by the Sandwichman
Say economic growth after the BIG BAILOUT is slow for several years (a modest proposition). Inevitably the unemployment rate will mount. People may attribute the increased unemployment to the aftermath of the financial crisis. Post hoc ergo propter hoc. But, rather than being the CAUSE of unemployment, it would be more accurate to view the financial distress as simply the withdrawal of a palliative.
Economic orthodoxy insists that "technology creates more jobs than it destroys" -- a view that by the end of 1932 even Fortune magazine dismissed as unsatisfactory. In an article titled "Obsolete Men", the Fortune editors recalled the mechanistic explanation that the reduced cost from the use of labor-saving devices led to lower prices, increased demand and new employment to meet the greater demand. Where demand for any particular good was inelastic, workers displaced from one industry would find employment elsewhere.
Fortune concluded that it was accelerated economic growth, not lower market prices, that counteracted the job-killing potential of labor-saving technology. But, as an article in today's Globe and Mail puts it, "... U.S. growth has always been fueled by easy access to debt."
Saturday, September 20, 2008
Hey, Secretary Paulson, Whatever Happened to Shock Therapy?
I thought the believers in the market accepted the logic of shock therapy. You know, when country stray too far from market fundamentals they need tough medicine to make their economy strong.
Consider the case of Jeffrey Sachs writing in his recent book, The End of Poverty. Looking back on his first prescription of shock therapy in the destitute nation of Bolivia Sachs had a revelation. He realized that "Bolivia's physical geography was a fundamental feature of its economic situation, not merely an incidental fact .... Of course I knew that Bolivia was landlocked and mountainous .... Yet I had not reflected on how these conditions were key geographical factors, perhaps the overriding factors, in Bolivia's chronic poverty .... Almost all the international commentary and academic economic writing about Bolivia neglected this very basic point. It bothered me greatly that the most basic and central features of economic reality could be overlooked by academic economists spinning their theories from thousands of miles away." Yet, he concluded: "Monetary theory, thank goodness, still worked at thirteen thousand feet."
Sachs, Jeffrey D. 2005. The End of Poverty (London: Penguin): p. 105.
Jeffrey Sachs is relatively liberal, as far as economists go. After all, economists today confidently tell us that Keynes is dead. Everyone has to accept the discipline of the market: the unemployed, people without medical insurance, and students facing high tuition. If workers wages fall short, they are at fault for lacking the skills of a financial manager.
But wait! Now that the financial managers are in trouble, boy do they need help.
I only have one question for market fundamentalists. If these bailouts succeed in putting Humpty Dumpty together again, will our fundamentalists agree to tax the fat cats or will they revise history and tell us that their rebuilt wealth owes everything to their hard work and intelligence?
Or, what I'm afraid is more likely, is that market fundamentalism is applicable only in impoverished countries 13,000 feet above sea level.
Consider the case of Jeffrey Sachs writing in his recent book, The End of Poverty. Looking back on his first prescription of shock therapy in the destitute nation of Bolivia Sachs had a revelation. He realized that "Bolivia's physical geography was a fundamental feature of its economic situation, not merely an incidental fact .... Of course I knew that Bolivia was landlocked and mountainous .... Yet I had not reflected on how these conditions were key geographical factors, perhaps the overriding factors, in Bolivia's chronic poverty .... Almost all the international commentary and academic economic writing about Bolivia neglected this very basic point. It bothered me greatly that the most basic and central features of economic reality could be overlooked by academic economists spinning their theories from thousands of miles away." Yet, he concluded: "Monetary theory, thank goodness, still worked at thirteen thousand feet."
Sachs, Jeffrey D. 2005. The End of Poverty (London: Penguin): p. 105.
Jeffrey Sachs is relatively liberal, as far as economists go. After all, economists today confidently tell us that Keynes is dead. Everyone has to accept the discipline of the market: the unemployed, people without medical insurance, and students facing high tuition. If workers wages fall short, they are at fault for lacking the skills of a financial manager.
But wait! Now that the financial managers are in trouble, boy do they need help.
