Monday, July 27, 2015

WHY CANCER CARE COSTS SO MUCH?

They ask, sometime in pure ignorance and oft times with incredulity, “why is cancer care so expensive?”

The rabbit hole is deep and dark, but if you shine the light, you can see the trail of the smoking caterpillar. 

Some try to create cost algorithm based on survival benefit of a drug on cancer care, others are trying to legislate lower costs, while still others reach out for subsidies from the eternal fountain of taxpayer wealth. Life in these United States is indeed interesting.

While searching for a gradient to seek the fissures of thought, let me break it down by category:

Drug development: The claim is that bringing a new drug to market is valued at $2.6 Billion (of which $1.2 Billion are time costs). ① 
Incurred in this cost is the old premise that of the 5000 drugs tested only one enters the market, showing benefit in the petri dish, mouse model and then through human Phase I and II trials leading to FDA approval. That $1.4 billion in actual expense is amortized over the next 7 years of patent protection with a certain Return on Investment or ROI for the risk undertaken by the company. There are quite a few “wrong-headed methodologies” in use there. ② However not all costs are related to drug development, some are purely annual price increases to keep up with the earnings per share (EPS).

Insurers: The Cost to insurers is defrayed easily by the price of the premiums. In essence for all the talk of “Risk Mitigation” from the insurers, there is little risk involved, except the agency risk of losing a bonus for the managers should the benchmark of the stock price not reach the intended target. Overall unless you happen to take some real wild risks like AIG with Credit Default Swaps and the like, your chance as an insurer of an extremal event is nigh impossible. ③ Meanwhile as the money trail indicates that the Insurers paid $102 million to lobby the congress to tweak the Obamacare and in return the Health Care Index has risen by 305% over the past three years! Stupendous Returns eh?


Supply and Demand: If a drug is developed for a condition that afflicts only a few souls, it is given an orphan drug status. The price of the drug development will always be high to amortize the drug development costs. But a drug for an affliction of the masses should not be that expensive. The case in point is a company named Dendreon and their drug product Provenge used for Prostate Cancer. The Provenge cost was $93,000 per treatment and enhanced survival by only 4 months led to the eventual decline in the fortunes of that company into a bankruptcy. ④ 

The fault line in this exceedingly pure appearing surface had been discovered. But there were two important lessons from that case; one, the concept of using immunity against malignancies and two, careful how you price the product with limited benefit. Careful of the faint light that beckons, like a mirage, and then dies. 

Oncologists in delivery of care: Much is made of the physician who uses the expensive medicine for his or her own benefit. Fortunately except in a select few unfortunate cases, the majority of the physicians use cancer drugs based on the data they have for the fullest benefit to their patients. This might appear a heresy to the journalists since it does not follow their narrative, but based on talking with my colleagues, the foregoing is a fact. The problem in most cases is the transparency of the drug cost itself. We as oncologists offer treatment on the basis of the best benefit against the malignancy and not necessarily based on cost to benefit ratio. We are after all doctors and not businessmen or women. Our purpose is to heal. And therein is the crux of the matter. Big Pharma and Biotech companies know our ethos and price their products according to their cost plus ROIs. Unfortunately more often than not the “studies” being quoted are based on a low “n” and tortured statistics based on assumptions that carry their argument. The studies are touted as the next best thing since sliced bread! ⑤. The fault may not fall too far from the physicians either at times when more expensive drugs are used where cheaper ones would suffice. The human dignity is best served through truth.

Mini-incrementalism:  There are very few large leaps in oncology patient care, more of the medical literature litters the landscape with mini-incrementalism in benefits through the tortured use of Progression Free Survival or PFS. Unfortunately half of those studies cannot be verified or validated. The purpose in some cases is a continuous source of incremental revenue. This is by far the most destructive force in medicine today. Read here on...PFS

800lb Gorilla: The Insurer-Lobbyist-Expert-Middling-Manager remains the big culprit. Realizing that from 1970 to 2009 physician population increased minimally  less than 5% in spite of the total population of the United States that grew to 320 million, the administrators however grew by over 3000% according to the Bureau of Labor Statistics (BLS).



To apply the Supply – Demand metrics to the oncology dilemma is akin to creating a skin in the game for the two main entities concerned; the patient and the physician. If the patient cannot afford the medication then the volume will dry up and the cost of the product will of necessity go down as long as the intermediaries are not in the process of processing these payments and extracting their bounty. Already China rejected the patent for Solvadi ($84,000 drug against Hepatitis C) India and France successfully negotiated the cost at 70% less. But in truth if one looks at the cost of the Hepatitis C infection, its complications and overall health costs of are for the illness, the cost of Solvadi is actually a fraction of that expense ⑥. Using mandated price controls however is a top-down measure that governments and policy makers use in an attempt to control price and show how they are working for the public benefit. Alas price controls never achieve their objective of cost reduction but in effect becomes the force du jour for control of care and higher prices.

We have come a long way baby! True. But where we are going is not that long. At this rate it will be a long hard winter soon and the chilling frost will last a very long time. 

References:


Saturday, July 18, 2015

INCENTIVES

What drives you is the same as what motivates you? Provocative, yes, but that statement needs an answer in your own silence.

We have long been stretched across the mountainous range of incentives; the higher the peak the better the result is the dogma. But is that true?



Behavior Theorists will say yes. They as you know have confused the issues of Mice and Men. Pavlov’s old ghost that rewarded with a snack from the correctly recognized trap door vs an electric shock from the wrong one in mice works to do more harm than good in the short and the long run both in mice and men. Mice are synaptically hard-wired to reach a certain destination to receive a reward in forms of food and little else. In men watching the mice, it accentuates their resolve of incentives to potentially enhance productivity.

