marketing hyperbole?

"Brain optimization." Been pondering the brain a good bit of late (mostly, but not exclusively, in the context of considering the implications for "AI"). See my post "The locus of Mind."

We shall see. My first reaction to Robin's email was "I'm havin' a Landmark Forum Moment." I went to one of those last year, invited by a friend.
The profitable field Landmark helped pioneer is now crowded with life coaches, time-management gurus, and productivity bloggers. Like David Allen's Getting Things Done or Stephen Covey's The 7 Habits of Highly Effective People, Landmark is just one of dozens of quasi-philosophies that promise to empty your inbox and fulfill your personal goals. And maybe survive the recession. Since the Great Depression, when Dale Carnegie's seminars on how to win friends and influence people became popular, the personal development industry has bloomed under darkening economic skies. Forget work/life balance; that's so 2008. How to do more in less time is today's hot productivity trend. (Landmark's website touts a survey in which one-third of Forum grads reported that their incomes rose at least 25 percent after participating; 94 percent of those attributed it to the program.) Yet if Landmark is just another outpost in lifehacking country, why does it seem so insidious?

Part of it is the in-your-face, hard-sell ethos embedded in the corporate DNA it inherited from est. Forum grads are urged to stay involved and "invite" friends and family. After finishing the Forum, I received calls asking me to volunteer at the Landmark call center and come in for one-on-one coaching. The company also vigorously guards its reputation from critics. After I told Beroset I'd be writing an article on my mixed feelings about the Forum, she called several times and sent me an email that might be described as threatening—but in the most benign, centered kind of way...
I found it creepy. Scientifically bogus, and, yes, irritatingly evangelistically hard-sell.

I first encountered Robin Farmanfarmaian during the "5th Annual AARP Health Innovation@50+ LivePitch" event. Bought and read her book (note: she appears onstage very briefly in the above promo video at 2:14).

So, after getting her pitch email. I started doing a bit a digging. Stay tuned. Is this stuff also "For Entertainment Purposes Only?"

More Eric Pfeiffer:
Kwik, like many of his brethren in the new generation of self-help, is no doctor. Rather, his stuff falls more in the realm of personal-management gurus like Tim Ferriss and Brendon Burchard, who themselves are modern-day versions of Tony Robbins. But he’s playing in a space full of people purporting to have real impact on your neurons: His competitors are companies like Lumosity, which provides brain games to keep you sharp, and which neuroscientists have spoken out against.

“It is 100 percent possible to use scientific methods to verify whether these programs improve memory and reading,” says Elliot Berkman, a neuroscientist and assistant professor in the University of Oregon’s department of psychology. All Kwik or Lumosity would need to do is conduct a controlled experiment. “As far as I can tell,” Berkman says, “neither Kwik nor Lumosity has done this.” Kwik is used to the criticism and says that all of his techniques are based on pre-existing methods backed by scientific studies. He says his role is more messenger than creator...
[Kwik] "says that all of his techniques are based on pre-existing methods backed by scientific studies."

Well, I've only begun searching, but thus far all I'm seeing on his many shiny websites are numerous breathless testimonials, along with swell photos of Mr. Kwik posing beamingly with numerous members of the Hollywood and sports worlds' rich and famous.

"Jim Kwik is a world expert in speed-reading, memory enhancement, and optimal brain performance."

"World expert," 'eh? In the following?
Neuroscience is the scientific study of the nervous system. Traditionally, neuroscience is recognized as a branch of biology. However, it is currently an interdisciplinary science that collaborates with other fields such as chemistry, cognitive science, computer science, engineering, linguistics, mathematics, medicine (including neurology), genetics, and allied disciplines including philosophy, physics, and psychology. It also exerts influence on other fields, such as neuroeducation, neuroethics, and neurolaw. The term neurobiology is often used interchangeably with the term neuroscience, although the former refers specifically to the biology of the nervous system, whereas the latter refers to the entire science of the nervous system, including elements of psychology as well as the purely physical sciences.

