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August 07, 2012

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the doctor's status as being caregiver is taken as being undercut while in the second, the doctor has seemingly abandoned any notion of being a caregiver.

This is a very complicated area. Prudent consumers of medical services seek second opinions and those damned gatekeepers at private insurers often try to fulfill the same roll, but with the opposite perverse incentive, gatekeepers being perceived as less interested in the patient's well being than in denying the need for surgery. Ethical doctors don't operate unnecessarily and good doctors occasionally will open a patient up when the clinical symptoms do not show an obviously objective reason for doing so.

I can give anecdotal evidence of each of the above.

One spinoff of bending the cost curve is the unintended consequences of lowering medicare reimbursements. Knife happy and greedy doctors will perform even more procedures while honest and ethical doctors go out of business because they don't do enough surgeries to keep their doors open.

You can raise the reimbursement rate and add in a 'truly independent' second opinion condition precedent to elective surgery but then you'd have to monitor the independence of the second opinion giver and, unfortunately, doctors are loath to second guess each other.

Thanks for this interesting post.

No system is going to be perfect. Often one can foresee the inherent problems. In the case of for=profit hospitals, it is ineveitable that the profit motive will lead to unnecesary procedures unless something is institutioalized into theprocess to prevent it.


I go to a non profit coop. So far I've had no serious problems and in the last thrity years thaer have been no scandals involving the coop. On the other hand I have to drive thrity five miles one way for any kind of service.

good doctors occasionally will open a patient up when the clinical symptoms do not show an obviously objective reason for doing so.

Just curious, but can you give an example? If there are no objective reasons to open someone up, why would you do it? Because God told you to?

Knife happy and greedy doctors will perform even more procedures while honest and ethical doctors go out of business because they don't do enough surgeries to keep their doors open.

In theory, that might be true. But since every developed country has significantly lower cost curves than we do, we could just compare and see. When last I looked, there was no evidence that comparable countries with lower cost curves had higher rates of dishonest practitioners.

Just curious, but can you give an example?

my father was having trouble lifting his right arm over his head. he went to an orthopedist who did some tests and concluded my father needed surgery.

my father is the kind of guy who would rather tough it out than deal with surgery and a long painful recovery, so he delayed. then he decided to skip the surgery. then, after hearing some stories that made him doubt the orthopedist's judgement (ex. he had lost operating privileges at multiple hospitals in the area), he got a second opinion. the second doctor said there was no reason at all to do surgery - the problem could be handled, and possibly cured, with local cortisone injections.

Just curious, but can you give an example? If there are no objective reasons to open someone up, why would you do it? Because God told you to?

Sure can. My brother, who is obese, was hospitalized with debilitating abdominal pain. MRI etc showed nothing. The first couple of docs said, "we can't see anything" and his blood work didn't indicate an issue. The last doc to look at the films, etc noted that they couldn't see the gall bladder. So, using substantial pain as the only clinical indicator, the doc went in and found that my brother's gall bladder was necrotic and that he was a day or so away from death. That was about 2 months ago.

If pain alone were a sufficient basis for surgical intervention, anyone with back pain would be a surgical candidate.

But since every developed country has significantly lower cost curves than we do, we could just compare and see. When last I looked, there was no evidence that comparable countries with lower cost curves had higher rates of dishonest practitioners.

Can you show your sources?

Just curious, but can you give an example?

oops. misread. ignore my lovely anecdote.

Fascinating stuff.

Of relevance to your first instance, lj, Redrum a couple of months ago had a rant regarding the percentage of doctors who were threatening to quit their professions because of Obamacare (to do what, who knows, maybe become high frequency traders? Maybe they could move to China and work in the Apple Computer contractor's factory where their every move is recorded and the suicide rate is abnormally high).

A poll was cited at Redscam, which I perused for a few minutes and one item that flew out at me was the very high percentage of physicians who want nothing to do with the push to share medical data via the new linked computer technology, produced by firms like Cerner, their hospitals are beginning to adopt.

Transparency regarding outcomes was also subject to a great amount of looking askance.

Now, the survey did not distinguish those doctors who cited privacy concerns from other reasons, but the question arises when it comes to accountability and transparency, are many doctors essentially Luddites in this particular area for reasons of expedience?

Though I suspect the Second Amendment purists among them are outfitted with the latest blood-curdling weaponry.

I'm curious, too, did Dr. Abdul Shadani and his shrugging staff wash their hands before the surgery.

Somehow I imagine, after wink-wink-winking the 90% blockage to all present, he spit into his hands, rubbed them together and began the operation, slicing the victim open from Adam's apple to pubic bone, and rifling through the contents, tossing unneeded stuff like a license plate, the head of a mannequin, a dog collar, and the keel end of a chewed surfboard into the corner of the room, like Richard Dreyfuss in "JAWS" dissecting Moby Dick.

There is a movement afoot nationally, too, which has met great resistance among our caregivers, to enforce proper hygiene and both resistant doctors/staff and antibiotic-resistant germs/staph don't seem to want to cooperate much.