Incentives are both Intrinsic and Extrinsic. The former have a moral compass attached to them and the latter are more coercive in nature. Or let us just say the difference is between, “what I want to do, vs. what you want me to do.” The misguided mind wishes to enforce the extrinsic incentives to modulate the intrinsic ones and that, time, data and reason suggest is impossible – Edwin Locke (Ref # 1)

The misguided view of such thought is obvious. Pavlov’s conditioning is based on avoidance as much as it is in survival. The human kind mistakes that as increase in productivity causal through rewards. Our weaknesses are revealed under the uncompromising high altitude truths and there we find; rewards that feed desires quickly cause the hunger of understanding to flame out faster and with that exploration and innovation.

What good do incentives do then? Here are a few answers you will hear from the managers who have grown up with the “If this then that” concept of the American way of life.

1.       1. Productivity goes up! Does it? The answer in the short term is it does but then as more productivity is needed to keep the incentive, the quality goes south. The initial incentive creates a temporary phenomenon which fades quickly forcing the manager to go back for more and more of the manna. The classic fallacy that follows is; the initial hypothesis is correct and therefore more incentivizing is needed. The spiraling structure rides the next turn of the screw. Ultimately the train of thought has to reach a destination and it does when the cost per widget equals the profit from that widget and demand equals supply. To the manager who benefits from incentive programs because of his own bonus tied to it, it is always a “self-fulfilling prophecy,” when things go bad from good and he chimes his new incentive program as the panacea for success.

2.     2.   It motivates the producer. Does it? Temporarily, but it also creates a window of discontent from the others in the field who are without the incentives and feel inferior or “left out.” This particular cycle ends viciously in employee rivalry and competing for the finite pool of incentives thus leading to short cuts and loss of real productivity in the intermediate and long term. It is demoralizing to the ones who do not receive the incentives to continue with their daily workload with the same enthusiasm.

3.      3.  It benefits the manager. Yes that it does!

Mimi and Eunice

What bad do incentives do? Plenty!

1.       1. Incentives do not lead to an enduring commitment to any action or any program. Rewards have a similar effect on the human behavior as punishment and both in the end from the individual’s perspective feel like manipulation.

2.       2. Individual gain becomes the name of the game. Call it the Agency problem where the incentivized motivated manager cares only for the short term solution for a long term issue. Example a CEO/CFO who for the sake of a large bonus has to show a rising Stock Price to gain the appropriate stock shares as bonus reward for his actions. His actions might consist of reducing the labor force to reduce expense and thus increase the net income during a decrease in revenue, or he might consider increasing the debt (to offset income tax) and use the debt to buy-back the shares to enhance share value or he might sell a long term promising project for a short term windfall to shore up the assets and the share value through buy-back or report financial problems within the company in arcane hidden parts of the financial reports as “Special Purpose Entities” used by Arthur Anderson, the auditing firm in the classic case of Enron, where realized losses were hidden.

3.     3.   Incentives destroy exploration of causality in dwindling productivity and try to fix it with rewards.

4.      4.  Incentives are thieves of individual intrinsic motivation and desire.

5.      5.  Extrinsic Incentives reduce innovation. (Ref #s 2-5)


Nowhere is there a better example of such promotion of behavioral reward followed by punitive action more visible than in the field of medicine.  The CMS Authority has burdened the physicians with miniscule rewards and heavy penalties to attempt to change physician behavior. The long held Damocles Sword over the physicians called the SGR (Sustainable Growth Rate) formula to pay physicians that kept hinting at a 21% cut in reimbursements was repealed and instead a worse APM (Alternate Payment Model) was adopted that gives the CMS sweeping powers for draconian reduction in payments to physician from the 7 cents per dollar paid to them of the total healthcare costs. The 7 cents are under the most glaring of scrutiny than any in any kind of vocation. Meanwhile the healthcare managers with 5-6 times the average salary of physician, continue to reap the rewards from the Agency Problem by creating surreptitious models that point fingers of blame at the physicians for the escalating healthcare costs. Another example, for instance in this game of sham is the 0.5% reward for following a directive (“Meaningful Use” of EMRs) otherwise a 2% penalty. Likewise promoting ACOs to cut costs through “Less is More” policy saved the CMS over $400 million and rewarded the ACOs with less than 1/10th in return. As the “Pioneer ACO” program fall out shows several of the ACOs disbanded due to belief that such dire cost cutting was leading to poor patient practices and hurting their chances of surviving financially in providing care to their communities.

More recently however the Insuring forces are incentivizing the use of poorly designed pseudo-scientific data to enforce limited screening of diseases like cancer.

Punitive actions are like their twin sister  incentives, neither present a long term viable behavioral modification. They actually lead to demoralization, as Robert W. Baird and Co., Inc., wrote in the 1985 book, Intrinsic Motivation and Self-Determination in Human Behavior“the research has consistently shown that any contingent payment system tends to undermine intrinsic motivation.” The basic effect is the same for a variety of rewards and tasks, although extrinsic motivators are particularly destructive when tied to interesting or complicated tasks.” Incentives like punitive actions perversely affect human behavior; opportunity for exploration, improvement of self, advancing of one’s self image, achieving personal goals and renders obsolete intrinsic motivation."

The last question that remains is, “Do incentives  motivate passion?”

The answer is NOT, as Jonathan Friedman of University of Toronto stated simply, “If they have to bribe me to do it, it must be something I wouldn’t want to do.” So it comes to this final conclusion should anyone care to listen: You cannot force passion into a mind that is closed to it, with rewards! Incentives squelch innovation and real growth.

REFERENCES:
1.         “Financial Incentives” G. Douglas Jenkins, Jr. in Generalizing from Laboratory to Field          Settings, edited by Edwin A. Locke (Lexington, MA: Lexington Books, 1986.

