#i dont even know how to phrase this its like. well in the grand scheme of things is this that big of a deal.

[loumandivorce]

theres specific kinds of media that are about Women Problems that are supposed to be fiercely feminist and relateable or whatever but all the problems are so middle class western white. theyre like. im bored. all the guys i meet are shallow. i am trapped in my job that pays well. i am in a slightly strained relationship w my family. like obviously these are issues that people go through that a lot of people relate to but is this what all media is about. is this all we have to discuss really.

[pwippy]

hey existing is pretty cool. and weird. everything wasnt and then everything was and like dimensions upon dimensions were created and will continue to exist even when all physical matter is gone. weird little particles mashed into different particles and so on and over a ton of time (which will barely be a blip in the grand scheme of things) until collections were formed and planets and other rocks were formed. then water which is SO WEIRD and hey look at that ive gone over like 8 billion years already. at some point life existed. and soso many life forms. weird stuff like bacteria and then theres SO MUCH of it. trying to create an estimate of how many life forms have existed and creating a network of what had turned into what (cant destroy matter innit? i ate a plant and that plant is now me but that plant is made of earth and energy from past plants and the sun yadda yadda) would 100% be impossible for like. ever.

idk why im creating paragraphs because this is already so long that this is more of a journal than something yall would gaf about but hey. you dont even know where the network would START. sun energy and like fusion and helium. sure. big bang. how did that happen? 2 black holes and a lot of energy. where did the energy come from? the concept of quantum uncertainty which "allows energy to be formed literally from nowhere" what. wtf. are we real. how does that work. i mean theres a wikipedia article explaining it but im not a wuantum mechanist im a random teen created from stardust or something. also im moving so its hard to read an ultimately subjective article that ik states something about plancks constant which immediately brings me flashbacks of chem.

anyways subjectivity leads me to my next point as im rapidly diverging from my other points! subjectivity. everything is subjective because (ithink) there isnt an omniscient being that can record everything as it really is. and an omniscient being isnt objective. knowledge vs application and linguistic phrasing of concepts is very different. is my blue your blue? what about a dogs vision? my experience is infinitely different from yours but so easily lumped together to create a common state of being. in terms of humans we have brains! they make subjectivity go brrr. theyre so easily affected by things which is so easily affected by things and on and on. technically speaking since you can scan a brain and see how it acts currently as well as look at itis history to see how it turned out that way. to an extent you can predict what someone will do based on that information, it works the same with physics, so TO AN EXTENT everything is predictable. hey but guess what. once you get to a certain scale a nice thing called entropy exists. which is in simple terms unpredictability. weird.

that brings me to the concept of determinism and other universes! if something is random that means an other event could have happened. this also applies to morals and ethics. saying you shouldve or couldve done something differently, like studying or helping someone, means that choice DID exist and therefore free will exists. also other universes. theres also a theory this universe was formed because 2 other universes merged. i need to look into that. another thing about universes is how variable they are. physics and what we know to be true could be completely false somrwhere else.

hey. philosophy! is what you did really what you did if you dont remember it? tree in a forest? dear evan hansen? thats just one concept upon trillions uppn trillions of other concepts our brains formed. what gives us the ability to comprehend anything anyways? is morals just a survival based aspect we call "academic" to sound like a higher force over something like schau. schaudenfreude. ? do animals have religion or a system of belief we couldnt even START to understand? if we give domesticated animals food and shelter what does that makes us to them?

i like my life but dang im procrastinating 💥💥

[house-of-kells]

A place where I am not myself.

Syntheticspacemagic | Fluff | Ikora x Shiro-4 | SFW 

Ikora had always liked being alone with her thoughts. Alone on mercury when the guardian went in after Osiris and Sagira, alone when she stormed her way through the crucible, and alone when it was just her and her ghost wandering the jungles of what had once been known as Africa, when she was still a fresh guardian.

But this time was different, staring out at the traveler as it pulled itself back together, Ikora felt, for once, uncomfortable with being alone with her thoughts.  she rubbed her palms over the smooth wood beneath her hands as she leaned out over the railing not unlike she had seen Zavala do so many times.  the dramatic irony was not lost on her.  It had been only 2 weeks since the guardian had returned from the tangled shore, informing the two remaining vanguard of Prince Uldren’s death. 

Despite having been the one to send the guardian on that journey, Ikora felt no sense of relief, no satisfaction, only what she could describe as disappointment. disappointment not in the guardian, but in herself, she had gone behind Zavala’s back to OK a mission that had in the grand scheme of things, accomplished nothing.  the two vanguard leaders still had not spoken.  

“Ikora.” a synthesized voice behind her spoke, low and solemn.  Ikora turned her head slightly, just enough to see the speaker from her peripheral vision.  Shiro-4, one of Cayde’s closest friends, leaned against the wall fifteen feet from where she stood, hands folded over his chest, regarding her with his robotic eyes, and for once Ikora wished that Exos’ could display just a little more emotion.  “Shiro, what are you doing here.” she responded in the same solemn tone, ordinarily she’d be more cordial, shaking his hand, all business, but today she just couldn’t muster the effort.

Shiro sported a new cloak sown from black cloth, instead of the yellow cloth he had worn originally, the cloak sported a long red stripe down its left half, as though mirroring the cloak Cayde had once worn. as he shifted his weight, Ikora caught a glint of silver at his hip, a small unassuming sidearm was strapped there.  

