Our dysfunctional health care system, part infinity

Really interesting story in the Times about how doctors are using new methods to try and get around typical insurance reimbursement and end up screwing patients and insurance companies and all of us (that is, when we allow somebody to actually get away with charging $117,000 to assist in a surgery yet their efforts are worth somewhere between 0 and $5000, we all pay in the form of higher medical costs.  It’s hard to summarize, but here’s the intro:

Before his three-hour neck surgery for herniated disks in December, Peter Drier, 37, signed a pile of consent forms. A bank technology manager who had researched his insurance coverage, Mr. Drier was prepared when the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan, $4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he knew would accept a fraction of that fee.

He was blindsided, though, by a bill of about $117,000 from an “assistant surgeon,” a Queens-based neurosurgeon whom Mr. Drier did not recall meeting.

“I thought I understood the risks,” Mr. Drier, who lives in New York City, said later. “But this was just so wrong — I had no choice and no negotiating power.”

In operating rooms and on hospital wards across the country, physicians and other health providers typically help one another in patient care. But in an increasingly common practice that some medical experts call drive-by doctoring, assistants, consultants and other hospital employees are charging patients or their insurers hefty fees. They may be called in when the need for them is questionable. And patients usually do not realize they have been involved or are charging until the bill arrives.

The practice increases revenue for physicians and other health care workers at a time when insurers are cutting down reimbursement for many services. The surprise charges can be especially significant because, as in Mr. Drier’s case, they may involve out-of-network providers who bill 20 to 40 times the usual local rates and often collect the full amount, or a substantial portion. [emphasis mine]

Yes, you read that right, 20-40 times the usual rate.

I think most doctors truly are good people who are in the profession because they want to help others.  But, boy, some are really after the money and the evidence is pretty clear in the article.  To wit:

The United States has more neurosurgeons per capita than almost any other developed country, and they compete with orthopedists for spinal surgery. At the same time, Medicare and private insurers have reduced payments to surgeons. The average base salary for neurosurgeons decreased to $590,000 in 2014 from $630,000 in 2010, according to Merritt Hawkins, a physician staffing firm.

To counter that trend, some spinal surgeons have turned to consultants — including a Long Island company called Business Dynamics RCM and a subsidiary, the Business of Spine — that offer advice on how to increase revenue through “innovative” coding, claim generation and collection services.

Some strategies used by surgeons, including billing large amounts for a second surgeon in the room or declaring an operation an emergency, raise serious questions. The indications for immediate spinal surgery, such as loss of bladder function or rapidly progressive paralysis, are rare. But insurers are more likely to reimburse a hospital or surgeon with whom they do not have a contract if a case is labeled an emergency.

Just so wrong.  I don’t often read the comments on articles, but this one was filled with all sorts of similar horror stories to the ones within the article.  Good on the state of NY for trying to address this problem.  But it is unfortunate that it has gotten so bad and most other states are lagging.  One thing I would have really liked was more international comparison.  I strongly suspect that countries with true national health care systems don’t have this problem.

Mega quick hits (part II)

1) The case for delayed adulthood.  Given what we now know about brain maturation, there’s something to be said for this.

2) Joe Nocera on the absurdity of how cavalier credit card companies and retailers are with our data.  And a great example of why we often need government to get involved:

For years, the banks and the retail industry have spent more time accusing each other of causing the problem than seeking a solution. By October 2015, the United States is supposed to move to a more secure card system, using a chip and P.I.N. instead of a magnetic stripe, as Europe did years ago. But even that won’t put an end to data breaches. It will make it harder and more expensive for criminals to crack, but not impossible.

Which is why the federal government needs to get involved. With the banks and retailers at loggerheads, only the government has the ability to force a solution — or at least make it painful enough for companies with lax security to improve.

3) People without kids fare better on all sorts of measures, except one.

4) Arizona voters passed a referendum to take the politics out of redistricting.  Sadly, the Arizona Republican Party is suing to put politics back in.

5) Fun facts about the original Star Trek.

6) Nice essay from a science-oriented mom of a child with autism on the vaccine-autism non-link.

7) Didn’t know anything about Arkansas Republican Senate candidate Tom Cotton before reading this profile.  Found it utterly fascinating.  And scary.

