No, It's Not the Sugar – Bittman and MotherJones have overinterpreted another study

Diet seems to be all over the New York Times this week, with an oversell of the benefits of the Mediterranean diet, and now Mark Bittman, everyone’s favorite food scold, declaring sugar is the culprit for rising diabetes. His article is based on this interesting new article in PLoS One and begins with this wildly-inaccurate summary:

Sugar is indeed toxic. It may not be the only problem with the Standard American Diet, but it’s fast becoming clear that it’s the major one.
A study published in the Feb. 27 issue of the journal PLoS One links increased consumption of sugar with increased rates of diabetes by examining the data on sugar availability and the rate of diabetes in 175 countries over the past decade. And after accounting for many other factors, the researchers found that increased sugar in a population’s food supply was linked to higher diabetes rates independent of rates of obesity.
In other words, according to this study, obesity doesn’t cause diabetes: sugar does.

No! Not even close. I hate to repeat his misstatement, because I’d hate to reinforce this as a new myth, but it’s critical to see his full mistake here. This is a wildly inaccurate summary of the authors’ findings, and one they don’t even endorse in their discussion. Bittman has actually just said “obesity doesn’t cause diabetes”, and now has proven himself a deluded fool.
Let’s talk about this paper. This is what is called an “ecological study”, which means it studies populations as a whole, rather than individual patients. Using data from the United Nations Food and Agricultural Organization, the International Diabetes Federation, and various economic indicators from the World Bank, the authors compared populations of whole countries, in particular the prevalence of diabetes correlated to other factors such as GDP, urbanization, age, obesity, and availability of certain varieties of food like sugar, meat, fibers, cereals and oil. Using the rise, or fall, of diabetes prevalence over the last decade in various countries, they correlated this increase with increasing availability of sugar, obesity, urbanization, aging populations etc., and found a few interesting things. For one, increases in GDP, overweight and obesity, tracked significantly with increasing diabetes prevalence. But interestingly, when those factors were controlled for, increasing availability of sugar also tracked linearly with increasing diabetes prevalence, and the longer the duration of the exposure, the worse it got.
However, this does not mean that “obesity doesn’t cause” diabetes, if anything, it’s further support for the exact opposite. While a correlative study can’t be a “smoking gun” for anything, the data in this paper supports increasing modernization/GDP, obesity, and sugar availability are all correlated with higher diabetes prevalence. Even if the sugar relationship is causal, which is no guarantee, the increase in sugar availability could only explain 1/4 of the increase in diabetes prevalence. Obesity is still the main cause of diabetes, which can be demonstrated on an individual level by increases in weight resulting in loss of glycemic control, and subsequent weight loss results in return of euglycemia. In particular, the results of studies of bariatric surgery, in both restrictive and bypass procedures, weight loss is accompanied by improvement in diabetes. The attempts of toxin paranoids like Bittman to reclassify sugar as a diabetes-causing agent, and to dismiss obesity as a cause, are highly premature.
Mother Jones, has a slightly more balanced read, but it still oversells the results.

This is a correlation, of course, and correlation does not always equal causation. On the other hand, it’s an exceptionally strong correlation.

Well, that’s another overstatement. Want to see a picture?

Article Source: The Relationship of Sugar to Population-Level Diabetes Prevalence: An Econometric Analysis of Repeated Cross-Sectional Data
Basu S, Yoffe P, Hills N, Lustig RH (2013) The Relationship of Sugar to Population-Level Diabetes Prevalence: An Econometric Analysis of Repeated Cross-Sectional Data. PLoS ONE 8(2): e57873. doi:10.1371/journal.pone.0057873
Figure 2. Adjusted association of sugar availability (kcal/person/day) with diabetes prevalence (% adults 20–79 years old).

I wonder what the R-squared is on that line fit. Now, consider a comparison with obesity rates by diabetes prevalence:
Figure 1. Relationship between obesity and diabetes prevalence rates worldwide.
Obesity prevalence is defined as the percentage of the population aged 15 to 100 years old with body mass index greater than or equal to 30 kg/meters squared, from the World Health Organization Global Infobase 2012 edition. Diabetes prevalence is defined as the percentage of the population aged 20 to 79 years old with diabetes, from the International Diabetes Federation Diabetes Atlas 2011 edition. Three-letter codes are ISO standard codes for country names.

