A Warning From One Who Knows

March 12th, 2020 by Tom Lynch

CoVid 19 appears to have begun in China. It then made its way around the world, and is now an “official global pandemic.” Last night, Donald Trump, in television primetime, addressed the nation and described what he and his administration are doing and plan to do to mitigate the pandemic’s effects in America. I won’t get into what I thought about his address, except to say that until the Fed intervened two hours ago, the stock market was down 9% and was on pace to have its sixth-worst one-day decline in history. So much for Wall Street’s response.

This morning, Trump, sitting in the Oval Office with Ireland’s Prime Minister, Leo Valadkar, answered questions from the press. He repeatedly made the point that things in America are ever so much better than in Europe, which he seemed to blame for our current pandemic difficulties. We have the “best doctors in the world” and all the resources needed to defeat the oncoming enemy. More than once, he said, “We’ve only had 32 deaths.” He opined in that certitudinous way of his that the virus will go away, maybe in a month or two, and urged everyone to “keep separation.”

I mention this by way of introducing the longest post WorkersCompInsider has ever published, about 2,400 words. And it’s all Dr. Jennifer Christian’s fault.

Jennifer, as many of you may know, is the Moderator of WFDRoundtable, an intelligent, illuminating and educational group chat site for clinicians, academics, workers’ compensation professionals, and anyone else who might be interested in learning what the medical profession, in general, is doing and thinking about sick and injured people. I wrote glowingly about Jennifer and her work in 2014. Might be worth a revisit.

This morning’s Roundtable arrived with Jennifer introducing a Facebook post by Dr. Daniele Macchini, from the Humanitas Gavazzeni hospital in Bergamo, Italy (northeast of Milan). Dr. Macchini is at the center of Italy’s CoVid 19 storm. He is smack dab in the middle of it, and what he’s seen isn’t pretty. He and his colleagues in northern Italy have been through a lot in the last couple of weeks, and what he’s written should be read by every American. it is a picture of what can, and very likely will, happen here, despite our President’s protestations to the contrary.

This is Dr. Macchini’s story. It’s been Google-Translated from Italian.

In one of the constant emails that I receive from my health department more than daily now these days, there was also a paragraph entitled “being sociably responsible”, which made some recommendations that I support. After thinking for a long time if and what to write about what is happening to us, I felt that silence was not at all responsible. I will therefore try to convey to people “not involved in the work” and more distant from our reality, what we are experiencing in Bergamo during these pandemic days from Covid-19.

I understand the need not to panic. I also understand the economic damage and I am also worried about that. After the epidemic, the tragedy will start again. However, apart from the fact that we are literally also devastating our National Health Service from an economic point of view, I allow myself to raise the importance of the health damage that is likely throughout the country and I find it nothing short of “chilling” for example that a red zone already requested by the region has not yet been established for the municipalities of Alzano Lombardo and Nembro (I would like to clarify that this is pure personal opinion).

I myself looked with some amazement at the reorganizations of the entire hospital in the previous week, when our current enemy was still in the shadows: the wards slowly “emptied”, the elective activities interrupted, the intensive therapies freed to create as many beds as possible. Containers arriving in front of the emergency room to create diversified routes and avoid any infections. All this rapid transformation brought into the corridors of the hospital an atmosphere of surreal silence and emptiness that we still did not understand, waiting for a war that was yet to begin and that many (including me) were not so sure would never come with such ferocity . (All this was done in silence and without publicity.)

I still remember my night watch a week ago that passed anxiously as I waited for a call from the microbiology unit. I was waiting for the outcome of a swab on the first suspect patient in our hospital, thinking about what consequences it would have for us and the clinic. If I think about it, my agitation for one possible case seems almost ridiculous and unjustified, now that I have seen what is happening.

Well, the situation is now nothing short of dramatic. No other words come to mind. The war has literally exploded and the battles are uninterrupted day and night. One after the other the unfortunate poor people come to the emergency room. What they have is nothing like the complications of a flu. Let’s stop saying it’s a bad flu. In these 2 years I have learned that the people of Bergamo do not come to the emergency room without cause. They did well this time too. They followed all the indications given: a week or ten days at home with a fever without going out and risking contagion, but now they can’t take it anymore. They can get enough breath, they need oxygen.

Drug therapies for this virus are few. The course mainly depends on our organism. We can only support it when it can’t take it anymore. It is mainly hoped that our body will eradicate the virus on its own, let’s face it. Antiviral therapies are experimental on this virus and we learn its behavior day after day. Staying at home until the symptoms worsen does not change the prognosis of the disease.

Now, however, that need for beds in all its drama has arrived. One after another, the departments that had been emptied are filling up at an impressive rate. The display boards with the names of the sick, of different colors depending on the operating unit they belong to, are now all red and instead of the surgical operation there is the diagnosis, which is always the same cursed: bilateral interstitial pneumonia.