I only have one question for market fundamentalists. If these bailouts succeed in putting Humpty Dumpty together again, will our fundamentalists agree to tax the fat cats or will they revise history and tell us that their rebuilt wealth owes everything to their hard work and intelligence?
Or, what I'm afraid is more likely, is that market fundamentalism is applicable only in impoverished countries 13,000 feet above sea level.
Troopergate: Was Monegan Fired Because He Wanted to Reduce Rapes in Alaska?
Justin Rood debunks the latest lie from McCain-Palin on Troopergate. The McCain-Palin latest excuse for the firing of Walt Monegan:
Let’s say we buy this story. This means that the Public Safety Commissioner was pushing for funding of something very important – government efforts to reduce the high rate of rape in his state. One would have thought the governor would be all for this but McCain-Palin now want us to believe that these efforts from Monegan were discouraged by the governor to the point that she fired him. Thank goodness this is not true:
So maybe the governor was not so indifferent towards the high rate of rape in Alaska. But then why did she fire Monegan? The story continues:
In other words, the governor did not want the Public Safety Commissioner discussing means to reduce rape in Alaska with Senator Murkowski? I’m really confused.
Fighting back against allegations she may have fired her then-Public Safety Commissioner, Walt Monegan, for refusing to go along with a personal vendetta, Palin on Monday argued in a legal filing that she fired Monegan because he had a "rogue mentality" and was bucking her administration's directives. "The last straw," her lawyer argued, came when he planned a trip to Washington, D.C., to seek federal funds for an aggressive anti-sexual-violence program. The project, expected to cost from $10 million to $20 million a year for five years, would have been the first of its kind in Alaska, which leads the nation in reported forcible rape. The McCain-Palin campaign echoed the charge in a press release it distributed Monday, concurrent with Palin's legal filing. "Mr. Monegan persisted in planning to make the unauthorized lobbying trip to D.C.," the release stated.
Let’s say we buy this story. This means that the Public Safety Commissioner was pushing for funding of something very important – government efforts to reduce the high rate of rape in his state. One would have thought the governor would be all for this but McCain-Palin now want us to believe that these efforts from Monegan were discouraged by the governor to the point that she fired him. Thank goodness this is not true:
But the governor's staff authorized the trip, according to an internal travel document from the Department of Public Safety, released Friday in response to an open records request. The document, a state travel authorization form, shows that Palin's chief of staff, Mike Nizich, approved Monegan's trip to Washington, D.C., "to attend meeting with Senator Murkowski." The date next to Nizich's signature reads June 18.
So maybe the governor was not so indifferent towards the high rate of rape in Alaska. But then why did she fire Monegan? The story continues:
In response to inquiries about the document Friday, the McCain-Palin campaign provided a statement from Randy Ruaro, another aide to Palin. According to Ruaro, Monegan asked for -- and received -- approval for the travel without telling Palin's staff his reason for going. "As a matter of routine, the travel was approved by Mike Nizich ... weeks before the actual purpose was made clear by former Commissioner Monegan," Ruaro wrote. "When you receive permission to travel, it does not mean that you receive blanket authorization to discuss or do whatever you would like on that trip," he added.
In other words, the governor did not want the Public Safety Commissioner discussing means to reduce rape in Alaska with Senator Murkowski? I’m really confused.
Friday, September 19, 2008
WORK AND THE FINANCIAL CRISIS
by the Sandwichman
Perelman has previously mentioned his forthcoming book on the irrelevance of workers in economic theory. Yesterday, I received a note from David Spencer about his forthcoming book, The Political Economy of Work, which is due out in about a week.
Everybody knows that the BIG BAILOUT heralds "the most radical regime change in global economic and financial affairs in decades." But what has it all got to do with work and workers? Higher unemployment? Increasing cost of living? Quite possibly those things -- but another as yet unspoken dimension of the collapse-and-bailout of the financial system and its impending re-regulation is that it authorizes a re-opening of debate about the regulation of labor markets.