Hmm, they didn’t fit a line here, but I can bet the fit would be better. Diabetes strongly correlates with BMI, this has been shown time and again using national survey data like NHANES or SHIELD. And before people start whining about BMI as an imperfect measure of obesity, it is perfectly appropriate for studies at a population level, and other metrics such as waist size, hip/waist ratios etc., all show the same thing. Diabetes risk increases linearly with BMI, with as many as 30% of people with BMI > 40 having diabetes, and further, we know from cohort and interventional studies that weight loss results in decreased diabetes. Much of this data is correlative as well (with the exception of the weight-loss studies), and the study that would prove this for certain – dividing people into diets providing excess fat, vs sugar, vs mixed calories, vs controls, with resultant measurement of diabetes rates, would be unethical. Either way, declaring sugar the enemy is both incomplete, and premature. While this paper provides interesting correlative evidence for increased sugar availability increasing diabetes prevalence, it is still subject to risk of confounding errors, it is correlative, and the link does not explain away other known causes of type II diabetes such as obesity. It is a warning however, and we should dedicate more study towards determining if sugar consumption (rather than mere availability) is an independent risk factor for type II diabetes.
Bittman has wildly overstated the case made by this article. He should retract his claims, and the title and false claims should be corrected by the editors. This is a terrible misrepresentation of what this study shows.

What happens when you study conspiracy theories? The conspiracy theorists make up conspiracy theories about you!

I’ve known about this effect for a while as I’ve been variously accused of being in the pocket of big pharma, big ag, big science, democrats and republicans etc. Now Stephan Lewandowsky, in follow up to his “NASA Faked the Moon Landings – Therefore (Climate) Science is a Hoax.” paper, has used these conspiratorial responses to study how conspiracy theorists respond to being studied! It’s called “Recursive fury: Conspiracist ideation in the blogosphere in response to research on conspiracist ideation“.
Here’s the abstract:

Conspiracist ideation has been repeatedly implicated in the rejection of scientific propositions, although empirical evidence to date has been sparse. A recent study involving visitors to climate blogs found that conspiracist ideation was associated with the rejection of climate science and the rejection of other scienti c propositions such as the link between lung cancer and smoking, and between HIV and AIDS (Lewandowsky, Oberauer, & Gignac, in press; LOG12 from here on). This article analyzes the response of the climate blogosphere to the publication of LOG12. We identify and trace the hypotheses that emerged in response to LOG12 and that questioned the validity of the paper’s conclusions. Using established criteria to identify conspiracist ideation, we show that many of the hypotheses exhibited conspiratorial content and counterfactual thinking. For example, whereas hypotheses were initially narrowly focused on LOG12, some ultimately grew in scope to include actors beyond the authors of LOG12, such as university executives, a media organization, and the Australian government. The overall pattern of the blogosphere’s response to LOG12 illustrates the possible role of conspiracist ideation in the rejection of science, although alternative scholarly interpretations may be advanced in the future.

Awesome. It’s actually a great paper, from the introduction discussing Diethelm and Mckee’s work on conspiratorial ideation (who cited us in their original paper), to the comparisons between censorship accusations by diverse anti-science movements from the tobacco/cancer denial to HIV/AIDS denial, Lewandowsky et al., lay the groundwork for understanding this problem as a fundamental characteristic of all anti-science. They even cite a book chapter in which the authors make the link that conspiracies are specifically used to rhetorically challenge science when one lacks adequate data (Lahsen, M. (1999). The detection and attribution of conspiracies: the controversy over Chapter 8. In G. Marcus (Ed.), Paranoia within reason: a casebook on conspiracy as explanation (pp. 111{136). Chicago: University of Chicago Press.) I’ll have to look that one up, as that was our primary conclusion about denialism when we started writing about it in 2007.
The authors then go on to the conspiracist reaction to their original paper:

When the article by Lewandowsky et al. became available for download in July-August 2012, the climate denialist blogosphere responded with considerable intensity along several prongs: Complaints were made to the rst author’s university alleging academic misconduct; several freedom-of-information requests were submitted to the author’s university for emails and documents relating to LOG12; multiple re-analyses of the LOG12 data were posted on blogs which purported to show that the e ects reported Recursive fury 8 by LOG12 did not exist; and a number of hypotheses were disseminated on the internet with arguably conspiracist content. This response is not altogether surprising in light of research which has shown that threats – in particular to people’s sense of control – can trigger targeted small-scale conspiracy theories (Whitson & Galinsky, 2008), especially those involving a speci c opponent (Sullivan, Landau, & Rothschild, 2010).

So what does any good scientist who is interested in the empirical study of conspiracy theories do in such a situation? Mine it for data!

The remainder of this article reports a content analysis of the hypotheses generated by the blogosphere to counter LOG12. The extent and vehemence of contrarian activity provided a particularly informative testbed for an analysis of how conspiracist ideation contributes to the rejection of science among web denizens. Unlike previous analyses of web content, the present project was conducted in real time” as the response to LOG12 unfolded, thus permitting a fi ne-grained temporal analysis of the emerging global conversation.