2.        “Intrinsic and Extrinsic Motivational Orientations: Reward-Induced Changes in Preference for Complexity” Thane S. Pittman, Jolee Emery, and Ann K. Boggiano (Journal of Personality and Social Psychology March 1982).

3.       “Enemies of Exploration: Self-Initiated Versus Other-Initiated Learning,” John Condry (Journal of Personality and Social Psychology July 1977).

4.       “Toward a Theory of Task Motivation and Incentives” Edwin A. Locke (Organizational Behavior and Human Performance Volume 3, 1968).


5.       Intrinsic Motivation and Self-Determination in Human Behavior, Edward L. Deci and Richard M. Ryan (New York: Plenum Press, 1985).

Friday, July 10, 2015

INTUITION



Funny thing about asking someone, “What is Intuition?” And you will get different answers. Some will say it is your inner conscience, others will say it is your ability to quickly differentiate while others will opine that it is mindless instantaneous reaction. Of all the answers the last one is intriguing. And it is pretty close to the official definition: “the ability to understand something immediately, without the need for conscious reasoning,” (from the Latin word "Intuir" or knowledge from within) don’t you think?

We function through the day as radiant blossoms or wilted lilies. The modus inspired by what elevates our spirits or weighs down our minds. It might be looking forward to a quiet evening listening to music, thinking about a solution to a pet project or starting a paper due in the math class the next day, a business plan for a customer, or dictating a consultation that involves a large dose of research.  In the more delightful measures of expectations, we dive head long with the Rosseauvian delight. All in! Here the corridors appear as large expectant runways at International Airports and navigating is applied with ease. In the latter each corridor is filled with constrictions to passage and the whole task is laborious and trying. Our ability to circumnavigate the complex jungle of our existence is enhanced through intuition. Intuition protects us, saves us from disasters and lacking it with equal measure can feed us into the lion’s den.


After conducting a “Human Factor and Decision Making” seminar at the FAA Seminar, I was asked to fly with a pilot for a flight review. He was good. All the steep turns, the slow flight, detecting impending stalls and recovery from actual stalls was done with proficiency and thoroughness. He after all had several thousand hours under his belt. Equally his gaze was never fixated. His eyes glanced at all the gauges under the glow and flicker of each instrument. Monitoring the airspeed, the attitude indicator, the Vertical Speed Indicator, the turn coordinator, the wind direction, the aircraft crab angle, the pitch and yaw in the turn, the fuel consumption, the ground-speed, the trim, the radio communication with Air Traffic Control, while my was gaze was outside the windshield to look for other aircraft and he all the while communicating with me about his intentions of what he was doing. All these actions were being performed effortlessly and with a certain command on the phraseology of the spoken sentence and the articulation of the intended thought. This was multitasking at its best. Or was it?


This was the Jeffersonian hand at play; a thoughtful, implicit consent to be governed by the explicit rules of the game. Experiential references carried the day. If you prefer we could term that as “muscle memory.” How do we build that muscle memory? The answer is obvious by practicing the required subset of practical knowledge. One cannot learn this straight from the book. Knowing that reducing power causes changes in the aircraft attitude is one relegated to experience as the acceleration decreases and the plan lurches forward nose down to regain that speed and without a pilot’s input it would reach the speed that would increase the lift and by virtue of aerodynamic laws it would try to climb again and create an unbalanced pitch motion. It goes back to the old mantra of Lift to weight and thrust to drag ratio. So unless you have felt the forces at play while flying the aircraft, you could hold yourself as an aviator in front of a landlubber class of hundreds and fool them, by regurgitating “bookish words.” Sitting in the pilot’s seat for a minute and experiencing the sensations is worth more than the countless hours of learning by rote.


Let us get back to my proficiency seeking pilot in the left seat for the moment. We had accomplished a lot in the almost four hours of flight. No there were no moments of fright in this flight. Everything was a seamless act of coordination and evaluation. This guy was good. We were flying over a beautiful countryside over Tennessee, with fields of green and red rose bushes visible too as cows snacked on grass and empty roads on a workday flew by below, all visible from the side window of my right seat.


We were at 3000 feet and about 10 miles from the nearest airport. I decided to test his one main skill.
I killed the engine!
He looked at me dumbfounded.
I asked, “What is the first thing you are going to do?”
“I will push the mixture, prop and throttle to the max!” he responded.
“Try again!”
“I will check the magnetos!”
“Try again!”
“I will change the fuel tanks and turn on the fuel boost pump!” he said in a husky voice, his face taking on an amber shade of yellow. The push and pull of remote thought and recent encounter danced in a fugue dreamscape; diving in madly then holding back to review, as all the memorization poured out in a linear splash.
“Nope!”
“I will change the Transponder to squawk 7700!”
“Nope!”
“I will call ATC and declare an Emergency!” His face was now the color of fusion between red and purple.
“Nope!”
Meanwhile the aircraft is flying at 165knots and we had lost 500 feet during this discussion. Now the cows seemed concerned too, their mouths frozen in mid mastication. The tiny windmill below shook to the sudden gusty breeze from the west. The moment lingered.
“Well then I give up.” He said as his face slumped. He had abrogated his responsibility in flying the aircraft. “Oh, I would pull out my Pilot Operating Handbook! Is that what you are looking for?”
“Glide Speed.”  I said quietly.
“Pitch to Glide Speed!” I said with a little emphasis. “That should be your first reaction…always. Transferring speed energy into altitude gives you more distance to find a suitable site to land. It also adds to your time to find the potential cause of the engine failure and find a safe landing zone and it diminishes your descent rate flying at L/D max (or maximum lift with the weakest of drag).”
“What do we do now?” he asked
“Land the plane!”
“You mean anywhere?”
“Anywhere, safe!” I answered.

