Contraception Costs

Rush's obscene comments are based either on a profound ignorance of how most woman-based contraception works, or on a profound cynicism about the American public's ignorance of how it works. Or (since we're talking about Rush, here) both.

I'm a computer scientist, so let me put it in computer science terms.

Cost of the most popular male-based contraceptives (i.e. condoms): O(n), where n is the number of sexual encounters. (Withdrawal not included.)

Cost of most female-based contraceptives (e.g. pill, IUD): O(1), with a large constant.

For non-computer scientists: to oversimplify somewhat, a function f(n) is O(n) if it is roughly proportional to n. In other words, as you increase n, you also increase f(n). A function f(n) is O(1) if it really doesn't matter how big n gets, it's always the same value. A good example of an O(n) function might be cost-of-gas-per-week as a function of number of miles driven. As the number of miles goes up, so does the amount I'm paying for gas (assuming prices don't drop). An example of an O(1) function: price-per-gallon as a function of the number of miles driven. It really doesn't matter how many miles I'm driving -- the cost per gallon remains the same.

Which brings me back to Rush. He thought he was being so clever with accusing Ms. Fluke of having so much sex that she couldn't afford to pay for it. Whereas for most forms of birth control that are fully in a woman's control (and I think that last bit is significant), it really doesn't matter whether you're getting it once an hour or (as primly as Rush or Rick could desire) conceding it once a year...the cost is the same. And it's jolly expensive, even for once a year.

Which is in stark contrast to the most popular male method: pay per use, and a fraction of the cost of the dinner/movie that precedes its use.

Why is that?

I guess I shouldn't be surprised that we're having this national conversation about who pays for birth control. Who wants to pay more to let women have control?

Good piece on the importance of locally grown food.

The notion of importing fruits and vegetables, the idea of having everything “fresh” all the time, was until recently inconceivable and is likely to become so again, as production and transportation costs rise and the absurdity of the “system” becomes evident even to those who now profit from it. When we ignore large-scale production of local food we invite apocalypse, or at least food shortages.

I always wonder about those $1.79 strawberry specials in December.

Bill Gates is getting serious about crap

The Bill and Melinda Gates Foundation is apparently sponsoring research to reinvent the toilet!

I think it's fabulous.

A couple of years back, BBC reported that public sanitation was considered by doctors the best medical advance in over a century. It's really sad that it's not available for a large portion of the world. Toilet technology improvements could really make inroads into that. In particular, the ability to process sewage locally, with minimal access to water infrastructure could make huge improvements in quality of life.

Apart from health considerations, the other big benefit they are looking into is use of raw sewage for energy generation (possibly using the energy for processing the waste, to recover water and minerals). Why should it only be cattle whose waste products produce power?

No vacation nation

Oh yeah... and while we're at it... another reason it's not so hot being a (working) US mom: not enough vacation time.

CNN has a piece on how lame our national vacation policy is, compared with other "advanced" nations.

Germany is among more than two dozen industrialized countries -- from Australia to Slovenia to Japan -- that require employers to offer four weeks or more of paid vacation to their workers, according to a 2009 study by the human resources consulting company Mercer.

Finland, Brazil and France are the champs, guaranteeing six weeks of time off.

But employers in the United States are not obligated under federal law to offer any paid vacation, so about a quarter of all American workers don't have access to it, government figures show.

That makes the U.S. the only advanced nation in the world that doesn't guarantee its workers annual leave, according to a report titled "No-Vacation Nation" by the Center for Economic and Policy Research, a liberal policy group.

For the record, mandatory (paid) leave is not just good for your mental health. It's a must from a computer security point of view -- it's one tool for detecting fraudulent activities -- the vacationer's backup will be exposed to the vacationer's records and may come across fishy transactions.

It's not so hot to be a US mom

In fact, "The United States ranked number 31 out of 43 developed countries," according to this article. It goes on to say,

Only 58% of U.S. kids go to preschool compared with 98% in Iceland, 95% in Norway and 82% in Australia.

Compared with other developed countries, U.S. scored dead last is in the issue of paid maternity leave, Powers said. In the U.S., the typical family leave is 12 weeks compared with six months to a year in Europe, where mothers can bond with their babies and establish good breast-feeding practices.