HCA. HCA? Oh, those guys. The Meidcare fraudsters. I thought htose guys were all in jail. What, the Florida Governor's Mansion is now a halfway house? I doubt the Governor of Florida washed his hands either before limiting voting rights.

The rest of us, of course, need to shower afterwards.

Look, there are many fine doctors (better people than I am, which goes without saying like everything else I say) across the board, but like every profession, some have become a conspiracy against the laity.

As Ben Franklin put it when asked what he and the others (no Others, just the other others) had wrought: "A Republic, if you any of you lot can submit to just a little bit of supervision for the common good."

Pipe dream.

Pipe dream.

A second opinion might be in order.

A good part of the problem, as far as I can see, is not only that the consumers (patients) who have insurance have little or no financial incentive to ration their consumption. It is also that (unlike Cheesecake Factory customers) hospital patients are unlikely to be providing very much repeat business. And even if they have a (survivable) bad experience and are unlikely to go back, does anybody else know about it?

So what is needed would appear to be something like Yelp. Some place where consumers can write reviews of medical providers. No, the hospitals and doctors don't get to make rebuttals, any more then restaurants do for bad reviews. But if a lot of people have good experiences, that will show. And if a lot have bad experiences, that will show up, too. Inn principle, new business will tend to flow to places which do well by their customers -- that is, which generally have good patient outcomes.

Is anyone aware of something like that starting up, somewhere in the country?

McTex, I can't find the source I had in mind now, but I'll try looking when I get home tonight.

So what is needed would appear to be something like Yelp. Some place where consumers can write reviews of medical providers.

This is a spectacularly bad idea. First, what's to stop doctor A from filing lots of false negative reviews for their competitors? Second, people aren't necessarily well equipped to rate their doctors. Just because the doctor refuses to give you a treatment you read about on the internet doesn't mean they're a bad physician. Third, right now, Yelp already looks a bit like a protection racket: Yelp is free for users and charges businesses money. And lots of businesses have complained that bad reviews disappeared once they started paying Yelp (more) money. You'd need to find a business model where incentives lined up properly; that is a really hard problem.

Finally, note that right now some doctors already make patients promise not to rate them on internet review sites as a condition for treating them.

the problem could be handled, and possibly cured, with local cortisone injections

My wife has been under treatment by a joint specialist who considers surgery to be a move of last resort, to be tried only when other means fail. This is not always something you can do in practice, but the fact that he, a surgeon, advised against surgery means that he's someone I would prefer to consult if I ever have a similar problem.

FWIW: her problem was addressed without surgery, using cortisone injections, stretching and an exercise regimen, as well as prescriptive NSAIDS.

note that right now some doctors already make patients promise not to rate them on internet review sites as a condition for treating them

I was as truthful making that promise as you were in making a correct diagnosis, doctor.

Just a quick side note, I've been released from the hospital. They did some laser work on my other eye, just to make sure it stays in place and I've got a follow up visit next week, but I'm out!

Cost was roughly 220,000 yen which is about 2,000 dollars when the dollar is at 100 yen, but it's at 78 yen right now, so that makes it about 2,800. (this is 30% of the cost, and there is insurance that the teacher's union has that will reimburse some of that, plus I'll be able to deduct more off my Japanese income tax) joel hanes wins the prize, so drop by, either now or when I put up the thread and give us the topic you want.

Thanks for everyone's comments and good wishes.

While institutionalized profit motive undoubtedly entices some of this [unnecessary surgical] behavior, there is also something to be said for the old saw that when all you have is a hammer, &c.

Or: as a friend of mine who recently finished med school and was thinking about specializing in surgery told me,

"Cutters wanna cut."

(He opted for psychiatry.)

This Clive Crook piece is about the Atul Gawande with this observation:

Size is the key? I think it would be more accurate to say that size is the consequence. Competition is the key--and competition works because enterprises like the Cheesecake Factory are answerable to their customers. As Gawande's health-care examples attest, that's the missing link in health care. Many would argue that accountability and competition can't be made to work in health care. I don't dismiss that possibility by any means. But surely that's the question. The issue isn't how do we scale up health-care delivery organizations to give them buying power and centralized common functions. It's how far can the consumers of health care be empowered to discipline the producers

I think that the profit motive is so powerful, it gets amazing things done, but if we go full bore with it, we are going to end up with cases like HCA. It's notable that the corporate headquarters in that story was investigating, and what made them investigate was the concern that they were opening themselves up to liability if they didn't. To me, it is a strong argument for public health care, in that this would attenuate the profit motive. This link about the VA health care system has appeared here before, but it underlines how a government driven health care system can improve. Two grafs:

Here's another curious fact. The Annals of Internal Medicine recently published a study that compared veterans health facilities with commercial managed-care systems in their treatment of diabetes patients. In seven out of seven measures of quality, the VA provided better care.

It gets stranger. Pushed by large employers who are eager to know what they are buying when they purchase health care for their employees, an outfit called the National Committee for Quality Assurance today ranks health-care plans on 17 different performance measures. These include how well the plans manage high blood pressure or how precisely they adhere to standard protocols of evidence-based medicine such as prescribing beta blockers for patients recovering from a heart attack. Winning NCQA's seal of approval is the gold standard in the health-care industry. And who do you suppose this year's winner is: Johns Hopkins? Mayo Clinic? Massachusetts General? Nope. In every single category, the VHA system outperforms the highest rated non-VHA hospitals.

