Relevant and even prescient commentary on news, politics and the economy.

A futile quest

A futile quest, Why “performance” measurement is not working, Minnesota Physician The Independent Medical Business Journal, Kip Sullivan, April 2020

Intro: “Pay for Performance” is not a new catch phrase in the healthcare community, but it is one that has seen a recent spike in interest from the general public and healthcare world alike. The renewed interest is due to the Affordable Care Act (ACA) and initiatives within the Act that require hospitals and providers who participate in Medicare to engage in pay for reporting activities that will transition to pay for performance over the course of the next 3-4 years. Kip Sullivan writes on the pay for performance. Kip has also been a proponent of Single Payer and has written many articles of which some have been on AB.

 

Over the last three decades, Minnesota’s health care policymakers have gotten into a bad habit: They recommend policies without asking whether there is sufficient evidence to implement the policy, and without spelling out how the policy is supposed to work. Measurement and “pay for performance” (P4P) schemes illustrate the problem. Multiple Minnesota commissions, legislators, agencies, and groups have endorsed the notion that it’s possible to measure the cost and quality of doctors, clinics, and hospitals accurately enough to produce results useful to regulators, patients, providers, and insurers.

But these policymakers did so with no explanation of how system-wide measurement was supposed to be done accurately, and without any reference to research demonstrating that accurate system-wide measurement is financially or technically feasible. The Minnesota Health Care Access Commission (in 1991) and the Minnesota Health Care Commission (in 1993) were the first of several commissions to exhibit this “shoot-first, aim-later” mentality. Both commissions recommended the establishment of massive data collection and reporting systems, and both articulated breathtaking expectations of the “report cards” these systems would produce. According to the latter commission, for example, the data collection and number crunching would facilitate “feedback of data that reflects the entire scope of the health care process, from the inputs or structural characteristics of health care to the processes and outcomes of care.” (p. 134) Yet neither commission offered even the crudest details on how such a scheme would be executed nor what it would cost, and, not surprisingly, neither commission offered evidence supporting their high hopes.

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A New Covid Study

Henry Ford Hospital Group (Michigan)  released its peer reviewed observational study on using HCQ, HCQ+AZT, and AZT in the treatment of Covid 19. At 4:30 AM (can’t sleep sometimes), I read it and this is difficult reading while yawning. The stats are within the text of the limited study. I am not going to put them in this brief recital of the study. My version is not all inclusive and I may have missed some issues or facts of importance. I invite you to read it and form your own conclusions.

Treatment with Hydroxychloroquine, Azithromycin, and Combination in Patients Hospitalized with COVID-19″, Henry Ford Covid-19 Task Force, International Journal of Infectious Diseases, July 1, 2020

Cohort, Application, and Dosage:

All patients evaluated were 18 years of age and older and were treated as inpatients for at least 48 hours unless they expired within the time period. The primary objective was to assess treatment experience with hydroxychloroquine versus hydroxychloroquine + azithromycin, azithromycin alone, and other treatments for COVID-19. Treatments were protocol driven, uniform in all hospitals and established by a system-wide interdisciplinary COVID-19 Task Force. Hydroxychloroquine was dosed as 400 mg twice daily for 2 doses on day 1, followed by 200 mg twice daily on days 2-5. Azithromycin was dosed as 500 mg once daily on day 1 followed by 250 mg once daily for the next 4 days. The combination of hydroxychloroquine + azithromycin was reserved for selected patients with severe COVID-19 and with minimal cardiac risk factors.

The methodology of application and dosage appears to be similar to what was used in France and as detailed in others less exact reports. This is not a full-fledged study as one might find in an FDA report. It did involve ~2400 patients.

