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Chinese Research: Not Quite the Juggernaut?

A perennial topic around here has been the state of scientific research in China (and other up-and-coming nations). There’s no doubt that the number of scientific publications from China has been increasing (be sure to read the comments to that post; there’s more to it than I made of it). But many of these papers, on closer inspection, are junk, and are published in junk journals of no impact whatsoever. Mind you, that’s not an exclusively Chinese problem – Sturgeon’s Law is hard to get away from, and there’s a lot of mediocre (and worse than mediocre) stuff coming out of every country’s scientific enterprise.

But what about patents? The last couple of years have seen many people predicting that China would soon be leading the world in patent applications as well, which can be the occasion for pride or hand-wringing, depending on your own orientation. But there’s a third response: derision. And that’s what Anil Gupta and Haiyan Wang provide in the Wall Street Journal. They think that most of these filings are junk:

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Deficit And Debt Politics: A Wake-Up Call For The Health Care Industry?

The 2010 Affordable Care Act (ACA) called for significant Medicare savings.  All told, the Congressional Budget Office projected that the law would trim over $400 billion from Medicare spending during 2010-2019, reducing the program’s annual growth rate from 6.8 percent to 5.5 percent.

Those savings were enabled, at least in the case of hospitals, by the promise of expanding insurance coverage that would bring in more insured patients (and thus more revenues to help offset the Medicare cuts).  Yet some observers in the health industry no doubt assumed that the ACA’s payment reductions could be reversed over time.   After all, they had seen Congress repeatedly cancel scheduled payment cuts to Medicare physicians in the annual melodrama surrounding the Sustainable Growth Rate.

Why couldn’t the health care industry similarly expect to evade the ACA’s cost controls?  In coming years, the industry could argue that any payment cuts would jeopardize patients’ access to care.  And given that Medicare’s own actuary cast doubt on how realistic the projected savings were, the odds must have seemed good to hospitals and other providers that they could sooner or later count on SGR-like relief from Washington.  Health reform offered an appealing political and business strategy:  initially accept the projected cuts in the ACA, then gain more paying customers through the implementation of insurance expansion, and, finally, work to reverse the cuts and “unbend” the cost curve.

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Why IPAB Is Essential — A Timely Review

A little over two weeks ago, while most of you were paying attention to the debate about how to raise the debt ceiling, those of us who study health care policy were following hearings before the House Budget Committee. The purpose of the hearings was to scrutinize the Independent Payment Advisory Board, a commission that the Affordable Care Act created as part of its apparatus to control health care costs. And the hearings produced some genuinely interesting testimony on everything from the scope of the board’s authority to the limits of its legal power. If we were in the middle of a dialogue about how to improve the board’s structure and function, that testimony would be extremely useful.

But we’re not having a discussion about whether to reform the IPAB. We’re having a discussion about whether to repeal it. Opponents of the Affordable Care Act see the IPAB as an instrument of, and metaphor for, everything that is wrong with the new health care law. The problem with this law, they keep saying, is that it tries to solve the health care cost problem through “central planning.” At best, they say, this strategy will misallocate resources in ways that stifle innovation and make access to care more difficult. And at worst? It will ration care in ways that deny life-saving treatment to people who need it. As one Republican lawmaker put it recently, “It will destroy the very core of what has made our medical system the best in the world.”

Yes, these arguments should sound familiar. They are the same ones critics began making in the summer of 2009, when enactment of the law first seemed imminent. And since neither the argument nor the people making it are going away, maybe it’s a good time to take a step back and remind everybody what the IPAB is; how it will work; and why it (or something very much like it) is essential to making health care accessible to all seniors and, eventually, all Americans.

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Can the Blind Lead the Seeing?

Many of you know that eight months ago I was diagnosed with Stage IV inflammatory breast cancer, which has spread to my spine.  My incurable diagnosis means that I live with a chronic disease, just like millions of older adults. Life continues to be fairly routine with work, play, friends, and family.  One of my routines occurs on the first Monday of each month, when I visit the Maimonides Cancer Center for an infusion of drugs designed to slow the cancer’s impact on my bones.  The center is cheerful.  The staff greets me by name and hands me a buzzer that vibrates when I am next, the same buzzer you get at your local Olive Garden.  Each month I see many of the same people receiving their treatments.  I have already figured out who likes Dr. Phil, the local news channel, or a good book as they dutifully absorb their chemotherapy regimen.

One woman in particular caught my eye, perhaps because she is elderly and frail—just the kind of person that the Hartford Foundation is dedicated to helping. She appears to be in her eighties. Standing less than five feet tall, she walks in slowly and carefully, a pink crocheted cap on her head, accompanied each time by her son. Over the course of her infusion, her color fades. She leaves more frail than she came in. Each visit, she is visibly worse.

Of course I know that chemotherapy almost always causes short-term debilitation. But looking at this older woman, I can’t help but wonder. Did her clinicians talk to her and her son about her prognosis and the relative benefit of the chemotherapy? Did they understand the risks and benefits of aggressive versus palliative treatment? Maybe they do understand, and the chemotherapy will cure the cancer after months of misery, making it all worthwhile. But maybe not.

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Can Everyone Become a Billionaire?

I’m going to tell you something that Barack Obama doesn’t understand.

And because he doesn’t understand it, our country is wasting hundreds of millions of dollars at a time when we cannot afford to waste hundreds of millions of dollars.

Time and again President Obama has told us how he intends to solve our health care problems: spend money on pilot programs and other experiments; find out what works and then go copy it. He’s also repeatedly said the same thing about education. The only difference: in education we’ve already been following this approach with no success for 25 years.