As for web based notions, googling for the VA info had me find this site, but I don't know anything else about it. When we were talking about OECD care, I did find that UK health care has a rather interesting website that has comparisons and data for consumers. I typed in Bristol and retinal detachment, and this page came back. Interesting stuff.

Slarti: her problem was addressed without surgery, using cortisone injections

my wife, too. bad hip, destroyed acetabular labrum. hip replacement is probably inevitable, but they're holding it off as long as they can with cortisone.

Turb: This is a spectacularly bad idea. First, what's to stop doctor A from filing lots of false negative reviews for their competitors?

Not a thing. Just as there is nothing to stop a restaurant from filing falsely bad Yelp reviews of their competitors. Yet somehow, the system doesn't seem to collapse. Possibly because it is possible to see lots of reviews, not just a single rating. Possibly because you can look at all of the ratings from a single reviewer -- which makes one-off smears of competitors noticable. Possibly for some other reason.

For that matter, there is nothing to stop any other form of feedback from being distorted. If anyone has come up with a system that cannot be gamed, I have yet to hear about it. But does that mean that it is a "bad idea" (not just worthless, but a bad idea) to try and get some widespread views on how well someone does his job?

As for patients being unqualified to rate what doctors do, I don't quite understand your point. I don't understand what chefs do either . . . but I can judge the quality of the results of what they do. Likewise with doctors. I don't know all of what they do, and I certainly don't have the training that would allow me to do it. But if I am the consumer here, I do have some idea whether I think I was well served or not.

The point is results, not methodology per se. Methodology is useful to someone trying to learn from it, or teach it to others, or improve upon it. But it is irrelevant to the person who merely wants results.

Yelp!

Suggestions for naming this new rating service:

Owwwwy!

Quack!

Turn Your Head To the Side and COUGH!

Post mortem!

GrinandBearIt.

A ratings system needs to be devised, but I'll second Turb's judgement regarding Quack for most medical procedures.

It would be fun though to observe avedis in such a forum. And what about me? I'm as reliable as the come.

It's all dicey, and I don't pretend to know the answer.

Yelp is fine for cheeseburgers, but Quack for brain surgery -- not so hot.

Some of medical care is a consumer commodity. Some is not.

I wouldn't mind, though, having the Magliozzi Brothers, Click and Clack, turn to medicine. You could call in, describe your symptoms, and Tom and Ray could ask the caller if the doctor owns a boat and then ask them to check in next week to see if their question stumped the chumps.

Yes, it did. In fact, the patient took the boys advice and sought out the referral on the website and we regret to report he can't be with us this week because he's dead as a carp now.

Would these amateur medical opinionators be subject to malpractice suits?

Somehow in many cases I don't think Yelp is to cheeseburger as Quack is to brain surgery.

Though I will give you that the heart is like a pump.

Should malpractice and outcome data be freely and transparently available?

Sure.

Prediction, there's a species of politician gone rogue in the land now and multiplying and they'll have two words for any criticism of the medical lobby: Death Panels.

Because: Citizens United.

You know, the same murderous vermin who want to shut down all of the reporting, data collection and transparency in Obamacare via Medicare

But the idea, as idea, despite my objections, has some indefinable merit.

I will report to all of you to avoid a certain orthodonist, however, who I had as a kid. He's probably, oh, 111 years old now and shaky on his feet, but I've seen better dentistry in "The Sorrow And The Pity".

Finally, I've asked this question before, but who are these many, many people who don't ration their healthcare?

What does that mean?

I try as much as possible to ration my healthcare to the extent of being dragged kicking and screaming to the doctor.

The poor ration their healthcare, so if you mean no money/no healthcare, set up your Yelp/Quack website and propose THAT idea and figure out (hopefully beforehand) a banning policy for when the server crashes and burns and the FBI needs to sort out the death threats.

I wonder what the outcomes ratings webpage would look like for a Geriatic Specialist.

EVERYONE died. Well, the doctor earned a 100% rating, which is right in line with all other geriaticians.

I try as much as possible to ration my healthcare to the extent of being dragged kicking and screaming to the doctor.

I'm glad someone wrote this. Now, when you get some news like "You have cancer" the rationing goes out the window. But I don't think anything's going to change that.

In any case, I don't like to spend my free time being poked, prodded and scanned - just because. Nor would I even absent a copay.

Different strokes, I guess.

Just as there is nothing to stop a restaurant from filing falsely bad Yelp reviews of their competitors.

This happens right now. In fact, you can pay companies to ruin your competitors' ratings for you. I don't really care if good restaurants get punished on Yelp; I do care if good doctors are driven out their field though. Health care is slightly more important than eating out occasionally.

Yet somehow, the system doesn't seem to collapse.