Now, tell me which flu virus causes such a rapid tragedy. Because that’s the difference (now I’m going down a bit in the technical field): in classical flu, apart from infecting much less of the population over several months, cases can be complicated less frequently, only when the VIRUS destroying the protective barriers of the our respiratory tract allowing BACTERIA normally resident in the upper tract to invade the bronchi and lungs, causing more serious cases. Covid 19 is mild in many young people, but in many elderly people (and not only) it causes a real Sudden Acute Respiratory Syndrome because it arrives directly in the alveoli of the lungs and infects them making them unable to perform their function.

Sorry, but to me as a doctor it shouldn’t reassure you that the most serious are mainly elderly people with other pathologies. The elderly population is the most represented in our country and it is difficult to find someone who, above 65 years of age, does not take at least the tablet for pressure or diabetes. I also assure you that when you see young people who end up in intubated intensive care, pronated or worse in ECMO (a machine for the worst cases, which extracts the blood, re-oxygenates it and returns it to the body, waiting for the organism, hopefully, heal its lungs), any comfort you might take from being young passes then and there.

And while there are still people on social networks who pride themselves on not being afraid by ignoring the indications, protesting that their normal lifestyle habits are “temporarily” in crisis, the epidemiological disaster is taking place. And there are no more surgeons, urologists, orthopedists. We are only doctors who suddenly become part of a single team to face this tsunami that has overwhelmed us. The cases multiply, we arrive at the rate of 15-20 hospitalizations a day all for the same reason. The results of the swabs now come one after the other: positive, positive, positive. Suddenly the emergency room is collapsing.

Emergency provisions are issued: help is needed in the emergency room. A quick meeting to learn how the first aid management software works and a few minutes later they are already downstairs, next to the warriors on the war front. The screen of the PC with the reasons for the access is always the same: fever and respiratory difficulty, fever and cough, respiratory insufficiency etc … Exams, radiology always with the same sentence: bilateral interstitial pneumonia, bilateral interstitial pneumonia, bilateral interstitial pneumonia. All to be hospitalized. Someone already to intubate and go to intensive care. For others it is too late …

Intensive care becomes saturated, and where intensive care ends, more are created. Each ventilator becomes like gold: those of the operating rooms that have now suspended their non-urgent activity become places for intensive care that did not exist before. I found it incredible, or at least I can speak for Humanitas Gavazzeni (where I work) how it was possible to put in place in such a short time a deployment and a reorganization of resources so finely designed to prepare for a disaster of this magnitude. And every reorganization of beds, departments, staff, work shifts and tasks is constantly reviewed day after day to try to give everything and even more.

Those wards that previously looked like ghosts are now saturated, ready to try to give their best for the sick, but exhausted. The staff is exhausted. I saw fatigue on faces that didn’t know what fatigue was despite the already grueling workloads they had. I have seen people still stop beyond the times they used to stop already, for overtime that was now habitual. I saw solidarity from all of us, who never failed to go to our internist colleagues to ask “what can I do for you now?” or “leave alone that shelter that I think of it.” Doctors who move beds and transfer patients, who administer therapies instead of nurses. Nurses with tears in their eyes because we are unable to save everyone and the vital signs of several patients at the same time reveal an already marked destiny.

There are no more shifts, schedules. Social life is suspended for us. I have been separated for a few months, and I assure you that I have always done everything possible to constantly see my son even on the days of taking the night off, without sleeping and postponing sleep until when I am without him, but for almost 2 weeks I have voluntarily avoided my son nor my family members for fear of infecting them and in turn infecting an elderly grandmother or relatives with other health problems. I’m happy with some photos of my son that I regard between tears and a few video calls.

So be patient too, you can’t go to the theater, museums or gym. Try to have mercy on that myriad of older people you could exterminate. It is not your fault, I know, but of those who put it in your head that you are exaggerating and even this testimony may seem just an exaggeration for those who are far from the epidemic, but please, listen to us, try to leave the house only to indispensable things. Do not go en masse to stock up in supermarkets: it is the worst thing because you concentrate and the risk of contacts with infected people who do not know they are higher. You can go there as you usually do. Maybe if you have a normal mask (even those that are used to do certain manual work) put it on. Don’t look for disease masks. Those should serve us and we are beginning to struggle to find them. By now we have had to optimize their use only in certain circumstances, as the WHO recently suggested in view of their almost ubiquitous impoverishment.

Oh yes, thanks to the shortage of certain devices, I and many other colleagues are certainly exposed despite all the means of protection we have. Some of us have already become infected despite the protocols. Some infected colleagues in turn have infected family members and some of their family members already struggle between life and death. We are where your fears could make you stay away. Try to make sure you stay away. Tell your elderly or other family members to stay indoors. Bring him the groceries please.

We have no alternative. It’s our job. In fact, what I do these days is not really the job I’m used to, but I do it anyway and I will like it as long as it responds to the same principles: try to make some sick people feel better and heal, or even just alleviate the suffering and the pain to those who unfortunately cannot heal.

