In the end times, there were only two monopolies left, ABC and Alphabet.
This may be good, but calling it "non-profit" is disingenuous. It's aiming to redistribute profits from one set of corporations to another.
Like a lot of industry-run non-profits, then. It's a non-profit, not a charity.
Bold prediction: Nothing will come of this.
If it reduces its patrons' running costs, it increases their profits. And in common parlance, I think non-profit is understood to mean charity, however wrongly.
Most private* health coverage in the U.S. is through non-profits that are really huge industrial players. This isn't something new (i.e. Blue Cross was the dominant player for decades), although the size of these non-profits is now much larger because the health care sector is swollen like in infected limb.
I don't know what people think about non-profits across the whole of the country, but locally nobody would conflate "non-profit" with "charity." Our largest local non-profit is certainly not seen that way.
* There are for-profit ones, but they are usually horrible.
5: Private universities are, I think, well understood to be non-profits but not charities. There must be other examples.
6: You live at the site of the greatest ongoing battle of the healthcare nonprofits ever. They have fought long and hard to be as non-profitable as they are.
Locally, four of the ten largest employers are non-profits (two health systems, two universities). It used to be five of ten, but two of them merged because one of them almost killed another.
Anyway, 1 in 5 local workers is employed by a non-profit. Nationally, it is 1 in 10.
All sorts of industry bodies are non-profits but not charities. The British Standards Institute, for example.
two of them merged because one of them almost killed another.
Hott.
I'm assuming the British Standards Institute is who makes sure people still eat peas off the back of their fork.
About the terminology. The peas thing is fucking stupid.
Gawande is IMO quite good, this will be really interesting. The criticisms of him that I've read come from oncologists who treat difficult cases. They have concerns that his approach to minimizing preventable error will restrict effective innovation.
He has posted his interesting New Yorker essays at his own website. For thinking about public health, the 2009 Cost Conundrum essay and the 2015 followup are worthwhile.
His approach applied to the easy targets (badly run hospitals) will definitely improve outcomes for a given amount of money spent. Having a capable proponent with some clout to maybe try improving other parts of US healthcare as well seems like a net win for the country. Viewing this as corporate conflict is IMO not especially useful until there's evidence that he's badly constrained by his backers.
There's a clear 2016 article looking at US health care expenditures by diagnosis and treatment type that I think is helpful for understanding status quo. Main figure
That's a beautiful chart.
Personally, I think it s great to try to minimize preventable error, but I also think any real fix won't happen unless the political system starts to function reasonably.
They have concerns that his approach to minimizing preventable error will restrict effective innovation.
How does that work?
17. That's true, but waiting for kum-ba-yah before applying feasible technical innovation would be bad.
IMO one real issue in the US is that there are lots of people who have both medical and social problems (addicts for example). Even with saner politicians, the lack of integration between medical and (much weaker) social care is a problem. The care systems are funded and run (or not funded and not run) completely differently, so integrating means taking high-level decisions, not just getting practitioners to talk to each other.
I would be interested to know what obstetricians think of Gawande-- it's a difficult branch of medicine. I don't know of any who write clearly for lay readers.
18. The claim is that checklists and mandatory best-practice directives are slow to change in light of new information.
ISTR that one of Gawande's central claims is that MDs left to their own devices are also slow to change in light of new information. Or indeed very old information.
I'm not an oncologist, but I would also have concerns about how mandatory best practices are implemented in a way that it doesn't just become something that requires doctors treating uncommon and expensive conditions to spend all day on the phone arguing with an insurance company trying to deny treatment.
There's certainly a major presence of non-profits/not-for-profits in the health insurance industry, but I think for-profit is now predominant. The top 10 by market share contain Centene, Cigna, Humana, Aetna, Anthem, and UnitedHealth. The remainder are Kaiser, Highmark, and HCSC, which is Blue Cross/Blue Shield in many states. Anthem is a successor to BC/BS in 14 states, including NY, CA, and OH, although not necessarily the only one there.
Right, the people who are critical of the approach are well above average. I don't believe they're disagreeing with his assessment of typical medical practice.
23: I'd forgotten about the BC/BS descendants that went private.
