Quote of the Week (Japan Edition)

I wanted to pull this week's Quote of the Week from Arnold Schwarzenegger's Q&A on Reddit last week, I really, really did. The concept of 1,000 duck-sized Predators is just too great to not mention, and I couldn't get that mental image out of my head all week. Brilliant stuff.

But I decided instead to give the honor to Japan's new Finance Minister (their 11th since 2007!) Taro Aso, whose brutal bout of honesty this week added a neat little twist onto Japan's growing fiscal problems (and demographic nightmare). In a statement that is almost certainly intended directly for the ears of Jiroemon Kimura, the oldest man in recorded history, Aso uttered a phrase (well, a few of them, really) that you might end up hearing a lot of around the world over the coming decades...

This week's QUOTE OF THE WEEK

"Taro Aso said on Monday that the elderly should be allowed to 'hurry up and die' to relieve pressure on the state to pay for their medical care.

'Heaven forbid if you are forced to live on when you want to die. I would wake up feeling increasingly bad knowing that [treatment] was all being paid for by the government,' he said during a meeting of the national council on social security reforms. 'The problem won't be solved unless you let them hurry up and die.'

Aso's comments are likely to cause offence in Japan, where almost a quarter of the 128 million population is aged over 60. The proportion is forecast to rise to 40% over the next 50 years.

To compound the insult, he referred to elderly patients who are no longer able to feed themselves as 'tube people'. The health and welfare ministry, he added, was 'well aware that it costs several tens of millions of yen' a month to treat a single patient in the final stages of life."
                                                     - Justin McCurry; Guardian

So, first of all, it needs to be said that this dude is completely off his rocker. If you read Mish Shedlock's whole piece, you'll see that Aso has previously made bizarre off-color remarks about Jews, Taiwanese, and blue-eyed U.S. diplomats, so clearly he has a habit of saying outlandish things to provoke a reaction (sort of like another economist we all know and love).

That said, this little moment of honesty might hit just a little close to home for all of us here in America. Our Medicare costs are already projected to go through the roof over the coming decades, in large part because we continue to refuse to have difficult conversations about end-of-life care (specifically, how much is it worth to keep somebody alive for an extra year at age 65, versus at age 75, versus at age 85? Is there an infinite value? A declining value? Do we even begin to know?).

We can choose to spend an infinite amount of money to keep a person (any person) alive for another day, and hospitals and doctors will surely be glad to dispense those services as long as somebody (i.e. the taxpayer) is willing to pay. But sooner or later, we simply can't afford to do so for everybody, and we have to have that difficult little conversation with each other. Japan is having it now; it's coming our way sooner than you might think.

[Mish Shedlock]

Santelli on Obamacare

I'm going to mostly avoid the discussion on today's Supreme Court ruling regarding the Affordable Care Act,  primarily because the issue has become so politically charged that I believe honest and respectful discourse is essentially impossible right now.

To summarize my own beliefs (which are admittedly based upon partial information, because full information has been hard to come by when it comes to this bear of a law), I think that the law as written is destined to fail regardless of its constitutionality, simply because it fails to address any of the root causes behind ever-increasing healthcare costs--if anything, it perpetuates and expands them. I appreciate the attempt to try to help, but I think the government's mostly-good intentions will go horrifically unrewarded here. Ironically, I think that's actually a good thing long term, because I think that it will eventually force a more complete overhaul of the system, rather than a simple tweaking of it (which is what I believe Obamacare to be). A complete overhaul is necessary, so anything that brings us closer to it is a good thing.

As for today's decision, the best response I've seen yet comes from CNBC's Rick Santelli. I missed watching this live, because I was over on CNN watching that network throw up all over itself by screwing up the scoop --another tough day for a struggling media outlet, although Fox News made the same mistake--but I'm glad my friends at ZeroHedge gave me the heads up. As usual, Santelli has a pretty interesting take on things, and I think he's dead on.

 [ZeroHedge]

On the idiocy of soda bans

Weeeelllll I was all ready to go ahead and post a rant here about Mayor Bloomberg's bizarre proposal to ban large sugary drinks in New York City, but then the Red Cowboy alerted me to the fact that Jon Stewart had not only beaten me to the punch, but done a better job than I ever could have.

So, yeah... here's Stewart, owning it as usual. He would be next week's Quote of the Week recipient, but I just can't wait that long.

"Wow, wow, wow, Mayor Bloomberg, wow. I love this idea you have of banning sodas larger than 16 ounces. It combines the draconian government overreach people love with the probable lack of results they expect. WHAT ARE YOU DOING?"

- Jon Stewart

The Daily Show
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The Daily Show
Get More: Daily Show Full Episodes,Political Humor & Satire Blog,The Daily Show on Facebook

On Junior Seau and smoking

I'm still shocked by the news of Junior Seau's suicide on Wednesday. Seau was well-liked at every step of his career (this anecdote gives you a pretty good idea of why), and his premature death is an unspeakable tragedy, especially to those in his hometown of San Diego. It's even more troubling to learn that Seau followed in the lead of Dave Duerson by shooting himself in the chest, so that his brain could be studied to better learn the impact of head trauma (concussions) on long-term mental health.

