ECHIDNE OF THE SNAKES

OPINIONS OF ECHIDNE OF THE SNAKES, A MINOR GREEK GODDESS. She can be reached at: ECHIDNE-OF-THE-SNAKES.COM

Thursday, August 28, 2008

Being Such an Elitist You Won’t be Satisfied Until Everyone is Elite. by Anthony McCarthy

One of the more irrational ideas that has become commonplace is that a passionate interest in what’s called classical music is a sign of snobbish elitism. Even when someone is advocating the wider encouragement of all classes of people to try classical music, the charge of “elitism” will follow. It’s a funny kind of elitism which insists on the right of all people to have access to high art. You’d think it would be obvious that it represents the exact opposite, radical populism.

Maybe its because there is, in fact, a snob audience for classical music who consider it their property, or at least their exclusive franchise. Anyone who has worked in classical music will have run into them. Some who aren’t musicians imagine that one of the greatest pleasures of being a musician, practicing, is the worst part of it. Actually, speaking for myself, it is the after concert reception that is the most brutal form of torture inflicted on musicians. The snobs who frequent and often are the reason for those events can be some of the most trying and obnoxious people in the world and you have to experience them at a time you are absolutely demolished by the experience of performance.

And there have been artistic snobs within classical music, though almost never have they represented the greatest figures of all, the great composers. Just about every really great composer was familiar with folk and popular music around them. They clearly listened to it and many of them explicitly incorporated it into their music. It’s always been that way, from Dufay to today. Jazz, even before it was jazz, absorbed the attention of composers from Brahms through Schoenberg. Stravinsky would never have composed the music he did if he hadn’t been aware of jazz and there are not many American composers who haven’t been thoroughly immersed in jazz. I’ve hardly ever met a good classical musician who didn’t have the highest respect for the great jazz composers and performers. Jazz composers have also composed very fine “classical” music.

And artists in other genres of music have certainly been interested in classical music, which has often stretched the limits of musical resources farther than their own idioms. Even many pop musicians, sometimes even the most banal of those, have enriched their music by borrowing or stealing from what classical composers have invented. The borrowing back and forth in what is called “country” music goes to the start and finds some of it’s clearest traces in the familiar suites of Bach and other baroque era composers and fiddle tune collections.

Just about to a person, the people I’ve known who have worked in classical music have been from the middle and upper middle class and just about every one has been on the populist side of the left. Some excellent classical musicians have had parents who worked in what would be considered menial jobs, a lot of them worked menial jobs themselves. The disadvantages of not starting out with good teachers due to lack of money is the real limiting factor for many people who would like to work in classical music. Unless people without money have parents interested in music and able to sacrifice and an unusual amount of drive, the disadvantages to them will be a roadblock to their achievement. But advocating that children be provided as good a basic musical education as possible will get you the “elitist” label faster than advocating the use of public money for a kitschy ornament for a little used venue. Isn’t it interesting that advocating tax breaks for the wealthy is unlikely to get someone called an elitist by the media.

You get the feeling that a lot of the pegging of classical music to elitism is done through the ignorance of people who don’t know the first thing about classical music, a lot of whom seem to be in charge of programming at public radio and TV stations. Since most of those I’ve met have been social climbers it’s possible that they deeply want to believe that “serious” classical music is beyond their audience’s attention span.

Or maybe they rely on those marketing surveys which should be banned by statute and charter for any public broadcasting medium. There was one I read about which seems to be responsible for the reduction of public broadcasting’s classical music programing into a manifestation of what Virgil Thomson called “the music appreciation racket”. The results are eternally repeated chestnuts and banal alternative offerings that are offensive because they achieve bathos through boring inoffensiveness. I’ve heard rumors that the disappearance of vocal and original instrument performances from some public radio stations are due to this kind of survey. When’s the last time you heard Bach that wasn’t played on a piano on your local radio station?

I once heard a program director who was outraged when someone said that the purpose of his station was to educate, something that is explicitly stated in their mission statement and, I’d guess, the excuse for the deductibility of donations to them. God help us if someone should learn something new from listing to public radio. Like just about all of what passes as contemporary culture, it’s practice is to confirm existing experiences and stereotypes, not to challenge or overturn them. But that will get me on the pathetic state of the “avant guard” again. “Posterior poseurs in pursuit of patronage”, would be more accurate. So you see that is a topic relevant to a discussion of American public broadcasting.

The descent of the news programming in public broadcasting into establishment babble has matched the destruction of its music programming. I don’t think it’s just a coincidence.

Maybe it’s because I was forced to go to so many of those after concert receptions. I’ve had my elbow rubbed by rich snobs, I’ve had my ear chewed by them. I’ve had to smile and answer them without having heard what they were saying. With few exceptions, I’d rather practice music with a rowdy bunch of public school students. You’re more likely to find someone who’s listening for the first time and having their imagination kindled. The experience I got as a teenager hearing, my first hearing Schoenberg’s Chamber Symphony, the clarinet after the introduction the non-stop compulsion to listen and pay attention to the very end, the amazing audacity and daring of it. The memory of that still raises my hair and makes me know life is worth the effort after more than four decades. It has dragged me out of low spots any number of times. That kind of experience is the birthright of every human being.

Posted by: olvlzl / 8/28/2008 09:07:00 AM

Wednesday, August 27, 2008

Fifteen days of blogging for health care reform: A Primer on the Obama Healthcare Platform

Guest post by Skylanda.

Tomorrow, in Denver, Barak Obama will take the stage to accept the nomination for the Democratic ticket for presidency. I will be there along with Americans from all over the nation, converging on a mile-high city that could not be more dead center of the country. Not a bad metaphor for Obama: a man who sometimes seems to walk so far above petty politics that even the swift-boaters haven’t had the juice to knee-cap him yet, and who seems to so thoroughly occupy middle-of-the-road America that the progressive left may be wondering - like I am - what exactly happened between his solemn promises of change and renewal.

So it might be a good time to take a moment to look at Obama’s health care platform through the lens of the issues and reforms I’ve brought up over the last two weeks. A thorough but sound-byte summary of the platform is available here, and if you really want to want knock yourself out cold, you can read the whole document in all its multi-page PDF glory here.

First, let’s examine the overarching, definitive issues.

Does he propose a single-payer system? No, frankly, he does not. But he cracks the door to some intriguing possibilities. His opening proposal is for a new national health plan available for all Americans to buy into (yeah, I know - if you could afford it, you’d have bought already). It includes clauses for subsidies to folks who cannot pay outright for this option, and promises affordable premiums, copays, and deductibles. Who would provide this insurance plan? Well, this is a little nebulous, but if you read the finer print, it appears that it would be administered via private insurers who contract to federal government. So: more access, still through individual contributions to private corporations. It has a certain ring to it - you get a certain sense that this might be a slow move toward a central, national system that could evolve into a single payer - and yet it lacks moxie. And it does nothing to address the question of why federal money should be going to private insurers in the first place.

Does he use the magic p-word? “Portability” makes a prominent (double-size header font!) appearance in the language of the Obama platform. Specifically mentioned is the problem of moving job to job, and the proposed answer is that through this new national health plan, you could keep your insurance through those transitions. Not mentioned are any other moments of salient relevance to portability: moving states, turning eighteen, getting divorced, suddenly making enough money to get booted off the Medicaid rolls, or, saying, losing a job altogether. I like that the word has entered the common vocabulary on a national platform; I’m not terribly pleased that the Obama platform would be satisfied with a “portability” that applies to only a fraction of cases in which it is required. A publicly funded system without full portability will incur all the taxpayer cost of a subsidized system without the streamlining benefit of single-payer sourcing - and I fear that this will end up costing more over the long haul than its own benefits are worth.

Does his platform include a provision for free small business from the yoke of paying for employee health insurance? Yes and no. Tax breaks are proposed for those that kick in for their employees health coverage, and small businesses would be exempt from a proposed requirement to tax commercial enterprises that do not offer employee health care. This is a move in a good direction, but it radically fails the fundamental task at hand: firmly and permanently extricating health benefits from employment.

Does he emphasize patient safety as a means of increasing patient confidence and reducing malpractice suits? Yes, and he proposes a steep investment into electronic medical records (though as a separate, not adjunctive, issue to the question of patient safety).

Does he acknowledge the role of prevention and public health? Yes: “Too little is spent on prevention and public health.” Good enough for me.

And then there’s some interesting details…

Investment into “Comparative effectiveness research.” You can read the detail on your own, but the content of what is proposed here already exists in several form - the most well-respected of which is the Cochrane collaboration. If the Obama camp failed to notice its existence (or thinks it can outdo Cochrane), it has another think coming.

“Millions of Americans are uninsured or underinsured because of rising medical costs.” I suppose one does not need a macro-economics lecture wrapped up in campaign promotional material, but statements like this belie a naïvete about the root causes of lack of access - things like a private insurance industry which relies on stock market investment and high interest rates for profitability and raises premiums when those do not come through; a growing disparity between rich and poor; monopolistic practices and obscuring of cost which disallow free choice (that whole “free market“ thing that we love so much in this country) in choosing providers and products; and a whole host of other complications.

Requiring that “providers that participate in the [federally supported plans] utilize proven disease management programs.” Though this sounds like a good, solid prop for evidence-based medicine, the wording raises some hairs on the back of my neck. Proven protocols exist for common and quotidian diseases like diabetes, high blood pressure, and cholesterol. Treatment algorithms are far less established for diseases like cancer (especially the rarer types). Some diseases simply require far more flexibility, ingenuity, and nuance - not a federal mandate that straitjackets them into narrow protocols with compliance enforced by the threat of yanking reimbursement.

And then there’s a few red flags…

Demanding “mandatory coverage of children” without explaining how he plans to enforce that mandate. The paragraph following this edict notes an emphasis on expanding S-CHIP and Medicaid (which both disproportionately cover children) as “critical safety net(s),” but fails to make anything other than a threatening overtures in answering the question of how to mandate insurance for a majority children. What plans do they have for the uninsured child - turn the case over to CYFD, throw the parents in jail for lack of compliance? It is not clear what “mandatory” means in this context. Aaah, the great unfunded mandate: the same no child that was left behind under the Bush education plan would be left behind once again with the Obama health care plan.

Promising comprehensive benefits by citing “maternity health” as one of the covered aspects of the proposed national health care plan. Why not just go and call it what most providers call this sort of stuff: reproductive health. Ah yes, because that might imply that we are going to cover birth control and abortion - two words which make absolutely no appearance on the Obama platform‘s exhaustive leading page. *sigh*

In summary, the Obama platform on health care reform is ambitious and far-reaching, but still far from aligned with the vast majority of points made here over the last couple of weeks. Will I vote for him? Yeah, I will. He’s our man, whether we want him or not, and his vision for health care reform at least leans in a tenable direction. This platform is a starting gate, a flawed and imperfect one, but a place we can work from nonetheless.

As for McCain - because you might be wondering - you can sum up his proposed health care policy in four words, and so I will:

More. of. the. same.

On to Denver…

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

Posted by: skylanda / 8/27/2008 10:00:00 AM

Tuesday, August 26, 2008

Beauty contest for nuns (by Suzie)

I hope to publish a calendar called "Priests: Straight From the Heart," with photos of priests looking as heterosexual as possible. I want to counter the stereotype that they're all gay. I won't dictate what they wear; I just want ones who look like models.

I got my inspiration from an Italian priest who is organizing a beauty pageant for nuns to prove they aren't all old and ugly.

Update: The priest has scrapped his plans.

Posted by: Suzie / 8/26/2008 05:36:00 PM

Fifteen days of blogging for health care reform: Paying the piper

Guest post by Skylanda.

Today, you’re going to hear something new and different. Today you are going to hear this bleeding heart, tree-hugging, west-coast, San Francisco-born, ivory-tower progressive make a neo-conservative argument. Free market, pay-your-own way, private enterprising, classical neo-liberalism. Hold on to your wallets, we’re going for a ride.

This argument concerns the question that underlies everyone’s hesitation with heath care, no matter what your political orientation: how are we going to pay for it. Covering every child, woman, and man in America is an expensive proposition, and paying for it is the key stumbling block between dreamy idealism and real movement forward toward universal health coverage.

Anyone who wants to answer this question - from the most laissez-faire neo-liberal to the farthest left socialist - needs to understand one thing, and one thing alone: we already are paying for it. No health care economist disputes this one common understanding: Americans pay more - per capita and as a percentage of our gross national product - for health care services than any other industrialized nation. And for that sacrifice, we cover less of our people, we live with the gripping national fear of health care insecurity, we measure out at some piss-poor rankings on standard outcomes measures like infant mortality and childhood nutrition. We pay more money for the great privilege of getting less health.

In other words, Americans are getting the rawest health deal on the block.

