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Tuesday, January 31, 2017

The Price is not right. Indu Subaiya speaks out

apropos, see my prior post on Tom Price.


Indu Subaiya, to the Senate Finance Committee: Vote “No” on Tom Price: a perspective from the innovation community; January 30, 2017
Honorable members of the Senate Finance committee:

My name is Indu Subaiya, MD MBA and I am Co-Chairman and CEO of Health 2.0, the largest healthcare innovation conference and network in the world. I submit this letter to oppose Tom Price’s nomination for Secretary of Health and Human Services.

We know that the ACA reduces barriers to health care for millions of Americans, but what many don’t know is that it also fuels a vibrant segment of the private sector, the health technology innovation economy.

In a decade of working alongside thousands of healthcare innovators globally, and in chapters in over 40 US cities from Nashville to Boston, Dallas to Chicago, we have never seen our healthcare system adapt so beautifully to reward private enterprise while saving lives and taking care of our most vulnerable without the heavy hand of government.

Dr. Price appears to be a well-intentioned, educated man, but he has been out of both the practice of medicine and a transforming health care industry for too long to lead us in this dynamic market. Appointing him to architect a replacement plan for the ACA would be like hiring a dinosaur to build a space station.

What healthcare needs today is a pragmatic voice who can put pedal to metal on the progress that’s begun, who can work on reforming the ACA dispassionately with business leaders, entrepreneurs and patients represented in equal proportions, and who understands the healthcare innovation economy.

But Dr. Price is far too polarizing in his politics to be taken seriously by the diverse and moderate mainstream on both sides of the aisle. Those of us fixing healthcare on the ground have blasted silos, left partisanship at the door and figured out how to advance a common interest. Ask Republican Governor Charlie Baker, Republican former Head of the ONC, Dr. David Brailer, Chelsea Clinton of the Clinton Foundation, Mark Bertolini, CEO of Aetna, Bernard Tyson, CEO of Kaiser all of whom we’ve warmly welcomed on stage at Health 2.0 not just as speakers but as partners in the work of transforming health care.

Dr. Price on the other hand has never reached out to our community, and he’s had a decade to do so. Instead he has represented the Association of American Physicians and Surgeons, seen as a fringe group promoting self-interest, technophobia, and a “doctor knows best” philosophy. That era in medicine is over. The era of shared decision making, data transparency, evidence-based medicine and providers as partners in care and innovation is here. Our era needs a Secretary of HHS who will command the respect of the brightest lights in the healthcare innovation economy and Dr. Price is just not that person.

What do I mean by the innovation economy in health care? I am not referring to the old generation of electronic medical record companies (EMR) that indirectly received incentives under the HITECH act. I’m referring to the more than four thousand new companies and many more thousand jobs that were created in response to the ACA’s imperative to make health care more accountable for its outcomes. These companies have applied the best of American business and technological ingenuity to support doctors in their workflow and decision-making, to promote collaboration among caregivers, to avoid redundancy in testing, to improve patient safety and to allow patients to take more responsibility for their health and care.

As a sector, they’ve raised over 19.8 billion dollars in venture capital since 2011 because investors could bet on the momentum of a system aligning around the best interests of patients for the first time in history. What happens when you leave the doctor’s office or hospital has always mattered to individuals and families; but now it made business sense.

All this capital isn’t just lining the pockets of Silicon Valley startups. Economic development corporations in New York City, Massachusetts, Detroit, and Louisiana are making long-term, strategic investments in the health technology innovation economy to attract innovative companies to set up shop in their cities to provide badly needed solutions and to be powerful engines of job growth.
That’s great you say. We’ll keep this thriving and virtuous economy alive, we’re just going to get rid of the individual mandate, some nasty corporate penalties and poorly run exchanges that limit choice and raise premiums for patients and we’ll handle pre-existing conditions with hiving off those patients into separate pools. But that’s a fool’s errand.

It was precisely because the ACA widened the tent of coverage that new private sector markets were created. It was precisely because of exchanges that Americans woke up to the fact that you need to take responsibility for your health and spend your pre-deductible dollars wisely, and private sector businesses rose to the occasion to build tools to educate consumers on managing health care expenses and decision-making.

Overstretched health systems also see innovative technology as a way to do more for patients with less overhead, to reach people in rural areas and at home cheaply and effectively, to refer repeat visitors to the ER to a lower cost option in the community. Hospitals like Massachusetts General in Boston, Cedars Sinai in Los Angeles, Dell Medical Center in Texas, UPMC in Philadelphia and New York Presbyterian in New York City all have either started their own or participated in health technology innovation programs to test new models of care delivery in partnership with the entrepreneurial community in healthcare.

It was the ACA’s imperative to take care of a wider and more diverse population that created demand for new products to address the social determinants of health that are killing our small towns: caregiving burden, mental health, substance abuse, food insecurity, health literacy, social support for the elderly and so much more. These social ills normally depend on inefficient government programs. But thanks to the ACA, for the first time entrepreneurs have paying customers for solutions to these issues. Customers like public health departments, community clinics and hospitals. At the national conference we run on health innovation, the session on “Community Health” normally draws a handful of do-gooders. This past year you couldn’t get in the room if you tried; it was packed with entrepreneurs. The ACA had succeeded in creating a market for doing well by doing good.

The train of progress toward a healthier America and a more efficient health care system has left the station. If confirmed, Dr. Price would waste time trying to run after it only to get run over by it. We have better Republican candidates to choose from who have worked shoulder to shoulder with patients and innovators, who’ve been part of the transformation of American healthcare on the ground, not in DC and not in the ivory tower.

Don’t appoint him because you are comfortable with him as a congressman and a doctor. Neither role prepares him for this job. Don’t appoint him because the AMA endorsed him. The AMA is a friend to the innovation community but it speaks for a minority of physicians. You have already heard from thousands of doctors who aren’t involved in politics who oppose this nomination. Take your time and don’t rush this vote. Let’s fix what’s broken together without taking a wrecking ball to progress. On behalf of those of us with real experience making positive change in the trenches of health care, I ask you to vote “no” on Tom Price.