On the other hand, I don’t spend a lot of words about the people who call us heroes these days and who until yesterday were ready to insult and report us. Both will return to insult and report as soon as everything is over. People forget everything quickly. And we’re not even heroes these days. It’s our job. We risked something bad every day before: when we put our hands in a belly full of blood of someone we don’t even know if he has HIV or hepatitis C; when we do it even though we know it has HIV or hepatitis C; when we sting with the one with HIV and take the drugs that make us vomit from morning to night for a month. When we open with the usual anguish the results of the tests at the various checks after an accidental puncture hoping not to be infected. We simply earn our living with something that gives us emotions. It doesn’t matter if they are beautiful or ugly, just take them home.

In the end we only try to make ourselves useful for everyone. Now try to do it too though: with our actions we influence the life and death of a few dozen people. You with yours, many more. Please share and share the message. We must spread the word to prevent what is happening here in Italy.

A Puzzlement Before The WCRI’s Annual Conference

March 3rd, 2020 by Tom Lynch

Thoughts and questions before heading to the Workers’ Compensation Research Institute’s (WCRI) annual conference this week in Boston.

Despite the erstwhile efforts of certain folks to put a big lid on scientific data and bury it all deep in the ground, the U.S. Bureau of Labor Statistics (BLS) continues to publish interesting and compellingly thought-provoking work. Take the paradox of union membership and earnings, for example.

Beginning of the paradox: Non-union wage and salary workers earn only 81% of what union members earn. Union workers in 2019 earned an average of $1,095 per week, as opposed to $892 for non-union workers, a difference of $203 per week, which, if you’re doing the math, is $10,556 per year.

The difference in earnings for men and women is stark: Men in unions earn an average of $1,147 per week, which contrasts with non-union earnings of $986. The difference here is $161 per week, or $8,372 per year. Unionized women, on the other hand, earn less than the men, but way more than non-unionized women: $1,018 versus $792, a difference of $226 per week, or $11,752 per year.

Clearly, union members earn significantly more than non-union workers.

So, will somebody tell me why union membership has been declining for decades? Every year, God bless ’em, the brainiacs at the BLS tell us by just how much, which is the second part of the paradox.  In January, 2020, BLS published data for 2019, which showed the union membership rate for wage and salary workers to be 10.3%, down 0.2% from 2018. Of course, our workforce is made up of both private and public sector workers, and here the public sector saves the day. The union membership rate of public-sector workers, at 33.6% is more than five times higher than the 6.2% rate for private-sector workers.

Some say the reason for declining union membership is the hefty annual dues union members have to pay. Well, the most any worker will pay in dues to the International Brotherhood of Electrical Workers for 2020 is $492; for the United Auto Workers, it’s $843.84. It doesn’t seem as if sky-high dues can be the answer.

I don’t know whether WCRI, or anyone else for that matter, has studied whether there is a statistically significant difference in workers’ compensation injuries and costs between union and non-union wage and salary workers. Might be interesting to find out whether the 10.3%, in addition to earning more, has better workers’ compensation performance

Hope to see you in Boston

Gun Deaths in America: An Unending Tragedy

September 5th, 2019 by Tom Lynch

September, 1970

Let me tell you a story.

We call it “going back to the world.” Home in the USA. And I’ve arrived in one piece. For the last couple of years I’ve been running around the jungles of Vietnam. My new orders direct me to report to the Army’s Officer Candidate School at Fort Benning, Georgia. I know the place well. It’s where I was trained and Commissioned a 2nd Lieutenant. Then on to Airborne and Ranger schools. Now a Captain, the job is to train the next bunch of happy warriors. My wife and I settle into the house at 3660 Plantation Road in the fine city of Columbus. It’s a nice neighborhood.

A few months after moving in a new civilian worker shows up at my office in the Infantry School. His name’s Bob. He’s a GS12 research analyst and I have no idea why he’s here, but he has a disability that makes it hard for him to walk or move even moderately weighted stuff. He’s rented a house in Columbus and is trying to figure out how to move his junk in. My wife and I offer to help.

So, on a sunny Saturday morning in the deep south we get into Marilyn’s red Corvair Corsa with turbocharged engine and dual carburetors, show up at Bob’s new place, and find a UHaul truck in his driveway packed with everything he owns. We get to work toting box after box into the house and putting it all where Bob wants it to go. It’s taken us all morning, but around noon we’re done and we sit down on Bob’s new furniture to celebrate the end of Bob’s beginning. Marilyn’s never met Bob, whom I’ve charitably described as being “a little strange.”  So, being a curious person she nicely asks about his life. This goes on for a while until the big moment.

The big moment is when Bob says to Marilyn, “Wanna see my hair-trigger Colt 45s?”

It’s like an E. F. Hutton commercial. Everything stops. I freeze for a second and then say, “Bob, do you really have hair-trigger Colt 45s?” He says, “Sure do. Two of ’em. They’re pearl-handled, too. Want to see?”