That is the bad news. But that bad news is also the seedling that sprouts the sapling of good news on the horizon. The good news is that if dozens of nations with similar wealth profiles to ours are able to squeeze better outcomes out of lesser health investments, that means that there is slack in the system, that we have already dedicated the resources and the means to the accomplish the task, and that providing America with a first-class health care system is merely a means of rearranging that system to fit the circumstance at hand. Simple, yes?

God, however, is in the details, as they say. So here are some of the nuance it behooves us to understand in tackling the dizzying problem of paying for universal health care.

Rationing. If you’re my age, the word might bring to mind propaganda shots of little old Russian ladies standing in line to buy bread just before the fall of the Iron Curtain, with a Reaganesque voiceover decrying the evils of Communism. A little older and you might remember the oil crisis and the self-rationing feat of standing in line for hours to pay for gas. If you’re my parents age, you might remember stamps that gave you the right to buy tires and butter and other household products that were scarce during the war.

Rationing is the hobgoblin under the bed, the Commie in the closet, that is yanked out to be puppetted around every time the prospect of a national health care plan arises. Do you know how long it takes to get an MRI scan in Canada?! - it threatens (and actually, I have no idea at all how long it takes to get an MRI in Canada; I suspect it depends on the same variables that drive wait times here: distance from nearest tertiary care center, relative wealth of the region, staffing issues, and the like). Because in America we use rationing as a strawman to promote the glories of capitalism over the evils of…well, just about everything else, we tend to be blind to the fact that there are actually two forms of rationing - one of which terrifies us to our very core (Commie plot that it is, of course), and one of which we live with so commonly that we fail to notice its sinister existence, the way we forget to notice the sky is blue after too many sunny days.

The first form of rationing - the one that invokes such terror - is rationing by wait time. These are the communist breadlines of old Russia, the gas lines of the 1970s, the apocryphal wait times to get that MRI scan in Canada (it also explains the way you have to put your name on the list now if you want to get a private permit to run the Grand Canyon by river raft some ten to fifteen years into the future - even in the good ol’ USofA, rationing by time has its well-worn time and place). If you stand there long enough, you’ll get your goods. The goods aren’t even necessarily any more expensive for your troubles; you just have to wait for them.

The other means of rationing is by cost - that is, you just raise the price until the right number of buyers drops out, and there you have your trade. This is the absolute fundament of free-market capitalism; a certain quantity of goods is out there, a certain demand is placed on that supply, and the winners are those whose cash and values come into best alignment with the available quantity of desired stuff. This is also what you see modeled in simple Cartesian form in every freshman econ class, with the supply on one axis, the demand on the other axis, and economic efficiency at that magical price where the two meet in the middle (I never saw rationing by time modeled on a two-axis graph - I suppose it‘s possible, but not so much the subject of talk in countries where the free market is the order of the day). This functions well for goods like luxury cars, designer jeans, concert tickets hawked on the day of the show, and artwork; it falters clumsily in the face of health care products which are not optional, and have great social consequence if they are not distributed with some efficiency of manner.

In America, we ration by cost so frequently and so thoroughly that we do not consider it rationing and we get very huffy when anyone implies that it might not be the best means out there to distribute goods like health care. And if we do complain - about, say, the cost of health care - it is not looked on as a reaction to rationing; it is looked on as the free market in action (which it is; it is also a formalized and highly regulated form of distributing limited supplies of goods…that is, rationing). Conversely, we recoil at the very thought of rationing by time, even though rationing by time may actually get services sooner for a large number of people than rationing by cost, because so many people can simply never mount the resources pay for something like an MRI.

The question of rationing by time versus cost is heavily reliant on regional values, and it speaks to the soul of America whether we would rather to continue rationing by cost - which allows quick access for the ever-shrinking numbers of those who can pony up cash (or bill their insurer) - or whether we might start to thinking about rationing by wait time, which equalizes the playing field across a wider socio-economic spectrum. The fact that those making policy usually have insurance (and the quick access it entitles) throws a wrench in any attempt to change this status quo (though insured individuals should remember that this is not a permanent status, rather an ephemeral notion of security that could evaporate tomorrow). Rationing by time does not necessarily mean that every cancer patient is going to wait eight months to see a specialist; a good health care rationing system uses effective triage to work in emergent cases first, then urgent, then routine, with preventive services tracked along a different route. These sorts of systems take planning and rational forethought (as well as continuous adjustment to feedback) to work effectively, but consider the alternative that we have now: a haphazard system where your entry into specialty care is wholly predicated on where you live, what emergency room your ambulance screamed into the night you first got sick, what providers happen to accept what insurance, who your primary doctor happens to know that she or he can pull strings with when time gets alarmingly short, and the like. Rationing by time provides a means to more efficiently utilize services that are today placed without overall regional planning for needs, often with a waste of investment inherent in that sort of decentralized system.

Which brings me to the second point that is vital to understand in the financing of health care:

The inevitability of decreasing returns on investment. Health care is like chocolate cake. The first bite of that cake is good, even fabulous. It satisfies that place in the belly that only chocolate cake can satisfy, it fires off a few dopamine receptors, and for a moment, life ain‘t so bad. The second bite? Also very good, but not quite as fulfilling as the first. By the fourth or fifth bite you’re getting kind of bored, and by the end of the plate, you wish you had stopped a few bites back.

Such is the investment in things like health care (and other public goods like education). If you had been uninsured and get, say, a sudden windfall of $2,000, the first thing you might do is spend a chunk of that money catching up on the pressing health issues that have been bothering you. A hundred fifty bucks to go to the dentist to take care of an aching tooth - money well spent, like that first bite of cake. After that you focus a little more on that gnawing feeling you get in your stomach after you eat, so you go to the doctor, who tells you it’s just severe heartburn and gives you a prescription. You feel better - not quite as much better as when you knocked that first burning priority off your list, but still, better. Next you’re wondering if that ugly twisted toenail could be fixed; it doesn’t really bother you, it’s just unsightly, and it turns out that it costs lots of time and money to fix something like that. You decide to forgo it, because you’ve already blown about five hundred bucks, and you want to spend the rest on a vacation you’ve been putting off, a contribution to your retirement account, and a new bike to replace the one that is breaking down in your garage. The toenail is the middle of that cake, the part you’re still enjoying but not really getting too much out of anymore. On the other hand, you might take that money and hit up a cosmetic dermatologist, who gives you an expensive cream to remedy that embarrassing adult acne and talks you into lasering the hair off your legs (or chest, or back…let’s not discriminate against the boys here) for $350 a shot. It sounds like a good idea at the time, but once the bill comes, you realize that not only is your entire $2000 gone, you now owe another $200 on top of that, and that‘s the end of your vacation and your retirement contribution and your new bike. This is that last bite of cake, the one you kind of wish you’d never eaten.

This model can be extrapolated to nation-wide health expenditure. There are pressing matters that can give great relief if funded: vaccines for children, primary care access, care for life-threatening illnesses, those kinds of things. Then there are secondary matters that are best addressed once those primary matters are covered - advanced care for professional sports injuries, cosmetic issues like acne and braces, etc. The primary issues tend to be (though are not always) mass, cheap interventions; after that, things usually become more costly and individualized. But if you go far enough on down the line, you can continue paying more and more money for incrementally smaller outcomes (let’s call those outcomes “health”) until you are paying so much cash for so little gain in health that it is questionable whether that is still something you want to spend your hard-earned dough on - or, more accurately, what we as a nation want to spend our hard-earned dough on. Not because health isn’t important, but because there are other important things too - roads, schools, social security, clean air and water, national defense - and the national budget (or GDP, or whatever your source of cash) is always going to be a limited resource.

For that reason, it is not necessary nor desirable to purchase an unlimited amount of health, nor does it make sense to spend unlimited funds on health care. It behooves us to plan what portion of our collective wealth we want to spend on this thing called “health” - or what sort of health we want to achieve given the limits of our wealth - and then to determine the most efficient way to reaching that end. Setting open-ended financial boundaries, on the other hand, does not make for sound planning and is not a sustainable means of establishing universal health care.

The year that I moved to Oregon, citizens of the state voted on a ballot measure to provide universal health care for every person within the state borders. It was a lovely thought - it would have paid for everything, for everybody. It set no limits on what would be covered, when, or for whom. It included things like aromatherapy as a covered medical service, despite the dubious benefit of that particular modality for any other purpose than making your nose happy. It was voted down by a resounding margin, something like 70-30 on the nay side. This was a wise move on the part of the voters. The measure included no cost estimates, but pundits and analysts on both sides noted that this kind of coverage for that number of people would exceed the entire state budget every year; no new funding source had been built into the proposed program. Had it passed, it would have failed with the thud of a thousand lead bricks hitting the ground, and it would have been hailed by opponents nationwide as a failure of universal coverage - a nail in the coffin of single-payer health care. For that reason, I can look back and say that I am very glad that, in this case, single-payer coverage did not pass muster.

Which brings me to the third point that I advocate everyone understand about health care financing:

Understanding that good business sense and the profit-making motive are two different things. That there is a very big difference between divorcing the profit motive from the health care industry, and removing good financial sense from the health care industry. Under no circumstances can I advocate the breezy, never-can-care idea that medicine should not be about money. Medicine is about money. Everything is about money. The last time that medical providers acted like they could work without a thought to the financial consequences of their actions, we ended up with a system of capitated HMOs...please, please let us not do that again.

On the other hand, prying our health care system back from profit-making ventures is not going to be an easy maneuver. The health insurance industry is a large and powerful lobbying force, one that gets its digs in every time a state or region starts tinkering around with the idea of single-payer coverage. And whereas pharmaceutical outfits have at least some mutual role in which profit motive operates toward the benefit of people who eventually receive their drugs, I am not sure I can come up with a solid social good provided by for-profit insurers that could not be equally provided by a well-funded single-payer system (aside from providing employment for a literal legion of administrators and bureaucrats along the way).

This is not to say that the free market has no place in health care - on the contrary, single-payer coverage may actually open up choice for consumers by unshackling the lock-down on preferred providers, formularies bargained for convenience instead of efficacy or cost-effectiveness, and regional limits that insurers tend to have over their patients. Moreover, ancillary services (such as imaging centers, laboratories, even clinics themselves) can still operate in the free market under single-payer coverage by providing competitive advantages over each other to attract business in the same manner they do currently. This is one of the main reasons I support single-payer sourcing but not an entire system of government-employed providers: by hybridizing socialism and capitalism, you can squeeze the best out of both without losing the aspects that makes each of them attractive.

So in the context of these three principles (rationing, decreasing returns per increased investment, and good financial planning with or without the profit motive), where is the American health care system now? One, we ration by cost, not by time, for almost every service…though some regions are so strapped for specialty care that we ration by both cost and time - a particularly potent recipe for disaster. Two, we are hugely overspending on health care and yet not even getting that first delicious, satisfying bite of cake out to the entire population. And three, we consistently emphasize profit over any kind of good business sense at all.

Pulling these three forces into alignment is - in this one opinion - key to founding a sustainable, affordable version of universal coverage that Americans can live with and thrive on. And here is the sinking realization that should haunt every American when it comes to health care: we already pay too much for too little. We are getting the rawest end of the deal in the developed world. We now have a choice: we can continue to bury our heads in a very expensive sort of sand and believe that a fractured system with ever-increasing premiums is working to our advantage, or we can start to wonder what would happen if we took all that cash - that enormous chunk of the GDP now wrapped up in health care - set it all into one collective system, redistributed without the skimming of profit or the redundancy of hundreds of parallel systems, and set about planning a rational health system for the next fifty years. Could we do it? It would be one of the toughest, most contentious enterprises America could take on…just a hair less tough and contentious than our current health care system, I would wager.

But, you say, would I have to pay higher taxes?

Well, that’s a good question. I submit that if you are paying insurance premiums in America today, you are subjecting yourself to one of the most ludicrously progressive tax schemes on the planet. You may consider yourself middle class (or otherwise), but the public good known as the nation’s health is resting on your shoulders - not only are you contributing directly to the private pooled premium fund, you are also paying federal taxes to support others on the Medicare-Medicaid axis and a variety of other programs. And if you are not paying health insurance premiums, it’s time to buck up and do your share - in the proportion to which you are able, so that you may draw resources that you require. There is only one way to accomplish this: taxes.

If you worry that only the wealthy, the documented, or the honest will pay their fair share? Well then heck, make it a sales tax - no one walks the American soil without buying something. If you want to ensure that every person stepping foot on American earth deserves their fair share of the health care pie because they contributed their piece, sales tax is probably the most thorough (though probably not the most equitable) way to do it.

