The WHY of medical cost variation

The inescapable Dr Atul Gawande has drilled down on the why of medical cost variation: Annals of Medicine: The Cost Conundrum: Atul Gawande: The New Yorker. He drills down into the town with the world’s (universe’s?) highest health care costs -- McAllen, Texas – a mid-sized city with explosive population growth – and a significant amount of poverty …

… The median income for a household in the city was $33,641, and the median income for a family was $36,050. Males had a median income of $30,089 versus $22,480 for females. The per capita income for the city was $14,939. About 20.9% of families and 23.8% of the population were below the poverty line, including 30.5% of those under age 18 and 20.3% of those age 65 or over…

This isn’t another boring (boring) article on health care cost variation. Gawande, who is no amateur, knows the interesting question is “why?”. I loved his description of the body language of an anesthesiologist and hospital entrepreneur during one of his visits. I bet that CEO would prefer a root canal to a Gawande interview…

… I visited the top managers of Doctors Hospital at Renaissance. We sat in their boardroom around one end of a yacht-length table. The chairman of the board offered me a soda. The chief of staff smiled at me. The chief financial officer shook my hand as if I were an old friend. The C.E.O., however, was having a hard time pretending that he was happy to see me. Lawrence Gelman was a fifty-seven-year-old anesthesiologist with a Bill Clinton shock of white hair and a weekly local radio show tag-lined “Opinions from an Unrelenting Conservative Spirit.” He had helped found the hospital. He barely greeted me, and while the others were trying for a how-can-I-help-you-today attitude, his body language was more let’s-get-this-over-with.

So I asked him why McAllen’s health-care costs were so high. What he gave me was a disquisition on the theory and history of American health-care financing going back to Lyndon Johnson and the creation of Medicare, the upshot of which was: (1) Government is the problem in health care. “The people in charge of the purse strings don’t know what they’re doing.” (2) If anything, government insurance programs like Medicare don’t pay enough. “I, as an anesthesiologist, know that they pay me ten per cent of what a private insurer pays.” (3) Government programs are full of waste. “Every person in this room could easily go through the expenditures of Medicare and Medicaid and see all kinds of waste.” (4) But not in McAllen. The clinicians here, at least at Doctors Hospital at Renaissance, “are providing necessary, essential health care,” Gelman said. “We don’t invent patients.”…

Gawande, like me, is interested in the (too few) qualitative studies of health care spending decisions

… Brenda Sirovich, another Dartmouth researcher, published a study last year that provided an important clue. She and her team surveyed some eight hundred primary-care physicians from high-cost cities (such as Las Vegas and New York), low-cost cities (such as Sacramento and Boise), and others in between. The researchers asked the physicians specifically how they would handle a variety of patient cases. It turned out that differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from…

But is it really where doctors trained, or is it something far more concrete?

.. I met with a hospital administrator who had extensive experience managing for-profit hospitals along the border. He offered a different possible explanation: the culture of money.

“In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine,” he said. But in McAllen, the administrator thought, that percentage would be a lot less.

He knew of doctors who owned strip malls, orange groves, apartment complexes—or imaging centers, surgery centers, or another part of the hospital they directed patients to…

… many physicians are remarkably oblivious to the financial implications of their decisions...

.. Others think of the money as a means of improving what they do…

…Then there are the physicians who see their practice primarily as a revenue stream...

In every community, you’ll find a mixture of these views among physicians, but one or another tends to predominate. McAllen seems simply to be the community at one extreme….

When we talk about practice variation we don’t usually think anthropology. That’s probably a mistake …

Woody Powell is a Stanford sociologist who studies the economic culture of cities..