Note that there's a hell of a lot more money in healthcare than in the restaurant business. Orders of magnitude more. Gaming a recommendation system might not be worthwhile when you're talking about a local restaurant but might be very profitable when you're talking about a cardiac surgeon.

As for patients being unqualified to rate what doctors do, I don't quite understand your point.

Customer satisfaction is not the same as good medical practice. People get pissed of with doctors who do the right thing all the time: consider smokers or alcoholics or anti-vaccination parents. Public health depends on doctors sometimes hurting people's feelings even though doing so might get them bad reviews.

To put it another way: wouldn't it be awesome if we paid teachers based only on student evaluations? This is another domain where professional practice (i.e., teaching) does not correlate well with customer satisfaction: hard teachers often get lower ratings than teachers who give everyone A's.

But if I am the consumer here, I do have some idea whether I think I was well served or not.

Every year, thousands of Americans undergo useless surgeries to relieve back pain. Because of the placebo effect, many of these people will even report an "improvement" in their condition. Your system would give doctors incentives to perform useless or dangerous treatments. Because people don't read medical journals and often can't tell that a given treatment has no scientific evidence justifying it.

The point is results, not methodology per se.

If you don't have good methodology, you're probably not going to get good results.

Look, I hang out with people running start ups a bit. And trust me, this brilliant idea of yours? You're not the first person to come up with it. Lots of people have thought about it. But when they research it and try to make a business plan they conclude that there's no way to make a viable business here without giving doctors or patients incredibly bad incentives. And that means running the business would be at least unethical and perhaps legally problematic.

I will add that for what I'm paying for my healthcare in the "private market" right now, I might start demanding a weekly colonoscopy, you know, because of the "incentives".

No, when I get cancer, I'm going to shop for a doctor, counting my pennies and my coupons on two-fer Fridays, take lots of metastisizing time trying on doctors in the changing rooms, and I'll stop at my favorite doctor joint, peruse the menu, sending doctor after doctor back to the kitchen because the porridge is just a little too hot a little too cold until everything is just as I like it.

I haven't determined my tipping strategy yet but I'm sure the cold-calling debt collectors will hurry that along.

Seriously, though, most doctors and health professionals know who the patients are who milk the healthcare system and forget to ration and floss.

Let's start a webpage and list their names and then we can pile on and, via peer pressure, get them to stop.

But wait, I notice it's always market oriented (yeah, who isn't?) conservatives who complain about those who aren't incentivized (I hope the guy who turned "incentive" into "incentivized" gets a fatal goiter condition; I'm looking at you Larry Kudlow, you of little dentistry) to ration their healthcare.

Somehow I suspect it's actually conservatives by and large who abuse the system, given all the projection.

Not Slart. He won't even get his head examined for putting up with me. ;)

Let me give you one example: Sarah Death Palin. Somehow, I think Governor Death Panel is going to try and get a tummy tuck at my taxpayer expense some day, because to disallow that is a Death Panel!

Ayn Rand was for rationing healthcare too, until she signed up for Medicare under her cuckolded husband's name.

Then she stayed alive long enough to peddle her shite on the Phil Donahue Show.

What a Commie!


Just received my New Yorker so I'll read the Cheesecake Factory article.

But first, go here: http://www.newyorker.com/cartoons ..........

....... for this week's Cartoon Caption Contest. Scroll down a little bit; the cartoon in question is on the left.

I have some caption suggestions, but I think I'll save them for the New Yorker for now

Seems to me that the strong reluctance of doctors to be "evaluated on outcomes" has some similarity to the reluctance of teachers to be "evaluated on outcomes".

While nobody really wants such oversight, it's particularly problematic when there are many confounding factors that make that push the final result out of the control of the person being evaluated, in spite of whatever professional skill and effort they exert.

You can have the best medical care in the entire world. You're still going to die.

Me, I'm not going to do that "dying" thing. However I can't discount the possibility of the Universe just up and disappearing sometime in the future. That'll suck.

Not to pile on, but doctors and restuaruants have very little in common.

It isn't that hard to find out what the ingrediets are, what the sources are for the ingredients, wha the standards are for the cooking area etc. Even in a prestigious restaurant the cooking follows a routine. And it is OK if the review relfects the personal predilections of the reviewer.

It's a lot harder to know anything about the surgery one is about to undergo and often people don't have time to research doctors. Bewsides even a routine surgery can hav eunnexpected complications. And a reveiw should be objectinve, not subjective, but how many patients can do an objective evaluation of a docter?

It was less than twentyfour hours between my diagnosis and my retinoplasty. I had time to look the procedure up ont eh Internet but I had to take the word of the doctor who did the dianosis tha thte docogtr who was going to do the retinaoplasty was competent. Turns out he was Asian (good stereotype!), had kids in the gifted progrm taught by a friend of mine(good personal connections!) and was a very nice guy(Good patient-side manner!)

Does that mean he did a good job on my retinoplasty? The immediate recovery period was awful: I couldn't stop puking and spent twenty four hours inthe hospital recovering from the anesthsia (I discovered later that spending hours puking from the anethesia is normal for me),It took nine months before my eyelid stopped drooping and eight or nine years before the weird muscle spasms stopped. HEW told me after the surgery that it had been a difficult surggery.