And if we paid for single-payer health care out of an increased tax, what would that buy you to make it worth your trouble? You could do away with your health care premiums. Stop wondering if Blue Cross is going to double your deductible this year just for the heck of it, or triple your premium because you just found out that persistent nagging cough is severe asthma, or deny your coverage because you had that condition before your employer switched plans last month. You would buy portability, security, and predictability - ratcheting the stochastic impact of health care costs out of your emergency budget. And if you get what you expect out of a single-payer system, you actually have a voting say in who stays in office to guide the system - unlike your coverage today, where you only have a voice in Blue Cross’ policies if you are a major stockholder. And remember, head for head, every other developed nation in the world - by controlling the profit motive and the redundancy issue - has managed to pull off some form of access that covers more of the population for less cost than we have. We are already paying the piper; now is the time we demand that the piper hand over the goods.

And how do we go about demanding those goods, forcing a system wracked by inertia to start a free-wheeled move in the direction of universal coverage? First there is the regional approach - county by county, city by city, state by state. State-wide universal coverage has been tried to varying degrees of success in a number of territories; New Mexico is among those currently wrestling (thus far unsuccessfully) with how to cover its total (albeit rather small) population within the bounds of a notoriously cash-strapped budget. On a smaller scale, cities like San Francisco and Albuquerque have made grand efforts to carve out havens of access within their boundaries. The pitfall of this approach is obvious: it creates a system more finely fractured than Yugoslavia after the fall of the Iron Curtain. You move ten miles down the road and lose your insurance.

A second tactic is to attempt grand sweeping reform at the national level. This might result in the best outcomes should it succeed, but please remember this was recently tried at the highest levels of power - during the Clinton years - and the plan was killed by political manhandling before it even got a chance to stretch its wings.

Another strategy - this one sneakier and designed to make an end-run around such organized resistance - is to simply pick the most successful federal program and quietly fund and expand its scope until it covers a larger and larger portion of the population. What the free-marketeers fail to mention so often is that we are have an enormous sector of America already on federally funded health insurance. Start adding up the numbers from these programs, and go from there: Medicare. Medicaid (alongside its state-by-state contribution). The VA system. The Indian Health Service. S-CHIP. (If you add every county and local coverage scheme across the nation, you might start to guess that we already have a heavily socialized, but very poorly planned, medical system - but that‘s a digression for another time.) Medicaid is fractured by state, the IHS is limited to tribal members only, and S-CHIP is for childhood coverage. But then there’s Medicare - a nationwide, full-spectrum insurer that (so long as its budget stays on an even keel) doesn’t do such a bad job of funding care for a large number of Americans, albeit usually of a particular age group. If one could slowly expand its population coverage (maybe even combine it with the contribution of the VA’s remarkable system of health care informatics), it is possible to build a system of universal coverage without ever having to do national battle on the gladiatorial field of the congressional floor. The infrastructure is already in place, the bureaucracy already pushing those papers; all we need is the will and the cash.

And now to bring it all back around to the place where I started, the neoliberal argument for universal health care. So far, this probably sounds pretty far to the opposite side - all kinds of people-taking-care-of-people, feel-good socialist talk. And it is. But flip it over for a second and take a look at what the burden of the providing insurance does to the free market in America:

Providing private health care benefits to employees saddles businesses - especially small businesses - with a burden so unpredictable, expensive, and bureaucratically top-heavy that it severely impinges the ability of the free market to operate in America today. The current health coverage system does its part to kill the entrepreneurial spirit as people feel locked into secure jobs purely for the health benefits. It imposes a legitimate but ultimately defeat-ist fear of going out and taking the risks needed to start a business, become self-employed, go out on one’s own - all those things that go along with free-style invention and innovation. It restricts the market for labor as people become geographically bounded by their need to maintain a particular insurance policy due to a pre-existing condition, or because one state has more sympathetic laws regarding repossession of personal property in medical bankruptcies (ironically, Texas - a bastion of neo-liberalism - has been repeated cited as a state with laws friendly toward individuals in crisis from the hit of medical bills on their finances…go figure), or because they are afraid to temporarily lose Medicaid coverage for a serious illness in the interim. I defy you to find another force in America that so deeply impinges in the entrepreneurial spirit for so little gain in social good.

It is a strange sort of backwardness in America that we are defiantly against government-sponsored socialism (at least on the surface: I‘d like a show of hands of how many neo-cons are on the Medicare or VA rolls), but we are quite happy to saddle commerce - especially small businesses - with what largely amounts to a social good obligation. I believe the reverse should be true. I believe that the free market should be unburdened of the heavy load of providing health benefits, and that once so unburdened, we may see a re-flowering of what Adam Smith envisioned when we first spoke of the capitalism and the invisible hand a couple centuries ago: a multitude of players, easy entry and exit from the market (a key component of “perfect competition”), a society of self-motivated self-sustaining players who can equally sell their labor to others or work it for themselves, as they so choose. That is capitalism, old-style, old-school, the way the game was meant to be played.

Single payer health care. Socialized medicine. It’s the new capitalism.

Moreover, health care security on the individual level is about that most American value of all: personal freedom. It is about the ability to choose a job that fits your interests and your skills, not your medical needs. It is about being able to quit that job and not worry that you‘re also quitting your best shot at health. It’s about being able to work hard and get that raise without worrying that it will be the straw that breaks the Medicaid threshold without offering any new benefits in return. It is about being able to divorce your spouse and not worry that you are also divorcing your right to be seen by a doctor for your health problems. It is about being able to cross state lines for a better job without leaving your benefits behind. It is about sleeping well at night knowing that a mis-step in front of a bus or a few cancer cells growing in your bones will not mean the capping out of your meager private benefits, repossession of your house, or the long road to permanent poverty.

Universal coverage is about security. It’s about freedom. It’s about time.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

Posted by: skylanda / 8/26/2008 10:00:00 AM

Monday, August 25, 2008

Science, The Bubble Reputation And The Scary Fact That Only Good Will Is Going To Save Us by Anthony McCarthy

Allegra Goodman’s op-ed in Monday’s Boston globe asks an odd question, “Why do we distrust scientists”. It’s a question I’ve been asked in many variations and temperatures of accusation, in the second person as a result of things I’ve posted here, as recently as this week. I don’t think it’s a valid question, put that way. Not that people don’t “distrust scientists”, they do. But, it’s just that there is no category “scientists” which is treated with uniform distrust or suspicion by an equivalent, unvaried “we”. If she had said “Why do we distrust science,” it would be an absurd question on its face.

Distrust or skeptical suspension of trust is an intrinsic part of what scientists are supposed to do. They’re supposed to seek verification before they consider work in their field to be reliable. They aren’t supposed to take the word of their colleagues on faith. But, like any other human activity, scientists have a success rate in practicing what they preach that falls way sort of 100%.

Skepticism is routinely suspended for practical reasons. You can’t read everything, you can’t verify everything you need to accept in order to just get on with things. Short of standing still, that ideal can’t be practiced.

And you often just accept things because of the reputation of people asserting them, everyone does that all the time. And there is the tendency to believe something just because you want it to be so, because you like the person saying it or you like what they are supposed to represent or because it props up your personal preferences. And many people, certainly including scientists, reject research on the basis of it offending some aspect of their personal preference. Much of the popular history of science creates drama based solely on the resultant wrestling matches and personal struggle created by this widespread phenomenon. Experience leads me to believe that most of the acceptance of science and much of the rejection of it is based on anything but personal verification of claims.

And scientists can be some of the most exigent, sometimes vicious and notably unfair critics of the work of their colleagues.

And what is true of people who make their living in science goes even more for people without the training to understand the original assertions, never mind supporting evidence or critiques of them. People constantly accept all kinds of science on faith. You don’t even have to be the type of science reporter who couldn’t calculate a probability or detect a break in a line of logic to do that.

The idea that “science” doesn’t enjoy the highest repute of just about any human activity today is most clearly and ironically contradicted by the “Intelligent Design” industry. It’s been pointed out here, before, that people wishing to confirm their religious or other metaphysical beliefs with science are giving science the greatest possible creedal reverence. They yearn for their beliefs to enjoy the repute of science, they want their religious beliefs to have the functional certainty of science. They are as human in demanding their personal preferences enjoy what they unconsciously admit is the unquestionable status routinely granted to “science”, which is just as routinely insisted on by some materialist devotees of scientism.

But in doing that they pay science a compliment that it can’t accept honestly. They want science, which is equipped only to study the natural universe, to make the supernatural its subject. You can’t turn a god into a subject without diminishing what you define as being god. You can’t make a god subject to natural laws, which can only exist within limits, without implying that god is limited by them. If god is not limited in such a way, science wouldn’t be able to make an approach, in any part. To assert the use of science to study the supernatural is to claim the supernatural as a part of the physical universe. It is to accept, tacitly, the assertions of materialists. You would think religious people would gladly, joyously embrace that the deity they believe in is not in any part subject to the human invention of science. Yet they, themselves, insist on chaining their god within the confines such laws of the universe as we limited beings have the power to discover them.

So, you see, even the enemies of science respect science more than you would think they would ever want to. Would that they realized that. And also that materialists who assert their ability to use science to study what was beyond its competence would also stop pretending what cannot be. It’s impossible to quantify which group are the more clearly irrational in their pretensions.

Science doesn’t also just enjoy the suspension of skepticism and necessary acknowledgment of its fundamental limitations, it also enjoys a form of reverential sanctity.

What jumped out of Goodman’s piece most was the seemingly unconscious removal of science from the sordid context in which an impressive amount of it is done. She mentions two scientists by name, Bruce Ivins, the suspected anthrax murderer and Stephen Hatfil, who has been pretty well vindicated as a victim of a smear by the government and the press. But nowhere in her article does she mention who they worked for. The military.

Some of the most be sainted figures in science have been weaponeers, those in various countries who produced atomic weapons, conventional munitions, biological and chemical weapons, etc. It’s astounding how often people assert that science is a beacon of light, the hope of humanity, the blameless, chaste pursuit of knowledge. It’s incredible how people involved with full knowledge of the purpose of their work, to kill more people in more efficient and easily effected ways, are given a place on a pedestal previously reserved for religious icons and anointed princes.

Quite often when the connection between science and the resultant military and industrial uses it was commissioned for is mentioned, the blame for that is quickly and loudly placed on engineers and other Beta level techies. It’s as if those most nearly omniscient scientists had no idea how their money from the DOD was intended to be spent in the first place. How can you talk about Bruce Ivins without acknowledging who he was working for and the ultimate use to which his research could easily have been put by his patrons? If he did send the anthrax through the mail, how could anyone suspect him of some diabolical innovation unknown to the people who were working with it.

I used to be a science romantic in that way. My mother has a degree in the biological sciences and other members of my family work in science. We were taught to respect science from the earliest years. And I do respect science and those who do it, but not universally and not removed from the context in which it is made manifest in practical reality. In other words, I put science on an equal footing with the rest of human life. I don’t think it’s an illuminating beacon, a talisman of purity or an Ariadne’s thread out of the labyrinth of death. It is a human activity, conducted by humans, within our species limitations of perception and our species, perhaps, biologically limited ability to address the universe. It is human activity carried out by individuals and entire communities which are as fully heir to human folly and villainy as religion or the arts, or politics or, especially, the sordid machinations of university and corporate departments.

The fact is that those who have made evil use of science aren’t routinely expelled from the cannon or even their positions of honor, prestige and influence. I recall reading a figure of scientific sanctity* once complained that even the odious Edward Teller wasn’t paid the respect due a physicist of his stature. Considering his history of scientific politics and back stabbing, you have to appreciate the size of the ethical disconnect in such an assertion.

It is an open question whether the science for the purpose of saving the biosphere, life and the human species will outstrip the science which is so widely used to destroy them. The assertion that “science might save us” is not even an unambiguous inference you can make from the available evidence. I don’t believe the contention is anymore than romantic and automatic piety of the kind that used to be the reserve of religion. “Science” seen this way is wishful thinking, the deus ex machina that will save us from ourselves even as we use science to destroy ourselves.

Science doesn’t provide the self-denial, self-sacrifice and empathy for other living beings which will be necessary to save the planet. It doesn’t contain them in sufficient quantities to make scientists notably less immoral than lesser mortals.

If the species is going to make it, those and other virtues will need to be practiced by a universally potent majority of humans. People holding those values might use science in the way that technology is taken to be the tool of science by the apologists of science. We will need science in order to save ourselves. Science is the most potent means of understanding and manipulating the physical universe we have. But without the governance of those scientifically unverifiable virtues overriding self-interest, self-service and indifference, science will serve other purposes. In fact it, like most other human activities, largely does now.

* Will provide the name as soon as I can locate an online citation.

Posted by: olvlzl / 8/25/2008 10:22:00 PM

Fifteen days of blogging for health care reform: Status iatrogenicus

Guest post by Skylanda.