Naturally, incidents like the Seau suicide tend to spur many of us into action, in hopes that we can learn some kind of lesson that will help prevent future tragedies. That reaction was evident in the following Twitter post from Hall of Fame running back Emmitt Smith, re-tweeted by Sports Illustrated columnist Peter King:

Smith makes a fair point, but as I replied to him (and King), the information is, for the most part, there--it's just that many players choose to ignore it, because their careers often depend on such ignorance.

Concussion awareness organizations like the Sports Legacy Institute (founded by Chris Nowinski, a former pro wrestler whom I knew in college) have existed since the mid-2000s, inspired by a growing body of evidence surrounding head trauma. Their findings have clearly had an impact on the NFL, and the league has tried its best to respond to their recommendations.

To be fair to players like Seau and Smith (not to mention Duerson), their careers began and essentially ended before they could have benefited from the most recent research. But there's no excuse for current players to be engaging in this kind of behavior, given the NFL's new emphasis on preventing serious head injuries:

A four-month look at how the NFL handles concussions in a more tightly controlled environment shows that following the new rules remains extremely arbitrary. Many times, players ignore them. Sometimes, teams do. In other instances, there is a pact between the two to skirt them. 

While NFL teams have enacted smart and thorough mechanisms to help players deal with the dangers of concussions, some have found a way around them by simply waving off doctors on the hits that aren't clearly visible or where the player doesn't lose consciousness. Some are hiding concussion symptoms from doctors, players said in dozens of interviews. 

"In some cases, if you avoid the doctors, you can avoid the concussion exams," one AFC North player said, "and the doctors know you're avoiding them, but let you." 

Said one player, who is also a player representative: "The concussion rules are the best they can be. The league and the union have done a good job protecting players, but the truth remains, players are still hiding concussions, because they want to protect their careers. In some cases, teams know a player is concussed and let it go. Yes, that still happens." 

The NFL and players union might soon respond to holes in the policy by placing independent doctors on the sidelines during games, taking the decision out of the hands of the interested parties: the teams and players. But until then, some players will continue to put themselves at risk by doing whatever they can to stay on the field.

In this regard, I see significant parallels between concussions in the NFL and the smoking of cigarettes.

In this day and age, everyone knows the dangers of smoking, and everyone (at least, everyone in the NFL) knows the dangers of football and concussions. But for various reasons, people continue to light up, just like they continue to buckle up their chinstraps and take the field. Simply put, some people just don't care about the risks--they want the rewards. That's why people continue to take steroids, and it's also why people continue to invest in the stock market (though that's probably a topic best left for another day).

The only way this dynamic will change is if people stop watching football because of incidents like the Seau suicide, whether as a means of protest or simply out of disgust. Until that day comes, the rewards of an NFL career will continue to be so great (particularly for uneducated or under-educated kids from lower class families) that many players will simply overlook the risks, hoping that maybe they'll be one of the lucky ones.

Simply knowing about the risks isn't enough to prevent future tragedies like the Junior Seau story--knowing is indeed half the battle, but that still leaves the other half. We as a society need to actually respond to those risks in a way that affects future behavior. Otherwise, we'll be doomed to learn nothing from the Seau tragedy, just as many of us learned nothing from millions of smoking-related deaths around the world over the past few decades.

In a sense, maybe that's okay. NFL players are consenting adults, and if they choose to put themselves in harm's way despite knowing the risks, then that's certainly their choice. But we shouldn't pretend that they don't know better, because by now, they absolutely do. If nothing else, Junior Seau's death has at least assured us of that much. Hopefully, it will do even more.

[Twitter]
[CBS Sports]

An update on prescription drugs

I think it's funny how I sometimes cover certain topics on the blogs in bunches, then ignore them for a while, before coming back to them again (think: China and currency manipulation). I can't fully explain why that's the case, though I'd love to spend some more time thinking about it.

At any rate, the reason I'm thinking about that dynamic today is that I recently came across this article (shared by Tim Iacono) regarding the explosion in painkiller prescriptions--specifically hydrocodone (Vicodin) and oxycodone (OxyContin/Percocet)--over the last decade. I was pretty sure that I'd covered this topic before, and indeed I had--three separate times. A sample take-away from what I wrote is this:

In general, I believe that we have become a nation that is incredibly good at treating symptoms, but woefully inadequate at solving underlying problems. Not feeling too happy today? Don't bother asking why, just pop some prozac. Short attention span? Here's some ritalin. Cholesterol hitting the roof? Don't pass on the steak and eggs just yet, just take some lipitor and don't look back. (Yes, I'm getting a little rant-y here, but I think it's justified). 

I've long complained that the problem with most government policy is that it is too reactionary, rather than pro-active. Affirmative action and the Patriot Act are frequent targets of my ire, for exactly that reason. We declared war on drugs without bothering to ask what made drug use so prevalent (could it be that recreational drugs and prescription drugs go hand-in-hand?). We fought a war on terror--and sacrificed personal freedoms--without wondering why we were the target of a terrorist act in the first place (it's best that I not go down that road).