.. Powell suspects that anchor tenants play a similarly powerful community role in other areas of economics, too, and health care may be no exception. I spoke to a marketing rep for a McAllen home-health agency who told me of a process uncannily similar to what Powell found in biotech. Her job is to persuade doctors to use her agency rather than others. The competition is fierce. I opened the phone book and found seventeen pages of listings for home-health agencies—two hundred and sixty in all. A patient typically brings in between twelve hundred and fifteen hundred dollars, and double that amount for specialized care. She described how, a decade or so ago, a few early agencies began rewarding doctors who ordered home visits with more than trinkets: they provided tickets to professional sporting events, jewelry, and other gifts. That set the tone. Other agencies jumped in. Some began paying doctors a supplemental salary, as “medical directors,” for steering business in their direction. Doctors came to expect a share of the revenue stream…

…The real puzzle of American health care, I realized on the airplane home, is not why McAllen is different from El Paso. It’s why El Paso isn’t like McAllen. Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up…

Culture really, really, matters. Damnit.

And now from my neighborhood (more or less) …

I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country…

…The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.

“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focused first on what was best for patients, and then on how to make this financially possible…

…Grand Junction’s medical community was not following anyone else’s recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.

This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys…

Gawande tries to come up with ways to replicate the lessons from Mayo et al. It’s not easy. One of lessons, which he quietly skates around, is that superb physicians will deliver superb medical care for much less than they’re paid in Texas. We don’t overpay our specialists as insanely as we overpay our CEOs – but we do pay far more than is needed to fill the jobs. CEOs are paid perhaps 5-20 times what they’d work for, but surgeons and many specialists are probably only paid 3-5 times too much.

Rationalizing reimbursement and incentives would more than pay for high quality universal health care – but it would be a devastating transition.

hat tip: Richard Neill, via Facebook

Mobile phone and automotive GPS collision avoidance for pedestrians, bicyclists, tricyclists, skaters and pets

Years ago I wondered about collision avoidance systems for bicycles and pedestrians.

Something like a vest that would reflect radar signals broadcast by cars.  The primary automobile use of the radar broadcasts would be to avoid auto collisions, but bicyclists would also benefit.

There would be lots of ways then to avoid bicycle fatalities. Maybe the bike is illuminated on an active windshield. Maybe there’s an audio alarm if vectors appear to intersect.

Now that we’ve got systems like Google Latitude (not available for iPhone – it needs background multitasking!) though, it’s obvious we can do the whole thing with next generation mobile phones.

We don’t even need to worry about this patent …

GPS collision avoidance system - Patent 5872526

… A collision avoidance system for a plurality of vehicles equipped with GPS receivers, each broadcasting current location information to other vehicles and receiving and displaying location information from other vehicles, enables a vehicle operator to be aware of the location of the other vehicles. For vehicles not equipped with GPS, and transceivers, information about location is taken from common ground control equipment such as an FAA control station and broadcast to all vehicles. In an aircraft environment, flight plans can be filed and closed out automatically…

The GPS source would be the mobile phones of the automobile passengers, and the mobile phone of the bicyclist. Not to mention the mobile-phone like device attached to dogs.

The phones can even manage the collision avoidance, though there are obvious advantages to having the car computer manage that.

It’s interesting to think how it could work with just phones, however.

If a phone knows it has a history of travel over 35 mph, it can assume it’s in a car. If Google Latitude 3.0 detects a car/mobile vector intersecting with a bicycle/skating/pet/pedestrian mobile vector it can send an audio message to the car stereo (“Pedestrian collision in 5 seconds … 4 seconds … 3 seconds … …. …. ambulance and police now enroute …”).

You can imagine lots of variants. Unfortunately, lots of opportunities for nasty abuse as well.

In a post-Peak Oil America of aging boomers, domesticating the wild and savage automobile will become increasingly important. These kinds of collision avoidance systems will mandated within 10 years.

How Apple could surprise

We know what to expect for our July iPhone. Sounds excellent. I'll buy one.

Sad not to have any surprises though.

Unless ... how about a combo display, keyboard, battery and iphone cradle for, say, $250?

Add iPhone, get netbook.

Excellent discussion of randomness in everyday life

Leonard Mlodinow shows more than a touch of wisdom in this interview about randomness in every day life: What Are The Odds?.

Once upon a time I thought I could predict my future. I gave up that idea a long time ago. There are too many wild cards, too many unexpected opportunities.

Sit back, relax, and enjoy the good parts of the show.

