The illogical economics of health care

Atul Gawande writes of one medical innovation that threatens to bankrupt the innovators:

Recently, clinicians at Children’s Hospital Boston adopted a more systematic approach for managing inner-city children who suffer severe asthma attacks, by introducing a bundle of preventive measures. Insurance would cover just one: prescribing an inhaler. The hospital agreed to pay for the rest, which included nurses who would visit parents after discharge and make sure that they had their child’s medicine, knew how to administer it, and had a follow-up appointment with a pediatrician; home inspections for mold and pests; and vacuum cleaners for families without one (which is cheaper than medication). After a year, the hospital readmission rate for these patients dropped by more than eighty per cent, and costs plunged. But an empty hospital bed is a revenue loss, and asthma is Children’s Hospital’s leading source of admissions. Under the current system, this sensible program could threaten to bankrupt it. So far, neither the government nor the insurance companies have figured out a solution.

The health care reform law tries to encourage such innovations through a new "Center for Medicare and Medicaid Innovation" where communities can experiment with different payment rules. For example, hospitals could be paid a set amount for asthmatic children regardless of how much treatment the children are provided. But there is no guarantee, of course, that any of this will work mainly because it goes dramatically against the incentives of physicians now to reduce the amount of care. My daughter's eye doctor wanted to check her for glasses three times in a period of six months! When I gently pushed back, I was told that it would be okay to come back in a year. As Gawande notes:

That’s the one truly scary thing about health reform: far from being a government takeover, it counts on local communities and clinicians for success.

Loss aversion at five

S2, the five-year old has just discovered jokes.  "Why did the banana cross the road?," she asked me a few weeks ago, pausing a few seconds before squealing out "because it wanted to be a banana split!" She tried out the joke on every adult she met for the next few days and that got her hankering for a banana split.  I promised her that I would get her a banana split if she did well at a forthcoming piano audition. She did do well today, and so we took the kids to Braum's.

S1, the eight-year old, decided that he wanted a strawberry shortcake. "I too want a strawberry shortcake," said S2.

"But," I protested, "you've been looking forward to a banana split for a month!"

"I want to get the same thing as S1," she said.  So, strawberry shortcake it was.

"You need to do what you want to do," I suggested, "and not just change your mind because S1 is doing something different." 

"But I want to taste what S1 is having."

"S1 would have let you have a spoon of his ice cream if you'd asked him.  You didn't need to also get the same thing."

"What if I have a taste of his ice cream and it is way, way better than mine?"

Becoming Africa?

A friend who also grew up in Africa, remarking on the threats to Democrats after the health-care vote, worried:  "This is becoming just like Africa."

I was 10 years old when I lived through my first coup d'etat.  The angry rhetoric, tweets about cross-hairs and reloading, bricks through windows, etc. do not quite match to the sense of foreboding and dread that precedes all hell breaking loose. 

So, no, we are not becoming Africa. But we need to watch it.  It won't take much.

Nutritional labeling coming soon to a restaurant near you

The health care bill that was recently passed has many, many cost control measures. Pretty much anything that anybody has suggested (tort reform being an obvious exception) is in the bill. They won't all work, but some of them will.

One of the ideas is that if restaurants post nutrition information, restaurants will be forced to use healthier ingredients because their customers will be able to do comparisons. The theory is that this will lead to better public health, and thus lower health care inflation (the link is from 2003: it took this health reform bill to make it law). The theory itself is debatable -- one study found that many customers will order the high-calorie items under a mistaken belief that they are a better deal. However, many more studies with larger samples have found that people eat healthier because of nutritional labels on processed foods. Any how, restaurants have to post calorie counts for all their meals. Who knows? It might make us healthier and bring health costs down. The cost to a restaurant chain? $200 per menu item. Peanuts in other words (Restaurants with fewer than 20 locations are exempted).

A very simple reform, right? Restaurants have to post the nutritional value of their meals and what percentage the fat content (for example) is of the USDA daily recommendation. Well, this is how the actual law looks. This is because all laws amend earlier laws. Laws are extremely hard to read, so the right-wing demagoguery against bills that are thousands of pages long is quite disingenuous.