To be clear, this kind of thinking isn't at all unique to government policy--the government (any government) simply reflects what the citizenry demands, and lately the citizenry has demanded that we treat symptoms, not causes. That's why I'm completely unsurprised by these graphics, although the growth rates were staggering even for me. (Side note: given the brand names in question, I'm not totally shocked that oxycodone sales increases have significantly outstripped hydrocodone sales increases over this time period--either way, both have skyrocketed).

[Yahoo! Finance]

The explosion in obesity

This chart comes courtesy of Tim Iacono, and it absolutely blew me away. I knew that obesity rates had been soaring, but I didn't appreciate how much and how quickly.

Every state in the country has seen an increase in obesity over the last 20 years, and many of these increases have been dramatic--consider that in 1994, not a single state had an obesity rate greater than 20%, but by 2008, only one state (Colorado) has a rate below that same 20% threshold. Tennessee and Oklahoma somehow pulled off the incredible feat of going from sub-15% to over-30% during this time period. Yikes.

Ultimately, this map raises as many questions for me (Why did it soar so quickly? Is it a result of a broad-based change in our food supply? Or is it due to a change in behavior in response to economic factors, like consistently "accommodative" monetary policy?) as it does concerns (How the hell are we going to afford to pay for all the health problems that this obesity creates? Am I totally certain that I'm doing everything in my power to avoid becoming part of that statistical trend?). I think this dynamic therefore has incredibly wide-ranging implications for our nation, encompassing issues both political and societal, and both in terms of public health and economic sustainability.

Along with the fate of Social Security and other public and private pension plans, I think that this dynamic will turn out to be one of the most important ones to keep track of over the next 20 to 25 years. How we as a society decide to deal with our ever-growing group of elderly citizens, as well as our overweight (or otherwise unhealthy) citizens will in large part determine the fate of our nation as a whole. Stay tuned.

Is disability the new unemployment?

Did you hear the good news? New jobless claims are falling, and they're now hovering at a four-year low! That's excellent news for the economy, right? Maybe... maybe not. As has been reported in several places recently, the drop in people filing for unemployment has been accompanied by a sharp rise in those filing for (and receiving) disability.

More than 8.5 million workers are now collecting disability insurance, in other words almost 6% of the labor force is officially disabled. Perhaps not surprisingly, disability applications shot up just as unemployment benefits started to exhaust... 

Since 1995 the number of disabled workers has doubled and expenditures have increased even faster than disabled workers, tripling since 1995. The increase in workers receiving disability insurance has come at the same time as the US working age population has become healthier. A large fraction of the increase in disability has come from increases in hard-to-verify back pain and mental problems... 

After the 2001 recession, disability applications also shot up and they never fell back to their old levels. We may be reaching a new, permanently higher, plateau. 

Disabled workers do not count as unemployed, they have been bought out of the labor force.

Ugh. This is a terrible development--as Karl Denninger described it, this is in many situations a case of "I lost my job, now I'm crazy!"

I've said here before that the national unemployment rate (as currently calculated) is an incredibly noisy and easily-gamed statistic, as are jobless claims. When considering the overall health of our economy--especially in the face of a rapidly aging population with monstrous entitlement benefits--the most important statistic to track is the employment rate of the population, which of course continues to plummet even amid an "improving" economy.

Having more people on permanent or semi-permanent disability only adds weakness to the overall fiscal condition of our country, as people who should be wage-earners (and taxpayers) are instead transformed into tax recipients. With our country already gaining tax recipients by the day as the Baby Boomers retire in droves, who is going to be left to pay all of these bills? Warren Buffett? Good luck with that.

The massive impending liabilities of Medicare and Social Security require that our overall labor force be growing, not stagnating or shrinking. That absolutely is not happening, regardless of underlying improvement in the official unemployment rate. We can't hide these people on the disability rolls forever--sooner or later, we need to find ways for them to contribute, rather than add to our already bloated federal dole. Any ideas?

[Marginal Revolution]
[Market Ticker]

Quote of the Week

This week's Quote comes courtesy of Karl Denninger, who has inspired more than a couple of my rants here in the past. It stems from the Congressional Budget Office's projections released yesterday, which are absolutely chock full of ugly numbers and statistics (ignore them at your own peril). Let's get right to it:

This week's QUOTE OF THE WEEK

"Government spending for Medicare, Medicaid and other healthcare programs will more than double over the next decade to $1.8 trillion, or 7.3 percent of the country's total economic output, congressional researchers said on Tuesday.


In its annual budget and economic outlook, the non-partisan Congressional Budget Office said that even under its most conservative projections, healthcare spending would rise by 8 percent a year from 2012 to 2022, mainly as a result of an aging U.S. population and rising treatment costs. It will continue to be a key driver of the U.S. budget deficit."
                                           - David Morgan, Reuters

Look at that first paragraph: that's 7.3 percent OF THE COUNTRY'S TOTAL ECONOMIC OUTPUT! Not of tax revenues, not of total government spending, of the ENTIRE ECONOMIC OUTPUT. In case you were wondering, total federal tax receipts in 2011 were approximately $2.3 trillion, on total economic output (GDP) of $14.6 trillion--about 15.8% of total economic output. That means that our expected expenditure on health care programs would be a full HALF of everything that we currently bring in from tax revenues.

