Society for Medical Decision Making Convention 2009 – a report

Your correspondent just returned from the annual meeting of the Society for Medical Decision Making. Their stated mission:

The Society for Medical Decision Making’s mission is to improve health outcomes through the advancement of proactive systematic approaches to clinical decision making and policy-formation in health care by providing a scholarly forum that connects and educates researchers, providers, policy-makers, and the public.

Regulars at P&aP might remember earlier this year when we talked about “Death and taxes” .  Among the topics dipped into at that time were medical decision making, cost-benefit analysis and rationing.  The SMDM is very much about that, and I saw some very intense analyses measuring quality adjusted life years (QALYs). Practically, rationing can be done by cost who pays, chooses), rationing by availability of resources (many organ transplant issues are wrapped up in “not enough donors” issues), and rationing by reasoning (does the patient really know the quality cost of those additional months of life, an issue often seen in cancer trials). It was interesting and enlightening to see how dispassionate analysts are able to rise above the simple emotional pleas for “Aunti Em” to consider true costs to individuals, to insurance companies and (most dangerously) costs to taxpayers of unstoppable government largesse.

So, the bottom line for me, today, is that I really cannot host a P&aP tonight, but surely would like to see some dialog here leading up to a discussion next week between the quants (QALYs) and the emotes (“Auntie Em”).  Questions to be answered include:

• do QALYs make any sense (I’ll have a short handout and will try to post an explanation here)
• which is the best place to place responsibility for paying for medical care?
  • in the individual
  • in the insurance industry
  • in the employers
  • in the government.

I’d like to think about some options, and we should probably send a scouting party to the Rep. Bly Health Care Forum in Northfield, this Thursday at 6:30PM in the Northfield Community Resource Center. There we will hear about a plan to make Minnesotans all fall in line for a government payer model.

So the next Politics and a Pint will be on health care, health insurance and keeping a healthy government. We’ll meet on 1 November at the usual time. We’ll find irony in the juxtaposition of the talk and All Saint’s Day, as well as the start of the Dia de los Muertos holiday.  Bring your spirits and imbibe (or not) with us as we contemplate all things mystical and mathematical.

Details:

What: Politics and a Pint
Where: The Contented Cow in Northfield
Date: 1 November 2009
Time: 6:00-7:30PM

Art? Who needs it? Next Politics and a Pint

Well, it’s time for our annual look at the arts. The Northfield ArtSwirl is coming back to town, and their most vocal champion, Ross Currier has once again volunteered to lead the Politics and a Pint crowd in a discussion of the role of art in the community.

Last year he  kind of looked at the history of philosophical discussion and/or academic analysis on artists and the economy. There seemed to be three phases:

1) artists save the real estate,

2) creative types save the economy,

3) artists’ mental capacities save our future.

This year, he is going to talk about the most recent thinking/writing/theorizing in this area. A rough summary includes:

1) details on what artists do for a physical community,

2) details on what attracts artists to a physical community, and

3) artists and the non-physical community.

So, we’ll be taking a good look at the arts and how an active arts culture (a probioatmospheric) adds to the wellness of the community. Come and tip a beer (but not a cow!) at the Contented Cow.

The fine print:

What: Politics and a Pint
Where: Northfield’s Contented Cow
When: 6-7:30PM, 10 August 2009

References:

• NDDC Downtown Forum, “Living the Artist’s Life in Northfield“

The rationing challenge … what are some options

One of our regulars, Steve, asks “Can we ground the PaaP discussion in a little more reality.  Let’s talk about rationing (of health care).”

Touchy subject, but should be interesting, so we’ll talk about it at the next PandaP.

Then, on the 16th August, Ross Currier will lead a discussion of Arts in Northfield as part of the Artswirl!

So come on down and we’ll pour a tall glass of good company, lively discussion and some fine brews.

