Archive for the ‘General’ Category

The Facts of Inequality

Thursday, April 17th, 2014

Once in a while, an economist comes along who puts out a disarmingly simple concept that seems to cut through the miasma of misinformation that is cable news. Once such person may be Thomas Piketty, a French economist  whose “Capital in the Twenty-first Century” looks at income equality in a striking way. His big thesis?  The reason so many people live so poorly is that G.D.P. growth (which impacts wages) has flagged while the rate of return on capital (things like dividends, capital gains) has soared. John Cassidy , the terrific writer at the New Yorker, has done a good job of explicating Pikettys ideas complete with graphs and charts. http://www.newyorker.com/online/blogs/johncassidy/2014/03/piketty-looks-at-inequality-in-six-charts.html

Lesson #1: Investment income trumps wages
So these statistics will feel familiar:  A recent report by Oxfam says that the richest eighty-five people in the world own more wealth than the roughly 3.5 billion people who make up the poorest half of the world’s population. In 2010, the richest ten per cent of US households owned 70% of the country’s wealth while the bottom 50% owned 50%. All of this wealth at the top is investment income. Piketty and his partner, Emmanuel Saez say that 95% of the income growth in the economy between 2010 and 2012 “accrued to the 1%”. These are the most disproportionate figures since 1928.

Lesson #2: The Income Gap is a corporate things
That’s a shocker – it’s not the ga-zillionaires that are the big beneficiaries but the MBA types. It’s the  “supermanagers,” (with incomes of $1.5 million and up) rather than “superstars,” who account for 70% of the top 0.1 per cent of the income distribution. In the 50s, the average CEO was paid 20 times as much as the typical worker; today, its 200 times.

So, the way to make things more equitable? Make G.D.P. grow as fast as return on capital

The Good News
For all the inequities, things are still relative. Here’s Cassidy again: “In 1981, according to figures from the World Bank, about two in five members of humanity were forced to subsist on roughly a dollar a day. Today, the figure is down to about one in seven. In the early nineteen-fifties, the average life expectancy in developing countries was forty-two years. By 2010, it had risen to sixty-eight years. He quotes Angus Deaton, a Princeton economist  who said, “Life is better now than at almost any time in history. More people are richer and fewer people live in dire poverty.”

Bad News for Jobs Due to ObamaCare? Take the Long View.

Wednesday, February 12th, 2014

So, it’s been a rough January — a second month of anemic job creation, a new CBO report saying that ObamaCare could cost 250,000 jobs and continuing blasts of arctic froideur that have shut down even the redoubtable Alter Group offices for days.

This is when perspective matters: Cassidy Turley takes a 6-month long view in the US Employment Tracker to find good news:

Taking this approach, the U.S. economy is creating a monthly average of 178,000 net new jobs, consumer spending is growing at an annual rate of 3.1% and the ISM manufacturing index has been a robust 60.6.” Also, after the usual revisions in the economic data, we found that “real GDP grew at an annualized rate of 3.2% in the final quarter of 2013, driven by the largest increase in consumer spending in three years. Business confidence is now at an 11-year high; consumer confidence has held up; fiscal policy is less of a drag; and the Fed is now tapering because it generally likes what it sees. Commercial real estate fundamentals have been consistently tightening for three straight years. Although the past few weeks have allowed some doubt to resurface, the outlook remains upbeat.

Then there’s the matter of looking at the right statistics for you. Such as the fact that office-using jobs that drive so much of commercial real estate have been on a tear recently — 34,000 in January. Overall office-using jobs have surpassed pre-recession levels (after bottoming out in 2009).

We can’t take a long view on bone-chilling temperatures but let’s look at the Obamacare costing a quarter million jobs. Here’s portion of the CBO report, “The Budget and Economic Outlook: 2014 to 2024.”:

The ACA’s largest impact on labor markets will probably occur after 2016, once its major provisions have taken full effect and overall economic output nears its maximum sustainable level. CBO estimates that the ACA will reduce the total number of hours worked, on net, by about 1.5 percent to 2.0 percent during the period from 2017 to 2024, almost entirely because workers will choose to supply less labor —given the new taxes and other incentives they will face and the financial benefits some will receive.

