Quotes of the Day

Victor Davis Hanson (at around 14:00):

What Thomas Friedman would need to do is get on a bicycle and go across rural China, and then compare that with biking across Nebraska, and see which society is more resilient and stable.

—-

Ann Althouse:

Well, you will pull the plug on grandma, but only after grandma has signed the document the doctor explained to her long before she got into the situation she’s in now, back when it seemed like autonomy and control.

“Using unwanted procedures in terminal illness is a form of assault,” [said Dr. Donald M. Berwick, administrator of the Centers for Medicare and Medicaid Service].

The question is what do patients want and how what they want will be determined. It seems to me that the effort is to get people to commit in advance to death-hastening choices, by getting everyone to sign these documents. Now, all the new regulation seems to do is to authorize Medicare reimbursements for the time health care professionals spend counseling patients about the value and importance of signing the document. It’s hard to see what’s wrong with that. If treatments are covered but advice about forgoing treatment is not covered, then there’s an incentive to do expensive things.

In a recent study of 3,700 people near the end of life, Dr. Maria J. Silveira of the University of Michigan found that many had “treatable, life-threatening conditions” but lacked decision-making capacity in their final days. With the new Medicare coverage, doctors can learn a patient’s wishes before a crisis occurs.

Treatable? You have a condition that can be treated, but you can’t think well enough anymore to decide whether you’d prefer to die? If you’ve signed the document, the answer is you’d rather let the condition kill you, because you allowed the doctors to “learn [your] wishes before” this “crisis” occurred. You didn’t know what the crisis would be or how you would feel when it happened, but you had “wishes” then and these will be taken as your “wishes” now.

(Many of the comments are also worth reading, particularly the one by Bender at 10:21 AM on 12/26/10 and the one by Ann Althouse at 2:21 PM on 12/26/10.)

—-

Oleg Atbashian:

* Why do those who object to tampering with the environment approve of tampering with the economy? Isn’t the economy also a fragile ecosystem where a sudden change can trigger a devastating chain reaction?
* Isn’t the latest economic crisis such a chain reaction?
* Aren’t most of today’s social ills the result of tampering with social ecosystems?
* Why is bioengineering bad, but social engineering good?

 

Super Size Me!

Here is a question for you – what size do you think a man a bit under six feet tall and around 200 pounds would wear? And the answer is… SMALL. This was at Eddie Bauer and among a vast stack of winter clothes and shirts. It fits me fine.

I won’t bore you with statistics that are easily obtainable everywhere on the Internet about how Americans are getting larger, but this is the most overt sign that I have seen yet.

Dan at his new fighting trim size would probably be an extra small from the waist line perspective, at least.

Cross posted at LITGM

The crisis of the intellectual

I was directed to an excellent post by Walter Russell Mead today. It is on the subject of the American social model and the coming era of tumultuous social unrest as the old welfare state model collapses. Europe is already seeing this collapse as nations like Greece face bankruptcy and England deals with the consequences of severe cutbacks in social spending to avoid it.

The US is facing similar economic consequences if the level of spending is not addressed soon. The 2010 elections show that the people recognize the crisis but the “political class” seems less concerned.

“It’s telling to note that while 65% of mainstream voters believe cutting spending is more important, 72% of the Political Class say the primary emphasis should be on deficit reduction,” Rasmussen said.

“Deficit reduction” is code for raising taxes. Spending is heavily embedded in the culture of the political class.

Mead is concerned that the intellectual demographic, those with advanced degrees and careers denominated by thinking rather than doing, is unable to cope with the new situation.

There’s a lot of work ahead to enable the United States to meet the coming challenges. I’m reasonably confident that we remain the best placed large society on earth to make the right moves. Our culture of enterprise and risk-taking is still strong; a critical mass of Americans still have the values and the characteristics that helped us overcome the challenges of the last two hundred years.

But when I look at the problems we face, I worry. It’s not just that some of our cultural strengths are eroding as both the financial and intellectual elites rush to shed many of the values that made the country great. And it’s not the deficit: we can and will deal with that if we get our policies and politics right. And it’s certainly not the international competition: our geopolitical advantages remain overwhelming and China, India and the EU all face challenges even more daunting than ours and they lack our long tradition of successful, radical but peaceful reform and renewal.