He’s asking a guy who’s just finished two years dodging bullets and other bad things in a spot where serious people really wanted to kill him and his men. To say I have developed a healthy respect for any kind of gun is not giving that phrase the value it needs. Having seen up close what they can do, the accidents that can happen, actually did happen, makes me scared to death of them. I’m not scared when they’re in my hands, but in somebody else’s who probably doesn’t know what he’s doing? I’m not scared yet, though, because Bob has yet to produce the firepower, but my tension level rises like a Goddard Rocket.

I look Bob dead in the eye and say, “Bob, please don’t get the 45s. Leave em’ right where they are. Marilyn and I have to be going. Hope you like your new place.” And with that, we leave.

We get back into the red Corvair Corsa with turbocharged engine and dual carburetors and drive home. When we get to the house on Plantation Road I pay the babysitter and look at the two-year-old daughter I’m just getting to know. And I think about the pearl-handled, hair-trigger Colt 45s in Bob’s house.

September, 2019 

Back in 1970 slightly more than 50% of Americans, mostly men, owned a firearm. Since then, although the population has grown, the percentage ownership has declined to 22.4%. Nonetheless, Harvard and Northeastern University researchers conclude there are about 265 million  handguns and rifles in the country now. Three percent of gun owners, super owners, own more than 50% of all firearms in the country. For the other 97%, average ownership is three firearms, mostly handguns.

Femicide, abusive men killing their intimate partners, is five times more likely if the abuser has a handgun and lives with the victim. Research shows the number one contributing factor to femicide is unemployment. Potential femicide victims who do not live with the abuser and own a handgun are significantly less likely to be killed by their abuser.

In 70% of workplace shooting deaths, the perpetrator used a handgun. Workplace shootings have declined significantly since the 1990s, but the 70% figure still holds. In the last 50 years there have been 50 workplace mass shootings with an average death count of six per event. According to Jillian Peterson and James Densley, who study mass shootings for a project funded by the National Institute of Justice: 

The perpetrators were almost exclusively men (94 percent) with an average age of 38 (the youngest was 19, the oldest was 66). More than three-quarters (77 percent) were blue-collar workers, and 53 percent had experienced a recent or traumatic change in work status before the shooting.

A University of Washington 2017 study found that three million Americans carry a loaded handgun daily; nine million do so at least once a month.

The National Center for Health Statistics, a unit of the Centers for Disease Control and Prevention, annually publishes National Vital Statistics Reports. One of those reports is about how we die. In Deaths: Final Data for 2017 (most recent data collection year), we note 38,396 deaths caused by firearms. Of those deaths, 23,854 were by suicide, 14,542 by homicide. Despite comprising 12.1% of the US population, non-hispanic blacks were homicide victims in 57% of the cases. Unfortunately, all CDC can do is report the numbers? Why? Because a 1996 appropriations act contained something that has come to be known as the Dickey Amendment. That amendment is interpreted to prohibit the CDC from doing any research into gun violence. The amendment says federal funding could not be used to “advocate or promote gun control.”  Since more than 38,000 people die by gun violence per year, is it too much to ask that the Centers for Disease Control and Prevention spend a few million of its $5 billion budget to research and analyze gun violence. Seems a modest proposal to me.

Although there is no universally accepted definition of a mass shooting, the Congressional Research Service defines a “mass shooting” as one in which four or more people are killed, not including the shooter. Using that definition, there have been 164 such events from 1966 through August, 2019. But they are increasing in frequency and deadliness. If the definition were expanded to include the death of the shooter, the raw numbers would rise substantially. Even so, mass public shootings represent only 0.5% of all homicides by firearms annually. But they are the incidents that garner all the attention, which the mass shooter is craving in most cases. And bigger body counts mean bigger headlines. One recently thwarted shooter posted that, “A good 100 kills would be nice,” and another wanted to “break a world record.”

In mass public shootings, the weapon du jour is the assault rifle. The National Shooting Sports Foundation has estimated that approximately 5 million to 10 million AR-15 style rifles exist in the U.S. Regarding assault rifles, I know a thing or two. And I can say with complete certainty and a good deal of experiential credibility that there is not a single reason on God’s lovely earth why anyone other than police and my military brothers should have one, especially one with automatic fire capability. Anybody who tells you differently is chock full up to their eyeballs with what makes the grass grow green and tall.

Now, I would not be an unhappy guy to wake up one morning to discover that all firearms in the hands of civilians have gone *poof* in the night. We all know that will never happen. But as Peterson and Densley argue:

One step needs to be depriving potential shooters of the means to carry out their plans. Potential shooting sites can be made less accessible with visible security measures such as metal detectors and police officers. And weapons need to be better controlled, through age restrictions, permit-to-purchase licensinguniversal background checkssafe storage campaigns and red-flag laws — measures that help control firearm access for vulnerable individuals or people in crisis.