Until recently, the official Anglo-American journalistic line on labor market regulation was that it was bad. Europeans had to liberalize their labor markets or risk falling further and further behind the dynamic US economy. Well, now we know -- as some of us have been pointing out all along -- that the dynamism was contrived. It is time to re-assess ALL the hoary myths about the inherent superiority of "free markets", including that one.
Perelman has previously mentioned his forthcoming book on the irrelevance of workers in economic theory. Yesterday, I received a note from David Spencer about his forthcoming book, The Political Economy of Work, which is due out in about a week.
Everybody knows that the BIG BAILOUT heralds "the most radical regime change in global economic and financial affairs in decades." But what has it all got to do with work and workers? Higher unemployment? Increasing cost of living? Quite possibly those things -- but another as yet unspoken dimension of the collapse-and-bailout of the financial system and its impending re-regulation is that it authorizes a re-opening of debate about the regulation of labor markets.
Until recently, the official Anglo-American journalistic line on labor market regulation was that it was bad. Europeans had to liberalize their labor markets or risk falling further and further behind the dynamic US economy. Well, now we know -- as some of us have been pointing out all along -- that the dynamism was contrived. It is time to re-assess ALL the hoary myths about the inherent superiority of "free markets", including that one.
Financial Health Versus Children's Health
Please help me out here. Bush vetoed the Children's Health Insurance Program fearing that the legislation could add $35 billion over five years.
McCain on Federal Reserve Policy: Don’t Solve the Problem – Make It Worse
I was stunned by this:
The second sentence basically advocates that the government should allow the current financial crisis to worsen. On this one, Brad DeLong needs the microphone:
The call for a strong dollar is a call for higher interest rates and dollar appreciation. How will discouraging investment and reducing net exports lead to an increase in aggregate demand is beyond me. I’d like one of McCain’s economic advisors to explain that!
the Federal Reserve should get back to its core business of responsibly managing our money supply and inflation. It needs to get out of the business of bailouts. The Fed needs to return to protecting the purchasing power of the dollar. A strong dollar will reduce energy and food prices. It will stimulate sustainable economic growth and get this economy moving again.
The second sentence basically advocates that the government should allow the current financial crisis to worsen. On this one, Brad DeLong needs the microphone:
Since before 1844 central banks have been in the business of managing financial crises. That's what they do. Milton Friedman is spinning in his grave. The prevention of large-scale bank failures--"bailouts," in McCain's terms--is an essential part of responsibly managing the money supply. John McCain does not know that. And nobody working for John McCain knows that
The call for a strong dollar is a call for higher interest rates and dollar appreciation. How will discouraging investment and reducing net exports lead to an increase in aggregate demand is beyond me. I’d like one of McCain’s economic advisors to explain that!
No Bush: No Problem?
Our nominal head of state has been invisible during this latest flare-up of the financial crisis. Of course, we would expect Bernanke and Paulson to be the public face of the administration’s crisis management plans, but in theory they (especially Paulson) do have a boss. We’re talking here about the largest, most consequential domestic program in the entire GWB era. I mean, who’s the decider here?
If congressional Republicans balk at the size and cost of the bailout, will Bush have to come out of confinement to talk them into it?
If congressional Republicans balk at the size and cost of the bailout, will Bush have to come out of confinement to talk them into it?
LIKE, THEY DON'T FLAG, YOU KNOW, THE MOLECULES?
by the Sandwichman
What was that John McCain was saying about valley girl Palin knowing "more about energy than probably anyone else in the United States of America"?
Like, totally.
What was that John McCain was saying about valley girl Palin knowing "more about energy than probably anyone else in the United States of America"?
Like, totally.
Who Will Finance the Bailout?
According to today’s New York Times, it’s the beleaguered US taxpayer. In fact, the word “taxpayer” appears five times in their report on Fed/Treasury actions, always in connection with where the burden will fall. But this is flatly wrong.