17: The political system is trending towards decrying any attempt at cooperation, even among large corporations, as collectivism and creeping socialism. Almost any proposals they come up with will require the government to engage in a level of regulation that many people now believe is the death of American freedom. Also, it carries the dangerous risk of benefitting everyone, not just the chosen favorites of the benevolent and strong leader Trump.
20, 24: thanks. Though this really does sound a bit like making the best be the enemy of the good.
"Checklists mean it'll take longer for doctors to start administering intravenous Dipravixoflan in cases of acute ceratopsian ellipsis, instead of oral Anticlimacticin, which has now been shown in the NEJM (Honk et al, 2018) to be markedly less effective!"
...yes, true no doubt, but checklists will also stop doctors sticking in central lines without washing their hands first.
And popping livers into their mouths.
A gentleman never "pops" liver into his mouth.
26: That's what I was thinking, but that some state with Republican control would deliberately fuck it up just for spite.
The one person I know who has met AG personally says he's a jerk, but I've really enjoyed his writing.
Bezos and Dimon hired a jerk?
ISTR that one of Gawande's central claims is that MDs left to their own devices are also slow to change in light of new information. Or indeed very old information.
Goldacre is big on this too. The proportion of doctors who are still prescribing treatments that are shown to be less effective than a newer treatment, or only as effective as a newer, cheaper treatment, is shockingly high.
I'd settle for them just washing their hands, honestly. That research is so old it's taught in philosophy courses.
Disruption: Steal the "Employees Must Wash Hands Before Returning To Work" signs from the fast food restaurants and put them in the hospitals.
"His approach applied to the easy targets (badly run hospitals) will definitely improve outcomes" -
Worse-run hospitals are not necessarily the easy targets they might seem, though, exactly because they are badly run. The operative phrase here in South Carolina, I think, is "You're not from 'round here, are you?"
35: With all my expertise and training, you still expect me to wash my hands like any peon in a restaurant. Fuck you! Remove your own goddammed tumor!
I've never been clear on why doctors are such jerks. Lawyers, sure, we sometimes get paid to be jerks, at least that's what clients sometimes think they want. But why doctors? Maybe something to do with all that memorization.
38: It's the cognitive dissonance. We work so hard to save all your lives, but deep-down we hate you all and want you to die.
Personally, I blame health insurance companies.
All the doctors who have good people skills become pediatricians.
38: Because they're never sure that you think they're as intelligent as they want you to think they are. What if you think it was all a bunch of memorization?!
OR MAYBE IT'S BECAUSE SOMEONE JUST DIDN'T BOTHER TO CODE ANY GENITALIA FOR YOU.
I tend to trust surgeons, but I've never been surgeried and would still write "Not this leg" on the leg I was supposed to keep if I was getting the other leg cut off.
I have wondered if doctors build up resentment during residency that can turn toxic. I worked long hours after law school, but they paid me stupidly large amounts of money and coddled me. My sister worked much, much longer hours after med school, and they paid her bupkis and made her forage for food while she worked late nights after the hospital cafeteria closed. It equalizes once doctors are out of residency, but I could see developing a powerful sense of feeling put-upon.
I have wondered if doctors build up resentment during residency that can turn toxic. I worked long hours after law school, but they paid me stupidly large amounts of money and coddled me. My sister worked much, much longer hours after med school, and they paid her bupkis and made her forage for food while she worked late nights after the hospital cafeteria closed. It equalizes once doctors are out of residency, but I could see developing a powerful sense of feeling put-upon.
I tend to trust surgeons, but I've never been surgeried and would still write "Not this leg" on the leg I was supposed to keep if I was getting the other leg cut off.
I do not trust breast surgeons!
Worse-run hospitals are not necessarily the easy targets they might seem, though, exactly because they are badly run. The operative phrase here in South Carolina, I think, is "You're not from 'round here, are you?"
Based on my data point of one (1) experience, I can say that I am deeply underwhelmed with the professionalism of a rural SC hospital, and their willingness to have an uppity* patient or her friend question Their Way of Doing Things.
*no, she wasn't white, why do you ask?
Honestly, I can't recommend getting sick south of Washington, PA.
My recommendation is not to get sick at all no matter where you are.
Let's not let perfect be the enemy of the good.