So should I conclude that he screwed it up somehow or are those sorts of effects just what happens if your eyebal istoo big to pull through your eye lids?

There's lots of research that indicates that people evaluate their doctor's perfomance based on their perception of the doctor's personality. If my retinaoplasty doctor had seemed like an arrogant asshole, would I have blamed him for the years of recovery from the surgery?

Maybe I should have blamed him but didn't because I got such a good impression of him.


OR maybe I'm just not qualified to evaluate his surgical skills. If I was going to review him I could wrtie objectively about my experience and subjectively about my perseption of his personality whidch might be helpful information for someone who is looking for a likable doctor, but would not be helpful for someone who is looking for objective inforamtion about his surgical skills.

ObWi needs a Like button, so i could click it for Laura's comment.

Read the New Yorker Cheesecake Factory article, which is written by a doctor.

I'm all for best practices in business and government as long as the differences between institutions are observed.

For example, government is not a business and its not the effing family kitchen table either.

But if Cheesecake Factory practices can be adapted to medicine, and they are in some large hospital chains, I'm all for it, particularly in the area of service and determining what works best in various medical procedures.

In fact, I'm going to dine at Cheesecake factory some time this week to see what's up.

I'll avoid the liver, even though the organ is my fave, for fear that some Cleveland Clinic internists might have been observing the efficiency of the Cheesecake kitchen production line and accidentally left something iffy in the larder.


But I have some impressions, expressed in my usual Socrates meets the Marx Brothers (YMMV) method of inquiry, g8ddamit.

Here goes:

Restaurants servers up-sell. THAT is a best business practice in all businesses, including the pharmaceutical and medical device industries. Notwithstanding the fact that most of the positive change in medicine seems to be coming from the non-profit sector, am I to expect HCA nurses, doctor's and technicians now to entice me with something a bit tastier and a little more expensive on the medical menu, while I'm flat on my back and a captive diner?

"Yes, we have the standard pre-surgical enema listed on the menu, but today the doctor has prepared something extra special and, I might add, soothing yet purgative. All of us on the nursing staff tried this morning and it was absolutely out of this world. It's a little more expensive, but I'm telling you, I've never run to the loo with such a skip in my step."

"Our specials today are the aortal stent procedure with fennel and seasonal beta blockers, and for a beverage, we're offering the flight of artisanal chemotherapy drugs, served intravenously.

Or, conversely, will the hospital staff be there to give me whatever I want on the menu, when I want and in the amounts I desire?

"That colonoscopy was so good that I'll have another. Also, could I have another order of Vicodin and put both this order and that one in a doggy-bag to go? And my friend here would like to supersize the opiates. Oh wait, and honey did you want the lube job and oil change too. Put that on my check as well.

"I'm sorry sir, but the doctor and the Command Center (yes, it turns out that faceless bureaucrats, control and command, and remote Death Panels are just the ticket; read the article) won't allow two colonoscopys in one day, let alone within the next five years, barring some unforeseen complication. And your Vicodin prescription is for the amount you have there in the little paper pill cup and no more."

"Alright, bring me some cheesecake. Hup. hup!"

"Sir, once again, your doctor has concluded that one more piece of cheesecake could, not to put too fine a point on it, kill you, via coronary infarction, I believe, yes, see, it says right here in your chart."

"I've never encountered such foot-dragging and outright insolence from wait staff. Alright, bring me a glass of champa....."

" ...... Sir, please, we have no liquor license here at Our Lady of The Pre-Existing Condition Surgical Center, and by the way, your dining insurance does not reimburse for repairing that neuroblastoma and hot fudge Sunday you had as a kid."


"Well, then, may I speak to the manager of this horse trough you call a bistro. You can expect to hear about this on Quack AND Yelp, because I've seen better breakfast granola in catboxes, I must say."

The customer is always right, despite the fact that in Mafia Italian restaurants customer complaints are countered with the manager spitting copiously into the marinara sauce and maybe even with a little gun play, which, after all is why the Second Amendment protects gun possession and NOT a guarantee of an answer to the question: "This sauce tastes a little off. Is that you, Guido?".

Is the patient always right? And how many tubes, wires, and restraints does the patient have to free himself from to walk down the street to another hospital?

Conversely, why can't I summon an ambulance to take me from one unsatisfactory restaurant to a better one, if, I'm say, unconscious, but a might bit peckish?

Why do doctors take an oath to serve and restauranteurs do not?

When do we get the good cheesecake for those sumptious hospital feasts?

In the short run, I must admit, Cheesecake Factory has a much better outcomes rate with far fewer fatalities. In the long, that next trip to the Cheesecake Factory could land you at the Betty Ford Clinic.

So everyone raise their hands for the following two choices:

Who wants to go the Cheesecake Factory?

Yea! Everyone!

Alright now, who wants to check in at Cedar's Sinai for the works?

Noooooooo!. BOOOOOO!

Well, how bout if take our medicine at Cedar's Sinai first and THEN I'll take all of you to the Cheesecake Factory!