Using google alerts and other strategies they tracked the response to their paper throughout the denialsphere, then evaluated them using 6 criteria to judge whether the author used conspiracist tendencies independent of actual content. These criteria were great, and as I read them I couldn’t help thinking it is really a beautiful summary of the aberrant thought processes of the conspiracist. They were (1) assuming nefarious intent (NI) on the part of their opponent, (2) delusions of persecution including Galileo comparisons (persecution/victimization or PV) -awesome-, (3) a “nihilistic degree of skepticism”/paranoid ideation (NS), (4) an inability to believe in coincidence or “not an accident” (NoA) thinking, (5) toleration of inconsistencies and contradictions in their own counter-hypotheses as long as they challenge the “official” version (or Must-Be-Wrong MbW), and (6) the incorporation of contrary evidence as further evidence of a conspiracy thus “self-sealing” their hypothesis (SS). This is a really brilliant break down of the behavior if you ask me in particular number 6 which they even provide the perfect example of:

Concerning climate denial, a case in point is the response to events surrounding the illegal hacking of personal emails by climate scientists, mainly at the University of East Anglia, in 2009. Selected content of those emails was used to support the theory that climate scientists conspired to conceal evidence against climate change or manipulated the data (see, e.g., Montford, 2010; Sussman, 2010). After the scientists in question were exonerated by 9 investigations in 2 countries, including various parliamentary and government committees in the U.S. and U. K., those exonerations were re-branded as a whitewash” (see, e.g., U.S. Representative Rohrabacher’s speech in Congress on 8 December 2011), thereby broadening the presumed involvement of people and institutions in the alleged conspiracy. We refer to this “self-sealing” criterion by the short label SS.

At denialism blog we’ve been describing these tactics for years, in particular I feel like the Crank Howto seems to incorporate most of these denialist tactics. In particular, that the authors recognized the persecution complex of the conspiracist is heart warming.
For the meat of the study, the authors then go through the evolution of reactions to their paper, and it’s fascinating. Starting with lots of allegations of “scamming” (must be wrong) and a smear to make them look like nutters (persecution victimization) the conspiracy theories then evolved about everything to whether or not the authors didn’t actually contact skeptic blogs (amazingly the blogs they did contact came out and appear to have lied about not being contacted), persecutorial delusions about the authors blocking individual skeptics IP addresses from accessing the paper (and further conspiracies that when they are being unblocked it’s just to make them look paranoid), conspiracies about it being a ploy by the Australian government (nefarious intent), and it gets crazier and crazier from there. One of the most fascinating aspects of the evolution of the response was how, predictably, as more information was made available, rather than quashing conspiracies, the conspiracy theorists would just broaden the nefarious actors to larger and larger circles of foes:

Second, self-sealing reasoning also became apparent in the broadening of the scope of presumed malfeasance on several occasions. When ethics approvals became public in response to an FOI request, the presumption of malfeasance was broadened from the authors of LOG12 to include university executives and the university’s ethics committee. Similarly, the response of the blogosphere evolved from an initial tight focus on LOG12 into an increasingly broader scope. Ultimately, the LOG12 authors were associated with global activism, a $6 million media initiative, and government censorship of dissent, thereby arguably connecting the response to LOG12 to the grand over-arching theory that “climate change is a hoax.” Notably, even that grand “hoax” theory is occasionally thought to be subordinate to an even grander theory: one of the bloggers involved in the response to LOG12 (cf. Table 1) considers climate change to be only the second biggest scam in history. The top-ranking scam is seen to be modern currency, dismissed as “government money” because it is not linked to the gold standard

And doesn’t that bring this back beautifully, full-circle, to the author’s original hypothesis in the first paper that free-market extremism is behind global warming denialism?
Finally the authors discuss implications for science communication, and, unlike most people, I think they actually understand the problem. That is, you can’t fix this problem with more communication, and more data. The nature of the conspiracy theorist is that all additional data and all contradictory data will only be used to demonstrate further evidence of conspiracy, that the conspiracy is even larger, or that the data are fraudulent. The “self-sealing” nature of the conspiracy theory, as the authors describe it, makes it fundamentally immune to penetration by logic, reason, or additional information.

Implications for science communication. A de fining attribute of conspiracist ideation is its resistance to contrary evidence (e.g., Bale, 2007; Keeley, 1999; Sunstein & Vermeule, 2009). This attribute is particularly troubling for science communicators, because providing additional scientifi c information may only serve to reinforce the rejection of the evidence, rather than foster its acceptance. A number of such “back fire” e ffects have been identi fied, and they are beginning to be reasonably well understood (Lewandowsky, Ecker, Recursive fury 37 et al., 2012). Although suggestions exist about how to rebut conspiracist ideations|e.g., by indirect means, such as affirmation of the competence and character of proponents of conspiracy theories, or affirmation of their other beliefs (e.g., Sunstein & Vermeule, 2009) we argue against direct engagement for two principal reasons.
First, much of science denial takes place in an epistemically closed system that is immune to falsifying evidence and counterarguments (Boudry & Braeckman, 2012; Kalichman, 2009). We therefore consider it highly unlikely that outreach e fforts to those groups could be met with success. Second, and more important, despite the amount of attention and scrutiny directed towards LOG12 over several months, the publication of recursive hypotheses was limited to posts on only 24 websites, with only 13 blogs featuring more than one post (see Table 1). This indicates that the recursive theories, while intensely promoted by certain bloggers and commenters, were largely contained to the “echo chamber” of climate denial. Although LOG12 received considerable media coverage when it first appeared, the response by the blogosphere was ignored by the mainstream media. This confinement of recursive hypotheses to a small “echo chamber” reflects the wider phenomenon of radical climate denial, whose ability to generate the appearance of a widely held opinion on the internet is disproportionate to the smaller number of people who actually hold those views (e.g., Leviston, Walker, & Morwinski, 2012). This discrepancy is greatest for the small group of people who deny that the climate is changing (around 6% of respondents; Leviston et al., 2012). Members of this small group believe that their denial is shared by roughly half the population. Thus, although an understanding of science denial is essential given the importance of climate change and the demonstrable role of the blogosphere in delaying mitigative action, it is arguably best met by underscoring the breadth of consensus among scientists (Ding, Maibach, Zhao, Roser-Renouf, & Leiserowitz, 2011; Lewandowsky, Gignac, & Vaughan, 2012) rather than by direct engagement.

