How not to de-politicize the USPSTF

Disease Management Care Blog has a good post on the politicization of the USPSTF and of science generally:

That's the bigger issue in this just-published article by Steven Wolf and Doug Campos-Outcalt. They're focusing on the political pressure that is being brought to bear on US Preventive Services Task Force (USPSTF). As readers may recall, the Affordable Care Act requires health insurers to fully cover screening services that are deemed effective by the USPSTF. Drs. Wolf and Campos-Outcalt point out that politics rudely intruded on the USPSTF's determination that the evidence supporting mammography for women under age 50 years was lacking. The resulting firestorm not only prompted Congress to not only waive the USPHSTF recommendation, but led some of its members to question the Task Force's integrity.

As academics writing in peer-reviewed journals are wont to do, the authors suggest that this can be remedied by another layer of bureaucracy. They want a new "firewall" committee to be inserted between the "pure" evidence-based USPHSTF and the "political" fisticuffs of the public square.  It'd be the job of this a new entity to insulate USPHSTF by reconciling the proof and the politics prior to the upload of the final recommendations to the mandarins that are running CMS.

"Another committee?" asks the dismayed DMCB. While that would end the Obamacare fiction that health reform was ever going to be truly "based on science," the real Achilles heel of the JAMA proposal is that it literally doubles the opportunity for political meddling. The smartest political operatives will see this as a target-rich environment and naturally seek to influence all of the committees with any jurisdiction over the medical-industrial complex of laboratory medicine, radiological imaging and medical devices.

DMCB suggests de-centralizing scientific decision-making, which I'm not convinced is a superior solution.  It might reduce the influence of special interests in many cases, but it probably also reduces the quality of the decision-makers.

Unfortunately, I think this is one area where centralized decision-making might be the lesser of two evils.  I've lived in DC long enough to know that there are no bodies of wise men with access to better knowledge than the rest of us.  But there is a lot of bad science out there and there is something to be said for having talented people reviewing literature and making these decisions.  Decentralizing decision-making can be a good way to reduce the influence of special interests, but I'm not sure that it would lead to better science here.  There is already a thriving pseudoscience industry in the health care sector, and I worry that this would only increase the opportunities for homeopaths, nutritionists and pharmaceutical company lobbyists to gain legitimacy through lobbying (rather than science).  This might be one instance where flawed wise-men might be wiser than a decentralized group of even more flawed wise-men.

Don't follow your passion

Cal Newport has terrific advice on how to love what you do and how to become an expert:

I set out to research a simple question: How do people end up loving what they do? If you ask people, the most common answer you’ll get is, “They followed their passion.” So I went out and researched: “Is this true?” From what I found, “Follow your passion” is terrible advice. If your goal is to end up passionate about what you do, “Follow your passion” is terrible advice. 

So the first fundamental misunderstanding is this idea that we all have a pre-existing passion that’s relevant to a career, and if we could just discover it, then we would be fine. Research says actually most people don’t have one. 

The second problem is that it’s built on this misbelief that matching your work to something you have a very strong interest in is going to lead to a long-term satisfaction and engagement in your career. It sounds obvious that it should be true, but actually the research shows that’s not at all the reality of how people end up really enjoying and gaining great satisfaction and meaning out of their career. 

If you study people who end up loving what they do, here’s what you find and if you study the research on it, you find the same thing: Long-term career satisfaction requires traits like a real sense of autonomy, a real sense of impact on the world, a sense of mastery that you’re good at what you do, and a sense of connection in relation to other people.  

Now, the key point is those traits are not matched to a specific piece of work and they have nothing to do with matching your job to some sort of ingrained, pre-existing passion.

The article is interesting throughout and it also has an interesting section on how to become an expert.

Economic growth in the Cote d'Ivoire

The Guardian reports on the economic boom in the Cote d'Ivoire:

Construction sites loom at every twist and turn of the super six-lane highways that weave around the Ébrié lagoon in the heart of Abidjan. Roads are being widened. New apartment blocks and shopping malls are joining 1970s skyscrapers on the skyline. And the final touches on a shiny new high-rise tower signal the African Development Bank's return after more than a decade.

Two years after the post-election conflict, when more than 3,000 people were killed, Ivory Coast's economy is bouncing back. With the country relieved of nearly $8bn (£5bn) in debt after reaching completion point of the heavily indebted poor countries initiative, investors are returning and GDP climbed to 9.8% last year.