NOOOOO! We're eating in for all the fun you are.

I have more.

NOOOOOO! BOOOOOO!

Does your dining insurance refuse to cover pre-existing bad meals?

I have an idea for a website like Yelp that would critique attorneys and law firms in no uncertain terms. (yes, they probably already exist).

Name: Slander.

joel hanes wins the prize

I'm protesting the decision of the judges.

bobbyp originally guessed $450, and then raised it to $850

I guessed twenty-two thousand and change.

bobbyp missed by at most $2,350

I missed by $19,700

My guess was very roughly 8.5 X farther away from the true answer than bobbyp's first guess, and even worse when compared to his second guess.

In short, bobbyp should choose the topic.

Who says the spirit of sportsmanship isn't alive! And who says I have any ability at math?!? I must have gotten my decimal point screwed up.

So bobbyp, what'll it be? I'm inclined to let joel choose next week's as well. When you are as bad at math as me, you can think you can afford to be magnanimous...

Not Slart. He won't even get his head examined for putting up with me. ;)

I am currently a stranger in a strange land, where I am not anywhere near certain that my insurance would apply. So, temporarily at least, I have an excuse.

You can raise the reimbursement rate and add in a 'truly independent' second opinion condition precedent to elective surgery but then you'd have to monitor the independence of the second opinion giver and, unfortunately, doctors are loath to second guess each other.

That might sort of help for elective surgery, with the very important caveats you mention.

But how do you get a second opinion about putting in a stent when you've gone to the ER with chest pains?

lj, I haven't seen such billing malfeasance since the last time I dined at Cheesecake Factory and they tried to charge me for removing the gall bladder of a guy sitting at an adjacent table. ;)

This controversy over "Rotten Tomatoes", the movie review service, is another cautionary tale warning about the pitfalls of our idea here: Quack!

http://andrewsullivan.thedailybeast.com/2012/08/film-partisans.html

Regarding Yelp!, I know a lot of people in the restaurant business and while they are on the front lines of "consumer judgement" at all times and obviously have no problem with that, the viral quality of one bad review on Yelp, especially for a newly opened restaurant that has otherwise satisfied the majority of their customers in that low margin business, can be quickly fatal.

Alright, big deal, it's just a restaurant, right?

Well, it may be that other satisfied patrons of the restaurant are now deprived of choice because of one or two vitriolic expressions of gustatory distemper, and yeah, I know the elite restaurant critics can do the same damage.

I'm just saying that transferring this model of viral judgement on the internet, where many folks, me included (though I have reactionary performance art reasons for my behavior, not that I expect allowance for that), do not stay within the bounds of normal human discourse, to reviewing doctors is a bad idea because maybe we're dealing with a horse of a different yellow brick road.

A couple of "0" ratings on the Quack scale for a doctor by the proverbial disgruntled "consumer" and not only could an otherwise fine career be scuttled but, in the field of medicine where lives, not appetites and palates, are on the line, a lot of otherwise satisfied patients could lose their doctors and end up in a van down by the river with some grotty former internist with a cold stethoscope and the erumpent nosehairs of a bounder past his prime.

Again, I'm no expert.

So, why would you want me throwing my bullsh*t around on Quack?

I'm expert at not liking experts, like all Americans who both worship expertise and would like to have all experts periodically filleted from gullet to pubic bone.

I notice the many, many attorneys who post and lurk here haven't yet endorsed my idea for "Slander", and its website competition: "Defamation", "Calumny", and "Libel", my service which would "rate" law firms and their employees.

Some interesting points. Laura, I think it is significant that they are talking about knee replacements in the article (which is basically a mechanical problem) and eye surgery, which seems to require a higher level of skills. I also think that people are scared as hell of hospitals because they will get the treatment that the restaurant manager gets, which I quote:

Recently, she’d had a fall, apparently after fainting, and was taken to a local emergency room. The doctors ordered a series of tests and scans, and kept her overnight. They never figured out what the problem was. Luz understood that sometimes explanations prove elusive. But the clinicians didn’t seem to be following any coördinated plan of action. The emergency doctor told the family one plan, the admitting internist described another, and the consulting specialist a third. Thousands of dollars had been spent on tests, but nobody ever told Luz the results.
A nurse came at ten the next morning and said that his mother was being discharged. But his mother’s nurse was on break, and the discharge paperwork with her instructions and prescriptions hadn’t been done. So they waited. Then the next person they needed was at lunch. It was as if the clinicians were the customers, and the patients’ job was to serve them. “We didn’t get to go until 6 P.M., with a tired, disabled lady and a long drive home.” Even then she still had to be changed out of her hospital gown and dressed. Luz pressed the call button to ask for help. No answer. He went out to the ward desk.
The aide was on break, the secretary said. “Don’t you dress her yourself at home?” He explained that he didn’t, and made a fuss.
An aide was sent. She was short with him and rough in changing his mother’s clothes. “She was manhandling her,” Luz said. “I felt like, ‘Stop. I’m not one to complain. I respect what you do enormously. But if there were a video camera in here, you’d be on the evening news.’ I sent her out. I had to do everything myself. I’m stuffing my mom’s boob in her bra. It was unbelievable.