8) Cool experiment showing your brain actually making decisions while you sleep.

9) There’s not really any good reason at all for conservatives to oppose federal loans for students at community colleges.  Of course, they oppose this anyway.

10) We need to publish more replication research and studies with null results.

11) Thanks to Derek for sharing this thought-provoking piece on visiting a cattle feedlot written by a vegan nutritionist:

And, I have to say it.  If my experience at Magnum is representative of other cattle farms, all those accounts of the dismal, depressing, disastrous cattle conditions seem to be exaggerated.

No, I’m not going to start eating meat again.

However, if I did eat meat, my visit to Magnum would have made me feel great about eating non-organic, non-grass-fed beef.   Seriously.  I can’t imagine the quality of meat would be substantially better with organic and grass-fed.  Nor can I imagine the living conditions would be substantially better for the cattle.

12) Perhaps the best piece I’ve read on the current Ebola crisis.   And Vox points out that pretty much no disease ever has gone from body-fluid transmission to airborne so there’s really no reason to think Ebola will.

13) Enjoyed this Wonkblog piece on how restaurants are cutting back the size of their menus, but it didn’t quite have me convinced on the reasons why.  Drum, convinved me, though:

Hmmm. Let me say, based on precisely no evidence, that I find this unlikely. Have American tastes really gotten more refined since 2008? Color me skeptical. And even if American palates are more discriminating, are we seriously suggesting that this has affected the menu length at IHOP, Tony Roma’s, and Olive Garden—the three examples cited in the article? I hope this isn’t just my inner elitist showing, but I don’t normally associate those fine establishments with a “growing appetite for exotic foods and a willingness to seek out specialized cuisines.”

So, anyway, put me down firmly in the cost-cutting camp. Long menus got too expensive to support, and when the Great Recession hit, casual dining chains needed to cut costs. They did this by lopping off dishes that were either expensive to prep or not very popular or both. Occam’s Razor, my friends, Occam’s Razor.

Yeah, Occam’s Razor!  Which, I actually explaned to my 8-year old yesterday.

14) There’s been a bit of a “nerdwar” of late with election prediction.  Wonderful rejoinder to the whole thing from Hans Noel:

So we can’t learn very much about the models from Election Day. We learn a little, but only as much as we learn from any one election, which is not much. But I guarantee you someone will claim otherwise. Which is why I’m not interested in predicting the future. It leads people to say the least interesting things.

15) A number of high profile reports this week on the fact that Chimpanzees regularly murder their own species.  This is not news!  I remember learning about this in college 20+ years ago.  Yes, there has been some scientific debate about the issue, but based on the headlines I’ve seen this week you would think scientists had somehow just discovered this behavior.

16) The latest college arms race?  Who can build a better water park for their students.  Seriously.  The winner?  Texas Tech.  This place makes me wish I was still there!

17) So, this is really cool.  One of my good friends from middle and high school was permanently disabled (paraplegic) in a car accident when we were 16.  His wife is a writer and just had her essay about their life together in the NYT (the main point is that she’s the more disabled one–oh, and she really likes writing about sex).

More on artificial sweeteners, the microbiome, and diabetes

Some very interesting pushback on the research I recently discussed:

The scientific community is already starting to pick over the results of this study, and dampen public reaction by putting it into perspective. First, the majority of this work was done in mice, who have a different glucose metabolism, diet, and tolerance than humans. The small study with 7 human subjects is very preliminary, and far from sufficient to conclude that the mice data will be applicable to people.

The Science Magazine article points out that the study was published in a basic science journal, and that a clinical science journal would probably have been much more critical of their clinical speculations.

Another potentially serious criticism is that the researchers combined saccharin, sucralose, and aspartame data. It seems highly unlikely that three very different molecules would all have the same effect on gut microbiota. It’s possible that what the researchers are seeing is isolated to saccharin alone, which the research focused on. Earlier trials used aspartame, which had a smaller effect so the researchers switched to saccharin.

