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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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Frederick Douglass’s oration on the 4th of July (abridged)

Frederick Douglass’s oration on the 4th of July (abridged)

The middle portion of Douglass’s famous speech, delivered in 1852 to white abolitionists in Rochester, NY, where Douglass lived at the time, and is buried — “What, to the American slave, is your 4th of July?” — is best known.

But in the first portion he allowed for the celebration of the principles enunciated by the Founders in the Declaration of Independence: “your fathers, the fathers of this republic, did, most deliberately, under the inspiration of a glorious patriotism, and with a sublime faith in the great principles of justice and freedom, lay deep the corner-stone of the national superstructure.”

And in the Concluding portion, he “dr[e]w[ ] encouragement from the Declaration of Independence, the great principles it contains, and the genius of American Institutions” for the future.

In our own moment of critical trial and literal iconoclasm, Douglass’s ability to see the Founding Fathers as 3 dimensional, lauding their accomplishments as well as damning their collusion in evil, and for girding one’s loins to the crisis of the present, with abiding hope for the universality of decency and justice in the future, is particularly inspiring.

The papers and placards say, that I am to deliver a 4th [of] July oration.
The fact is, ladies and gentlemen, the distance between this platform and the slave plantation, from which I escaped, is considerable—
This, for the purpose of this celebration, is the 4th of July. It is the birthday of your National Independence, and of your political freedom. This, to you, is what the Passover was to the emancipated people of God. It carries your minds back to the day, and to the act of your great deliverance; and to the signs, and to the wonders, associated with that act, and that day. This celebration also marks the beginning of another year of your national life; … The eye of the reformer is met with angry flashes, portending disastrous times; but his heart may well beat lighter at the thought that America is young, and that she is still in the impressible stage of her existence. May he not hope that high lessons of wisdom, of justice and of truth, will yet give direction to her destiny? Were the nation older, the patriot’s heart might be sadder, and the reformer’s brow heavier. Its future might be shrouded in gloom, and the hope of its prophets go out in sorrow. There is consolation in the thought that America is young. ….
there was a time when to pronounce against England, and in favor of the cause of the colonies, tried men’s souls. They who did so were accounted in their day, plotters of mischief, agitators and rebels, dangerous men. To side with the right, against the wrong, with the weak against the strong, and with the oppressed against the oppressor! here lies the merit, and the one which, of all others, seems unfashionable in our day. The cause of liberty may be stabbed by the men who glory in the deeds of your fathers. But, to proceed….

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by   Ken Melvin

What is the first criteria when a Board of Directors goes looking for a new CEO? When the construction firm goes looking for a project manager?

Of late, too often, US Politics seems to have a new standard for selecting officeholders. We have been, are, watching this horror of a Pandemic being mismanaged by elected incompetents. Incompetents who might have been promoted to yet higher positions if their incompetence hadn’t been exposed by the course of events. This isn’t about The Peter Principle at play. This is about a large group of US Politicians who were elected to high-level Executive positions based on their perceived allegiance to a specific ideology or dogma.

It is to be expected that Political Appointees, chits come due, are most often incompetent. But, here, we are talking about some Mayors and Governors, people elected to Executive Roles; that simply could not step up to the task at hand. Noted: There were, indeed, those who did step up; did so handsomely.

For weeks, we had been witness to some of these Governors’ media paean to: Markets, Capitalism, The Confederacy, Christian Values, Western Heroes, American Independence, … only too soon to be followed by record rates of Covid Infections in their states. Why follow the advice of Science and the Scientists? Why heed the guidelines of the CDC? What does Science know?

Appears that they still don’t understand the math, the doubling, science stuff like that. Easily influenced, these Governors followed the lead of an incompetent President who, too, didn’t understand the Science, nor the math; who couldn’t be bothered to read his briefings.

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Trump’s recent polling in retrospect

The betting markets and statistical models of the 2020 election suggest Trump is either likely or very likely to lose.  I have no reason to doubt this, but it is interesting to look back at the history of his approval ratings.

Trump’s approval trended down throughout his first year in office, with low points in the summer (Charlottesville, Obamacare repeal) and winter (highly unpopular corporate tax cut).  He finished the year with approval around 37 or 38%.  In 2018, his approval rose from the high 30s to the low 40s, with a dip in September to around 40% corresponding to the Mannafort prosecution and Kavanaugh fiasco.  In January 2019 his approval briefly dipped below 40% due to the month long government shutdown.  Since then his approval has bounced around from 41 to 43%, with a surge to 46% in March 2020 due to a relatively small coronavirus “rally around the flag” effect, before falling to around 41% over the past couple of months due to some combination of COVID and his response to the George Floyd murder and the BLM protests.  So right now, Trump’s approval is not all that much lower than it has been the past couple of years, and it’s still higher than it was during the highly unpopular policy actions Republicans took while they controlled Congress in 2017.  That’s interesting, to me anyway.  COVID and Trump’s racist response to the police brutality protests is less of a problem for him than Charlottesville/Obamacare were.