When? 6-7:30 PM on the 9th of August, 2009
Where? At the Contented Cow in Northfield

Ticklers – think about these rationing options

• European model:  Ration the number of doctors and clinics.  This controls costs by limiting the overall resource.  It creates long waits for even the most routine visits.
• Canadian (other European countries):  Limit the types of locations of specialists procedures and equipment.  Very few MRI machines in the country.  People in Alberta and Saskatoon travel to Ontario for routine knee surgery.
• Cuban model:  Everyone gets unlimited technologically circa 1955 medicine / care.
• Swiss model:  Universal base-line care.  Huge numbers of lightly regulated “private” and research clinics, which must be paid for out-of-pocket. Some private insurance.
• U.S. model: Ability to pay is rationing

No special topic for 26th July 2009

I won’t be at P&aP this weekend, so have not prepared any special topics. Hope you all enjoy a bit of polite conversation and a pint of Norm’s best!

Freedom!

Freedom of speech

Freedom! Let’s talk about freedom and whether we have lost sight of this valuable target in our efforts to be safe, fed and housed. Are we trading our essential freedoms for false securities?

Bring thoughts, bring posters, bring signs and join us in this most important celebration. Sure, we give Thanks in the fall, and we celebrate the changing of the four seasons, but this celebration of freedom must come first in our hearts, just as freedom must come before peace, and peace must come before justice. Though the mob calls for justice first (no peace without justice), they do so at risk of their political souls (think of the French revolution, how’s that working for ya?).

So, let’s get warmed up for a rousing debate: Can we have peace or justice without freedom? And what freedom(s) do we mean?

See you at the Contented Cow on Sunday for the next Politics and a Pint.

Details:

What: Lively discussion and good company
Where: Politics and a Pint at the Contented Cow in Northfield Minnesota
When: 6-7:30PM, 05 July 2009

Another rip in the economic fabric – 21 Jun 2009

There’s another rip in the economic fabric heading our way. So in a Potpourri Politics and a Pint, we’ll talk a little about cap-and-trade, unintended consequences and the economic house of cards we find ourselves hiding under.

Details:

What: Lively discussion and good company
Where: Politics and a Pint at the Contented Cow in Northfield Minnesota
When: 6-7:30PM, 21 Jun 2009

References:

• Guest Post: Cap and Trade Draws An Ace – Rebuilding The House of Cards, by Doug Williams, Bogus Gold
• Dude, Where’s My Cap-And-Trade Primer?, by David Kestenbaum and Steve Inskeep
• Meet Cap ‘n Trade, “Cap and Trade is the linchpin of the government’s effort to curb carbon emissions. Senior Editor Paddy Hirsch explains how the cap and trade model works.”

(More)

My comments at the House of Cards:

You [the author] nicely wrote: “But now, suddenly, through clever use of modeling against a particular set of climate data, we now have that previously elusive formula by which we can take a single variable – in this case carbon dioxide emitted – ignore every other related factor and state with certainty what its proper impact in the overall “global warming” scheme will be! Amazing!“

It’s deja vu all over again. It’s just like when Kansas declared pi was 3.0 (as opposed to 3.14159259(etc)).  The government will set a function as the standard for measuring the impact and predicting outcomes of changes in carbon emissions. The fact that the equation is not connected to reality does not impact the trading and money exchanging, but it sure makes for an ugly moving target when the real mathematics drive the system away from the predicted (and bought and paid for) behavior. Li’s equations are the latest example, but my favorite mathematics of hope winning out over the mathematics of reality is the former Soviet Union’s use of “Leontiev equations” in an attempt to plan their economy. As an analyst schooled in statistics and mathematics I tremble when “too big to fail” governments worship at the altar of hopes and dreams and ignored the realities beneath. As I tell people, “it is fun to dream of flying, but if I am at 30,000 feet I want a correctly engineered plane around me, and that usually means ‘engineering safety margins’ built in because sometimes 2+2 is just not quite accurate enough.

Memorial Day Weekend 2009 (24 May 2009)

Yesterday I bought my 2009 buddy poppy. Buddy poppies are put together by veterans for sale before Memorial Day each year.  They have special significance for me. I remember my grandfather, a World War I vet, and his poppies.  He would be visiting with us in Rochester, and as the time grew near he would start to get antsy. “I’ve got to get back to the [veteran's] home. Got to make my poppies.”  I missed the chance to talk with him about his time in the war, but did get to learn my lessons about poker, raising puppies and raising kids.  And as recently as yesterday I was missing him and my dad as I tore down an old workbench.

