May 29th, 2011

LIFO and Dana Goldstein

Ezra Klein has some guest bloggers so I figured I'd go check out some new blogs. In particular, I figured I'd poke a toe into education politics, since I recently had a conversation with A. and A. is one of my indicators for things-everyone-will-shortly-become-obsessed-with. A.'s tried a variety of educational choices for her children, and is both very open-minded and very realistic about the pros and cons. She also values education beyond the 3Rs and knows that people can become good at a job via a variety of paths.

Anyway. I stumbled across this entry in Dana Goldstein's blog:

http://www.danagoldstein.net/dana_goldstein/2011/05/the-history-of-lifo.html

Now, I don't care who you are, or what topic you are writing on, if you write about the etymology and use of LIFO, you're going to get my attention. And I was genuinely puzzled by this entry. A few posts later (earlier in the order I was reading them), Goldstein does a nice job breaking down where the money is coming from in education philanthropy, and let's just say that Bill Gates Has Influence. Yet the entire discussion of LIFO is focused on accounting.

I _cannot_ imagine (literally Can Not) that Bill Gates could get all involved in anything and fail to import a computer-y science-y view of the world. And that view is going to include ideas like LIFO. I can't speak to where the term originally came from or when it specifically entered the education debate (Goldstein presents a believable case). But I cannot help but feel that a big chunk of the story -- what happened behind what gotten written up -- is missing.

_Overdiagnosed_, H. Gilbert Welch, Lisa Schwartz, Steven Woloshin

Subtitled: Making People Sick in the Pursuit of Health
Published by Beacon Press

First, a word about Beacon Press:

http://en.wikipedia.org/wiki/Beacon_Press

I got Welch's _Should I Be Tested for Cancer?_ years ago (probably shortly after it was published, but I think I got it at the library) when I stumbled across the public health guys in White River Junction. The researcher I initially found (name escapes me at the moment) had not written a book, but he pointed me at Welch's work. The trio listed as the authors on this are the same as a book I bought in 2008, _Know Your Numbers_, which I also really liked.

If you read _Overdiagnosed_, you probably don't need to go back and read the earlier works; it is more or less an updated superset of the ideas and evidence of the earlier ones.

The nature of this topic is inherently repetitive. It isn't the fault of the authors but rather an important component of their thesis. Many, many aspects of medicine share a very similar pattern: a treatment (surgical, medical, radiological or other) is devised for a previously unrecognized or untreatable problem. It works great -- people live way longer, maybe die of something totally unrelated decades later, instead of dying in a shorter number of years from the problem. So then people start thinking, hey, let's catch this earlier. But as you get earlier and earlier, you get more and more people who have the "problem" or the health number proxy for it or are at risk for it, etc. Some -- maybe many or even most -- of these people weren't going to get sick from that much less die of it for a long time, and the treatments are, alas, not risk free.

Obviously, mammograms and PSA are discussed, as are hypertension, high cholesterol, a bunch of "cancers", "incidentalomas" and the problems they present, etc. They touch on some of the many problems associated with turning pregnancy and childbirth into a disease process.

This group is really scrupulous. They don't reason in advance of the data (sometimes I wish they would, because there are some pretty obvious places they could go but they decline). I never worry about recommending them. Should you read this? Oh yeah. Buy a copy and loan it around when you're done. It's like Consumer Reports; it pays for itself almost immediately by helping you make better decisions. You save money AND the results are better.

If you're wondering why I didn't review this back in January when it came out, that's because I didn't know about it until T., the midwife who did my well woman visit, mentioned it to me. Had I known then who it was by, I could have told her right off what I would think about it even without reading it.

Another perspective on health care inflation

http://www.clevelandfed.org/Forefront/2011/spring/ff_2011_spring_06.cfm

I got to this from reading Brad DeLong's blog and chasing links down. There's a wide ranging conversation, but the bit about health care inflation is interesting.

"If I compare healthcare costs today versus in the year 1800, well, I could go out and buy a bunch of leeches today for almost nothing. And I could have the healthcare I had in 1800. If you had a certain condition and you had $10,000 to get treated at today’s health prices, or $10,000 to get treated at 1960s prices with 1960s technology, I don’t think it’s so obvious that people would want to go back in time to get their important health conditions dealt with. In that sense, you say, I don’t know if there’s inflation. It’s pretty hard to say that there’s been a lot of inflation over the long haul in healthcare."

I'm always a little suspicious of "hedonics" (also discussed in this interview), in particular its highly selective application, and I feel a little suspicious of this as well. If we were comparing public health measures (water safety, say) between 1800 vs 1960 vs today, I'd be all for this analogy. There are certainly aspects to our health care system that are _way_ better today, but there's also a lot of aspects to our health care system that we didn't have in 1800 or 1960 and that we would be better off without now.