The scope of neuroscience has broadened to include different approaches used to study the molecular, cellular, developmental, structural, functional, evolutionary, computational, and medical aspects of the nervous system. The techniques used by neuroscientists have also expanded enormously, from molecular and cellular studies of individual nerve cells to imaging of sensory and motor tasks in the brain. Recent theoretical advances in neuroscience have also been aided by the study of neural networks...
I'm still looking for a CV and/or a list of Jim Kwik books and other publications. Zilch thus far.

On "testimonials." From Dr. Rawlins' book cited above:
Secret 10. Communal reinforcement 
As Robert Carroll suggests in The Skeptic’s Dictionary, CAM practitioners network and those in the network feed off each other’s enthusiasm in a climate of mutual support. So of course do conventional practitioners. Camists may come to believe each other’s hype and that they have ‘the secret, the powers, the gift’. They note each other’s patient testimonials of benefit – the CAM ‘worked’. The camist feels revitalised and empowered. Testimonials are not followed up to check that what may be a patient’s temporary lift in mood due to expectation actually lasts. The regressive fallacy is overlooked. There is no monitoring of patients who do not return to the camist and may not have benefitted. There is no credible scientific evidence. Camists are complacent about this lack of attention to detail, but given others in the network who accept this stance, the community simply reinforces its faith.

Rawlins, Richard (2016-05-15). Real Secrets of Alternative Medicine: An Exposé (pp. 281-282). Placedo Publishing. Kindle Edition.
I've reached out to Dr. Berkman for reaction and comment.

A couple of quick observations:
  1. What would comprise "scientific methods to verify whether these programs improve memory and reading." Well, it would be difficult, and rather expensive just getting a methodologically defensible (adequately sized and stratified) baseline against which to run a proper "clinical trial" (wherein "improve" is accorded an outset operational definition).
  2. I take issue with the framing. What truly should count is effective analytical critical thinking, not simply reading speed and memory. Whipping through reams of text and subsequently being able to better recall "facts" is only part of the story. Being able to adequately evaluate arguments is what matters in the end (when I was a kid in school back before indoor plumbing, much of this was simply known as "reading comprehension").

    Unless, of course, your goal is simply being entertained. Nothing wrong with that, I guess. It's your money. But, let's not infer that it's summarily "neuroscience" that will improve your health and your life.
Regarding point 2 above, on "evaluating arguments": Most real-world arguments of any social significance are maddeningly complex and fraught with opacity and contradiction, requiring Kahneman's "Slow Thinking." My first grad school semester paper comprised an analytical deconstruction and evaluation of the 1994 JAMA Single Payer proposal (pdf). It was ploddingly deliberative, involving accurately flow-charting and then assessing every individual "premise-conclusion" claim leading to the final proffer. I have at least a good hundred hours in that effort.

Would speed reading and memory improvement training have helped, net? I rather doubt it.


Recall my snarky tweet above?

It is increasingly fashionable to cavalierly toss around "neuro"-this and "neuro"-that amid the digerati / Silicon Valley hype-fest. Come up with some smartphone app called "NeuroYoga" or "NeuroQigong" and you can probably land a 7-figure Seed Round (while you sip on some "NeuroBliss" juice). I may have to add the word "neurobabble" to my list of dubiety -- e.g., "interoperababble" (and, "omics-o-babble" may soon be a candidate as well).

OK, how about this app, which I've cited before?

Again, NeuroTrainer is the startup founded by my niece's husband Jeff Nyquist. A core claim of therapeutic benefit they proffer is that of "collision sports" concussion risk mitigation and remediation, via gamified VR visual acuity training. Jeff's 2007 Vanderbilt "neuropsychology" doctoral dissertation, Perceptual Training Yields Rapid Improvements in Visually Impaired Youth, established much of the scientific grounding (9 pages of citations at the end). Several subsequent Nyquist et al publications have built on the work, e.g., Peripheral Vision of Youths with Low Vision: Motion Perception, Crowding, and Visual Search (2012). The latter paper contains two concluding pages comprising 55 scholarly citations. 

I first made note of NeuroTrainer back in January while covering the Health 2.0 "WinterTech" Conference. From that post:
Jeff holds a PhD in Neuropsychology from Vanderbilt. A principal initial focus of his technology is brain injury mitigation within the collision sports (e.g., football, hockey, soccer) via virtual reality-based neural training, specifically occipital lobe visual cortex enhancement -- technology historically rooted in part in the naval combat air "Top Gun School" peripheral vision acuity methods.
April emailed the other day to let me know that some of Jeff's work is on deck to be published in's publication "Scientific Reports."

