Sunday, January 23, 2005

The Rise and Fall of the Body-Scanning Clinics

The New York Times > Health > Rapid Rise and Fall for Body-Scanning Clinics

There's not that much that surprises me in health technology and marketing, but this did. I did not expect the body-scanning clinics to crash and burn. Is the story really over? These services struck me as a really awful idea, but I'm used to awful ideas being popular.

Overall it seems like the market for these services was more limited than expected; vendors overbuilt then slashed prices. Maybe they'll continue at a lower level of demand, or maybe they'll find a way to provide CT services for far less money. The latter would be interesting if it happened, but it may be the demand simply isn't there. On the other hand the non-medical fetal ultrasound clinics seem to be still in business

This is a great story by Gina Kolata, one of the best medical journalists around. She exposes the greed of some prestigious academic health centers -- who jumped on the bandwagon even though they knew well that this service was likely to cause more harm than help. Shame on Harvard for succumbing, and credit to Yale for resisting.

One of the most important aspects of this story is what it says about the effects of a true marketplace on healthcare costs. There are almost NO true markets in medicine, this was one of them. Prices fell by 50% over a year -- to the very edge of profitability. It may say something about how medical savings accounts might work (I'm a cautious fan):
The New York Times
January 23, 2005
Rapid Rise and Fall for Body-Scanning Clinics
By GINA KOLATA

For a brief moment, Dr. Thomas Giannulli, a Seattle internist, thought he was getting in at the start of an exciting new area of medicine. He was opening a company to offer CT scans to the public - no doctor's referral necessary. The scans, he said, could find diseases like cancer or heart disease early, long before there were symptoms. And, for the scan centers, there was money to be made.

The demand for the scans - of the chest, of the abdomen, of the whole body - was so great that when Dr. Giannulli opened his center in 2001, he could hardly keep up. "We were very successful; we had waiting lists," he said. He was spending $20,000 a month on advertising and still making money.

Three years later, the center was down to one or two patients a day and Dr. Giannulli was forgoing a paycheck. Finally, late last year, he gave up and closed the center.

Dr. Giannulli's experience, repeated across the country, is one of the most remarkable stories yet of a medical technology bubble that burst, health care researchers say.

It began as a sort of medical gold rush, with hundreds of scanning centers, with ceaseless direct-to-consumer advertising, and with thousands of Americans paying out of pocket for the scans, which could cost $1,000 or more.

It ended abruptly with the wholesale shuttering of businesses.

CT Screening International, which scanned 25,000 people at 13 centers across the nation, went out of business. AmeriScan, another national chain, also closed. So, radiologists say, did another company that put scanners in vans and traveled to small towns in the South.

The business's collapse, health care researchers say, holds lessons about the workings of American medicine.

It shows the limits of direct-to-consumer advertising and the power of dissuasion by professional societies, which warned against getting one of these scans. The tests, they said, would mostly find innocuous lumps in places like the thyroid or lungs, requiring rounds of additional tests to rule out real problems, and would miss common cancers, like those of the breast.

It also shows the workings of the medical market - when insurers refused to pay, requiring customers to dig into their own pockets for the tests, scanning centers found themselves cutting prices to compete. Within a year, some centers said, prices fell to less than $500 from $1,000 or more.

... The scans were something new in American medicine - not like traditional screening scans, mammograms or colonoscopies, for example, in which patients are overseen by their doctors. People requested these scans on their own. They paid on their own, with no hints that insurers would start picking up the bill. And the reports came to the customers, not their doctors.

Some proponents said the scans would enable people to take their health care into their own hands. Critics said the scans were medical nightmares, a powerful medical technology gone out of control.

But few anticipated the precipitous reversal of fortune for the scanning centers...

... Dr. Carl Rosenkrantz, a radiologist in Boca Raton, Fla., said the business had another appeal - it promised radiologists a good living without being on call at a hospital and even without necessarily being present at the scanning center.

...Academic medical centers also got into the business, including Beth Israel Deaconess Medical Center at Harvard, which opened Be Well Body Scan. The center is owned by the Beth Israel Radiology Foundation, a nonprofit organization that supports the hospital's radiology department...

At Yale, Dr. Howard Forman, an associate professor of diagnostic radiology and management, said he had felt pressure from hospital administrators to explore the possibility of offering whole body scans to healthy people. He could see why. "From a profitability standpoint, you would go in this direction." But he and his colleagues resisted. "There is no evidence that the scans are good medicine," Dr. Forman said.