And therein lies the key phrase — “choose”. In other words, it is not jobs that will be eliminated but workers who will elect to retire, stay at home to raise the kids or go to a 3-day schedule so they have time to get another degree. They won’t feel tethered to their current employment because of the fear of not having health coverage.

Dr. Ari Robicsek on Big Data & Healthcare

Wednesday, August 14th, 2013

Dr. Ari Robiszek podcast iconBig Data have become ubiquitous buzz words for the aggregation of information in data sets and the use of algorithms to define patterns. Overall, the growth of the sector is being driven by the trend towards backing up data in the proverbial cloud, online shopping (which grew 14% between 2011 and 2012 to $42.3b in sales), and all the time we spend posting content on social media. McKinsey & Company predicts a 40 percent growth annually in the data being generated. American healthcare providers currently have $300 billion invested in data, including GPS and mobile apps. With the adoption of Electronic Health Records (EHR), it is estimated that data could save providers between $300 billion and $450 billion annually (we spend about $2.6 trillion overall on healthcare).

There is no question that Big Data is a heuristic change in medicine. Through the data compiled in EHRs, it allows use of predictive modeling in order to address health issues at a population level.   For example, we are able to find out if patients are doing preventive care, taking their medication, and whether they might be at risk for chronic conditions. Population health management is a new, more proactive way to segment patients by need (both financial and clinical) and to target them for outreach. It provides a powerful tool to address hospital readmissions and hospital-based infections. For example, NorthShore University HealthSystem (NorthShore) in Evanston, Ill., aggregated 40,000 patients into a data set and analyzed 50 different pieces of data to build a predictive model. This allowed NorthShore to evaluate whether patients might be at a high risk for being carriers of particular bacteria like MRSA, a highly antibiotic-resistant strain.

There are issues going forward such as the barrier that EHRs put between the patient and the physician; in the new tech-enabled world, the doctor might spend the visit staring at the computer rather than the patient. This is a real concern. Doctors have also noted that it is harder to retrieve information in EHRs than from a paper chart. On the flip side, EHRs do provide patients with more transparency, including a portal to their lab tests, billing, scheduling, doctor notes as well as email contact with their physicians.

To listen to Dr. Ari Robicsek’s full interview on Big Data and Population Health Management, click here for the podcast.

Primary Care Gets a Break

Tuesday, July 30th, 2013

There’s no question that primary-care physicians have long been spurned by the fee-for-service model that doesn’t recognize or reimburse fully the time spent with patients. Well, internists had a pretty good summer. Firstly , the CMS “proposed creating new evaluation-and-management codes for non face-to-face activities relating to the coordination of care for patients with two or more chronic conditions”.  And, now a bipartisan draft bill from the House Energy and Commerce Committee’s health subcommittee extends that to care coordination between multiple physicians and other suppliers and providers of services.The number of chronic patients is expected to rise to 171m by 2030.
The CMS proposal solicited public comment on whether general third-party designation of a practice as a medical home could be considered evidence that the practice was up to the task of providing care-coordination services. But the draft of the House bill specifically mentions the National Committee for Quality Assurance’s (NCQA) medical home and patient-centered specialty practice recognition programs.

Part of the solution is to recognize practices as medical homes so they qualify under the new payment model.  Thus far, the NCQA program has designated 5,770 practices as medical homes.

“We are particularly pleased the draft includes expedited recognition of patient-centered medical homes as an approved alternative payment model for medical practices,” Dr. Jeffrey Cain, AAFP president of The American Academy of Family Physicians, said. That said, Cain did add that family doctors are “disappointed that the subcommittee’s draft does not include a provision to specify a higher base-payment rate for those services provided by primary-care physicians,” Cain said.

