Monday, June 8, 2009

Change we can believe in

Look, this blog isn't supposed to be about healthcare politics. It's supposed to be about healthcare IT. But the intersection between the two is enough that I feel justified in commenting about this blog entry that one of my spies alerted me to.

The Kennedy-Dodd bill would create an individual mandate requiring you to buy a “qualified” health insurance plan, as defined by the government.  If you don’t have “qualified” health insurance for a given month, you will pay a new Federal tax.

And then it continues with a whole lot of analysis, which my spy aptly summarized as:

Take all the things that are off about US healthcare, ignore them, and heave a corporate subsidy into place as a solution.

Well, I think that's a pretty good summary. But that's what they did with the wunch of bankers, so why would you expect anything different in healthcare?

As I said, I had hoped that “Change we can believe in” didn’t mean that kind of change the Health IT Nerd believes in, the kind that I usually see in the healthcare system – namely, just a different kind of stupid. But it looks like that's what we're getting, and what we're going to continue to get. 

I say that because just like every 'reform' proposal is stupid, every criticism has its own built in time bombs. Take, for example, this:

Those who keep themselves healthy would be subsidizing premiums for those with risky or unhealthy behaviors

Just think that one through. Who's going to say, 'well, you know, someone else is going to pay my healthcare costs, so I'll drink myself into the ground'? Look, I know plenty of people who are drinking themselves into the ground, but for most of them, the availability of healthcare sure doesn't factor into that choice (and for the few that it is, it's the fact that they can't get the healthcare they need that means they have no reason not to drink).

And just how do you think any form of healthcare coverage works, from pay-for-yourself-as-you-go through to a fully collectivized economy? The healthy pay for the sick, either by saving up for when they're sick, or entering into some cost sharing scheme known as "insurance" or "tax" whereby their sickness risks are shared to the mutual benefit of all. 

So, the real question here is, do people indulge in risky or unhealthy behaviors because their consequential healthcare is subsidized? Economists believe this sort of stuff as a matter of religion, but real people don't make health decisions like that based on financial considerations. They're far more... emotional. Anyway, it's not as if private insurance schemes are really successful at preventing those with risky or unhealthy behaviors from getting coverage. No, what they're good at is preventing those with risky or unhealthy heritages or histories from getting coverage, which is a whole different kettle of fish (usually called discrimination).

Another typical claim of the opponents of national healthcare services is this:

force patients to accept what a bureaucrat deems “proper” healthcare regardless of what the patient deems proper care

Yes, I can see why people are skeptical about accepting what a government bureaucrat thinks is best. I sure can. After all, the government bureaucrats have no stake in the outcomes either way, what would they care?

So I've got a heaps better idea: instead, we'll let some company decide what proper healthcare you should get, and you can pay them for that instead of relying on the government. After all, they have a stake in the game, which is that the less healthcare you get, the more profit they make. Yep, definitely an all-round better idea! I can see why everyone wants to go for that. (at least, that is, it's a better deal for the people who own the insurance companies, who seem to be the only ones at the table)

Ahh, but wait, the economists will be saying right now, you've missed the key point, which is that it's all about choice. If the consumer has choice, then the insurers will be forced to compete to give us the best deal, and that'll be much better than if the government takes that choice away. 

Well, my response to that is three-fold. 
  1. if you are economist, have you actually heard about transaction costs? (and see also this about free market efficiency)
  2. for the rest of us who live in the real world, does the word "cartel" sound familiar? At least you vote for the government (and round the rest of the world, governments routinely get voted out over the state of their health systems)
  3. yep, choice itself is a good thing, but the mere fact that the government is going to provide healthcare doesn't mean choice goes away. 
Just to reinforce that last point, to my knowledge only Canada prohibits a private healthcare system. Because only Canada has USA as a realistic option for providing the second-tier healthcare system- because everyone needs a two-tier system (everyone important anyway). 

Not that any of this matters anyway - as long as the government is paying, then nothing will change. The costs will keep climbing like a rocket. In addition to the reasons I explained earlier, also because as long as the government is just paying, people (I guess we have to call those beasts running the health insurers that) will be just ripping the government off, and we've just been shown how to do that on a grand scale in a real expert fashion. That's why in other countries, the government is not only payer, it's also provider. 