Dr. Barnett Kramer, director of the National Institutes of Health's office of disease prevention, said: "For every 100 healthy people who undergo a scan, somewhere between 30 and 80 of them will be told that there is something that needs a workup - and it will turn out to be nothing."

The same arguments were made by the American College of Radiology and the Food and Drug Administration.

...As for Dr. Giannulli, he has moved on to other things. He founded a company, CareTools Inc., which sells software for medical record keeping to doctors' offices. That, he says, is the new frontier in medicine.
I work in the clinical automation industry, so it's a bad sign that Dr. Giannulli thinks we're the next big thing ...

Saturday, January 22, 2005

Twixters: marooned in the twenties

TIME canada.com

My brother Brian was ahead of his time. He followed the path outlined in this Time Canada article during the 1990s. It's the path of the twixters "marooned" in their 20s, done with college but not ready to commit to the long dry road.

More recently, however, it seems to be the rule among my friend's children and pretty common among the recent grads I know of from our neighborhood college (Macalester). I don't think the article describes these people very well though; besides establishing "twixterhood" as an official phenom it doesn't provide much insight into why this is (supposedly) common now. Is it simply a wealth effect? Is it a gestalt reaction to an unpredictable world, a "Lady or the Tiger" paralysis?

I think there's something different happening, and I suspect that there's not one simple explanation. I think of these social transitions as being manifestations of a nonlinear (chaotic) system. (The murder rate is my favorite example of such a manifestation -- it's driven by demographics and employment but transitions are dramatic and affected by many interacting sub-drivers.) There are probably some primary contributors, but also many peripheral interactions that cause a sudden prevalence spike.

It will be interesting to see if the phenomena persists, or if it recedes as quickly as it came.

Hong Kong -- views of another galaxy

MICHAEL WOLF | PHOTOGRAPHY | HONGKONG

It's been over 20 years since I flew into Hong Kong, past the riot of skyscraping housing. This site provides a pictorial update. It looks like another order of magnitude increase in density. I would like to read about what it's like to live in those buildings.

A blog at least partially made up of Iraqi (english) voices

Words From Iraq

It's a bit confusing, but it appears to include posts from various english writing Iraqis. The descriptions of everyday anarchy and violence in Iraq ring true. (via metafilter)

Evolutionary game theory: people are strategies in a "game" played by natural selection

Marginal Revolution: Are you a player or a strategy?

This is new to me, but it has face validity. In some ways humans can be thought of as "strategies" in a kind of meta-game that emerges from the fundamental properties of natural selection.
Our colleague, Dan Houser, has just published an important new paper (co-authored with Robert Kurzban) that supports the assumption of evolutionary game theory. (The paper is also featured in the Economist.)  In a public goods game, Kurzban and Houser are able to identify three systematic strategies; cooperate, free ride and reciprocate (cooperate more when others do so).  The first surprising result of their paper is that these strategies can be tied to specific individuals.  Some individuals cooperate, others free ride and others reciprocate and the strategies that these individuals 'choose' are stable.  (This doesn't mean that individuals play strategies robotically regardless of context a better analogy may be to think of strategies like personalities - even a quiet person can yell sometimes.)

Strategy choice is so stable that Kurzban and Houser can create very cooperative groups simply by weeding out the free riders.  What is even more surprising, however, is that when individuals are randomly assigned to groups each strategy type earns about the same payoff.  Even though the strategies are very different, no strategy dominates the others in a randomly assigned group - this is exactly what one would predict if individuals are strategies in an evolutionary game.
Hmm. Reminds me of this.

Is it childish to call David Brooks "Bobo"?

Crooked Timber: How To Ascribe Super-Powers To Words - David Brooks on the inaugural address
Does Bobo believe this, or what?
Hmm. It seems a big childish to call David Brooks "Bobo". On the other hand, he does inflict his inanities on us. It's a real ethical quandry.

Brooks is emblematic of the fall of the New York Times.

Where commercial copy protection will lead

Boing Boing: Debunking a DRM press-release

Cory's right:
And that is exactly what they will do: they will bring home lawfully purchased CDs and DVDs and try to do something normal, like watch it on their laptop, or move the music to their iPod, and they will discover that the media that they have bought has DRM systems in place to prevent exactly this sort of activity, because the studios and labels perceive an opportunity to sell you your media again and again -- the iPod version, the auto version, the American and UK version, the ringtone version, und zo weiter. Customers who try to buy legitimate media rather than downloading the unfettered DRM-free versions will be punished for their commitment to enriching the entertainment companies. That commitment will falter as a consequence.
I'm an unlikely pirate, but the first time I buy a CD I can't listen to on my iPod (legal use) I'll be hoisting the jolly roger.