Another Cheney fan rediscovers waterboarding really is torture

Now if only we could persuade Limbaugh and Cheney to take the treatment (emphases mine)…

Mancow Waterboarded, Admits It's Torture | NBC Chicago

… WLS radio host Erich "Mancow" Muller decided to subject himself to … waterboarding live on his show.

… "I want to find out if it's torture," Mancow told his listeners Friday morning, adding that he hoped his on-air test would help prove that waterboarding did not, in fact, constitute torture.

.. With a Chicago Fire Department paramedic on hand,  Mancow was placed on a 7-foot long table, his legs were elevated, and his feet were tied up.  

Turns out the stunt wasn't so funny. Witnesses said Muller thrashed on the table, and even instantly threw the toy cow he was holding as his emergency tool to signify when he wanted the experiment to stop.  He only lasted 6 or 7 seconds.

"It is way worse than I thought it would be, and that's no joke,"Mancow said, likening it to a time when he nearly drowned as a child.  "It is such an odd feeling to have water poured down your nose with your head back...It was instantaneous...and I don't want to say this: absolutely torture."

"I wanted to prove it wasn't torture," Mancow said.  "They cut off our heads, we put water on their face...I got voted to do this but I really thought 'I'm going to laugh this off.' "

Last year, Vanity Fair writer Christopher Hitchens endured the same experiment -- and came to a similar conclusion. The conservative writer said he found the treatment terrifying, and was haunted by it for months afterward.

"Well, then, if waterboarding does not constitute torture, then there is no such thing as torture," Hitchens concluded in the article.

One the one hand, Mancow is a complete idiot*. How could he have failed to do even a trivial amount of research?

On the other hand, as a human being, he’s an improvement over Cheney, Limbaugh, Rumsfeld and the like. He at least has a sense of honor.

* In the modern sense of the word, as in someone who’s cognitively intact but voluntarily makes astoundingly bad choices.

Google needs to add permalinks to their social link generated feed page

Google generates a web view of the blog posts I share in Google reader.

That's great, but they're missing a killer feature.

I can link link to the page, but I can't create a link to a specific comment/reference pair on the page, such as this comment of mine

... (link) Fallows, who really knows better, slowly falls upon the nub of the matter.

There are a lot of good-enough amateur writers and thinkers in the world.

No, not usually as good as a professional journalist, but pretty darned good.

That's always been true, but over the past 17 years the cost of entry to the world of publishing has fallen by a factor of ... about 10,000.

Damned, that's disruptive.

Journalism needs to refocus on core strengths and value. The old equation doesn't work.

Oh, and newsprint is dead, dead, dead.

Google needs to add an inline permalink to the generated page, so we can reference a Google-generated feed-share with all associated notes and comments.

IBM should buy Bloglines and roll it into Lotus Connections

I was once a Bloglines customer, but Google Reader surpassed them years ago. Bloglines didn’t have the money to compete; their inability to produce a good mobile product in 2008 was the last straw for me.

Happily, they’re still around. I can’t see how they survive though.

There is a better future. In my corporate life I’ve been confounded by the lack of a decent, shareable, web-based feed reader for inside-the-firewall Sharepoint and other blogs. There aren’t even any decent Windows desktop feed readers left (though I’ve not tried the astoundingly horrible Outlook 2007 reader with SP2).

IBM wants to compete in this subscription/collaboration world with Lotus Connections, but their current web reader component is less than ideal.

Bingo.

IBM acquires or licenses Bloglines and funds Active Directory integration to support Sharepoint feed integration.

Win-win.

Dementia is normal - and what that means

In a post-industrial age of low birth rates the greatest economic challenge for wealthy nations is acquired cognitive disability -- better known as dementia.

So we ought to think clearly about dementia. It doesn't help that my generation of physicians were taught to think of dementia as an "abnormal" disease like the flu, rather than an all-but-inevitable consequence of aging.

A recent popular review, which was ironically intended to be inspiring, underscores how "normal" (typical) dementia is (emphases mine) ...

BRAIN POWER: At the Bridge Table, Clues to a Lucid Old Age

By BENEDICT CAREY

... In recent years scientists have become intensely interested in what could be called a super memory club — the fewer than one in 200 of us who ... have lived past 90 without a trace of dementia....