No, what worries me most today is the state of the people who should be the natural leaders of the next American transformation: our intellectuals and professionals. Not all of them, I hasten to say: the United States is still rich in great scholars and daring thinkers. A few of them even blog.

His concern is that the intellectuals seem caught in a mind set that goes back to the 19th century and the Progressive Era.

Since the late nineteenth century most intellectuals have identified progress with the advance of the bureaucratic, redistributionist and administrative state. The government, guided by credentialed intellectuals with scientific training and values, would lead society through the economic and political perils of the day. An ever more powerful state would play an ever larger role in achieving ever greater degrees of affluence and stability for the population at large, redistributing wealth to provide basic sustenance and justice to the poor. The social mission of intellectuals was to build political support for the development of the new order, to provide enlightened guidance based on rational and scientific thought to policymakers, to administer the state through a merit based civil service, and to train new generations of managers and administrators.

It’s interesting that one of the comments, a lengthy one, exactly restates this issue but supports this model and argues with Mead that it is still superior.

Second, there are the related questions of interest and class. Most intellectuals today still live in a guild economy. The learned professions lawyers, doctors, university professors, the clergy of most mainline denominations, and (aspirationally anyway) school teachers and journalists are organized in modern day versions of the medieval guilds. Membership in the guilds is restricted, and the self-regulated guilds do their best to uphold an ideal of service and fairness and also to defend the economic interests of the members. The culture and structure of the learned professions shape the world view of most American intellectuals today, but high on the list of necessary changes our society must make is the restructuring and in many cases the destruction of the guilds. Just as the industrial revolution broke up the manufacturing guilds, the information revolution today is breaking up the knowledge guilds.

He goes on to criticize medicine as a guild but I think he is unaware of the rapid changes going on in medicine today. The image of the family GP is quickly shifting to the multispecialty group with primary care provided by nurse practitioners and physician assistants. Those who want a personal relationship with a primary care physician, or even a favored specialist, will increasingly be required to pay cash for the privilege as many doctors who want to continue this model of practice are dropping out of insurance and Medicare contracts because of the micromanagement and poor reimbursement.

In most of our learned professions and knowledge guilds today, promotion is linked to the needs and aspirations of the guild rather than to society at large. Promotion in the academy is almost universally linked to the production of ever more specialized, theory-rich (and, outside the natural sciences, too often application-poor) texts, pulling the discourse in one discipline after another into increasingly self-referential black holes. We suffer from ‘runaway guilds’: costs skyrocket in medicine, the civil service, education and the law in part because the imperatives of the guilds and the interests of their members too often triumph over the needs and interests of the wider society.

Almost everywhere one looks in American intellectual institutions there is a hypertrophy of the theoretical, galloping credentialism and a withering of the real. In literature, critics and theoreticians erect increasingly complex structures of interpretation and reflection while the general audience for good literature diminishes from year to year. We are moving towards a society in which a tiny but very well credentialed minority obsessively produces arcane and self referential (but carefully peer reviewed) theory about texts that nobody reads.

Once again, costs in medicine are a subject by themselves but the solution does not lie in controlling doctors’ incomes. With respect to the academic institutions, I have personal experience here and will describe some of it. The Humanities have been hollowed out by a trend to both politicize and to leave the subject behind as “critical thinking” goes on to analysis that has little to do with it. The Sokol Hoax is but one example.

