MacDoctor

Two US surgeons have offered some commentary on Why US Healthcare Costs Are Out of Control. It is a highly revealing read. They cite six reasons:

1. The Building of Shrines for Hospital Administrators – buildings constructed out of desire to make a mark rather than out of necessity.
2. Unnecessary Duplication of Services – Often added under the aegis of point one.
3. Absence of Medical Malpractice Tort Reform – as they correctly point out, the real cost is not in insurance expenditure but in excessively defensive medicine. They put the cost of unnecessary investigations, procedures and hospitalisations at up to $200 billion. MacDoctor thinks this is a bit on the low side and probably does not include unneeded follow up visits and unnecessary time expended in obsessive note-taking and quality control initiatives.
4. Need for Hospitals to Be in the Black - Failing hospitals do have a tendency to try to boost their admission rates rather than make their processes more efficient. Most hospitals in the US would improve their bottom lines tremendously if they specialised, rather than tried to offer all services.
5. Decreased Physician Reimbursement Leading to Unnecessary Procedures – I once knew many doctors in South Africa (where the medical insurance rates were kept artificially low) that saw 100-120 patients a day. The vast majority were return visits for colds and flus and similar self-limited diseases. One doctor I knew routinely saw colds every day until their symptoms resolved – rarely less than five visits. Meanwhile back in New Zealand, most A&Ms charge ACC like a wounded bull…
6. Pay-for-Performance Systems – artificial incentives to perform the easiest, most lucrative procedures, leaving the complex work to an ever-decreasing pool of doctors.

Read the whole thing (you may have to register, but it is free). Two observations:

• Mr. Obama’s healthcare package addresses none of these things. In fact, it is obvious that Obamacare will make most of these things (certainly the last four) significantly worse.
• New Zealand has a similar set of problems. We just call them by other names eg.

1. 1. Empire building
   2. Turf protection
   3. Criminalisation of medical malpractice
   4. Need for DHBs to stay within budget
   5. ACC procedures and investigations
   6. Medical Productivity
    

Do any of these sound familiar?

APN News & Media announced today that, in a major cost-saving drive, they will be cutting the number of pages in the New Zealand Herald to five. The newspaper will retain the same number of advertisements but will be publishing smalls only in a special expanded edition of the Herald on Sunday. Obituaries, births and marriage announcements will now be only available online under a new tab, “miscellaneous”.

There will be no full-time journalists but the newspaper will accept any free-lance work from former journalists provided it contains at least one approved word in it’s opening sentence. Approved words are “Sex”, “Gay”, “Hot”, “Global Warming”, “John Key”, and “Pussy”. Names of famous people, politicians and double entendres will be considered.

The Herald will retain it’s entire sub-editing staff of three monkeys and a giraffe who will be employed cutting and pasting parliamentary press releases, Associated Press articles and blog posts. This is not anticipated to require much retraining.

The editor will be replaced next year by a gerbil named Cyril, prior to reducing the number of newspaper pages to three. Quality of editorials is unlikely to diminish.

APN expect to achieve their goal of zero pages by mid 2012, in anticipation of the switch to computer bots assembling the Herald website from small fragments of blog posts, mainly from a housewife in Minnesota.

Just so we understand each other, I consider the entire Charles-Chauvel/Noisy-Kids-in-airplane episode to be slightly less newsworthy than “cat stuck in tree”. My interest in the affair can be accurately gauged by comparing the entire mass of the earth to the full stop at the end of this sentence. The only relevant result is that the media have outed Boomtownprat (Hi, Fred. Nice to meet a fellow blogging medic!) and shown Mr. Chauvel to be a completely clueless politician. The latter fact being already established long ago. I mean, seriously, what politician makes a statement like this:

““It’s a bit frustrating for somebody in my job who spends half their time trying to get the media to take seriously the fact that we might be in electricity crisis next year, which nobody is interested in. And suddenly [the media] getting all worked up about what somebody says on a blog which I don’t think is entirely true.””