Many, many moons ago, a man came to the emergency department. He was older, suffering a raft of chronic medical problems, and now short of breath - so short of breath he could hardly pace out the length of his ER cubicle without stopping to rest in ragged gasping heaves. The ER doctors began working him up and called upon the admitting service to get him a bed in the hospital.

In the ER they took an x-ray, which showed lungs wet with pulmonary edema - fluid backed up behind a failing heart. They drew a wide variety of labs, and while these cooked upstairs, suspicion grew that this man might have thrown a clot from one of his sluggish leg veins into his lungs. A chest CT was ordered with appropriate haste, and IV contrast was injected into his veins to better elucidate his pathology in the scanner. Somewhere, somehow, a call did not get made. A number, shy and timid, sat quietly in the online medical records, but did not get shouted across the halls to the ED doctor, the admitting doctor, or the radiology tech who wheeled the man down for the scan. The number was the patient’s creatinine, a direct reflection of his kidney function. The number was resoundingly high, indicating that some kind of kidney failure was at work, driving the fluid overload that was backing up into his lungs and impairing oxygen exchange to his blood. That number would have told any one of the doctors, nurses, or techs involved that this man should not have IV contrast dye administered to his veins; IV contrast dye is toxic to stressed kidneys, and can drive them over into permanent failure. He received the dye, and was subsequently admitted to the hospital for an extended stay for his severely compromised kidneys.

Those following his case could identify at least half a dozen possible reasons why his kidneys were failing before he even arrived at the emergency room, and every one of them was the result of combined self-inflicted misery and some kind of medical intervention. Top among the usual suspects were one of several medications he was on that can cause acute renal failure; he was prescribed these medications by health professionals, for certain, but they were prescribed for life-threatening chronic and acute conditions that were largely the result of lifestyle diseases. Also contributing were his chronic conditions themselves, two of which cause kidney failure over the long term. And then he arrived at the emergency department and was ordered up a test that was entirely appropriate for his less-than-stable condition, and then he received it even though it would have been halted if the lab put the ER on notice that his kidneys were not fully functional, or had the ER been proactive about rechecking the labs.

So a mistake is made in the delivery of care that deviates from the standard of that care. Of that we are certain. Harm, on the other hand, is a more nebulous concept. Was he harmed? Hard to tell; his kidneys were already in florid failure. Was the harm done worth the risk of the CT exam, which ruled out a potentially life-threatening condition? Hard to tell; the test was negative, but we weren’t going to know that until it was completed. If you were a jury hearing this case, would you award a sum of money to a gentleman who had already shot his chance at good kidney function by leaving chronic conditions uncontrolled despite repeated attempts at management? Or would you side against the hospital for a gross misstep in the management of this patient even in the absence of evidence of direct harm to him?

I outline this story - which roughly parallels one that I saw at a distance quite some time ago now - because the ambiguity is similar in nearly every malpractice case I have ever been close enough to know any kind of detail of. Everyone once in a while, something grossly negligent happens, and someone healthy gets irrevocably and obviously harmed. But usually, malpractices cases look like this one: the cause of bad outcomes is multifactorial, the case for harm not entirely clear. Lots of dicey details in the middle.

Malpractice - and malpractice reform - is a touchy subject. No matter what one’s political bias at the outset, close involvement with the medical field almost always causes a hard gear shift in one’s thinking about malpractice once one is in the target scope of the malpractice beast. It is said that most doctors trained today will, statistically speaking, be sued at least once in their career - and for some like neurosurgeons, the rate of lawsuits can be calculated on a per year average (ie. they will be sued an average of every two years, or twice per year, or the like). Something does not quite jive about this scenario: either there are a whole hell of a lot of harm out there, or people have some wildly unsupportable expectations of the medical industry, or both. Probably both.

The first thing to acknowledge - openly and honestly - is that medicine does indeed cause harm. In the year 2000 the National Institutes of Health published an alarming report aptly (and graciously) named To Err Is Human, documenting the stark patterns of error and harm in American medical institutions. The report is worth perusing; it is both sobering and bearing some beacons of hope, as such whistle-blowing documents usually are.

Most of this harm is unintentional, difficult to avoid, and part of the risk of undergoing treatment for conditions that do need treating. Medications have side effects, hospitals are notorious sites of drug-resistant infection even under the best of hygienic circumstances, every procedure has a risk and a documented failure rate. Layered on top of that is the alterable variable of human error caused by fatigue, mismanagement, under-staffing, lack of training or supervision, lack of system checks, negligence, and just plain old human fallibility. And finally, there is just a limit to what medicine can do to fix the human body, and a limited knowledge of where we go right, where we go wrong, and where are rightly obligated to do better given limited knowledge and resources.

The complication in medical malpractice is figuring out which cases fall into the middle category…because as much as it may be one of life‘s hard knocks to suffer bad outcomes, this alone is not cause for medical malpractice. Being alive has with it the inherent risk of suddenly not being alive any more (or being alive but in a much altered state), and you only get to collect cold hard cash for your troubles if you can prove that a bad outcome was the fault of another person - not the result of bad health, not a reasonably expected outcome of treatment, not a quirk of fate, but someone’s fault.

Proving harm is notoriously hard to do, and it engenders an industry whose sole mission is less to find and elucidate the truth than to spin information just enough in one or another direction that a judge or jury finds a particular way. Courts of law have never proven particularly apt at sorting out scientific truth (just asked the two hundred men and women freed from jail so far after The Innocence Project demanded that DNA evidence be brought to bear in challenging their convictions), and there is no reason to think that malpractice claims heard before a lay jury will consistently and accurately reflect who suffered actual harm and who merely suffered bad outcomes. (There is also the question of compensation for potential harm…when Vioxx was pulled off the market, I saw a number of discussions online and in newspapers of how people might go about putting in claims for harm simply for having taken the drug without experiencing the side effects that it was yanked off the market for; it is a uniquely American habit to ask for compensation for harm that has not happened, and it’s one of the quirks of the medical profession that makes it difficult at times to feel empathy for the malpractice industry.)

Moreover, it is often difficult to ascertain who is at fault for harm done. For example: a patient is given a dose of insulin units ten times the prescribed dose, experiences severe low blood sugar, seizes, and sustains hypoxic brain damage. The nurse who gave the insulin holds up a barely legible order sheet and reads off the dose (say, “100 u“) she gave, which looks like what is written on the orders. The ordering physician asks what kind of idiot would administer such an enormous dose of insulin without thinking first, as of course the order said “10.0 u.” The nursing supervisor bitterly adds that floor staff would have time to re-check orders if they were not routinely short three nurses per floor due to poor management and high turnover at the administrative level. The administration asks in return if the nurses have any idea what it’s like to try to run a hospital in a state so strapped for cash that the only tertiary care center for hundred of miles around has to divert patients to rural care centers because it can’t pay for staffing while hospital beds sit empty. A progressive state senator adds an op-ed piece in the newspaper noting that the voters of the state routinely turn down bonds that would increase funding to schools and public hospitals. Who do you sue? Who will pay? And most of all, if the patient wins a $10 million law suit, does this diversion of funds help or hinder the reforms needed to ensure that this same problem never happen to another patient again?

Part of this quagmire is the question of personal versus systemic responsibility for error. Individual sources of error occur when a doctor or nurse fails (or refuses) to follow protocol, shows gross incompetence, or acts negligently toward a patient; in my experience, these are relatively rare occurrences. Conversely, systemic approaches to error acknowledge that people are fallible beings, and that error is inevitable unless the whole system is built with a mind to minimize error through checks, rechecks, and constant monitoring built into the system to catch error before it does harm. Medicine has been slow to build in systemic approaches to preventing error - slower, for example, than the avionics industry, which pioneered the systematic approach to preventing accidents. Within medicine, certain specialties such as anesthesiology have taken on the strict methodological approach and have been rewarded with rapid gains in safety over short years, with concomitant gains in patient trust (though this works for a large predictable, algorithmic practice like anesthesiology, it is less helpful in more unpredictable fields of medicine…especially obstetrics, where observational studies are easy to accomplish but randomized controlled trials are difficult: no one, after all, wants to experiment on pregnant women).

The error I mentioned above, for example, should never happen in an American hospital today. Several years back, studies were done that identified about a dozen very common sources of miscommunication between written error and medication administration; doctors are now strictly disallowed from writing “trailing zeros” (ie. the zero after the decimal point) and the shorthand “u” for “units” (which looks too much like “cc” - the equivalent of a milliliter - when written by a fast and tired hand) on orders, and these forbidden orders are posted everywhere is hospitals all over the country. These rules are easy on me - I never practiced medicine when they were allowed - but tougher on providers who wrote “10.0 u” for decades and suddenly have to go rewrite orders every time a nurse catches this shorthand.

Handwriting of any sort is the source of so much error that it is questionable whether handwriting has a place in the modern medical institution (and while doctors traditionally have atrocious handwriting, really: I challenge anyone to take a random sample of the population, have them write the same general thing several times a day under severe time pressure, and see what sort of result you get from them), but medicine as a whole has been very slow to engage the sort of technological infrastructure that even your local post office has had for years. Some argue good reason for this: electronic medical records (EMRs) are like credit records - the more digitized, the easier the access for folks with nefarious intent, whether that be the nosy medical assistant or the picky life insurer who would like to deny your policy. Health information is sensitive to a degree beyond even financial information, and current technology far from guarantees the security of either. But that is largely a superficial excuse; really, EMRs are expensive and hard to introduce to a notoriously stodgy old profession.

Ironically, the most comprehensive EMR out there comes from a most unexpected source: the US government. The Veterans Administration hospitals uniformly use an EMR (called CPRS) so advanced that one wonders how it ever came from a behemoth bureaucracy like the American military-industrial complex (they do exert their bureaucratic prowess by making sure it takes half a dozen passwords - which randomly expire in the middle of the night - to get into it, but that’s a different problem altogether). CPRS allows you to see every note ever written about a patient since its inception, enter notes by typing or dictation, access patient data from other centers in the VA system directly, and enter orders directly from a vast array of pre-set menus. The learning curve is short and steep (and sometimes painful), but once you master it, it is hard to return to the messy hybrid systems of most other hospitals. It cuts costs by allowing you to see what tests have been run and instantly accessing the results, preventing repeated exams just because faxed copies of results would be too long coming. It allows for rapid assessment of vast quantities of searchable information.

Most salient for patient safety, however, is the direct entry of orders. To order medications, providers choose from an enormous menu of choices - drugs, common doses, routes of administration. Any pre-set order can be overridden should the provider decide they want an unusual quantity or unusual route, but these overrides have to be done manually. You have to think about it first. You are forced to notice that you are doing something out of the ordinary.

You might think this is shocking, that people providing your health care don’t have every drug dose memorized in their vast bank of knowledge. Well, on the commonly prescribed drugs, we usually do. But sometimes, we’re terribly tired (remember, those thirty hour shifts…some time try remembering your own kid’s birth date after you’ve been up thirty hours at a stretch). And sometimes we are on specialty services prescribing drugs that are brand new to us. And those vast banks of knowledge - they are built with training, they are not inherent, and if you check into any teaching hospital, you will probably have trainees working on your case (if you check in in July, you will have trainees who are mere days out of medical school). And sometimes, we just make mistakes - thinking of one thing, writing another. It’s a funny thing that way, we’re human too. Sophisticated electronic ordering systems cut out whole layers of potential error.

Most hospitals have some form of EMRs, but their weakness are legion. They are not searchable; they archive data too soon; they are not compatible with the main outpatient clinics the hospital interfaces with; half the information is still found on paper floor charts. And most of all, they do not allow for direct provider entry of orders, losing the one salient detail that makes EMRs so useful for improving patient safety. It is my contention that the VA’s CPRS system should be made available and expanded to every hospital in the nation. That is not a popular assertion (especially with the myriad vendors who sell expensive second-rate EMR products), but there it is. Someone already invented that wheel, and the free market has so far done a shoddy job of reinventing a better one. Can I prove the VA hospitals provide better, safer service to their clients than your average private or university hospital because of their EMR? No, I don’t have that data in front or me, nor am I sure it exists. But at the least I can tell you that no mistakes are made there due to doctors’ shoddy handwriting (and I can tell you that in the VA hospitals, I can see double my efficiency in seeing patients because I spend so much less time wrestling the dual paper-electronic system typical of most other hospitals).

But no matter how many preventive protocols are in place, no matter what system checks you implement (safety lists before surgery, double verification of blood types before transfusions, that “x” you get on your knee before they do surgery so that you don’t get the wrong leg operated on), errors will happen. You can reduce them to their most minimal number, but harm will occur somewhere - it’s the nature of the game. So what do we do when someone is harmed?