Thank you for your consideration.

Sincerely,
Indu Subaiya, MD MBA
CEO, Health 2.0
Indu Subaiya, MD, MBA is the Co-Chairman and CEO of Health 2.0, a leading conference series and network for innovation in health care.

Indu is scary smart, and someone I've characterized as "the most cheerful person in all of health care." When she speaks, we do well to listen carefully.

Also relevant to health policy reform, my prior post "Put patients back in control of their health care."

UPDATE
BREAKING: Price confirmation for HHS Secretary advances without votes from Democrats
By Virgil Dickson  | February 1, 2017
The Senate Finance Committee has approved U.S. Rep. Tom Price as HHS Secretary in a vote that excluded committee Democrats.

Price's nomination still needs to be voted on by the full senate, which is likely to approve him along straight party lines. The vote took place during an executive session of the Senate Finance Committee called by Chairman Sen. Orrin Hatch (R-Utah)...
We are probably going to lose this fight, but we should press it forward in the full Senate nonetheless.
____________

Monday, January 30, 2017

I am not a scientist

"Wherever the people are well informed they can be trusted with their own government; that whenever things get so far wrong as to attract their notice, they may be relied on to set them to rights." —Thomas Jefferson, January 8, 1789

Read it
Amid the acrimonious Celebrity Apprentice @POTUS distraction of the contentious "Muslim Ban," I reflect here on our early introduction to the reactionary Trump science denial/suppression era... #MarchForScience


I just joined AAAS (American Association for the Advancement of Science), and the Union of Concerned Scientists. I also gave them permanent links in my right-hand links column. Recall from my prior post:

Our Science Denier in Chief:
Is Anyone Actually a Scientist?
Forget the terrible “I’m not a scientist” schtick. Trump’s comments on climate change suggest no one is a scientist.

My favorite Trumpism is “nobody really knows.” He says it all the time. Did Russia interfere in the U.S. presidential election? “Nobody really knows.” How big is ISIS? “Nobody really knows.” Why did President George W. Bush invade Iraq? “Nobody really knows.” How can we identify potential terrorists? “Nobody really knows.” Most of the time, “nobody really knows” means Trump doesn’t want to, or isn’t prepared to, answer the question. (That’s why he says it so often.)

Climate change is different. “Nobody really knows” is simply Trump’s official position on global warming. It’s one of the rare times he uses his catchphrase offensively, rather than to get himself out of a jam. He doesn’t say it with a shrug and a casual toss of his hands. He leans in. To borrow a well-worn phrase from Trump supporter(ish) Donald Rumsfeld, Trump considers climate change a “known unknown“—the fact is that nobody knows about it...
I don't think we can overstate the risk here. Time to push back forcefully, particularly in light of reports of the Trump administration's attempts to suppress the public communications of federal departments and agencies such as the EPA, USDA, and National Park Service. Others whose legal charters are science-oriented rather than administrative are likely not far behind, e.g., FDA, NIH, CDC, NASA, NOAA and numerous others.
__

Unlike a couple of the entertaining, huckstering poseurs I've written up on this blog recently (e.g., Will Henshall, Jim Kwik*), I would never be so arrogant as to call myself a "scientist." Neither would I properly refer to myself as a "technologist," notwithstanding that I've spent my entire white collar career (which commenced in January 1986 at the age of 39 after finally getting my first degree) working in applied science and technology of one sort or another.
* In fairness, and to be precise, while young Mr. I-build-better-brains Kwik doesn't directly call himself a "scientist," he does repeatedly claim his methods to be "scientific" (neuroscience specifically). I have reached out multiple times since first encountering him asking him for credible, documentable verification. I don't expect to ever get any sort of reply.
From the Preface in a forthcoming book on "critical thinking / argument analysis / persuasion" I'm working on:
...my initial job out of undergraduate school in January of 1986 was that of a quality control statistician and programmer [pdf] in an environmental radiation laboratory in Oak Ridge under the direction of acclaimed nuclear scientist John A. Auxier, PhD, CHP (so much for the anticipated corporate-industrial ad career). Much of our work was performed to a "forensic" standard, meaning that the laboratory's results would be used as evidence in litigation (e.g., contamination and dose/exposure cases) and regulatory enforcement actions. I spent more than five years there participating in excellent analytical science under the best of mentors, co-authoring several technical papers across my time there (see bgladd.com/papers). I learned a thing or two during my lab days about being extremely careful with computer coding and numerical results, lest I find myself sweating under Oath on a witness stand anxiously defending the accuracy of my work under intense cross-examination.

Fast forward a number of years. I started in graduate school in 1994 after working for a time as a Medicare hospitalization analyst [pdf], intending to pursue a Master's degree in Statistics, but soon switched over to an intriguing program known as "Ethics and Policy Studies" ("EPS," a unique interdisciplinary liberal arts course of study comprised of economics, political science, law, and applied philosophy). It played to my analytical writing strengths, as well as my long-standing interests in policy and political affairs.


It was there I absorbed the skills involved in honest and effective "argument analysis" (e.g., see my first grad school paper, an analytical, logic flow-charting deconstruction of the 1994 JAMA health care "Single Payer" argument [pdf] ). I also became steeped in the historical and contemporary literature of "applied ethics," — "doing the right things" beyond simply "doing things right."
Not long after completing graduate school, I was invited to join the part-time evening adjunct faculty at my local community college and university (my day job at the time was that of a risk analyst in a bank) to teach undergraduate courses in "critical thinking" as well as the EPS graduate seminar in "argument analysis." It was great fun. I would do it again in a heartbeat...