Still, if the president were right about health and education, why wouldn’t the same idea apply to every other field? Why couldn’t we study the best way to make a computer, or invest in the stock market and do any number of other things — and then copy it?

I want to propose a principle that covers all of this: entrepreneurship cannot be replicated. Put differently, there is no such thing as a cookbook entrepreneur.

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Making Doctors More Human

Recently at lunch I sat with a general surgeon who I have known for many years. Like many of our peers, he is hard working and puts in many more than 40 hours of work each week. Before I decided to “slow down” a few years ago, my typical workweek was 60-80 hours.  Dr. N, the surgeon, was lamenting about how things had changed and how new physicians did not share our same work ethic. He should know––his son is in training now to become a surgeon too.

“They don’t want to work as hard as we did,” he said. They realize they will make less money, but they want more time off for themselves and their family.”

“How can they do that and still practice good medicine?” I asked.

His response was simple and obvious––“Shift work.”

In the years since the two of us completed our training, the medical establishment has finally realized that putting in such grueling and long hours is not good for either the patient or the doctor.  As an intern in the emergency room, I recall doing a two-month rotation of “24 on/24 off, meaning working non-stop for 24 hours, and then off for 24 hours. This pace was purportedly to prepare us for the rigors of private practice. It also weeded out those docs who would later enter a specialty with more humane hours like dermatology or pathology.

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Bending the Curve with EHRs

The post you are about to read may not be suitable for wonks. Its claims are not fact checked. Its author is not a researcher. And its opinions are not fully thought through. Reader discretion is advised.*

EHR adoption rates are picking up significantly, exceeding the most optimistic expectations. Instead of an EHR for every American by 2014, as the President commanded, we will have dozens of EHRs for each American long before that. And in health care, more is always better, not to mention the freedom of choice that comes with having a different EHR in each care setting. Not surprisingly, we are seeing a decrease in health care expenditures taking place in parallel with the uptick in EHR adoption. Following best practices in health care economics research, when two phenomena develop in parallel, the learned assumption is that there is a causality connection between the two. Deciding which phenomenon is the cause and which is the effect is discretionary and commonly based on undisclosed agendas.

It is therefore postulated here that health care expenditures are inversely proportional to EHR usage rates. The following is a rigorous analysis of the mechanisms by which EHRs are reducing health care costs, intended to inform policy makers as customary in most health care related studies, which cannot be completed, or published, without a salient recommendation of interest to policy makers.

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From Gray to Red

With their vote this week to impose strict limits on future federal spending, House Republicans continued an argument not so much with Democrats as with demography. The real current they are seeking to reverse is not some ideological drive from President Obama to convert America into Sweden; it’s the inexorably rising cost of providing retirement security, especially health care, to an aging society.

The cut, cap, and balance bill that Republicans muscled through the House would authorize an increase in the federal debt ceiling only after Congress approved a constitutional amendment to balance the federal budget. The bill doesn’t specify the spending level at which Washington must balance the budget, but each of the major balanced-budget proposals that House Republicans have already introduced would eventually limit federal spending to an amount equal to 18 percent of the nation’s total economic output.

Federal spending hasn’t represented that small a share of the economy since 1966, when it stood at 17.8 percent. That’s an especially revealing comparison because 1966 was the year when Medicare went into effect—the first guarantee of health coverage for the nation’s seniors. The program didn’t even begin until July 1; Washington spent only about $100 million on it that first fiscal year. Medicaid, which provides care for both the poor and the elderly, was also just getting started; it cost the federal government only about $800 million in fiscal 1966.

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Is FDA Getting Ready to Stifle Innovation in Diagnostic Software?

FDA is proposing regulation for mobile medical applications. Not a bad idea. But I have some concerns about what it will mean for clinical diagnostics software. Here’s the definitional passage:

Mobile apps that allow the user to input patient-specific information and – using formulae or processing algorithms – output a patient-specific result, diagnosis, or treatment recommendation to be used in clinical practice or to assist in making clinical decisions. Examples include mobile apps that provide a questionnaire for collecting patient-specific lab results and compute the prognosis of a particular condition or disease, perform calculations that result in an index or score, calculate dosage for a specific medication or radiation treatment, or provide recommendations that aid a clinician in making a diagnosis or selecting a specific treatment for a patient.

Apps that provide differential diagnosis tools for a clinician to systematically compare and contrast clinical findings (symptoms/ results, etc.) to arrive at possible diagnosis for a patient.

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Don’t Forget Medicaid

As we wait for the white smoke to emerge from the “grand bargain” negotiations at the White House, most Americans are already aware of the Republicans’ plan to dismantle and privatize Medicare and Social Security. But what many people may not realize is just how dangerous it would be to slash funding for a program that 60 million Americans rely on for their basic health care needs: Medicaid.

While it seems that just about every major industry or interest group has teams of lobbyists in Washington looking out for them, some of our most vulnerable citizens simply don’t have a voice in a town where unfortunately, money still talks the loudest.

Why? Medicaid covers only the impoverished and disabled, so it lacks a traditional advocacy base. This may be news to Republicans — but most poor people I know are spending all their time trying to find a job and put food on the table. Lobbying Congress just isn’t on these folks’ to-do list right now. Unfortunately, this means that my colleagues aren’t going to spend a lot of time over the next 30 days sticking up for the 60 million Americans who rely on Medicaid to pay their medical bills. That’s unfortunate, because if the Republicans are successful in turning the program into a block grant program that greatly diminishes funding to states, three awful things are going to happen — people are going to die, more jobs are going to be lost, and health care costs and taxes will actually increase.

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