What a wonderful idea. Criticise the media and the blogger all in the same sentence. Mr. Chauvel has a political acumen only surpassed by Mr Goff.

Free tip: Next time apologise unreservedly and then pleasantly and good-naturedly deflect all approaches by the media to re-ignite the issue.

The silly, trivial affair was not an entire wash-out. We did, in fact, learn three things:

1. That we should never again to take any notice of main stream media when they complain that bloggers are just “parasites”. This year bloggers have supplied the MSM with this item, “Climategate”, Name suppression and a number of other stories/trivia.
2. That Phil Goff has little control over his caucus. Can you imagine Clark allowing one of her MPs to make so many elementary mistakes?
3. That a 30 minute news bulletin will be a blessing. 60 minutes of this sort of crap is exactly 60 minutes too long.

It looks like the Democrats are going to attempt to shoehorn the Obamacare bill through on the thinnest of margins. Considering the controversial nature of some parts of the bill and the partisan sentiment it has generated, one can only say that this is a foolish and dangerous thing to try and do. Time has run out for Pelosi and Obama and they are now going to try and bully Democrats into voting for a bill that contains segments on abortion that are abhorrent to them.

Obama clearly understands the last-minute nature of the bill as he attempts to place a human face of suffering onto the healthcare scene in the form of cancer sufferer, Natoma Canfield. Canfield wrote to the President worried that her lack of health insurance (which she cancelled due to excessive premiums) would mean that she would lose her house. Fox News has been quick to point out that there is little danger of that happening as Canfield is likely to be entitled to state aid and is eligible for charitable aid from the cancer hospital she attends. Such is the danger of using specific people (as Phil Goff can confirm)

Unfortunately, the underlying problem with Obama’s health care bill is that it will almost certainly drive most doctors to refuse medicaid patients. Already the large drop in medicaid rates has forced many doctors to refuse medicaid. This will only get worse as large numbers of patients eligible for Obama’s plan are patients who would be likely to access more than the average amount of services (people like Natoma Canfield, for instance). This will force medicaid to steadily revise its payments downwards, rather than upwards, leading to a tsunami of doctors refusing these patients. Particularly as these are the sort of patients most likely to sue you.

Picture it. More and more taxpayers dollars being siphoned down the giant healthcare black hole that Obama is creating. Fewer and fewer people actually able to use medicaid to obtain healthcare. Larger and larger co-payments. Fewer and fewer people remaining on private insurances as Obamacare forces up premiums. And Obama will be saving the best for last…

Waiting lists.

Enjoy.

New Zealand is now contemplating using the same set of incentives to boost immunisation rates that Australia used to boost it’s rates from 50% to 91%. The MacDoctor is not convinced that New Zealanders will respond quite as well as Australians to the incentives. The incentives were:

1. Cash payments to parents for completing immunisations at 6 months and four years.
2. Cash bonuses to doctors for improving their immunisation uptake
3. Monitoring immunisation targets and having immunisation days
4. Attempted eradication of measles
5. Schools refusing to take un-immunised children

While this worked well in Australia, one has to consider the composition of parents un-vacccinated children. They come in two types.

1. Parents who are genuinely concerned that vaccination is dangerous
2. Parents who couldn’t be arsed to vaccinate their kids.

I postulate that Australia had a great deal of parents in the second category. Unfortunately, I suspect New Zealand has a far smaller portion of parents in category 2 and a much higher spread of parents in category 1. Parents in category 1 are not going to be moved by any financial incentive (seen as “we’ll give you this small amount of money, if you let us poison your children”). They will not be persuaded by GPs with a vested financial interest, nor by nurses with a gung-ho “vaccinate anything that moves” attitude. Schools refusing to take children will just see these parents move their children to private schools or to a home-schooling environment (where, frankly, they will be unlikely to catch the childhood diseases they are not immunised against!). In short, New Zealand is unlikely to see the massive improvement Australia saw and the increase expenditure will be largely wasted.

Note: I have no hard data to support my conclusion, just my general experience. But it would be very advisable for the MoH to run a survey to determine the mix of parents who decline to immunise their children before copying Australia’s effort.