In recent years, I have worked again in the medical field, helping physicians and their staffs convert from the paper chart documentation method to electronic medical record systems. These software systems are extremely complex and controversial, with some clinicians arguing that they impede their work and decision-making processes. I've had to undertake deep study of the training, cognitive abilities, and diagnostic methods of physicians -- "How Doctors Think" (there's an excellent book by Jerome Groopman, MD with that title) -- as well as the thought processes of other "subject matter experts," in order to ferret out tactics that can help clients become better decisionmakers. I delve into a lot of these issues on my KHIT.org blog.

Effective, sustained "critical thinking" coupled with successful rational advocacy ("persuasiveness") are of particular importance in high-stakes fields such as medicine, various other applied sciences, and engineering (not to mention national and international governance, where misunderstandings can result in war or other tragedies). However, I argue also that it's equally important for all of us ordinary citizens to become better critical thinkers and constructively persuasive communicators to help each other get to truths large and small and put issues to rest. There will never be any shortage of disputes to resolve...

So, again, I am not a "scientist." I tout myself as a "quantitative analyst and writer," which I regard as more succinctly, reservedly appropriate. Nonetheless, I am thoroughly trained in and steeped in (and an enthusiastic advocate of) the methods of applied science and technology across a number of technical disciplines. I will put my operations science PDSA Process QI chops up against anyone's. My 1992 CQE exam was all about process improvement science. My 1994 IHC CQI cert was all about process improvement science in the clinical setting.

While the core founding topic of this blog was that of support for the national effort to extend the reach and efficacy of digital health information technology, I have taken the independent's pro bono liberty to extend my purview to encompass the gamut of topics and issues critical to the health care space.

Defense of science per se, it would seem obvious to me, sits atop that list. And, science is now more acutely under attack than during any time I can recall. We cannot afford a back-to-the-future return to "Soviet Science / Lysenkoism 2.0."

REPOSTING

What is the Scientists' March on Washington
Welcome! We want to thank you all for your incredible outpouring of support for this march. We are working to schedule a March for Science on DC and across the United States. We have not settled on a date yet but will do so as quickly as possible and announce it here.

Although this will start with a march, we hope to use this as a starting point to take a stand for science in politics. Slashing funding and restricting scientists from communicating their findings (from tax-funded research!) with the public is absurd and cannot be allowed to stand as policy. This is a non-partisan issue that reaches far beyond people in the STEM fields and should concern anyone who values empirical research and science. 

 There are certain things that we accept as facts with no alternatives. The Earth is becoming warmer due to human action. The diversity of life arose by evolution. Politicians who devalue expertise risk making decisions that do not reflect reality and must be held accountable. An American government that ignores science to pursue ideological agendas endangers the world.

 Please bear with us as pull together our mission statement and further details. Many more updates to come on Monday. 
Twitter: @ScienceMarchDC
Facebook: https://www.facebook.com/groups/1862739727343189/
Reddit: /r/scientistsmarch
Get Email Updates
To help: https://goo.gl/forms/zAdY02dBEz3Ykii42
Contact: scientistsmarchonwashington@gmail.com
Count me in.

QUOTING SHAWN OTTO
Democratic governments the world over are increasingly paralyzed, unable to act on many key issues that threaten the economic and environmental stability of their countries and the world. They often enact policies that seem to run against their own interests, quashing or directly contradicting well-known evidence. Ideology and rhetoric guide policy discussions, often with a brazenly willful denial of facts. Even elected officials seem willing to defy laws, often paying negligible prices. And the civil society we once knew now seems divided and angry, defiantly embracing unreason. Everyone, we are told, has his or her own experience of reality, and history is written by the victors. What could be happening?

At the same time, science and technology have come to affect every aspect of life on the planet. There is a phase change going on in the scientific revolution: a shifting from one state to another, as from a solid to a liquid. There is a sudden, quantitative expansion of the number of scientists and engineers around the globe, coupled with a sudden qualitative expansion of their ability to collaborate with each other over the Internet.

These two changes are dramatically speeding up the process of discovery and the convergence of knowledge across once-separate fields, a process Harvard entomologist Edward O. Wilson named consilience. We now have fields where economics merges with environmental science, electrical engineering with neuroscience and physics, computer science with biology and genetics, astronomy with biology, and many more. This consilience is shedding new light on long-held assumptions about the world we live in and the nature of life.

Over the course of the next forty years, science is poised to create more knowledge than humans have created in all of recorded history, completely redefining our concepts about— and power over— life and the physical and mental worlds as we assume editing control over the genetic code and mastery in our understanding of the brain. One only has to recall the political battles fought over past scientific advances to see that we are in for a rocky ride. How that rush of new knowledge will impact life, how it will be applied through technology and law, and whether our societies and governments will be able to withstand the immense social and economic upheavals it will bring depends upon whether we can update our political process to accommodate it. Can we manage the next phase of the scientific revolution to our advantage, or will we become its unwilling victims? 

If that were not enough, the explosion of information technology is creating a power struggle between individual privacy and the public good, and between the organizations— businesses, criminal enterprises, terrorist groups, and governments— who seek to use this new technology for influence and control. Sensing technology and robotics are threatening to replace millions of truck drivers and taxi drivers over the next decade, and to mechanize warfare with tiny autonomous robots that carry enough charge and intelligence to hunt and kill humans. These advancements have prompted many of the world’s leading scientists and engineers to warn that we must get ahead of artificial intelligence before it gets ahead of us. 

As we are being overwhelmed by new scientific and technological developments, we also are facing a host of legacy challenges caused by commercialization of the incomplete scientific knowledge of the past. Thanks to early science, humans have prospered, but at a cost: significant climate disruption, unprecedented environmental degradation, massive extinction of other species, vast economic and power inequities, and a world armed to the teeth with the products of a military-industrial complex, including weapons that could destroy nearly all life on the planet. 

Without a better way of incorporating science into our policymaking, democracy may ultimately fail its promise. We now have a population that we cannot support without destroying our environment— and the developing world is advancing by using the same model of unsustainable development. We are 100 percent dependent on science and technology to find a solution.