Obviously, I hope they will be successful. If they are, I am comfortable that the success, beyond factors of market timing, savvy marketing and sales, and adroit company management, will in large measure owe of the underlying science of the technology.
In fairness, I would not expect Jeff (or other digitech startup entrepreneurs) to publish their proprietary intellectual property "secret sauce," although, as we have recently learned via the sad Theranos Silicon Valley multibillion dollar CusterFluck, independently confirmable foundational science transparency goes to credibility -- and, success, long-term.
In sum, when I see hyperbolic claims such as Mr. Kwik's buttressed mainly by glitzy websites and twitter pages festooned with photos of the rich and famous (along with their myriad superlatives-laden testimonials, and the concomitant arrays of corporate logos), I reflexively just skeptically have to ask "what's the evidence, the science?"

Go to one of the Kwik sites, and you are promptly hit with this popup:

Love the "No thanks. I like being just an average human."

A bit condescending, that. That's supposed to give me the warm fuzzies?

"I build better brains."

OK. Prove it. "In God we trust. All others bring data."

I have no doubt that Mr. Kwik is a delightful person, one with a heartrending personal story of struggle and surmount. Not the issue. You don't get a pass just because you're in the chirpy, well-meaning consumer-facing "wellness"/ self-help market. Every dollar wasted on woo is a dollar not available to be spent on tx's buttressed by scientific evidence that they work.

apropos of current applied neuro-science, this just came to my attention. I will download and study this book forthwith:

"Most of us will freely admit that we are obsessed with our devices. We pride ourselves on our ability to multitask -- read work email, reply to a text, check Facebook, watch a video clip. Talk on the phone, send a text, drive a car. Enjoy family dinner with a glowing smartphone next to our plates. We can do it all, 24/7! Never mind the errors in the email, the near-miss on the road, and the unheard conversation at the table. In The Distracted Mind, Adam Gazzaley and Larry Rosen -- a neuroscientist and a psychologist -- explain why our brains aren't built for multitasking, and suggest better ways to live in a high-tech world without giving up our modern technology. The authors explain that our brains are limited in their ability to pay attention. We don't really multitask but rather switch rapidly between tasks. Distractions and interruptions, often technology-related -- referred to by the authors as "interference" -- collide with our goal-setting abilities. We want to finish this paper/spreadsheet/sentence, but our phone signals an incoming message and we drop everything. Even without an alert, we decide that we "must" check in on social media immediately. Gazzaley and Rosen offer practical strategies, backed by science, to fight distraction. We can change our brains with meditation, video games, and physical exercise; we can change our behavior by planning our accessibility and recognizing our anxiety about being out of touch even briefly. They don't suggest that we give up our devices, but that we use them in a more balanced way."
Heard the authors interviewed on the NPR Diane Rehm Show: "A Neuroscientist And A Psychologist On How Our Ancient Brains Work In A High-Tech World." Great 48 minute online audio discussion there. Well worth your time.
"Gazzaley and Rosen offer practical strategies, backed by science, to fight distraction."
One need not wait long in starting the book for encouraging words:
The Distracted Mind is not a pseudo-science book that offers colorful brain scans and questionable neuroscience as a way of making a topic appear more credible. In this book, we apply our complementary scientific lenses to present timely and practical insights. Dr. Adam Gazzaley is a cognitive neuroscientist and a trailblazer in the study of how the brain manages distractions and interruptions. Dr. Larry Rosen is a psychologist who has studied the “psychology of technology” as a pioneer in this field for more than thirty years. Our complementary perspectives focus on demonstrating why we fail to successfully navigate our modern technological ecosystem and how that has detrimentally affected our safety, cognition, education, workplace, and our relationships with family and friends. We enrich this discussion with our own research and scientific hypotheses, as well as views of other scholars in the field, to explain why our brains struggle to keep up with demands of communication and information.