Regarding Bob and his pearl-handled, hair-trigger Colt 45s? One evening in 1975 a bullet from one of them went straight through his head. Police classified it an accident, but I didn’t buy that for one minute.

 

 

 

 

Workers Memorial Day – April 28.

April 26th, 2019 by Tom Lynch

Today, just in time for Worker Memorial Day this coming Sunday, the Bureau of Labor Statistics (BLS) released employee injury and fatality data for 2017 contrasted with 2016. I guess you know the Great Recession is really over when worker injuries and fatalities reach pre-recession levels.

Compared with 2016, worker fatalities declined in 2017 – by 43 – from 5,190 to 5,147, a negligible and statistically insignificant difference of 0.8%.

Curiously, transportation incidents make up only 6% of non-fatal worker injuries, but 40% of fatalities. Essentially, 3% of all employment transportation incidents result in fatalities. Think about that the next time you merge into traffic on the freeway.

If you’ve ever wondered why car and truck manufacturers now devote so much effort to robotic, AI safety enhancements for their machines, you only have to look at the chart above to understand. They’re banking that taking the human out of the picture will reduce fatalities and sell more vehicles. In the end, everything reduces to economics.

Here at the Insider, we offer heartfelt condolences to the families and friends of the 5,147 men and women who died on the job in 2017. May they rest in peace.

After Catching Bus, Dog Still Doesn’t Know What To Do. But The Bus Just Got Bigger!

March 26th, 2019 by Tom Lynch

In February, 2018, a Texas-led coalition of 20 states sued the federal government claiming the Affordable Care Act is unconstitutional in its entirety. The states argued that after Congress in December 2017 gutted one of its major provisions, a financial penalty for not having health insurance, known as the “individual mandate,” the rest of the law became unconstitutional.

In June, 2018, the US Department of Justice announced it would not defend the suit, which prompted a counter-coalition of states, led by California, to step in to defend the law. In the Brief, the Trump Administration, while refusing to defend, had agreed the individual mandate was unconstitutional, but argued this only invalidated the ACA’s preexisting condition protections and not the remainder of the ACA. This was ironic, indeed, because the part of the ACA with the most public popularity is the part protecting preexisting conditions. Attorney General Jeff Sessions pointed out he had made the not-to-defend decision after conferring with the President.

In December, Judge Reed O’Connor, of the 5th Circuit Court, ruled in favor of the Texas coalition and declared the entire Affordable Care Act unconstitutional. Very few legal scholars, make that nearly none, thought Judge O’Connor’s ruling would stand. Many died-in-the-wool conservatives, make that nearly all, thought the same. We wrote about this in a “Dog Catches The Bus. Now What?” post.

Last night, the Department of Justice sent a two-sentence letter to the U. S. Court of Appeals for the Fifth Circuit saying the DOJ now supports Judge O’Connor’s ruling that the entire ACA be struck down. Further, it will shortly file a Brief endorsing the decision. Here’s the letter:

The Department of Justice has determined that the district court’s judgment
should be affirmed. Because the United States is not urging that any portion of the
district court’s judgment be reversed, the government intends to file a brief on the
appellees’ schedule.

So, in two sentences, the DOJ went from everything in the ACA, except the preexisting conditions part, is constitutional, to everything is unconstitutional.

Reaction in Republican circles has not exactly been one of untold delight. In fact, so far, it’s been as quiet as midnight in Death Valley. So, what was William Barr thinking and why did his minions send the midnight missive?

Here’s a thought. Since most of the heavy money is on Judge O’Connor’s ruling being overturned somewhere along Appellate Way, could the DOJ have sent its billet doux with the intention of showing its ultra-conservative allies that it’s with them all the way, while all the while realizing it will never have to put the ACA toothpaste back in the tube? Think about it.

After all, you have to admit it’s easier to think about that than about what will happen if O’Connor’s ruling becomes the law of the land.

We’re goin’ right straight back to 2010
And start the healthcare war all over again!

God help us.

It Really Is The Prices, Stupid!

March 21st, 2019 by Tom Lynch

Trying to understand American health care these days is a little like trying to do the breast stroke through molasses. A lot of effort for not much progress.

The scope of the issue is vast. In 2017, US health care spending grew 4.6%, exactly double the growth rate of inflation, to $3.5 trillion. In 2018, it grew another 4.4% to $3.65 trillion. That’s 18% of US Gross Domestic Product (GDP). To put this in perspective, consider this: $3.65 trillion is more than the entire GDP economies of Italy and Spain – combined! It is $1 trillion more than the entire GDP of France and  equals that of Germany’s $3.6 trillion GDP.

Each of the health care players say they want to do something about this, just as long as you don’t touch their particular slice of the pie. And, because the health care lobby dwarfs every other one, we’re reduced to nibbling around the edges.