Otto, Shawn Lawrence (2016-06-07). The War on Science: Who's Waging It, Why It Matters, What We Can Do About It (Kindle Locations 159-193). Milkweed Editions. Kindle Edition.
A must-read, this book.

I will be cross-referencing it with this one (below), among others.

Otto takes some hard shots at the journalism field for its too-prevalent "subjectivist" 'just present all sides uncritically" ethos -- in particular when it comes to science reporting. To the extent that "investigative journalism" fails to hew to a scientific standard of reporting generally, well...

"Democracy's Detectives" is a fine, fine, thorough, analytical book, but I was disappointed to find just one reference to the scientific method in the body of the text.
[Pulitzer Prize-winning investigative reporter Pat] Stith’s experience made him a frequent speaker about CAR [Computer Assisted Reporting] techniques. In a 1996 talk to the Society of Professional Journalists, he laid out best practices in using data and software to develop investigative work. He stressed that CAR stories were similar in many ways to other articles in that “Computer assisted stories work best when the leads grow out of our reporting, out of our attempts to find answers to questions raised in our communities.”  CAR might often involve significant time and effort to gather and clean data, analyze patterns, and (sometimes) conduct statistical tests. But much of this would remain out of sight of the reader. Stith noted:
Numbers often are the essential element in a story— the “what” of the five “Ws.” They can tell us what happened.… But readers usually are more interested in the answers to questions raised by numbers.

Numbers may be the foundation, but it’s people, their experiences, their explanations, their feelings, that will bring the story to life, that make people want to read.

In the Internet era, “Nerd boxes” eventually became popular ways for online public affairs outlets such as ProPublica to show their work. Though Stith warned reporters not to load articles with too many figures, in the mid-1990s Stith was counseling reporters to be ready to share their results and methods when asked. His description of the importance of transparency, replication, and openness to revising hypotheses are all consistent with the scientific method [emphasis mine]. He noted:
We are glad to tell anyone exactly how we did a report. In a few cases, we have given the agency we’re writing about copies of key reports, and allowed them to study figures we intend to use, and those we don’t.

Our theory is, we’re not ashamed of our work, and the choices we’ve made. If we’ve made a mistake, by all means, find it, and bring it to our attention before we publish. Our work— and our results— can be duplicated. And we’ll show you how.

Hamilton, James T. (2016-10-10). Democracy’s Detectives (Kindle Locations 10092-10111). Harvard University Press. Kindle Edition. 
Dr. Hamilton devotes extensive attention to the work of IRE (Investigative Reporters and Editors):
Investigative Reporters and Editors, Inc. is a grassroots nonprofit organization dedicated to improving the quality of investigative reporting. IRE was formed in 1975 to create a forum in which journalists throughout the world could help each other by sharing story ideas, newsgathering techniques and news sources.
IRE provides members access to thousands of reporting tip sheets and other materials through its resource center and hosts conferences and specialized training throughout the country. Programs of IRE include the National Institute for Computer Assisted Reporting and DocumentCloud...
"Improving the quality of investigative reporting." Like, well, having it comport with science?

One of Shawn Otto's repeated critical shots at the journalism trade:
The clash between the science-literate and a science-illiterate society creates unique problems not just for hapless individuals who run afoul of ignorant or racist authorities, but for the mainstream media as well. Budget-strapped and increasingly unable to discern between knowledge and opinion, science-illiterate journalists too often aid the slide into unreason. Many journalists believe there is no such thing as objectivity, rendering otherwise brilliant minds unable to discern between objective knowledge developed from years of scientific investigation, on the one hand, and a well-argued opinion made by an impassioned and charismatic advocate on the other. This problem extends beyond journalists. Cumulatively, newspaper editors have allowed themselves to be heavily manipulated by antiscience public-relations campaigns. One cannot be certain exactly why an opinion editor chooses to run one piece and not another, for example, but in December, 2015, the nonprofit Media Matters did an analysis of opinion pieces that mentioned the recently concluded Paris climate talks and ran in the ten largest-circulation newspapers in the United States: USA Today, the Wall Street Journal, the New York Times, the Orange County Register, the Los Angeles Times, the San Jose Mercury News, the New York Post, the New York Daily News, Newsday, and the Washington Post. Nine of the pieces, or 17 percent, included climate-science denial. Just 3 percent of climate scientists in any way dispute human-caused disruption of the Earth’s climate system. This means that the major US papers expressed views that were more than five times as doubtful about climate change as the actual climate scientists publishing in the field. By engaging in this sort of misrepresentation, the media deprives the public of the reliable information necessary for self-governance. [Otto, op cit, Kindle Locations 292-305]
Keyword search "journalists" in The War on Science. 100 hits. "Journalism," 75 hits. Most of them linking to passages highly critical of the field (sometimes excessively so?) in the context of science reportage.

Stay tuned. For now, you might like my recent post "2017: Disruption ahead on all fronts, for good and ill."

UPDATE: JUST IN FROM SCIENTIFIC AMERICAN
"In our new era of fake news and post-truth gloom, the quest for objective truth and (non-alternative) facts has become more critical than ever before. Scientists and journalists must join forces in this common endeavor, and not hesitate to call out present and future falsehoods, whether due to innocent mistakes or to frank attempts to mislead. Whereas post-truth is an illusion—with no basis in reality—the actual truth is impervious to our wishes, emotions or beliefs. The scientific method teaches us that we will only ever attain truth by stubbornly stripping away every piece of misinformation that stands in its way. Investigative reporting and aggressive fact-checking will be crucial to get us there."
Glad I signed up for their email feeds.


ERRATUM
Op-Ed: Trump is playing a dangerous game with these 'alternative facts'

UPDATE

See my follow-on post "Update on the March for Science."
____________

More to come...

