Richard Neill: The case against pay for performance

Richard has assembled a diverse set of links on the case gainst P4P: "The result of this thinking is P4P programs that promote physician behaviors that detract from the demonstrably valuable task of balancing complex competing co-morbidities to achieve improved outcomes.".

It reminds me of 'no child left behind'. From a special needs perspective I have mixed feelings. On the one hand testing less capable children makes it harder to ignore them. On the other hand, it creates paradoxical incentives to make them disappear. I think we'll learn similar lessons when we emerge from the other side of P4P.

When I was a real doctor, most of my patients were "special needs". Sure they were diabetic, but that wasn't necessarily their biggest problem -- or even in the top 3. Strange, but true. You dealt with what they were ready to deal with, and negotiated between the physician's priority and the patient's priority.

P4P will happen. It lets payors reduce payments, so it's inevitable. (Surely you were not so naive as to think P4P really meant extra money for doing well, rather than cuts for not doing well?) It will cause good and harm, but in the end I suspect Richard will be proven right.

Average age for mobile phone in Britain

This was a throwaway line at the end of an article on IPv6:

340,282,366,920,938,000,000,000,000,000,000,000,000 new web addresses created by internet chiefs . . . so we won't run out of space soon, then - World - Times Online:

8 The average age at which a child gets a mobile phone in Britain.

Huh? Age 8? Come on.

Mommy, what's smoking?

On the one hand, girls and women smoke for weight control and the foul spawn of satan are marketing candy flavored tobacco.

On the other hand, our 7 yo asks "Mommy, what is smoking" when reading a children's story from the 1960s. That's when we realize that nobody smokes in our neighborhood. Nobody. Our children don't see people inhaling burning materials.

Tonight my date* and I had a beer at a local bar -- which has been smoke free for a few months - along with the rest of the metro area. It was very pleasant.

When I was 7 I definitely knew what smoking was, and I knew about cleaning ashtrays. It's easy to miss progress.

* aka my spouse

DeLong, Mankiw, Krugman and why Paul should leave the NYT

Brad DeLong, Paul Krugman and Greg Mankiw are having a 3 way debate. Paul writes in the NYT, a sad place to be now that he's behind the Paywall (more below). Brad champions Paul in DeLong's blog, Mankiw challenges Paul (and Brad) from his blog. Spectators chime in from the comments section and kibitzers add items in their own blogs. It's all very 21st century.

Mankiw represents a rare breed, the hyper-intelligent and articulate "Republican" (actually, I'm not sure he's Republican, but he did work for Bush for a while). [1] Paul and Brad are Clinton democrats. So it's a great discussion. Today Brad writes:

Brad DeLong's Semi-Daily Journal: The Pattern of Growth in Income Inequality

...The big rise in inequality in the U.S. since 1980 has been overwhelmingly concentrated among the top 1% of income earners: their share has risen from 8% in 1980 to 16% in 2004. By contrast, the share of the next 4% of income earners has only risen from 13% to 15%, and the share of the next 5% of income earners has stuck at 12%. The top 1% have gone from 8 to 16 times average income, the next 4% have gone from 3.2 to 3.7 times average income, and the next 5% have been stuck at 3 times average income...

Mankiw argues that talent and education is worth more than it was, Krugman/DeLong agree that's probably true below the 99th percentile, but the real gains are a "market failure" presumably resulting from the actions of a corrupted legislature (my summary, read the articles to draw your own conclusion).

It's great to see this debate, and it shows again that the the NYT is dying. Krugman can't respond in detail because he's constrained by his 700 word limit. We can't read him directly because the NYT is desperate and needs Krugman to pull in subscribers. One result is we've lost Paul's voice. That's not good.

I'd like to see a major paper lure Paul away, and have Krugman negotiate two things: no paywalls and a blog extension of the printed column ...

[1] Most intelligent Republicans are silent these days, shamed by the glories of Bush.

Why the second front?

Why has Israel gone to war now with both Hezbollah and Hamas? Why did Hezbollah and Hamas choose to incite Israel now?

Obviously I don't have any inside information, or even any expert knowledge. So I'll resort to what one usually does when one is ignorant; I'll imagine There's a logical explanation.