"The recovery has been very impressive," said Marcelo Giugale, the World Bank's head of economic policy and poverty reduction in Africa, on a recent visit. "Not just economically speaking, but institutionally."

The economy is expected to grow another 8% in 2013, and the fiscal deficit will shrink from 4.7% to 3.2%.  The IMF also reports that the government is attempting to reform the cocoa sector, increase the supply of energy and create commercial courts that strengthen the business environment.

The initial Guardian article also details some of the problems with reconciliation, but I'm saving that for a separate post.

The purchaser-provider split

Interesting article from the Economist on "post ideological" Sweden's increasing use of private companies to provide public services:

Sweden has gone further than any other European country in embracing the purchaser-provider split—that is, in using government money to buy public services from whichever providers, public or private, offer the best combination of price and quality. Private firms provide 20% of public hospital care in Sweden and 30% of public primary care. Both the public and private sectors are obsessed with lean management; they realise that a high-cost country such as Sweden must make the best use of its resources...

Saint Goran's hospital is one of the glories of the Swedish welfare state. It is also a laboratory for applying business principles to the public sector. The hospital is run by a private company, Capio, which in turn is run by a consortium of private-equity funds, including Nordic Capital and Apax Partners. The doctors and nurses are Capio employees, answerable to a boss and a board. Doctors talk enthusiastically about “the Toyota model of production” and “harnessing innovation” to cut costs.

St Goran’s is the medical equivalent of a budget airline. There are four to six patients to a room. The decor is institutional. Everything is done to “maximise throughput”. The aim is to give taxpayers value for money. Hospitals should not be in the hotel business, the argument goes. St Goran’s has reduced waiting times by increasing throughput. It has also reduced each patient’s likelihood of picking up an infection. However, scrimping on hotel services means that it has to invest in preparing patients for admission and providing support after they are released.

St Goran’s also acts as a hare for Capio, one of Europe’s largest health-care companies, with 11,000 employees across the continent and 2.9m visits from patients in 2012. Sweden is Capio’s biggest market, accounting for 48.2% of its sales (France comes second with 37.6%). The firm performs 10% of all Swedish cataract operations, and much more besides. Capio thinks it can make huge savings in other countries by transferring the lessons it has learned in Sweden. The average length of a hospital stay in Sweden is 4.5 days, compared with 5.2 days in France and 7.5 days in Germany. Sweden has 2.8 hospital beds per 1,000 citizens. France has 6.6; Germany, 8.2. Yet Swedes live slightly longer.

These public-private partnerships suggest the importance of context and culture in policymaking.  Such an arrangement seems to work well in Sweden, but it works largely because they have terrific levels of social capital and trust.  I would be more reluctant to recommend such an arrangement in a country with poor social capital.

Defining the problem -- benchmarking and health system performance goals

Roberts et al. discuss the importance of "defining the problem," an issue that takes on particular relevance in light of the recent Oregon Medicaid debate:

The most overlooked, yet one of the most important steps in health-sector reform is defining the problem.  Heath-care systems give rise to hundreds of statistics on their performance.  But which are an appropriate focus for public attention?

The group that succeeds in having its problem definition accepted as the basis for discussion about reform will have a great effect on the solutions pursued and the policies adopted.  

This is basic Public Policy 101 stuff, but a good reminder.  Roberts and Co. also lay out their three main performance goals for health reform: 1) health status; 2) satisfaction (that the health system produces among its citizens); and 3) financial risk protection.  I would argue that 3) is a more worthy goal than 2), but I could be persuaded otherwise.

Within "problem definition" Roberts also discusses the usefulness of "benchmarking," a concept that I like:

In health sector reform, benchmarking means looking at countries similar to one's own in income and spending levels, whose health system performance is particularly effective.  Thus, reformers in Thailand might wonder why Sri Lanka has longer life expectancy while spending less on health care, and use that fact to focus their own problem definition.  Similarly, Latin American countries could look at health statistics from Cuba or Costa Rica for setting their own objectives.   

Caffeine and public health

It may not be a huge one nor a very well studied one, but it looks like there is a public health issue here somewhere: 

"The number of American emergency hospital visits involving energy drinks doubled between 2007 and 2011 to more than 20,000." 

I'm not saying that I support a particular ban or regulation, but I do think there may be a problem here requiring more regulation at some point down the road.