“I came to check in, got a message from Cayde saying he had died, and left some things for me.”  he shifted uncomfortably.  “whole place isn’t what I expected to come back to honestly.”  Ikora turned back to stare up at the traveler again.  “and what were you expecting Shiro?” Shiro stood up to his full height, no longer leaning against the wall, and approached. “wasn’t expecting Cayde dead and you and Zavala giving each other the cold shoulder, that’s for sure.”  he gestured to the railing next to her. “May I?” Ikora waved her hand in a dismissive gesture, and he mimicked her position, hands placed on the railing, only his eyes weren’t on the traveler.  

Ikora held the silence for a few long moments, cherishing it, before snapping it in her hands. “I never intended it to be like this.”  she said, lowering her eyes to the city. “I’m assuming you mean the guardian skipping off to the shore to do the deed.” Shiro quipped.  Ikora nodded in confirmation, honestly Shiro would have made a fine hidden had he been a warlock, his skills of perception almost beyond reason.  “I thought it would bring...” Ikora paused searching for a phrase to convey what she felt, in truth she had no idea what she had ‘thought it would bring’.  

Once again Shiro came to her rescue. “you thought it would help things make sense, like how it used to be.  you thought it would drive Zavala onto your path. you thought it would bring resolution to Cayde’s death.” again he had hit the nail on the head, but Ikora made no move to confirm his guess.  “I feel as though your words are wasted on me Shiro, why are you here exactly?”  the exo shifted a bit, clearly uncomfortable with the topic. “ah, well, you see...” he shrugged. “when Andal died, there was this restaurant I brought Cayde to, down in the city, it was sort of a place away from places, if you get what I mean.”  she didn’t. “No I don’t I’m afraid.”  Shiro sighed, rubbing the back of his head. “Cayde eventually ended up calling it ‘the place where I can be not myself’, its sort of a place where you don’t have to be a guardian for a while. you’re a guardian, but not there. you’re a soldier, but not there. you’re a civilian, a titan, a warlock, a hunter. but not there.”

Ikora finally looked over to the hunter, the barest hint of a smile gracing her face, the thought of a place where she could think things over not as the vanguard, not as a guardian, not as a scholar, but as herself, as Ikora, seemed oddly cathartic. 

“you know Shiro, I think I would like that.”  she said, keeping her eyes on the traveler.  the hunter nodded. “I’ll get it set up, and ping you the coordinates tonight, wear something nice.” he looked down at her robes. “and uh, not that sort of nice, like, normal nice.”  Ikora didn’t understand but nodded along anyway.  “Great.” Shiro said, rising up again to his full height “just look, not you.” he said, striding away. Ikora shook her head, wondering how in the world she could not look like herself. 

it had taken a few hours for Shiro to send her the coordinates as well as a time, and a few hours more for her to put together a suitable disguise, but Ikora had managed to dig the robes she had worn as a young guardian out of her closet, and reattach the shoulder sling to her old shotgun, Invective.  the robes were simple, maroon in color, with black leather serving to fill in the gaps, and a handy hood to pull over her head.  across her arm, Ikora had placed one of her old wearable colliders’, and had departed the tower in secret, placing an old teal helm over her head, and pulling up the hood about her neck.  

saying the restaurant was hard to find was the understatement of a lifetime, even with her ghost, Hugin, supplying active coordinates, it had taken them nearly two hours to find it, and the result both was and wasn’t what Ikora had been expecting.  put together from what seemed to be random bits of metal and wood, the ‘restaurant’ was nothing more than a large shack with a corrugated steel panel as a roof, hanging from the roof, just above the doorway, was a fizzled out neon sign suspended by wires threaded through what looked suspiciously like bullet holes; the sign read “the Middle of Nowhere”.  Ikora looked around, there was no sign of Shiro yet, and this didn’t feel like the sort of place to be alone in, and she began to have second thoughts.  letting out a small hum, Ikora leaned toward Hugin and said “Maybe this wasn’t the best idea...”  just as she began to turn to leave, a familiar voice called out to her.

“Ikora.” Shiro called from across the small grassy yard outside of the shack. jogging across, he stopped a few feet in front of her.  “I’m so glad you were able to make it.” Ikora nodded cautiously. “Shiro when you said a place...” she paused, uncertain. “I wasn’t expecting this.”  Shiro nodded, easily reading what she implied. “yeah I know, but give it a shot, and if you don’t like it, we don’t come back.  Deal?” Ikora felt a bit shocked by how forward he was being, she had never taken a chance to talk to Shiro without being in a vanguard meeting, and now that she was alone with him, his calm reassurance was... nice.  “Alright.” she managed to say.  “I can give it a try.”

“Fantastic.” Shiro replied, moving towards the shack, Ikora in tow.  before the pair arrived at the door, Shiro laid his arm across her shoulders; when she moved to step away, he tightened his grip. “okay Ikora, trust me on this, you’re gonna want me around here, at least until folks warm up to you, so just follow my lead.”  Ikora sighed slightly and nodded, Shiro nodded in return, before pushing open the door to the restaurant, while saying. “welcome to the Middle of Nowhere.”  