I'm George Bush. There's a civil war in Iraq and US forces are strained. Iran and Syria are using Iraq for their own ends, which includes trying to keep the US tied down. (That's what I'd do if I were Iran and Syria, because it's entirely reasonable to fear Bush will go after me next.)

What can Bush do? He could open a second front -- give Iran and Syria something else to worry about. Except he doesn't want to attack them directly -- not with a US senate election coming up. Maybe he knows Israel is worried about Hamas and Hezbollah anyway. So he gives Israel an explicity statement of support -- if you decide to go after these guys, we'll guard your back and funnel supplies as needed.

And so there's a second front.

I don't know if any of this is a good idea, but Bushian incompetence has foreclosed most of the good ideas. All that's left now are the bad ideas. It makes a kind of sense ...

Update 7/21/06: At least one person who's not ignorant came to the same conclusion, though he portrays Israel as an unwitting tool of the Bush agenda. I think it's more of a cooperative decison.

Fountain of reason or den of chaos? The best news is ...

One of Brad DeLong's hobbies is ripping the New York Times and (especially) the Washington Post for crummy journalism. In general, he makes his case well. On the other hand, people who read DeLong would probably agree with him:

Brad DeLong's Semi-Daily Journal: "If You Really Want to Know What's Going on, I Recommend Sticking to the Blogs":

But this is the world in which we live in: respected weblogs run by intelligent commentators with good track records and strong senses of honor are our best information sources these days.

The more mainstream journalists criticize the "rabid blogosphere", the more panicky they seem. The people on my bloglist are simply more informed, intelligent, and rational than 99% of what I read in the NYT or elsewhere. I don't know why that is so. Many the people I read are journalists and writers, so it's not a problem with journalists per se. My guess is that something's broken about the way the work of journalists gets turned into newspaper columns...

The universe as an engine

Serendipity brought the non-zero vacuum energy and thermodynamics into my head recently, which led to a science fictional idea.

Engines work because energy flows "downhill". You can't do work with the vacuum energy because it has nowhere to go. Now if one could connect to a universe with a different vacuum energy, one could presumably do work. One might even bring universes of differing vacuum energies into being simply for this purpose. And thus the science fiction story -- the vacuum energy of our universe is rising because an entity is pouring energy into it from another universe ...

There's got to be a short story in there somewhere.

The Yahoo death spiral: firefox incompatible

Yahoo's new map service doesn't work properly with Firefox. Forget Safari. Same story with their mail beta.

Interesting.

Yahoo was fingered recently in a NYT spyware expose -- they funded malignant spyware installation.

Interesting.

Conclusion -- irregardless of whatever anyone may be saying, Yahoo's days are numbered. Look for an acquisition. Microsoft has their choice of either AOL or Yahoo and both are playing as nice as they can. My guess is that Yahoo goes to Microsoft and AOL disintegrates with Google picking up most of the pieces.

Mac Attack the Minneapolis Star Tribune!

Mac users of the world unite! It's time to savage the Minneapolis Star Tribune -- my home town paper. (We had another, but it's been acquired for shredding purposes.)

Umm, seriously. Strib pages take minutes to load in Safari; they load well in Firefox/Mac. It's one of the irritating glitches that's pushing me to use only Firefox, despite its lack of Cocoa goodness and OS X services. When Firefox goes Cocoa (soon, soon) Safari will be toast.

Which is a shame, since I like Safari better. It's snappier, has far better printing, looks nicer, etc.

What to do? The Strib ignores my plaintive emails. So we need a bigger voice! All OS X fans are called upon to do two things:

1. Visit a few Strib pages with Safari and verify the agonizing slowness, then send feedback to the Strib. I suggest the Content:News link, there's no feedback link for site problems (suggest that too!).

2. On the Safari toolbar, click the bug icon on the right and send a report including the page code and image.

I'm betting this is a Strib bug that FF and IE handle better than Safari. Whatever, send feedback!

The limits of statistical methods: health, wealth and smoking

Rich people live longer than poor people.