Don’t argue with cranks. I can’t agree more. And historically this is what has worked with denialist groups. You don’t debate them as if they’re honest brokers, you treat them as the defective brains that they are, and eventually, their influence dwindles, and they’ll be reduced to a small community of losers sharing their delusions of grandeur and righteous indignation in some tiny corner of the internet.
The key to preventing denialism isn’t in arguing with those that have already formed fixed, irrational ideas. It can only happen with prevention – early education that emphasizes logic, scientific methods, rational thought and non-ideological, pragmatic approaches to problem solving.

What is the cause of excess costs in health care Part 4 – Time's "Bitter Pill", CEO compensation and the Kafkaesque chargemaster

Steven Brill’s extensive piece in Time has generated a good discussion once again on why Americans pay so much more for health care than other countries, and while I agree with most of his critiques, he seems to have gotten overly hung-up on the hospital chargemaster.
Readers of this blog know I’ve also discussed reform in health care, the diverse sources of excess cost including price gouging on pharmaceuticals, defensive medicine, expensive end-of-life care, the high cost of primary care in the ER etc, and both Brill and I appear to have relied on the same sources of data in the McKinsey report. We’ve also discussed the “hidden tax” of the uninsured, as well as some signs of reform (although of note, my belief that and EMR would reduce waste has proven wrong as the software designers have designed their programs to gouge medicare on behalf of the doctor – increasing costs!).
Brill has written a piece for Time that takes a different tactic, however. Rather than starting from the data on sources of excess costs (although he does reference them), he starts with the patients’ bills and then tries to figure out where all these expenses come from. This is a creative and innovative approach to the problem, except I cringed when I read it because I knew what he was going to find before the end of the first page. Medical bills are insane.

The total cost, in advance, for Sean to get his treatment plan and initial doses of chemotherapy was $83,900.
The first of the 344 lines printed out across eight pages of his hospital bill — filled with indecipherable numerical codes and acronyms — seemed innocuous. But it set the tone for all that followed. It read, “1 ACETAMINOPHE TABS 325 MG.” The charge was only $1.50, but it was for a generic version of a Tylenol pill. You can buy 100 of them on Amazon for $1.49 even without a hospital’s purchasing power.
Dozens of midpriced items were embedded with similarly aggressive markups, like $283.00 for a “CHEST, PA AND LAT 71020.” That’s a simple chest X-ray, for which MD Anderson is routinely paid $20.44 when it treats a patient on Medicare, the government health care program for the elderly.
Every time a nurse drew blood, a “ROUTINE VENIPUNCTURE” charge of $36.00 appeared, accompanied by charges of $23 to $78 for each of a dozen or more lab analyses performed on the blood sample. In all, the charges for blood and other lab tests done on Recchi amounted to more than $15,000. Had Recchi been old enough for Medicare, MD Anderson would have been paid a few hundred dollars for all those tests. By law, Medicare’s payments approximate a hospital’s cost of providing a service, including overhead, equipment and salaries.

This is the fascinating aspect of his article but also the tragedy. Because Brill becomes so highly focused on what hospitals charge, and the apparent horrifying mark-up of medicine, I worry that people will come away thinking that this is the cause of excess costs.
The problem Brill is describing is that the costs itemized by hospitals on their bills come from a mysterious document called the “chargemaster”. I’m pretty sure no one knows how the costs are calculated, and I know there is no rational basis for the prices on it. But as shocking as the bills that are generated by these documents are, they are largely irrelevant to the excess costs of healthcare. The chargemaster is a red herring, and despite Brill’s protestations that it is some central evil in health care expenditure, it really isn’t.
The tragic circumstances Brill describes, repeatedly, are what happens when someone who is uninsured, underinsured, or paying out of pocket for medical care experiences when they receive their bill. It is covered with charges that seem insane – because they are – and lacking the knowledge and tools to deal with these ridiculous charges, the uninsured, understandably, believe they need to pay this full, ridiculous bill. But they don’t, and shouldn’t. An uninsured person receiving one of these bills is a little like a tourist who has just been dropped in a foreign bazaar, with no understanding of the rules of the market, discounts, haggling, gouging, or any idea of what other actors in the same market are paying. The reality is that hospital bills, and many other bills in medical care are little more than an opening gambit in an irrational, and largely incomprehensible, cost war between providers and payers. Hospitals, knowing that insurers never pay a full hospital bill, and will haggle and discount charges away or pay a percentage of “chargemaster” costs, push back by artificially inflating costs – as demonstrated throughout Brill’s article. When someone who doesn’t have the power or expertise of the insurance company receives their bill (hospitals of course can’t send different bills to different kinds of customers right?) they end up paying more, or worse, think they have to actually pay the full bill, because they have fallen into this market without the tools or knowledge to navigate it.
The proof of this are the medical bill advocates Brill interviews for the article. For a fee, you can hire someone who has similar expertise as the payers to fight back, and often reduce these bills to a tiny fraction of their original amount.