So, we’ll be remembering our veterans this Memorial Day weekend, at the next Politics and a Pint.

The fine print:

What: Politics and a Pint
Where: The Contented Cow, Northfield
When: 24 May 2009, 6-7:30PM

Mother’s Day … no politics this day. 10 May 09

We presume that most of our gentle Politics and a Pint Players have Mothers, or are Mothers, or know a Mother they love, and we therefore declare this day a day without politics.

Next week … back to the fray.

Potpourri and headlines – 26 April 2009

This week we will just sort of see how everyone is doing, I’d like to repeat a little story on a local politician (who will be left nameless) and a local issue relating to the stimulus package, then move on to discuss the state of the world with respect to the debate over torture. We won’t talk so much about whether we did or didn’t, but more about whether we should or not.

The stimulus package … are we stimulating the wrong economy? Do we really want to restart the consumption-based economy just because it generates more jobs in the short run? Can we really all make a living by selling each other our arts and crafts? And what does a local politician’s comments tell us about why we are in trouble deep?

Torture – is it ever justified? We’ll do some of those thinking exercises left over from high school or any ethics class. Consider the following references.

Code of Conduct: The new Code of Conduct is not a part of the Uniform Code of Military Justice (UCMJ).  Instead, the Code of Conduct is a personal conduct mandate for members of the American armed forces throughout the world.

Article I: I am an American, fighting in the armed forces which guard my country and our way of life.  I am prepared to give my life in their defense.

Article II: I will never surrender of my own free will.  If in command I will never surrender the members of my command while they still have the means to resist.

Article III: If I am captured, I will continue to resist by all means available.  I will make every effort to escape and aid others to escape.  I will accept neither parole nor special favors from the enemy.

Article IV: If I become a prisoner of war, I will keep faith with my fellow prisoners.  I will give no information nor take part in any action which might be harmful to my comrades.  If I am senior, I will take command.  If not, I will obey the lawful orders of those appointed over me and will back them up in every way.

Article V: When questioned, should I become a prisoner of war, I am required to give name, rank, service, number, and date of birth.  I will evade answering further questions to the utmost of my ability.  I will make no oral or written statements disloyal to my country and its allies or harmful to their cause.

Article VI: I will never forget that I am an American, responsible for my actions, and dedicated to the principles which made my country free.  I will trust in my God and in the United States of America.

Prisoner of War: (pow, or Pw), any person captured or interned by a belligerent power during war. In the strictest sense it is applied only to members of regularly organized armed forces, but by broader definition it has also included guerrillas, civilians who take up arms against an enemy openly, or noncombatants associated with a military force.

Hypocrosy? The old who knew what when?

The fine print:

What: Politics and a Pint
Where: The Contented Cow, Northfield
When: 26 April 2009, 6-7:30PM

References:

• http://www.theweek.com/article/index/95773/Nancy_Pelosi_and_waterboarding
• http://www.usmcpress.com/heritage/code_conduct.htm – code of conduct
• http://www.britannica.com/EBchecked/topic/477235/prisoner-of-war

Death and Taxes … next Politics and a Pint (19 Apr 2009)

Well, we all just passed through that little bump we call tax time, and as we breathe a sigh of relief it is interesting to look at a little thing called “Tax Freedom Day”.  Tax freedom day estimates the day each calendar year that the taxpayers are finished paying for their government and can start earning for themselves. It is a simple measure, based on total income tax, total earnings, and a 365-day year. This year tax freedom day fell on the 13th of April. The Tax Foundation explains this this way

(1) the recession has reduced tax collections even faster than it has reduced income, and

(2) the stimulus package includes large temporary tax cuts for 2009 and 2010. Nevertheless, Americans will pay more in taxes than they will spend on food, clothing and housing combined.
[emphasis added, editorial: boy, is temporary an overstatement or what?]

Look at the graph below (from The Tax Foundation (est. 1937) and study it well.

The Tax Foundation

Note that during the 1992-2000 Clinton years (yellow) taxes went up and the adjusted date went down, indicating we were making progress on one front while losing ground on another in what is always a highly correlated pair of measures. During the war years (2000-2008) the economy and spending showed some instability as the beginning of the current troubles was evident.