Wednesday, January 25, 2017

Dr. Aaron Carroll on "Repeal and Replace"


From The Incidental Economist. One of my many requisite stops. Always fine content there. Nice summary of the GOP alternative propositions, including those of the controversial and contentious Trump HHS Nominee Dr. Tom Price.

The health space blogosphere is on fire this week with anxious speculation over the fate of "ObamaCare." See my prior post on the topic.

Meanwhile, The Celebrity Apprentice Administration is off to a wild, disconcerting start.

READING LIST UPDATE

I'm deep into this fine book.


Highly recommended, based on my study thus far. Interesting stuff therein on the intertwined topics of "big data" / "computational journalism." Relevant to health policy as well, given the new administration's reported week one federal agencies' gag orders.

My Pinterest Page characterization:
Among other things, an utter (albeit implicit, unintended) refutation of "Libertarianism," and concomitant validation of the ever-present Gresham's Dynamic risk.
There will be a nexus with these two books below, in addition to a number of other titles in my recent stash.


The new Trump administration is staffing up with Science Deniers at the cabinet level and taking early steps toward increased opacity.

UPDATE

What is the Scientists' March on Washington
Welcome! We want to thank you all for your incredible outpouring of support for this march. We are working to schedule a March for Science on DC and across the United States. We have not settled on a date yet but will do so as quickly as possible and announce it here.

Although this will start with a march, we hope to use this as a starting point to take a stand for science in politics. Slashing funding and restricting scientists from communicating their findings (from tax-funded research!) with the public is absurd and cannot be allowed to stand as policy. This is a non-partisan issue that reaches far beyond people in the STEM fields and should concern anyone who values empirical research and science. 

 There are certain things that we accept as facts with no alternatives. The Earth is becoming warmer due to human action. The diversity of life arose by evolution. Politicians who devalue expertise risk making decisions that do not reflect reality and must be held accountable. An American government that ignores science to pursue ideological agendas endangers the world.

 Please bear with us as pull together our mission statement and further details. Many more updates to come on Monday. 
Twitter: @ScienceMarchDC
Facebook: https://www.facebook.com/groups/1862739727343189/
Reddit: /r/scientistsmarch
Get Email Updates
To help: https://goo.gl/forms/zAdY02dBEz3Ykii42
Contact: scientistsmarchonwashington@gmail.com
Count me in.

For openers, concerned people minimally simply must closely read Shawn Otto's book "The War on Science." Reciting again the Amazon blurb:
"Wherever the people are well informed," Thomas Jefferson wrote, "they can be trusted with their own government." But what happens when they are not? In every issue of modern society--from climate change to vaccinations, transportation to technology, health care to defense--we are in the midst of an unprecedented expansion of scientific progress and a simultaneous expansion of danger. At the very time we need them most, scientists and the idea of objective knowledge are being bombarded by a vast, well-funded, three-part war on science: the identity politics war on science, the ideological war on science, and the industrial war on science. The result is an unprecedented erosion of thought in Western democracies as voters, policymakers, and justices actively ignore the evidence from science, leaving major policy decisions to be based more on the demands of the most strident voices.

Shawn Otto’s compelling new book investigates the historical, social, philosophical, political, and emotional reasons why evidence-based politics are in decline and authoritarian politics are once again on the rise on both left and right, and provides some compelling solutions to bring us to our collective senses, before it's too late.
We now perhaps stand on at precipice of a destructive U.S. "Soviet Science 2.0 / Lyskenoism 2.0" that bodes ill for every aspect of the STEM space (and beyond) in our country.

Our Science Denier in Chief:
Is Anyone Actually a Scientist?
Forget the terrible “I’m not a scientist” schtick. Trump’s comments on climate change suggest no one is a scientist.

My favorite Trumpism is “nobody really knows.” He says it all the time. Did Russia interfere in the U.S. presidential election? “Nobody really knows.” How big is ISIS? “Nobody really knows.” Why did President George W. Bush invade Iraq? “Nobody really knows.” How can we identify potential terrorists? “Nobody really knows.” Most of the time, “nobody really knows” means Trump doesn’t want to, or isn’t prepared to, answer the question. (That’s why he says it so often.)

Climate change is different. “Nobody really knows” is simply Trump’s official position on global warming. It’s one of the rare times he uses his catchphrase offensively, rather than to get himself out of a jam. He doesn’t say it with a shrug and a casual toss of his hands. He leans in. To borrow a well-worn phrase from Trump supporter(ish) Donald Rumsfeld, Trump considers climate change a “known unknown“—the fact is that nobody knows about it...
I don't think we can overstate the risk here. Time to push back forcefully.
____________

More to come...

Thursday, January 19, 2017

"Put patients back in control of their health care"

LOL. Redolent of Kahneman and Tversky.

Well, OK, then, here we go...

From a Republican House Speaker Paul Ryan tweet.


The axiomatic platitude now being parroted by the Republicans every day regarding repealing “Obamacare” (one that Trump HHS nominee GA Rep. Tom Price just repeated during his Senate confirmation hearing). They all say they are going to “put patients back in control of their health care." Okeee-dokeee, then. What does that even mean?

It was recently reported in a GAO study that fully half of Americans ages 55 and older have no money saved for retirement, and have a household net worth of less than $25,000. apropos, here's a short list of estimated "fair prices" (Healthcare Bluebook) for a number of fairly common acute medical events and procedures (mostly incurred as we age):
  • CABG: Coronary artery bypass graft, $56k
  • Aortic valve replacement with CABG, $67k
  • Hip or knee replacement, $31k
  • Partial mastectomy, $22k
  • Prostatectomy, $17k
  • Lung cancer lobe removal, $29k
  • Kidney transplant, $48k
  • Liver transplant, $78k
  • Chemotherapy hospitalization episode, $12k
  • Stroke hospitalization, $10k
Enjoy being "in control" (assuming you can cut the checks), in light of the likelihood of Republican "Repeal without Replacement," and given that such repeal means the insurance industry reverts to where it was prior to passage of the ACA — pre-existing conditions policy denials, policy cancellations ("recission"), exclusions, and lifetime coverage caps. You may become one of millions of newly uninusurable patients. A "full retail chargemaster self-payer" (30 days sent-to-Collections*) in your future?

