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National Health Care Program Part V
Posted: 17 December 2008 12:46 PM   [ Ignore ]   [ # 16 ]
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Chris Crawford - 17 December 2008 10:49 AM

I think you’re allowing your defensiveness to bias your reading of what I write. Each of your paragraphs is predicated on a misreading of a particular element of my proposal. For example, your first argument, objecting to what you perceive to be arrogance, completely misconstrues the point I made. My argument here is no more complicated than “He who pays the piper calls the tune”. It is economically untenable to have Party A pay for work done by Party B at the latter’s discretion. In every case where that is done, Party A inevitably ends up feeling cheated. And I think it is fundamentally unfair for anybody—including physicians—to expect freedom to make decisions affecting others while evading responsibility for the financial consequences of those decisions. Our society has developed all sorts of extremely complicated mechanisms for matching decision-making power with financial liability. True, there are still plenty of violations of that basic goal, but we all agree that those violations constitute flaws in the system.

I understand your point, but you’ll have to excuse me for misconstruing it. You need to understand I’ve already been there, done that. I have dealt with insurance companies who refused to allow a patient to have a particular test that was truly necessary. I was in the position of dealing with a person who apparently had no more than a high school degree who was looking at a computer screen and decided that my patient didn’t meet the criteria for getting a head CT. Apparently the program didn’t differentiate between ” the patient has a bad headache” and “the patient is screeming in pain with the worst headache of his life”. The answer I got from the insurance rep was. “well we’re not sayin he can’t have the CT he can just pay for it himself”.  I do find it arrogant that a person can speak to someone of clearly greater training with that degree of detachment assured of the correctness of their decision because a computer program told them they were doing the right thing. Your comment sounded hauntingly like that very situation.

Chris Crawford - 17 December 2008 10:49 AM

argue that physicians do not order tests to advance their financial interests. I disagree. A great many physicians order tests whose diagnostic value is slight, but they do so to protect themselves against litigation. I don’t blame them one bit—we’ve set up the incentives to induce them to do that. The problem is not with physicians, the problem is with a system that motivates reasonable people (physicians) to waste resources.

I didn’t actually say that. Here You have misread what I said. What I said is that a very high percentage of the tests ordered by me ( and most primary care docs) are not done in their own office and therefor do not benefit me (them). I agree that a good percentage of these tests are done for CYA ( cover your ass) reasons and if a legitimate effort were made to limit litigation, this would decrease substantially. However, to handcuff a physician and not allow him to order these tests without tying that directly to such limits would be disastrous for physicians. I understand you are trying to do that I am just not optimistic that you can.

[ Edited: 17 December 2008 12:57 PM by macgyver ]
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Posted: 17 December 2008 01:25 PM   [ Ignore ]   [ # 17 ]
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OldSquid - 17 December 2008 10:47 AM

I disagree, there are good a bad insurance companies out there.  The minority of them (typically the large national ones) give the good ones (typically the small regional ones) bad names.  Almost everyone in healthcare is in it to make money, the insurance companies, the hospitals, the doctors.  Without insurance companies who will look after the other two.  And the hospitals and doctors watch the insurance companies.

Insurance companies - whether you want to call them good or bad - are unnecessary medians, and that is the whole point. They play no necessary role in providing health care at all. What is worse is that they, since they are private companies, can deny health care with little or not accountability. At least in a government administered program the accountability is greater.

I am not going to bother getting into political economics and go on a rant on the intrinsic ills of markets in general so I will leave alone the comment about “Almost everyone in healthcare is in it to make money.” I agree with it but it opens up a whole new conversation that I am not going to bother getting into outside of referencing Participatory Economics.

That being said, insurance companies are absolutely unnecessary to providing health care. All they succeed in doing is driving up the cost of health care - so much so that most of those who file bankruptcy over medical bills had insurance! - and preventing tens of millions of others from having access. The fact is indisputable and clear: we spend twice as much per capita on health care than the rest of the developed world with a single-payer program and on top of it, we have a large portion of society without coverage.