In case my previous post was too oblique, let me say it bluntly: Taxpayers are not and will not be the ones to finance the bailout of the financial sector. There will be no tax increase to pay for it, nor will there be drastic (eleven-figure) cuts in other federal spending. It will be financed by substantially greater public borrowing from sovereign creditors, especially the People’s Bank of China and the various entities of the Gulf Cooperation Council. (Russia is an uncertainty in light of its own financial crisis.) The feasibility of the bailout depends entirely on the continued willingness of these deeply authoritarian countries to continue recycling their mountainous piles of dollars into dollar-denominated assets—formerly including private sector debt but now public debt exclusively.
In the absence of this external support, no bailout plan is remotely possible.
In case my previous post was too oblique, let me say it bluntly: Taxpayers are not and will not be the ones to finance the bailout of the financial sector. There will be no tax increase to pay for it, nor will there be drastic (eleven-figure) cuts in other federal spending. It will be financed by substantially greater public borrowing from sovereign creditors, especially the People’s Bank of China and the various entities of the Gulf Cooperation Council. (Russia is an uncertainty in light of its own financial crisis.) The feasibility of the bailout depends entirely on the continued willingness of these deeply authoritarian countries to continue recycling their mountainous piles of dollars into dollar-denominated assets—formerly including private sector debt but now public debt exclusively.
In the absence of this external support, no bailout plan is remotely possible.
Financial Catastrophe: Here We Go Again
I mentioned earlier that I thought that looking at production and distribution of income was crucial to understanding the financial crisis. Of course, the financial side provided the tipping point.
Some thing similar happened a few decades ago with a war, a different Bush, and John McCain.
Many years ago, Lyndon Johnson, who would have just celebrated his hundredth birthday couple days ago, found himself stuck in a war he couldn't win. He also knew that if he raised taxes to pay for the war, the public would demand an immediate halt with an intensity that he could not resist. Johnson relied on borrowing, which raised interest rates.
Savings and loan institutions, like the investment banks today, borrowed short and lent long. In this case, people put their savings in the banks and the banks lent out money on 30 year mortgages. To prevent gouging and make mortgages affordable, the Savings and Loans were prevented from paying interest rates high enough to keep depositors from exiting, which could make them bankrupt.
The Reagan administration, including daddy Bush, moved to deregulate the Savings and Loans. Given this newfound freedom, crooks and nincompoops (including President Bush's younger brother) rushed in to take advantage of profiting from other people's money. As the scope of this disaster was becoming obvious, five senators, including John McCain along with Alan Greenspan (perhaps the Godfather of the recent financial crisis), rushed in to defend one of the more egregious Savings and Loan operations run by Charles Keating. Oh, yes, a small savings-and-loan in Arkansas, which was connected with Bill Clinton (who allowed Congress to deregulate the current financial system, led by Senator Phil Gramm, John McCain's chief economic adviser) also ran into difficulties.
The savings-and-loan scam crashed leaving the government to pick up the pieces at a cost that is still debated, but which was still well over $100 billion -- pocket change today.
The difference today is that our politicians will really do excellent regulation this time, just as they did with Sarbanes-Oxley in the wake of Enron.
Some thing similar happened a few decades ago with a war, a different Bush, and John McCain.
Many years ago, Lyndon Johnson, who would have just celebrated his hundredth birthday couple days ago, found himself stuck in a war he couldn't win. He also knew that if he raised taxes to pay for the war, the public would demand an immediate halt with an intensity that he could not resist. Johnson relied on borrowing, which raised interest rates.
Savings and loan institutions, like the investment banks today, borrowed short and lent long. In this case, people put their savings in the banks and the banks lent out money on 30 year mortgages. To prevent gouging and make mortgages affordable, the Savings and Loans were prevented from paying interest rates high enough to keep depositors from exiting, which could make them bankrupt.
The Reagan administration, including daddy Bush, moved to deregulate the Savings and Loans. Given this newfound freedom, crooks and nincompoops (including President Bush's younger brother) rushed in to take advantage of profiting from other people's money. As the scope of this disaster was becoming obvious, five senators, including John McCain along with Alan Greenspan (perhaps the Godfather of the recent financial crisis), rushed in to defend one of the more egregious Savings and Loan operations run by Charles Keating. Oh, yes, a small savings-and-loan in Arkansas, which was connected with Bill Clinton (who allowed Congress to deregulate the current financial system, led by Senator Phil Gramm, John McCain's chief economic adviser) also ran into difficulties.