And here’s really the key bit from my perspective:

If this effect is unique to saccharin, that would also explain the disconnect with other data focusing on the consumption of diet soft drinks, which use aspartame and sucralose. A large European epidemiological trialpublished last year and involving cohorts with >10,000 subjects found an association between drinking sugary drinks and Type II diabetes. It also found an association with drinking NAS containing drinks, but this association vanished when controlled for energy intake and BMI. In other words, people drink diet soda because they are overweight, not the other way around. [emphasis mine]

Alright, I think I’m back to drinking diet soda guilt free.  I think I might pay some attention to saccharin, though.  Of course, those of us to remember Tab and Diet Rite recall that sodas sweetened with saccharin alone are mouth-puckeringly bad.

Mega Quick hits (part I)

Lots and lots this week.  Two big parts coming at you.

1) Really liked this from Kristof on the way to beat poverty.  Low-hanging policy fruit that it’s just crazy we’re not investing in:

The visits [to poor families from home nurses] have been studied extensively through randomized controlled trials — the gold standard of evidence — and are stunningly effective. Children randomly assigned to nurse visits suffer 79 percent fewer cases of state-verified abuse or neglect than similar children randomly assigned to other programs. Even though the program ends at age 2, the children at age 15 have fewer than half as many arrests on average. At the 15-year follow-up, the mothers themselves have one-third fewer subsequent births and have spent 30 fewer months on welfare than the controls. A RAND Corporation study found that each dollar invested in nurse visits to low-income unmarried mothers produced $5.70 in benefits.

This also featured prominently in the terrific How Children Succeed.  Which you really, really should read.  Yes, you.

2) Fall color map of North Carolina foliage.

3) Stop taking vertical photos, says this post.  Actually, now that I pay attention to composition I always think about whether to compose horizontally or vertically and many a photo should be vertical.  That said, people really need to stop with the vertical videos.  So obvious with all the bucket challenge videos.

4) It’s not easy accusing someone of sexual assault in Florida.

5) We should be like Germany.  At least when it comes to renewable energy.

6) Nice set of tips to help kids learn.  

7) The power of random noise in biology and why identical twins are not identical.

8) How a species of porpoise is going extinct before our eyes.

9) Once many addicts kick their drug of choice, they end up addicted to sugar.  Mmmm, donuts.

10) I really liked this Kevin Drum post on how images rule our world.  If you have any doubt, just think of how the news would be different the past couple weeks without A) the Isis beheading videos; and B) the Ray Rice video.

11) The political tables have turned and now Democrats are the ones using “cultural issues” i.e., gay marriage and birth control, as a political weapon.

12) Stupid people are quite convinced of their own intelligence.  Than again, so am I.  Uh oh.

13) If you’ve heard of the Food Babe, you know she’s an ascientific idiot.

14) Medieval style longsword fighting is making a comeback. So much cooler than fencing. I love how the subjects of this video have bruises on their faces.

15) About that politics of smell piece, here’s a really nice takedown from Andrew Gelman.  Also love this short critique from Seth Masket from when he shared my earlier post on FB:

Would it be nuts to say that spouses tend to come from similar communities, racial groups, socio-economic levels, etc., and that those groups tend to have not only ideological similarities but also dietary similarities, and that diet can influence body odor?

16) Sit less; live longer.  (It’s the telomeres, JD!)

17) Thomas Frank (of Wht’s the Matter with Kansas fame) wrote a horrible column attacking political scientists.  Great takedown from Chait.  And an even better one from Ezra.

18) David Brooks says friendships are good.  Uhhh, yeah.  Seriously, though, the decline of adult friendships is a problem.  I wish I had more good ones.

More soda; more walking

Let’s go with two days, two posts on soda (perhaps I need to re-name the sub-title of the blog)!  Anyway, maybe artificial sweeteners are harming your microbiome, but on the other hand, the high fructose corn syrup in regular soda is directly giving you diabetes.  From NYT:

High-fructose corn syrup is used to sweeten many processed foods and nearly all soft drinks.

The problem with the sweetener is that, unlike sucrose, the formal name for common table sugar, fructose is metabolized primarily in the liver. There, much of the fructose is transformed into fatty acids, some of which remain in the liver, marbling that organ and contributing to nonalcoholic fatty liver disease.