I also have deep concerns about the ethical nature of banning children from creche, primary and secondary schooling on the basis of their immunisation status. That goes for threatening to cut benefits as well. To me, it seems incredibly stupid to seriously harm children’s education and deepen their poverty levels in order to force people to have their children immunised. The consequence will be that those who opt out for conscientious reasons will suffer these harms, since they sincerely believe their children’s health will be seriously harmed by vaccination. These methods are therefore, in my opinion, completely inappropriate, regardless of the numbers of parents in the first category above.

You wouldn’t approve of a doctor who gave a person (of sound mind) an injection against their will. Why should we approve a government that tries the same thing?

It is unfortunate that the Herald appears to have a bee in it’s bonnet about Brian Tamaki and the Destiny Church. I say unfortunate, because the Herald does not appear to have the tools, understanding or, indeed, the inclination to approach the topic of donations to a church, or to the pecunious “Bishop” in question, with anything like a competent analysis. I have remained silent on the issue of Tamaki simply because it is not really an issue of public debate per se, it is more an internal issue amongst Christians. However, the Herald persists in making observations that make little sense. Take this one from the HoS Insight article on giving (not on line)

“But, plainly, churches are not like other charities.

“If the boss of a secular, non-profit organisation, let’s say, the CEO of a trust for disabled children, used donor cash to buy a mini-mansion and a Harley, supporters would go elsewhere.”

One assumes that the journalist, Heather McCracken, has not yet realised that CEOs have salaries, upon which they can spend whatever they like, including mansions and Harleys, if they are that well-paid. Taking donations directly is, of course, fraud and would warrant immediate police investigation. It is highly unlikely that Brian Tamaki’s income is fraudulent in this sense of the word.

The thing is, his income is not the issue, nor is his wealth. The Bible makes no restriction on your earnings or your assets and that lack of restriction extends to pastors. Wealth is often mentioned in a negative sense, particularly in the New Testament, but always in conjunction with warnings not to let your wealth supplant the place of God in your life. Having wealth is not the problem, it is trusting in wealth. This is not to say that I am quite comfortable with the extent of Tamaki’s wealth, but that is because I am fully aware that his congregation is not wealthy and that Tamaki’s wealth derives mostly from their donations (rather than from Tamaki’s own resources). This tells me that there is something seriously wrong.

The wrongness, however, has absolutely nothing to do with the eftpos machines in Destiny Church, that the Herald is so excited about. The church I worship at has an eftpos machine. It is extremely convenient for making (free-will) donations when you have forgotten to draw money (a frequent occurrence for me). It’s presence is not an issue, because no-one is being co-erced into giving. Eftpos is not the problem – bad doctrine is.

In fairness to the Herald, their articles have touched on both aspects of Destiny/Tamaki doctrine that are poor. Unfortunately, the Herald does not have the background or the interest to explore these, preferring to waffle on about Tamaki’s boat and Harley. But the doctrinal issues are central to understanding the problem.

The first issue is the one of tithing. Many churches, particularly Pacific Island congregations, have a strict adherence to a 10% tithe of all of your income. This is a misunderstanding of the doctrine of tithing. The biblical injunction to give is :

“2Cor. 9:7 Let each one [give] as he has made up his own mind and purposed in his heart, not reluctantly or sorrowfully or under compulsion, for God loves (He takes pleasure in, prizes above other things, and is unwilling to abandon or to do without) a cheerful (joyous, “prompt to do it”) giver [whose heart is in his giving]. [Amplified Bible]”

I have purposefully used the Amplified Bible here because it renders the meaning of the passage very explicit. The decision to give brings God pleasure, but it is our decision. This passage does not make any sense if there is some biblical injunction to give 10% of our income. I do not have space, or inclination, to give a biblical exposition on what the Old Testament tithe means to us today. If you are really interested, you can download Eating Sacred Cows by Graeme Carlé, the pastor of the church I attend. It is by far the best exposition of the biblical tithe I have read (and it is a short and easy read). I also recommend Matthew E Narramore’s Tithing: Low-realm, Obsolete and Defunct which is available on-line here.