His instincts took over as he gained some altitude, transitioning to glide speed and making all the arrangements to land. He looked at an open pasture and set himself up to land on the green grassy field to his left.

Once he had committed and the safe landing was assured I  restarted the engine at around 700 feet and off we went headed back for the airport, which was now only 4 miles away. In a debriefing later, he acknowledged that had he resorted to glide speed immediately that we would have easily made it to the airport given the winds at 3000 feet.

You cannot learn that kind of knowledge from reading books. If ever he was faced with such a dilemma, he will know what to do without hesitation. Now this will be in his repertoire to execute effortlessly as a routine. After the red blush on his face had waned a bit, he came over during dinner the next night and thanked me for the lesson. “I will never forget that.” he said. The Angel of Reason had visited him overnight. 


That in itself was the best reward!

A Short Psychology of Intuition:
From William James' two mode Intuitions of "Effortless and Fast or Rational and Analytical to Kahneman's Type and Type II modes of intuition, both embody the visceral mid-brain response and the contemplated neo-cortical revisions. The Type I is ingrained from age-old hunter gatherer fear and flight function to escape beasts and monsters and the Type II is learnt. As Massimo Pigliucci stated in his book Answers for Aristotle,"Moreover, intuitions get better with practice — especially with a lot of practice — because at bottom intuition is about the brain’s ability to pick up on certain recurring patterns; the more we are exposed to a particular domain of activity the more familiar we become with the relevant patterns (medical charts, positions of chess pieces), and the more and faster our brains generate heuristic solutions to the problem we happen to be facing within that domain." Meanwhile causal links that determine our intuition is illustrated by this statement from Kahneman, "You have to think of [your associative memory] as a huge repository of ideas, linked to each other in many ways, including causal links and other links, and activation spreading from ideas to other ideas until a small subset of that enormous network is illuminated, and the subset is what’s happening in the mind at the moment. You’re not conscious of it, you’re conscious of very little of it."  Thus it is all about the coherence of the causal links that are arrived at in the form of intuition. Perceived causality and the reaction to it, after all are the underpinnings of all rational reasoned thoughts. Inadvertently however, there are moments where the fly in the ointment is perceived and the flaw of jumping to conclusions comes into play and overconfidence is the outcome. This overconfidence stems from the coherence of disjointed beliefs and thus can create a major error. The human mind has the capacity and capability to fool itself with wonderful stories built upon a foundation of little or no evidence. Unfortunately, when executing such ill-begotten plans the person subjectively has the same sense of accomplishment as another who has done his or her due diligence. So at times raw intuition is a man with a Janus face holding a double-edged sword!

Intuition is borne of experience. No amount of cognitive rationalizing and reasoning in moments of distress can bring about the right outcome except a brush with that one dose of raw experience. Speaking of comparing medicine and piloting, as most experts tend to do, this is the only intersect between the two; learning from raw experience!


Friday, June 26, 2015

The New BUSINESS of MEDICINE


When I was in medical school, the most important person was the patient. Your entire being was focused on the patient. What can I do to resolve this person’s ailment? In fact at one time, I rattled on about the information I had gleaned from the textbook and was babbling along when the professor interrupted, “That is all good, but what does it have to do with this patient?” That broke my train of thought and all I could do was speechlessly stare at him. Today we use terminologies like “Patient centered” and “Patient Centric,” but we fail to actually embody those words. We talk of “listening” as if listening is a new found treasure. We talk about “outcomes” as if previously we were not concerned with the well-being of our patients. We talk about “performance” as if caring for a patient is a function of a metric related athletic score. Medical care has always been about patient’s well-being. Today however the business oriented statisticians are using population medicine inspired data to treat individual patients. The wrongness of this is obvious, yet they, the experts continue to pontificate with “Hazard ratios and p-values” to the eager ears of the uninformed.

In Business parlance there has been a Merger and Acquisition between the business and the medicine mind. The merger was actuated by the "managers" in the two fields without the consent of the voting block in medicine and now that has morphed into an outright acquisition by the business mind with associated divestiture of the medical mind with layoffs and other cost control measures in progress...

When and where did we as physicians go wrong?

In the midst of this dilemma, I decided, I wanted to learn about what makes the entire healthcare system tick? Who was at the till? And what is the motive? I decided to go to a business school. I wanted to learn how business people think? The dean of the university who interviewed me told me that going through the business school would change the way I think!

It did!

I learned that business minds think differently than medical minds, in ways that are inconceivable to one another.

THE MEDICAL MIND
Let me dissect the medical mind first since I have had it for many years and my heart still beats the rhythm of medicine as surely as it conveys the next moment. The medical mind is quite simple and very complex at the same time. Simple because it has a simple ethos; to conquer the malady that afflicts another human; to salve the wound, to soothe and comfort, to help regain what is lost in human functionality, to help live, to help alleviate pain, to heal and to cure. Simple stuff there! Not a lot to think about. Complex because, what ails the individual and how many different maladies can and do create similar symptoms and signs creates mountains of stress. Further, to differentiate between cancer of the lung and to the lung is a whole textbook somewhere ready for the learning. The dilemma proceeds from medication induced damage to illness related ones, from a benign nodule in the lung to a cancer that kills in less than a year, from a cold causing fever to a more sinister disease such as kidney cancer, which sometime only presents as fever and nothing else. These and others footnotes present the conundrum, a physician faces in daily life. To embark on the correct strategy lives the need for appropriate diagnostic work, experiential intuition, much like Sir Arthur Conan Doyle’s Sherlock. “Elementary my dear Watson,” that only comes after the workup has been completed, the correct decision has been arrived at and executed. The constant vigilance of evaluating the benefits to the patient from that decision is a recurring theme in the medical mind. Medicine is true science borne of empiricism in the strictest sense not through the jargon of ratios.


