June 14th, 2011

The Changing of the Cell Phone

For the last couple years I've had a Blackberry Curve. At the time, I picked a somewhat out of date model, because I wanted reliability and Blackberry delivered on the reliability. Messaging, browsing the web and email all worked really well. I was annoyed at the difficulty of getting contacts on and off. It was nice to carry a single device, something I hadn't been able to do since I gave up on Treo, and this was a better single device than Treo had been for me.

I got R. an iPhone for Xmas, and he spends a lot of time with his glasses perched above his eyes so he can better make out screen detail. But he never complains. He plays Sudoku and Angry Birds and browses the web and I'm not sure what else. As I mentioned before, he got me an iPhone for my birthday, after Apple backed down on the App Store rules and I was sure I'd have ongoing access to read kindle on the phone. I had _not_ been able to read kindle on the Blackberry, because my version wasn't supported. Which was a huge bummer.

The biggest hassle associated with setting up the iPhone was getting my contacts back off. I was reluctant to use Verizon's Backup Assistant, because a lot of people had mangled fields issues with it. Also, my home computer is a Macbook, so I figured if I could just dump the Blackberry contacts into AddressBook, I'd be home free. PocketMac delivered; I have no idea why I didn't find this months ago; it would have made the Blackberry a much more useful tool. Instead, I kept hoping RIM's Desktop Software would acquire a reasonable feature set for Mac users.

When RIM decided to more or less ignore Mac users, it was the only sensible thing to do. Apple was a tiny fraction of the market and there was no expectation that that would ever change. There was no real enterprise component in that market (hey, let's have an argument about "real", shall we? <-- sarcasm) and that's where RIM's business lay. Blackberry, by all accounts, works great with Outlook, which is what an enterprise user would be using anyway. Of course, after several years of the iPhone rampaging through the market like an Arizona wildfire (possibly an inappropriate metaphor; if so, tell me which part to apologize for and I will), the decision to ignore Mac users doesn't look sensible anymore. It looks suicidally stupid.

Having been through the process on the iPad a couple of times, setting up my email on the iPhone was really easy. Activation through iTunes was easy. Connecting my kindle app was easy. Syncing universal and iPhone specific games that I already owned was easy. I'm sure music won't be too painful, either. All I have to do now is avoid scratching the screen and I'll continue to be a happy woman.

Bipartisan activity on Ethanol subsidy

http://thehill.com/blogs/floor-action/senate/166295-farm-state-senators-offer-alternative-to-ending-ethanol-subsidy

Tom Coburn is trying to completely end the tax credit for ethanol-gasoline blenders right away.

Several senators from farm states are trying to modify the subsidy instead.

"Under this proposal, ethanol blenders would get no subsidy at all when oil prices are above $90 a barrel. If oil falls to between $80 and $90 a barrel, they would get a six cents per gallon subsidy. Another six cents would be added for each $10 drop in the price of oil, and a maximum subsidy of 30 cents a gallon could be received when oil falls to $50 a barrel or less (a summary of the bill is here).

That's still less than the current 45 cents a gallon subsidy that ethanol blenders receive currently, regardless of the price of oil."

Here are the Senators with the alternative proposal:

"John Thune (R-SD), .. Amy Klobuchar (D-Minn), .. Dan Coats (R-Ind.), Richard Durbin (D-Ill.), Al Franken (D-Minn.), Charles Grassley (R-Iowa), Tom Harkin (D-Iowa), John Hoeven (R-ND), Mike Johanns (R-Neb.), Tim Johnson (D-SD), Mark Kirk (R-Ill.), Claire McCaskill (D-Mo.), Jerry Moran (R-Kan.) and Ben Nelson (D-Neb.)." (<-- That may not be a complete list.)

Thus far, the Republicans have been treating things like eliminating subsidies for oil companies as "tax increases" and therefore totally unacceptable. If it turns out that eliminating or modifying/reducing a subsidy for ethanol producers is acceptable, there may be an opportunity for raising revenue that does not run up against Republican "no new taxes" ideology. In all likelihood, Republicans will continue to defend the oil subsidy, but at least this could be turned into an interesting set of campaign ads.