Despite its outward appearance, the inside of the shack was well lit, with round tables, their finish almost completely peeled off, and old rustic chairs, which probably never had any finish applied in the first place, light bulbs hung from cords stretching upwards to the ceiling;  off to the left on the far side of the single room was a bar, in similar condition to the tables and chairs.  as the pair entered, figures seated alone or in groups at the tables turned their eyes on Ikora and Shiro.  Ikora felt Shiro shift his hand down from her shoulder to around her waist, while he simultaneously raised his other hand into the air slightly and lowered his head in what Ikora could only describe as a half nod. the patrons, most of them hunters by Ikora’s wager, repeated the gesture, lowering their heads and raising their hands, before returning to their drinks or other activities. 

pulling her over to an empty table with two chairs, Shiro took his hand from Ikora’s waist and kicked one of the chairs out from the table a ways, before taking the other chair and sitting down.  Ikora took the chair shiro had moved, presumably for her in the weird way hunters did things, and sat, pulling herself up to the table.  after a moment a young woman came by and dropped two old menu’s onto the table between them. “Anything for drinks?” she asked, pulling out a notepad, her tone somewhat apathetic.  “Two glasses of water, and something for a departed friend if you get my meaning.”  Shiro chimed in.  the woman nodded, not looking up from the notepad. “Sure thing Shiro.” she turned on her heel and wove her way through the tables back to the bar.  Ikora stared after her for a few seconds before pulling one of the menu’s across the table and beginning to unfold it, turning her gaze back to Shiro. “they know you?” Shiro nodded. “yeah, and before you ask, they don’t care that we’re guardians, place operates on a ‘don’t ask don’t tell policy’” Shiro reached out and placed his hand on top of Ikora’s menu, obscuring her vision of the orders. “and don’t, order anything here.”  Ikora would have asked why but decided against it, Shiro was clearly in his element here, and it felt best to just follow his lead. 

The woman returned with the glasses and a dark bottle of cheap wine,  which Shiro took and thanked her, tipping her a few pieces of glimmer before turning his attention back to Ikora. “So Ikora.” he began, and Ikora braced herself. “I heard what happened, and I’m not talking about Cayde, I’m talking about you and Zavala.” there it was, the question she had hoped not to hear. “Listen Shiro, I appreciate this, but I don’t think” she was cut off by Shiro leaning forward, onto the table. “I know you don’t think this is a good Idea Ikora, but I want to hear your side of things, every guardian I’ve talked to knows Zavala’s side, but I want to hear yours.”

Ikora took a moment to compose herself, sifting through her memories, trying to find a place to start;  after she had compiled what she felt was a proper explanation, she cast her eyes downward to her hands.  “I didn’t understand.” she finally said, watching Shiro sit back, listening.  “with Cayde dead, I didn’t understand why Zavala didn’t want to go after Uldren Sov, at first I thought him a coward, too afraid of his own light’s frailty to trust anyone else to do a good job, it felt as though he thought if he couldn’t do something, no one could.”  Shiro nodded. “But that wasn’t the case.” he prompted, and Ikora shook her head. “No it wasn’t, after the guardian returned, and I felt no satisfaction, I turned my thoughts inward.” she looked up to Shiro’s glowing blue eyes.  “if we had sent an army, a raid party, or even a fire-team, the chances of an unnecessary loss would have skyrocketed, and...” she paused for a second, casting her eyes back down to her hands and willing herself to say what she had been avoiding, a result she had until now refused to face. “And despite all how much I despaired, Cayde was still just a single guardian, a loss of another guardian wouldn’t have changed that. simple numbers.”  

As Ikora stared down at her hands, clenched into fists, another gloved hand appeared, looking up slightly, Ikora watched Shiro place his right hand over top her left, a small gesture of reassurance.  “from up in the tower, it all seems like simple math and science.” he said, his tone soft. “if we lose two guardians instead of one, its a net loss, if we don’t prove a point here or there, net loss.” he stared at Ikora intently. “but down here, when the enemy really hits home, its not so simple anymore.”  Ikora nodded, and Shiro sat back in his chair, pouring some of the wine at the table into a spare glass and pushing it towards her.  “I know it’s tough, believe me, but it’ll get better.  I promise”  Ikora nodded, removing her teal helmet.  as the cool air hit her face, she felt her eyes burn, withing the confines and filtered air of her helmet, she had failed to realize she had begun to cry.  “thank you Shiro.” she managed, her voice warbling as she spoke;  she grasped the glass and took a sip, it had a strange, sour flavor to it, but not a flavor she despised. Shiro emptied his glass of water before filling it again with wine, and raised it slightly. “to Cayde.” Ikora nodded and raised her glass slightly off the table as well.

Ikora couldnt help but giggle as Shiro regaled her with yet another tale of Cayde’s antics before he became a vanguard, tipping back her glass, Ikora noticed she had run out of wine again, and went to pour more wine into her glass another time, only to have none pour from the bottle.  as she sat there, pondering why nothing was happening, Shiro gently took the bottle from her hand, and placed it on the table, next to the other empty bottle.  “I think that’s enough Ikora, its getting late.”  Ikora stared at him, dumbfounded. “It is?” she peered up at the small clock on a nearby wall, trying to will her vision to stop wobbling so she could see the time.  Shiro took her gently by the arm, and led her out of the bar, and Ikora had to admit, the cool night air did help straighten out her vision a bit, but not her balance, as she would have almost immediately fallen had it not been for Shiro’s support.  leaning her full weight against him, she stumbled along with him back in the vague direction of the tower.  as he helped her into her dormitory, Ikora put her free hand on his shoulder. “I wanted to thank you Shiro, it was nice to be away from the tower for a while.” Shiro seemed to nod. “whatever you say Ikora, you should get some sleep.”  not that it had been mentioned, Ikora felt the weight of exhaustion creeping over her body, nodding along with him, she mumbled. “yes, sleep would be nice...” Shiro helped her over to the couch, too unfamiliar with the layout of her room to help her to her bed, before turning to leave. “try to take it easy tomorrow Ikora.” he called over his shoulder, Ikora simply waved her hand in agreement, pulling Invective off of her shoulder, and allowing it to drop onto the ground with a loud thud.  the last thing she remembered was watching Shiro close the door behind him, bathing the room in darkness.