Right now, of course, we either do nothing, or we call a lawyer and file a malpractice suit. And I am of the firm belief that neither of these options are particularly efficient or fair means of compensating people for harm done by bad medicine. On one hand, calling a lawyer starts you down a road of gambles that would catch the keen eye of compulsive betters. But - you might argue - malpractice lawyers often work on commission, charging only a portion of potential eventual winnings. True that, but upfront fees are not the only cost; since it usually takes malpractice suits months to years to actually go to court or settle, you actually invest a heavy part of your life (hours, days, weeks…never mind your emotional wellbeing) into the process…something I would argue is far more valuable than upfront attorney’s fees.

On the other hand, you can do nothing, which is what most victims of medical harm do. These people receive nothing for their troubles, and often personally absorb the cost of the disability associated with that harm.

As such malpractice suits are a bad-luck lottery in which many people are hurt to provide a very few with a big hurt, big harm jackpot. Though everyone may get a righteous buzz when a particularly egregious example of harm is met with a proportionately dramatic comeuppance, this comes at the expense of dozens of victims receiving nothing but the big blow off for their pains. There is nothing just about this system from any angle I can think of.

There are other means out there of compensating victims of medical harms; one has even been tried in America. This is the National Vaccine Injury Compensation Program (VICP). Acknowledging that if you inject every kid in America with any substance at least a few are going to have some kind of problem with it (leaving aside autism because I simple refuse to open that can o’worms here), this fund was established as a “no-fault alternative to the traditional tort system for resolving vaccine injury claims that provides compensation to people found to be injured by certain vaccines.” Except for a few highly publicized autism controversies, this has largely kept vaccines out of the courts; people take a small risk with vaccines for the public good, and if some harm comes of it, they are compensated without having to engage in the legal roulette game that is the malpractice courts. The supply of vaccines remains stable, the data stream helps monitor true patterns of problems with the vaccines, and people who truly experience adverse effects are shuttled into compensatory programs rather than being left out in the cold or forced to invest years into trying to pry justice out of a very tight-lipped system. It’s not perfect, but it works. This type of approach could be applied to other areas of low-level medical harm - not the sorts of harm that occurs when a homeless person is let to die on the floor of an urban ER, but the sort that occurs when the details are ambiguous and the line between the risk of being alive and the risk of being in a hospital turns grey and obscure. Maybe we could keep a large portion of cases out of the courts, save people the risk of an extended and draining settlement process, extend the safety net for those harmed by medicine that is intended to heal.

Overall though, broad-arching reforms are needed to bring malpractice into line with the values of healing and care provision that medicine needs to be able to offer across the board. These are what I would offer up; yours may vary wildly; feel free to discuss.

* Institution of systematic safety protocols (including EMRs) to reduce medical harm, including a scorched-earth approach to eliminating all “never events” - the term given to errors so egregious (eg. operating on the wrong person, or the wrong side of the body) that they should never happen.

* Medical malpractice-specific tort reform. Monetary settlements should cover lost work time, lost potential income, medical and rehabilitation costs, and some limited sum (say, a quarter million dollars) for the nebulous concept known as “pain and suffering.” But the large, deep-pocket, punitive settlements out there for damages for these kinds things cause a reverberating effect on the ability of providers to afford malpractice premiums and go on providing care. Unlimited medical malpractice settlements impinge on the public good in a way than settlements against, say, polluters do not, and they should be subject to a different set of rules than other tort claims.

* Publicly funded malpractice coverage, especially in areas of physician shortage and where historically problematic malpractice environments has caused staffing and recruitment issues.

* Monitoring of quality and improvement through non-punitive means. Quality control incentives are a notoriously double-edged sword, often punishing institutions for accepting tough cases and motivating them to deny care for people who are difficult to cajole into good outcomes - the chronically ill, the homeless, the poor (this is known among cynics as the “No Child Left Behind“ effect). Troubled hospitals should receive focused help and programmatic improvement efforts, not punitive threats to funding in response to their issues.

* Planned and systematic compensation for victims of medical harm, along the VICP model. This should include a universal policy of halting billing of patients (and families of patients) whose cases have been flagged as having been profoundly harmed by some kind of medical error.

In conclusion, we might go back to the incident I started this post. The error was caught within minutes, giving the raft of doctors involved some time to start corrective measures before the ultimate damage was done. The patient was informed, a pre-emptive call was made to the ever-so-euphemistically named “risk management” department. That I know of, no complaint was ever filed, no malpractice claim was ever made against the hospital or the doctors involved. I checked in on the patient’s electronic chart a couple years after the case; his kidney function never recovered fully, and surgeons had scheduled him for a vascular shunt - he would soon be receiving dialysis. In his case, the line between error and harm, between acceptable risk and unacceptable damage, between outcomes of his own doing and outcomes of an inflicted nature, was a shaded and obscured region indeed.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

Posted by: skylanda / 8/25/2008 10:00:00 AM

Sunday, August 24, 2008

Gladly Ripping Up My Ticket For The Wayback Machine by Anthony McCarthy

It was during NPR’s report from Prague, recounting the events of 1968, that my creeping suspicions came together. Someone might be hoping to get a benefit from the usually concentrated looks back at events of that bitterly divisive year coming up to the election in November.

They reported that, as opposed to the American media, the people who went through the Soviet invasion that ended the Prague Spring showed little interest in dredging up the history. They seem to be more interested in the present. Could there be a feeling that the Czechs are negligent to not stir up that pot again for this anniversary year, concentrating on their present? You can imagine some listeners to NPR feeling nostalgic, remembering what they were up to as the tanks rolled in. Perhaps the people there are looking for ways to avoid repeating the past, sitting right on top of it right now, as it is.

Put that together with the 1948 style coverage of the Russian intervention in Georgia in our media. God help us if this the beginning of a rerun of the next fifty awful years. The superficiality of the coverage here has not shown an improvement on the press that ushered in the cold war and the red scare. You could have gotten through much of the coverage without knowing that it’s a long standing division over parts of the country which largely want out of Georgia and into Russia. There was an effective partition going back a long way and our boy in Georgia isn’t exactly smelling of roses over his handling of it this year. Maybe since he didn’t exactly get that shelling the breakaway provinces would be an invitation to Russia to intervene, the finest heads talking in New York, Washington and Atlanta bureaus might not have gotten it either. Add putting the phonied-up missile shield in Poland and you wonder if a second go-round of the Cuban crisis might not be the results. Only, we have a No-John-Kennedy sitting in the White House this time.

Then there is the planned Reenactment of Chicago 1968 Encampment. I haven’t looked too much at the effort to recreate that political bloodbath for the left, but don’t see anything good about it. Unless you happen to be a Nixon Republican, who were the direct beneficiaries of the original event.

Having experienced first hand the rage and frustration over the Vietnam War, the stalled civil-rights movement and the assassinations that year, and felt the anger of the response to seeing the police riot in Chicago, I have to report that the demonstrations around the Democratic Convention didn’t accomplish anything to make the world a better place. Political demonstrations that end up reinforcing their opposition’s hold on power, what could be stupider? Risking a rerun hoping for a better result, perhaps?

Of course, people who inadvertantly helped make Nixon president might not have fully appreciated what was to come. Some can be forgiven their shortsightedness and bad planning, though I’ll never forgive those for who it was entirely a question of their bruised egos. We don’t even have to rehash the various cults of personality on the left, though. There have been forty years of resultant bad policies stemming from the Nixon presidency and the Republican ascendancy ushered in by the left’s fragmentation in 1968, to look at dispassionately and to learn from.

Maybe the underlying issue is the difference between history and antiquities, looking at the past in order to try to understand the present as opposed to trying to experience the past, something that is impossible and so really only produces let’s pretend. The reality of those of us who were active in the anti-war movement was that we were all trying to get out of what was a real-life nightmare that led to even worse things in the years that followed. Who in their right minds going through 1968 would want to reexperience that?

Some of us learned from how the media covered us in 1968, a lot haven’t, apparently. What good will come of giving new images of flakiness and irrational chaos to TV networks which are infinitely less interested in pretending to accuracy and fairness than the decidedly pro-Republican networks of that year? There was some attempt at the appearance of objectivity back then, as they were blatantly supporting Nixon.

Experience shows that trying to use the failed tactics of the past now will produce similar results. Doing it because it just feels good is an indulgence for those removed from the resulting reaction. The number of those involved in bringing about Chicago 1968 who brushed the dirt off and went on to become Republicans is as much a part of the story as the misguided nostalgia for the event itself.

Having started out that year supporting the Robert Kennedy of 1968* but in the end having to support Humphrey wasn’t a great experience. But there is absolutely no reason to believe that the U.S. involvement in Vietnam wouldn’t have ended faster under him than it did under Nixon. Kissinger would likely not have played his evil part in a Humphrey administration, just for starters. William Rehnquist wouldn’t have become a justice of the Supreme Court. Those and countless other differences would have shaped the realities we have today. If we’re going to indulge our imaginations, trying to imagine the possible results of choices Humphrey would have made might get us a lot farther than reliving the mistakes that got us where we are now. We don’t live in a theme museum, we live in what we really get. People really end up dead here, they don’t get up and shower the ersatz blood off before going to supper with your friends.

* Robert Kennedy’s evolution during his public career carries a lot of lessons about learning from some really terrible mistakes and swallowing pride.

Posted by: olvlzl / 8/24/2008 11:09:00 AM

Fifteen days of blogging for health care reform: Burden of debt

Guest post by Skylanda.

Not long ago, I was cruising along the highway at about 75 miles an hour (hey, it’s a rural state, that’s not even speeding here). I was headed north to sign some papers; after innumerable years on a student budget (four undergraduate years, a couple more to the premed classes I hadn’t taken the first time around, four years of medical school, and a year to complete my masters in public health), I finally had a solid resident income. I somehow managed to wangle a mortgage out of the messiest era in history to lock down a line of credit, and I was buying me a house.

The sign at the roadside was for a casino. This is Indian country, brightly lit casinos cling to the highways and byways like hummingbirds on honeysuckle. The billboard glittered and flashed and promised - wow! - a half million dollar jackpot. Top prize! Some lucky soul will take it home!

A pit opened in my stomach and I almost turned around and called the whole thing off. Half a million dollars, I realized…if I signed those papers, half a million dollars would no longer pay off - nay, not even come close to paying off - the total dollar amount I owed to the world at large for the enormous debts I had accrued over the last five years.

I kept driving. I signed those papers. I am now thirty-three years old and the proud owner of two-thirds of a million dollars of accumulated debt. Far, far less than half of which is tied up in that real estate deal.

Four years of medical school, one year of graduate school to obtain a masters in public health. Fifty-something thousand a year, add on five years’ worth of accumulated interest (capitalized twice when I lost eligibility for deferral due to quirks of the federal loan program), and you have my total school debt: three hundred thousand dollars. When those loans skid into repayment two years from now, they will cost me about three thousand dollars a month to service - that’s thirty-six thousand dollars a year in loan payments alone, more than my entire take-home pay as a resident last year.

In some ways, I struggled. The vast bulk of those loans contributed directly to tuition; the living expenses portion of my student loans put me within about 150% of the poverty level after you subtracted unavoidable school expenses from the checks cut to us every three months. By then my parents had their hands full with other financial obligations and could not by any means put me through medical school; nor did I have a partner to share expenses with. My home state boasts all notoriously competitive medical schools, and though I was accepted to several schools throughout the country, I would have paid private school or out-of-state tuition at all of them - and so I just chose the one that best suited my needs.

In other ways, I was lucky. I have no debt from my undergraduate years, thanks to parents who were both generous and able to support me through those years. My medical education coincided with historic interest rate lows, and I have the majority of those debts locked in at rates that would make you drool (and here’s my public service announcement for the day: if you have unconsolidated federal student loans out there, talk to the Direct Loan people now). I had a lucrative contract job leftover from my former career that I could squeeze into vacations and off rotations, and if I was willing to work eighty-hour weeks while my classmates were playing on their off time, I could pull down a reasonable income. And that I did, pulling in roughly $40,000 in real income over five years; I figure it like this: I came out of medical school no savings at all and living frugally most of that time…if I had not worked that contract job, I would be $40,000 in the hole on credit card debt just to stay even.

Three hundred grand debt from student loans alone, thirty five years old by the time I start making a full physician’s salary, no retirement in the bank, a couple of toes in the dicey-est investment in the market today (real estate, that is), and that’s what I’ve got. So if you ask me if doctors - especially primary care doctors - make too much money, I might just have to say no.