In 2003, Uwe Reinhardt, Gerard Anderson, Peter Hussie and Varduhi Petrosyan published their seminal work, It’s The Prices Stupid: Why The United States Is So Different From Other CountriesThey examined health care data from 30 OECD countries for the year 2000. Here is the basic conclusion from their Abstract:

U.S. public spending as a percentage of GDP (5.8 percent) is virtually identical to public spending in the United Kingdom, Italy, and Japan (5.9 percent each) and not much smaller than in Canada (6.5 percent). The paper also compares pharmaceutical spending, health system capacity, and use of medical services. The data show that the United States spends more on health care than any other country. However, on most measures of health services use, the United States is below the OECD median. These facts suggest that the difference in spending is caused mostly by higher prices for health care goods and services (my emphasis) in the United States.

In 2017, Reinhardt died, after which his co-authors decided to re-examine their original conclusions and publish their findings as a tribute to him. Their new paper, It’s Still The Prices, Stupid, which they published in January, 2019, concluded that their original conclusions were “still valid.”

The conclusion that prices are the primary reason why the US spends more on health care than any other country remains valid, despite health policy reforms and health systems restructuring that have occurred in the US and other industrialized countries since the 2003 article’s publication. On key measures of health care resources per capita (hospital beds, physicians, and nurses), the US still provides significantly fewer resources compared to the OECD median country. Since the US is not consuming greater resources than other countries, the most logical factor is the higher prices paid in the US. Because the differential between what the public and private sectors pay for medical services has grown significantly in the past fifteen years, US policy makers should focus on prices in the private sector.

Another way to look at this is to compare the growth of health care utilization with the growth of prices. This produces some highly informative, surprising and, sometimes confounding, data. For example, from 2012 through 2016, US hospital in-patient prices rose 24.3%, yet in-patient utilization decreased 12.9%. I guess all that hospital consolidation has really lowered hospital prices, hasn’t it? During that period, and due primarily to the opioid epidemic, prescription drug utilization was the only medical service whose utilization rose, and it was up only 1.9%, despite the prices of prescription drugs rising 24.9%.

Question: Who has the most skin in this game?

Answer: Employers and the 156,199,800 people who work for them.

That answer is why I believe Warren Buffet, Jamie Diamond and Jeff Bezos, three major employers, have formed their joint health plan, Haven, and hired Atul Gawande to run it.  They have given Dr. Gawande time and a lot of money not just to slow the spending growth in their respective companies, but to reverse it. Buffet has spoken loudly about how health care costs place America at a competitive disadvantage. He has been vocal in his criticism of Republicans’ devotion to reducing corporate taxes, which, at 1.9% of GDP, are now the lowest among advanced nations and pale to near insignificance when compared to the health care costs borne by employers. He has said, “Medical costs are the tapeworm of American economic competitiveness.” Further, they are a major cause for little or no real wage growth.

More proof for his point: According to the US Census Bureau, employer sponsored insurance plans (ESIs) cover 56% of the US population. In 2018, the year we hit $3.65 trillion, the average annual premium for a family in an ESI was $19,616, of which employees paid an average of 29%, or $5,688. Employees in family plans also had an average deductible of $2,788, plus co-pays. So, even without the co-pays, employees are paying more than $8,000 for an ESI family plan. In 2019, we will blow through $20,000 for the cost of an ESI family plan. This is patently unsustainable and leads to two inescapable conclusions: First, Washington has not fixed this, and, given past experience, it is doubtful it ever will, regardless of efforts by progressives. Second, employers are the only people with the leverage and urgent incentive to do anything constructive. They need to stop worrying about corporate taxes, get on the Buffet, Bezos and Diamond bus, and throw all the muscle they have at the American health care fiasco.

 

Robots In The Manufacturing Sector – We’re Lagging Behind

March 14th, 2019 by Tom Lynch

In 2013, Oxford professors Carl Frey and Michael Osborne published what became a highly read, highly cited and highly criticized study suggesting that machines could replace 47% of America’s jobs over the following 25 years. This landed like a stink bomb on the robotic revolution.

The study, which examined more than 700 US occupations, found that jobs in transportation, logistics, and administrative and office work were at “high risk” for automation. “We identified several key bottlenecks currently preventing occupations being automated,” said Dr. Osborne when the study was released. “As big data helps to overcome these obstacles, a great number of jobs will be put at risk.”

Following the study, academics and pundits jumped into the middle of the debate to argue its conclusions. In 2015, Forrester Research’s J. P. Gownder authored The Future Of Jobs, 2025: Working Side By Side With Robots and updated it two years later in 2017. Gownder concludes that, yes, AI will replace many jobs, but it will also create many jobs. He suggests a net job loss of perhaps 9.1 million, or about 7% of the workforce. Seven percent isn’t 47%, but 9.1 million jobs are a lot of jobs. And a lot of people who could be swept away by the rise of the robots.

So, clearly, the robots are coming. And, just as clearly, there is now, and will continue to be, human collateral damage. We should do everything in our power to help the millions of people the robots will displace. It would be outrageously stupid, and immoral as well, not to do that.

