October 19th, 2013

This Should Be Prosecuted as Fraud

h/t Jacob Reider, who tweeted this:

http://www.nejm.org/doi/full/10.1056/NEJMp1307295

I don't think this is anything peer reviewed; it's in the "Perspective" section. The author, Cheryl Bettigole, M.D., M.P.H., opens with this paragraph:

"The first time a patient called me to say that she'd been billed more than $600 for her Pap smear, I was sure it was a mistake. The second time, I was less sure, and these days I am no longer surprised to find laboratory charges of $1,000 or more for a test that until recently cost only $20 or $30."

The author describes the problem: it's easy for a health care provider to take the sample, check the "wrong" box, and wind up with a much higher charge than anticipated, because the "wrong" box contains a laundry list of other tests along with the Pap smear -- and a more expensive version of the Pap smear. The other tests make little sense for an asymptomatic woman coming in for a once-every-1-3 years checkup, and even _less_ sense once you figure in the cost of the test and the risk and cost of false positives.

While the author is happy about the success of the Pap smear as a screening test, it really is a lot closer to the edge in terms of cost benefit than many people realize. If you crank the cost by 50X, and add a bunch of unnecessary testing and consequent false positives and additional risk for further testing/treatment, you could tip over onto the wrong side of the cost/benefit tradeoff. Worse, if a woman comes in for a regular checkup and gets a surprise medical bill of hundreds or a thousand dollars, that money comes from somewhere if she pays it: healthy food for her or her children, money for heat or air conditioning, money for the rent or insurance, etc. And then she may decide to avoid the doctor in the future to avoid the associated financial stress.

Here is the USPSTF recommendation for pap smears:

"The USPSTF recommends screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. See the Clinical Considerations for discussion of cytology method, HPV testing, and screening interval."

Most ob/gyns and insurance companies in general try to get women in annually. I don't know why. It's pushes the false positive rate up to a point that the cost/benefit starts looking bad -- which is why the A recommendation is for every three years. More is _not_ better.

In any event, if you figure there are something like 25-33 million (roughly) women who might get a pap smear by following these recommendations in any given year, the additional money associated with the extra, let's call it $500, per test is a ton. Tens of billions of dollars a year (figure it $10-15 billion a year at the low end. I'm aiming a bit low on the number of women and on the dollars per test, since the author mentioned $1000, $600 and similar amounts for the "wrong" test).

Here's what the author concludes:

"As health care costs grow and laboratories develop savvy marketing tactics resembling those deployed by pharmaceutical companies, it is becoming increasingly clear that physicians have an obligation to be good stewards of limited resources and to understand the financial effects that the orders we write have on our patients."

I would argue that this is _exactly_ the same wrong lesson that I complained about in a previous blog post about Home Ec. If test makers have figured out they can make $10+ billion dollars a year more by parasitically charging 50x the proper amount for a basic screening test (honestly, if every woman went in annually, and they all go the "wrong" test, we'd be talking more like a hundred billion dollars), we shouldn't be going after the doctors to save money by filling out the form more carefully. That's trying to solve a problem involving bad actors by teaching people to be more wary of them.

We should be exploring criminal fraud charges against the people who sell the form and the test.

But I bet we won't, because a whole bunch of people with money to burn will look at those extra tests and only see protection and good, not false positives, and the impact on median and below income women who will be plunged further into debt.

There's a whole lot more work to be done here.

Is that a muted business cycle effect?

http://www.centurycouncil.org/files/images/30-days-college.gif

I've been trying to figure out whether alcohol poisoning, underage drinking, etc. is getting better, worse or staying the same, and whether regional differences in laws, enforcement and culture have any noticeable impact. I ran across this graph, and was sort of staring at it when I realized that it looks kind of like college kiddies drink more when the economy tanks and drink less at the peak of the business cycle, and then underneath all that there's a long term decrease.

Which sort of suggests that a really good way to reduce drinking among college kiddies might be to, you know, get the economy going again.

But I'm doing this off of eye-smooth, so it'll probably turn out the effect isn't statistically significant at all.

Daily Activities Include: dentist, groceries, rotating video

Lately, T. has been wanting me to take video (using the iPhone) of him doing stuff. This started when he saw some video R. took of A., continued through Wednesday's swimming lesson and included this morning's trip to the dentist. It's wonderful, in that he suddenly is _excited_ to do things that would normally take a lot of negotiation and possibly some bribery to get him to do. It is less wonderful, in that I'm having to figure out ways to upload the video and make it available to him on his computer, without necessarily opening it up to the whole world. This is tricky, because nobody wants to give a kid his age an account, so the usual sharing options on google drive don't work.