Debt is only one reason that doctors expect to be compensated a certain way. Another is the soul-sucking vortex of the residency years. Until you’ve lived a medical or surgical internship, you can’t really compare it; it destroys marriages, sparks mental illnesses, invokes ulcers and bouts of depression and vague hints of personality pathologies in even the most stable and competent people. In 2003, residents nationwide were put under work hours limitations for the first time - eighty hours a week no more than thirty hours at a time, can you imagine the luxury (luxury, I say, because prior to that, hours worked by residents were totally unlimited). During my intern year, I ran roughshod over these hard-and-fast “rules” with alarming regularity; my department made it clear that so long as they did not get caught at it, they did not care. The week I broke a hundred hours I calculated my hourly take-home pay for those seven days: $6.68. I could probably double that wage at Starbucks.

And then there is the fatigue, that bone-aching tired than never leaves you, so tired you can’t even conjure up a yawn anymore, so tired that sleep no longer helps. Because there is no universally validated scale to measure fatigue, imaginative means have been invented to measure this otherwise very subjective parameter; one study standardized fatigue on a scale of blood alcohol level equivalents, and compared residents after a thirty-hour call shift unfavorably to a blood alcohol beyond the legal limit of .08%. During my intern year, I woke up behind the wheel of my car at stoplights, wrote and submitted admission notes so asleep I didn‘t recognize them the next morning because my eyes were closed and flitting around the inside of my eyelids in the throes of REM sleep as I was typing them, lit my kitchen ablaze after a scheduling glitch forced me to fire off two thirty hour shifts with only a seven-hour sleep between them, stopped eating because I fared better through on-call nights if I didn‘t hit that hard downswing in energy after dinner. I lost twenty-five pounds in three months; people I didn’t know asked me in the grocery store if I was alright. Fatigue makes you learn what it means to hate irrationally, it’s the closest most people in modern industrialized nations come to engaging their most primal needs; you have no idea how much you would give for something as simple as sleep until you have done several months back-to-back staying up all night every fourth night.

So let’s see a show of hands of people who would, under any circumstance, choose to let a doctor (in training, no less) who is in their twenty-eighth hour without sleep for the second time that week take care of your urgent problem - your heart attack, your critically low blood sugar, your c-section. Anybody…anybody?

The work-hours regulations were born in New York state after a particularly notorious case of harm from an overtired, overworked resident; the dead victim was no different than a hundred other victims of exhausted residents, except that Libby Zion was the daughter of a local lawyer and journalist, who had the voice and the wherewithal and the bewilderment to ask in a very public voice why we needed impaired doctors taking care of critical patients. Nearly two decades years passed before New York’s pioneering (and meager) regulations were extended into the national work hours limitations, and even these are under continual fire (one notorious controversy surrounds conflicting data on medical floors - where resident hour limitations have consistently shown improved patient safety - and surgical floors, where the data has not shown improvement; though much hoo-hawing has been made over this paradoxical discovery, anyone who spends time with residents knows that the policy of yanking accreditation for programs in violation of the work-hours rules means that surgical residents are under great pressure to simply lie about their hours…and that is all I will say in a public forum on that matter).

I rotated through a hospital in Britain during my fourth year of medical school. One afternoon I asked the wild-eyed, bushy-haired Irish attending physician if I might show up early the following morning to see my patients before we started rounds as a group at the ripe hour of nine am and thus be better prepared to present their problems. He fixed a jaundiced eye on me and said, only half in jest, “You Americans, we know about your habits…you all think something very important happens before the sun rises, that if you’re not here every moment of the day you’ll miss out, you want to start the morning earlier and earlier. Well, we don’t want your over-eager, overachieving ways here, you will keep that to yourself thank you very much…you will arrive at nine am and not a minute earlier!” I heeded his stern warning and dutifully slept in til 8 am the following day. In Britain, you see, trainee doctors are limited to more or less sixty hours per week. Somehow, they turn out world-class physicians, not unlike American physicians. Somehow, they do it without the soul-sucking demand of the eighty-plus hour work week.

One way they do it is to start medical training earlier, and stretch it out longer. British medical student go to high school one year longer than Americans, but start medical school right after that. Medical school is also one year longer, and then begins a rather extended period of post-graduate training. It is hard to compare the two system because chronologically they are so different, but one thing is clear: they both turn out good doctors, and one does it without asking its acolytes to bow to the god of the 80-hour work week. (As a side note, there is some serious grumbling about reform of the content of the US medical curriculum; the first licensing exam is heavily biased toward non-clinical material, a raft of detailed information that students are forced to memorize then promptly forget after they past the test, which forces medical schools to spin their wheels the first two years on topics of limited use to a practicing doctor. It is questionable whether - in a world where clinical knowledge is expanding exponentially - we still need such an emphasis on a classical education where the detail of theory is emphasized to the exclusion of practical clinical material. This is unlikely to change any time soon, but the time spent rememorizing and forgetting the Krebs cycle certainly contributes to the frenetic pace of learning required later on if one is to master the practice of medicine in the limited time allowed by an American medical education.)

You cannot pay people enough to make up for what they endure during the typical residency in America - especially surgeons, who endure five or more years of it, and who are largely at the mercy of unlimited work hours despite clumsy efforts to the contrary. Cash is all we offer doctors in return for those years of their lives (other old-fashioned notions like renown and universal respect are largely phenomena of the past), and that cash has to compensate not only for the sucking vortex of the residency years, but also for the enormous debt and interest that medical students accrue.

As such, expected payment over a lifetime necessarily has a profound impact on how medical students choose their future careers. Many choose by following their passion alone, but many have multiple areas of interest and make the final decision on which promises a quicker loan payoff, a better guarantee of a reasonable age of retirement, a promise that their investment in their education would not have been better spent on a computer sciences BS capped off by a two-year MBA (which, frankly, is what I would tell any 18 year-old to do if they professed an interest in going into medicine purely for the money - there are quicker, easier, and far less painful ways of making a buck, let me tell you).

Why is this of interest to you? Because there is profound and growing crisis in the staffing of primary care services in this country, and because the increased reliance on specialist services is one of the driving factors behind increasing medical costs. In some ways, this is a region-specific phenomenon; in my adopted home state of New Mexico, for example, every specialty under the sun is in grave demand, from family medicine to dermatology, and whole agencies have been set up to recruit all sorts of doctors to all sorts of regions. But in many areas, recruitment into primary care is suffering from the growing emphasis on specialist care, care that costs more to provide without clear evidence of improved outcomes per dollar spent.

So how can one balance my two assertions above - that we cannot pay doctors (especially in certain specialties) enough for the tortuous training they endure and the debt they acquire, and that we cannot afford to continue to pay certain specialties as much as we are paying them now? First, we can reform the medical education system to treat trainees in manner more akin to the way patients expect to be treated: humanely, with respect to human limitations, and with the idea that residents are not an limitless pool of cheap labor that hospitals might otherwise have to pay a real attending physician a real salary for. And in return we can ask that once they graduate, they not expect to command limitless sums of cash for their troubles. These reforms might have to include starting medical school earlier, with less undergraduate training (a tactic already in place at a handful of US institutions that combine undergraduate and medical school into a single six-year program); reorienting the emphasis away from basic sciences and toward more clinically useful practices earlier on to lighten the load later; and offering longer residencies in exchange for reduced hours. These reforms might also have to include giving residents a voice at the planning table; unionization of trainees at my particular residency proved to be a rapid and potent means of improving working conditions and benefits, and the improvement in those conditions visibly cascades back down into patient care.

Second, keep a lid on medical education costs. The prohibitive cost of medical school not only has a profound effect on specialty choice at the end of school, it also has a prohibitive effect on the diversity of students who enter medical school. It takes a solidly middle class outlook to believe the fanciful notion that a $60k per year outlay will ever pay itself off, and for potential students who do not arrive with significant family support, living on student loans well into one‘s twenties (or even thirties) is still a struggle. Any hope of maintaining diversity in the medical profession will rely heavily on keeping the doors open to medical education, and that means keeping some kind of cap on the ever-expanding cost of attending school. We subsidize every other form of education in this country, and medical education should continue to be no exception.

Third, we can restructure reimbursement away from the current emphasis on high pay for procedures and low pay for the kind of work that primary care doctors do - medication management, counseling, dealing with the problems of life. Small procedures that take ten minutes (and no greater skill or capital input) often reimburse at ridiculously higher rates than an hour spent attempting to get a diabetic’s blood sugar under control - though the latter may have a far greater impact on the patient’s morbidity and mortality over the duration - for no greater reason than mere custom. Careers should pay in proportion to the training they require and the benefits they provide, not arbitrary notions of the importance of procedures over non-procedural services. (Britain - one of the most notoriously socialist of the European medical systems, where doctors are actually employees of the state - recently used a classical market-based approach to try to solve their crisis in primary care: faced with a dearth of GPs and a rapidly aging population, they simply offered to pay them enough that the profession all of sudden became lucrative again.)

As for me, I chose family medicine over my other more lucrative areas of interest because of the philosophy of service and the wide-ranging skill it would provide me. Except for the days when I sit down to calculate how many hundreds of dollars of interest are accruing on my loans each month, I don’t regret it. I know a few folks who have no student loans; they are the ones who will go wherever they want to work, who will go abroad and blow a few months volunteering with Doctors Without Borders after residency ends, who have the choice to work at the lower end of the pay scale for community clinics instead of counting every penny toward that debt pay-down, who can feel righteous about their choice to work for lower pay because they don’t need to make those $3k a month loan payments. I’m not one of those people; my every choice for the next ten years will be driven, necessarily, by money. Ironically, I went into primary care despite the money, and because of that, money will drive my every decision until that last penny of debt is paid off.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

Posted by: skylanda / 8/24/2008 10:00:00 AM

Saturday, August 23, 2008

A Summer Night in 1958

Dinah Washington: All of Me.

Catch her fooling around with the vibes during the break. She looks like she knows what she’s doing to me.

Posted by: olvlzl / 8/23/2008 08:40:00 PM

Fifteen days of blogging for health care reform: Down on the pharm

Guest post by Skylanda...and sorry folks, this is a long one!

A virile sixty-ish male chucks a football through a tire swing, raises a couple of fists in victory, and manhandles his comely wife; the final voiceover lists headache, flushing, dizziness, rash, cognitive dissonance, sudden loss of conscience, and pernicious priapism as possible unintended consequences of the little blue pill that made this moment possible. I might have just made up the side effects, but you’ve seen the ads.

If you’re old enough to remember ten years back or more, you remember a time when pharmaceutical ads did not appear on television. These ads first appeared around 1996, when changes in FDA regulations began allowing direct marketing of pharmaceuticals to consumers, bypassing the expertise of your doctor and asking you as the patient to approach your provider and ask for medication that might benefit you. Pharmaceutical peddlers now go to a lot of trouble to make sure that you know their brand names as you know the brand of your kid’s cereal: they debut ads during Superbowls, they hire ex-presidential candidates to plug drugs for conditions that no one wanted to talk about in public a year earlier (Bob Dole wants you to know that Bob Dole has trouble with his wee wee, says Bob Dole).

Among the most eye-browing raising ads I ever saw for a pharmaceutical product was for Procrit, an extraordinarily expensive injection used to drag red blood cell counts up in anemic chemotherapy patients, those with end-stage renal disease, and those doping for high altitude sports. The former patients are usually managed closely by specialists who keep an eye on issues like this, so unless you are trying to get yourself kicked off the Tour de France, this is probably not something you need to ask your doctor for. Nevertheless, these ads are more or less asking you to call up your doctor and request yourself what roughly amounts to a chemotherapy drug (Patients, ask your doctor if adriamycin is right for you today! …sorry, geek humor…move along…nothing to see here…)

The opening of the advertising for pharmaceuticals was ostensibly done equally in the name of the free market and in the name of full patient education. And indeed, there is some equalizing factor poured into the mix when you as a patient find out that there are six roughly equal allergy medications on the market instead of the one marginally effective one that your doctor has been prescribing you for ten years simply because it is the one that he or she is comfortable with. The concurrent explosion of direct-to-consumer advertising and the arrival of the world wide web have contributed to a double-edged sword for doctors: a generation of patients that is perhaps the best-informed in history, and the enormous headache of trying to sift through the raft of misleading misinformation that is now at every patient’s fingertips.

Aside from direct advertising, pharmaceutical companies have more insidious ways of inserting their buy! buy! buy! message into the public consciousness. Gone are the halcyon days of all-expense-paid golfing trips to the Bahamas to hear a one-hour lecture on the newest heart drug, but pharmaceutical money still pays its way into physicians’ minds in a variety of ways. Drug companies buy their way into trainees’ heads by providing food for required lunchtime lectures in return for a few minutes of air time on their latest product. They sponsor professional conferences, which for small states and less lucrative specialties like mine, could not happen without some commercial support (ironically, in family medicine, these conferences are often the site of ragged ongoing debate about the issues du jour surrounding affordable health care and - always - the role of drug pricing in that affordability). They litter the hallways with cheap pens, clocks, and other products bearing the flashy logo of their expensive wares. You would think that future doctors and practicing doctors wouldn’t sell out quite so cheap, but this is an awful large outlay of funds across the nation for these efforts; something must be working.