Anyhow, as long as morons are running around making these kinds of claims, and voters are listening, then there won't be any real progress on healthcare in USA. But it seems to me that these kinds of concerns are built into the very fabric of USA, part of the basic social contract enshrined in the constitution: what's good for me is what's good for everybody. And, therefore, vice versa: what's good for everyone can be judged by whether it's good for me. USA is a country founded on a very different set of principles than other countries. Accordingly, it can't have the kind of healthcare system other countries can have, and comparisons with other countries (such as seen here on The Big Picture) are pointless and misleading. Because USA isn't ever going to achieve the outcomes other countries can - and neither can the other countries achieve what USA does. 

See, if you choose individual wealth over shared wellness, then that's what you're going to get.


Monday, March 30, 2009

Patients = Patience

You hear at all the time: the problem with socialized healthcare is that it leads to waiting lists, people waiting too long for operations. Months, I hear, people have to wait months for operations you shouldn’t have to wait for, and sometimes they even die before the operation can happen.

Well, I say that’s crap.

Let’s start with some mathematics. Let’s say that we have a population P, and D, the rate occurrence of a particular condition that requires treatment.

Now let’s, for the sake of argument, assume that P is large enough – major city size,> 1,000,000 – to provide some constancy in statistics. So you can tell right away that we’re dismissing rural medicine. Stupid hillbillies who still live out in the boondocks, what the hell do we care about them anyway? All decent people live in slums cities with at least that number of people in it.

A P that large means that the rate of D is basically fairly constant, with the daily rate of Dd having a standard distribution around the mean D, and an approximate Standard Deviation of √D.

Look, these are rough statistics, and you know the drill: lies, lies, and statistics. But if I had a polished statistician go over this stuff, instead of the weird Health IT Nerd, the picture wouldn’t change that much.

So we have this condition occurring Dd number of times per day in the city. Now let’s say that this condition requires treatment on the same day. If this treatment is not provided, the patient will die. Perhaps the condition is extreme exhaustion from exposure to the political shenanigans associated with the bail-out, and the treatment is to be forced to read the War Nerd. Or we could try taking life seriously and posit that the condition is a renal stone, and the treatment is ultrasonic destruction of the stone. (Not that this is generally highly successful, but I’ve always though it’s the perfect procedure: we’ve got a problem – a real painful one, so what we’re going to do is have a good scream at it for a little while, and see if it goes away all by itself.)

Whatever, there’s a rate T, the number of treatments for the condition that can be provided in a day. Unlike D, this number is not subject to a normal statistical variation. Instead, it’s influenced by the availability of staff and long term institutional policies (which often produce unexpected results on the value of T). So for the sake of argument, let’s assume that T is a fixed constant.

If T is less than D, then this is a disastrous outcome - the queue for services will rapidly grow longer and people will die. The queue will get shorter on some days, but in general it will grow longer. However the length of the queue is limited by the number of people who die before they get to the front of the queue. So eventually the queue will stop growing. (So next time you hear of a long queue, understand: the people waiting aren't dying like flies while they're waiting...)

If T = D, then the queue will quickly reach a steady state – but roughly 50% of people will still have to wait until the next day. (Actually, it starts out much lower than that – a small number miss out on some days, say when Dd = D + 1 * √D. And they get carried over to the next day, where they compete with Dd for that day. The eventual outcome of this, what the average carry over is, depends on a variety of modeling and simulation assumptions, but as a rule of thumb, about 50% get carried over the next iteration.)

So when T = D, only 50% of the target is met. Note that like the previous case, the actual length of the queue depends on the number of people who die before treatment.

As T > D, and the gap increases, the percentage chance that a patient will have to wait until the next day drops – but T has to be quite a bit bigger than D before it approaches 0. (How much bigger depends on the value of D, given that the standard deviation of D was posited to be √D, but a useful rule of thumb is T = D + (3 x √D) gives 1% missed targets)

This is well and good, but what does it mean?

If you want to have immediate treatment available, you have to build considerably more than the average required treatment capacity into the system.

This is true for almost all kinds of treatment, whether obstetrics, oncology, cardiology, or what. You just plug different numbers in, and different requirements, but the same basic principles are in play.

Note that it’s mostly not as bad as it sounds because many treatments share a common set of resources, particularly facilities and staff. By pooling these things, the overall size of D increases, and the ratio of D/√D goes up, and the built in waste is ameliorated.