The other doctrinal problem is the one that has plagued the “prosperity cults”. The strange idea that, if you give generously, God will make you wealthy. Not bless you, mind you, but make you wealthy. This is simply playing a game of spiritual Lotto. I put money into the offering and. magically, more money appears in my bank account.

This would be great, if it was true, but God does not work like this (if He did, people would become Christians just to get money, obviously). Whereas God does love a cheerful giver and God loves to bless those he loves, His blessings rarely consist of financial rewards. And our motivation for giving is not to receive rewards anyway, at least, not immediate, tangible rewards. This does not mean that God does not reward His children, just that He is not obliged to by our giving.

This sort of non-biblical teaching inevitably leads to vast disappointment and disillusionment amongst the believers. It also tends to lead to pastors who know no financial constraints and start to see the congregation as their very own inexhaustible syphon of money. Their motives may remain pure rather than venal, but the end result is always the same – grandiose dreams destroyed by ugly rifts as disenchantment spreads through the body of the church. The split we have just seen in Brisbane (where Tamaki’s influence is the least) is just the first signs of a great deal of internal disruption. I suspect that the recent “vows of allegiance” that Destiny’s leaders had to take (“voluntarily”, of course) is simply another sign that things at Destiny are starting to fall apart – Tamaki’s “loyal” lieutenants are attempting to consolidate authority.

“And everyone who hears these words of Mine and does not do them will be like a stupid (foolish) man who built his house upon the sand.

“And the rain fell and the floods came and the winds blew and beat against that house, and it fell—and great and complete was the fall of it. Matt. 7:26-27 [Amplified]”

Pink Floyd have won their long-standing lawsuit against EMI, part of which was a complaint that they had an agreement with EMI not to sell incomplete albums. This has been pitched as a triumph for artistic integrity and has lead to some postulate that Pink Floyd may withdraw their songs from iTunes or insist that their albums are sold in their entirety only. Both of these observations are likely to be poppycock.

To argue that this legal victory is a triumph for artistic integrity, is to remain locked in the old model of music dominated by the record labels. That model dictated that artists produced 45-60 minutes of music that the labels could sell as a commodity unit called an LP (later a CD). All LPs/CDs from new acts cost roughly the same, with only a little price-flexibility for the most popular artists – a reason for viewing the recording labels complaints about iTunes uniform pricing strategy with suspicion.

This commoditisation meant that artists were essentially paid the same for 45 minutes of good music as they were for 15 minutes of good music and 30 minutes of garbage. Incentives being what they are, it is not surprising that most musicians supply the latter (in fact 15 minutes is probably overly generous!). The primary reason why CD sales have fallen so far, and continue to fall, is that people are less prepared to pay for garbage in order to get the music they like – and online sales of individual tracks has made it possible to do exactly that. Previously, your only way of buying a single track was the expensive CD single, which has now appeared to have morphed into the EP. Thankfully, Steve Jobs mostly stuck to his guns on pricing, thus killing the CD single.

iTunes and the other online stores have now changed the game drastically. The Record labels and, if the truth be known, most musicians do not appreciate this. It is no longer necessary for bands to produce 45 minutes of music before they can sell it. Musicians who only have a one-hit-wonder in them will no longer be obliged to subject the world to a pile of indifferent music. They may still do so, but at least they now have a choice. It may be that those musicians, once they are no longer under pressure to produce a certain quantity of music, will be able to produce far better pieces, less often.

It is also no longer necessary to use a record label to promote your music. Currently most musicians who become well-known on the internet (typically by distributing their works for free) eventually sign on to record labels, rather than going the next step (which is to use their internet leverage to promote themselves and start charging people). This is not to imply that the labels are not useful for promoting musicians, but why take the retrograde step of going with a record label when you have already done all the hard promotion work?

The other thing that online music also provides is an outlet for hobbyist musicians. There is a wealth of free music available from these musicians (obviously of variable quality) but there is no reason why the better hobby musicians should not place their better works on iTunes themselves. Eventually, their hobby might pay enough to go professional, but in any case the opportunity is now there.