Worse, the video I took at the dentist I took landscape, and when I uploaded them to google drive, they were portrait. Not Cool. There is no obvious way to rotate the video on google drive (if you know of one, please tell me how). Fortunately, you can do it in QuickTime, so I downloaded it from google drive to my laptop, rotated it (slow! But that makes sense -- it may have to do it frame by frame), and uploaded it back to google drive where it had to be reprocessed.

But hey, every day I seem to learn new things. I'm not sure if this will keep me young, or age me prematurely. Only time will tell?

In unrelated news, T. wanted to go to the store to get cooking class supplies (chocolate pudding pie, duh -- that's all _he_ ever wants to make). He wanted to take the trike, so we did. We even did the conversion to use it as a shopping cart upon arrival, and then converted it back to trike mode to ride home. It all went off without a hitch; we didn't even run into anyone. Yay!

When we got back, R. was making cookies. Yum, but the kitchen was fully occupied, which sets me off when I need to unload groceries, and I was also over an hour late on eating lunch so I was the one with the temper tantrum. T. kept asking if I was mad or happy. I kept telling him I was mad until I wasn't, and could honestly tell him I was happy (the burritos turned out well, and cookies!). It was actually kind of nice that he cared and kept checking in with me.

Less good: he turned the knob on one of the burners when I wasn't paying attention and I didn't notice for a while. :( We have removed the knobs and had a conversation about We Could Die. Not sure he understands dying (other than in an iOS game context), but he does seem to get that is undesirable.

Cry for Help posted to Instagram, Heard and Responded to, Person Who Made it Retracts It

Sample coverage:

http://www.usatoday.com/story/life/people/2013/10/16/donald-glover-alarms-fans-with-dark-musings-on-instagram/2994467/

I have reached a point in my life where depressed people who are in serious trouble, express how bad they are feeling, receive offers of help and observations that their mood is _not normal_, and that help is available, and then say, oh, never mind, everyone feels like that -- those people annoy me.

I do actually understand that depression makes it really difficult to take effective action to attain one's own goals. But the issue I have here is the bad judgment of not _setting a goal_ to address the mood problem effectively.

If you are depressed and telling people (not in so many words, but you know what I mean), and they think professionals should be involved, LET THEM HELP. Don't dismiss them by asserting that everyone feels like you do. If the people around you are genuinely over-reacting, a professional can identify that, and help you with your communication style.

We don't all feel that down. We don't all worry that much, most of the time. At least, we don't after we get the help we needed. And you should, too.

Two observations: Amazon drop-shipping paper goods, Ancestry.com improves ethnicity

These are completely unrelated, but both short.

Ancestry.com's DNA offering had two components two it. The really cool part was where it matched you against other people who submitted tests _and their tree_ (if they had one, and it wasn't private). So you can truly confirm your work, which is keen. The rate of identified fourth cousins (genetic match AND confirmatory tree on both sides) rises by the week.

The much less important part of the offering is an ethnicity calculation. (Please, feel free to complain about the whole idea of an ethnicity, much less a genetic calculation thereof. I will probably agree with even those arguments I haven't already encountered.) Ancestry's ethnicity breakdown has been unusually bad, if you can imagine scaling bad-mediocre-good on something as f'ed up as an ethnicity calculation. I know (see above paragraph) who I am descended from and related to, and the old analysis didn't match. Like, at all.

The 2.0, match, however, is excellent. So that's something. Especially if you have big gaps in your tree, this might be helpful to you?

That's it for the genealogy part of this post. The rest is an unrelated remark about some Amazon news.

As near as I can tell, this describes Amazon and Procter & Gamble partnering so Amazon can drop ship you paper towels and similar household paper goods.

http://finance.yahoo.com/blogs/daily-ticker/paper-towels-could-key-amazon-growth-lower-prices-161506784.html

The Brad Stone book (which I have on the kindle, but haven't read yet) has been chewed over pretty thoroughly, including the Quidsi/diapers.com acquisition. In the comments thread over on The Digital Reader, I noted that one of the vanishingly few things I didn't buy on Amazon was diapers (either cloth or paper), and didn't really have an explanation why (their prices are competitive and I have Prime -- I did the whole time the kids needed diapers, which was for a very long time). I also don't buy paper towel, toilet paper, pads or similar through Amazon, and I don't have a really good explanation for _that_ either (altho maybe I do; R. tends to buy that stuff in large lots at Costco).

While I don't think (haven't really checked the other articles on the topic) the coverage has gotten into inventory smoothing, that might be a factor encouraging P&G and similar companies to pursue this partnership, especially if it gets them hooked up to the Amazon subscription model. This kind of household paper product is notorious for having completely pointless variability in ordering at the retail level, which causes problems for the producer; direct from the maker's warehouse to the customer should reduce that problem.

I feel like I should follow this up with a post about two unrelated news articles involving companies which start with the letter 'B'. But I won't.