My late Dad had a valve job w/CABG in 1996. My late Mom subsequently had a hip job.** That's roughly a hundred grand right there, based on the Bluebook current numbers. Unlike most Americans, were such to befall me (given that the family history fruit don't fall far from the tree), I now have it in the bank, in liquid, non-retirement accounts. So, I could unhappily weather those (or some of the others), worst case (cash payment). Not that it wouldn't be a significant dent in our retirement stash.
** I served a lengthy stint as next-of-kin caregiver for both of my parents, beginning in late 1996 and ending in late 2011 with my Mother's passing -- POA on my Ma and Legal Guardian to my dementia-addled Dad -- so I've been witness to EoB Hell. Pop was WWII combat disabled full-benefits VA (lost a leg in Europe), they both had UnitedHealthcare coverage that was part of his Bell Labs retirement package, Ma was eligible for military spouse Tricare For Life, and they were both on Medicare. Man! The paper-shuffling, the "coordination-of-benefits" madness.
Those scenarios are becoming increasingly rare.
* In 2010, I had an AMI false-positive ambulance trip to the ER. The ~$900 ambo bill was in my mailbox when I got home after discharge (I was admitted for tests), apprising me that it would be "referred to Collections" if not paid in full within 30 days. "We do not file insurance claims."
My wife and I are now Medicare benes, so maybe we're relatively "safe" from those sorts of financial calamities. Maybe. For now. The goal on the political right of turning all federal "entitlements" (including Social Security) into means-tested spend-down-to-poverty-for-eligibility welfare programs is hardly a secret.

What's the old joke?


Pardon the "vulgarity" (or, as Donald Trump would no doubt shrug and say, "mere locker-room" vocabulary). Crassness aside, the point is valid. Which goes to...

Another new read, just downloaded:

From the Amazon blurb:
Economic inequality is one of the most divisive issues of our time. Yet few would argue that inequality is a greater evil than poverty. The poor suffer because they don’t have enough, not because others have more, and some have far too much. So why do many people appear to be more distressed by the rich than by the poor?

In this provocative book, the #1 New York Times bestselling author of On Bullshit presents a compelling and unsettling response to those who believe that the goal of social justice should be economic equality or less inequality. Harry Frankfurt, one of the most influential moral philosophers in the world, argues that we are morally obligated to eliminate poverty—not achieve equality or reduce inequality. Our focus should be on making sure everyone has a sufficient amount to live a decent life. To focus instead on inequality is distracting and alienating.

At the same time, Frankfurt argues that the conjunction of vast wealth and poverty is offensive. If we dedicate ourselves to making sure everyone has enough, we may reduce inequality as a side effect. But it’s essential to see that the ultimate goal of justice is to end poverty, not inequality.

A serious challenge to cherished beliefs on both the political left and right, On Inequality promises to have a profound impact on one of the great debates of our time.
We'll see. Our newly-empowered social darwinist righties will no doubt disagree.

I have Dr. Frankfurt's other books. Cited "On Bullshit" here. You might also be interested in my review of Peter Frase's book "Four Futures" as it goes to the implications of relative economic abundance and scarcity going forward. Unhappily, I see a "Quadrant IV" coming. I would love to be wrong.

NEW FROM ATUL GAWANDE

A long read, well worth your time. From The New Yorker:
Annals of Medicine
THE HEROISM OF INCREMENTAL CARE
We devote vast resources to intensive, one-off procedures, while starving the kind of steady, intimate care that often helps people more.
 
...Our ability to use information to understand and reshape the future is accelerating in multiple ways. We have at least four kinds of information that matter to your health and well-being over time: information about the state of your internal systems (from your imaging and lab-test results, your genome sequencing); the state of your living conditions (your housing, community, economic, and environmental circumstances); the state of the care you receive (what your practitioners have done and how well they did it, what medications and other treatments they have provided); and the state of your behaviors (your patterns of sleep, exercise, stress, eating, sexual activity, adherence to treatments). The potential of this information is so enormous it is almost scary.

Instead of once-a-year checkups, in which people are like bridges undergoing annual inspection, we will increasingly be able to use smartphones and wearables to continuously monitor our heart rhythm, breathing, sleep, and activity, registering signs of illness as well as the effectiveness and the side effects of treatments. Engineers have proposed bathtub scanners that could track your internal organs for minute changes over time. We can decode our entire genome for less than the cost of an iPad and, increasingly, tune our care to the exact makeup we were born with.

Our health-care system is not designed for this future—or, indeed, for this present. We built it at a time when such capabilities were virtually nonexistent. When illness was experienced as a random catastrophe, and medical discoveries focussed on rescue, insurance for unanticipated, episodic needs was what we needed. Hospitals and heroic interventions got the large investments; incrementalists were scanted. After all, in the nineteen-fifties and sixties, they had little to offer that made a major difference in people’s lives. But the more capacity we develop to monitor the body and the brain for signs of future breakdown and to correct course along the way—to deliver “precision medicine,” as the lingo goes—the greater the difference health care can make in people’s lives, as well as in reducing future costs.

This potential for incremental medicine to improve and save lives, however, is dramatically at odds with our system’s allocation of rewards. According to a 2016 compensation survey, the five highest-paid specialties in American medicine are orthopedics, cardiology, dermatology, gastroenterology, and radiology. Practitioners in these fields have an average income of four hundred thousand dollars a year. All are interventionists: they make most of their income on defined, minutes- to hours-long procedures—replacing hips, excising basal-cell carcinomas, doing endoscopies, conducting and reading MRIs—and then move on. (One clear indicator: the starting income for cardiologists who perform invasive procedures is twice that of cardiologists who mainly provide preventive, longitudinal care.)