Primary care has long been affected by dwindling reimbursements — In the 20th annual Modern Healthcare Physician Compensation Survey, family physicians finished last among the 23 specialties tracked – and a consequent migration of family physicians towards hospital employment. Medical students are increasingly avoiding family medicine (the number of students selecting careers in primary care has declined by 41% in the last decade), leading to an expected shortage of 44,000 primary care physicians by 2025.

DOMA Bites the Dust

Monday, July 1st, 2013

The U.S. Supreme Court’s voted 5-4 to strike down the 1996 Defense of Marriage Act. Swing voter Anthony Kennedy joined the liberal wing of the court –Ruth Bader Ginsburg, Stephen Breyer, Sonia Sotomayor, and Elena Kagan. Dissenting were Chief Justice John Roberts and justices Antonin Scalia, Clarence Thomas, and Samuel Alito.. They also ruled that the plaintiffs in the case of Proposition 8, which banned same-sex marriage in California, did not have the legal standing to bring that lawsuit.

The decision is expected to have major consequences on health coverage for legally married same-sex partners of federal employees and members of the military, as well as on tax treatment for private health coverage (a 2007 report from left-leaning think tank Center for American Progress and the UCLA’s Williams Institute found that employees with partners pay over $1,000 more in taxes each year than their married peers).  The caveat is that the ruling applies on to states where same-sex marriage is legal. New Yorkers will benefit; Pennsylvanians will not.

The ruling seems to confirm a sea change in gay rights in this century. Take American corporations which have been far more progressive than the courts on these issues. Hundreds of U.S. employers, both large and small, signed on to an amicus brief against DOMA in February, arguing that treating same-sex couples differently hurt recruiting efforts, as well as employer-employee relations. Nike, Apple and Starbucks were among the nearly 300 firms that joined in filing the brief. According to the Human Rights Coalition, a group that advocates for gay rights, 62 percent of Fortune 500 companies offer domestic partner health benefits.

DOMA barred the government from treating same-sex partners as married, raising the cost of healthcare for same-sex couples and denying them eligibility for federally guaranteed rights such as medical and family leave, and, in some cases, Medicare. In all, it denied more than 1,100 benefits to married gay and lesbian couples.

Thirteen states have or are in the process of legalizing gay marriage.  They join thirteen countries around the world including Argentina, Belgium, Brazil, Canada, Denmark, France, Iceland, Netherlands, Norway, Portugal, Spain, South Africa, and Sweden.

“The principal purpose and the necessary effect of this law are to demean those persons who are in a lawful same-sex marriage,” Justice Anthony Kennedy wrote in the 5-4 decision. “This requires the Court to hold, as it now does, that DOMA is unconstitutional as a deprivation of the liberty of the person protected by the Fifth Amendment of the Constitution.” Kennedy’s 26-page opinion says Congress’ explicit purpose in passing DOMA was to expose same-sex couples in state-sanctioned marriages to “a disadvantage, a separate status, and so a stigma,” which violated the Fifth Amendment guarantee of rights to life, liberty and property.

The law also harmed these children financially, Kennedy wrote, because health benefits provided to same-sex spouses were not entitled to the same federal tax-exemptions as those of heterosexual families’, creating unequal costs for same-sex households. The law also denied survivorship benefits for spouses and children through Social Security.

The Concierge Revolution: Bringing Back Marcus Welby

Thursday, February 21st, 2013

During  a historic time of change within the healthcare sector, most notably the passage of the $938 billion Affordable Care Act (ACA), which will reduce healthcare spending by $138 billion according to the independent Congressional Budget Office, doctors are feeling new pressures. As the Physician Administrator for Evanston Northwestern Healthcare (now NorthShore University HealthSystem Highland Park Hospital) for more than ten years, I saw this first hand. Just think, a single physician routinely sees 1,500 to 2,000 patients in one year’s time, and the average time spent with a patient is now reduced to about 7 minutes and dropping (that includes time spent with the nurse as they take vital signs). With reimbursements being slashed and the number of chronic patients at 145 million, doctors today are expected to do so much more in less time.  This is one of the main drivers for many primary care physicians and even some specialists to look for another way.  They want to practice medicine the way they believe it should be…as they imagined it would be when they first graduated from medical school.