That is, in a word, untenable. There's absolutely no way to make these programs solvent, and we need to stop pretending that there is. We can't grow our way out of this problem, we can't inflate our way out of this problem (hi, Ben), and we certainly can't default our way out of it (although that's where we're heading).

Oh yeah, and just repealing Obamacare doesn't do anything to help matters either, in case any of you Republican-lovers were wondering.

This country is bumping up against fundamental problems with respect to how it cares for its elderly, and it's clear that we've made promises that we mathematically cannot keep. A millionaire tax or a wealth tax or an inflation tax or whatever other tax can't compensate for the fact that there's just simply not enough money to go around. We need to admit that we've made promises that we can't keep, and begin the ugly and unpleasant process of reneging on those promises. The longer we wait, the worse the problem will get--procrastination is an expensive vice that we simply cannot afford.

[Reuters]
(h/t Karl Denninger)

On cancer and heart disease

Way back when, I posted a somewhat disjointed rant about our nation's uneven progress in the war against cancer. I wrote then,

Unfortunately, any successes have been fleeting, as new carcinogens are introduced into our environment daily, and preventive behavior in general has made little progress. You can spend as many millions as you want trying to find a cure, but if the root of the problem is unchanged (or getting worse), you'll make little real progress. It's a harsh Sisyphean reality that any weed-picking gardener knows well.

In keeping with the theme of that rant, I was intrigued to see this post on the Freakonomics blog earlier this week. It adds a little bit of color (and, probably, fairness) to my earlier rant.

The age-adjusted mortality rate for cancer is essentially unchanged over the past half-century, at about 200 deaths per 100,000 people. This is despite President Nixon’s declaration of a “war on cancer” more than thirty years ago, which led to a dramatic increase in funding and public awareness.

Believe it or not, this flat mortality rate actually hides some good news. Over the same period, age-adjusted mortality from cardiovascular disease has plummeted, from nearly 600 people per 100,000 to well beneath 300. What does this mean?

Many people who in previous generations would have died from heart disease are now living long enough to die from cancer instead.

Indeed, nearly 90 percent of newly diagnosed lung-cancer victims are fifty-five or older; the median age is seventy-one. The flat cancer death rate obscures another hopeful trend. For people twenty and younger, mortality has fallen by more than 50 percent, while people aged twenty to forty have seen a decline of 20 percent. These gains are real and heartening — all the more so because the incidence of cancer among those age groups has been increasing. (The reasons for this increase aren’t yet clear, but among the suspects are diet, behaviors, and environmental factors.)

Fair point. Any time we look at a statistic like "cancer mortality rate", we need to make sure we place it in a larger context, like "overall life expectancy". It doesn't exactly mean that we've been doing a great job against cancer, it just means that we have been doing a great job against some other things, which makes our stagnation in the cancer area that much more visible and striking.

Until we as a society unlock the secret of infinite life, people are guaranteed to die from something. Even if we some day succeed in curing cancer, something else will surely show up to take its place as the leading cause of death (it might even be heart disease again). It's sad, but of course true. This dynamic is just another reminder that all statistics need context.

[Freakonomics]

Quote of the Week

We'll keep this one short and sweet. Stephen Colbert is absolutely on fire in this clip, in which he tackles the revelation that our new health care law will mandate that birth control be provided for women essentially free of charge.

I've certainly got my own issues with that concept, but I don't think it's anywhere near the list of top 50 most nauseating things to come out of Washington in the last 5 years. Of course, you wouldn't know that from the response in some corners of the media world, and that's what Colbert does such an expert job of taking down in his inimitable comedic style.

This week's QUOTE OF THE WEEK

"If we give your daughters and granddaughters access to birth control, they will instantly turn into wanton harlots with an insatiable appetite. Because you know women--they're always on the edge of nymphomaniacal orgiastic abandon."
                               - Stephen Colbert

The Colbert Report
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What is the point of prison?

The Chicago Tribune passes along the fascinating story of James Verone, whose tale provides some incredibly intriguing insights into the current state of our union.

A man in Gaston County, N.C., was jailed after holding up a bank for $1 -- but the crime was all part of a larger plan, according to the robber. 

Richard James Verone is 59 and was unemployed with multiple health issues before the crime. Verone says he robbed the RBC bank in order to go to prison and get treatment -- he said it was the only way he could get healthcare. 

Verone has an undiagnosed growth in his chest, two ruptured back discs, and a problem with his foot. 

His medical ailments made working difficult after his 17-year career as a Coca-Cola delivery driver ended a few years ago. He tried living off of savings and part time jobs, but still came up short. He applied for Social Security benefits but only received food stamps which did not help his medical problems. 

When Verone robbed the bank he presented the teller with a note explaining that he was robbing the bank and only wanted $1. He did not want to scare anyone and was not doing it for the money. After receiving the dollar, Verone told the teller, "I'll be sitting right over here on the chair waiting for the police." 

When they arrived, the police found Verone sitting on a sofa inside the bank.

There's all sorts of angles that you can take in analyzing this story--the economic side, the health care side, the welfare side, even the "screw the banks" side if you feel like stretching--but I'm mostly intrigued by the prison side. I think that we rarely think about what the actual function of prison is in our society, even as we're spending ever-increasing amounts of taxpayer dollars to take care of incarcerated people.