[68ejgppd-blog]

Is health insurance more expensive if the insured suffered a miscarriage?

Is health insurance more expensive if the insured suffered a miscarriage?

My girlfriend had an unplanned pregnancy before I met her and suffered a miscarriage 17 weeks in. I plan to marry her and have a family one day. I already know that women that have miscarried are more at risk of it happening again with subsequent pregnancies. I also know that health insurance is more expensive for young women than for young men. I just wonder if the health-care provider considers a previous miscarriage a potential risk and raises the premium price as a result.

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[kristinsimmons]

Obsessive Measurement Disorder: Etiology of an Epidemic

By KIP SULLIVAN JD 

Review of The Tyranny of Metrics by Jerry Z. Muller, Princeton University Press, 2018

In the introduction to The Tyranny of Metrics, Jerry Muller urges readers to type “metrics” into Google’s Ngram, a program that searches through books and other material published over the last five centuries. He tells us we will find that the use of “metrics” soared after approximately 1985. I followed his instructions and confirmed his conclusion (see graph below). We see the same pattern for two other buzzwords that activate Muller’s BS antennae – “benchmarks,” and “performance indicators.” [1]



Muller’s purpose in asking us to perform this little exercise is to set the stage for his sweeping review of the history of “metric fixation,” which he defines as an irresistible “aspiration to replace judgment based on personal experience with standardized measurement.” (p. 6) His book takes a long view – he takes us back to the turn of the last century – and a wide view – he examines the destructive impact of the measurement craze on the medical profession, schools and colleges, police departments, the armed forces, banks, businesses, charities, and foreign aid offices.

Foreign aid? Yes, even that profession. According to a long-time expert in that field, employees of government foreign aid agencies have “become infected with a very bad case of Obsessive Measurement Disorder, an intellectual dysfunction rooted in the notion that counting everything in government programs will produce better policy choices and improved management.” (p. 155)

Muller, a professor of history at the Catholic University of America in Washington, DC, makes it clear at the outset that measurement itself is not the problem. Measurement is helpful in developing hypotheses for further investigation, and it is essential in improving anything that is complex or requires discipline. The object of Muller’s criticism is the rampant use of crude measures of efficiency (cost and quality) to dish out rewards and punishment – bonuses and financial penalties, promotion or demotion, or greater or less market share. Measurement can be crude because it fails to adjust scores for factors outside the subject’s control, and because it measures only actions that are relatively easy to measure and ignores valuable but less visible behaviors (such as creative thinking and mentoring). The use of inaccurate measurement is not just a waste of money; it invites undesirable behavior in both the measurers and the “measurees.” The measurers receive misleading information and therefore make less effective decisions (for example, “body count” totals tell them the war in Viet Nam is going well), and the subjects of measurement game the measurements (teachers “teach to the test” and surgeons refuse to perform surgery on sicker patients who would have benefited from surgery).

What puzzles Muller, and what motivated him to write this book, is why faith in the inappropriate use of measurement persists in the face of overwhelming evidence that it doesn’t work and has toxic consequences to boot. This mulish persistence in promoting measurement that doesn’t work and often causes harm (including driving good teachers and doctors out of their professions) justifies Muller’s harsh characterization of measurement mavens with phrases like “obsession,” “fixation,” and “cult.” “[A]lthough there is a large body of scholarship in the fields of psychology and economics that call into question the premises and effectiveness of pay for measured performance, that literature seems to have done little to halt the spread of metric fixation,” he writes. “That is why I wrote this book.” (p. 13)

A short history of Obsession Measurement Disorder in medicine

I read Muller’s book because I share his astonishment at the persistence of the measurement craze in the face of so much evidence that it is not working. Over the three decades that I have studied health policy, I have become increasingly baffled by people who promote various iterations of managed care in the face of evidence that they don’t work. In search of an explanation, I have, as Muller has, read books and news stories about the misuse of measurement in other fields, particularly education and banking. I have been especially baffled by the managed care movement’s enthusiasm for measuring the cost and quality of all actors in the health care system, an enthusiasm that emerged in the late 1980s when it was obvious that the propagation of HMOs, the movement’s founding project, was failing to control inflation. [2]

By the 1990s the enthusiasm for documents that handed out grades to insurance companies and providers on “consumer satisfaction,” mortality rates, etc. had become an obsession. Proponents of “report cards,” as these documents were called, hoped that “consumers” would read them and reward the good actors with their business and punish the bad actors by leaving them. That, of course, did not happen.

Frustrated by consumer disinterest in report cards, managed care proponents, such as the Medicare Payment Advisory Commission (MedPAC) and the Institute of Medicine (IOM), declared in the early 2000s that it was time to punish doctors and hospitals directly by rewarding them if they got good grades on crude measurements and punishing them if they didn’t. The term they used to describe this direct method of punishment was “pay for performance,” a phrase borrowed from the business world. By about 2004, that phrase had become so common in the health policy literature it was shortened to “P4P.”