This sort of opportunity should not be lightly dismissed. The opening up of the music industry to hobbyists adds a wealth of talent (and non-talent) to the music world, providing us with the possibility of discovering new talents who would not have otherwise taken the plunge into the financially dangerous world of professional music.

Admittedly, the iTunes model makes it difficult to produce “concept albums”, where each track is meant to be played in a particular order and the whole piece needs to be played together. But there are easy ways around that. Simply making the entire album a single track being the easiest. iTunes automatically makes any track longer than 10 minutes an “album only” track, stopping individual purchase. However, I suspect Pink Floyd do not really care about this issue, using it only as leverage against EMI. They have produced a number of compilation albums and allowed their “concept” music to be used as backgrounds to many, many commercials and documentaries (especially the track “Money”). In fact, I would guess their sentiments might be expressed by this line from that famous song:

“Money, It’s a hit. Don’t give me that do goody good bullshit”

Indeed.

Though many people are highly critical of the columns of Garth George, I often find that, past the general curmudgeonly nature of his columns, he often makes a great deal of sense. Unfortunately, he tends to couch his points in a fashion designed to bring out the worst in the blogosphere. It is not simply his overtly Christian content that irks people, after all people do not react quite so vituperatively to M&M or NZ Conservative. It is more the way he expresses Christian views in a rigid, legalistic, condemnatory fashion that mimics the worst aspects of the Pharisees of the New Testament. For instance, his column today on Garrett’s unwise espousal of voluntary sterilisation incentives has this to say on the subject in hand:

“Apart from the fact that even voluntary sterilisation under such circumstances is a violation of what little is left of the moral and ethical framework of a civilised democracy, what would it achieve?”

I fail to see how offering someone – who is clearly incapable of decent parenting in any shape or form – an incentive to have no more children, can be construed as a violation of ethics. Offering the incentive to someone because they are Maori or Poor or Jewish would be exceedingly dubious, I agree. These things have nothing to do with a person’s ability to bring up a child. But offering the incentive to a child abuser makes a great deal more sense than offering the same person DPB for having another child.

I rather think that Mr George’s extreme reaction to this suggestion is rather more to do with his take on sterilisation in general – viz.

“voluntary sterilisation amounts to self-mutilation and renounces the natural law of self-preservation.”

I can find no biblical basis for this remark at all and I suspect Mr. George’s take on contraception would be equally extreme. He is, of course, entitled to his beliefs on this matter but he cannot use his opinion as a valid argument  for the ethicality and morality of sterilisation. Note, we are talking about voluntary sterilisation here. There is no question that involuntary sterilisation is completely unethical and entirely distasteful.

Sterilisation is a reasonable medical procedure done when a couple have decided not to have more children. The only alternative would be to continue with various forms of contraception which may have side effects and may not be entirely effective. This risks the health of the mother (who has to take the contraception) or risks an unwanted child or, worse, an abortion.  In other words, the alternatives to sterilisation are considerably worse than any consideration for the “natural law of self-preservation” (whatever that may be).

The unfortunate thing about these remarks is they detract from Mr. George’s otherwise very reasonable argument – that voluntary sterilisation will do little or nothing to the statistics of child abuse and amounts to little more than putting a band-aid over a festering, cancerous sore. This is entirely true and an excellent point of which politicians should take note. The tendency of people, especially politicians, to hide from this nasty truth is exactly what encumbers us with myriad unwieldy laws and regulations, while doing nothing for the very real social problems that plague our society.

Daft he may be at times, but Garth George is also right.