... Laguna Woods, a sprawling retirement community of 20,000 south of Los Angeles, is at the center of the world’s largest decades-long study of health and mental acuity in the elderly. Begun by University of Southern California researchers in 1981 and called the 90+ Study, it has included more than 14,000 people aged 65 and older, and more than 1,000 aged 90 or older.

... researchers have also demonstrated that the percentage of people with dementia after 90 does not plateau or taper off, as some experts had suspected. It continues to increase, so that for the one in 600 people who make it to 95, nearly 40 percent of the men and 60 percent of the women qualify for a diagnosis of dementia.

... it is precisely that ability to form new memories of the day, the present, that usually goes first in dementia cases, studies in Laguna Woods and elsewhere have found.

The very old who live among their peers know this intimately, and have developed their own expertise, their own laboratory. They diagnose each other, based on careful observation....

...Here at Laguna Woods, many residents make such delicate calculations in one place: the bridge table.

Contract bridge requires a strong memory. It involves four players, paired off, and each player must read his or her partner’s strategy by closely following what is played. Good players remember every card played and its significance for the team. Forget a card, or fall behind, and it can cost the team — and the social connection — dearly.

“When a partner starts to slip, you can’t trust them,” said Julie Davis, 89, a regular player living in Laguna Woods. “That’s what it comes down to. It’s terrible to say it that way, and worse to watch it happen. But other players get very annoyed. You can’t help yourself.”

... Later, the partner stares uncertainly at the cards on the table. “Is that ——”

“We played that trick already,” Ms. Cummins says. “You’re a trick behind.”

Most regular players at Laguna Woods know of at least one player who, embarrassed by lapses, bowed out of the regular game. “A friend of mine, a very good player, when she thought she couldn’t keep up, she automatically dropped out,” Ms. Cummins said. “That’s usually what happens.”

Yet it is part of the tragedy of dementia that, in many cases, the condition quickly robs people of self-awareness. They will not voluntarily abandon the one thing that, perhaps more than any other, defines their daily existence...

... In studies of the very old, researchers in California, New York, Boston and elsewhere have found clues to that good fortune. For instance, Dr. Kawas’s group has found that some people who are lucid until the end of a very long life have brains that appear riddled with Alzheimer’s disease. In a study released last month, the researchers report that many of them carry a gene variant called APOE2, which may help them maintain mental sharpness.

Dr. Nir Barzilai of the Albert Einstein College of Medicine has found that lucid Ashkenazi Jewish centenarians are three times more likely to carry a gene called CETP, which appears to increase the size and amount of so-called good cholesterol particles, than peers who succumbed to dementia...

Imagine how hellish that bridge table can be. Every game, a test. Show weakness, slip, and death is your fate. First social death, then the grave. It makes professional baseball look like ... child's play.

I'd bet a good amount that the "protective" "social" effect of playing bridge is bull poop. This is all about a survivor-effect correlation. Only the genetically gifted slow agers can play. On the other hand, I doubt that even the best of those bridge players could handle a modern knowledge worker job -- they are good for their age, but they are not immortal.

So if we (mostly) set aside wistful hopes of some kind of mental activity that protects against normal, all-but-inevitable, age related dementia, what do we have left to learn from these and similar studies?

We know it helps to be born clever, but that only gives your airplane more fuel -- it doesn't by itself slow the normal process of brain mush. Many brilliant thinkers with, at their peak, one in a million minds, are relatively disabled by their 70s - though still better off than most of us.

We can't do much with the brains we're born with, but we do have animal model evidence, and less definitive human evidence (because we don't randomly experiment then autopsy humans), that physical exercise is protective against normal dementia. Seems bizarre to me, but it holds up. On the other hand, head injury accelerates dementia, so don't make your exercise football, contact hockey, boxing, or horse jumping.

Exercise and head whacks aside, this is all about genes and medicines. It's about identifying those whose brains hold up longer, then figuring out the trick of it, then looking for a medicine that will help the average person. It's slow, hard work, but success is worth trillions in economic growth and a significant reduction in human suffering. By that metric, we're grossly underfunding this research. The potential payoff is enormous compared to say, cancer research. (I've been pointing this out, incidentally, for at least twenty years. It's not hard to do the math.)