The CNN article is based on statistics Save the Children's 12th annual Mothers' Index, which "analyzes health, education and economic conditions for women and children in 164 countries". It is worth taking a look at. Among the other horrifying statistics, we have

• An under 5 mortality rate of 8 per 1000 live births -- only 10 "developed" countries countries do worse (places like Albania, Belarus, Romania, etc.)
• A lifetime risk of maternal death of 1 in 2100, higher than any of the 43 developed countries except Albania, the Republic of Moldova and the Russian Federation

It never fails to amaze me how we manage to be the richest country on earth, and yet take such poor care of women and children.

Electronic Medical Records -- at what cost?

President-elect Barack Obama has made Electronic Medical Records (EMRs) one of the centerpieces of his plans for economic stimulus and healthcare reform. Now I'm certainly in favor of both stimulus and greater access to healthcare with lower costs, but I have some serious concerns about the use of EMRs to accomplish this. While automation would undoubtedly improve the productivity of healthcare delivery, it is also likely to improve the productivity of misuse. And considering how sensitive health information is, we need to be extra careful about building in safeguards against misuse. I just don't have a lot of faith that those safeguards will be thought out or implemented properly.

Let me start with the good part. The expectation, as I understand it, is that EMRs would

1. provide stimulus by employing a large number of IT and healthcare professionals to implement the EMR infrastructure


2. improve healthcare quality by centralizing information about a patient, to enable more informed decisions by healthcare providers (thereby also reducing dangerous errors)


3. reduce healthcare costs by reducing duplication of services, dangerous errors and insurance fraud


4. though nobody mentions it much, these days, I'd have to say another benefit would be the research that would be enabled: with large bodies of patient information, it would become possible to analyze more thoroughly the efficacy and safety of various drugs and treatment protocols, as well as disease models, etc.

Now I'm all for these goals. Especially the bit about employing more IT professionals. Not to mention the bit about helping scientific research (I still have a soft corner for AI and medicine, and all that, don't you know?) And I do believe that all of these benefits would ultimately be realized.

However, there are two main classes of concerns that I have:

1. I don't see net cost savings any time soon (like any time in the next 8 years)


2. I see massive societal risks to consolidating patient information

We're already up to our ears in debt, and we need some big spending to get our economy going, so what the heck? Cost savings isn't the gamechanger in my mind. I consider the societal risks the more serious issue, so let's begin with that.

First of all, I hereby admit that I haven't been able to find any details on exactly what an Obama administration would call for, in terms of EMRs. And the exact risks depend on the exact model. From a purely productivity point of view, I imagine that the ideal thing would be for a massive central database of health records for every patient in the country. It is possible that Obama envisions something rather different, such as a sort of federation of independently owned and operated databases managed by different stakeholders, with rules about when and how they can exchange data. But even in a de-centralized approach, there would almost certainly be design requirements to ensure ease of exchange of information, which in practice would probably lead to more or less aggregation of information about individuals. So most of my comments will address the risks of a centralized database. However, you may be certain that arguments over the exact model (centralized or federated or ...) will dominate the first several years of the effort -- different parties (companies, industries, trade and professional organizations, etc.) will have a lot at stake in the decision of what model to adopt. Hence some of my cynicism about when we can expect to see any savings. But I digress.

So what sort of risks are we looking at? I can't begin to do justice, but here's some broad categories:

1. Risks from malicious outsiders (hackers, etc.)
   A massive database of patient information would be an exceptionally juicy target for all sorts of hackers for all sorts of reasons. It would be a fantastic target for a Denial of Service attack: just imagine the havoc you could wreak by taking the system down -- the health of millions of people could be put in jeopardy. (Denial of Service would be less of an issue in a de-centralized model.) It would also be a terrific target for all sorts of hackers aiming for shake-down information about specific individuals (e.g. politicians, celebrities, annoying next door neighbors, ex-girlfriends, etc.)
   