Shocked by her bill from Stamford hospital and unable to pay it, Janice S. found a local woman on the Internet who is part of a growing cottage industry of people who call themselves medical-billing advocates. They help people read and understand their bills and try to reduce them. “The hospitals all know the bills are fiction, or at least only a place to start the discussion, so you bargain with them,” says Katalin Goencz, a former appeals coordinator in a hospital billing department who negotiated Janice S.’s bills from a home office in Stamford.
Goencz is part of a trade group called the Alliance of Claim Assistant Professionals, which has about 40 members across the country. Another group, Medical Billing Advocates of America, has about 50 members. Each advocate seems to handle 40 to 70 cases a year for the uninsured and those disputing insurance claims. That would be about 5,000 patients a year out of what must be tens of millions of Americans facing these issues — which may help explain why 60% of the personal bankruptcy filings each year are related to medical bills.
“I can pretty much always get it down 30% to 50% simply by saying the patient is ready to pay but will not pay $300 for a blood test or an X-ray,” says Goencz. “They hand out blood tests and X-rays in hospitals like bottled water, and they know it.”
After weeks of back-and-forth phone calls, for which Goencz charged Janice S. $97 an hour, Stamford Hospital cut its bill in half. Most of the doctors did about the same, reducing Janice S.’s overall tab from $21,000 to about $11,000.

Brill also seems very disturbed by two consistently capitalistic elements of hospitals, high compensation of hospital CEOs and non-physician administrators, and the ability of “non-profit” hospitals to actually make a profit. The difference, is, of course, “profits” in this case go back into the hospital, hiring staff, into equipment, buildings, etc., rather than shareholders pockets so one could argue the money largely goes back into the community (disclosure – I work for a non-profit hospital). But what about CEO pay? Brill seems largely offended that they make so much, even making the suggestion at the end of the article that hospital profits be taxed at 75% (insuring no one will ever invest in them again) and that CEO pay be limited to some multiple of a lower-level employee’s salary. Sounds wonderful, except it will only work if that model is applied to CEOs across the board. Brill cites hospital CEO compensations of between 1-4 million dollars. But the average CEO salary is about 13 million dollars as of 2011. Yes CEOs are paid too much, but it’s a global problem, not just in healthcare. If anything, healthcare CEOs are payed a great deal less than their counterparts in other industries, it seems strange to single out healthcare as the one service where CEO pay is somehow more sinful than in others, especially if you want hospitals and medical centers to be able to attract talented management. So am I bothered by CEO pay? Sure, but not as much in my industry as in say, finance, where CEOs who aren’t making profit, and are hurting shareholders get rewarded with bonuses and golden parachutes. Brill seems to be upset that the industry is profitable and are CEOs are well-compensated. But this isn’t so much a source of excess costs in healthcare as it is a source of excess costs in capitalism, and I don’t anticipate that changing any time soon, nor do I think it’s ultimately a good idea to nationalize or socialize the industry to make no profit.
This is too bad, because in an extensive, lengthy documentation of the absurdity of the hospital billing scheme, and anger at CEO pay, Brill’s final recommendations hit many of the true sources of excess cost.

So how can we fix it?
Changing Our Choices
We should tighten antitrust laws related to hospitals to keep them from becoming so dominant in a region that insurance companies are helpless in negotiating prices with them. The hospitals’ continuing consolidation of both lab work and doctors’ practices is one reason that trying to cut the deficit by simply lowering the fees Medicare and Medicaid pay to hospitals will not work. It will only cause the hospitals to shift the costs to non-Medicare patients in order to maintain profits — which they will be able to do because of their increasing leverage in their markets over insurers. Insurance premiums will therefore go up — which in turn will drive the deficit back up, because the subsidies on insurance premiums that Obamacare will soon offer to those who cannot afford them will have to go up.

Agreed. In particular I find the financial conflict of doctors owning labs and radiology equipment, that they then can profit from ordering tests on, is very disturbing. It’s been shown in the literature that this arrangement results in the physicians ordering more unnecessary tests, and demonstrates that it’s an unacceptable conflict of interest that only increases costs.