The complete absence of evidence that P4P would improve the quality of medical care didn’t matter to MedPAC and other P4P advocates. [3] As evidence has piled up over the last decade indicating P4P doesn’t reduce costs and has mixed effects on quality, P4P proponents, true to form, have ignored it. [4]

Taylorism: Ground zero of the epidemic

It is impossible to identify a single Typhoid Mary responsible for the metrics-fixation epidemic, but it is fair to say a very important Typhoid Mary was Frederick Winslow Taylor. Muller identifies the rise of “Taylorism” in manufacturing in the early 1900s as a primary cause of the epidemic. Taylor, an American engineer, studied every action of workers in pig iron factories, estimated the average time of each action, then proposed to pay slower workers less and faster workers more. According to Taylor, determining who was slow and who was fast and paying accordingly required “an elaborate system for monitoring and controlling the workplace,” as Muller puts it. (p. 32) Taylor called his measurement-and-control system “scientific management.”

“Scientific management” assumed that managers with clipboards could distill the wisdom of their work force into a set of rules (later called “best practices,” another buzzword catapulted to stardom in the 1990s) and enforce those rules with pay-for-performance. The outcome of “scientific management,” according to Taylor, was that “all of the planning which under the old system was done by the workmen, must of necessity under the new system be done by management in accordance with the law of science.” (Muller, pp. 32-33) Here we see the beginning of the double standard now prevalent in health policy: People who flog faith-based P4P schemes hold themselves out as the bearers of “scientific” values (“evidence-based medicine,” to use the lingo invented in the early 1990s), while doctors who criticize metrics madness are said to be stuck in a “paternalistic culture.” [5]

The obvious corollary to “scientific management” was that leaders of corporations didn’t need any hands-on experience or training in the production of whatever it was their corporation produced. If you had a degree from a business school that taught “scientific management,” it shouldn’t matter to Sunbeam, for example, that “Chainsaw” Al Dunlap had no knowledge of how appliances are made. As long as he knew “management,” he was qualified to be Sunbeam’s CEO. Decades after Taylorism arose, this same logic would justify allowing managers of insurance company executives, Fortune 500 companies, and government insurance programs who never went to medical school to measure and micromanage doctors.

By the 1950s, this notion that standardized data in the hands of managers trumped experience had become deeply embedded in American business culture. By the 1960s, reports Muller, it had spread to the US military (Robert MacNamara’s background in accounting got him a job running a car company, and from there he jumped to the Pentagon where he and his “whiz kids” told the generals to count enemy corpses). By the 1980s it had infected other government agencies and much of the non-profit world, and by the late 1990s it had infected the services sector, including medicine.

Measuring the doctor and patient from afar

“Nowhere are metrics in greater vogue than in the field of medicine,” writes Muller. (p 103) The following statement by report-card and P4P guru Michael Porter, which Muller took from an article Porter co-authored for the Harvard Business Review, is a good illustration of how P4P proponents think and talk.

Rapid improvement in any field requires measuring results – a familiar principle in management…. Indeed, rigorous measurement of value (outcomes and costs) is perhaps the single most important step in improving health care. Wherever we see systematic measurement of results in health care … we see those results improve. [p. 107]

From this excerpt plus other sections of the Harvard Business Review article, we learn that Porter is absolutely convinced it’s possible to measure “outcomes and costs” accurately, and then divide cost into quality to derive “value.”

Note first the voice-of-God tone. God doesn’t have to document anything, and neither does Porter; there are no footnotes in this lengthy essay. Note next the grand assumption that improvement is only possible if “results” are measured. How do we know this? We just do. It’s a “principle of management,” says Porter (no doubt going all the way back to Frederick Taylor). Third, note the misrepresentation of the evidence. It simply isn’t true that “wherever” managers conduct “systematic measurement” of “performance” by doctors and hospitals, costs go down and/or quality goes up.

Muller compares the groupthink represented by Porter with research on both report cards and P4P schemes. The small body of research on report cards finds they have no impact on “consumer” behavior or patient outcomes. The large body of research on P4P indicates it may be raising costs when the costs providers incur to improve “performance” is taken into account, and it has at best a mixed effect on measured quality.

Muller suggests that the net effect of P4P on the health of all patients, that is, those whose care is measured and those whose care is not measured, is negative. Sicker patients are the ones most at risk in a system where P4P is rampant. Because the measures of cost and quality upon which P4P schemes are based are so inaccurate (because scores cannot be adjusted with anything resembling accuracy to reflect factors outside provider control), it induces a variety of “gaming” strategies, the worst of which are avoiding sicker patients and shifting resources away from patients whose care is not measured to those whose care is measured (“treating to the test”).

To illustrate how P4P damages sicker patients, Muller devotes two pages to the damage done by Medicare’s Hospital Readmissions Reduction Program (HRRP). This program, which began in 2012, punishes hospitals that have an above-average rate of 30-day readmissions (admissions that occur within 30 days of a discharge from a hospital) for patients with a half-dozen diagnoses. Muller reports that the HRRP has clearly had two negative effects. First, it has incentivized hospitals to keep sick patients away for at least 30 days after discharge, and if that’s not possible, to let them in but to put them on “observation” status, which means they are not counted as “readmitted.” [6] Second, it has led to the punishment of hospitals that treat sicker and poorer patients.