Turning to polls of the contest between Trump and Biden, Biden has been fairly stable since March, at around 50%, and Trump has declined by about 4 points to 41.5%.

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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.


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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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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The US Presidential election as forecast by State polling: tending towards a Biden blowout?

The US Presidential election as forecast by State polling: tending towards a Biden blowout?

Last week I posted a projection of the Electoral College vote based solely on State rather than national polls (since after all that is how the College operates) that have been reported in the last 30 days. There has been extensive polling in the past week, so I have updated the map.

Here’s how it works:

– States where the race is closer than 3% are shown as toss-ups.
– States where the range is between 3% to 5% are light colors.
– States where the range is between 5% and 10% are medium colors.
– States where the candidate is leading by 10% plus are dark colors.

Here is the updated map:

The most important change since last week is that we got extensive polling for Pennsylvania, which moves that State from toss-up into likely Biden. Florida and Minnesota both moved one category more firmly into Biden territory.

Even though I certainly expect some of the Confederate States, like Texas and Arkansas, to return to the Trump fold, as of now, if Biden were to simply win the States in which he leads by 5% or more in the polling, he would win the Electoral College, without even winning a single “toss-up” or “lean Biden” State as shown on the map.

Last week I noted that Trump always polls his worst when he appears both cruel and clueless. Let me illustrate that using Nate Silver’s graph of Trump approval and disapproval

Trump polled his best during the impeachment and immediately after when he briefly seemed to take the coronavirus seriously; the “rally round the flag” effect. Conversely, his worst approvals have come at four times:

     (1) late 2017, when he tried – and failed – to repeal Obamacare. That was cruel, and he failed at it.
     (2) summer 2018, during the “kids in cages” publicity. It was intentionally and especially cruel, and again, it didn’t even “solve the problem” from the RW point of view.
     (3) the government shutdown of January 2019. Again, it was cruel, and he failed.
     (4) the coronavirus pandemic now. Trump basically wants old people to go ahead and die now so that the economy can recover in time for the election. Again, cruel – and it isn’t working anyway. And on top of that, he is advocating for police brutality and Confederate statues – two other issues on which the majority is firmly on the other side.

Trump has totally backed himself into a corner where the pandemic is concerned. He can’t suddenly start taking it seriously again. After all, that would be admitting that he was wrong before. And the pandemic will not be controlled in the next several months, which means the economy is not going to meaningfully improve. Indeed, in the recklessly reopened States, where businesses will likely have to close again, it is probably going to get worse. And some of these are swing States.

Finally, Biden is a well-known politician. He isn’t a newcomer like Dukakis who can be defined by a few devastating ads. While Trump’s standing may revert towards his mean, I just don’t see a big improvement from here. If anything, I think it is more likely that more of his fans abandon him as they sense that he will lose, and the US election moves towards a Biden blowout.

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by Ken Melvin

… He said I have no opinion about this

And I have no opinion about that

Asked an Honors History Class what they thought was the most important issue facing America. In an earlier period, Patrick, a kid from Africa, responded, “our differences.” In a later period, a black female, in a plaintive voice, responded, “we are different.”

Indeed. We are a world of people with many differences: different politics, different religions, … different cultures. Not just here; worldwide, humans are wrestling with this question: How to live with our differences? Can we humans, after all our centuries, change enough? Change enough to accept our differences?

The importance of these questions came to the fore with the recent onslaught of immigration into Europe and has since played out in referenda/elections throughout Europe and the United States. The pending further, and of greater scale, dislocations caused by global warming/climate change and globalization, makes their answering imperative. Plus: What will resulting cultures look like? At what point does an existing culture become more like that of the immigrant? What is the tipping point? Can the center hold?

Over the past 20 years, really quite late, much of our nation has come to believe that someone else’s sexuality is really none of our business. We, as a nation, now accept lesbian, gay, bisexual, and transgender, LGBT, people as they are. Not ignore them, not tolerate them, not demand that they change; but accept them as they are. Yet, there are still regions of America, sectors of the population, where a majority of the people think that they know how people should act, should think, … that they have the right to demand that others change.


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All 4 coincident indicators of recession improved in May vs. April

All 4 coincident indicators of recession improved in May vs. April

With this morning’s release of personal income and spending, we now have all 4 coincident indicators for May that the NBER uses to determine whether the economy is in a recession or recovery/expansion. And all 4 improved from their “most horrible” readings in April.

A recession is a generalized downturn in production, employment, sales, and income. The “income” metric that the NBER uses is “real personal income excluding current transfer receipts,” (basically, government program payments to individuals) and as shown in the graph below, it improved from April:

Still a horrible decline from February, but “less horrible” compared to April.


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