THE BUSINESS MIND
On the converse side in the recent past what I have learnt from the business world is also simple and complex. Simple, that 2+2 = 4 and 4-2=2, these are, you will agree very simple arithmetic concepts. If the revenue is higher than the expense then there will be income, if the expenses are higher than the revenue there will be borrowing to maintain the business until lenders tire of the lending without evidence of higher forecast revenues. If you thought that was all, you would be wrong. There are many complex shenanigans within these simplified concepts that are employed to obfuscate. Difference between cash based and accrual based is a very interesting scenario to visit and learn from. The “Goodwill” category in income statements also poses a nice source of fodder to hide and not hint. But we will let those issues pass for the likes of HBR to contemplate.

THE HUMAN ELEMENT
My purpose is to look only at the human element in this short treatise. If you look at the “forward looking statements” from CEOs of large corporations you will notice that they always mouth these words, “Our employees are our best assets!” Yet when the net income declines, the first thing these managers do is choke off the employees. Pink slips fly and the “Agency Rule” comes into play so the bonuses at the year end do not suffer. Needless to say the stockholders are happy since the market rewards a rising net income which translates to the Earnings Per Share (EPS), hence the share price rises to meet their expectations. If Net income does not rise with this strategy, then by all means buyback with borrowed money is the order of the day to raise the stock artificially. This short term thinking is evident in most businesses and if you were to look back the past 5 years you might notice the headlines of thousands of workers being fired across the globe and in the U.S. In the latter part of the world there are now 93,000,000+ sitting on their hands without a job. Speaking of stock buybacks, the S and P 500 spent $914 Billion in 2014 in buybacks. Yet thinking of employees as a disposable commodity to beef up the short term quarterly interests for personal benefits has unseen but real consequences in productivity as well. Take for example the difference between Costco and Walmart. The former has loyal well-paid employees that make a decent livelihood at around $43,000 average salary. The latter has a higher turnover rate due to dissatisfaction. The former commands a $21,850 in U.S. operating profit per hour per employee vs. $11,615 at Sam’s Club, a Walmart subsidiary. And if the managers would look at the cause that should light their personal wealth fire; Costco stock price rose 139% and Walmart was up 41%, they would treat their employees as assets and not as expense.  (here: https://hbr.org/2006/12/the-high-cost-of-low-wages.)
Blue: Costco Red: Walmart

So this “employees are our assets” is nothing more than  a tired old rhetoric that fits the narrative to exploit the emotions of the employees and the shareholders. A crocodile tear at the right moment when the flash goes off is worth a few front page photos and headlines.

Unfortunately, I feel that same mentality has wormed its way into medicine.

FORCED MERGING OF THE DISCIPLINES
Let us for the moment assume the following; that medicine is a large company and doctors are the main employees. The owners of the “Company,” are the Government and the Insurers, since they dole out the “reimbursements” and the patients are customers. Simple enough! The business mind attracted into the fold of medicine sees the situation in the same context as it does a widget producing manufacturer. The customers (patients) get the widget (care), employees (physicians)are told to work overtime with a lower pay or skimp on the materials (diagnostics and therapeutics) to make the widget, for the sake of the “Company” and if they refuse or if the expenses exceed the desired results are easily discarded from the payroll. Mechanisms of discard include forcing doctors out of hospital staff membership if they don’t comply with onerous requirements of hospital or other private enterprise profitability; MOC (Maintenance of Certification) a continuing annual process of re-certification (for the sake of revenues - more on it below) and Hospitals using sham peer reviews etc. Hospital and Company CEOs are flexing their collective muscles.

UNPROVEN HYPOTHESES INTO PRACTICAL APPLICATIONS
Reimbursements to the physicians are easily controlled; previously through the SGR formula and now through newly minted methodologies (MACRA) via ACOs and APMs which, it turns out, are more punitive than the SGR, bu their full impact will not be known till after 2018. These formulations are the work of managers of the government bureaucrats, insurance company executives, elitists that are bounded by bookends of sly and slippery words and lecture from high lecterns, all the while partaking in large grants and salaries. One only has to look at the American Board of Internal Medicine (ABIM) and the revelations by Kurt Eichenwald in the Newsweek articles of how they have fleeced the U.S. physicians (a humiliation of unparalleled proportions that certainly needs further scrutiny). The carrot and stick model used by CMS of giving a 0.5% raise now to follow the preferential business based guidelines to lower costs vs. 2-5% penalties later for not reaching to those arbitrary standards of cost control (as primary endpoint) is the dujour modus operandi. Patient care is implied as the secondary endpoint (for those of you who like reading medical literature) but is never given much credence. The Kahneman and Tversky Loss-aversion behavioral economics are fully applied with prejudice to medicine. The business side of commoditization (and here on YouTube) with “Less is More,” no doubt a business concept, is allowing unsupervised practice by NPs and PAs in some states that are facing physician shortage, akin to: (Hire the underage workers at Foxconn). There lives a beast that will turn Medusa into stone!

THE AIRLINE PILOT AND THE DOCTOR FALLACY
The idea of constantly retraining pilots and therefore the physicians is simple but here are a few loose ends; training does not equate to wisdom. One can rattle away concepts without a clear understanding that only comes with layer upon layered experience and critical thinking. I am reminded of my professor and what he said at those times. It is easy to train anyone to do a sequential task of minimal complexity, it is altogether another issue to be able to apply wisdom to the need or want for that task that comes from education and experiential reference. One can be trained in triage for routine care but when human pathos complexity hits as it does most times, repetitive training alone will not do!