Limitations:

Include the retrospective, non-randomized, non-blinded study design. Also, information on duration of symptoms prior to hospitalization was not available for analysis. However, our study is notable for use of a cohort of consecutive patients from a multi-hospital institution, regularly updated and standardized institutional clinical treatment guidelines and a QTc interval-based algorithm specifically designed to ensure the safe use of hydroxychloroquine. To mitigate potential limitations associated with missing or inaccurate documentation in electronic medical records, we manually reviewed all deaths to confirm the primary mortality outcome and ascertain the cause of death. A review of our COVID-19 mortality data demonstrated no major cardiac arrhythmias; specifically, no torsades de pointes that has been observed with hydroxychloroquine treatment. This finding may be explained in two ways. First, our patient population received aggressive early medical intervention, and were less prone to development of myocarditis, and cardiac inflammation commonly seen in later stages of COVID-19 disease. Second, and importantly, inpatient telemetry with established electrolyte protocols were stringently applied to our population and monitoring for cardiac dysrhythmias was effective in controlling for adverse events. Additional strengths were the inclusion of a multi-racial patient composition, confirmation of all patients for infection with PCR, and control for various confounding factors including patient characteristics such as severity of illness by propensity matching.

The First (bolded) point made is important as all other commentary made concerning HCQ stressed early intervention in the treatment of Covid to prevent replication of the virus. Subsequent studies such as the VA study involved later intervention of treatment when using hydroxychloroquine.

A Suggestion for further study and a role in treatment:

Our results also require further confirmation in prospective, randomized controlled trials that rigorously evaluate the safety, and efficacy of hydroxychloroquine therapy for COVID-19 in hospitalized patients. Considered in the context of current studies on the use of hydroxychloroquine for COVID-19, our results suggest that hydroxychloroquine may have an important role to play in reducing COVID-19 mortality.

This document is open to the general public. There is “nothing” blocking you from reading it.

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June jobs report: the last hurrah of the wished-for “V-shaped” coronavirus recovery

June jobs report: the last hurrah of the wished-for “V-shaped” coronavirus recovery

HEADLINES:
  • 4,800,000 million jobs added. This makes up about 22% of the 22.1 million job losses in March and April.
  • U3 unemployment rate improved 2.2% from 13.3% to 11.1%, compared with the January low of 3.5%.
  • U6 underemployment rate improved 3.2% from 21.2% to 18.0%, compared with the January low of 6.9%.
  • Those on temporary layoff declined 4,778,000 to 10.565 million.
  • Permanent job losers increased by 588,000.
  • April was revised downward by -100,000. May was revised higher by 190,000 respectively, for a net of 90,000 more jobs gained compared with previous reports.

Leading employment indicators of a slowdown or recession

 

I am still highlighting these because of their leading nature for the economy overall.  These were uniformly very positive:

  • the average manufacturing workweek rose 0.5 hours from a downwardly revised 38.7 hours to 39.2 hours. This is one of the 10 components of the LEI and will be positive.
  • Manufacturing jobs rose by 356,000. Manufacturing has still lost 757,000  jobs in the past 4 months, or 6% of the total.
  • construction jobs rose by 158,000. Even so, in the past 4 months 472,000 construction jobs have been lost, or about 6% of the total.
  • Residential construction jobs, which are even more leading, rose by 19,100. Even so, in the past 4 months there have still been 45,900 lost jobs or about 5% of the total.
  • temporary jobs rose by 148,900. Since February, there have still been 696,100 jobs lost, or 24% of all temporary help jobs.
  • the number of people unemployed for 5 weeks or less declined by 1.037 million to 2.838 million, compared with April’s total of 14.283 million. This is similar to the “less awful” readings of the weekly initial jobless claims.
  • Professional and business employment rose by 306,000, which is still 1.830 million, or about 8% below its February peak.

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Equivalence

Equivalence

by

Ken Melvin

These two things are not the same.

Giving a woman the right of choice doesn’t deny others that right of choice; makes no imposition on the rights of others. Denying a woman the right of choice imposes the will of others upon her.