The rest of the fatty acids migrate into the bloodstream, causing metabolic havoc. Past animal and human studies have linked the intake of even moderate amounts of fructose with dangerous gyrations in blood sugar levels, escalating insulin resistance, Type 2 diabetes, added fat around the middle, obesity, poor cholesterol profiles and other metabolic disruptions.

Uh-oh.  But good news… turns out you can pretty much undo all the damage just by walking more:

But Amy Bidwell, then a researcher at Syracuse University, noticed that few of these studies had examined interactions between physical activity and fructose. That was a critical omission, she thought, because movement and exercise change how the body utilizes fuels, including fructose…

The second study, published this month in The European Journal of Clinical Nutrition, focused on blood-sugar responses to fructose and activity, and found equally striking changes among the young people when they didn’t move much. Two weeks of extra fructose left them with clear signs of incipient insulin resistance, which is typically the first step toward Type 2 diabetes.

But in both studies, walking at least 12,000 steps a day effectively wiped out all of the disagreeable changes wrought by the extra fructose. [emphasis mine] When the young people moved more, their cholesterol and blood sugar levels remained normal, even though they were consuming plenty of fructose every day.

Cool!  Around Christmas time I got myself a Fitbit Flex, which counts my daily steps among other things.  On days I jog (3-4 times/week), I generally hit 15,000 or so.  Though on day’s I don’t, I am usually short of 12,000.  Actually, what I’ve found is how little I actually move on weekends (hello, TV sports).  Good thing I’m sticking with aspartame then instead of HFCS :-).

Is Nutrasweet ruining my microbiome?

I suspect not (though still waiting on the American Gut project to send me the results of my very own intestinal microbiome), but some very interesting new evidence brings together research on two of my favorite topics– the human microbiome and artificial sweeteners.  I was not entirely sold by the WP write-up of the research, but this NYT story really gets into the details of the methodology and there’s surely something going on here:

In the initial set of experiments, the scientists added saccharin (the sweetener in the pink packets of Sweet’N Low), sucralose (the yellow packets of Splenda) or aspartame (the blue packets of Equal) to the drinking water of 10-week-old mice. Other mice drank plain water or water supplemented with glucose or with ordinary table sugar. After a week, there was little change in the mice who drank water or sugar water, but the group getting artificial sweeteners developed marked intolerance to glucose.

Glucose intolerance, in which the body is less able to cope with large amounts of sugar, can lead to more serious illnesses like metabolic syndrome and Type 2 diabetes.

When the researchers treated the mice with antibiotics, killing much of the bacteria in the digestive system, the glucose intolerance went away…

To further test their hypothesis that the change in glucose metabolism was caused by a change in bacteria, they performed another series of experiments, this time focusing just on saccharin. They took intestinal bacteria from mice who had drank saccharin-laced water and injected them in mice that had never been exposed any saccharin. Those mice developed the same glucose intolerance. And DNA sequencing showed that saccharin had markedly changed the variety of bacteria in the guts of the mice that consumed it.

Honestly, that’s pretty compelling stuff.  And as much as my motivated reasoning wants to knock it all down, it is clear that there is something going on.  One of the researchers changed his own habits:

While acknowledging that it is too early for broad or definitive conclusions, Dr. Elinav said he had already changed his own behavior.

“I’ve consumed very large amounts of coffee, and extensively used sweeteners, thinking like many other people that they are at least not harmful to me and perhaps even beneficial,” he said. “Given the surprising results that we got in our study, I made a personal preference to stop using them.

As for me, I’m definitely going to keep following this research, but I’m not yet ready to give up my diet sodas.  This is a laboratory experiment with mice. The factors influencing the human microbiome awash in artificial sweeteners, and sugar, and the myriad other features of life, food and otherwise, that surely affect our microbiome have got to be quite complex.  My naive hypothesis would be that for some humans with some lifestyles artificial sweeteners are a bad thing.  Perhaps even worse than excess sugar.  For now, though, I’m willing to gamble that, at least for me personally, between lots of fruits and vegetables, whole grains, and plenty of exercise, (and probiotics via yogurt and Culturelle), that my microbiome is still looking pretty good.

Now, as for society, I think the evidence is pretty compelling that you should avoid sweetened drinks if at all possible.  That said, if you are drinking soda (surely the main source of artificial sweeteners) the jury is still very much out on whether regular or diet is likely to cause you more harm.