Friday, January 21, 2005

Kaplan rips the inaugural address

Give Me Liberty or Give Me... What? - The muddle in Bush's inaugural address. By Fred Kaplan

No, it wasn't a great speech. It was a disturbing speech.
... Whatever freedom is, how do we go about spreading it? The president said in his speech that the mission "is not primarily the task of arms," though he added that sometimes it must be. If not with arms, then how do we spread freedom? With rhetorical encouragement? Bush's answer was intriguing: "All who live in tyranny and hopelessness can know: The United States will not ignore your oppression or excuse your oppressors. When you stand for your liberty, we will stand with you." The United States will also "encourage reform" in repressive governments "by making clear that success in our relations will require the decent treatment of their own people. … Start on this journey of progress and justice," President Bush told these rogue leaders, "and America will walk on your side."

This sort of talk raises three questions. First, does the president really know what he's saying here? In 1956, the Voice of America encouraged the rebels of Hungary to rise up against their Communist regime, and when they did so, they were mowed down; the United States did not come to their aid and had no ability to do so. In 1991, George Bush's father encouraged the Shiite rebels of southern Iraq to rise up and overthrow Saddam Hussein, and after the Iraqi army was expelled from Kuwait and the war declared over, Saddam mowed down the rebels; the United States did not come to their aid. If the leaders of a democratic underground in some dictatorship hear this speech and rise up tomorrow against their own tyrants, will George W. Bush "stand with" them? Really?...
When Kaplan's done, there's not much left of Bush's inaugural address.

Fox flips out

IFILM
A Fox News anchor flips out when a guest dares to question the nature of Bush's elaborate 2nd inauguration.
A delightful video clip. Heh, heh.

The world called Titan

ESA Portal - Seeing, touching and smelling the extraordinarily Earth-like world of Titan
Thus, while many of Earth's familiar geophysical processes occur on Titan, the chemistry involved is quite different. Instead of liquid water, Titan has liquid methane. Instead of silicate rocks, Titan has frozen water ice. Instead of dirt, Titan has hydrocarbon particles settling out of the atmosphere, and instead of lava, Titanian volcanoes spew very cold ice.

Titan is an extraordinary world having Earth-like geophysical processes operating on exotic materials in very alien conditions.
A fascinating press release from the ESA, but where does "smelling" come into the picture?

Update: A Guardian article clarified the "smell". It's the probe's analytic chemistry.

Did the KGB blow up those Russian apartment buildings?

This story has been all but forgotten ...
In September 1999, four apartment buildings, two in Moscow and two in other Russian cities, were blown up, killing over 300 people, wounding hundreds more.

Russians suspected Chechen terrorists. Putin, newly in power, solidified his position and launched the invasion of Chechnya. Horror followed.
I remember when this happened. At the time some Chechens claimed the Russian secret services (heirs to the KGB) had staged the attack. This claim didn't get much traction. I didn't believe it. In those days the Soviet era seemed to be ancient history -- Russia was going to rejoin the world. A few tin hat types continued the story; I linked to a representative web site above.

I've not thought much about that 1999 attack, though it was later recalled in the context of several terrorist attacks in Russia (Opera house, school, etc). I was quite surprised, then, to read this in a book review from The Economist (emphases mine):
Economist.com | Russia | Arts |Bleak house

Three books by journalists cast a gloomy light on the question. “Inside Putin's Russia”, by Andrew Jack, latterly the Financial Times correspondent there, is a fluent, detailed and balanced account of Russian power politics, with a lively emphasis on the Kremlin's onslaught against independent media and stroppy tycoons.

Mr Jack also addresses the most sensational charge made against Mr Putin—that the tower-block bombings which killed hundreds of people in 1999 were committed not by the ostensible culprits, Chechen terrorists, but by security services wanting to smooth Mr Putin's rise to power. The charge is not completely absurd, and was well outlined in "Darkness at Dawn" (2003), by David Satter, who set up the Financial Times's bureau in Moscow in 1976.

