fricat1ve

There's nothing like Boston or NYC in the control states. If the effect is as big as they seem to think--a 21% increase in mortality--that should be visible on a plot of deaths over time.

The "objective metrics" part is key. Medical records are generally written in a way that weaves a standard narrative of the doctor as either a hero/savior or a valiant defender of a lost cause.

Doctors only get investigated when derogatory facts accumulate to an extent that this "standard narrative" collapses. It's not really an objective or scientific standard.

As far as a performance evaluation that directly scores a surgeon's judgment and whether the procedures s/he is performing are actually beneficial...in the absence of a big screw-up or complaint, I don't believe there is any forum to do that after training is complete.

In the US, if the surgery is in hospital:

- Well-regarded hospitals will vet surgeons before granting privileges.

- Average hospitals give out privileges fairly easily if there are no actions against a person's license.

- There is a "collegial" review of big screw-ups that carry major reputational risk.

- As with any fee-for-service firm, "rainmakers" are highly sought after and get away with more.

- Privileges are difficult to take away once granted. (Have stronger legal protections than academic tenure in some states.)

If the surgery is in an ambulatory surgery center or doctor's office:

Basically anything goes. Ice-pick lobotomies, tonsillectomy mills, boob job factories in strip malls....all have happened in recent US history. About as well-regulated as traveling carnivals.

One problem is that fee-for-service incentives strongly distort what people think they "know full well."

A better way to make this claim would be to plot the mortality rates for the states over time and show that the rates in those places requiring reporting begin to diverge as the new policy is implemented.

Even consent itself is something that's overly fetishized in our society. It's a sign that a group's common understanding of people's basic rights and responsibilities has fallen apart. So everything comes down to some idealized notion of "consent" which, in a well-functioning society, is necessary but not sufficient to determine whether an action is acceptable or not.

> if you want a cure for cancer, you have to pay scientists to look for it.

We do that. It's a two-tier system where the public pays for the science and the companies fish ideas from the science to make into medicines.

>The fact that it's hard is the reason it's expensive.

No, the reason it is expensive is because we've signalled that we are willing to pay large amounts of money, essentially regardless of the actual benefit extended by the state of the art treatment. Even if the state of the science doesn't have much to offer in the way of a cure, you can count on the private sector to make drugs that push the envelope of what we are willing to pay.

But because the job that the private sector does is not the "rate limiting step" as it were, dumping more cash on them is just wasted money.

There was a story that checking ID's on plane tickets was at the top of the airlines lobbying wishlist after 9/11 so they could curtail the practice of people selling unused tickets to another (same gender) person.

>If it wasn't, why has it taken this long for someone to take ownership of that huge pile of risk-free money

Maybe because no one thought of it before?

The picture you're painting is fine if you're evaluating a handful of candidate molecules each with, you'd guess, a 5% chance of having the right PK profile or something.

But for major breakthroughs, there are "unknown unknowns" that make it impossible to estimate that likelihood. It's nice to think that, if you let the full value be captured, it would incentivize more people to pursue one-in-a-million "lottery ticket" cures, but it just doesn't work that way. They're not lottery tickets if they have incalculable odds.

For the most part, the difference between management and cures is in this latter category. I.e. we don't have a cure because we just don't know how to do it, not because we were too cheap to invest in the biochemical trench warfare to find the right molecule.

>People should be willing to pay as much for it as the alternative

Maybe. But maybe there's also something wrong with expecting that much. Somehow Sidney Farber didn't decide that he was going to charge the families of kids with ALL the actuarial value of the remainder of their lives.

It can be frustrating to see the public, out of ignorance, grossly misjudge the relative contributions to health of, say, a vaccine developer relative to a self-promoting surgeon. But there is something new and rather strange with this way of seeing medicine as a "capture the value"-type enterprise.

I found this comment unintentionally hilarious.

They solve this by working on diseases whose diagnostic criteria are vague enough that they can never be fully cured. Or at least no physician will ever tell someone they're "cured." Diabetes, hypertension, heart disease, autoimmune...

Still doesn't explain why they couldn't just release a statement warning people not to rely on the autopilot until the authorities have completed their investigation.

That avoids prejudging whether it was primarily a defect with the vehicle, or driver error, or both.

Above all just respect the process. It's important to yield to an impartial entity when people have been hurt or killed.

I doubt it's really about legal issues. Could they just disable or scale back the autopilot? Or at least warn people to not rely on it while avoiding any commentary about the facts of the accident. That'd be more polite/deferential to the investigators and to the victim.

I wouldn't be surprised if there's some fear over allowing uncertainty to fester for a year while awaiting the results of the investigation. But I think there's a much bigger risk in being perceived as unwilling to play by the same rules as everyone else.

Those studies don't say what you're claiming.