Nevertheless, you need to have excess capacity built into the system. Now this is hardly a radical conclusion – it arises in other industries all the time, particularly in telecommunications and transportation, and it’s a pretty well understood problem.

But people seem to forget this when they start talking about health, and we have these stupid debates about resources and waiting lists. In these, people not only ignore the simple principles above, they also ignore the fact that no society on earth can afford to pay for unlimited healthcare, let alone have excess capacity in the system.

So, how do you limit the resources available without creating waiting queues? Want a hint?

You can’t.

Well, actually, I lie. You can. But only if you deny some people access to the queue at all. Then they turn into a “totally negative healthcare outcome” instead of screwing up your statistics (i.e. they screw someone else’s stats up. Since funding is linked to statistics in most jurisdictions, this is just a way of externalizing the costs).

So, you choose: the immoral or the distasteful? Which is it to be?

Though there’s a third option. The way this works is simple: You know that a queue has to exist, but you personally don’t want to wait. So you create a two-tier system that ensures you don’t have to wait when you need the treatment, that someone else will wait. Or miss out altogether.

This only really works well if you can arrange that everyone who matters is in the top tier, and people in the second tier are such losers that they either don’t have representation (e.g. communist paradises)  or don’t have the wit or leverage to be heard anyway (say, UAW members ;-). Note that this can only work if the second-tier people fund the first tier some way or other (kind of socialism in reverse).

I’ll leave it to you to decide for yourself how well your country manages this issue, whether you’re happy with the way the case-by-case decision is made, whether it’s going to be the immoral or the distasteful for you and your loved ones.§


But next time you hear someone discussing the disgraceful state of waiting lists in [country/system/state] as compared to [other country/system/state], ask yourself: how are the statistics lying this time? How many people had a totally negative outcome before the possibly positive outcome got counted? And who were they?

§ The correct answer to the question above is ‘no, I’m not happy’. It doesn’t matter which country you live in. Tricky huh?

p.s. Here’s an excellent example of this stuff in practice, quoted from
http://tedstumor.blogspot.com/2009/03/natasha-richardson-epidural-hemorrhage.html
“It's important to ask this question, because this is precisely the situation where the Canadian-type health care system -- much touted by reform advocates -- tends to fail Canadians.”
Yes, the Canadian government makes one set of decisions. These weight some situations preferentially over others. And then:
“In the United States if someone falls and hits her head and then an hour later is rushed to the emergency room you can bet she will get a STAT CT scan and immediate neurosurgical attention.”
This is another set of decisions. Because there’s a word or two missing from this paragraph – this doesn’t apply to all citizens, only to those with “coverage” – a number steadily decreasing at this time. Both of these are two-tier systems. The Canadians just outsource their first tier to USA – works well for everything but emergency medicine.

Sunday, January 18, 2009

All I want for Christmas

It’s Christmas time. [Well, okay, it’s not anymore. This was written before Christmas, but the one friend I do have reviews these posts first, and he disappeared on holiday beforehand, so I’m only getting to post it now].

It’s a hard time of year for everyone, especially if you have any sense of the ridiculous. After all, what’s the basis for Christmas? The Son of God came to the world, and told everyone that God was angry because of everyone’s injustice and greed. So naturally, we remember Jesus by giving gifts to anyone who’ll give us stuff back, and by eating and drinking far too much. We can’t even get the time of year right – though maybe it’s best that Christmas is just a pagan feast at heart.

Of course, when I’m stupid enough to say something like this to my friends, they tell me that the best part of Christmas – what it’s really all about – is spending time with my family. Well, they’re quite welcome to spend time with my family. Though if they think that’ll be fun, they don’t know my family as well as I do. So I’m back hiding in my hovel, thinking about healthcare and IT (and not before time too. Apologies for the long delay between posts – apparently our customers expected me to get some actual work done before they got to go on their family fun-time holidays).

And what I’m thinking about right now is, what will you and your loved ones – if you have any – what will you be talking about this Christmas once you’ve had too much to eat and drink, and all the presents are opened? Well, I can’t think of anything better than to talk about healthcare system reform. 

“Umm, yeah,” you’re saying, “right. What else would we talk about?”

Well, don’t blame me. Instead, you can blame Senator Tom Daschle:

Daschle wants Americans to host “holiday-season house parties to brainstorm over how best to overhaul the U.S. health-care system,” the WSJ reports.