The savings-and-loan scam crashed leaving the government to pick up the pieces at a cost that is still debated, but which was still well over $100 billion -- pocket change today.
The difference today is that our politicians will really do excellent regulation this time, just as they did with Sarbanes-Oxley in the wake of Enron.
As Glenn Hubbard Advises the Presidential Candidates on Economic Policies – He Also Misrepresents
Glenn Hubbard calls for smarter regulations to address the current financial crisis. While it hard to disagree with his plea, this offends me:
Glenn’s praise of McCain is simply wrong. McCain used to champion the removal of regulations but now he has flipped-flopped into an uber-regulator who abhors short selling and thinks the head of the SEC should be fired. I seriously doubt Glenn thinks such inconsistencies from our policy makers is a good idea. I’ll leave it to the economists advising Obama as to Glenn’s claim that they don’t believe in the gains from trade.
Now, consider the candidates' economic philosophies. John McCain champions openness, low taxes and efficient regulation. Barack Obama is more skeptical of gains from trade and global finance, and he favors tax increases on capital and a variety of regulatory solutions. In this environment, these differences are revealing (and the advantage goes to McCain).
Glenn’s praise of McCain is simply wrong. McCain used to champion the removal of regulations but now he has flipped-flopped into an uber-regulator who abhors short selling and thinks the head of the SEC should be fired. I seriously doubt Glenn thinks such inconsistencies from our policy makers is a good idea. I’ll leave it to the economists advising Obama as to Glenn’s claim that they don’t believe in the gains from trade.
How the Fed/Treasury Are Rebalancing Global Portfolios
A question I sometimes ask my intro macro students is, could the Fed, if it wished, conduct open market operations by buying (and later perhaps selling) famous paintings, rock memorabilia, etc.? This tests their understanding of the concept: any asset can be used to inject or absorb liquidity. Little did I suspect that the asset in question might be vast swaths of suburban tract housing. But the recent announcement that the Fed’s acquisition of junk mortgages would be partly financed by $100B in new Treasury issues indicates that the bailout is being insulated as far as possible from monetary policy.
But this is interesting from the standpoint of global capital flows too. Many of the investments of the last few years, like Chinese purchases of Fannie and Freddie stuff and Gulf capitalizations of US banks and shadow banks, aren’t looking very good right now. All indications, in fact, are that sovereign funds are rebalancing as fast as they can away from anything that bears the slightest whiff of the US housing market. But where can they go and still stay in dollars? Answer: the Fed can buy up the tainted assets our creditors no longer want to hold, financed by new Treasury bonds, financed by these same creditors. The creditors are happy (or at least placated) by being able to shift away from risk, the capital inflows needed to finance the US external deficit keep flowing, and enough domestic credit market players are refloated to keep the debt game going a while longer. In theory the Fed/Treasury risk laundering scheme could be extended to new classes of debt, like consumer credit and corporate paper, as their quality deteriorates. The longer it continues, the longer US employment and income can be buoyed up by borrowing, giving the macroeconomy a semblance of stability. I’m getting the feeling, however, that this is an endgame scenario, not a new financial equilibrium.
But this is interesting from the standpoint of global capital flows too. Many of the investments of the last few years, like Chinese purchases of Fannie and Freddie stuff and Gulf capitalizations of US banks and shadow banks, aren’t looking very good right now. All indications, in fact, are that sovereign funds are rebalancing as fast as they can away from anything that bears the slightest whiff of the US housing market. But where can they go and still stay in dollars? Answer: the Fed can buy up the tainted assets our creditors no longer want to hold, financed by new Treasury bonds, financed by these same creditors. The creditors are happy (or at least placated) by being able to shift away from risk, the capital inflows needed to finance the US external deficit keep flowing, and enough domestic credit market players are refloated to keep the debt game going a while longer. In theory the Fed/Treasury risk laundering scheme could be extended to new classes of debt, like consumer credit and corporate paper, as their quality deteriorates. The longer it continues, the longer US employment and income can be buoyed up by borrowing, giving the macroeconomy a semblance of stability. I’m getting the feeling, however, that this is an endgame scenario, not a new financial equilibrium.