Well, there seems to be no doubt what the (supposedly unbiased) Herald’s official position is on the proposed “three strikes” law. The headline

‘Unjust’ bill means 11,000 per cent rise in prison time

is not exactly studiedly neutral. And making out that Kim Workman comes from “an independent organisation on crime” is simply a bad old-fashioned lie. It is rather like saying that Phil Goff comes from an independent organisation on Politics. Of course, the headline and the statement on Kim Workman’s “independent” status as one and the same thing. The 11,000 percent (PS Herald – percent is a single word) is a typical Kim Workman “statistic”. Invariably derived from taking the most far-fetched scenario or most bizarre comparison he can think of to make his point. In this case he is postulating that his third strike criminal will only deserve a two month sentence for his crime instead of “life” – not the most likely scenario. Mr Workman is also full of strange comparisons, quoting a bizarre Californian case (despite it not being applicable to our proposed law) and then postulating that Bruce Emery (he of tagger-murdering fame) may have received a life sentence if he had two previous strike – which he did not. Mr Workman possibly chose Emery because if he had used someone like Graeme Burton as an example, he would have disproved his point (that the three strikes law is unjust) immediately.

Which is a pity because, in this case, I am inclined to agree with Workman. The Californian version of this law does not work well because of two obvious defects. The first is that the list of offenses causing a strike is too long and contains many minor offenses. The second is that there is no way of differentiating a less severe offense from a more severe offense, making those minor offenses damning. Sadly the New Zealand version of the law contains the same two flaws.

For some reason known only to the Law and Order Committee, they have chosen to remove the clause limiting strikes to offenses with a sentence greater than 5 years or an indefinite (i.e. life) sentence. This means that they now have no way of differentiating between severe offenses worthy of a strike and fairly trivial offenses. For instance, “indecent assault” is a strike offense. So if you are a bottom-pinching chauvinist, you may well find yourself imprisoned for life after you have annoyed your third victim. Of course, you would have to be grossly stupid to gain three strikes in this fashion, but the point is that the law is not intended to have this effect, it is intended to take violent criminals out of circulation.

Perhaps a less frivolous example is that someone can have two strikes for robbery and then get into a bar fight and find themselves in jail for life.

Clearly, there needs to be some rider that differentiates these more minor crimes from others. The five year sentence rules did exactly that, which makes it a complete mystery why the rule has been reversed. While there may be some debate around the exactly length of sentence that would spark a strike, there should be no debate about the actual rule itself. In addition, some of the non-violent offenses should be removed, as the entire thrust of this law is to remove violent offenders, not simply crims.

The three strike law could be made to work well, but there seems to be a great deal of undercover politicking going on that is threatening to produce a bizarre and unworkable law that will produce the same crazy injustices of the californian law. This will serve no-one well and it is time that the Law and Order Committee got its act together (in both senses) and produced a more sensible document.

Steven Joyce has said today that some tertiary education funding would be linked to student performance and drop-out rates. This is an excellent idea and should provide some incentive for universities and colleges to pay attention to those students who are clearly not doing well, instead of simply writing them off as they usually do. I have known numerous teenagers who have attended the first year of university only to be overwhelmed by the volume of work and the need to be self motivated. Little or no help came their way and they failed hopelessly. My brother was one of these unfortunates (who then went on to educate himself through technical college correspondence courses and is now a highly regarded planning engineer). Anything that might induce lecturers to climb down from their ivory towers and actually do some educating would be definitely in order.

Of course, one might more or less guarantee that Labour would take a contrary position (and pretty much guaranteed that NZPA would lead with it):

“Hitting tertiary education providers with funding penalties for high student drop out and fail rates would put teachers under pressure to give passes even when they were not deserved, Labour tertiary education spokeswoman Maryan Street says.”

Nonsense. Excessive pass rates are statistically quite easy to spot (there is a great chapter on it in the original Freakonomics book) and universities watch out for it all the time anyway. There is nothing more deadly to a university’s reputation than lowering standards. And Ms Street’s suggestion that universities will offer less challenging courses is laughable. She appears to have forgotten that it was Labour’s willingness to fund every course in creation, no matter how bizarre, that lead to the profusion of daft courses being offered by the technical colleges. But even in the midst of that the universities stayed well away from such things.

Standards are everything to a university and even the tech colleges usually maintain reasonable ones. But it is crazy to have students chalking up large student debts while not attaining any sort of qualification that would help them pay that debt off.