When is it lawful for some members of a society to impose their will upon others? What right has the State to impose its will upon its citizens? When it is the writ of law. A State can declare acts to be illegal, even criminal, by the enactment of laws, so long as such laws aren’t in conflict with the State’s constitution. Since at least the 13th century, advanced States’ constitutions have guaranteed certain individual rights. The US Constitution explicitly guarantees certain individual rights and freedoms in the first (8) of its first (10) Amendments. Other rights are implicitly granted with:

the 9th Amendment

  • The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people —

and the 10th Amendment

  • The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people 

Succeeding ratified Amendments have explicitly, and implicitly, guaranteed other individual rights and freedoms. A citizen doesn’t have a constitutional right to steal from others, so it is constitutional to make stealing from others a crime; a case of society having the right to tell someone what they can not do.

So, it seems that the State might have the right to deny a woman the right of choice if women do not have the constitutional right of choice. It seems highly unlikely that such a right would be found in the Constitution or the Bill of Rights since women were but inhabitants, not even granted full citizenship, or even personhood, at the time, or even later when these first 10 Amendments were ratified. Women didn’t get the right to vote until 1920.

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Oklahoma Expands Medicaid

Kind of a big deal because Oklahomans rejected Trunp’s Medicaid and Republican block grant-program which would be more vulnerable to cuts of Federal funding.  It is unfortunate Oklahoma did not get on board with the ACA Medicaid expansion as 100% of the costs of the Medicaid expansion from 2014 – 2016 and 90% there after. I could never understand the cold-hearted logic of states in not expanding Medicaid. Much of the costs of expanding Medicaid now would have been covered.

In spite of Oklahoma Governor Kevin Stitt’s plan to make the state a test case for the Trump administration Medicaid block grant program, Oklahoma voters narrowly approved its own initiative to expand Medicaid for low income people. In theory, the state will be in the driver’s sit (mostly) in deciding how much money it will allocate to the program rather than the Federal government.

Oklahoma is the the first state to expand Medicaid during the Covid pandemic. Oklahoma has the second-highest uninsured rate in the country following up Texas who is #1 in both uninsured and the numbers of new Covid cases. The State Question 802 initiative was passed by a margin of less than 1 percentage point amongst voters. It was strongly supported in metropolitan areas such as Tulsa and Oklahoma City and widely opposed in rural counties. While Idaho, Maine, Nebraska and Utah expanded Medicaid through ballot questions and amended state statutes, Oklahoma State Question 802 amended the Oklahoma Constitution which prevents  the Republican-controlled Legislature from altering  the Medicaid program or rolling back coverage.

At an “Americans for Prosperity” forum, Governor Stitt said “We will have a $billion shortfall next year. The state will have to consider raising taxes or cut to such services as education, first responders, or roads and bridges” in order to cover the additional costs of Medicaid.

Looking back, the expansion of Medicaid and also the ACA mandate would increase the numbers of people having healthcare insurance which would be a boon to healthcare insurance companies. The ACA tax on healthcare insurance companies (who would benefit greatly from the new business) was meant to provide additional funds to cover the costs of healthcare. Instead, the Oklahoma plan will increase the fees on hospitals from 2.5% to 4%.  There is more to this issue and I will tackle it another time.

 

 

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Coronavirus dashboard for June 29: renewed exponential growth in infections, decline in deaths has stalled

Coronavirus dashboard for June 29: renewed exponential growth in infections, decline in deaths has stalled

Total US infections: 2,549,069,  42,161 in last day

Total US deaths: 125,803,  273 in last day

Here is the regional breakdown of the 7 day average of new cases per capita:

There is renewed exponential growth in the South and West. The Midwest also is beginning to look bad.

 

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Coronavirus dashboard for June 27: infections -> hospitalizations -> deaths

Coronavirus dashboard for June 27: infections -> hospitalizations -> deaths

Total US infections: 2,480,786,  44,373 new cases
Total US deaths: 125,120,  619 new deathsA quandary over the past month has been why deaths declined so much more than new cases, while cases were declining; and more recently why deaths have continued to decline in the face of soaring new infections.Is it because of better treatments? Changing demographics – e.g., fewer nursing home cases, more younger people? Or is something more even more fundamental with the nature of the virus itself going on? In short, should we expect deaths to continue to decline, or to turn up following the increase in new infections?I am expecting deaths to begin to rise again, imminently.Here’s why: the progression is:
– first, infections increase/decrease
-second, hospitalizations increase/decrease
-finally, deaths increase/decrease.