Needed: rational opposition to GMO food

Really interesting New Yorker article from Michael Specter looking at GMO food via a profile of it’s leading international opponent, Vandana Shiva.  It seems that Shiva has gained a huge following by spouting tidbits such as:

Earlier this year, she said, “Farmers are dying because Monsanto is making profits—by owning life that it never created but it pretends to create. That is why we need to reclaim the seed. That is why we need to get rid of the G.M.O.s. That is why we need to stop the patenting of life.”…

Shiva has repeatedly said that the company [Monsanto] should be tried for “ecocide and genocide.”…

In a recent speech, Shiva explained why she rejects studies suggesting that genetically engineered products like Pental’s mustard oil are safe. Monsanto, she said, had simply paid for false stories, and “now they control the entire scientific literature of the world.” Nature, Science, and Scientific American, three widely admired publications, “have just become extensions of their propaganda. There is no independent science left in the world.”

But here’s the real killer.  Despite being trained as a scientist, Shiva shows utter disdain for basic concepts such as correlation does not equal causation:

Shiva began a speech to a local food-rights group by revealing alarming new information about the impact of agricultural biotechnology on human health. “The Centers for Disease Control and Prevention has said that in two years the figure of autism has jumped from one in eighty-eight to one in sixty-eight,” she said, referring to an article in USA Today. “Then they go on to say obviously this is a trend showing that something’s wrong, and that whether something in the environment could be causing the uptick remains the million-dollar question.

“That question’s been answered,” Shiva continued. She mentioned glyphosate, the Monsanto herbicide that is commonly used with modified crops. “If you look at the graph of the growth of G.M.O.s, the growth of application of glyphosate and autism, it’s literally a one-to-one correspondence. And you could make that graph for kidney failure, you could make that graph for diabetes, you could make that graph even for Alzheimer’s.”

Specter brings all-too-easy smackdown:

Shiva had committed a common, but dangerous, fallacy: confusing a correlation with causation. (It turns out, for example, that the growth in sales of organic produce in the past decade matches the rise of autism, almost exactly. For that matter, so does the rise in sales of high-definition televisions, as well as the number of Americans who commute to work every day by bicycle.)

There are genuine issues we should be concerned about with GMO’s, primarily with potential effects on the environment (and conventional crops, too, of course, but there are some unique issues), various unintended consequences, etc.  To make sure we take these concerns seriously, though, we need people who have legitimate concerns regarding GMO food, not people who rely on a bunch of pseudo-science, appeals to romanticized views of nature, and out-and-out lies/misinformation about GMO food.  Furthermore, it makes it hard to take any GMO opposition seriously when all too much of it comes from people who absolutely reject a scientific viewpoint in their arguments (“playing God” “Monsanto is evil,” etc.).

I found this summary of Specter’s article and a Shiva response in the foodpolitics blog interesting, but off-base:

They raise and debate the same arguments I discussed in Safe Food: The Politics of Food Safety, first published in 2003 and out in a second edition in 2010. As I explain in the book, the gist of the arguments comes from two apparently irreconcilable views of GMO foods:

  1. The “science-based” position: If GMOs are safe (which they demonstrably are), there can be no rational reason to oppose them.
  2. The “societal value-based” position: Even if GMOs are safe (and this is debatable), there are still plenty of other reasons to oppose them.

Specter holds the first position.  Shiva and Hirshberg hold the second. Those who hold the “science-based” position would do well to take societal values more seriously.

Alas, this is not like some science versus religion debate for the beginnings of life which is simply not reconcilable.  The problem is not that we have science-based and societal values in opposition.  I support both positions to a degree– that is I think we should legitimately consider the broader social implications.  But we should do that while relying on accurate science.  The problem is that so many of the societal values based opponents to GMO food are full of knee-jerk anti-science and ignorance.  I’m happy to have a wide-ranging debate about GMO’s with persons who accept the basic scientific conclusions.  I am definitely not willing to do so with those who willfully ignore (or obfuscate) the science.

[Also, a nice blog post from Specter on the anti-scientific frivolousness of GMO labeling]


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