But if you believe development and adoption of robots is essential to keep the country competitive and prosperous, then you should be concerned, because other countries are outpacing us. By long shot.

A new report from the Information Technology & Innovation Foundation (ITIF) finds the US ranks 7th in the world in the rate of robot adoption in the manufacturing sector.

When controlling for worker pay, the situation is even more bleak. In that case, we’re 17th in the world.

The report relies on International Federation of Robots data for industrial robot adoption rates but adjusted the rankings to control for differences in manufacturing worker pay. The decision to use robots usually weighs the cost savings that can be achieved when a robot can perform a task instead of a human worker, and those cost savings are positively related to the worker compensation levels. Higher wages lead to faster payback, making more robots a more economical investment.

On a compensation-adjusted basis, the report found that southeast Asian nations significantly outperform the rest of the world in robot adoption, with South Korea, Singapore, Thailand, China, and Taiwan the top five nations, in that order. Moreover, China’s rate of robot adoption is so high, fueled by massive government subsidies, that if China and South Korea’s respective growth rates continue, by 2026 China will lead the world with the highest number of industrial robots as a share of industrial workers, when controlling for compensation levels.

Robert Atkinson, ITIF’s President, has some sensible suggestions for how we can catch up. Policy makers should listen to him.

Rob Restuccia Passes The Torch

February 25th, 2019 by Tom Lynch

Every once in a while in life, if you’re lucky, you’ll come to know and work with a person whose commitment to service, whose dedication to justice, whose devotion to helping the less fortunate among us live full and healthy lives is both humbling and inspirational. For me, such a person has been Rob Restuccia.

Rob is a founder of Health Care For All and Community Catalyst. Health Care For All was instrumental in making Massachusetts a first-in-the-nation model of near-universal health coverage in 2006, and Community Catalyst played a vital role in the passage of the Affordable Care Act in 2010 and its successful defense against repeal in 2017.

Since late-2003, Rob and I have served together on the Board of Commonwealth Care Alliance (CCA), a Massachusetts HMO serving dual-eligible beneficiaries, meaning they qualify for both Medicare and Medicaid. They are the sickest of the sick and the poorest of the poor, and they represent about 5% of the nation’s population, but consume 35% to 40% of our health care costs. As a founding Board member, Rob has been a constant north star to staying true to our mission. He is one of the reasons CCA has been the highest rated plan of its kind in the nation for each of the last two years. But much more than that, Rob is one of the reasons tens of millions in this country now have health insurance and no longer have to face impending disaster because they cannot afford the health care they need.

Now, Rob is dying.  Five months ago he was diagnosed with pancreatic cancer, a terrible disease. The cancer was too advanced for surgery. He tried chemotherapy, but that was unsuccessful. So, he has chosen to seek the highest quality of the life that remains, not the greatest quantity.

Today, the Boston Globe ran an op-ed by Rob. It is his farewell, his swan song, and it is beautiful. It is also a clarion call to continue the battle for universal health care, the kind every other developed nation on earth has, except America. It is a call that we treat health care as a basic, human right, not a privilege. If you do nothing else today, please read Rob’s articulate and rational argument for the cause to which he has devoted his life. In the article, he writes, “Though I will not live to see it, I am convinced the march toward universal, affordable, equitable, quality health care is unstoppable. The next generation of advocacy leaders will continue the work I leave unfinished.”

We will all be poorer with the passing of Rob Restuccia, whose entire, all too brief life has been dedicated to service to others. We can learn much from this brilliant and accomplished icon, both in the way he’s lived, and now in the way he’s dying.

The Wizard Behind The Curtain – Addendum To Drive Home The Point

February 14th, 2019 by Tom Lynch

Among other things, yesterday’s post made a point about the way the PBM system (if you can call it that) makes it difficult for uninsured Type 1 diabetics to buy insulin, because of price. To beat that horse even deader, here is an excerpt from a Kaiser Health News article, in partnership with NPR, published yesterday entitled, Insulin At A Fraction Of US Cost:

Almost one year to the day after her daughter’s diagnosis, Lija Greenseid and her family were visiting Quebec City, Canada, in July 2014. Her daughter’s blood sugar started spiking and Greenseid feared her insulin might have gone bad, so she went to a pharmacy. With no prescription and fearing that her daughter’s life was on the line, Greenseid was prepared to pay a fortune.

Instead the box of insulin pens that normally costs $700 in the U.S. was only around $65 or so.

“At that point I started tearing up. I could not believe how inexpensive it was and how easy it was,” Greenseid said.

“I said to [the pharmacist], ‘Do you have any idea what it’s like to get insulin in the United States? It’s just so much more expensive.’ And he turned to me and said, ‘Why would we want to make it difficult? You need insulin to live.’”

The more Greenseid traveled with her family, the more they realized how inexpensive insulin was everywhere except in the United States. In Nuremberg, Germany, she could get that $700 box of insulin pens for $73. The same box was $57 in Tel Aviv, Israel, $51 in Greece, $61 in Rome and $40 in Taiwan.