ETA: The Coburn version failed. WaPo coverage is very focused on the Grover Norquist aspect. It looks like Norquist's maneuvering is receiving much more serious coverage now, and I believe that WaPo is positioning Norquist as The Bad Guy and as Overreaching. But I might be reading things into the article that aren't there.

http://www.washingtonpost.com/business/economy/senate-vote-to-repeal-ethanol-tax-credit-fails-but-some-in-gop-break-ranks/2011/06/14/AGydKEVH_story.html

Hospital Acquired Infections

In an earlier entry, I described a Baltimore area hospital which had addressed a serious problem it had with availability of beds in their emergency department leading to ambulances being diverted. They solved the problem by adding capacity, improving flow and making sure poor people knew how to get access to primary care at a clinic. The problem took off initially when the economic bust happened but good management brought it under control long before a boom has returned (assuming one ever will again).

In general, we are more likely to pay attention to Really Bad Things, and to lose interest as they improve. Our capacity as individual citizens to pay sustained attention to a problem to fix it in an organized way is limited -- that's why we hire professionals to do it as a job, instead.

Paying attention is pretty boring, detailed stuff: figuring out how to count something, counting it, figuring out how to increase or decrease it (whichever we decide is desirable), implement, re-assess. Lather, rinse repeat.

We can see this process in action here:

www.cdc.gov/hai/pdfs/stateplans/SIR_05_25_2010.pdf

Here's the part that's easiest to pay attention to:

"Previous analysis of NHSN CLABSI data, comprised almost exclusively of data reported before state mandates for reporting CLABSI were in place, documented annual decreases in CLABSI incidence rates among intensive care unit patients. In addition, a subset of these CLABSIs, those associated with MRSA, documented a decrease in CLABSI incidence estimated at 8-10 percent per year. This paralleled changes in population-based incidence of MRSA bloodstream infections documented from a distinct CDC surveillance program dedicated to invasive MRSA surveillance.14 This observation suggests that the national SIR in this report likely reflects rates that are truly less than the referent population rates, and not artificially low rates resulting from poor reporting. Regardless, additional steps to bolster the reliability of these HAI data include efforts planned by CDC to evaluate NHSN HAI data using external data sources, to improve assessment of training and application of appropriate methodology by those reporting to NHSN, and to develop novel measures relying more on electronically-captured data elements."

Without getting into the details, what that means is, YES, we are making progress on central line infections involving MRSA -- we've got visibility on that through two very different observations. That's great news.

There's a lot more in the report. It isn't exciting. It's people paying attention and applying the pressure that will improve care AND save money over time. This is what will bring down health care costs over the long haul.

Health Insurance Premium Reductions

No, health insurance companies have not suddenly become The Good Guys.

http://www.ama-assn.org/amednews/2011/05/30/bise0601.htm

"Under the health system reform law, insurers must pay at least 80% to 85% (depending on the plan) of every premium dollar on health care. If they do not meet that standard over the course of a year, they must pay back a portion of their customers' premiums the following year."

We're halfway through 2011. The last couple years, utilization ("going to the doctor" and "getting treated" and so forth) has been quite low. The expectation was that the economy would pick up this year (it didn't) and when it did, utilization would go up (it _really_ did not). Also, in the leadup to the passage of ACA ("ObamaCare"), many insurance companies lobbied hard to raise rates because (they said) they expected their costs to go way up covering all these really sick people, etc. The companies can either reduce rates, or they can cut checks rebating those rates later in the year. While it is possible to imagine a world in which everyone looks forward to their health insurance rebate check every year, I'm pretty sure that's not our world.

The Blue Shield of California story is probably a little more complicated, because Aetna (above) is a for-profit company but Blue Shield of California is a non-profit. Which is sitting on a ton of cash and has amazing margins.

"a major health insurance company with hefty returns that have swelled its reserve to more than $3.5 billion."

Blue Shield has been pushing for universal coverage in the state for about a decade now; OTOH, their executives make a lot of money. It makes them an ambiguous target for activists.

http://articles.latimes.com/2011/jun/08/business/la-fi-0608-blue-shield-20110608

If you've been wondering what impact the passage of ACA might have in your life, tho, I think insurance premium reductions might well be it.

Massachusetts Hospital Services Price Variations

Late last month, there was a little blip of local coverage of a state report on the prices various hospitals around the state were charging for a sample menu of services.

http://www.boston.com/news/local/massachusetts/articles/2011/05/26/study_wide_price_differences_at_mass_hospitals/

You can read the report here:

http://www.mass.gov/?pageID=eohhs2terminal&L=4&L0=Home&L1=Government&L2=Departments+and+Divisions&L3=Division+of+Health+Care+Finance+%26+Policy&sid=Eeohhs2&b=terminalcontent&f=dhcfp_researcher_cost_trends_2011_cost_trends_02&csid=Eeohhs2

Sorry -- that's a really ugly URL.