When Muller publishes a second edition of this book, he’ll no doubt add a page describing research done since his book was published showing that the HRRP appears to be killing patients with congestive heart failure (CHF). CHF was one of the three diagnoses that has been measured by the HRRP since it began (readmissions for heart attack and pneumonia were the other two).

Reversing the epidemic

Muller ends his book with a series of recommendations. He suggests, for example, that measures be developed from the bottom up and that financial rewards and penalties should be kept low if they are to be used at all. He does not attempt to offer political solutions. For this I do not criticize him. His book, which must have required years of research, is a valuable contribution to the largely one-sided debate about P4P in medicine, a debate which has only recently become more audible.

Here are my two cents on the politics of this issue. Groups representing doctors and nurses must take the lead in rolling back measurement mania. Doctors and nurses have great credibility with the public, and they have to cope every day with the consequences of measurement mania. They should focus on rolling back the P4P schemes now inflicted on the fee-for-service Medicare program because Medicare is so influential (“reforms” inflicted by Congress on Medicare are typically mimicked by the insurance industry). Groups working to reduce the cost of health care or improve quality of care for patients should also join the fight. They too have an interest in undermining the tyranny of metrics.

Of course, it would be nice if those who make a living promoting the inappropriate use of measurement would practice what they preach and examine their own behavior to see how it could be improved. Here’s a question that people in that business might pose to themselves now and then: Would you like your work to be subjected to measurement of its cost and quality by third parties, and would you like those third parties to alter your income based on the grades they decide to give you?

Footnotes: 

[1] Just to test NGram, I entered other terms. “Automobile,” for example, rises up from zero mentions just before 1900 to a peak during about 1938-1942, then declines rapidly so that the rate by 2000 (the last year on the graph) is equal to the rate of 1910. “Database,” on the other hand, stays at zero mentions until about 1970, then skyrockets in the late 1970s.

[2] Accurate measurement of the cost and quality of insurance companies and providers was an essential element of “managed competition,” a proposal introduced in 1989 by Alaine Enthoven and enthusiastically promoted by Paul Ellwood (the “father of the HMO”), insurance industry executives, Bill and Hillary Clinton, and the editors of the New York Times, to name just a few of Enthoven’s most influential disciples.

[3] A 2006 edition of Medical Care Research and Review devoted entirely to the emerging P4P fad stated, “P4P programs are being implemented in a near-scientific vacuum.”

[4] We are seeing rare exceptions to the P4P groupthink only in the last two or three years. In January 2018, MedPAC formally voted to reverse its decision to recommend P4P at the individual physician level. Donald Berwick, a leading proponent of measurement, announced in 2016  that it was time to reduce the reporting burden on doctors by 50 to 75 percent and to eliminate P4P at the individual level.

[5] The IOM, for example, has peddled measurement and control of providers for decades on the basis of no evidence, yet it maintains a “roundtable” of P4P disciples the IOM deems to be “science-driven.”

[6] “Observation stays” were designed for Medicare beneficiaries who were not clearly in need of inpatient care but who were not clearly ready to go home either. Such patients are typically placed on the same wards with admitted patients but not treated.

Kip Sullivan is a member of the Health Care for All MN advisory board, and of MN Physicians for a National Health Program.

Obsessive Measurement Disorder: Etiology of an Epidemic published first on https://wittooth.tumblr.com/

[kristinsimmons]

Obsessive Measurement Disorder: Etiology of an Epidemic

By KIP SULLIVAN JD 

Review of The Tyranny of Metrics by Jerry Z. Muller, Princeton University Press, 2018

In the introduction to The Tyranny of Metrics, Jerry Muller urges readers to type “metrics” into Google’s Ngram, a program that searches through books and other material published over the last five centuries. He tells us we will find that the use of “metrics” soared after approximately 1985. I followed his instructions and confirmed his conclusion (see graph below). We see the same pattern for two other buzzwords that activate Muller’s BS antennae – “benchmarks,” and “performance indicators.” [1]



Muller’s purpose in asking us to perform this little exercise is to set the stage for his sweeping review of the history of “metric fixation,” which he defines as an irresistible “aspiration to replace judgment based on personal experience with standardized measurement.” (p. 6) His book takes a long view – he takes us back to the turn of the last century – and a wide view – he examines the destructive impact of the measurement craze on the medical profession, schools and colleges, police departments, the armed forces, banks, businesses, charities, and foreign aid offices.

Foreign aid? Yes, even that profession. According to a long-time expert in that field, employees of government foreign aid agencies have “become infected with a very bad case of Obsessive Measurement Disorder, an intellectual dysfunction rooted in the notion that counting everything in government programs will produce better policy choices and improved management.” (p. 155)

Muller, a professor of history at the Catholic University of America in Washington, DC, makes it clear at the outset that measurement itself is not the problem. Measurement is helpful in developing hypotheses for further investigation, and it is essential in improving anything that is complex or requires discipline. The object of Muller’s criticism is the rampant use of crude measures of efficiency (cost and quality) to dish out rewards and punishment – bonuses and financial penalties, promotion or demotion, or greater or less market share. Measurement can be crude because it fails to adjust scores for factors outside the subject’s control, and because it measures only actions that are relatively easy to measure and ignores valuable but less visible behaviors (such as creative thinking and mentoring). The use of inaccurate measurement is not just a waste of money; it invites undesirable behavior in both the measurers and the “measurees.” The measurers receive misleading information and therefore make less effective decisions (for example, “body count” totals tell them the war in Viet Nam is going well), and the subjects of measurement game the measurements (teachers “teach to the test” and surgeons refuse to perform surgery on sicker patients who would have benefited from surgery).