O.K. Let's all go to the nearest Christian Science Reading Room and learn the trick.
I always remind people that almost every MD was once a premed, it explains a lot.
I wonder (and could probably find out with a bit of research) what AG's position is on capitation vs. fee for service. I've aleays heard that's where the big money savings are but that doctors hate it.
It is somewhat ironic to me that Gawande is (was?) employed by the most expensive healthcare system in MA. And in certain areas of routine care they are probably no better -if not worse- than community hospitals or even the other local academic medical centers.
Doctors are super hard to change, and they are used to a lot of deference. Also EHRs and billing do suck the life out of them. There's a lot of data entry type stuff.
54: The guy I knew whose Dad was an engineer and who was in engineering grad school before going to med school wAs so much more sane. I suppose that qualifies as not having been a pre-med.
From a rather different British perspective, the thing about doctors in the public sphere always being motivated by whatever annoyed them is definitely true.
You can't have a conversation about the NHS without someone calling for war against people who miss doctors' appointments. But I have never been able to understand how they arrive at the enormous numbers they blame on no-shows. Every GP surgery or hospital department I have ever seen or heard of has people sitting in a waiting room, waiting, flipping through stiff copies of What Car?, trying not to look at the HERE ARE 10 HORRIBLE DISEASES YOU WEREN'T SCARED OF BEFORE YOU SAW THIS POSTER posters. If they just call the next patient, surely the only cost that arises is sending a letter/e-mail/whatever.
But of course it's personally annoying as hell.
Similarly the same conversation invariably covers people who get into bar fights and go to casualty. Sure they shouldn't be doing it but stitching 18-year olds' busted lips ain't what costs £100bn a year. Is it annoying if you're pulling the Friday night shift? Sure. Is it a substantial line item? No.
You should try giving the bar fighters a fuckton of guns. That would raise the costs.
Barfights seem like the one area where "an armed society is a polite society" seems to hold true. The ISA has a similarly assholish and aggressive population than the UK but way fewer barfights, albeit fewer but more lethal barfights.
The USA, not the International Society of Arboriculture, which also probably has few, but lethal, barfights.
55 is pretty milquetoast anonymizing.
Butter is just milk that's been beaten into submission.
And toast is just bread with scars.
||
What's a good verb for the sound cicadas make? "The forest was electric with the ____ing of cicadas." I can think of lots of adjectives, but no verb except "chirp" which sucks.
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The cicadas seem unusually intense here, this year, too.
We don't have any this year so far. Whoever named them "cicada" and said it was because of onomatopoeia has worse ears than Halford.
I feel the frequency is too high for a thrum.
obstetricians think of Gawande-- it's a difficult branch of medicine. I don't know of any who write clearly for lay readers
... Oh, Perri Klass is a pediatrician, I'm remembering what she wrote about her own pregnancy.
It doesn't really sound like a buzz, that's why I was struggling. Too high frequency, or maybe too low amplitude, for a buzz.
A chirp is a distinct sound, which cicadas don't do, they're more continuous. Drone maybe, but I think again frequency and amplitude wrong. Pulsing maybe. I was thinking "shimmer" but don't know an aural equivalent.
Drone maybe, but I think again frequency and amplitude wrong.
This is what modifying adjectives are for, no? Call it a "high-pitched drone."
Elegance, bro. I thought you were a coder.
The Iliad has a strange solution to this problem, saying that cicadas ὄπα λειριόεσσαν ἱεῖσι: "sound their lily-like voices." Apparently "lily-like" here has the connotation of being delicate, which isn't how I think of cicadas, but the Greeks seem to have liked cicadas better than Americans do.
I love Homer, but he had his off days.
indignor quandoque bonus dormitat Homerus
Do cicadas sound the same in Greece, or is it a similar species that shares a common name?
Perhaps a cicada of the Heroic Age scraped its wings with a delicacy that could not be matched by four of such lesser cicadas as live today.
Apparently there are thousands of species with different sounds, but I just went on YouTube and searched for "greece cicada" and was aurally assaulted in pretty much the same way as stateside.
Also it's not wing-scraping, they have a thing called a tymbal, I am learning way too much about cicadas and have to go to bed.