Gazzaley, Adam; Rosen, Larry D. (2016-09-16). The Distracted Mind: Ancient Brains in a High-Tech World (MIT Press) . The MIT Press. Location 127, Kindle Edition.
Nice. Science. That's all we're asking. Go to the Gazzaley Lab, look at the publications.

"Distracted Mind" things I will be looking for in particular are any implications for the irreducibly high cognitive burden environment of clinical workflow in a digital world. During my time in the Meaningful Use program, I was the goto guy for "workflow redesign / improvement" at my REC. WKFL, and "process QI" more broadly, remains core interests.

One interesting "Distracted Mind" connection I anticipate goes to Dr. Dan Lieberman's excellent book The Story of the Human Body: Evolution, Health, and Disease, which I cited back in April: Digital Health IT = "Better Care at Lower Cost." Right?

"Evolutionary mismatch" ailments. They extend to the brain and mind. And, we are now at a point where the exponentially increasing pace of anthropocene "cultural evolution" (which includes technology and is decidely Lamarkist) is utterly dwarfing that of biological evolution.

There may also be tangential / triangulational implications concerning these two current reads of mine.

Been a fan of Robert Cialdini's work for a long time, and the Dave Gray book was a total delight.


We are now reciprocal Twitter followers. apropos of my discussion of Jeff's NeuroTrainer startup effort, I found this on one of Dr. Fleming's blogs:
I invite readers consider more closely the topic of brain development in professional athletes. What do I mean by this? For years, prior to today’s neuro “a-ha!” moment, we have seen peak performance questions limited to a realm mostly called “performance enhancement.” If you asked any elite athlete what word associations come to mind when you say this phrase you would get responses like:
  • mental health
  • focus/concentration
  • winning at the mental game
  • psychological tools
  • harnessing the power of the mind
Doing a performance enhancement search for resources on shows a radical preference of thought towards mentalism: if you put the word “mind’ in front of “performance enchancement,” as opposed to “brain,” you get nearly four times as many hits to choose from. In my job as a neuroscience-based consultant working with high-performers worldwide, I can tell you that there is a huge paradigm shift in the making, and it has to do with the brain – not the mind – holding most of the secrets to mastery, both on and off the field/court. And here is the kicker: this is true with or without prior head injuries or concussions. When I conducted a random sampling nationally of psychologists, including sports psychologists, over 50% of these professionals commented that the brain was mostly influential in high impact situations, but that working with the “mental aspects” was something different, and highly generalizable to most athletic situations where behavior change or performance improvements were needed. It is as if a Descartes-like dualism is rearing its ugly head, ignoring neuroscience research that has shown time and time again consciousness is a matter of the brain. Consider the irony: sports psychology choosing to ignore the body, as though the brain were not as much a part of the body as are the muscles and bones of an athlete...
'eh? Reminds me yet again of my prior post "The locus of Mind."

Below, more intriguing stuff from Dr. Fleming:
Most of human behavior is predictably irrational without head injury complications. This is a critical point to understand, for it screams out the hidden assumption that brain issues are for those impaired; and that if you are not impaired then you must be normal; and if you are normal, then you are rational and logical. Most of the training I received in psychotherapy really followed this logic, as I was supposed to flag disorders that needed intervention and treatment, and then those outside that arena, well, we could get together each week in sessions and talk about strategies to change. Little did I know I was merely describing the water as they drowned and calling it “success,” as people would leave the office, do something different, make a rationalization the next time that reduced the dissonance, and we would start the circle all over again. Neuroscience and behavioral economics have helped us finally understand that the “deciding brain” is quite different than the brain that engages in supposed rational dialogues. New assessment tools have been designed in order to increase the meta-cognition that we use in my work to help close this gap.

There is another side to high performance that rarely gets acknowledged and worked with. Be careful what you wish for it may come true. Most performance enhancement interventions solve a problem linearly and do not include systems thinking. That is not a fault, per se, but it is an accurate perception, for that is what these people are hired to do. But many times, as systems thinkers have taught us, changing one wheel without working with the other 10, say, in a life system can cause some inadvertent consequences. The brain’s mechanisms and communications are a system following many laws of homeostasis. If you push down on an air bubble, it is going to even out and pop up somewhere else. High performance lifestyles/goals and decision-making grounded in sustainable, reality-based perceptions have grown oddly apart from each other, as we have seen in the headlines of derailed, at-risk athletes. Understanding the distinctions between pleasure and joy, and understanding the neurological curveballs thrown to the consciousness of an athlete, are issues rarely addressed in traditional treatment programs and talk therapy. Such understanding cannot be achieved without working with the undertow of the limbic system that is helping call the emotional shots...
I could write an entire new post just ruminating on all of that.