Barring any breakthroughs, however, we boomers need to get real about our future. We expect we're going to have to keep working to 70 or beyond, but you can't cheat mother nature. Dementia is the end-point of a disabling process that starts, for most of us, when we're about 25. We'll be working, but we'll be doing more grocery bagging than particle physics.

Maybe we should think about how to make the less cognitive life more appealing. Maybe we ought to think about how society supports those with cognitive disabilities at all ages ...

The GOP's new message: we are a nation of cowards

Gail Collins said it well today.

The GOP's meme of the day is that we're a nation of cowards; we cannot tolerate evildoers living within massive prisons anywhere near our homes. Instead we should leave then near, say, Cuban homes. Or, better yet, kill 'em all without trial.

We are still a sick nation, but the GOP is sicker than the rest of us.

Get a freakin' grip America! Show some spine for a change.

It must be a sad thing to have to give allegiance to the modern GOP. If their idea of "reform" is Newt Gingrich then the party should be euthanized. America needs a new alternative to the Dems.

Obama vs. Cheney is as simple as Good vs. Evil

I really am a shades of gray guy.

Sometimes, though, the shades are pretty extreme.

The Obama vs. Cheney speeches are about as simple as good vs. evil.

No, Cheney's not (yet) a mass murderer. He does, however, want America to travel a road well worn by evil regimes. He champions an evil cause.

No, Obama is far from a saint. He does, however, call on America to remember its nobility.

It's rare to have such a clear choice.

Obama stands firm on closing Guantanamo |World news | guardian.co.uk

Barack Obama today laid out a broad case for closing the Guantánamo Bay prison and banning the "enhanced interrogation techniques" that have been condemned as torture – while accusing his opponents of wanting to scare Americans to win political battles.

In a grand hall at the US national archives, standing directly in front of original copies of the US constitution and declaration of independence, Obama said the current legal and political battles in Washington over the fate of the 240 prisoners there stemmed not from his decision to close the facility, but from George Bush's move seven years ago to open it...

... , Dick Cheney gave a rebuttal at a conservative Washington think tank, the American Enterprise Institute. The former vice-president defended many of the Bush administration policies Obama is now unraveling, and mentioned either "September 11" or "9/11" 25 times.

Cheney said Saddam Hussein had "known ties" to terrorists, an apparent rehashing of the widely discredited Bush administration effort to link the Iraqi dictator to the September 11 2001 hijackers.

... Obama today said that indefinite detention at Guantánamo Bay and the prison's harsh interrogation methods had undermined the rule of law, alienated America from the rest of the world, served as a rallying cry and recruiting symbol for terrorists, risked the lives of American troops by making it less likely enemy combatants would surrender, and increased the likelihood American prisoners of war would be mistreated. The camp's existence discouraged US allies from cooperating in the fight against international terrorism, he said.

"There is also no question that Guantánamo set back the moral authority that is America's strongest currency in the world," he said. "Instead of building a durable framework for the struggle against al-Qaida that drew upon our deeply held values and traditions, our government was defending positions that undermined the rule of law."

Calling Guantánamo "a mess, a misguided experiment", he condemned the re-emergence of bitter political fighting over the prison and the future of its 240 inmates.

"We will be ill-served by some of the fear-mongering that emerges whenever we discuss this issue," he said. "Listening to the recent debate, I've heard words that are calculated to scare people rather than educate them; words that have more to do with politics than protecting our country."

... He acknowledged that a number of Guantánamo prisoners could not be prosecuted yet posed a clear threat to the US: those who had trained at al-Qaida camps, commanded Taliban troops, pledged loyalty to Osama bin Laden and sworn to kill Americans.

"These are people who, in effect, remain at war with the United States," he said.

He pledged to construct a new legal framework to deal with those prisoners, saying that if they warranted long-term detention the decision should be made not by the president alone but with congressional and judicial oversight...

One day your children may ask, did you stand with evil or with good.

Now is the time you will determine your answer.