I meant the pricing was post-hoc in the sense that they came up with a story like yours for why it was worth $84,000 when they were bringing it to market. There was no precedent for a pill that costly when the research was undertaken. Even in the case of HCV--the best case to be discussing if you're an advocate of for-profit medicine--it's not a good example of an incentive structure.

You're making this very hand-wavy calculation. Hardly any 45 year olds were dying of hep C, even the older ones had lots of comorbidities & other risk factors, which is what one would expect for a disease acquired through intravenous drug use, and often transmitted in prisons or unsanitary tattoo parlors, and the drugs don't have a perfect cure rate.

In any case it's nearly irrelevant because this was a completely post-hoc rationale for pricing this drug. I am not opposed to large cash bounties for major advances but our current system is not remotely designed around that principle. Forgive me for thinking you are defending the wrong system.

You keep stating this as if it were a fact, but did it occur to you that delineating what research spending in fact contributed is complex?

Medicine is perhaps the industry that most exemplifies one with large confluent streams of money from public, private, and charitable sources involved at different levels of training, research, and practice.

Then allow prop 13 to stay but only for a primary residence. Maybe even limit it to native born citizens if you want. The benefit should definitely not be available to landlords or foreign buyers.

The current situation is bad enough that it's actually driving away people who were born here and have regular jobs, and causing a lot of the traffic problems you mention by increasing commuting.

I see. I'm just not sure they have so much of a dog in the Prop 13 fight per se. Land values there haven't risen to nearly the levels as in coastal communities. And there are all sorts of special rules for ag taxes that I'm not really familiar with. The Central Valley farming community definitely leans very rightward and sees themselves as a somewhat aggrieved minority in California.

Are we talking about real agribusiness in the Central Valley or are we talking about a couple "family farms" in Cupertino or wherever?

In the former case, are these people are at any competitive disadvantage relative to rural areas of other states?

As for the latter case....well how much sentimentality are you going to attach to land uses from the past? Sure, Silicon Valley is built on some of the highest quality farmland in the country but most of the farms are gone now. If you want to keep whatever few are left there are probably more targeted ways of doing that.

So now it's "redistribution" to have people pay the same tax rates on their property? Oyy...

I was born here too but your arguments sound a lot like special pleading.

Do you really think that a tax loophole is "earned"?

It doesn't support property ownership anymore because it incentivizes people to hang onto and rent out properties that haven't been reassessed.

I have heard this argument advanced against the estate tax. But even if you eliminate the reassessment loop hole the property tax rates are still cappped at the 1-ish percent level.

A family farm that can't afford 1% of its assessed value doesn't sound like a very viable business.

>I know it'll never hit the ballot.

Why so fatalistic? California is probably the most open state in the union in terms of citizens having the ability to place ballot measures.

That's how Prop 13 got passed in the first place :)

https://ballotpedia.org/Signature_requirements_for_ballot_me...

Not one mention of Prop 13? Poor reporting.

It's basically the rent control story writ large. Everyone who bought in the 20th century has such an "amazing deal" that they won't give it up unless you a) entice them with a better deal or b) gore their oxen and repeal 13.

Perhaps Americans are just confident that if these things start happening there will be ample opportunity to implement legislative fixes.

I mean c'mon...."Refused entry into establishments"? Unless the Civil Rights Act of 1964 somehow gets repealed I don't see this as very likely.

Electronic health records have been way oversold. Expecting every little medical office to have industrial-grade data protection makes them far more of a liability than they are worth.

At best mostly subjective observations, at worst full of outright errors, they're largely useless from a health care perspective let alone for research purposes.

>the idea of being in an "elite", informed group is more important than the actual issues.

Do you mean to say it's voyeurism, i.e. the draw of being "informed"? Sitting in the eye of the panopticon?

I think people just have a tendency to focus on the positive things that might be gained from data mining. There's just a lot of naivete about how compromised an ad-supported business ultimately is.

Ok, I understand a little better now. I still think this "legality" line of argument is a bit of a red herring and I'm not sure where the poster you responded to got his ideas about how things were "in earlier days" and what "was always the standard."

I think it's probably fair to say that Vietnam was an eye-opener that shook a lot of people's trust in the wisdom of our society's leadership in general. And that a segment of society nevertheless responded like Kissinger by doubling down and shaming the doubters.

>there has been a massive campaign to roll back what was called “Vietnam syndrome” — the idea that you should consider the morality of your actions and contributions to society, not mere legality.

Is that what is typically meant by "Vietnam syndrome"?

https://en.m.wikipedia.org/wiki/Vietnam_Syndrome

Also, isn't it a stretch to say Hollywood movies about WWII propagandize the idea one should only consider the legality of one's actions rather than the morality? If anything I would think most films attempt (in a sappy and trite way) to defend the rightness of the Allied cause.