Concierge/personalized care practices have continually been gaining traction over the past decade.  Personalized medicine means true consumer medicine —  for patients, it means little or no office waiting, more face-to-face time with their own doctor, prompt return of phone calls, important additional services not covered by their insurance and a renewed sense of personal connection between patient and doctor. For the physician, it means having more time and resources exclusively dedicated to patient care rather than to the “business” of modern medicine. Now more than ever, physicians are exploring their options as they navigate through new legislation and our country’s ever evolving healthcare system. They are not giving up on medicine. Rather they’ve given up on a broken system and created their own – one that that works for them, for their staff, and most importantly for their patients.

Roberta Greenspan is the Founder of Specialdocs Consultants, Inc., a medical practice consulting firm dedicated to converting traditional medical practices to “personalized care or concierge” models.

To hear Roberta Greenspan and Michael Friedlander on the Concierge Revolution, click here.

PTSD Can Last a Lifetime

Tuesday, August 14th, 2012

Picture this: Late at night, in the middle of winter, a 69-year-old woman, less than 5 feet tall, flees her north suburban home, carrying two shopping bags filled with her belongings. When found wandering by police, she insists that someone is trying to kill her. 

The woman in question is Sonia Reich (mother of Chicago Tribune jazz critic Howard Reich), who is the subject of “Prisoner of Her Past,” a documentary from Kartemquin Films, renowned for “Hoop Dreams.” Sonia, who managed to hide from the Nazis as a young girl in the woods outside a small Polish village (now a part of Ukraine) has been diagnosed with late-onset post-traumatic stress disorder (the same PTSD which we normally associate with army veterans). Prisoner of Her Past, directed by Gordon Quinn, deals with the type of PTSD which appears years, or even decades after the trauma occurs. Moreover, the extent of Sonia’s PTSD is so great that not only is she suffering from the usual symptoms (sleeplessness and hypervigilance among others) but that she also, as her son writes, “had so deeply absorbed her childhood traumas into the fabric of her being that there simply was no way she could ever escape them…they were replaying themselves in an endless loop in her traumatized psyche.”

PTSD is something we need to think about seriously as we deal with the aftermath of traumatic events like the recent mass shootings in Colorado and Wisconsin and the return of servicemen and women from Iraq and Afghanistan. It is estimated that one in five soldiers suffers from PTSD or major depression. Brian Scott Ostrom is one of them. He was the subject of a 2012 Pulitzer Prize-winning essay in the Denver Post.  After serving four years as a reconnaissance marine and deploying twice to Iraq, he has struggled with daily life, from finding and keeping employment to maintaining healthy relationships. But most of all, five years later, he’s struggled to overcome his brutal and haunting memories of Iraq.

PTSD Awareness Day was first established by Congress in 2010 after Sen. Kent Conrad, (D-N.D.), proposed honoring North Dakota Army National Guard Staff Sgt. Joe Biel, who took his own life following two tours in Iraq. Biel’s birthday was June 27. “National PTSD Awareness Day should serve as an opportunity for all of us to listen and learn about post-traumatic stress and let all our troops — past and present — know it’s okay to come forward and ask for help,” Conrad said in a statement.

Secretary of Defense Leon Panetta called the recent surge in the number of military suicides “troubling and tragic” at a suicide prevention conference sponsored by the departments of Defense and Veterans Affairs in Washington last week. 

There were 154 suicides among active-duty troops in the first 155 days of the year, according to a recent report from the Associated Press, a number that is 50 percent higher than the number of U.S. forces killed in action in Afghanistan over that time period. It is the highest rate in 10 years of war. Panetta also said he wants to make the Department of Defense a “game-changing innovator” on research in areas related to suicide prevention, including in post-traumatic stress and traumatic brain injury.