Let me bring in the Airline pilot training that all the "experts" are advocating, here for comparison. If any of you remember the Sioux City Iowa crash of United flight #232, it was not the training that helped, but Captain Al Haynes' sheer intuitive brilliance that saved 185 passenger lives. In fact 55 test pilots failed to equal his success in the simulator given identical conditions and having been pre-warned of what was to happen. So a word of caution to those beating the drum of pilot training and equating it to doctor training, it is more than training! A corollary to that crash is the more recent Asiana Airline crash in San Francisco where pilots were trained in Instrument flight by the Autopilot and failed to realize that in case of Instrument Landing System failure they had to hand fly the plane and you guessed it, they couldn't! They were trained to manage the autopilot flight!


The intuition gathered from compiling years of education, knowledge and critical thinking is needed in caring for the patient. So if NPs and PAs desire to practice medicine then they should simply go to medical school, follow through with a residency in training and be ready to take on the medical world. I say welcome to that. Doctors learn daily through human - human interaction. Pathology differs in each individual as does to some extent physiology. No two humans are the same.

Meanwhile guys and gals, ease up on the physicians, if you will. Tone down the demonization! Enough is enough!

USING THE PHILOSOPHICAL BENT
Using syllogisms to prove points are constructs of the pseudo-intellectuals. They use the informal fallacy of "post hoc ergo propter hoc" or this happened because of the preceding that! A classic example is:
The cost of medical care goes up
because of greedy doctors
Healthcare costs are rising
The doctors are greedy

This form of modus ponens methodology obfuscates, confuses and destabilizes the noble profession. In fact the very act of forced balancing a model unbalances it. To prove the point there is a daily barrage of wrongdoings highlighted in the media. Lately caring for patient's in pain with painkillers subjects the physician to criminal charge. But since the modus has been broadcast earlier the corresponding asymmetric il-logic must also be true; doctors are bad people. The result; patients are left to deal with their pain by the physicians for fear of over-prescribing allegations and indictments against the doctor.

HOW BUSINESSES DIE
By now you might have guessed that the business mind differs greatly from the medical mind. It does not discern the effects on the consumer as much as it covets its growth and success, although in the long run, those that survive time, pay attention to the widget creation and customer satisfaction equally. The current business mind however is a short term thinker; the next quarter and the surreptitious mechanisms to inflate the correct numbers to be rewarded for such acts has become an art form. The widget may be of sub-par value but if you say it is great on TV and the Internet through populated bots, it achieves a longer "time value." Enron is a prime example of accounting fraud that destroyed a large number of shareholder savings. LTCM, another entity which exploited small asymmetries in pricing until it took down $4.8 billion in stockholder wealth and needed $3.5 billion in bailout from the Fed.. Also remember the Gremlin and the Chevy Volt in the same context for further illumination of thought. The latter two products (widgets) expose the forced logic of failure with precision. History teaches us but as George Santanaya prophesied, "Those who cannot remember the past are condemned to repeat it."

The business mind is focused on net asset value. They consider the machines, the robots, the buildings, the pencil and paper as assets. Human workers are considered a “Fixed Cost.” Therein lies the greatest misadventures of the business mind meddling in the field of medicine.

The medical mind is focused on human healing, recovery and overall health. The business mind on the next quarterly revenue and net income!

Yes, I did learn to think differently. I see the holes in the dam where the tips of the fingers are visible. How long will it take for these cracks to rupture can only be measured in the “near term!”

Wednesday, June 17, 2015

OUTCOMES

and the FLY in the OINTMENT

Edward Kaplan and Paul Meyer came up with an elegant solution in discussing outcomes. They created the Kaplan-Meyer Estimator; a non-parametric estimator of survival function using timed data. Each entity logged in as present, absent or deceased. No gimmicks! A treatment for cancer would be graphed on an X-Y axis and the survival data would lend itself to an easy view. Each step-wise ladder would denote those that perished to the disease and those still surviving or censored as little tick marks on the steps. Comparisons with superimposed placebo survival curve identify the benefits or risks (as in the graph below) of the new treatment.

But here we are embarking on this lauded “Outcomes” as a metric to determine quality. I don’t know about you, but I have few misgivings about this form of measure. Actually I have two problems to be exact; a) How does one define Outcome and b) how does one define quality?

In a timed data if one were to treat pneumococcal pneumonia with Penicillin and the fever, chills and the chest XRay improved, then one could consider that as a good outcome. Easy peasy! However throw in the mix of fungus, immunological deficiency from age, disease, cancer and what you have putting it mildly is a major conundrum. No easy cure! Now let us bring in a patient with cancer into the equation. Is survival a good measure? If you say yes, then I have a bridge in Brooklyn available for sale. You see survival is not a simple measure in cancer care either. There are many tiny incalculable genes mutating as they play their game of life. The whole biology of the cancer and its rate of growth thing is a complex dance filled with many characters. There is no one character that struts on the stage momentarily to signify nothing. Every moving and non-moving genetic construct signifies something in the life of a human being. The many that are involved have each a bucketful of colorful lives and a plethora of epigenetic sauces to create the soup of life. So will the individual physician’s entire caseload of patients with a certain diagnosis be put through the K-M curve and compared to the national average? If we do that, even then we might be flawed in our thinking, especially if the physician has a disproportionate number of African American, or Hispanic or Asian patients or older or younger or more females than males, or right-handed than left-handed, or more artists than scientists, or movie-goers vs. internet-obsessed in that population (you get the drift).

Survival Curves 20-100 years & % of Survivors 
A: White women in US (1939-1941)
B: Women in India (1921-1938)
C: Theoretical Population with half-life of 18 yrs.