What puzzles Muller, and what motivated him to write this book, is why faith in the inappropriate use of measurement persists in the face of overwhelming evidence that it doesn’t work and has toxic consequences to boot. This mulish persistence in promoting measurement that doesn’t work and often causes harm (including driving good teachers and doctors out of their professions) justifies Muller’s harsh characterization of measurement mavens with phrases like “obsession,” “fixation,” and “cult.” “[A]lthough there is a large body of scholarship in the fields of psychology and economics that call into question the premises and effectiveness of pay for measured performance, that literature seems to have done little to halt the spread of metric fixation,” he writes. “That is why I wrote this book.” (p. 13)

A short history of Obsession Measurement Disorder in medicine

I read Muller’s book because I share his astonishment at the persistence of the measurement craze in the face of so much evidence that it is not working. Over the three decades that I have studied health policy, I have become increasingly baffled by people who promote various iterations of managed care in the face of evidence that they don’t work. In search of an explanation, I have, as Muller has, read books and news stories about the misuse of measurement in other fields, particularly education and banking. I have been especially baffled by the managed care movement’s enthusiasm for measuring the cost and quality of all actors in the health care system, an enthusiasm that emerged in the late 1980s when it was obvious that the propagation of HMOs, the movement’s founding project, was failing to control inflation. [2]

By the 1990s the enthusiasm for documents that handed out grades to insurance companies and providers on “consumer satisfaction,” mortality rates, etc. had become an obsession. Proponents of “report cards,” as these documents were called, hoped that “consumers” would read them and reward the good actors with their business and punish the bad actors by leaving them. That, of course, did not happen.

Frustrated by consumer disinterest in report cards, managed care proponents, such as the Medicare Payment Advisory Commission (MedPAC) and the Institute of Medicine (IOM), declared in the early 2000s that it was time to punish doctors and hospitals directly by rewarding them if they got good grades on crude measurements and punishing them if they didn’t. The term they used to describe this direct method of punishment was “pay for performance,” a phrase borrowed from the business world. By about 2004, that phrase had become so common in the health policy literature it was shortened to “P4P.”

The complete absence of evidence that P4P would improve the quality of medical care didn’t matter to MedPAC and other P4P advocates. [3] As evidence has piled up over the last decade indicating P4P doesn’t reduce costs and has mixed effects on quality, P4P proponents, true to form, have ignored it. [4]

Taylorism: Ground zero of the epidemic

It is impossible to identify a single Typhoid Mary responsible for the metrics-fixation epidemic, but it is fair to say a very important Typhoid Mary was Frederick Winslow Taylor. Muller identifies the rise of “Taylorism” in manufacturing in the early 1900s as a primary cause of the epidemic. Taylor, an American engineer, studied every action of workers in pig iron factories, estimated the average time of each action, then proposed to pay slower workers less and faster workers more. According to Taylor, determining who was slow and who was fast and paying accordingly required “an elaborate system for monitoring and controlling the workplace,” as Muller puts it. (p. 32) Taylor called his measurement-and-control system “scientific management.”

“Scientific management” assumed that managers with clipboards could distill the wisdom of their work force into a set of rules (later called “best practices,” another buzzword catapulted to stardom in the 1990s) and enforce those rules with pay-for-performance. The outcome of “scientific management,” according to Taylor, was that “all of the planning which under the old system was done by the workmen, must of necessity under the new system be done by management in accordance with the law of science.” (Muller, pp. 32-33) Here we see the beginning of the double standard now prevalent in health policy: People who flog faith-based P4P schemes hold themselves out as the bearers of “scientific” values (“evidence-based medicine,” to use the lingo invented in the early 1990s), while doctors who criticize metrics madness are said to be stuck in a “paternalistic culture.” [5]

The obvious corollary to “scientific management” was that leaders of corporations didn’t need any hands-on experience or training in the production of whatever it was their corporation produced. If you had a degree from a business school that taught “scientific management,” it shouldn’t matter to Sunbeam, for example, that “Chainsaw” Al Dunlap had no knowledge of how appliances are made. As long as he knew “management,” he was qualified to be Sunbeam’s CEO. Decades after Taylorism arose, this same logic would justify allowing managers of insurance company executives, Fortune 500 companies, and government insurance programs who never went to medical school to measure and micromanage doctors.

By the 1950s, this notion that standardized data in the hands of managers trumped experience had become deeply embedded in American business culture. By the 1960s, reports Muller, it had spread to the US military (Robert MacNamara’s background in accounting got him a job running a car company, and from there he jumped to the Pentagon where he and his “whiz kids” told the generals to count enemy corpses). By the 1980s it had infected other government agencies and much of the non-profit world, and by the late 1990s it had infected the services sector, including medicine.

Measuring the doctor and patient from afar

“Nowhere are metrics in greater vogue than in the field of medicine,” writes Muller. (p 103) The following statement by report-card and P4P guru Michael Porter, which Muller took from an article Porter co-authored for the Harvard Business Review, is a good illustration of how P4P proponents think and talk.

Rapid improvement in any field requires measuring results – a familiar principle in management…. Indeed, rigorous measurement of value (outcomes and costs) is perhaps the single most important step in improving health care. Wherever we see systematic measurement of results in health care … we see those results improve. [p. 107]

From this excerpt plus other sections of the Harvard Business Review article, we learn that Porter is absolutely convinced it’s possible to measure “outcomes and costs” accurately, and then divide cost into quality to derive “value.”