Don’t believe me? Check out the WSJ for the whole outrage. And thanks to my spies in the USA who alerted me to this gem.

At first I laughed at this. I was pretty disappointed too. I was certainly hoping for more from the incoming administration. After eight years of the Bush power slide, we’re in desperate need of a responsible approach to prevent the inevitable, though a quick survey shows that the Democrats have quite happy competed with the Republicans to see who offers worse government (it’s a US thing: governments are bad, so we vote for bad governments). Nevertheless, I found myself hoping that “Change we can believe in” didn’t mean that kind of change the Health IT Nerd believes in, the kind that I usually see in the healthcare system – namely, just a different kind of stupid.

As I said, I thought, who’d be stupid enough to talk about healthcare policy over a Christmas meal? But the more I thought about it, the more I realized that we always talk about healthcare policy when my family gets together. It starts easily enough, talking about our family’s latest encounter with the healthcare system. What with the many little accidents of life – backyard, kitchen, and bedroom - and getting old (also accidental; at least, it certainly seems to happen while you’re looking the other way), the extended families of the Health IT Nerd and his suffering wife have regular encounters with the healthcare systems across the world, and whichever side of the family we have the “luck” to spend the festive season with, the subject is sure to come up.

And once the subject does come up, you can be sure of one thing: everyone is going to start complaining about how terrible the healthcare system is. After all, it’s never our fault that we needed healthcare. Actually, it’s not our fault. Since the only thing that’s sure in life is death and hospitals, it’s just because we were born. So the fact that we need healthcare is our parent’s fault – it’s important to know who to blame for all life’s ills. For this reason, the best time to talk about how to reform the healthcare system is when you get together with those whose fault it is. 

It doesn’t matter what country you’re in, either. You can be sure that everyone’s going to be complaining about the quality of the healthcare system. And also how much we have to pay for it. Again, it doesn’t matter how it gets paid for, directly, indirectly through insurance, or indirectly through taxation. We pay too much, and the quality of service sucks. 

So, this year, when you get together as families, do your patriotic duty, and brainstorm how to overhaul the U.S. health-care system, because, as Daschle points out:

There is no question that the economic health of this country is directly related to our ability to reform our health-care system

For a start, you can tell by looking at the way we celebrate Christmas, you can tell for sure that it would be a waste of time asking us to consider the healthcare system from some altruistic perspective about what would actually be good for our health. No, we definitely need to talk about money. And since there’s a war or two to fight, and the worst financial crisis this century, we need all the money we can get. 

So this year, instead of simply complaining about how poor the system is, instead, try and figure out how to pay less, either by defrauding someone, or perhaps by setting up some kind of ponzi scheme to raise enough money to pay for it (as if any kind of savings plan isn’t a ponzi scheme in the end). If that doesn’t work out for you, see if you can figure out how to overhaul the US healthcare system. And the best kind of overhaul is one that saves money – in other words, one that makes the system poorer. 

It’s kind of a game, see. Basic level, you get to plan a healthcare system assuming no constraints, like worrying about how much it costs. But anyone can design a pretty good healthcare system that way. At the intermediate level, factor in real world constraints like costs, staffing levels, and inefficiencies like organizational dysfunction. There’s a special advanced level where you also get to make allowances for things like liability funding, and on-going educational resourcing. If your family wins at that level, then you move onto wizard level, where you get to figure out how to overhaul the US healthcare system to make it better, while factoring in unreal world constraints like eating long lunches with friendly lobbyists.

No one wins the wizard level. Ever.

But it’s Christmas, so there’s no harm in hoping for the best. After all, wishes can come true. So what does the Health IT Nerd wish for?

Of course, I wish for world peace, justice for all, the end of famine, an end to bad governments, and that people would stop sponging off their richer neighbors. And in healthcare, I wish that people would stop getting sick, and that everybody would be happy to let their poor sick neighbors sponge off them.

Hmm. This isn’t going well. Though at least Bush the Second is going to be gone. I guess that’s not much a Christmas present though, since it was all organized years ago. 

No, other than a bit more of that river of gold, what I really want for Christmas is that everyone would finally come to really understand: Interoperability – it’s all about the people.

[Belated Christmas note: I sure hope you got what you wanted for Christmas. Because I didn't)