Thursday, September 18, 2008
So, is Social Security Safe for Now?
Over at Angry Bear, that great defender of Social Security, Bruce Webb, has declared that he is taking a vacation until next spring because Social Security is safe for now? Is he right? The obvious answer would seem to be "yes," with the most recent financial crises seriously undermining the argument for privatization that Republicans have pushed so relentlessly, including both President Bush and candidate John McCain, whose plan has not been well defined, anymore than was Bush's was back in 2005, when he made his big failed push.
Of course, this leaves the question of what Obama might do, with a Dem more in the position to actually do something to Social Security. I used to worry that Hillary would get in and follow her husband's former desire to "reform" SS. However, it seems that Obama's position has improved. I, like Bruce Webb, am a hardliner that nothing needs to be done, disagreeing even with Dean Baker, who says nothing needs to be done, but who buys into CBO projections that say the system will be "bankrupt" in the late 2040s. Bruce and I are skeptical. Obama has proposed putting a fica tax on wage earners above $250,000 per year income, but more recently has said this should be done only "if necessary," thus putting it off. This is an improvement.
Actually, at this point, I agree with Paul Begala. Given the financial crises and McCain's incoherent pro-privatization position, I think Obama should use the issue and hit hard on McCain over it. Heck, time to play for Florida for real.
Of course, this leaves the question of what Obama might do, with a Dem more in the position to actually do something to Social Security. I used to worry that Hillary would get in and follow her husband's former desire to "reform" SS. However, it seems that Obama's position has improved. I, like Bruce Webb, am a hardliner that nothing needs to be done, disagreeing even with Dean Baker, who says nothing needs to be done, but who buys into CBO projections that say the system will be "bankrupt" in the late 2040s. Bruce and I are skeptical. Obama has proposed putting a fica tax on wage earners above $250,000 per year income, but more recently has said this should be done only "if necessary," thus putting it off. This is an improvement.
Actually, at this point, I agree with Paul Begala. Given the financial crises and McCain's incoherent pro-privatization position, I think Obama should use the issue and hit hard on McCain over it. Heck, time to play for Florida for real.
Two Vignettes of Regulation: I
Bureaucratic regulation is very difficult. Even when the government sets up regulations, financial corporations manage to circumvent them without much more oversight than domesticate politicians are willing to provide.
In contrast, enormous resources are used to micromanage people without much power. This type of regulation is strangling education. Instead of single payer, ridiculous regulations of medicine are costing lives. Here is valuable testimony from a doctor writing in the new York Times.
"Not long ago, a colleague asked me for help in treating a patient with congestive heart failure who had just been transferred from another hospital. When I looked over the medical chart, I noticed that the patient, in his early 60s, was receiving an intravenous antibiotic every day. No one seemed to know why. Apparently it had been started in the emergency room at the other hospital because doctors there thought he might have pneumonia. But he did not appear to have pneumonia or any other infection. He had no fever. His white blood cell count was normal, and he wasn't coughing up sputum. His chest X-ray did show a vague marking, but that was probably just fluid in the lungs from heart failure."
"I ordered the antibiotic stopped - but not in time to prevent the patient from developing a severe diarrheal infection called C. difficile colitis, often caused by antibiotics. He became dehydrated. His temperature spiked to alarming levels. His white blood cell count almost tripled. In the end, with different antibiotics, the infection was brought under control, but not before the patient had spent almost two weeks in the hospital."
"The case illustrates a problem all too common in hospitals today: patients receiving antibiotics without solid evidence of an infection. And part of the blame lies with a program meant to improve patient care. The program is called pay for performance, P4P for short. Employers and insurers, including Medicare, have started about 100 such initiatives across the country. The general intent is to reward doctors for providing better care. For example, doctors receive bonuses if they prescribe ACE inhibitor drugs to patients with congestive heart failure. Hospitals get bonuses if they administer antibiotics to pneumonia patients in a timely manner."