You see where I am getting at? It does grind out the cogs in the wheels of thought. But for simplicity’s sake, let us take a diabetic patient. If the measure Hemoglobin A1C is not below a certain limit then that would constitute a poor measure. Correct? Not so quick my dear Watson! The assumption here is that the world is a perfect place and that certain input leads to a perfect stream of output. But that is not the case, is it? The patient might like their case-load of Twinkies unbeknownst to the physician and never mention that they consume 3, 3-liter bottles of Cola daily and consider that as hydration. Or simply never take their medications on time due to forgetfulness, expense or laziness. How would that measure in the “Outcomes” category? Oh and while I have your attention, Is Outcome like a Warranty? You know like the many page document found with cars and electronic products? The Six Sigma approach might become necessary for root cause analysis in human outcomes as well. Eventually we as humans might need a MTBF (Mean Time Between Failure) for the population, drilled down to subsets of society and then individual level of existence for comparison, don't you think? And if doctors by virtue of intuition considered gods then so be it, let the Kaplan Meyer Curves roll!

Where exactly do Behavioral Modification and Behavioral Economics intersect? At the expense level or at the payer level? Or at the arbitrariness of the expert level, where most things today seem to live and breathe? Your guess is as good as any!

Now imagine given these simple scenarios that the elite experts who reside in those vaunted ivory towers consider outcomes as a measure of a good doctor and make payments predicated on such faulty thinking? Now before you go saying that cannot happen. No one would be so stupid to accept that? Guess what? That is exactly where we are today. “Outcome” is the new big buzzword. And CMS is trying mightily to convince the “Gruber’s Stupid” that, "this is the way it should be."


We are not done yet. Now add to it some “Satisfaction Scores” from the patients and we have a whole new enchilada in front of us. Say a patient perceived your smile as a cynical one. There goes your score. Or imagine you prescribed a medication that cost him or her more money than anticipated, or you did not recognize him at a department store, or your receptionist missed calling him or her on the specified time, or you as a physician had an emergency and the waiting room with five patients turned into one with ten patients sitting and filling out the “satisfaction Score” form? Any doubt that your “Reimbursement” from the Insurance would be returned “denied.” And you will have to jump through hoops to get a fraction of that expense 3 months later. That would constitute a certain Win-Win for the Insurer, wouldn’t it?

Ah the cleverness in it all!

Breathe!

The fly in the ointment continues to flutter its wings, trying mightily to get out, but the ossified mindset seems unlikely to remove it because that mindset believes in that  removing the fly means failure and more arduous hours of toil to rework a new flawed concept from inception. And guess what, according to them, the fly is part of the ointment and therefore makes for a perfect recipe.

Sunday, June 14, 2015

CODON 127


A very interesting study in Nature caught my attention the other day. A misfolded protein causing Kuru or CJD (Creutzfeldt-Jakob disease) and both can be stopped by a single point mutation at Codon 127 (a substitution of glycine for valine). That Codon 127 is the filter that could have prevented the decimation of the 2% population of Papua, New Guinea from “Prion disease.” Imagine that! Eating the brain tissue of the dead relatives is not the ideal scenario as it lends itself to propagation of the prions into animals (mad cow disease) doing the same and the vicious cycle comes back home to haunt humans in the end. Alas this codon mutation is an acquired benefit through the learning agility of the human genome.
Normal Healthy Brain

What about Codon 127?

Assuming you are crafting this thought in your mind, Codon 127 therefore acts like a filter, doesn’t it? Pass through and the brain is inundated with mis-folded proteins that cause signal disruption, chaos and confusion. Filter the pass through and voila no madness!
(Mis-Folded Protein on the right below)


And there it dawned upon me about Big Data and its chaotic perturbations upon our society.

Everything is “Big this or that” even the data and there is a daily bombardment of information boring into our skulls. Some are surreptitious; subtle programmed music to entice you to buy in a department store and others not so subtle advertising in the form of “studies” purporting eating or drinking this or that can lead to good health. We are being, in such gentle and unknowing terms, programmed into thinking thoughts that do not necessarily belong to us, but are the dictates of those that can pull our strings. Even in medicine, actually especially in medicine, this concept is in full force. A hodgepodge of studies with large biased assumptions are being bandied about to convince doctors that, “That is not the way it should be!” But, “This is the way it should be!” Beneath the surface, if one looks deeper, the author is in his birthday suit!

So what is happening is the failure in learning from our experiences to switch our Codon 127. The filter to see through what is real and what is false and by virtue of that insight, eliminate confusion. This filter then defines the nature of reality and removes the extraneous large datasets of useless information and allows us to process reality as it really is. The brain’s fuzzy logic (as in removing the blind spot from our vision) added to the subtle programming nuanced by “others” can scuttle our ends to someone else’s means as surely as the daily barrage of untruths can change the truth (Nazi propaganda) in the minds of the knowledgeable too. Critical thinking is the only means to keep our own wits’ ends.

“How does one do that?” is the logical question.

 1.  Compiling your own database of right and wrong.
2. Using Common Sense as a filter.
3.  Seeing through the lens of limited bias.
4. Remembering if something is too good to be true, it, of necessity usually is.
5.  Understand the motive behind the action.
6. Follow the money- the trail will usually surprise you.
7. Never assume.
8. Verify and validate the hypothesis.
9.  No one or entity is inclined to pursue benefits for you. They are in it for themselves.
10. True Charity is unconditional as is true love.

You can, I am sure add to this list and please do. It makes us all resilient in the end.

Tuesday, June 9, 2015

THE MISANTHROPIC ITCH

It goes on and on and on! Why, I ask is there such a desire to limit; to limit access to information, to limit access to knowledge, to limit the use of resources, to limit the desire to help some? Why? I think thinking is falling off the cliff! We skirt about the edges of real knowledge and then rush to make streets without plans and build buildings sans codes. All hurried in an attempt to harness the powers of persuasion, for deep in that persuasion lies the lonely seed of power.