Do Olympic Athletes Risk Permanent Injury?

Monday, August 13th, 2012

Those of us joining the more than 3 billion people around the world in Olympics watching, may find one part of the experience uncomfortable and even withering – the sight of healthy men and women and boys and girls risking life and limb for a laurel wreath. There was German weightlifter, Matthias Steiner, dropping a 432-pound barbell on his neck;. South Korean weightlifter Jaehyouk Sa, dislocating his right elbow while trying to push his lifts up to 357 lbs; and American sprinter, Manteo Mitchell, running 200m in the 4×400-meter relay preliminaries with a broken leg.

Now, the experts have stepped up to calm the concerns of the audience. It is a time of extremes, but scientific evidence suggests no-one will push beyond the limit. “You’ll never die because of intensity of exercise,” said Gregoire Millet, director of the Sport Science Institute at the University of Lausanne in Switzerland. “You will never die because you push yourself so hard.”

Enter The Governor

Research, much of it led by Tim Noakes, a professor of exercise and sports science at the University of Cape Town in South Africa, suggests that however much some athletes may want to push beyond all previous performances, a switch in the brain – known as the “central governor” – will keep them safe. “The brain uses the symptoms of fatigue as key regulators to ensure that the exercise is completed before harm develops,” Noakes wrote in a recent paper in the journal Frontiers In Physiology. For Richard Budgett, chief medical officer at the London 2012 Games, having the “central governor” around is a good thing. Himself a former Olympic gold-medal winning rower, Budgett is also eager to point out that many myths about potentially negative health effects of many years of hard exercise are generally not borne out by the scientific evidence. Studies in weightlifters, for example – who many might suspect would suffer lower back pain and damage as they get older – show that these athletes actually have less back pain in later life than other people. A scientific paper published in 1997 on the health status of former elite athletes from Finland found those who focused on aerobic sports in particular had long, healthy life expectancy and low risk of heart disease and diabetes in later years.

What About Accidents?

Of course, what the mavens aren’t addressing are the accidents along the way to Olympic glory: In March of 2010, Courtney King-Dye, 33, an Olympic dressage rider heading to Beijing, fell on her head, suffering a traumatic brain injury. She was in a coma for a month. Four years later, King-Dye says, “I’m still a definite fall risk, can’t walk without my cane, can’t brush my hair or teeth or eat with Righty (her right hand) and now I talk like a 5 year old instead of a 3 year old.”  And weightlifter, Jaehyouk Sa’s career may be cut short by his injury.

Take it to the Limit

There has been some scholarship recently about what the human body can bear as we see athletes routinely break records because they are fitter, stronger and faster. A recent article in the New Yorker used the spectacle of the World’s Strongest Man competition to opine on whether the athletic arms race has gone too far.

As an example, Brian Shaw, one of the sport’s superstars has deadlifted more than a thousand pounds; pressed a nearly quarter-ton log above his head; harnessed himself to fire engines, Mack trucks, and a Lockheed C-130 transport plane and dragged them hundreds of yards. To be fair, this is hardly comparable to the Olympics since these competitions don’t regulate drug and steroid use and so put their athletes at much greater risk. In 1977, one of the leaders in the early rounds was Franco Columbu, a former Mr. Olympia from Sardinia who weighed only a hundred and eighty-two pounds. Columbu might have gone on to win, had the next event not been the Refrigerator Race. This involved strapping a four-hundred-pound appliance, weighted with lead shot, onto your back and scuttling across a parking lot. Within a few yards, Columbu’s left leg crumpled beneath him. All the ligaments were torn, and the calf muscle,the hamstring, and the front patella sustained enormous damage. The injury required seven hours of surgery and threatened to cripple Columbu for life (he later settled a lawsuit against the World’s Strongest Man for eight hundred thousand dollars.)