Microsoft ads wound Apple. You know my number Apple …

From a few personal anecdotes, I think the ad agency that created the “laptop hunters” ads deserves its bonuses …

CHART OF THE DAY: Microsoft's 'Laptop Hunters' Ads Are Hurting Apple (MSFT, AAPL)

… Microsoft's (MSFT) "Laptop Hunters" ad campaign focuses on the price difference between Windows PCs and expensive Apple (AAPL) Macs. The commercials have raised consumers' perception of Microsoft's "value" -- and have hurt Apple…

So, Apple.

Are you ready to talk yet?

Yeah, it’s me. One of the geeks you forgot about. You know, your volunteer evangelists. Yeah, we’re still around. It’s just that you haven’t done anything for us for a while.

Take me (why not?). iPhoto has had the same lethal movie export bug for at least 3 years, but Apple doesn’t care. iPhoto Library import? Apple doesn’t care. Aperture metadata on albums? Nope, doesn’t care. Support for open file formats in iWork? Nope.

Then there’s MobileMe.

Oh, and iChat abandonware and Apple’s multi-faceted serial calendaring and contacts screw-ups.

Yes, I know. Only geeks care about this stuff.

Thing is, maybe Apple needs their geeks to praise ‘em. When value perceptions can fall this quickly, Apple’s support is weaker than it seems.

Pay attention Apple. Fix my problems, and maybe I’ll say something nice about you.

Memories of the Chevette

I'm not a car guy. Not at all. Even so, this is worth reading...

Sunday Times: Honda Insight Review

... The Honda’s petrol engine is a much-shaved, built-for-economy, low-friction 1.3 that, at full chat, makes a noise worse than someone else’s crying baby on an airliner. It’s worse than the sound of your parachute failing to open. Really, to get an idea of how awful it is, you’d have to sit a dog on a ham slicer.

So you’re sitting there with the engine screaming its head off, and your ears bleeding, and you’re doing only 23mph because that’s about the top speed, and you’re thinking things can’t get any worse, and then they do because you run over a small piece of grit...

A dog on a ham slicer?! Yech.

Which reminds me of the time I rented a Chevette. The Wikipedia article doesn't do justice to the 1975 model. It was made in America when GM made incredibly lousy cars, far lousier than anything sold today, and it was a desperate flail at a mileage target.

I remember merging onto a highway on a hill and watching a truck grow large behind me as the Chevette's lawnmower engine screamed in agony.

Maybe Honda can rethink this one?

Relativity as a consequence of quantum entanglement

Useful at parties ...

Relativity as a Consequence of Quantum Entanglement: A Quantum Logic Gate Space Model for the Universe

Everything in the Universe is assumed to be compromised of pure reversible quantum Toffoli gates, including empty space itself...

Obama's retreat strengthens calls for a Truth Commission

Scanning the NYT this evening, it's not hard to see a consensus emerging. Even those who weren't in favor of an American Truth Commission, like Dowd, have come around.

Obama's retreat on the photos and the tribunals shows this is too tough a problem for him to lead on alone. We do need an investigative committee. We need to know what Cheney, Rumsfeld, and their scummy minions did.

The state of wilderness tracking

I've a personal interest in the state of wilderness tracking and communications. It's much less advanced than many imagine.

The Economist tells us that's going to change soon...

...The first generation of phone satellites are coming to the end of their natural life...

A second generation of satellites, which are about to be launched by Globalstar atop trusty old Soyuz rockets from Baikonur in Kazakhstan, will whisk data around the planet at a far more respectable speed of 250 kilobits a second.

By later next year, when Globalstar has all 24 of its new satellites in orbit, high-quality voice and 3G data transmission will be possible from anywhere on the planet, except for polar latitudes. In making broadband available more or less anywhere anytime, Globalstar reckons it is six years ahead of the competition.

Your correspondent almost cannot wait. Globalstar already sells a tempting little $170 device called SPOT, which can send your GPS location to friends and family, along with a preprogrammed message and a link to Google Maps that lets them track your progress...

This was the vision of the 1994 McCaw-Gates Teledesic (often mis-spelled teledisc) project; that project was to provide worldwide internet coverage and initially involved 840 satellites.