Mr Jack agrees that the official version of events is full of holes. In particular, the Russian security services have never explained an episode in which they were caught apparently planting explosives in a block of flats in the provincial city of Ryazan. But he steers clear of an all-embracing conspiracy theory—too risky for its backers, he reckons. Instead, he suggests that the Ryazan affair may have been an attempt by spooks to stage a terrorist attack in order to gain credit for foiling it.
So the bottom line seems to be that (foreign) journalists don't know, but they find it conceivable that Putin's men (KGB) staged the bombing. This does make it easier to understand why many in the middle east at one time believed the CIA/Mossad blew up the WTC. After all, if Russia/Putin could do it, why not Bush? Didn't it allow him to do to Iraq what Putin did to Chechnya?

For the record, much as I dislike GWB (I think he's now morphing into a disciple of both Yahweh and Any Rand), I am certain that he didn't stage the WTC attack. He did, however, use it to attack Iraq in much the same way Putin used the apartment explosions to attack Chechnya. The level of evidence used to justify the twin invasions was also, in retrospect, rather similar.

Why does the US media persist in comparing the Iraq invasion to Vietnam? It's really more like the Russian invasion of Chechnya.

Social security: fundamentals of privatization

The New York Times > Opinion > Krugman: The Free Lunch Bunch:
There are several ways to explain why this particular lunch isn't free, but the clearest comes from Michael Kinsley, editorial and opinion editor of The Los Angeles Times. He points out that the math of Bush-style privatization works only if you assume both that stocks are a much better investment than government bonds and that somebody out there in the private sector will nonetheless sell those private accounts lots of stocks while buying lots of government bonds.

So privatizers are in effect asserting that politicians are smart - they know that stocks are a much better investment than bonds - while private investors are stupid, and will swap their valuable stocks for much less valuable government bonds. Isn't such an assertion very peculiar coming from people who claim to trust markets?

Thursday, January 20, 2005

Coronation Day reading

The BEAST: 50 Most Loathsome People in America, 2004 You're on the list.

Search Bot wars: How Yahoo can attack Google's Blogger products

Blogger: Create your Blog Now -- FREE

Google owns Blogger. Yahoo does a far better job of indexing my Blogger posts than Google does. Google used to do a much better job of indexing my posts -- back when I first started the blogs! Yahoo is a Google competitor, they too offer blogs and search services.

Google and Yahoo are competitors. Hmmm.

What about this:

1. Blogger has grown very fast. It has had to redo its servers and software several times. It often has performance issues.

2. Indexing robots are a heavy burden for Blogger's servers. If the servers are in trouble, Google may want to reduce the burden to help Blogger stay up.

3. Yahoo has no such motivation. Indeed, Yahoo is incented to be particularly conscientious about keeping its Blogger indexes very current. Perhaps indexing Blogger every few hours might be a good idea ... Shame about Blogger's servers, but that's Google's problem ...

Isn't it interesting how some wars just seem inevitable?

Wednesday, January 19, 2005

The Yazidi/Dasin of Iraq

Yazidi - Wikipedia, the free encyclopedia

Anyone think Iraq is a simple place?
The Yezidi or Yazidi (Kurdish; Êzidî) are adherents of a small Middle Eastern religion with ancient origins. They are primarily ethnic Kurds, and most Yazidis live near Mosul, Iraq with smaller communities in Syria, Turkey, Iran, Georgia and Armenia, and are estimated to number ca. 500,000 individuals in total.

There are also Yazidi refugees in Europe. The Yazidi worship Malak Ta’us, apparently a pre-Islamic peacock angel who has fallen into disgrace. Malak Ta’us has links to Mithraism and, through it, to Zoroastrianism. The Yazidi maintain a well-preserved culture, rich in traditions and customs.

In the region that is now Iraq, the Yazidi have been oppressed and labeled as devil worshippers for centuries. During the reign of Saddam Hussein, however, they were considered to be Arabs and maneuvered to oppose the Kurds, in order to tilt the ethnic balance in northern Iraq. Since the 2003 occupation of Iraq, the Kurds want the Yazidi to be recognized as ethnic Kurds.

The Yazidi’s own name for themselves is Dasin. While popular etymology connects the religion to the Umayyad khalif Yazid I (680-683), the name Yazidi is actually most likely derived from the Pahlavi (Middle Persian) word 'yezd,' meaning angel, probably in reference to Malak Ta’us.
The Pehlavi (Shah of Iran) family were said by their enemies to be closet Zoroastrians.