Note first the voice-of-God tone. God doesn’t have to document anything, and neither does Porter; there are no footnotes in this lengthy essay. Note next the grand assumption that improvement is only possible if “results” are measured. How do we know this? We just do. It’s a “principle of management,” says Porter (no doubt going all the way back to Frederick Taylor). Third, note the misrepresentation of the evidence. It simply isn’t true that “wherever” managers conduct “systematic measurement” of “performance” by doctors and hospitals, costs go down and/or quality goes up.

Muller compares the groupthink represented by Porter with research on both report cards and P4P schemes. The small body of research on report cards finds they have no impact on “consumer” behavior or patient outcomes. The large body of research on P4P indicates it may be raising costs when the costs providers incur to improve “performance” is taken into account, and it has at best a mixed effect on measured quality.

Muller suggests that the net effect of P4P on the health of all patients, that is, those whose care is measured and those whose care is not measured, is negative. Sicker patients are the ones most at risk in a system where P4P is rampant. Because the measures of cost and quality upon which P4P schemes are based are so inaccurate (because scores cannot be adjusted with anything resembling accuracy to reflect factors outside provider control), it induces a variety of “gaming” strategies, the worst of which are avoiding sicker patients and shifting resources away from patients whose care is not measured to those whose care is measured (“treating to the test”).

To illustrate how P4P damages sicker patients, Muller devotes two pages to the damage done by Medicare’s Hospital Readmissions Reduction Program (HRRP). This program, which began in 2012, punishes hospitals that have an above-average rate of 30-day readmissions (admissions that occur within 30 days of a discharge from a hospital) for patients with a half-dozen diagnoses. Muller reports that the HRRP has clearly had two negative effects. First, it has incentivized hospitals to keep sick patients away for at least 30 days after discharge, and if that’s not possible, to let them in but to put them on “observation” status, which means they are not counted as “readmitted.” [6] Second, it has led to the punishment of hospitals that treat sicker and poorer patients.

When Muller publishes a second edition of this book, he’ll no doubt add a page describing research done since his book was published showing that the HRRP appears to be killing patients with congestive heart failure (CHF). CHF was one of the three diagnoses that has been measured by the HRRP since it began (readmissions for heart attack and pneumonia were the other two).

Reversing the epidemic

Muller ends his book with a series of recommendations. He suggests, for example, that measures be developed from the bottom up and that financial rewards and penalties should be kept low if they are to be used at all. He does not attempt to offer political solutions. For this I do not criticize him. His book, which must have required years of research, is a valuable contribution to the largely one-sided debate about P4P in medicine, a debate which has only recently become more audible.

Here are my two cents on the politics of this issue. Groups representing doctors and nurses must take the lead in rolling back measurement mania. Doctors and nurses have great credibility with the public, and they have to cope every day with the consequences of measurement mania. They should focus on rolling back the P4P schemes now inflicted on the fee-for-service Medicare program because Medicare is so influential (“reforms” inflicted by Congress on Medicare are typically mimicked by the insurance industry). Groups working to reduce the cost of health care or improve quality of care for patients should also join the fight. They too have an interest in undermining the tyranny of metrics.

Of course, it would be nice if those who make a living promoting the inappropriate use of measurement would practice what they preach and examine their own behavior to see how it could be improved. Here’s a question that people in that business might pose to themselves now and then: Would you like your work to be subjected to measurement of its cost and quality by third parties, and would you like those third parties to alter your income based on the grades they decide to give you?

Footnotes: 

[1] Just to test NGram, I entered other terms. “Automobile,” for example, rises up from zero mentions just before 1900 to a peak during about 1938-1942, then declines rapidly so that the rate by 2000 (the last year on the graph) is equal to the rate of 1910. “Database,” on the other hand, stays at zero mentions until about 1970, then skyrockets in the late 1970s.

[2] Accurate measurement of the cost and quality of insurance companies and providers was an essential element of “managed competition,” a proposal introduced in 1989 by Alaine Enthoven and enthusiastically promoted by Paul Ellwood (the “father of the HMO”), insurance industry executives, Bill and Hillary Clinton, and the editors of the New York Times, to name just a few of Enthoven’s most influential disciples.

[3] A 2006 edition of Medical Care Research and Review devoted entirely to the emerging P4P fad stated, “P4P programs are being implemented in a near-scientific vacuum.”

[4] We are seeing rare exceptions to the P4P groupthink only in the last two or three years. In January 2018, MedPAC formally voted to reverse its decision to recommend P4P at the individual physician level. Donald Berwick, a leading proponent of measurement, announced in 2016  that it was time to reduce the reporting burden on doctors by 50 to 75 percent and to eliminate P4P at the individual level.

[5] The IOM, for example, has peddled measurement and control of providers for decades on the basis of no evidence, yet it maintains a “roundtable” of P4P disciples the IOM deems to be “science-driven.”

[6] “Observation stays” were designed for Medicare beneficiaries who were not clearly in need of inpatient care but who were not clearly ready to go home either. Such patients are typically placed on the same wards with admitted patients but not treated.

Kip Sullivan is a member of the Health Care for All MN advisory board, and of MN Physicians for a National Health Program.

Obsessive Measurement Disorder: Etiology of an Epidemic published first on https://wittooth.tumblr.com/