The Sokal affair (also known as Sokal’s hoax) was a publishing hoax perpetrated by Alan Sokal, a physics professor at New York University. In 1996, Sokal submitted an article to Social Text, an academic journal of postmodern cultural studies. The submission was an experiment to test the magazine’s intellectual rigor and, specifically, to learn if such a journal would “publish an article liberally salted with nonsense if it (a) sounded good and (b) flattered the editors’ ideological preconceptions.”[1]

The hoax precipitated a furor but did not result in much improvement in such publications. My daughter had personal experience when her freshman courses in English Composition and American History Since 1877 both contained numerous examples of political and “social justice” alteration of the subject matter. For example, she was taught that the pioneers in the west survived by “learning to live like the Native Americans.” The fact is that the pioneers were mostly farmers and ranchers and the Native American tribes of the southwest were hunter gatherer societies who did not use agriculture or animal husbandry. She was also taught that the “Silent Majority” of the 1960s were white people who rejected the Civil Rights Act of 1964. Thus they were racists. Even Wikipedia, no conservative source, disagrees:

The term was popularized (though not first used) by U.S. President Richard Nixon in a November 3, 1969, speech in which he said, “And so tonight—to you, the great silent majority of my fellow Americans—I ask for your support.”[1] In this usage it referred to those Americans who did not join in the large demonstrations against the Vietnam War at the time, who did not join in the counterculture, and who did not participate in public discourse. Nixon along with many others saw this group as being overshadowed in the media by the more vocal minority.

She has since transferred to another college.

The foundational assumptions of American intellectuals as a group are firmly based on the assumptions of the progressive state and the Blue Social Model. Those who run our government agencies, our universities, our foundations, our mainstream media outlets and other key institutions cannot at this point look the future in the face. The world is moving in ways so opposed to their most hallowed assumptions that they simply cannot make sense of it. They resist blindly and uncreatively and, unable to appreciate the extraordinary prospects for human liberation that this change can bring, they are incapable of creative and innovative response.

I think this is the source of the “media bias” so prominently referred to by the Right and by many who are not politically focused. This is why talk radio and Fox News have been such huge successes to the consternation of the political class and their supporters. Charles Krauthammer famously said, “Rupert Murdoch (owner of Fox News) found a niche market that contained 50% of the population.”

The Tea Parties are another manifestation of the frustration of the general population with the political class but also with the intellectual class that seems to be wedded to the first. The university community is, at least in the non-science segment of it, increasingly isolated from the concerns of the society that supports them. CalTech has for many years had a Humanities program to expose science and engineering students to culture. Unfortunately, a student in a large university will find much less culture and much more politics in Humanities departments these days.

A couple of other blog posts are worth reading on this subject. One is here and the other is here. They are both worth reading in full.

The Obama care runaway train.

There is talk of repealing Obamacare if the Republicans take over Congress on November 2. Of course, that is unlikely with President Obama ready to veto any repeal legislation. “OK, we will defund it,” is the response. I doubt anyone realizes how fast this is moving and how difficult it will be to alter the course of this program.

A week ago, I posted on my blog a set of new rules that are being implemented for physician reimbursement. I review workers compensation cases as a part time job. The company that employs me has now come out with a new line of business to review cases for Obamacare. I have been asked if I would be willing to review cases on a 24 hour timeline. This includes weekends. I have spent 40 years reviewing cases for Medicare and the state medical boards for poor care. Now, I am being solicited to do concurrent review on a 24 hour basis for healthcare. I do some concurrent review for workers comp cases but the timeline is usually 3-5 days. Why weekends ? Does this mean that care cannot be provided without approval ?

The pace of change is breathtaking. Today, the Wall Street Journal explains.

A wave of consolidation is washing over the health markets, and the result is going to be higher costs.

The turn toward consolidation among insurance companies is not new, and neither is it among doctors, hospitals and other providers. Yet the health bill has accelerated these trends, as all sides race to anticipate and manage political risk and regulatory uncertainty. This dynamic is leading to much larger hospital systems and physician groups, and fewer insurers dominated by a handful of national conglomerates. ObamaCare was sold using the language of choice and competition, but it is actually reducing both.

The first surge will come among the 1,200 insurers doing business in the U.S., given that a major goal of ObamaCare is to convert these companies into de facto public utilities. Those regulations are now being written—and once they’re up and running some medium-sized carriers will collapse under the new mandates and higher overhead. State insurance commissioners warned the Administration this month that “improper or overly strident application . . . could threaten the solvency of insurers or significantly reduce competition in some insurance markets.” They also implied that bankruptcies are likely.