I, for one, am looking forward to seeing nutritional labels at restaurants soon.

P.S. The National Restaurant Association is in favor. They'd rather have a national law than deal with a California law and a New York law each of which is different -- another example of how the Democrats bought off every interest group in advance.

The silver lining

The BBC reports:
"A receding hairline can be a good thing, according to US scientists, who say men who go bald by 30 appear to be less likely to develop prostate cancer."

A totally desi place

How full of desis are the New Jersey suburbs of New York City? So full that even the perverts are desis:

He's been going up behind females who were waiting for the bus or just walking and just urinating on the back of their leg. According to WPIX, Nitinkuma Patel was nabbed after a plainsclothes police officer saw him peeing on a 16-year-old girl at a bus stop. Patel allegedly would strike "between the hours of 7 a.m. and 9 a.m., when young women were headed to work and school," targeting females in their teens to early 30s.

Deja vu all over again

Long-time readers will remember last winter's mailbox saga. I went to pick up the newspaper this morning when I noticed this:

There are no tire marks this time. No cringing person showed up on our doorstep last night. The top of the mailbox is not by the curb either. This one's probably a deliberate act of vandalism.
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The Bronx paradox: why obese people are also the most hungry

The "Bronx paradox" is hard to get your mind around: in America, the most obese individuals are also the most hungry. It is truly a paradox: after all, if you are obese, shouldn't you be having too much food rather than not enough?

The explanation goes something like this: obesity in America is a marker of poverty. The individual may be obese not because they have too much food but because the only food they can eat is unhealthy -- healthful foods are more expensive. But if they have food -- healthy food or unhealthy food -- why they are hungry? I assume that's also a function of poverty -- they may have unhealthy food early in the month (when they've just been paid) and no food at the end of the month.

p.s. With this in mind, go read this know-nothing, nasty bit of work.

Not such a bargain after all

Spring is almost here and the wife insists that I bag the first time I mow the lawn -- she finds dried grass mulch unattractive. That and the garden needing to be tilled were giving me a guilt trip until I found a lawn care duo willing to do both jobs for the bargain price of $75. $75 to save 3 hours? Show me where to sign.

They showed up yesterday and mowed, edged and trimmed the lawn and tilled the garden. This afternoon, when I switched on the sprinkler was when I realized the drawbacks of a $75 job. One of the sprinkler heads was broken -- it must have been sticking out and the fellows must have mowed the head right off.

A trip to the hardware store, and I came back with a 4" pop-up sprinkler. "Screw the old one off," the sales guy told me, "and screw this one on." Easier said than done. I wrenched the old one loose but the hole that housed the sprinkler flooded immediately. So, the old sprinkler is off but the new one's not on. I'm hoping that the place drains enough by tomorrow for me to clean out the threads and screw this on.

UPDATE: Nope, the sprinkler pipe is below the water table. I need to call a sprinkler repair guy to pump out the water and replace the pipe. Another $100 perhaps.

Contradictory fears, but still a No vote

Bart Stupak will not vote for health care reform because he believes that the Senate bill is not strong enough against abortions. The Senate bill says that federal money can not go towards abortions, but Stupak is concerned that millions of people will get federal subsidies to buy private health insurance and many (most?) private insurance plans do cover abortion.

This objection is truly illogical: someone one who gets federal subsidies to open a small business might also smoke pot on the side. Does that mean the federal government is subsidizing his pot habit? More to the point, private insurers all cover abortion because (even though it is illegal to explicitly carry out this cost-benefit analysis) abortions are cheaper than prenatal care. Stupak's beef is with private insurers, not with the federal government.