The most shocking is the red, where we see tax freedom day dropping to a low unvisited since 1967, but the adjusted tax freedom day shoots nearly off the charts.  Anyone want to project this forward 10 years and see when the true tax freedom day will arrive when we have added $10T in debt? I don’t think any politicians want us to think that far ahead. Lucky for us, 12 year olds (who will get to lead the way in paying this off) don’t get to vote either. Talk about your “taxation without representation!“.

After this discussion, I would like to share some insights I picked up from a couple of recent seminars I attended at the Mayo Clinic (where I work). We saw two speakers who presented on the looming Medicare crisis, and who had some very interesting comments.  The discussion will focus on how to handle a $36T implied debt.  We’ll talk about the two terms you cannot use in politics, but since we are not running for office, we can use them, they are: cost-benefit analysis and rationing.

So if taxes made you sick, wait till you see the health care system up close and personal.

The fine print:

What: Politics and a Pint
Where: The Contented Cow, Northfield
When: 19 April 2009, 6-7:30PM

References:

Part I: The Tax Foundation.

Part II: Healthcare at risk

• Can Americans Say No? A British Perspective

It is evident that particularly for the rich, dying is an un-American activity! This accounts in part for Americans’ spending twice as much per capita on health care as the British do. The British reluctantly accept two facts of life. First, they are all suffering from a terminal, sexually transmitted disease called life. Second, with death inevitable and resources finite, health care rationing is inevitable. Rationing involves depriving patients of care from which they could benefit and which they wish to consume. The British are much more vigorous than Americans are in “drawing the line,” as Henry Aaron, William Schwartz, and Melissa Cox show in Can We Say No? But even with Americans’ higher levels of health spending, rationing in the United States is also inevitable.

• The cost of living: kidney dialysis, rationing and health economics in Britain, 1965–1996

Jennifer Stanton, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK

Available online 10 August 1999.

Abstract:  How important is research in shaping policy when a new life-saving medical technology becomes available, but happens to be very expensive? Taking the case of kidney dialysis, this paper argues that the emerging discipline of health economics had little influence relative to national differences in health service organization and cultures of expectation of provision. Paradoxically, the most effective covert rationing was achieved under the British NHS which ostensibly provides free care for all, while the uncentralised market system in the US gave way, on this issue, to almost universal state-subsidised provision. Under the British system, the most cost-effective options for renal care tended to flourish, but some patients were turned away. Physicians have been held responsible for complying with covert rationing: this paper suggests that early gearing towards socially-useful survival filtered back to selection at primary level, possibly continuing long after specialists wished to expand. Public outcry, though muted, reached parliament and caused minor shifts in policy; the main aim of the voluntary pressure campaign, to release more organs for transplant through ‘opt-out’, remained unrealised in the UK. Yet dialysis was targetted [sic] for expansion in the 1980s just at the point when health economists were presenting evidence for its low cost-effectiveness compared with other expensive interventions. According to the main strand of argument in this paper, comparisons with other countries and between regions were most influential in breaking the hold of covert rationing: policy making by embarrassment. However, in the 1990s, there are both theoretical discussions of explicit rationing, and open intiatives afoot to target dialysis for rationing.

Author Keywords: Rationing; Kidney dialysis; Health economics; QALYs; Expensive technologies; NHS; UK
Article Outline

• Introduction
• Contrast between early dialysis provision in the USA and Britain
• Selection of patients for dialysis in Britain, 1960s and 1970s
• ‘Simple’ economic research and a shift in policy?
• Kidneys in parliament, 1976–1984
• Was Britain killing kidney patients: the medical press, 1981–1984
• 1984–1990: target-setting, contracting-out, and QALYs
• Discussion

• Experience with rationing health care in New Zealand

New Zealand’s health reforms were introduced in 1993 and changed the framework for health service delivery; this framework clearly contemplates rationing. We describe the development of guidelines for entry into end stage renal failure programmes in the northern region of New Zealand,1 how they were used in the clinical decision making process, and how they influenced public opinion. In particular, we describe two cases which put the decision to ration renal dialysis under the public spotlight.