It's remarkable--and yet rarely mentioned--that with only 5% of the world's population, the United States nevertheless boasts 25% of the world's prison population. The question is, why are they there?

For much of our nation's history (and especially the last century or so), we have been caught hopelessly between two completely mutually exclusive views of what prisons should be--prisons as rehabilitation centers and prisons as crime deterrents. It should be quite clear that prisons cannot simultaneously serve both roles, and increasingly it seems that our nation has leaned toward the "rehabilitation center" side of things.

That's what leads us to the curious case of Mr. Verone, who like many prisoners saw jail as the best of several poor options. It doesn't speak well of any society that any individual--let alone many individuals--would rather be incarcerated than live out their lives on the streets, or in the ghettos, or worse.

Therefore, we ignore Mr. Verone's story at our own peril. What does his story say about our society? What does it say about our prisons? What does it say about our hospitals? And what if health care some day becomes so expensive that a significant portion of Americans choose the same route that he did, out of sheer necessity? Will we then end up with a back-door socialized health care system after all? Food for thought.

[Chicago Tribune]

On drugs and health insurance

I've written here before about America's seeming love affair with prescription drugs, and how it seems like the interests of our largest pharmaceutical companies seem to have taken precedence over the interests of the public health. This article from the New York Times, published last weekend, demonstrated another element to the problem, describing the role of the insurance companies in the process of determining and dispensing medical care.

Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help.

But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”

Like many of the nation’s 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, the form of psychiatry popularized by Sigmund Freud that dominated the profession for decades. Instead, he prescribes medication, usually after a brief consultation with each patient. So Dr. Levin sent the man away with a referral to a less costly therapist and a personal crisis unexplored and unresolved.

Medicine is rapidly changing in the United States from a cottage industry to one dominated by large hospital groups and corporations, but the new efficiencies can be accompanied by a telling loss of intimacy between doctors and patients. And no specialty has suffered this loss more profoundly than psychiatry.

The Times article goes on to report that as of 2005, only 11% of psychiatrists provided any kind of talk therapy at all, a figure that has probably declined further in recent years. As mentioned above, the impact of insurance companies is likely to blame.

Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression, but fewer than half of depressed patients now get such therapy compared with the vast majority 20 years ago. Insurance company reimbursement rates and policies that discourage talk therapy are part of the reason. A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.

Of course, there are thousands of psychiatrists who still offer talk therapy to all their patients, but they care mostly for the worried wealthy who pay in cash. In New York City, for instance, a select group of psychiatrists charge $600 or more per hour to treat investment bankers, and top child psychiatrists charge $2,000 and more for initial evaluations.

That last paragraph is a bit disturbing, and seemingly part of a broader trend. Say what you will about mental health issues, and whether or not psychological disorders have become overdiagnosed--we should all be able to agree that the treatment choices available to us should be determined by our doctor and our own personal preferences, not by the whims of the insurance companies who we are now forced to use as an intermediary.

It's somehow unsurprising that insurance company policies tend to steer us toward the choices that most benefit large pharmaceutical companies. When two large corporations--a pharmaceutical company and an insurance company--get together, do we really expect that an individual's health is the first priority? I certainly don't, and it's a big part of why I believe that solving our health care problems must not rely on insurance companies' determinations of what constitutes proper treatment.

[New York Times]

The strange drug/surgery dichotomy

I've dabbled in the realm of health care here before, most notably when I discussed the explosion of the prescription drug industry and its somewhat questionable benefits. I thought it was pertinent, then, to give some mention here to this item from the University of Michigan's Risk Science Blog, which cited a JAMA study that found that many women have undergone unnecessary surgeries in futile attempts to help cure their breast cancer.

It has long been believed that women diagnosed with breast cancer should have “sentinel” lymph nodes near the affected breast checked to see if cancer has spread to them. If cancerous cells were found, standard practice was to have surgery to remove many nodes near the breast and under the arm. This procedure was supposed to help prevent the spread of cancer throughout the body. However, it comes with significant side effects, including infection and lymphedema, a type of chronic and often painful swelling.

In the JAMA study, however, researchers found that some women with early stage breast cancer gained no survival benefit from removal of the lymph nodes even though cancer had been found in the lymphatic system. This finding sparked a wave of publicity, including an insightful Room for Debate feature in the New York Times that included 7 authors’ perspectives on whether American surgeons promote unnecessary surgery.

I have no doubt that many of the issues raised by the New York Times commentators are important. Surgeons do have financial incentives, established practices, and natural responses to clinical uncertainty that lead them to suggest surgery in some cases where there is no clinical evidence to support such an action.

Yet, I think we also need to acknowledge that we, the public, also contribute to overuse of surgical procedures. We do not often complain when our doctor recommends surgery. Many times, in fact, I think patients are relieved when a doctor suggests surgery. We trust that the physical act of cutting out a cancerous tumor, fusing vertebrea in our back, or replacing an aging hip will “fix” our problems. We do not stop to consider whether other approaches might work just as well or better. We do not worry about the fact that someone will cut us open and potentially cause us pain and expose us to significant complication risks.