In the end, we need safety more than we need glory and we commend the legions of regulatory bodies and coaches who take the safety of their athletes seriously.

Walking and Texting – Hazard To Your Health

Monday, August 6th, 2012

In the old days, it was people reading a book while they walked. But these days, one of the most perilous activities to your health may be: texting on foot. Police are even enforcing 60 year old jaywalking laws in order to get people to watch where they’re going. 

According to the Consumer Product Safety Commission, 1,152 people wound up in hospital emergency rooms in the last year for injuries caused when walking and using a cell phone or electronic device. Injuries to distracted walkers have quadrupled in the past seven years, according to emergency room numbers, and that’s probably a low estimate because either patients don’t admit a cell phone was involved or doctors don’t include that sort of detail on hospital reports.

No one is impervious.  According to a recent Newsweek article, “texting has become like blinking: the average person, regardless of age, sends or receives 400 texts a month, four times the 2007 number.” Teens are particularly vulnerable. That same Newsweek article clocked the average teen processing 3,700 texts a month, double their 2007 numbers.  Another report by the Pew Internet & American Life Project looked at the behavior of nearly 800 teens ages 12 to 17 during a three-part survey between April and July 2011 and a series of focus groups involving 57 people ages 12 to 19. Teens on average were shown to be sending and receiving 60 texts each day, up from 50 in 2009. The increase is being led by older teens ages 14-17 who went from a median of 60 texts a day to 100 two years later (that’s 6 texts an hour assuming you sleep for 8 hours).  Girls are still the most active texters, sending and receiving a median of 100 texts a day compared to boys sending 50. However, boys are texting more than they were just two years ago — in 2009, they sent about 30 each day. Worldwide, the highest average is in the Philippines, with an average of 27 texts sent per day by subscribers.

Life Expectancy in the US Dropping

Wednesday, August 1st, 2012

In 2009, a baby born in America could expect to live an average of 78 years, according to estimates from the U.S. Centers for Disease Control (CDC).  But this is now changing: A study in the Journal of Health Metrics shows the United States now ranks behind 10 other developed countries when it comes to life expectancy, even though Americans spend more on health care than people in most other countries.

Another study by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, found that between 2000 and 2007, more than 80% of counties in the US fell in standing against the average of the 10 nations with the best life expectancies in the world. Five counties in Mississippi have the lowest life expectancies for women, all below 74.5 years, putting them behind Honduras, El Salvador, and Peru. Four of those counties, along with Humphreys County, MS, have the lowest life expectancies for men, all below 67 years, meaning they are behind Brazil, Latvia, and the Philippines.

Nationwide, women fare more poorly than men. The researchers found that women in 1,373 counties – about 40% of US counties – fell more than five years behind the nations with the best life expectancies. Journal of Health Metrics editor, Dr. Chris Murray says “It’s a real surprise to us in the study that women are faring so much worse than men. American women still live longer than men by five to eight years. But they have picked up some bad habits: Women are now smoking more.  The obesity epidemic in women is greater than in men. Progress in tackling blood pressure is much worse in women,” Murray added.

So, what we need right now is more Blue Zones in the US.  The phrase was coined by in 2004 by author, Dan Buettner, who teamed up with National Geographic and hired the world’s best longevity researchers to identify pockets around the world where people reach age 100 at rates 10 times greater than in the United States – the blue zones. Some of them are:

  • Okinawa, Japan
  • Sardinia, Italy
  • Loma Linda, California
  • Nicoya, Costa Rica
  • Ikaria, Greece

So, where are our Blue Zones? Women live the longest in Collier, FL, at 86 years on average, better than France, Switzerland, and Spain. Men live the longest in Fairfax County, VA, at 81.1 years, which is higher than life expectancies in Japan and Australia. Women are also living long lives in Teton, Wyoming; San Mateo and Marin, California; and Montgomery, Maryland. For men, long life spans also can be found in Marin, California; Montgomery, Maryland; Santa Clara, California; and Douglas, Colorado.