2. Risks from (malicious) insiders (people who have legitimate access to data but misuse it)
   Anyone remember the flap last spring about those naughty State Department contractors who peeked at Obama's passport records? Just imagine that on steroids. Again, we're talking about all kinds of possibilities of improper access to peek at records of politicians, celebrities, annoying next door neighbors, ex-girlfriends, etc. Some of this can be prevented with proper auditing (which was responsible for catching the passport peekers). But given the large number of people potentially involved in providing healthcare services, I believe that there is still considerable risk from this. Of course, there could be some entertainment value. Imagine the fun that we'd have when unnamed sources from a large hospital divulged to the National Enquirer that some pro-life candidate once had an abortion 10 years ago :-) Oh yeah, and apart from the malicious thing, how long until some contractor goes out for lunch carrying around health records for 300,000 patients and loses the laptop?
   


3. Risks based on poorly designed policy (who do we give access to the data and what are they allowed to do with it?)
   Number one on my list would have to be: what do insurance companies get access to and what do they get to do with it? Full patient information for health care providers also potentially means full information for insurance companies to simplify their cherry picking. We need to build in anti-discrimination policy. This would be far less of a worry to me if we were looking at a single payer system -- ain't gonna happen. Number two on my list would probably be the financial pressure for targeted direct-to-consumer marketing. What a gold mine for pharmaceutical companies (and/or hospitals co-marketing on their behalf)!
   
   
4. Risks based on poorly designed processes
   I recently read a piece by Tom Yager which really gives me pause. He describes a rather unpleasant personal experience with e-prescription (a small part of EMRs), which almost amounted to a denial of service for him. When you're talking about things that people's lives depend on on a day-to-day basis, you've got to be especially careful to not hold them up because "the system said so". But it's not easy (and it is fraud-prone) to build flexibility into a system. Also, consider the potential for errors and identity confusion. Imagine your situation if somebody entered a positive HIV test result in your record, intending it for someone else with the same name? There's been lots of fun with the no-fly list (google David Nelson no fly). Imagine the fun with a nation-sized list (a couple of orders of magnitude larger). By the way, this is one place where a single centralized database might work a little better, in that you could have a national ID that could uniquely identify you. Oh, I forgot...Social Security Numbers...identity theft. Forget I mentioned that.
   

Apart from the risks inherent in EMRs, I see the cost-savings as gradual, at best. If we're talking about a single central database, you can just forget about it until oh, I don't know, maybe some time before Sasha and Malia O. retire. A typical largish project, in my experience requires about

• A year to argue about what the project goals are (scope, standards, etc.)
  
• A year to decide on an approach to the project (technologies, buy-vs-build, players, etc.)
  
• About two years to implement a rudimentary system that achieves about 60% of What We Really Want -- enough to give an illusion of business as usual, but not enough to feel really comfortable
  
• A year or so to get people up and running with the rudimentary system and develop workarounds for the kinks in the system
• Several more years to evolve to a mature system with most of the functionalities that users need and just a few annoyances
  

And mind you, I've never worked on a really large, government-sized, industrial strength project. (I have worked on a smallish government project, and it's in the mature stage where non-radical changes take 8 months.) If we're not talking about a single central database, change could be achieved more quickly, but delay will arise due to incompatibilities between independently developed systems that will need to interoperate. And don't forget, once there are systems in place, it will take time to get data from existing paper records into electronic format. Again, I think we can expect that once a system's in place, there will be savings. Just don't expect a quick payoff.

So am I saying we shouldn't implement Electronic Medical Records? No, I don't think so. No more than I am saying that we should ban pencils because some people use them to write hate literature. No more so than that we should forget about computers because they cost more and are more complicated than pencils and paper.

But I would call for some sober reflection on what we are getting into.

Edited 1/12/09: CNN has an interesting piece which makes many of the same points. It has some useful statistics, I think.

http://money.cnn.com/2009/01/12/technology/stimulus_health_care/index.htm

US Maternal Mortality rate on the rise

The US maternal mortality rate (essentially the rate of women dying from childbirth-related causes) was reported as 13 per 100,000 live births for 2004, up from 12 per 100,000 in 2003, which according to this article was the first time since 1977 that it was above 10.

Let's compare that with our neighbors to the north...an otherwise similar culture, by most accounts. WHO cites Canada's maternal mortality rate as 4 per 100,000 live births in 2000.

The US rise in maternal mortality is attributed to (among other things)

• a whopping 29% C-section rate
  
• obesity
• changes in how maternal mortality is reported
• older women having children

The first two factors, at very least, are highly addressable.

This is unforgiveable.