We used to say this was because rich people took better care of themselves and smoked less, wore seatbelts, got vaccinated, had dental care, bettery bypass surgery, better breast cancer care, etc.

Then, a few years ago, a meme developed that the gap was due largely to power relationships. There was something about being on top that made one live longer (presumably this would be true of other social animals). The statisticians claimed that they'd controlled for the effects of smoking, seat belts, etc.

Now, smoking is back [2]:

Smoking is to blame for half of the difference in male death rates between men in the top and bottom social classes, say international researchers...

Half is quite a bit considering that researchers previously thought they'd accounted for the effects of smoking on mortality gaps.

We've seen this many times in healthcare research over the past decades -- case control research is essential and suggestive, but caution is always indicated.

We can't randomize infants to being rich or poor, or switch thousands of accountants and CEOs, so there's no alternative to population research. The results become more persuasive when reinforced by other lines of inquiry [1]. So if the power=health meme is reinforced by animal studies where one can randomize status it becomes stronger, but smoking is a powerfully proven source of mortality.

Occam's razor favors smoking as the simplest explanation for mortality differences, and researchers know that, so for me this is really a story about how hard it is to draw strong conclusions from population studies.

The battle will go on, and power relationships may indeed be more important as smoking decreases, because we need data to guide policy. Is it better to put effort into immunization adherence, smoking bans, breast cancer screening or liver transplants [3]?

--

[1] Science is about consistent and reinforcing models, each supported by variable amoungs of testable predictions. Where tests are less rigorous, we rely more on integration with other parts of the knowledge model.

[2] The slimeballs haven't given up yet, btw.

[3] The transplant bit was a joke. To date reducing the rich/poor mortality gap has seemed either relatively inexpensive (seatbelt laws, immunization, smoking bans) or impossible (substance abuse, power relationships). If things like expensive biosubstances, transplants, or stem cell therapies become more important the social strains will be significant.

Income growth in 2004 and exponential gaps

DeLong channels Krugman, now hidden from us by the NYT's paywall:

Brad DeLong's Semi-Daily Journal: Krugman - The Further Derangement of the U.S. Income Distribution

... Here's what happened in 2004. The U.S. economy grew 4.2 percent, a very good number. Yet last August the Census Bureau reported that real median family income -- the purchasing power of the typical family -- actually fell.

... in 2004 the real income of the richest 1 percent of Americans surged by almost 12.5 percent. Meanwhile, the average real income of the bottom 99 percent of the population rose only 1.5 percent. In other words, a relative handful of people received most of the benefits of growth.... Even people at the 95th percentile of the income distribution -- that is, people richer than 19 out of 20 Americans -- gained only modestly. The big increases went only to people who were already in the economic stratosphere.... [T]he real earnings of the typical college graduate actually fell in 2004.

Real earnings are after inflation. So the vast majority of US productivity gains in 2004 went to the wealthiest 1%. Everyone else fought over the scraps, with college grads actually losing ground (hmmm, outsourcing influence? It's hard to outsource plumbing, easy to outsource accounting).

The top 1% is departing from the bottom 99% at an exponential rate -- ascending to a neo-medieval world of relative power.

The curious thing about this is that Americans don't seem to care. I've heard the usual explanations of this (everyone thinks they might get rich too) and I find them hard to believe. On the other hand, I've realized in my old age that I'm not much like other people [1] and I can't really model their thinking ...

[1] The fact that this came to me rather late in life says something about my perceptual limitations ...

Democrat fund raising: incompetence or dirty tricks?

We worked pretty hard for the Kerry campaign. Our reward now is relentless spam from Minnesota DFL candidates and phone calls from other groups claiming to be related to democratic candidates. I believe the political parties are exempt from the telemarketer laws, so they have free rein. It's so obnoxious my wife jokes that these must be undercover GOP initiatives, trying to drive away funding for liberal candidates.

Well, full credit to the tricksters if there are any -- it's working. I suspect, however, that this is the result of sheer, unadulterated, incompetence and stupidity rather than sabotage.

I bet the GOP isn't nearly this braindead about exploiting their donors.

If there are any grown-ups with influence in dem fund raising -- wake-up! You're going to drive the party off a cliff. Stop the spam (the 'take me off your list' links only work transiently, we get added back in periodically), stop the calls, rethink this.