In the world of drugs, at least, several rounds of famously onerous clinical trials are required before a medication can be brought to market. This process guarantees that a drug has at least displayed some efficacy before it is put into widespread use. But there is no such process for vetting and approving experimental surgical procedures, and patients are therefore given drastically fewer safeguards when the surgical option is proposed.

I'll admit that my ignorance of the health care world makes me unable to go to much farther in my analysis, lest I say (or accuse or criticize) something that is not fully true. But I nevertheless find it unsettling that a relatively cheap and non-invasive procedure like a medication can be subject to a world of regulation, while a much more expensive and invasive surgical procedure can be put into practice nearly on a whim, with little scientific evidence to support it.

I have to wonder if this dynamic is at least in part to blame for our skyrocketing medical costs. How many people have undergone an expensive but unnecessary surgical procedure, taxing our medical community (and the insurance community) for no tangible benefit? It's an almost unanswerable question, especially because it is impossible to decide what is a "necessary" as opposed to an "unnecessary" surgery.

If any of you out there have any insight as to why there is this strange dichotomy between drug approval and surgical procedure approval, I'd be interested to hear more. These are exactly the kinds of questions that must be answered if we are ever to have meaningful health care reform (which, of course, is a much larger question, isn't it?)

[Risk Science Blog]
(h/t Overcoming Bias)

Skyrocketing medical costs, revisited

I've posted here before about skyrocketing medical costs in the United States, but this article adds a new twist to the conversation (emphasis mine).

For Mary Cotter, the first sign of concern came when her 7-year-old, Logan, appeared dizzy. His regular doctor said everything was fine, but Cotter insisted Logan be seen by a neurologist, who after an MRI found a tumor in his inner ear. An operation followed, and for the next month Cotter took Logan on a four-hour round-trip trek every day from her home in Ledyard, Conn., to a specialty hospital in Boston for radiation therapy.

The total bill for the tests, blood work, surgery and radiation came to $14,000 — not surprising in this age of sky-high medical costs. Except for one thing. Logan is a golden retriever. After another surgery for an unrelated illness, the total cost of Logan's care is approaching $20,000. Today Logan is healthy, but he has a new nickname: "20K."

It's no secret that Americans love their pets. But these days, all that love is leading to an unprecedented level of expense for millions of owners, who are only beginning to understand the pet-world concept of sticker shock. Caught up in a wave of new medical options and lured by an increasingly sophisticated cadre of veterinarians, pet owners across the country are forking over thousands — and even tens of thousands — of dollars to treat illnesses that would have gone undiagnosed or untreated just a few years ago. And then doing it again if they have to.

Of course, pet owners and most vets have the animals' best interest in mind. But that doesn't make it any easier: With health insurance covering the humans in many families, it's not unusual for pet owners to spend far more money on health care for their cats and dogs than for their sons and daughters. Even the Great Recession failed to take a bite out of Fido's health care tab. According to a report by market-research company Packaged Facts, Americans spent $20 billion on veterinary bills in 2010 — an 8.5% increase from a year earlier and more than double the amount spent just a decade ago.

Oh hey, look at that, it's a cat getting a CAT scan...

At any rate, in the interest of full disclosure, my wife and I are guilty of having added to the increase in expenditures. When our SPCA rescue kitten, Jobu, was diagnosed with a vaccine-related fibrosarcoma (a cancerous tumor on his rear left hip) last year, we were basically presented with three choices: let the cancer run its course, which would likely mean that our one-year old kitten would die within the year; amputate the affected leg, a procedure which had no guarantee of success; or surgically remove the tumor and initiate a chemotherapy treatment to treat the cancer.

We elected to try the chemotherapy, and did so in large part because we thought it might extend his life from one year to a more full twelve or thirteen (no definitive answer on that yet--he's still kicking but showing signs of kidney problems). While the cost was not negligible, it was just a small fraction of the $20,000 figure cited in the article (which is why even I am able to look at that figure and shake my head in disbelief), and we still wrestled with the somewhat ridiculous concept of feline chemotherapy.

Being the trader that I am, I of course viewed it through the economical eyes of an investor--how many years could this procedure buy us, and how much are we then spending per extra expected year of Jobu's life? By its logical extension, this approach means that if Jobu had already been 9 or 10 years old, I absolutely would have said "no way" to the chemotherapy. Hooray for mental amortization.

But many other people make vastly different decisions, choosing to spend much more money than we did on animals with many fewer years left to live. It's not too different from the situation in human health care, where an estimated 27.4% of total Medicare expenses are used to treat patients in their last year of life, much of it in the last two months. A callous and heartless trader like me would just as soon save the money and spend it on preventive care for younger people...but that's just me.

The question that this article ultimately raises for me is, what is really the best allocation of limited resources? Granted, anyone who is willing to spend $20k on an animal probably doesn't have "limited resources", but the use of $20k on one animal is probably a poor use of them no matter how you slice it.

At a time when animal shelters across the country are facing budget crises (due to decreases in both public and private funding), forcing many of them to reconsider their status as "no-kill" shelters, the question becomes that much more acute for animal lovers. How many animal lives could have been saved with that same $20k that was spent to extend the life of just one sick puppy? And would saving those lives have been a better investment than extending the one life?