Also, Snarki, when you say

Seems to me that the strong reluctance of doctors to be "evaluated on outcomes" has some similarity to the reluctance of teachers to be "evaluated on outcomes".

While nobody really wants such oversight, it's particularly problematic when there are many confounding factors that make that push the final result out of the control of the person being evaluated, in spite of whatever professional skill and effort they exert.

Actually, the article doesn't suggest that doctors should be evaluated on outcomes, it suggests that when things are standardized, outcomes improve. A shortcut might be to evaluate outcomes, but it's a shortcut that causes a lot of problems. The problem is that there are a range of things that might really benefit from standardization, but there are other things that would really be lost.

Still waiting for bobbyp to give me an open thread topic. If you are out there, let me know!

lj wrote:

"The problem is that there are a range of things that might really benefit from standardization, but there are other things that would really be lost."

Excellent come-away from that article.

All of the service-related things cited in Luz' experience seeking care for his mother are what would definitely benefit from the "Cheesecake" business practices and I expect too from wj's idea for a ratings website. (I know it sounds like I've made up my mind against, but I can be emphatic in either direction).

It's when we get into the medical procedures themselves, administered by the experts with knowledge we lay people do not possess that things become iffy.

Yes, standardization for most procedures would be a positive development, but it is being standardized by whom?

Experts. Who have knowledge that is not accessible, transparent, or is veiled to the rest of us.

I'm reading Christopher Hayes' "Twilight Of The Elites" just now and he writes (within the overall theme of this very lucid and depressing book) of this especially American tendency to confer money and status on the experts and the opposite pole of totally rejecting, to narrow it to the case before us now, medical authority.

We must trust and verify, but the sheer volume of specialized knowledge and esoteric information needed in the medical realm to be "informed consumers" (it's not just a matter of taste -- hmmmm, yum, we're coming back to this restaurant -- and there is no accounting for individual taste) is overwhelming and my objection to half-as*ed forums like Yelp is that it will be inadequate, at best, and corrupting and misleading at worst, though it all comes down to the details.

The web of mediation is fraught.

Yeah, I visit the Mayo Clinic when I have a new stitch in my side to see what might be up. Let me tell you something, the last time I self-diagnosed with roughly 168 terminal conditions, dozens of them only available to me if I lived in an equatorial jungle.

I mentioned it to my physician (he WAS the second opinion and he said "Other than the fact that you're ugly, there nothing wrong with you.) Yeah, but the Mayo Clinic said ...

Hayes writes: "Imagine a weary sailor coming home to port in the midst of a brutal storm. Along the horizon he sees the burning lights of dozens of lighthouses. And yet he knows from experience that some are so old they've receded miles inland as the shore has grown. Others are simply fakes, put out by sadists and rivals. To be a citizen in these strange times is to perpetually find oneself in that poor sailor's perilous state. We know the danger lurks in the darkness, but we don't know if we have the means to avoid it."

Here's an example of lay opinion about a scientific subject in the hands of one of the "sadists" Hayes speaks of: Rush Limbaugh.

As Hayes' relates, in 2010 Limbaugh told his 15 million listeners on the subject of global warming (and now public policy is paralyzed) that "government, academia, science, and media" are now corrupt and exist by virtue of deceit. That's how they promulgate themselves; it is how they prosper."

Now, good people can differ on whether or not Al Gore is a Cassandra, but if Gore is wrong, what is lost but some expense and mis-allocated resources?

But imagine if Limbaugh's words about global warming scientists were applied carte blanche to the medical community -- all professionals at every level are liars and cheats -- you know like the bankers and Wall Street (see, it's easy ;) )

If Limbaugh is wrong in his blanket judgements regarding the "malign", self-dealing professional motives behind climate science, and I'd like someone to deny that his demagogic, corrupt ideology is a least questionable (I won't call him vermin lying filth because it's obvious that he is vermin, lying, subhuman, anti-American filth), the cost of his propaganda, unlike Gore's will destroy lives, property, and the environment.

Gore can be ignored if he is wrong. Maybe we can put him on a payment schedule for the unneeded expense incurred.

Not Limbaugh. Judgment and punishment will be doled out and I'm here to tell you it won't be meted out on an effing website devoted to rating radio talk show hate jocks.

See, Limbaugh and his ilk are the real elites today. You can tell by their f*cking paychecks. They are the cream of the crop of the B*llshitocracy.

I will be Judge, Jury, and Executioner and drone technology will find its domestic target.

If avedis doesn't get to him first.

That would be the Mayo Clinic "website".

I can't afford the actual "Meat World" facilities.

But how do you get a second opinion about putting in a stent when you've gone to the ER with chest pains?

You don't. You hope that there is a pre-set criteria that are met. "Hope" being relative in this context--you'd rather not need a stent.

I notice the many, many attorneys who post and lurk here haven't yet endorsed my idea for "Slander", and its website competition: "Defamation", "Calumny", and "Libel", my service which would "rate" law firms and their employees.

We've all been tied up getting copyrights and domain names.