Similarly, we should tax hospital profits at 75% and have a tax surcharge on all nondoctor hospital salaries that exceed, say, $750,000. Why are high profits at hospitals regarded as a given that we have to work around? Why shouldn’t those who are profiting the most from a market whose costs are victimizing everyone else chip in to help? If we recouped 75% of all hospital profits (from nonprofit as well as for-profit institutions), that would save over $80 billion a year before counting what we would save on tests that hospitals might not perform if their profit incentives were shaved.

We could save lots of money if we forbade various industries from making profit and taxed their incomes at 75%. But I don’t think this is a viable suggestion in a capitalist society, and I believe that if we did increase competition in insurance, pharmaceutical, and other healthcare markets we could decrease costs. Socialism is not the answer, although Brill makes a compelling argument for a public-option as medicare’s administration and pricing is highlighted in the article as a model of efficiency compared to the private insurers. I’d have no problem with expanding medicare as a payer. Next:

We should outlaw the chargemaster. Everyone involved, except a patient who gets a bill based on one (or worse, gets sued on the basis of one), shrugs off chargemasters as a fiction. So why not require that they be rewritten to reflect a process that considers actual and thoroughly transparent costs? After all, hospitals are supposed to be government-sanctioned institutions accountable to the public. Hospitals love the chargemaster because it gives them a big number to put in front of rich uninsured patients (typically from outside the U.S.) or, as is more likely, to attach to lawsuits or give to bill collectors, establishing a place from which they can negotiate settlements. It’s also a great place from which to start negotiations with insurance companies, which also love the chargemaster because they can then make their customers feel good when they get an Explanation of Benefits that shows the terrific discounts their insurance company won for them.

While I agree outlawing the chargemaster should be considered, I’m not really sure it will work. For one, yes, it is a fiction, it’s not an actual source of excess costs like so many other problems described in the McKinsey report. And hospitals are in a bind. They can’t charge what things actually cost, because insurance companies will still try to pay less. Hospitals know what their costs are, but it’s nearly impossible to truly itemize a patient’s stay, and take into account the exact time every physician doctor and nurse spent with them versus another patient, exactly how many disposable materials were used, as well as factor in all the other costs hospitals need to balance such as covering uninsured patients (most of whom never pay their bills), profit-losing divisions of hospitals and “mission” costs, as well as having a adequate nest egg at the end of the year to ensure adequate capital to expand as needed to meet demand, buy new equipment, and hire new staff. My guess as to what the chargemaster is accomplishing (and it is just a guess), is that it’s a strategy that reliably returns a certain amount of profit on each hospitalization relative to patient utilization of specific services, while providing plausible deniability for what is ultimately overcharging the insured to subsidize the total costs of running their operation. It has to be inflated to cover all the costs of overhead, supplies, etc., that just can’t be reliably quantified, and the fact that insurance companies will only pay a fraction of the final bill. The alternative would be to “bundle” costs so that hospitalizations for specific services cost a set amount, and hospitals then have an incentive to come in under that reasonable fixed price for the service. But then, you run into the problem of penalizing the hospitals that treat needier, poorer, sicker, older populations that cost more to treat, and will have poorer outcomes, readmissions, and complications.
It’s a pickle. You want hospitals to have some measure of profitability – they provide a necessary service, employment, and pride to the community. But if you create profit incentives that put them in conflict with the community – like avoiding poorer, sicker, older patients, they won’t provide the very service for which they exist.
I don’t have a good solution to this problem. We need to own up to the costs of treating the difficult populations, rather than continuing to play the insurance shell-game. Hospitals have to treat people who are sick no matter what because of laws like EMTALA. EMTALA is an unfunded mandate, passed during the Reagan years, that doesn’t specify how hospitals shall recoup their losses when someone can’t pay, just that they have to provide care for sick people no matter what. The unwillingness to pay for the poor and the uninsured pushes even their primary care into the ER, and they present with more acute problems that earlier access to primary care could have managed more cheaply, raising the costs of their care, and foisting it on the hospitals – especially the non-profit, inner-city hospitals providing care to the most at-risk. They then have to figure out some way of spreading these costs back onto medicare and the insured and paying patients without attaching a rider to the bill that simply says, “paying for the sick and uninsured in your community — $1200” (then you actually only have to pay only $200 for this service in reality because everything is inflated). I suspect the chargemaster, in its irrational and frightening way, is accomplishing this task. It’s not pretty, but I’d love to hear suggestions to address the need of hospitals to provide universal health care without a funding source to do so.
Then Brill gets to the things which I agree the McKinsey report shows are our real sources of excess costs:

We should amend patent laws so that makers of wonder drugs would be limited in how they can exploit the monopoly our patent laws give them. Or we could simply set price limits or profit-margin caps on these drugs. Why are the drug profit margins treated as another given that we have to work around to get out of the $750 billion annual overspend, rather than a problem to be solved?
Just bringing these overall profits down to those of the software industry would save billions of dollars. Reducing drugmakers’ prices to what they get in other developed countries would save over $90 billion a year. It could save Medicare — meaning the taxpayers — more than $25 billion a year, or $250 billion over 10 years. Depending on whether that $250 billion is compared with the Republican or Democratic deficit-cutting proposals, that’s a third or a half of the Medicare cuts now being talked about.