The list of "Key Findings" is a beautiful representation of just how thoroughly health care doesn't behave like a market:

"Data on the selected 14 routine inpatient services indicates that service volume tends to be
concentrated in higher paid hospitals"

"There is little measurable variation among Massachusetts hospitals based on the available
quality metrics related specifically to the 14 selected inpatient services. In contrast, the price
variation for those services is significant, and lower priced hospitals are often associated with
slightly higher quality scores and vice versa."

"There was no correlation between a hospital’s share of Medicaid patients and the prices they
received from private payers, with some of the lowest paid hospitals having the highest
proportion of Medicaid discharges. ... This finding is inconsistent with providers’ and private payers’ assertions that higher private payer prices are needed to compensate for losses incurred by serving Medicaid patients."

"Hospitals that receive higher payments from Medicare are not necessarily the same hospitals that receive higher payments from commercial carriers, suggesting that factors other than what Medicare
considers are influencing private payer prices."

Getting into the nitty gritty:

"Prices paid for an appendectomy (DRG 225) varied by more than 11-fold for a severity-115 stay and
16-fold for a severity-2 stay. Prices paid for each of the other selected DRGs varied less significantly, but in no instance did they vary by less than 300 percent statewide."

R. and I are not surprised. He had an appendectomy (in New Hampshire, IIRC, but presumably he'll say in a comment later on) over a decade before I had mine, and the price difference was kind of incredible (even allowing for the rate of health care inflation -- and we had comparable severity). Also, given the sheer volume of bills that showed up over time, I'm wondering how the state managed to wrap it all up into one number.

I would also add that I am not surprised by this, either:

"While only 28 percent of hospitals providing cesarean deliveries and 24 percent of hospitals
providing vaginal deliveries had a median severity-adjusted price that was higher than the
statewide median price, services delivered by those providers accounted for 50 and 47 percent
of discharges"

Massachusetts readmission rates for pneumonia and heart failure are noted as higher than the national average ("Among Massachusetts hospitals, the 30-day readmission rate after discharge from the hospital is 20.4 percent for heart attack, 25.2 percent for heart failure, and 19.1 percent for pneumonia compared to 20.0 percent, 24.7 percent, and 18.3 percent, respectively, for hospitals across the nation during the same reporting period."), representing an opportunity for cost savings -- of course, it seems like _everyone_ is aggressively pursuing readmissions rates as an opportunity for cost savings.

It's really tough for someone as far outside the health care field as I am to know what to do with this report as a whole. It feels like an undigested mass of tables and charts and while I can poke at bits of it, it doesn't mean much to me. Certain things stick out (Medicaid pays the least, then Medicare, then everyone else; the cheapest rates are available at the places that see the most Medicaid patients because they _have_ to keep their costs down. When The Herd decides to have their babies some place, that place will surely be unreasonably expensive as a result.), but I suspect the most important lesson is that cost control in medicine is an excruciating exercise in detail. No simple rule is going to produce reliable cost savings -- but if we're willing to pay enough attention consistently, we can probably get better results for less money.

Why I Heart David Weigel: the scoop on Chris Lee

http://www.slate.com/blogs/blogs/weigel/archive/2011/06/08/chris-lee-didn-t-just-resign-over-a-shirtless-photo.aspx?wpisrc=obinsite

"What was the nightmare scenario for Republicans if Lee stuck around A first-of-its kind scandal about an anti-gay marriage member of Congress who liked to flirt with male prostitutes who wore wigs and high heels?"

I particularly love that Weigel can write about this and capture how _bad_ this situation was for Republicans without reproducing statements of prejudice himself. [ETA: OK, the wigs and high heels bit is walking right up to the edge, granted.]

ETA:

Here's one of the links in Weigel's coverage:

http://gawker.com/5769037/the-craigslist-congressman-and-the-crossdressing-prostitute

It's a little breathtaking that Lee didn't even bother to set up a separate email address, so googling the email address on the craigslist ad turned up his "real" identity. But even better, when one of the women told him she knew who he was, he apparently turned around and told his staff that email account had been hacked. I guess that's what the kids are calling it these days?