Seems to me that the strong reluctance of doctors to be "evaluated on outcomes" has some similarity to the reluctance of teachers to be "evaluated on outcomes".

I was just reading about how hedge funds, as an asset class, lose money compared to T-bills. In other words, rich people put hundreds of billions of dollars a year into an asset class with high risk and astonishingly poor returns. Why do they do that? I mean, shouldn't wealthy people be able to determine that hedge funds are bad ideas? Yes, they should, but the industry works hard to hide outcomes so that people can't evaluate them on it.

When a hedge fund does well, it publishes its returns. When it does poorly, it stops publishing its returns. When a hedge fund has done well for a few years, it gets invited into hedge fund indices and the past years of good performance get retroactively added to the index. There's no central registration so it is really hard to tell how hedge funds do as a class.

I also learned that while most hedge funds charge 2 and 20 (2% of the capital and 20% of profits), the awesome ones charge more like 5 and 44.

MckT:

Here's another for your stable: reTORT

When you have a State Medical Board of Quacks, what good does quacking on Quack do ya?

http://digbysblog.blogspot.com/2012/08/when-zealots-take-over-medical-boards.html

The Russian feminist punk-rock collective, Pussy Riot, you'll notice, hasn't requested asylum in Kansas, believing jail time in totalitarian Russia is better than assassination in totalitarian Kansas.

I've noticed too that despite Mitt Romney's harsh words for the dangerous totalitarian Putin/vermin Russia, he hasn't invited Pussy Riot to perform as the house band at the dangerous totalitarian Republican/vermin National Convention in Tampa.

Fascist hands meet across the water.

Looks like some kind of Axis to me

When a hedge fund does well, it publishes its returns. When it does poorly, it stops publishing its returns.

Mutual fund companies have been known to play the same game. A poorly performing fund is liquidated, or merged into another fund, and, voila, its performance vanishes from the company's record.

It's easy and popular to poke fun at the Efficient Market Hypothesis, but as a principle for individuals to bear in mind when making investment decisions it's pretty accurate.

"It's easy and popular to poke fun at the Efficient Market Hypothesis, but as a principle for individuals to bear in mind when making investment decisions it's pretty accurate."

That is because like many good social science concepts it can break down at extreme margins, which everyone who doesn't it like it then pretends means that it is not generally applicable.

As for the health care discussion, I find the research and talking points pretty empty. The recent chart going around showing a slow down in medical spending growth is a classic case in point. We can't tell if the slowing is because fewer people are getting good care (bad), cost of good care is going down (good), unnecessary procedures are down (good), necessary procedures are down (bad), doctors are getting cost squeezed (mixed), heroic end of life spending is down (probably good), or research spending is down (probably bad). Since we don't get a look at that, people use the chart for whatever their own views are and we get no where.

Hi Sebastian, if you could give a link to the chart, I'd like to try and make a post about it, thx.

And in collecting stuff for that post, this thing about startups related to medical costs popped up

Sure, here is Kevin Drum talking about it. [cite]

Here's a small view on the problems that occurred and are probably still occurring in facilities performing heart cauterization in combination with cardiac stents- When a patient is referred to a cardiologist, that same cardiologist routinely performs the heart cauterization at the cath lab. During the procedure if the cardiologist sees a problem, they go ahead and place a stent. Hence the wink-wink if there isn't really a problem. There is no time for a second opinion and if the patient asked for one, they would be told- You could have a heart attach and die, don't you want us to save you? And what does the average patient respond? Go ahead and do the stent. The patients are treated as if they do not have a brain- they are not show the lesion (except by the most caring cardiologists that have nothing to hide.
As a contrast, if the patient has a narrowing in an artery of their leg, the sequence of events goes like this. Seen by their primary physician
who refers the patient to a surgeon. Surgeon examines and orders an arteriogram of the aorta and legs. Radiologist does the procedure (yes we are on physician #3). Arteriogram is completed. Exam is ready by radiologist and report is sent to surgeon. Surgeon reviews exam findings and decides if the patient needs a stent to open the artery of if they need a bypass procedure (highly invasive) When they chose the stent, the patient is sent back to the Radiology department and the stent is placed by the Radiologist. Several physicians have been involved in the decision making and hopefully the least invasive procedure is performed and the one that will benefit the patient the most. In the cath lab, the cardiologist is the only physician present and makes the decision himself, for his own gain and the facilities gain. Hey who is to complain then. The staff surely can't say anything. If they do, they will lose their jobs and remember, this atrocity was first reported in 2008 and I'm sure we all know what year it is now. Problems abound. As a former healthcare professional, it is frightening to find a proper physician who practices medicine the old fashioned way.

reTORT

I like 'Caveat Vendor'.

Here's the problem with 'outcomes' as a metric: leaving aside the notion that each of us has his/her own individual baseline from which the 'outcome' would have to be measured, not everyone is going to get well. You'd create all kinds of perverse incentives. Docs would paint the worst possible case in order to make the outcome look better. Plus, it would justify more treatment. Or, Docs would only take patients who they can cure or objectively mitigate.

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Whatnot


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