They're difficult questions to answer, and they become that much more difficult when emotions become involved. People will always be willing to spend more to extend the life of someone they know personally or intimately than that of an unnamed stranger--it's a strange type of cognitive dissonance that was at the heart of the recent movie The Box (which apparently sucked, but so be it).

These are, however, questions that will need to be answered as we try to fix our national health care problems (for people, not just cats and dogs). At a certain point, we can't spend unlimited dollars--taxpayer dollars, insurance dollars, or otherwise--to extend the life of someone who is certain to die. Different people are bound to draw their cutoff line at different points, and so determining the proper cutoff is a difficult policy issue. Most of us can agree that spending $20k on a dog is absurd, but obviously at least one person disagrees. The question is, what is the right amount, and whose opinion matters most?

[Smart Money]

Yikes

Charts often lie, but these ones seem to speak for themselves. Thanks to Barry Ritholtz for the links.

Health Care Costs, 1960-2010

 

 Health Care Costs as Percent of GDP by Year

Health Care Costs as Percent of GDP by Year, with Presidential Terms

[The Big Picture]

Interesting...

Well, I told you I'd be keeping my eye on California...

California Governor Arnold Schwarzenegger signed a bill Friday morning that decriminalizes possession of marijuana in the state.

Those caught with less than an ounce of marijuana will still receive a maximum penalty of $100. However, Senate Bill 1449 reduces the legal categorization of marijuana possession from a misdemeanor to a civil infraction. This means that those caught will not have to appear in court, pay court fees or receive a criminal record.

Basically, possession of a small amount of marijuana will now draw a penalty akin to a traffic ticket. Schwarzenegger opposes Proposition 19, a referendum that would essentially legalize marijuana production and garner taxes from its sale, but this bill is obviously a step in that direction. 

Independent of Prop 19, this bill will save California some money in court costs as it no longer arrests and arraigns people on marijuana possession (estimated around 60,000 people annually). At a time when California's budget can use the help, it's fairly clear to see why the decriminalization movement is gaining traction. Vermont, you're up next.

[Examiner.com]

Revisiting self-defeating behavior

Last week, I wrote a post about self-defeating behavior, focusing on the fact that Americans' most frequent "moderate physical activity" actually consists of preparing themselves a meal. I was therefore amused to read this piece in The Observer, entitled "Why exercise won't make you thin". To summarize,

More and more research in both the UK and the US is emerging to show that exercise has a negligible impact on weight loss... The Mayo Clinic, a not-for-profit medical research establishment in the US, reports that, in general, studies "have demonstrated no or modest weight loss with exercise alone" and that "an exercise regimen… is unlikely to result in short-term weight loss beyond what is achieved with dietary change."

"It's simple maths," says Professor Paul Gately, of the Carnegie Weight Management institution in Leeds. "If you want to lose a pound of body fat, then that requires you to run from Leeds to Nottingham, but if you want to do it through diet, you just have to skip a meal for seven days." Both Jebb and Gately are keen to stress that there is plenty of evidence that exercise can add value to a diet: "It certainly does maximise the amount you lose as fat rather than tissue," Jebb points out. But Gately sums it up: "Most people, offered the choice, are going to go for the diet, because it's easier to achieve."

First of all, these kinds of conclusions (and headlines) are incredibly dangerous for the average reader, and border on irresponsible journalism. While "exercise alone" will rarely help you LOSE weight, it is absolutely essential for maintaining weight and preventing weight gain. Clearly, calorie ingestion is the biggest lever when it comes to effecting weight loss, especially since we all typically eat too much to begin with. You don't need to burn what you never ingested. If you're obese, start by eating less, not by walking on a treadmill.

But buried deep within The Observer's semi-sensational article is one of the more important points--that of the self-defeating behavior (emphasis mine).

In what has become a defining experiment at the University of Louisiana, led by Dr Timothy Church, hundreds of overweight women were put on exercise regimes for a six-month period...Against all the laws of natural justice, at the end of the study, there was no significant difference in weight loss between those who had exercised – some of them for several days a week – and those who hadn't...Some of the women even gained weight.

Church identified the problem and called it "compensation": those who exercised cancelled out the calories they had burned by eating more, generally as a form of self-reward. The post-workout pastry to celebrate a job well done – or even a few pieces of fruit to satisfy their stimulated appetites – undid their good work. In some cases, they were less physically active in their daily life as well.

This study (and its conclusion) seems to be MUCH more important than those on which The Observer chooses to focus. Exercise certainly isn't useless, as the headline of the article seems to want to indicate. It may not be as efficient as a diet in terms of losing weight, but it is certainly longer-lasting and absolutely essential as a prevention tool. But if you're using your exercise as an excuse to eat more terrible food, well you're just going to be treading water (or, doing this).

I really hope that people don't read articles like this and use it as fuel for their self-defeating behavior, missing the important points buried within. While headlines like these easily generate clicks and page-views, they only confuse the public as to what they should or shouldn't be doing to lead a healthy lifestyle. So seriously, people, go to the gym.

[The Guardian]

No accepted medical use

Courtesy of Barry Ritholtz (again) comes this video on medical marijuana. If you have some time, it's worth a watch. As Barry writes,

The U.S. government classifies marijuana—along with heroin and LSD—as a Schedule I drug, the most tightly restricted category of drugs in the United States. According to the federal government, Schedule I drugs are unsafe and have “no currently accepted medical use in treatment in the United States.”