“We get so accustomed in the United States to thinking that health care has to be difficult and so expensive that people don’t even consider the fact that it could be so much easier and less expensive in other places,” Greenseid said. “In fact, that is the case in most countries.”

Take a moment out of your busy day and think about that. Please.

And answer this question: Do you  believe America’s 1.3 million Type 1 diabetics  who require insulin every day ─ just to stay alive ─ should be forced to pay hundreds, even thousands, of dollars a month for that medicine? Or are they not worthy enough to be treated like their fellow diabetics the world over?

The Wizard Behind The Curtain – Part 2

February 13th, 2019 by Tom Lynch

Let me tell you a story.

The year is 2015, and a workers’ compensation consultant is sitting in a highly respected insurer’s plush conference room. The consultant is meeting with the insurer’s Senior Vice President of Claims to negotiate price for an innovative specialty medicine program. What kind of program? Doesn’t matter.

The consultant has come armed with pro formas showing all costs of the program. Down to the penny. The problem is the insurer and the program are miles apart on what the insurer will pay the program’s doctors for each patient encounter. The Senior Vice President says, “Look, this isn’t exactly in our fee schedule, but the closest we can come to what is in the fee schedule is to pay your folks $85 per visit.” Hearing this, the consultant once again begins to explain why the fee needs to be $150 per visit.

This goes on for another half hour. The Senior VP finally says, “Well, maybe we could go to $91 per visit, but it’s the best we can do. Take it or leave it.” The consultant offers $140, but won’t go lower, because to do so would torpedo the program, which has demonstrated far more success, accompanied by significant cost savings, than others of its kind.

And then, it happens. The Senior Vice President in that plush conference room of this highly respected insurer says, “Hang on a minute. I’ve got it. You’re a specialty program, so we have a little latitude there. Charge us $300. We’ll pay you $150, and save our insureds $150 in the process.”

And that was how it was done. And it’s perfectly legal.

I tell that story by way of analogy.

Now let’s dream a bit. Imagine for a moment you are a pharmaceutical company CEO. You produce drugs that help sick people be healthy. Trouble is, the great big US healthcare system in which you operate makes Rube Goldberg seem like Thomas Edison. And in the center of your part of it sit pharmacy benefit managers, PBMs.

As we saw in Part One, the PBM industry has evolved in a rather chaotic way since Pharmaceutical Card System, Inc., invented the plastic benefit card in 1968. Over the intervening years, pharmacies and PBMs have developed into sometimes incestuous relationships. Today, three PBMs, Express Scripts, CVS Caremark and Optum RX, control 78% of the market. They wield tremendous power in drug pricing in a system designed to be opaque.

Essentially, the PBM’s job is to negotiate with pharmacies and drug companies, like yours, on behalf of their insurer and health plan clients. They create formularies, negotiate prices down (you give them a big discount in return for your drug being listed in their formulary), return some of the savings, called rebates,  to the clients (nobody really knows how much), and keep some for themselves. Seems simple, right? Well, it’s not. It’s infinitely more complicated and complex. And because only a very few actually understand PBMs, they remind me of the shenanigans in The Wizard Of Oz. However, it is that way only because we have allowed it to happen over the last four decades.

But back to you, Here’s your issue as a drug company CEO: You know, regardless of what price you set for your super-duper drug, you’re going to have to give a lot of it back as a discount to the PBM so it can give rebates to its clients. What’s a busy CEO to do?

Well, one answer is to set the price, the list price, so high that you’ll be able to provide a generous discount and still make what your finance folks say you must have for a profit. Just like in my analogy from above.

In a weird sort of way, this works most of the time for patients, but only if they have health insurance. What happens if they don’t? This is where things get sticky. Uninsured people get stuck paying the full list price, the one you inflated in order to provide the discount that allows you to make a profit and PBMs to (kind of) save money for their customers. This has been especially difficult for some uninsured Type 1 diabetics, who, as we have written previously (here and here), have had great difficulty paying for the insulin they need to take every day ─  just to stay alive.

Many employers have had enough of this. According to the National Business Group on Health, 75% of surveyed employers believe the rebate system does not serve to lower prices for employees, and 91% believe an alternative, more simple approach is required. Then there is CMS’s Alex Azar, of Ely Lilly fame, who wants you to price your drugs like Europeans do, which is a water fall lower than prices in the US. And let us not forget the current occupant of 1600 Pennsylvania Avenue, who, as yet unable to fulfill a campaign promise about a wall, has an outside chance of fulfilling one about drug prices.

Neither the healthcare industry, nor the US Chamber of Commerce like any of this. I imagine it might also be a bit awkward for quite a few US legislators who have been significant beneficiaries of the healthcare industry’s largesse, largess of the campaign contribution variety.

Regardless, I’m an optimist, and I keep hoping that in some way the wizard behind the healthcare curtain will go ‘poof,’ and be gone. Silly me.