"The power of population is indefinitely greater than the power in the earth to produce subsistence for man" -Malthus T.R. 1798. An Essay on the Principle of Population.

Some decades ago an English cleric and scholar had the wild idea that resources on this planet are finite and that the population boom will ultimately outstrip the resources leading to famine and chaos. His heart was in the right place, but his conjecture as it turns out was misplaced. The human capacity to change the future is limitless. What we can imagine we can create. 

Think about the Star Trek tricorder and your iWatch or iPhone already can measure the human body metrics. 


Think about flying and from the Wright Brothers “Wright Flyer” 


we arrive at the latest “Hypersonic Technology Vehicle 2” that flies at 13,000 mph (2011).

 Think about the limited fossil fuel reserves and out comes the “Shale Fuel” horizontal fracking technology, Solar and Wind power. Think about food and associated changes of “crop rotation” and fertilizer use leads to a 35% reduction in land use for more crop yields. Think about the movies in the theaters to now having one on demand on your favorite tablet computer wherever you go. Think about vinyl records and now stream the latest music on demand to a receiver in your pocket. So Malthus was errant and from that error, unfortunately grew a boatload of tyrants that decreed “One child policy” as in China under their Chairman Mao, Eugenics in California and Nazi Germany and the start of the bleeding heart Aid packages to third world nations. Malthusian vogue of crying catastrophe was when the population had barely touched 3 billion on this planet. Now for those keeping score it is at 7.1 billion. The destitution seen in some countries is not for want of food, but for want of desire to cultivate for it. The tyrants remain powerful and the citizenry depends on the tiny subsidy to keep them relatively content. Meanwhile heart-rending photos are flashed across the globe of children drinking from the polluted lakes to entice others to donate to the cause, while the rich get richer and the poor get poorer. However through all the talk about “preventative checks” of population control, Malthus, himself was against “Poor Relief” and was more in line with Adam Smith’s philosophy.

Speaking of what the U.S. Aid package, has done to those poor countries? It has made the citizenry poorer and made their leaders rich! Check it out. De-incentivizing the human mind is a crime of unparalleled proportion. It subjugates, it takes the yearn out of the Yin and sets up a multitudes of frustrations. Eventually in pursuant to such goals, one runs out of other people's money! 
The corpus of the entire thought remains an elegantly designed Utopian mystery. Proponents of the “welfare state” stand erect and demonize those that speak against it. Power and influence is a strong motivator for those standing in between the “giver” and the “taker” and articulating the heartlessness of those who point out to the chinks in the window pane.  Indeed for these few and well-entrenched society members the more citizens that can be forced to fill the roster sheets, the better it is. However as the cartoon suggests, eventually the society crumbles as a whole. Since 1968 the United States has paid out $43 Trillion towards ending the "War on Poverty" and the problem has worsened! From boundless opportunities to Weber's bureaucratic rationales, we have arrived at today.

Unfortunately this Malthusian itch has gotten steeped into the medical elite and the policy wonks that has created new and enriched tortured data-sets to show the similar "virtue" in medicine. “Less is More” is one of those itches and another is “Choosing Wisely.” Both are dream't up in the philosophy of the Malthusian backers. Using “Bleeding heart” technology and “futuristic shocks” as a correlational variables they have devised a path to control the limitless human endeavor of innovation. Even the new innovative movements are designed towards the power to limit. If screening of diseases leads to early diagnosis and successful intervention, they use the power of statistics to claim “harm!” If the appropriate treatment is costly then convoluted algorithms define need. If the physician orders tests to determine the real need in an individual then he is at odds of running afoul with the “Choosing Wisely” program.

And here is the kicker...Whereas in national meetings the pontificating experts claim, "Don't just stand there, do something!" as in give an antibiotic to a diagnosis of pneumonia in the first 4 hours, in another breath state, "Don't do something, just stand there," implying as in screening for prostate cancer and breast cancer that screening leads to harm. This schizophrenia in the elite is a daunting jungle to traverse and if you are a patient, there is no help on the way!

The buy-in from the physicians is less than stellar so the pith and moment of the movement is to convince the public to read their E-manual to basically give up the pursuit of living for the betterment of the society after a certain age.

Forced limiting childbirth is like snuffing the potential of innovation. Is that progress?  Are we progressive? Enabling entitlements limits desire/incentive and escalates the status quo. Is that progress? Are we being progressive? Limiting use of resources is to guide the principle that the future is bleak and therefore unsustainable. Is that not proven wrong over the past 1000-years? Man was bipedal, walked a few miles, then used beasts to travel further and now travels thousands of miles without breaking a sweat. That is progress!

Data is the new buzz word. We define our very existence based on data. In fact data has reached such an unparalleled position in our society that we simply say, “data suggests…” and all is received and accepted. Population data science is tortured to “best fit” in an individual, even if it has no relevance. Life has become a virtual Amazon jungle with colorful creatures that create strange and enticing sounds to woo and capture the spirit of the yielding.

We now live in an ocean of data that keeps getting deeper and deeper. We use data sciences and torture statistical methods to create an artificial reality that does not exist. We package that as the future and sell it to the hard-working populace that has little time to spend in thought and to the easily fooled. As Emanuel Derman, a professor of financial engineering at Columbia University states, “Statistics…is neither purely a language nor purely a science of the natural world but, rather a collection of techniques to be applied to test hypotheses.” He goes on to say, “Let us not get too enamored of the data science, whose great triumphs so far are mainly in advertising and persuasion.”

Did I say persuasion?
Oh my!