WATCH: Can exercise make you smarter? Scientists think it’s possible
...Wendy Suzuki, a psychologist at New York University ... runs a lab where she can carefully measure the [exercise] effect. Suzuki has volunteers run on a treadmill in her lab while she measures their oxygen consumption. Then she gives her subjects a battery of psychological tests to measure things like their memory and attention.

Suzuki has found that healthy people can improve their cognition with exercise right away. She has also found that people with brain injuries experience significant improvement in their mood. Now she’s running a class in which her students exercise at a gym three times a week, to see how their brains change over a full semester...


A long read by Trudy Lieberman (paywalled, but may be viewable once by non-subscribers):

“Don’t Touch My Medicare!”
Is the beloved program on its last legs?

...The Medicare Modernization Act poked yet another hole in Lyndon Johnson’s fraying compact. It called for wealthier beneficiaries—people with incomes above $85,000 if single or $170,000 if married—to pay higher premiums for Part B benefits. The provision moved through Congress with “unexpected support from some Democrats,” the New York Times reported. As the law neared final approval, though, the Times noted that AARP, the UAW, and liberal Democrats, including Senator Edward Kennedy, viewed some of its proposals as a “dangerous first step in turning Medicare from a universal social insurance program into a welfare program.”

In a sense, the conservative assault on Medicare is two-pronged. On the one hand, there is a drive to privatize. On the other, critics hope to rebrand Medicare as a variety of welfare. The former Hill staffer says that the Republicans have “been on a very consistent march for decades now. They basically want to get rid of the entitlement and want everything means-tested.” Means-testing—that is, basing eligibility for benefits on whether a person has the means to do without that help—saves billions for the government. But it would also make Medicare into the equivalent of food stamps or Medicaid. And that, of course, is the objective.

So far, privatization remains the more politically correct solution for Medicare’s financial shortfalls. These are real, at least potentially. In large part, they have been caused by the lack of serious cost controls, and exacerbated by the influx of millions of baby boomers needing medical services. Even the government’s attempts at cost control introduced during the Reagan era failed to permanently curb medical inflation. Indeed, containing the prices charged by the doctors, hospitals, drug makers, nursing homes, and home-care agencies that rely on the Washington gravy train has been an almost impossible task. The 2003 prescription-drug law, for example, prohibits Medicare from negotiating the prices it pays for drugs. “There are obstacles statutorily and politically,” says former Medicare administrator Don Berwick. “We can’t negotiate for purchasing, in one of the largest insurance systems in the world. The moneyed interests are calling the shots.”

Many of those moneyed interests sell health-care technology, which has long been a major cause of exploding costs. Richard Foster, who was Medicare’s chief actuary from 1994 to 2013, describes the situation: “As long as there’s an automatic market for new technology, even if it’s not any more effective, cost growth will keep going up.” In fact, Medicare has historically not considered cost effectiveness when deciding whether to cover new drugs and technologies...
Read all of it. Of particular interest to me these days, given that my wife and I are now Medicare benes. More broadly, this kind of policy stuff is every bit as important as clinical science, process QI, biotech, and health infotech. The finest clinical capability on earth is of nil utility if it's increasingly out of reach financially.


Sent this Twitter query to Mr. I-Build-Better-Brains on the 28th.

It is now October 30th. I rather doubt I'll hear back.

November 2nd update: still no response. New hashtags? #Neurotainer, #Neurotainment?

BTW, I am well into the excellent Gazzaley-Rosen book "The Distracted Mind." 38 pages of scholarly / scientific citations in the end notes. Stay tuned for more once I finish.

UPDATE, Nov. 17th: finished the Gazzaley-Rosen book. Wow.

More to come...