With these headwinds, investors and Wall Street analysts are now predicting a lost decade for health insurance stocks. But it may be more accurate to say that there will be a lot of losers and some very big winners. Mergers and acquisitions will increase dramatically once companies get a better look at the regulation and figure out the valuation of M&A targets. Larger carriers will swallow smaller ones quietly before they fail.

The pace of change is far more rapid than is appreciated.

Across the country, providers are building giant hospital systems and much tighter doctor alliances like multispecialty groups to get out ahead of a concept known as “accountable care organizations,” or ACOs. To modernize the delivery of medical services, ACOs would encourage doctors to work in teams to use resources more efficiently, streamline treatment and improve quality. The model is the Mayo Clinic and other large integrated systems.

The Mayo Clinic has concluded that it cannot afford to treat Medicare patients. The Phoenix branch of the Clinic has already informed patients that they will accept no more Medicare. The model does not think it will work.

At the moment ACOs are only a gleam in some bureaucrat’s eye, and no one has a clue how they’ll operate in practice until the government releases a working regulatory definition next year. Yet the percussive effects are already being felt across medicine.

Hospitals are now on a buying spree of private physician practices in the rush to build something that will qualify as an ACO. Some 65% of doctors who changed jobs in 2009 moved into a hospital-owned practice, while 49% of doctors out of residency were hired by hospitals, according to the Medical Group Management Association. In its 2010 census, the American College of Cardiology reports that nearly 40% of private cardiology groups are currently integrating with hospitals or merging with other practices.

I spent a few minutes researching the doctors who appeared in white coats to support Obamacare last spring. Those who really were doctors were all hospital employees. Most of them had been hired right out of residency.

Doctors are selling because complying with the ever-growing list of mandates has become more cumbersome; and while staff physicians on salary do gain predictability, they also lose the autonomy of independent practice. The other problem is price controls in Medicare, which are about 20% below private payments for doctors and 30% lower for hospitals. Hospitals are also scooping up practices to lock in referral sources and make up for ObamaCare’s Medicare cuts. As it is, two-thirds of hospitals lose money today on Medicare inpatient services, according to Medicare.

This is an impossible situation and the Medicare patient will become indistinguishable from the Medicaid patient, a burden on the system to be treated by “physician extenders.”

The changes are coming like a runaway train and they will change American medicine irreversibly. Private medicine cannot afford to care for the discounted Medicare patients. Obamacare will convert private care to Medicare. Every one will be a charity case except for the gentry class that votes for Obama. University Hospital physicians may feel that they are immune to these changes but it has been known for 50 years that the value of salaried university physicians is directly related to the income of private physicians. In fact, the university physician has no overhead but they can always tell the administration that they can leave and earn as much, if not more, and this has given them a lot of power.

When I was in training, my surgical training program had three full time faculty members. Now, the same program has 90 full time members. In the same interval, their success in having graduates pass the American Board of Surgery has declined. That may or may not be significant but the culture of medicine is changing rapidly. Many physicians no longer recommend medicine as a career for their children. What this all means, I don’t know. What I do know is that it is coming very fast and few people realize it.

Anti-Vaccination Hysterics Kill Seven Babies

Great, anti-vaccination hysteria has killed seven infants in California. Whooping cough, once thought to be virtually wiped-out in the developed world, is making a comeback thanks to illegal immigration and greedy anti-vaccination activists.

As I noted in my previous post on the subject, too many people make emotional decisions based on graphic images. They see pictures of kids with autism or whatever the anti-vaccination hysteria du jour is but they don’t see countervailing images of the diseases that vaccinations prevent.

Just to provide some real education, here is a video of a 12-week-old infant with whooping cough. You can hear the distinctive strangling intake of breath at the end of a coughing fit which gives the disease its name.

As you listen to this, recall that in the normal course of the disease, this horrific coughing last for a month with two more months of less-harsh coughing. The disease kills by sheer exhaustion.

There is an adult whooping cough booster available. If you have contact with infants and/or a large illegal population (legal immigrants have to get vaccinations), I strongly recommend you get the booster.

And, if you know some anti-vaccination idiot, strap them down and make them listen to the video in a loop.