Most controversial of all is the provision of free sample drugs to clinics. Ostensibly, this is charity: who can nay-say free drugs? But by providing free drugs as a start-up pack, pharmaceuticals hope to buy patient-doctor loyalty to that brand, and this is often the case - and it is important to note that only patented, on-brand drugs are given out for free (no one runs around in fancy suits with branded pens and clocks pedaling drugs that cost four dollars a month). A patient is started on, for example, a cholesterol medication out of the doctor’s free sample closet, and once the samples run out, the patients transitions to paying for the medication at full price because it works and they are comfortable with it and they know the brand. You can see how this does not work at all as a charity for uninsured patients, it only works as a come-on for insured patients. You’ve probably seen this tactic before; it’s called “First one’s free!” and - not to be too prejudicial or anything - it’s also used by the guy selling heroin a block down the street from your local high school.

It is for all these reasons that some institutions - often at the behest of medical students and residents - have started to boot the pharmaceutical companies out of their clinics, their mailbox, their lunchrooms, and their drug closets. The integrity of education is at stake, they argue, as is the integrity of their ability to treat patients without this ultimately costly interference. The American Medical Student Association’s Pharm Free campaign has successfully spearheaded the movement to drive the pharmaceutical companies out of several major university hospitals, and is gunning for more. (Of note, some community-oriented providers have made interesting compromises with pharmaceuticals to continue providing expensive drugs without compromising patient priorities. Both community clinics I have worked in within New Mexico have had a policy of allowing pharmaceutical companies to hawk their wares and leave samples, but only those with whom the clinic has established means of continuing uninsured patients on those expensive drugs through corporate-sponsored patient assistance programs, which give a certain number of prescriptions out for free each year as a charity write-off for the drug company. Why the pharmaceutical companies even bother with these clinics, I cannot imagine - perhaps the hope that one day these patients will receive paying Medicare benefits? - but nevertheless, there it is.)

So the move is afoot to boot the pharm companies from places they should not be sticking their noses, to reclaim a less biased territory for training new doctors, and to control costs. This is a universal good, yes?

Well, it may be more complicated than that. Drug innovation is a mighty expensive enterprise. It depends who you ask (and what their motivation is for cooking the numbers in any given direction), but from the moment a drug is first thought up to the time the first commercial batch is sold off the assembly line, the total cost of developing a new drug is somewhere between $75 million and $800 million dollars. This can include versions of the drug that are canned early on because of safety or efficacy failures - expenses which biotech companies routinely swallow as a cost of doing business, which is part of why it is so hard to say exactly how much a new drug costs to get to market. And every drug that does reach the market risks being yanked later (amidst a raft of lawsuits) due to unforeseen safety problems…even a blockbuster like Vioxx. With that kind of up-front investment required of pharm companies to keep the conveyor belt of innovation moving, it requires some powerful motivation to keep the pipeline open. That motivation is known as profit. There is a danger to impinging too deeply on pharm profit, and that danger is that we slow the pipeline for innovation into advances that may be life-altering or life-saving down the road. What is the use in inventing drugs that no one can afford?, you might ask, and that is indeed the balance that has to be struck: keeping the pipeline open, but in a means that at least a useful critical mass of people can afford.

It is also useful at this point to widen out the scope of this discussion to a more global scale, to understand the role of the US market in the drug trade (the legal drug trade, that is) around the world. And for that, we have to go back in history a few years, to a very different time and place.

That place is New Hampshire, around 1944, in a town called Bretton Woods. The Allied victory was starting to look like a sure thing, and the representatives of the future victors gathered quietly to start planning for what that victory would look like. Galvanized with the understanding that punitive measures against the loser nations (especially Germany) after World War I largely sparked the disastrous build-up toward World War II in Europe, these planners sought to employ the lessons of the 1920s and 1930s toward building a better world. You’ve probably never heard of Bretton Woods, but you’ve certainly heard of at least one of the global institutions that were born or consolidated that summer in New Hampshire: the International Bank for Reconstruction & Development (later the World Bank), the International Monetary Fund, the General Agreement on Tariffs and Trade (GATT), and the United Nations, which had its roots in the post-WWI League of Nations and was formalized in the spring of the following year. Together these formed the logistical underpinning of the Marshall Plan, perhaps the most ambitious (and arguably the most successful) program ever undertaken to promote peace and prosperity in the world to date; in a couple of decades, western Europe was transformed from a zone of constant conflict and cyclical spasms of poverty into the wealthy and relatively peaceable place we know it as today.

Among these institutions, the one you are least likely to have heard of is GATT. The GATT treaty was designed to create a forum for breaking down trade barriers that had both hindered free movement of goods and people and also encouraged the kind of regional Balkanization that historically sparked wars throughout Europe. When GATT was originated, its founders probably had no idea the sort of contentiousness and riots would one day be fomented in its name wherever its representatives gathered, for what started as GATT eventually morphed into its heir child, the World Trade Organzation.

A full discussion of the WTO and its controversies is entirely beyond the scope of this post, but the role of pharmaceuticals in that morass serves as both an example and a parable of globalization and its complications. And the best place to go to study the globalization of the pharmaceutical industry is the Indian subcontinent. In 1970, India’s populist government passed a law that no pharmaceutical compound could be patented within its borders (patents, incidentally, are nation-by-nation protection; the WTO tries to enforce world-wide patents, but has no legal authority to do so, and can only attempt to wangle compliance through economic pressure on member nations); a nascent industry was born in generic knock-offs of costly medicines patented in industrial nations, unhindered by any legal ramifications of this sort of intellectual piracy. But in 1995, India joined the WTO and was given 10 years to comply with intellectual property rules (known as TRIPS - “Trade Related Aspects of Intellectual Property Rights” in one of the clumsiest excuses for an acronymn ever invented) and cut out the business of knocking off expensive drugs invented in other countries. The intervening ten years saw some profound advances in the treatment of cancer, AIDS, and other devastating diseases, and the dust is still settling on the nuances of which patents are enforceable in the massive Indian pharmaceutical business (some drugs were patented before 1995 but not marketed til later; others receive exemptions from WTO patent rules for their life-saving public health properties; the gritty details go on and on).

The moral right of Indian generic pharmaceutical producers to knock off patent medicines is a tricky one. On one hand, India has a burgeoning population to take care of, and its pharmaceutical industry has traditionally also been a prime source of drugs for developing nations that do not have infrastructure to produce their own nor the cash to buy them on the global market from legitimate producers. On the other hand, lopping a billion or so of the increasingly wealthy Indian people out of the profit-making market for any given drug is liable to put such a crimp on expected revenues that it may hinder motivation for new drugs to be sent down the pipeline in first world countries, when corporations know that these drugs can be knocked off the moment they start coming down the production line. Patent rights may still to this day be threatened on newly marketed drugs because many compounds are patented years before they are proven to be at all useful; this was the driving logic behind the Gleevec decision (which allowed generic versions of a very expensive cancer drug in India), of which I wrote extensively two years ago in this very forum.

Which brings us back to the role of the US market in global drug development. We all know that Americans pay more for the same drugs, no matter how many variables you adjust, than any other nation in the world. Sometimes on an exponential scale. While pricing out drugs in a number of nations for the masters thesis I wrote on TB pharmaceuticals, I stumbled across a policy paper out of the British National Health Service that unequivocably declared that the antibiotic Avelox - at some two pounds per pill - was far too expensive to consider as a first-line drug for any known condition. In translating that number through the exchange rate, I generously doubled two pounds to four dollars (to account for our ghastly exchange rate at the moment) and looked up the price per pill at Walgreen’s: ten bucks a pill. Two and a half times a number that the British medical authorities had deemed too ridiculously expensive to consider for routine use. Avelox is on formulary at the hospital where I work now; not a day goes that we don’t have someone on the inpatient service taking this drug. The mind does boggle.

We pay for prescription drugs at a rate that would impress your local cocaine pusher. We do it because we can, we do it because we’ve been pushed into it, we do it because we have such an obscured system that the only people who actually know the true retail price of a drug are those who are paying out of pocket without insurance coverage. And when we get fed up with it, we get sneaky and order our prescriptions from Canada or India or Mexico and feel like we’ve just got the deal of the century over it (and on that note, here’s today’s PSA: order drugs from Canada, fine, that’s a developed nation with drug standards similar to our own; but caveat emptor if you order medications from developing nations, including India - serious questions of purity, efficacy, and even content have arisen, especially in batches sent abroad to unsuspecting and well-paying foreign buyers). But if you start to strand out the threads of the story, you’ll find that it is not only the pharmaceutical companies that are parasiting off the American consumer; in a very real way, drug consumers in other nations aren’t just getting a better deal than American patients, they are quite literally freeloading off Americans who pay full price for medication. And here’s why:

When a multinational pharmaceutical corporation looks at a promising compound and calculates the plausible return on investment if they take that compound into trials, part of that profit projection comes from bloated, high-roller drug costs in the good ol’ USofA. A large part. If you removed the American portion of that profit margin (or just tightened its belt by a good notch), you would be looking at a far thinner profile. Investment into patent drugs sits heavily on the American consumer; you may eat your shirt every time you pay a hundred bucks for a month’s worth of one drug, but come on, revel in it: you’re ensuring the next generation of cancer cures, blood pressure controllers, and cholesterol fighters in a way that consumers throughout the rest of the world are not contributing so much.

If only the truth were so clear-cut as that murky road home, eh? But of course there is one more twist. And that twist is that the pharmaceutical pipeline is not necessarily as responsive to consumer needs - even the very American consumer that feeds it money-hungry maw - as we might like it to be. You would like to see a safer, more effective treatment for cancer this year; what you get instead is yet another cholesterol drug, in the same class as a half dozen other cholesterol drugs, that is one atom different and costs ten times more than those that have gone generic for no provable increased benefit. You want to a new class of antiretrovirals - AIDS drugs - to see the market this decade; what you get is a blood pressure drug in the same class as ten other blood pressure drugs…again, for an increased price, with little increased benefit. How on earth do you get anyone to buy this stuff - same product, higher price - you might ask? Well, go back to the beginning of this wordy diatribe…advertising, accessing young doctors at their places of training, building brand loyalty through free sampling, obscuring the true cost by filtering it through the insurance industry. The cycle is vicious indeed.

So where do we go from here? We can’t single-handedly redirect corporate funds to socially worthy drugs over yet another branded me-too blood pressure drug, or reform the WTO stance on patent medications (although throwing rocks at WTO conventions seems popular enough world-wide to make an Olympic sport of it). But remarkably, this is an area where patients as individuals do have a marked bit of control. You buy this stuff, you are a market force. Here’s how you can use your dollars to effect this issue.

First of all, the next time a doctor prescribes you a medication, you have the right (you might get a little annoyance in return - but still, you have the right) to ask these questions: Is this the cheapest effective drug for my condition? Are there generic alternatives that are equally effective? If I am being prescribed an expensive medication in a class where there are cheaper alternatives, why is that? You may get a legitimate answer to this last question: because you had side effects to the cheaper alternatives that we tried, remember?; because your condition is severe enough that we go for broke with the absolute best in the class; because the expensive medication happens to be on your insurance provider’s formulary, while a less expensive one is not; because there is no cheaper effective alternative. But many times, there is no good answer, and the next right answer is: There is no good reason why; let’s try a cheaper alternative instead.

Second, you can understand that pharmacies are a market like any other, and that drug prices vary wildly between them. Call around next time you get a prescription and ask how much it will cost before you fill it, even if your insurance will cover it; the answer may surprise you (when I was between insurance plans once, I paid $18 for prescription eye drops that I later found out I could get for $4 down the street…I‘m not talking about fifty cents, I‘m talking about a four-fold price difference). Part (but not all) of this variation is wrapped up in the four-dollar prescription programs at Walmart, Target, K-Mart, and a few chain groceries like Smiths. Far be it for me to gives props to the vortex of social ills that is Walmart, but credit where credit is due: Walmart initiated the four-dollar pharmaceutical plan a couple years ago to provide a month‘s worth of certain generic prescription drugs at a fixed price (a couple hundred different medications at last count), and the others scrambled to follow suit. Walmart surely crunched some heavy numbers before establishing this policy, some numbers that ensure market share and profitability and competitive edge over the mom-and-pop pharmacies that you would love to support instead of the globe-eating big-box chain, but still: gotta give some credit for affordability, transparency of cost, and ease of accessing their list.