Here are the lowest-paid specialties: pediatrics, endocrinology, family medicine, H.I.V./infectious disease, allergy/immunology, internal medicine, psychiatry, and rheumatology. The average income for these practitioners is about two hundred thousand dollars a year. Almost certainly at the bottom, too, but not evaluated in the compensation survey: geriatricians, palliative-care physicians, and headache specialists. All are incrementalists—they produce value by improving people’s lives over extended periods of time, typically months to years.

This hundred-per-cent difference in incomes actually understates the degree to which our policies and payment systems have given short shrift to incremental care. As an American surgeon, I have a battalion of people and millions of dollars of equipment on hand when I arrive in my operating room. Incrementalists are lucky if they can hire a nurse...
"According to a 2016 compensation survey, the five highest-paid specialties in American medicine are orthopedics, cardiology, dermatology, gastroenterology, and radiology."

HHS nominee Congressman Tom Price, MD (R-GA) is an orthopedic surgeon. I have to say, having watched much of his confirmation hearing testimony, Dr. Price is a forceful, articulate, and unequivocal advocate for his views. I continue to dislike him, but I have to admit to a grudging new respect for his fiesty, adept-on-his-feet combativeness. Not sure his alleged insider-trading medical stock purchase conflict-on-interest problems are a show-stopper.

There's a lot at stake. From a new Atlantic article:
Georgia Representative Tom Price is a wealthy man. A successful orthopedic surgeon in Atlanta before his tenure in the U.S. House, Price amassed a net worth of millions in private practice before entering public service. Since then, he’s managed his wealth via investments in a diverse portfolio. His net worth places him somewhere comfortably in Congress’s upper tier of wealth.

That net worth and just how Price maintains it have become the subjects of scrutiny this week after a CNN report found that Price—a member of the Ways and Means Subcommittee on Health and a leading author of health-policy legislation—disclosed a number of investments in pharmaceutical and medical-products companies that lobbied for rules that Price endorsed or introduced. Democrats claim that Price’s holdings and actions while in Congress could violate federal law, but even if they don’t, they also could bring conflicts of interest if he is confirmed as Secretary of Health and Human Services. Those potential conflicts were one of the central sources of partisan tension in his confirmation hearing on Wednesday...
UPDATE: See Paul Keckley's THCB take on the Price hearing here.
Price stated that universal access to affordable insurance coverage is the aim and regulatory relief for insurers in the individual and small group insurance markets as keys. Dem’s probed the distinction between access and actual coverage, noting that last week’s Congressional Budget Office’ report estimated a spike in the numbers who will go without coverage in coming years if “replace” doesn’t achieve current levels of coverage...
"Universal access." Another of my favorite evasive cliches. As I've cracked elsewhere, "y'know, much in the same way that I already have 'universal access' to walk off the street into any Mazerati dealership in the nation."
"It its majestic equality, the law forbids rich and poor alike to sleep under bridges, beg in the streets and steal loaves of bread." - Anatoly France
Probably worth reposting some observations I proffered in my prior post.

BTW: The policy debate has been fairly raging over at THCB these days. I mostly stay out of the comments of late. Let these (mostly untraceable screen name) know-it-alls have their respective contending says.

To me, health care policy arguments ignore a couple of fundamental things. First, there's the "Ich/Du/Sie" PoV problem:
  • I deserve full, affordable first-dollar indemnity coverage for my medical misfortunes;
  • You need to have significant "skin the the game" to inhibit you from overutilization, which drives up my costs;
  • He is a mooching parasite, a free-rider driving up my costs.
Then there's the ideologically glossed-over actuarial reality:
Health care UTIL risk is roughly, speaking of only adults in E-Z round numbers, a 60-year proposition tightly coupled in the aggregate with age (in sort of "hockey stick" fashion). We have long known this. Yet we continue to insist on selling "coverage" (much of which is 3rd party-intermediated "pre-payment," not "insurance") in one-year chunks (wherein everyone thinks they're getting screwed on both the insuree and insuror sides). None of the ensuing administrative paper-shuffling going to deductibles, co-pays, coinsurance, and other fine-print policy babble adds any value to actual care delivery (notwithstanding its profitability to the intermediaries).
Of course, the alternative would be the "social insurance" model now decidely out of favor with the GOP.
Agggh...

JOE FLOWER AT THCB
...Congressional Republicans are up a different creek right now: What they are attempting is mathematically impossible. The things they and President Trump have promised do not add up. Literally. Their problem is arithmetic. Getting more people covered, with better coverage, with lower deductibles and out-of-pocket costs — all that will cost more money, lots of it. Getting rid of the tax penalties for not having insurance (the “individual mandate” that is the most-hated part of Obamacare) and the taxes built into Obamacare on wealthy people and on segments of the healthcare industry — all these will cost the government revenue, the very revenue it would need to pay for the better coverage of more people. All this while they aim to cut taxes and lower the deficit. And of course they have on every Holy Book within reach that they will repeal Obamacare, so they can’t just leave it in place. This means it is highly unpredictable what they will come up with, or that they will come up with anything at all.

They are indeed in a place of chaos. But it’s not, as Skiff would have it, the usual chaos of constructing complex legislation. This is unusual, special chaos. In a class all it’s own. Really amazing chaos, chaos like you wouldn’t believe... 
ERRATUM

Interesting tweet about the Tom Price HHS confirmation hearing.


Oh, the lovely Irony-Free Zone. In 2013 the Federal Reserve Board did a study that found that roughly half of Americans would have trouble coming up with merely $400 to deal with an emergency (medical, auto, etc). But, hey, they'll all have amply-stocked HSA accounts, right?

Oh, wait! No spare discretionary funds, no problem! I know! We'll give people tax credits for funding their HSA's. What? They don't earn enough to pay FIT? We'll give them each $1,000 subsidies, that'll do it! Coupled with private market "premium support," problem solved. Now, quit griping and go get your CABG px.