Really?

As medical marijuana proponents have pointed out since the Controlled Substances Act was passed by Congress in 1970, cannabis has been used medicinally for thousands of years, and there has never been a reported case of a marijuana overdose. Moreover, in recent years clinical researchers around the world have demonstrated the medicinal value of cannabis.

As pointed out in the video, most of the medical benefits of marijuana are what would be deemed "pain management" benefits. Marijuana doesn't cure or attempt to cure any ailments, but neither do many prescription drugs being peddled today. It would be hard to argue that marijuana has any less "medical use" than any legal opiate-based pain medication, such as codeine, morphine, or oxycodone. The pain-alleviating effects are extremely similar, without the dependency/withdrawal issues that are commonly associated with the opiate-based drugs.

The primary reasons behind marijuana's declaration as a Schedule I drug are unclear, though many claim that racist and cultural motivations were a significant factor. Either way, its continued treatment as a dangerous drug has cost federal and local governments untold millions in law enforcement and legal costs, with little effect on actual use.

At a time when balancing budgets is a primary concern, I would not be surprised to see marijuana legalization movements gain traction. By legalizing and taxing marijuana sales, we could actually turn a large government expenditure into a source of revenue. Ultimately, the need to balance government budgets may trump all other arguments in favor of criminalization, whatever they originally may have been. I'll certainly be keeping my eye on California.

[The Big Picture]

Self-defeating behavior at its best

There are any number of paths to take when discussing the obesity epidemic in America, and most of them have been beaten to death. We are all basically aware by now that obesity rates have gone parabolic in the last two decades, doubling in adults and tripling among children. Reasons are well-documented--we're not exercising enough, we're eating too much, we're eating the wrong foods, the quality of food produced has declined, ad nauseum.

But a study published yesterday in the American Journal of Preventive Medicine placed a new spin on the issue, finding that Americans are in fact engaging in self-defeating behavior when it comes to their health. In a study that categorized activity by type (sedentary, light, moderate, and vigorous), doctors found that:

Only 5.07 percent of Americans reported doing any vigorous-intensity activity like running, while at the other end of the scale, more than 95 percent said they had engaged in the highly sedentary activity of eating and drinking. The next most common activity was another sedentary one -- watching television or a movie, which eight in 10 Americans did.

The "most frequently reported moderate activities were food and drink preparation (25.7 percent), followed by lawn, garden, and houseplant care (10.6 percent)," the study said.

It's already been well-documented that relatively few Americans are engaging in sufficient vigorous exercise. But I think that the finding that the most frequent moderate activity (the next level below vigorous) was preparing a meal is more interesting. I'm not even certain how this qualifies as a moderate activity to begin with, but it's the absolute epitome of self-defeating behavior. The only thing I can imagine that would be worse would be if Americans' most vigorous activity in a day was to get in their car and drive to the McDonald's drive-thru.

Self-defeating behavior is never pretty, and it's something that I've discussed in multiple contexts already on this blog. But this is a new one, and I don't have much to add on the topic except to shake my head and say, "wow".

[PhysOrg.com]

Who is Mr. Baker?

This weekend, I stopped into my local CVS to pick up some NyQuil and cough drops for my wife, who had been diagnosed with strep throat (she also wanted to know if she could take NyQuil, Aleve, and penicillin all at the same time...goes along nicely with my posts on prescription drugs, but I digress).

When I got to the checkout counter, the clerk asked me if I had a CVS card. I don't, but my wife does, so he said he could look it up by phone number. I gave him my home phone number, he punched it in, and we were good to go. Then after I'd paid for my things, he gave me my receipt and said "have a nice day, Mr. Baker".

I laughed it off, considered whether the clerk had lost his mind, and got in my car to drive home. Then I thought about it some more and began to wonder. Who the hell is Mr. Baker, anyway? My wife and I purchased our home 3 years ago from its original owners, the Millers. I'm not certain if the Millers had our same home phone number, but we've had the number since at least June of 2007. So either there's a Mr. Baker out there somewhere making CVS purchases of Lord-knows-what using my phone number with malicious intent...or Mr. Baker sincerely needs to update his phone number.

Either way, the incident got me to thinking about privacy and fun with databases. My wife and many of my friends have recently become very concerned about protecting their personal information (with good reason), de-tagging photos of themselves on Facebook and taking care not to provide merchants with personal information unless completely necessary. But how many databases do we exist in that we don't even realize? And how many people could be using our information without us possibly knowing about it?

The Baker/Powers mismatch at my CVS could be an isolated incident, and probably doesn't matter much anyway. But as someone who recently changed his cell phone number, I do have to wonder how many databases the new Mr. 781-367-XXXX is now listed in under my name. What other information might he be able to learn about me, simply by having my old phone number? If I had asked the CVS clerk, what would he have been willing (and able) to tell me about Mr. Baker? I worry that in this new era of identity theft and privacy concerns, there might be more to protect than we could possibly manage. But if you do happen to come across Mr. Baker in your travels, please tell him to call CVS and change his number.