Or maybe it's all Libertarian tricksters ...

PS. The Dems should take some lessons from CARE Intl. When we first sent them a donation I wrote that I'd stop the moment they bugged me for more. They put me on some kind of 'if you call this guy you die' list -- we never get anything. Every year they get their check.

Memories of a lost brother - July 12, 2002

It's that time of year again, now four years since my brother disappeared on a day hike in the wilderness around Whistler, British Columbia. There's no news, but the hiking season begins once again ...

Contextual Google Ad above my Gmail spam list

French Fry Spam Casserole - Bake 30-40 minutes.

Cute. Google has finally added a 'delete all spam' link. It took out 6500 items at once -- 30 days of spam.

Physics in crisis: the non-zero vacuum energy

When I did my BS in 1981, I bought a copy of Thorne, Wheeler and Meisner's 'Gravitation'. I figured I'd study it in retirement, with a computer aide to do the math for me. It's a marvels book, one of the most extraordinary textbooks I've seen anywhere. My copy is autographed by Kip Thorne.

I think of that book now when I read of a conference Thorne attended, a Caribbean party for celebrity cosmologists. This comes from a report of the meeting:

Edge: THE ENERGY OF EMPTY SPACE THAT ISN'T ZERO: A Talk with Lawrence Krauss

...When you apply quantum mechanics and special relativity, empty space inevitably has energy. The problem is, way too much energy. It has 120 orders of magnitude more energy than is contained in everything we see!...

...One of the greatest developments in physics in the 20th century was to realize that when you incorporate special relativity in quantum mechanics you have virtual particles that can pop in and out of existence, and they change the nature of a hydrogen atom, because a hydrogen atom isn't just a proton and electron.

That's the wrong picture, because every now and then you have an electron positron pair that pops into existence. And the electron is going to want to hang around near the proton because it's oppositely charged, the positron is going to be pushed out to the outskirts of the atom, and while they're there they change the charged distribution in the atom in a very small, but calculable, way. Feynman and others calculated that effect, which allows us to get agreement between theory and observation at the level of nine decimal places. It's the best prediction in all of science. There's no other place in science where, from fundamental principles, you can calculate a number and compare it to an experiment at nine decimal places like that.

But then when we ask, if they're there, how much should they contribute to the energy in the universe, we come up with the worst prediction in physics. It says if empty space has so much energy we shouldn't be here. And physicists like me, theoretical physicists, knew they had the answer. They didn't know how to get there. It reminds me or the Sidney Harris cartoon where you've got this big equation, and the answer, and the middle step says "And then a miracle occurs". And then one scientist says to another, "I think you have to be a little more specific at this step right here".

The answer had to be zero. The energy of empty space had to be precisely zero. Why? Because you've got these virtual particles that are apparently contributing huge amounts of energy, you can imagine in physics, how underlying symmetries in nature can produce exact cancellations — that happens all the time. Symmetries produce two numbers that are exactly equal and opposite because somewhere there's an underlying mathematical symmetry of equations. So that you can understand how symmetries could somehow cause an exact cancellation of the energy of empty space.

But what you couldn't understand was how to cancel a number to a hundred and twenty decimal places and leave something finite left over. You can't take two numbers that are very large and expect them to almost exactly cancel leaving something that's 120 orders of magnitude smaller left over. And that's what would be required to have an energy that was comparable with the observational upper limits on the energy of empty space.

We knew the answer. There was a symmetry and the number had to be exactly zero. Well, what have we discovered? There appears to be this energy of empty space that isn't zero! This flies in the face of all conventional wisdom in theoretical particle physics...

This is the best summary of the physics dilemma I've read. The same math leads to a perfect prediction and a perfectly outrageous prediction. So we know the physics is very broken, but we don't have a path to follow. The best minds in the world can't come up with experiments to guide us. No wonder physicsts are extremely frustrated! I just hope I see a breakthrough before I get to meet Einstein in person ...

PS. Virtual particles came courtesy of Richard Feynman. I have his books too, but he was a much better lecturer than textbook writer.