We pay twice as much for our drugs as any other country, R&D is a BS excuse, and the inability of medicare to collectively bargain is anti-capitalistic and anti-market. How is it possible that in a capitalistic society a buyer isn’t allowed to bargain for bulk purchase? It’s just a wealth-redistribution scheme! And the proof is systems like the Veterans Administration, which is allowed to negotiate for lower prices, and does, typically paying about half as much for the same drugs.

Similarly, we should tighten what Medicare pays for CT or MRI tests a lot more and even cap what insurance companies can pay for them. This is a huge contributor to our massive overspending on outpatient costs. And we should cap profits on lab tests done in-house by hospitals or doctors.

I think that particular conflict of interest should be banned, but one must remember again that differing CT and MRI costs are largely a reflection of which hospitals have higher “mission” costs. It’s not the CT in the suburb that costs medicare more, it’s the CT in the inner-city.

Finally, we should embarrass Democrats into stopping their fight against medical-malpractice reform and instead provide safe-harbor defenses for doctors so they don’t have to order a CT scan whenever, as one hospital administrator put it, someone in the emergency room says the word head. Trial lawyers who make their bread and butter from civil suits have been the Democrats’ biggest financial backer for decades. Republicans are right when they argue that tort reform is overdue. Eliminating the rationale or excuse for all the extra doctor exams, lab tests and use of CT scans and MRIs could cut tens of billions of dollars a year while drastically cutting what hospitals and doctors spend on malpractice insurance and pass along to patients.

Tort reform may benefit but it’s effects will take decades to see. It’s almost impossible to adequately quantitate the cost of “defensive” medicine, and how it has inculcated generations of physicians to overtest, overtreat, and overspend on patients. Even if such changes were made, the paranoia runs deep within us. I agree it’s costly, but it will take more than just removing the threat of lawsuits to generate more responsible cost-practices for physicians.

Over the past few decades, we’ve enriched the labs, drug companies, medical device makers, hospital administrators and purveyors of CT scans, MRIs, canes and wheelchairs. Meanwhile, we’ve squeezed the doctors who don’t own their own clinics, don’t work as drug or device consultants or don’t otherwise game a system that is so gameable. And of course, we’ve squeezed everyone outside the system who gets stuck with the bills.
We’ve created a secure, prosperous island in an economy that is suffering under the weight of the riches those on the island extract.
And we’ve allowed those on the island and their lobbyists and allies to control the debate, diverting us from what Gerard Anderson, a health care economist at the Johns Hopkins Bloomberg School of Public Health, says is the obvious and only issue: “All the prices are too damn high.”

If you throw in a ban on Direct To Consumer Advertising on Drugs, implementation of CPRS or a universal record standard for the EMR (not these medicare-gauging EMRs that for-profit companies are designing), and better end-of-life planning, data, and management, I think we’d go a long way to reducing costs. Brill’s final recommendations hit the mark, but I’m concerned his obsession with the admittedly Kafkaesque chargemaster is a distraction. That’s not the true source of the excess costs. Rather I suspect it’s a way for hospitals to try to rationalize the redistribution of resources from medicare and the insured to cover their broader mission.
And one final petty complaint which as a surgeon I couldn’t resist:

Steve H.’s bill for his day at Mercy contained all the usual and customary overcharges. One item was “MARKER SKIN REG TIP RULER” for $3. That’s the marking pen, presumably reusable, that marked the place on Steve H.’s back where the incision was to go.

No! The pen is sterile! We have to mark the skin after prep – the alcohol based preps we use will wash away most markings placed before sterile preparation, and iodine preps hide them pretty well too. Complaining about a lot of potentially “reusable” items is also just not going to fly in this modern world of MRSA and nosocomial infections.

Denialism From Forbes Courtesy of Heartland Hack James Taylor

It’s fascinating when you catch the start of a new bogus claim enter the denialsphere, bounce from site to site, and echo about without any evidence of critical analysis or intelligence on the part of the denialists. A good example of this was an article by Heartland Institute’s contributor to Forbes, James Taylor, falsely claiming only a minority of scientists endorse the IPCC position on the causes of global warming. This new nonsense meme gets repeated by crank extraordinaire Steve Milloy, bounces the next day to Morano’s denialist aggregation site, and before long I’m sure we’ll be seeing it on Watt’s site, Fox news, and in a couple more weeks, in an argument with our conservative uncles.
The claim is, of course, a deception (or possibly total incompetence) on the part of Heartland’s “senior fellow for environment policy” (I wonder if there is significance to the use of “environment” as opposed to “environmental”). Linking this paper in the journal Organization studies, Taylor makes a false claim that a mere 36% of scientists, when surveyed, hold the consensus view. Anyone want to guess at the deception? Cherry-picking! It was a survey of largely industry engineers and geoloscientists in Alberta, home of the tar sands. In the study authors’ words:

To address this, we reconstruct the frames of one group of experts who have not received much attention in previous research and yet play a central role in understanding industry responses – professional experts in petroleum and related industries. Not only are we interested in the positions they take towards climate change and in the recommendations for policy development and organizational decision-making that they derive from their framings, but also in how they construct and attempt to safeguard their expert status against others. To gain an understanding of the competing expert claims and to link them to issues of professional resistance and defensive institutional work, we combine insights from various disciplines and approaches: framing, professions literature, and institutional theory.

This is pretty classic denialist cherry-picking and and is one of the most common deceptive practices of denialists like Taylor. By suggesting a survey of industry geoscientists can be generalized to scientists as whole, Taylor has demonstrated the intellectual dishonesty inherent in denialist argumentation. You might as well make claims about the consensus that tobacco causes lung cancer by surveying scientists in the Altria corporation headquarters.
The paper is actually quite interesting, and I’m glad I read it, as it is consistent with our thesis that ideological conflicts result in refusal to accept science that contradicts one’s overvalued ideas or personal interests. The authors surveyed a professional association of geoscientists in Alberta Canada (APEGGA), most of whom are working for the petroleum industry, and then performed a detailed analysis of their free-text responses on why they accept or reject climate science. What they found was there are 5 general “frames” used by respondents that their answers conformed to. The most common response was that global warming is real, and we need to act with regulation to address the problem (at 36%, the number quoted by Taylor to suggest there is no consensus), another 5% expressed doubt at the cause but agreed green house gases needed to be regulated. The second most common responses were “it’s nature” or “it’s a eco-regulatory conspiracy” and these responses showed a great deal of hostility in language towards environmentalism, proponents of global warming, liberalism etc. These came in at about 34% of responses and were more common from older white males in the higher tiers of the oil industry corporate structure. The most common remaining frame was a “fatalist” frame (17%) which could take or leave the science because hey, we’re screwed no matter what we do.
The authors weren’t attempting to validate the consensus with this study, but rather were trying to understand how scientists working in industry justify their position on global warming, as they often reject the consensus view of climate science. When a true cross-section of climate scientists is sampled, agreement with consensus is found among about 90% of scientists and 97% of those publishing in the field. A more appropriate summary of what these authors showed was that oil industry geoscientists and engineers most frequently express a view consistent with the consensus IPCC view and a need for regulation of green house gases. A similar but slightly smaller number express hostility to the consensus view and about half as many as that think we’re screwed no matter what we do.
It all would have been short-circuited if Forbes had exercised any kind of appropriate editorial control over this crank James Taylor. Or, if the echo chamber had read some of the comments on the initial post before rebroadcasting a false claim far and wide, but then, that would require intellectual honesty and a desire to promote factual information. Does Forbes have any interest that one of their bloggers is misrepresenting the literature in this way? Is this acceptable practice among their contributors? Is this the kind of publication they wish to be?
Finally, I see the authors of the paper (who I alerted to the Forbes article’s presence – they clearly were not contacted by Taylor for comment) have response. From their comment:

First and foremost, our study is not a representative survey. Although our data set is large and diverse enough for our research questions, it cannot be used for generalizations such as “respondents believe …” or “scientists don’t believe …” Our research reconstructs the frames the members of a professional association hold about the issue and the argumentative patterns and legitimation strategies these professionals use when articulating their assumptions. Our research does not investigate the distribution of these frames and, thus, does not allow for any conclusions in this direction. We do point this out several times in the paper, and it is important to highlight it again.
In addition, even within the confines of our non-representative data set, the interpretation that a majority of the respondents believe that nature is the primary cause of global warming is simply not correct. To the contrary: the majority believes that humans do have their hands in climate change, even if many of them believe that humans are not the only cause. What is striking is how little support that the Kyoto Protocol had among our respondents. However, it is also not the case that all frames except “Support Kyoto” are against regulation – the “Regulation Activists” mobilize for a more encompassing and more strongly enforced regulation. Correct interpretations would be, for instance, that – among our respondents – more geoscientists are critical towards regulation (and especially the Kyoto Protocol) than non-geoscientists, or that more people in higher hierarchical positions in the industry oppose regulation than people in lower hierarchical positions.

Incompetence or deception by Taylor? You tell me. Either way, this is the kind of shoddy, non-academic discourse we get from bogus ideological think tanks like Heartland. They should be embarrassed.
Article Cited:
Lianne M. Lefsrud and Renate E. Meyer
Science or Science Fiction? Professionals’ Discursive Construction of Climate Change Organization Studies November 2012 33: 1477-1506, doi:10.1177/0170840612463317