Under the Federal Employees Health Benefits Program (FEHB), insurees pay only 30% of their premiums, with their respective federal agencies picking up the other 70%. Sweet.
____________

More to come...

Monday, January 16, 2017

Health 2.0 #WinterTech 2017

Following up on my prior post. Above, Julia Morgan Ballroom, 465 California Street, downtown San Francisco, 7 a.m., the calm before the storm.


Above, the emblematic WinterTech 2017 slide of the day. The recurrent major topic was that of speculations as to the future of "Obama Care" (and specifically what it portends for #SiliconValley and venture capital investments in Health IT) under the incoming Trump administration. Below, the signature of Tea Party Republican Dr. Tom Price (orthopedic surgeon) of Georgia, Trump's nominee for the next Secretary of HHS." The Price is Right?"


Above, an audience phone-text poll on the likely alternative futures of Obama Care under Trump. "Obama Care Lite with Slowed Value" was the winner with about 2/3rds of the vote. ("Obama Care Lite" meaning that "repeal" measures will be in large measure "cosmetic" --  meant to be political pacifiers, while core coverage elements of the ACA will remain quietly in place, with some decrements in "value" QI initiatives).

Anybody's guess at this point. As I write, it's Monday Jan. 16th. This headline blares forth online at HuffPo:

President-elect Donald Trump says he’s putting the finishing touches on his plan to replace Obamacare.

It sounds absolutely terrific, like the best health plan ever!

It also sounds wildly out of step with what Republicans in Congress, or even some of Trump’s own advisers, have said they would like to do.

Trump’s comments, which he made in an interview with The Washington Post that appeared Sunday, could mean he’s gone rogue and decided that, at least on health care policy, he has more in common with Sen. Bernie Sanders (I-Vt.) than House Speaker Paul Ryan (R-Wis.).

Or they could mean that, in reaction to public anxiety and recent protests over the possibility of more than 20 million people losing insurance, Trump is already misleading people about what he and his Republicans are planning to do.

Or Trump’s statements could mean that he has no idea what he’s talking about...
You're gonna get cognitive whiplash trying to stay abreast of this stuff.

Succinct summary update of the day's highlights in my inbox:


Co-host Indu laid out the day's WinterTech themes at the outset, based on emergent trends stemming from 2016:
  • New care delivery models;
  • New insurance models;
  • Technology advances;
  • Analytics;
  • Emerging (non-U.S.) markets.
If there was any consensus coming off the stage as to where things are headed, it was a prediction of inexorably increasing patient "OoP" (Out of Pocket) participation in health care expenditures, and whatever that may imply for "innovative care delivery" and other "consumer-facing apps" models.

BTW: The policy debate has been fairly raging over at THCB these days. I mostly stay out of the comments of late. Let these (mostly untraceable screen name) know-it-alls have their respective contending says.

To me, health care policy arguments ignore a couple of fundamental things. First, there's the "Ich/Du/Sie" PoV problem:
  • I deserve full, affordable first-dollar indemnity coverage for my medical misfortunes;
  • You need to have significant "skin the the game" to inhibit you from overutilization, which drives up my costs;
  • He is a mooching parasite, a free-rider driving up my costs.
Then there's the ideologically glossed-over actuarial reality:
Health care UTIL risk is roughly, speaking of only adults in E-Z round numbers, a 60-year proposition tightly coupled in the aggregate with age (in sort of "hockey stick" fashion). We have long known this. Yet we continue to insist on selling "coverage" (much of which is 3rd party-intermediated "pre-payment," not "insurance") in one-year chunks (wherein everyone thinks they're getting screwed on both the insuree and insuror sides). None of the ensuing administrative paper-shuffling going to deductibles, co-pays, coinsurance, and other fine-print policy babble adds any value to actual care delivery (notwithstanding its profitability to the intermediaries).
Of course, the alternative would be the "social insurance" model now decidely out of favor with the GOP.
Agggh...
___

Some random photos from WinterTech...


All told, an interesting day, notwithstanding the intractable equivocality of the myriad learned opinions set forth.

Met some cool people.
  • Aristotle Mannon, Founder and CEO of bosWell. "Client data collection, made simple.
    bosWell provides free web-based record keeping and reporting tools for community based organizations."
  • Ursula Hessenflow, CEO and Co-Founder, myLAB Box. "myLAB Box is a first-of-its-kind service that delivers STD screening solutions to your doorstep allowing you to keep private things private."
I spoke with a young woman with the company DesignMap, one of the WinterTech booth vendors.
"User experience design to improve the workplace."
"DesignMap brings years of experience from internal teams, startups and enterprise tech firms to deliver smart 
solutions to make enterprise software great."
I asked her a number of questions going to EHR "usability" (UX). I don't think she understood the drift. I got nothing but generalities. I expect to have better luck when I do a follow-up with ElationHealth.

 BTW, in the context of "Venture Capital," it's worth revisiting my recent citing of Steve Tobak's fine book. I still think Steve would be a great WinterTech panelist.

ERRATUM

My latest book.


From the Conclusion:
Public ignorance means power for institutions, because it lowers the probability of accountability. Institutions are built on delegation of decision-making, which allows a division of labor and the development of expertise. Yet delegating choice also creates the opportunity for abuse, for an agent to take hidden actions against the principles interest or to use limited knowledge about options to pursue an agenda the principal would not favor if fully informed. Information costs involving uncertainty about quality or trust often drive choices away from markets and into the hierarchical structure of firms. Information costs contribute to him perfectly functioning markets when there are negative spillovers like pollution, anti-competitive acts and cartels, or asymmetries in knowledge about goods and services such as with credit, insurance, and healthcare industries...
 Theranos, anyone? apropos, see my recent post "2017: Disruption ahead on all fronts, for good and ill."
____________

More to come...