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Posted: 17 December 2008 01:58 PM   [ Ignore ]   [ # 18 ]
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I am not familiar with the first moment and second moment figuring.

Those are just five-dollar terms for average and standard deviation. They’re more mathematically precise, because average and standard deviation are, strictly speaking, only applicable to normal distributions. In many cases, it doesn’t hurt to just talk about average and standard deviation. However, there are cases where those standard calculations yield results that are are way out of line with our expectations. So “first moment” and “second moment” are general terms that cover the basic calculations for all types of distributions. Here’s a good example: suppose that, after a big forest fire, you planted lots of seedlings. Ten years later you come back and plant some more to fill in gaps. The “average” age of the trees is five years, but that concept is so screwy in a case like this that it’s more prudent to talk about “first moment” and “second moment”.

Voice recognition software is not as advanced as you would like to believe.

There are three kinds of software recognition. The snazziest, but least effective, is general speech recognition, that can listen to anybody talking and figure out what they’re saying. That has a lot of problems, because everybody’s voice is different and the vocabulary they use is impossibly broad. How’s a poor computer to figure out the difference between ‘chassis’ and ‘sassy’?

The first fix is to customize the software to a particular voice. This usually involves some training sessions where you repeat the words you see on the screen and the software tunes the voicebox parameters. The good stuff can nail a voice with less than a hundred words, but most of these programs use lots of redundancy to make sure they’ve got it right. Once they’ve got your voicebox parameters, their reliability goes way up.

The second fix is vocabulary limitations. You will not need to use words like ‘cosmonaut’, ‘lava’, or ‘deciduous’ in your system; indeed, it’s possible in many applications to narrow it down to less than a hundred words, but for this application you’d want a few thousand words. Even then, that’s a huge advantage. Limiting the word range makes matters much easier: they had voice recognition systems for inventory twenty years ago. These systems had to know about about twenty words: the numerals and a few syntactical terms. They require little training; the users simply work their way through the warehouse, calling out stock numbers digit by digit and quantities. As I said, this has been in use commercially for twenty years.

A third factor has always been computer resource requirements and size and weight. A computer fast enough and powerful enough to pull this off would be a bit of a pain to lug around. However, now that we have snazzy channel-hopping technology, and we know that doctors don’t have to record their data from the tops of volcanos or the bottoms of gold mines, we can set up a low-range system that works for one building, rather like a WiFi network. The doctors just send audio to the central computer, which has all the huge lookup files on its hard drives and recognizes the words fast and reliably.

When you combine these design constraints, you can get very impressive results. The killer problem has always been background noise. The human ear is very good at singling out one voice in a babble of many, but the speech recognition algorithms still can’t do that. So a doctor would not be able to use the system in a big noisy room. Inasmuch as most medical examinations take place in somewhat private locations, this should not be much of a problem.

Think of the speech recognition system in this manner. Suppose that you could have a stenographer at your footsteps all the time, and every time you want to record something, you simply say, “Take a note: ...” Are you sure that would be clumsier than writing it down?

I suppose that we could come up with something for diehards who refuse to use microphones. We could probably use something like the old Apple Newton, but of course with the passage of time and the huge leaps in technology, we could get much better results. But I think that the speech recognition would work a lot better.

Your point that none of this is politically feasible is absolutely on the mark. This scheme is a fantasy only; the odds of the American body politic ever coming up with ANY reasonable scheme are microscopic. I believe that there are likely thousands of different schemes that would work much better than our current system, none of which are politically viable. I am claiming that my scheme is one of those thousands of workable schemes that are better than current practice but politically impossible. I would not ask you to believe that it is the best scheme; my only claim is that it is *technically and financially* viable and would be better than the current system.

We all know that Mr. Obama will make an inspired effort to repair our health care system, and we all know that he will be seriously handicapped in this effort by all the crazy political forces at work. Let’s just hope that the real-world solution he comes up with (as opposed to my pie-in-the-sky scheme) will somehow get through Congress unmangled.

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