June 11th, 2011

One More Reason to Distrust David Kessler's _End of Overeating_

http://www.jstor.org/pss/25568464

Short form:

We all know that people smoked so they'd stay thin. While people who chose to smoke had a lot of delusional ideas, this particular aspect of smoking had some basis in reality. Recently, there's been coverage of a Science article which found a specific receptor (in mice) that could be a mechanism for this phenomenon and also a potential target for weight loss drug development.

Sample secondary coverage: http://www.medscape.com/viewarticle/744382

R. mentioned this to me, and when I finally remembered to go look at the coverage, it reminded me how annoying I found Kessler's focus on the 1980s as a time when adults in the US started gaining weight in a way they never had before.

The article at JSTOR above is a 1997 study based on a 1980s data series from WHO MONICA. The data was across many countries and it showed a consistent inverse correlation between smoking and BMI -- until populations started including a smaller fraction of smokers and a larger fraction of non-smokers [ETA: whoops. ex-smokers].

Kessler _completely_ ignored smoking as a possible factor in collective weight gain starting in the 1980s. Many, many things invalidate his argument, but this is arguably the worst of them all.

Sensible Commentary on Medicare/Medicaid

http://www.kff.org/pullingittogether/medicaid_medicare_multiplier.cfm

Lots of people use Medicare, Medicaid or both in any given year (say, this one). About 1 in 3 in the US. Even more people, however, are closely connected to people who use Medicare, Medicaid or both. And even _more_ people are closely connected to people who _have_ used Medicare, Medicaid or both within their memory.

As a result, big changes to these programs are difficult.

"So, when you think about the reaction to a big policy proposal like premium support for Medicare or a Medicaid block grant (or other big programs like Social Security), remember to look beyond the narrow constituencies and voting blocs and multiply, because that’s what voters will be doing."

This is a very sensible article.

Health Care Providers and Willingness to See More Medicaid Patients

http://www.kff.org/medicaid/8178.cfm

I'm always a little suspicious of the "doctors won't take them" assertion, since it reminds me forcibly of the "we're about to run out of baby catchers" argument. OB/GYN doctors mostly switch to just GYN when they can -- yet we never run out of people wantingn to catch babies. The docs _say_ it's because their insurance premiums went up, but that's a marginal impact compared to the scheduling issues (very, very, very few calls on Christmas to come do an emergency well-woman visit. As in, none.).

It turns out that there are doctors that take Medicaid patients and doctors who don't. The doctors who do are happy to take more. The doctors who don't don't want to take any. And reading the analysis reminded me a lot of trying to zone increased density: it's _way_ easier to get a relatively dense city neighborhood to tolerate a big increase in density than an exurb (and a 50% jump in density in a city neighborhood is way more people than a 100% jump in density in an exurb). The practice composition turns out to matter, too: big, hospital affiliated practices take Medicare/Medicaid; small practices don't (or maybe only take Medicare and then moan about reimbursement rates constantly).

Given the direction that practice composition is going overall, it's pretty easy to predict how this is going to turn out on the primary care level.

The problem, of course, involves specialists and access to them. That's going to be a tougher nut.

Nocturnists

A few years ago, we finally got some sanity about work hours for doctors and doctors-in-training in hospitals. So if we're not making the totally inexperienced and sleep-deprived run the hospitals at night any more, who is doing it?

There's a new specialty, or, I suppose, subspecialty of hospitalist:

http://www.kaiserhealthnews.org/Stories/2011/June/07/nocturnist.aspx

Rotating shift work is really hazardous to everyone and everything involved, so having a dedicated team is a brilliant development.

Fox: the pre-Weiner

I checked in on Elizabeth Pisani's excellent blog recently (that's what got me reading Kaiser Foundation stuff) and one of her entries was about David Fox's firing from Reuters over a mis-directed private message that wound up in a Reuters staff-only chat room in the middle of the night.

Like Weiner, Fox immediately tried to undo the error. Reuters fired Fox over the incident and an extensive discussion ensued.

This is pretty good coverage:

http://theunspunblog.com/2011/04/29/the-fox-dismissal-from-reuters-laid-bare-pubic-hair-and-all/

Fox at no point claimed to have been hacked -- that's a difference -- and of course Weiner is an elected official and Fox was employed by a private (?) corporation. Both work in areas where Speech Matters and an individual's right to free speech may be curtailed by the nature of their employment. The argument in Fox's case is that gallows humor helps morale. The argument in Weiner's case is more or less that this isn't any of our business anyway.

I think none of the details matter. I think our collective fascination with misdirected, inappropriate speech reflects two major trends in play right now.

(1) We definitively established that it is NOT OK to say certain things in mixed/polite company (women driver jokes, racist jokes, homophobic remarks, etc.). However, we haven't actually required that people stop thinking these things, and generally speaking we've allowed people to continue to maintain communities in which this sort of speech is acceptable. THIS IS NOT ABOUT THE LAW. I AM NOT THE GOVERNMENT. NOTHING I AM SAYING HAS ANY THING TO DO WITH LIBERTARIANISM. So don't reply to this on that basis. I am talking about social pressure: who we think it is okay to be friends with, employ, etc.

(2) The capacity to Screw Up communications with technology is immense and Very, Very New to most people. (Not to me. I've been dealing with this kind of fuck up for a couple decades now.) Most people have HUGE anxiety about hitting reply all or whatever when they meant to forward something to a particular person or whatever. I think these two instances are where we're collectively working out our feelings on these screwups and how they should be handled.

Protecting Medicare

http://www.niemanwatchdog.org/index.cfm?fuseaction=background.view&backgroundid=00552

This is a commentary piece from the "Nieman Foundation for Journalism at Harvard University".

It is a list of 6 specific actions that could be taken to protect and improve Medicare. I found it by googling "dual eligible", because I've decided that a lot of people confuse Medicare and Medicaid (which are really quite different in a lot of important ways), and seem to be absolutely unaware of "dual eligibles" as a category. Given how much of the cost of both programs is buried in this category of a little under 10 million people, failing to be aware of them leads to Really Stupid Ideas. People who _are_ aware of dual eligibles might have better ideas (that's the theory I'm exploring right now).

The ideas in this piece are simple and obvious: let Medicare negotiate drug prices, stop paying private Medicare plans more than traditional, add a drug benefit to traditional Medicare to keep people on the cheaper/more efficient side, make sure dual eligibles' drugs are handled the Medicaid way rather than the Medicare way (wow, that seems obvious), let people 55-65 buy into Medicare (thus including some less sick people and spreading the costs around more), implement the ACA.

I find nothing in that list of proposals to argue with. At all. If we could get out of heated arguments about cutting benefits and instead collect some of the low-hanging technical fruit, we'd be better off.

ETA: This opinion piece at Firedoglake

http://news.firedoglake.com/2011/06/11/joe-lieberman-wants-to-increase-medicare-eligibility-age/

critiques an op-ed by Lieberman, who is proposing roughly the opposite of everything mentioned in the Nieman piece above.

The "raise the eligiblity age" issue from 65 to 67 is addressed here:

http://theincidentaleconomist.com/wordpress/delaying-medicare-eligibility-is-bad-for-health/

Basically, some very good research has been done to compare people who become eligible for Medicare at 65 with a consistent history of health care coverage vs. those who have been uninsured prior to Medicare. As one would expect, delayed health care makes this group of people particularly expensive to Medicare once they are eligible. There are charts.

ETAYA:

Here's what KFF has to say about raising the eligibility age from 65 to 67:

http://www.kff.org/medicare/8169.cfm