"On the surface, this seems like a good idea: reward doctors and hospitals for quality, not just quantity. But even as it gains momentum, the initiative may be having untoward consequences. To get an inkling of the potential problems, one simply has to look at another quality-improvement program: surgical report cards. In the early 1990s, report cards were issued on surgeons performing coronary bypasses. The idea was to improve the quality of cardiac surgery by pointing out deficiencies in hospitals and surgeons; those who did not measure up would be forced to improve. But studies showed a very different result. A 2003 report by researchers at Northwestern and Stanford demonstrated there was a significant amount of "cherry-picking" of patients in states with mandatory report cards. In a survey in New York State, 63 percent of cardiac surgeons acknowledged that because of report cards, they were accepting only relatively healthy patients for heart bypass surgery. Fifty-nine percent of cardiologists said it had become harder to find a surgeon to operate on their most severely ill patients."
"Whenever you try to legislate professional behavior, there are bound to be unintended consequences. With surgical report cards, surgeons' numbers improved not only because of better performance but also because dying patients were not getting the operations they needed. Pay for performance is likely to have similar repercussions. Consider the requirement from Medicare that antibiotics be administered to a pneumonia patient within six hours of arriving at the hospital. The trouble is that doctors often cannot diagnose pneumonia that quickly. You have to talk to and examine a patient and wait for blood tests, chest X-rays and so on."
"Under P4P, there is pressure to treat even when the diagnosis isn't firm, as was the case with my patient with heart failure. So more and more antibiotics are being used in emergency rooms today, despite all-too-evident dangers like antibiotic-resistant bacteria and antibiotic-associated infections. I recently spoke with Dr. Charles Stimler, a senior health care quality consultant, about this problem. "We're in a difficult situation," he said. "We're introducing these things without thinking, without looking at the consequences. Doctors who wrote care guidelines never expected them to become performance measures." And the guidelines could have a chilling effect. "What about hospitals that stray from the guidelines in an effort to do even better?" Dr. Stimler asked.
"Should they be punished for trying to innovate? Will they have to take a hit financially until performance measures catch up with current research"?"
"The incentives for physicians raise problems too. Doctors are now being encouraged to voluntarily report to Medicare on 16 quality indicators, including prescribing aspirin and beta blocker drugs to patients who have suffered heart attacks and strict cholesterol and blood pressure control for diabetics. Those who perform well receive cash bonuses. But what to do about complex patients with multiple medical problems? Forty-eight percent of Medicare beneficiaries over 65 have at least three chronic conditions. Twenty-one percent have five or more. P4P quality measures are focused on acute illness. It isn't at all clear that they should be applied to elderly patients with multiple disorders who may have trouble keeping track of their medications."
"With P4P doling out bonuses, many doctors have expressed concern that they will feel pressured to prescribe "mandated" drugs, even to elderly patients who may not benefit, and to cherry-pick patients who can comply with pay-for-performance measures. And which doctor should be held responsible for meeting the quality guidelines? On average, Medicare patients see two primary-care physicians in any given year, and five specialists working in four practices. Care is widely dispersed, so it is difficult to assign responsibility to one doctor. If a doctor assumes responsibility for only a minority of her patients, then there is little financial incentive to participate in P4P. If she assumes too much responsibility, she may be unfairly blamed for any lapses in quality."
"Nor is it clear that pay for performance will actually result in better care, because it may end up benefiting mainly those physicians who already meet the guidelines. If they can collect bonuses by maintaining the status quo, what is the incentive to improve? Doctors have seldom been rewarded for excellence, at least not in any tangible way. In medical school, there were tests, board exams and lab practicals, but once you go into clinical practice, these traditional measures fall away. At first glance, pay for performance would seem to remedy this problem. But first its deep flaws must be addressed before patient care is compromised in unexpected ways."