Third, you can refuse (unless there is good reason to do otherwise) to buy expensive, new-generation medications for which there is an older, cheaper equivalent. Market forces allow the continued arrival of me-too drugs, and as consumers, we can just refuse to buy them unless there is some pressing reason to do so. Your single purchase won’t re-shape the market, but if as a whole nation we start refusing to buy me-too drugs at inflated prices, the incentive to continue investing in them (instead of in truly innovative and necessary classes of drugs) will dry up.

But eventually we have to tackle the core idea of the how much we are willing to pay for truly spectacular new drugs - cancer cures, HIV treatments, and the like. These will continue to filter down the pipeline to us if we are willing to pay for them - but the price is steep. The top tag I’ve seen cited on a medication is a whomping $100,000 per year for Avastin, a drug which chokes off the blood supply to breast and colon cancers. These drugs arrive because of market forces, and it is entirely possible that we have other priorities that are more important - such as covering all diabetics with drugs that we already know to save lives. Maybe we don’t need a pipeline of new drugs bad enough to pay what we are being asked to pay for them. Maybe innovation should slow a bit to accommodate a market that cannot handle this kind of expense. Maybe the inflated pharmaceutical market needs to accept a slow-down before it hits the kind of skids the similarly inflated mortgage market just took in the gut.

Or perhaps we can work collectively to cap prices while maintaining incentive, by means like trading government or university funding for caps on prices (the former is already in effect, the latter has not generally been demanded yet), or allowing increased patent times in return for limits on prices or guaranteed supplies to patients who cannot pay.

There is no one answer, no victorious football-through-the-tireswing to mark a successful remedy to the question of balancing drugs and prices in America and throughout the world. What we have is a big, snarly, expensive problem. What we need are thoughtful, balanced, comprehensive solutions. And those are never easy to come by.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

Posted by: skylanda / 8/23/2008 10:00:00 AM

Friday, August 22, 2008

Bound and gagged (by Suzie)

From an interview with Jewel Staite, who plays Dr. Keller in the sci-fi TV show Stargate Atlantis:

So I understand that Dr. Keller gets tied up in the woods in like every other episode of Stargate. What's up with that?
Yeah, I don't know what that's about. In season four, I was kidnapped and bound and gagged. This year, it's happened to me twice so far. And I just read yet another script where I am again bound and gagged… .
Is there a site somewhere where they're charging five dollars a minute? Is it a fetish thing?
Maybe that's what it is. … And it's the same writer every time that writes the episode where I'm being kidnapped. Maybe he likes seeing me dragged through the woods. I don't know what's going on. And you know what? I don't question it. I guess. At least he's writing for me.

Since he’s not writing for me, here’s a question: If Dr. Keller were a man, would there be as many scenes of him bound and gagged? ETA: Maybe so! Please see the comments.

Update: Stargate Atlantis has been canceled.

Posted by: Suzie / 8/22/2008 10:32:00 AM

Fifteen days of blogging for health care reform: End of the road

Guest post by Skylanda.

Several months ago, I was admitting a gentleman to the general medicine floor of the university hospital. Per protocol, I gave him our standard speech about how we don’t expect him to drop over dead during this admission, but in case he did, we needed to know in advance if he would like us to make all attempts at resuscitation or let him to die peacefully. I promise, the speech came out a good deal more gently than that; the first time an intern has to ask this it usually feels awkward, but after a several dozen times, you get down a speech that you feel comfortable with, that patients don’t recoil in horror to, and you make it part of your routine admission. It’s quite far from the weirdest thing we do every day, believe me (rectal exams: now there‘s one of the weirdest things we do every day).

“Well,” this gentleman said thoughtfully, “I guess you can bring me back. Just so long as they don’t keep me alive like a vegetable or something. I just don’t want to be a burden on anyone.”

This a guy who was being admitted for the sixth time in as many months for one of those diseases you develop by following a particular lifestyle. He had been abstaining from his vice of choice for some number of weeks, and had been asymptomatic of the disease it had been causing, but that evening something had provoked him to hit up one of the local houses of marginal repute. He sat down at a slot machine, he indulged, he landed on our floor via ambulance an hour later, groaning in pain and wondering if this was the event that was finally going to get him.

His response was not new; you might have thought it - or said it - yourself if you’d been asked the question. But it brings up the question: what does it mean to be a burden? Who is a burden on the system? More aptly, is any one of us not a burden on the system? What do we do with those who cost so much for individual care that we are forced to consider the financial consequences of that care on the larger picture - that is, the health we cannot provide to others because of the gross expenditure we are pouring into one person?

There is much rhetoric around the idea of being a burden, or of not wanting to become one. Most of this comes from healthy able-bodied people who do not actually have to face down the question - now, today - of whether or not they want their own burdensome self taken off the human map. Much of this rhetoric is sanctimonious in nature: “I would never want to live like that,” it says of the disabled body or ill body; “Kill me if I ever need a machine to help me breathe, or a tube to help me eat,” it threatens. This rhetoric makes movies like Million Dollar Baby; it creates Jerry Lewis telethons where the disabled are reified as hapless children incapable of anything but receiving your benevolent charity; it finds tragedy in disability, and redemption in a throw-yourself-on-the-fire-for-the-greater-good stance from the disabled, who usually have zero interest in throwing themselves on fires for the comfort of others. It inspires a hypervigilant but entirely necessary form of activism known as the disability rights movement, spearheaded by people with precisely those conditions who have decided that indeed, they would not like to be invited to die just because they require a tube to eat or a wheelchair to move about the world in.

But let’s back up a second. What does it mean to be a burden? On one hand, you could define a “burden” as someone who requires so much individual care that it profoundly disrupts the lives of the people around them, reorienting entire families around the care of a sick member. Financially, you could call a “burden” anyone who draws more off the health care system than they pay into it. The popular rhetoric on this topic would have you believe that the follow groups are the most frequent offenders in the category of “burdens” on the system: Illegal immigrants. Those who frequently visit the emergency room instead of accessing primary care. Severely disabled people. Uninsured patients who don‘t pay their hospital bills. People who smoke. People who don’t eat right and don’t exercise. Drinkers. Drug addicts. Fat people.

I beg to differ with that rhetoric. I argue that just about every last one of us is a burden on the system. There are many reasons why, and here is the first: because at the current cost of medical services, any of us who use any quantity of medical services in a given year - even those of us paying out the nose to maintain private insurance premiums - are likely using more resources than we are paying in. In one particular year of medical school - when I was grousing about paying cash out of student loan funds (which I will be repaying, with interest, for the next thirty years) for a group health insurance plan, I was treated for two benign conditions: chronic migraines, and an allergic reaction to a skin infection that required a long course of powerful antibiotics overseen by a dermatologist. Nothing profound, nothing terribly out of the ordinary. But unless my insurance company was bargaining far lower prices than were showing up my billing summaries, those alone racked up costs in excess of my total premiums. There I am: a burden on society. Few but the healthiest people won’t suddenly rack up costs in excess of their contribution even with just a couple of routine conditions - this is one reason (among myriad others) why premiums go up every year but never seem to quite catch up.

The second way most people become a burden on the system is by outliving their own health. You can be the most good eatin’, clean livin’, regular exercising’ guy or gal on the block, but eventually something is going to get you. And unless that something kills you dead (say, a full frontal bus wreck or a drop-dead cardiac arrest) before you have any chance to haul your rear end into your local health care provider, it doesn’t matter how old you got to be before that bad stuff caught up with you: you too are now a burden on society.

This is the dirty little secret of the public health world we like to call the “prevention paradox”: that good preventive care saves money now, but it generally does not save money in the long run. Here is why: people who stay healthy live longer and take incrementally more out of the system year by year using those preventive and routine services than someone who dies younger. And eventually, all those healthy people will get old, and they will die of something; in the months just before they do just that, they will - on average - run up some astronomical medical bills that short circuit all the savings they accrued over all those long years of good health.

The irony of course is that we spend ungodly sums of money in America to keep people alive during the time of their lives when they are least likely to benefit. Where we hedge about vaccinations for children and click a mouse to donate one hundredth of a free mammogram to a middle-aged adult, we seem quite happy to hurl sums worthy of the national defense budget into stretching life out another month or two when the writing is so clearly on the wall. Bang per buck, keeping a ninety year-old alive for another three months at the cost of four hospital stays does not make near as much sense as getting the whole population to ninety as healthy and happy as can do. You better enjoy those last six months - hospitalizations, crises, dialysis, adult diapers, and all - because they will cost you (or, that is, cost the collective us) some hundreds of thousands of dollars to drag that end heroically out to the last possible second.

And since we are all playing a part in this all-consuming system suck together, it is time to dispense of the notion of who is a bigger burden than whom else. Your contribution to the insurance pool - assuming you do pay insurance premiums - is a poor marginal quantity compared to what you will in all likelihood one day draw off of it. The leg you stand on when feeling self-righteous about your contribution over the contribution of the illegal alien who picks your grapes, or the guy down the street who is that much fatter than you, or the kid with cerebral palsy who needs monthly health maintenance, or the smoker next door, is an ephemeral and illusory source of self-righteousness indeed. Promoting health for the sake of quality of life, controlling cost along the way, and doing some serious soul searching about our emphasis on end-of-life heroics over end-of-life comfort…these are the things that diverge the pathway of “burden” from the pathway of reasonable cost. Not whether you pay your premiums or not, not whether you were born in the country or not, not whether you use a wheelchair, and not whether your BMI fits between the numbers 20.1 and 24.9. Thusfar, the most of us can wear that scarlet B for “burden” without standing out from any kind of crowd.

As for the gentleman I admitted to the hospital that night, he survived just fine to be a burden for another day. Good for him.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

Posted by: skylanda / 8/22/2008 10:00:00 AM

When Men Not Only Let Their Hangups Show But Hang Them For Display Themselves by Anthony McCarthy

What is this about, anyway?

Maybe you already knew but I gladly acknowledge my spotty education had left me ignorant of “truck nuts” until a friend told me about them yesterday. For those of you who are as behind the times as I am, they are simulated testicles in a scrotum meant to be hung below the trailer hitch of a truck. Self awareness isn’t high among the attributes of the macho mind but this is too obviously weird to miss.

When he first told me, I thought my friend was pulling my, uh, leg. Then I looked it up and found out that it, seriously, is going on. And until I read deeply on the subject I hadn’t suspected it was a mature cultural expression complete with artistic evolution, esthetic nuance and moral ramifications.

* There are two major differences between the 1st Generation AND the 2nd Generation of Truck Balls developed by BullsBalls.com.

* The Original 2nd Generation Balls are 2" shorter and have the hole through the side rather than front to back like the 1st Generation Balls. (top hanger type)

* This 2nd Generation Balls * Lock-and-Chain Mounting System was designed primarily for ALL trucks (1/2, 3/4 and 1 tons) with the 2" x 2" hitch receiver tube on the truck. Simply wrap the chain around the hitch receiver tube, snug it up and lock it in place, rotating the brass lock up on top out of sight. (no tools required)

# This slightly shorter length also works well for vehicles OTHER than 1/2, 3/4 and 1 ton trucks, such as suvs, cars, quads & bikes.

# 2nd Generation Balls are shorter and lighter, however they have not lost the hefty, fullness of the O r i g i n a l 1st Generation Bulls Balls and Big Boy Nuts.

# Our 2nd Generation chain balls allow more ways to hang AND they remain swinging even when pulling a trailer, also this design prevents the negative look of flippity flopping of the nuts at higher speeds. They simply float nicely as the air pushes them gently up and back.

# Also with the hanging chain and padlock ( included ) they are much more secure from impromptu theft. At least the bad guys have to bring a pair of " Bolt Cutters."

Yes, that unsightly flippity flopping at higher speeds is just so off putting. No doubt we can all appreciate that the “hefty, fullness of the Original” was retained in the second generation. You appreciate that they’re fairly redolent with quality. Standards to rival those of many Olympic sporting events. It’s nice to see that there’s one part of the Bush economy that isn’t lagging, drooping or cutting back.

A quick google of the them will show they are sold in many colors, including brass and other metallic colors. The message of those is probably self explanatory. If I could make an critical point, the symbolism might be a bit muddled on the blue ones.

Who is supposed to admire these things? Women, either lesbian or straight? I don’t think the right sound to express the idea that a woman would find these alluring can be produced by the human vocal apparatus. Eeeew! doesn’t get to the start of it. One hopes that it isn’t gay men who are supposed to find this attractive, at least this gay man hopes not. If either straight women or gay men could be attracted to intimacy by these, I despair of humanity.

That leaves only one segment of the possible audience and the thought of straight men hanging these for the admiration of other straight men, the implications of which are too twisted to follow. As my friend said, men are buying them and crawling under their trucks to install them, so this isn’t an unconsidered act. What does it mean? It’s not Yosemite Sam on a mud flap. Anyone care to speculate?

Posted by: olvlzl / 8/22/2008 07:27:00 AM