On the reverse side of the coin, several Hispanic Democrats are threatening to bolt because illegal immigrants would be prohibited from buying private insurance in the federally-regulated exchanges. Similar to the abortion language, illegal immigrants can not get federal subsidies anyway. What the Senate bill does is that it prohibits private insurance companies from taking on illegal immigrants. The Senate bill is idiotic: it is like prohibiting Southwest Airlines from selling tickets to illegal immigrants. So, the Hispanic legislators do have a point. But such rules go against the best interest of the industries in question -- no industry wants to turn away customers who voluntary give it business. You can be sure that the law is not going to work.

The common thread to both the abortion and the immigration argument is that they imagine that the federal government can actually ban abortion coverage or ban coverage of illegal immigrants. The law tries to do one and not the other. But neither effort is going to work because insurance companies will make more money by covering abortion and by covering illegal immigrants. Both will go on regardless of whether health reform passes or not, and regardless of what the law says. Bart Stupak is fighting a losing battle and the Hispanic legislators are afraid of a phantom threat. Unfortunately, even though their fears are exactly contradictory, both these groups are "No" votes on health reform.

The madness of uncoordinated sports fans

There is such a thing as too much government transparency. The city government in Edmonton, Canada publishes water consumption in real-time. An enterprising soul grabbed the data and annotated the graph around the time of the Olympic Hockey game to create one of the funniest mashups I've ever seen:
You can over-analyze this graph, but I just want to point out that folks were pre-clearing their bladders for the game (compare the water usage just before the game started with the green baseline). Then, you can literally hear their thoughts as they decide to hold off to the end of each quarter and the medal ceremony.

Priceless view into the madness of crowds.

Stupidity taxes

Towards the end of preparing my tax return, I came upon a tax screen that asked if I wanted to pay the filing fees using "Simple Pay". The text explained that the fees would be deducted from my tax refund and so I wouldn't have to plug in my credit card number. But there was a worrying asterisk right by the name, so I found the fine print that led to the popup window that finally explained that the "convenience fee" for the $20 filing fee was $29.95!

A quick Google Search points out that there are enough suckers who fell for that ruse. This is probably the sort of thing that a Consumer Finance Agency should help put a kibosh to.

But while we are at it, why on earth am I filling out taxes in the first place? The IRS already had nearly every bit of data that I entered in, and so it could have simply sent me a prefilled form that I could have corrected in 10 minutes. This one turns out to be the doing of Intuit and right-wing nuts. So, whatever time and effort you spent filing your income taxes is another stupidity tax. Only, this time no amount of trawling through the fine print would have helped you avoid it.

p.s. Once H R Block has decided to take advantage of its customers by piling a $30 fee on top of a $20 one, why do they feel the need to put in that pesky asterisk?

Chopsticks for the five-year old!

The wife will not allow the five-year old to eat Cheetos in the car because of the "orange crap" that she might then get on all the upholstery.

Time, perhaps, to get her started on chopsticks.

Political correctness leads to unflattering juxtaposition

To my surprise, Asha Bosle was screeching out from NPR this morning. The segment turned out to be labeled "50 great voices". She is popular, yes, but wouldn't -- shouldn't -- make any list of magnificent voices. I had to go to the website to find out what their selection criteria were. And it's as addled as anything you'd expect out of a bunch of liberal artsy types:
what this project should do is look at artists who are great, but not as recognizable or as obvious a choice as Frank [Sinatra] ... The bedrock of 50 Great Voices is the emphasis on singers from abroad. We wanted to find out who are the Frank Sinatras and Aretha Franklins in other countries.
In effect, their segment aims to explicitly try to find undiscovered voices. And, yet, the undiscovered Indian voices they find are Lata Mangeshkar and Asha Bosle, two of the most ubiquitous voices in Indian popular music.

I would have no problem if they had included Frank Sinatra and Asha Bosle in the same list. Then, the criterion would have been popularity. Or kept Mahalia Jackson and chosen M. S. Subbulakshmi or Rabindranath Tagore, in which case the criterion would have been rich cultural influence.

Instead, you have a selection that picks authentic, rich Western voices and popular, tinny non-Western ones, leading to a very glaring and unflattering juxtaposition. All with the best intentions, of course.