The problem in the US data has been that hospitalizations have been missing from almost all compilations. That’s because not all States – and most especially, Florida – track hospitalizations.

Conor Kelly, however, *does* track reported hospitalizations from all States which have reported for at least 30 days, which totals roughly 40 States. So if deaths are going to start to increase again, it should first appear in this data. Further, if this is because of the reckless reopening of some States, it should most plainly appear in those regions. With that in mind, here is the data.

Total US hospitalizations bottomed on June 14 at 26,441. In the 12 days since, they have risen by almost 14% to 30,065:

One benefit of Conor Kelly’s compilation is that it allows users to generate customized regions of States. So, for example, here is the data for the East Coast megalopolis from Maine through Virginia:

 

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Pandemic boundaries

Via the Boston Globe  comes the consideration of boundary problems this pandemic poses between US states. Worth a discussion. Also, on the world stage, the EU and other countries consider relaxing travel restrictions from ‘safe’ countries, the US not among them.

Visitor quarantines may seem like a smart intervention to keep the virus from crossing state lines. Symptoms can take up to 14 days to appear after someone is infected, and research suggests people can transmit the virus even when they’re showing no signs of illness, said Dr. Nahid Bhadelia, an infectious diseases physician and medical director of the Special Pathogens Unit at Boston Medical Center.

But a quarantine strategy may not be a realistic approach to stopping further infections, she said, because it’s hard to monitor every car crossing the border, and the state can’t stop travelers flying in to airports, which are federal sites.

“After states have been going it on their own, we are now quickly realizing our state is tied to [other] states,” Bhadelia said. “What happens in Florida or Arizona is not independent. Our borders are so porous.”

Legal issues associated with attempting to block or impede travel may also prove an obstacle, said Wendy Parmet, a professor of law, public policy, and urban affairs at Northeastern University.

“Travel advisories are themselves deeply problematic,” she said. “The dilemma is showing up the disaster of what’s been happening: the fact that we don’t have a federal policy, and no consistency among the states.”

She allowed that the plight of Massachusetts this summer “may be an instance where there is some merit to [travel quarantines] because you have situations with people coming in from jurisdictions that are not doing social distancing, or widespread use of masks, and it’s a real problem.”

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Weekly Indicators for June 22 – 26 at Seeking Alpha

by New Deal democrat

Weekly Indicators for June 22 – 26 at Seeking Alpha

My Weekly Indicators post is up at Seeking Alpha. The coincident indicators, as well as the short leading indicators, have continued to improve gradually each week.

But this week may be the near term peak, as the reality of renewed exponential spread of the coronavirus in recklessly reopened States starts to hit home. You cannot force people to patronize businesses if they believe it is unsafe, and when complacency leads to new outbreaks, the pain threshold will be hit at which people pull back again. Most noteworthy is that restaurant reservations did not improve in the past week – people are shying away from danger.

As usual, clicking over and reading rewards me with a little jingle in my pocket as well as bringing you right up to date with what is happening in the economy.

P.S.: I plan on putting up an extra coronavirus update later today. Stay tuned.

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Coronavirus dashboard for June 23: focusing on deaths, and the Trumpist South and Southwest

Coronavirus dashboard for June 23: focusing on deaths, and the Trumpist South and Southwest

Confirmed total US infections: 2,312,302. (+31,433 in past 24 hours)
Confirmed total US deaths: 120,402 (+425 in past 24 hours)

We know that new cases are accelerating again. Is it translating into an increase in deaths? The answer appears to be: not yet, but getting close.

Here is the 7 day average of new deaths in the US:

Figure 1

In the past 3 days, the decline has ceased at roughly 610/day.

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