Cicadas don't chitter. Monkeys and mice chitter. It's a burr, I tell you, a burr! A tinnital burr, to be specific.
Ume is playing cicada sounds on her laptop and I just want to get in first and point out that they are clearly modems.
And when they finally make the connection with whatever's out there, we are all going to be in such trouble.
I'm not feeling chitter either. Sussurate is wrong. A calm ocean sussurates. Cicadas are the opposite of calm, they're literally begging to be fucked.
Screeching, screaming, shrilling.
Some Japanese onomatopoeia for cicada songs: miiin min min min, tsukutsukoboushi, kanakanakana, sha sha, jiri jiri, nii nii.
Burr looks good, but if it is as good as you say, fm, why have I never before encountered it as a verb?
Shrill! The ones I'm hearing now actually aren't that piercing, but that's only because there aren't enough of them.
There, is a tree singing
And insects are
In the night ringing
More piercing and more alien
Than a distant star.
103: It isn't, usually, and I wouldn't use it as one, because that would be perverse, but I didn't see a reason why you needed a gerund there, and I was becoming annoyed with the English language's lack of cicada descriptors. I'm now more or less satisfied.
Your work will be appreciated by the sweltering Anglo masses of the climate-changed future.
twas shrillig, and the ringing burrs
did tyre and tymbal in the cabe
You say cicada, I say cicahda, let's call the whole thing off for 17 years.
The forest rose to a shattering cicado.
has met AG personally says he's a jerk
First, let's remember the rule that anyone you have heard of, but not met, is very likely an asshole. Second, anyone who comes across as so thoroughly decent in his own writing is very likely a slick, controlling asshole.
But why doctors?
Dude, think about what being a doctor means--and this is setting aside surgeons who are, by and large, sociopaths. As a doctor, you're the authority over other people's own bodies, and you wear a halo of "helper." It would fuck with anyone's ego. The sane ones have a healthy skepticism about the whole enterprise. My friend the GI doc describes himself as "a glorified plumber" and likes doing procedures because they're like playing a video game, and he likes making a shit-ton of money.
Ned is right that pediatricians (and family practice docs) tend to be sane and nice.
44. If you were at MGH (or, as far as I know, any modern hospital) you wouldn't have to worry about this. They will mark your leg for you. Seriously, they check constantly that you are who they think you are, and if they are going to work on something you have two of they mark the proper one after you have verified it's the proper one. Then they ask you again later to confirm it. It actually gets sort of tedious after a while.
It's like they have a checklist or something.
I also worry that they will drill the wrong side of my skull when they want to let the evil spirits out.
Don't worry about that. The whole bicameralism thing is totally debunked, they can drill wherever.
That's what the dentist said and he was wrong.
Dude, think about what being a doctor means--and this is setting aside surgeons who are, by and large, sociopaths.
Yup. And Gawande is a surgeon.
If being a surgeon is so bad, why do Russians eat their eggs as a delicacy?
119: Moby's from Nebraska, so he's unicameral.
After I broke my shoulder last month, the orthopedic surgeon to whom I was referred took a cursory look at the x-rays and said, talking very fast and with seeming great authority, that I would definitely need screws and a plate in there, but after that, "in my hands, you'll be fine in a month or two." That "in my hands" was the only phrase that felt truly weird, but I guess that's the thing about sociopaths, you never can quite tell, can you.
What saved me a needless procedure was that my brother-in-law (also an orthopedic surgeon, and if a sociopath a much more genial one) happened to look at the x-rays and said I should just go get a sling at Walgreens, wear it for a month and let the rest take care of itself.
The first surgeon had a boat payment due.
I think orthopedic surgeons are generally reputed as among the strongest adherents of the "do procedures, make money, fuck everybody" outlook. Viz Tom Price who is that and is a bit of an outlier even by GOP health devil standards.
It's hard to do blinded, random studies of surgical procedures, so they tend to have more art (in the sense of what seems right) and less science. Exception: Finland.
There's probably other exceptions, but I can't know everything.
Or be bothered to google stuff when I pontificate about it.
The pope doesn't use Google, so I think you're in the clear.
First, let's remember the rule that anyone you have heard of, but not met, is very likely an asshole