Jauhar, Sandeep. 2008. "The Pitfalls of Linking Doctors' Pay to Performance." New York Times (8 September).
http://www.nytimes.com/2008/09/09/health/09essa.html
In contrast, enormous resources are used to micromanage people without much power. This type of regulation is strangling education. Instead of single payer, ridiculous regulations of medicine are costing lives. Here is valuable testimony from a doctor writing in the new York Times.
"Not long ago, a colleague asked me for help in treating a patient with congestive heart failure who had just been transferred from another hospital. When I looked over the medical chart, I noticed that the patient, in his early 60s, was receiving an intravenous antibiotic every day. No one seemed to know why. Apparently it had been started in the emergency room at the other hospital because doctors there thought he might have pneumonia. But he did not appear to have pneumonia or any other infection. He had no fever. His white blood cell count was normal, and he wasn't coughing up sputum. His chest X-ray did show a vague marking, but that was probably just fluid in the lungs from heart failure."
"I ordered the antibiotic stopped - but not in time to prevent the patient from developing a severe diarrheal infection called C. difficile colitis, often caused by antibiotics. He became dehydrated. His temperature spiked to alarming levels. His white blood cell count almost tripled. In the end, with different antibiotics, the infection was brought under control, but not before the patient had spent almost two weeks in the hospital."
"The case illustrates a problem all too common in hospitals today: patients receiving antibiotics without solid evidence of an infection. And part of the blame lies with a program meant to improve patient care. The program is called pay for performance, P4P for short. Employers and insurers, including Medicare, have started about 100 such initiatives across the country. The general intent is to reward doctors for providing better care. For example, doctors receive bonuses if they prescribe ACE inhibitor drugs to patients with congestive heart failure. Hospitals get bonuses if they administer antibiotics to pneumonia patients in a timely manner."
"On the surface, this seems like a good idea: reward doctors and hospitals for quality, not just quantity. But even as it gains momentum, the initiative may be having untoward consequences. To get an inkling of the potential problems, one simply has to look at another quality-improvement program: surgical report cards. In the early 1990s, report cards were issued on surgeons performing coronary bypasses. The idea was to improve the quality of cardiac surgery by pointing out deficiencies in hospitals and surgeons; those who did not measure up would be forced to improve. But studies showed a very different result. A 2003 report by researchers at Northwestern and Stanford demonstrated there was a significant amount of "cherry-picking" of patients in states with mandatory report cards. In a survey in New York State, 63 percent of cardiac surgeons acknowledged that because of report cards, they were accepting only relatively healthy patients for heart bypass surgery. Fifty-nine percent of cardiologists said it had become harder to find a surgeon to operate on their most severely ill patients."
"Whenever you try to legislate professional behavior, there are bound to be unintended consequences. With surgical report cards, surgeons' numbers improved not only because of better performance but also because dying patients were not getting the operations they needed. Pay for performance is likely to have similar repercussions. Consider the requirement from Medicare that antibiotics be administered to a pneumonia patient within six hours of arriving at the hospital. The trouble is that doctors often cannot diagnose pneumonia that quickly. You have to talk to and examine a patient and wait for blood tests, chest X-rays and so on."
"Under P4P, there is pressure to treat even when the diagnosis isn't firm, as was the case with my patient with heart failure. So more and more antibiotics are being used in emergency rooms today, despite all-too-evident dangers like antibiotic-resistant bacteria and antibiotic-associated infections. I recently spoke with Dr. Charles Stimler, a senior health care quality consultant, about this problem. "We're in a difficult situation," he said. "We're introducing these things without thinking, without looking at the consequences. Doctors who wrote care guidelines never expected them to become performance measures." And the guidelines could have a chilling effect. "What about hospitals that stray from the guidelines in an effort to do even better?" Dr. Stimler asked.
"Should they be punished for trying to innovate? Will they have to take a hit financially until performance measures catch up with current research"?"
"The incentives for physicians raise problems too. Doctors are now being encouraged to voluntarily report to Medicare on 16 quality indicators, including prescribing aspirin and beta blocker drugs to patients who have suffered heart attacks and strict cholesterol and blood pressure control for diabetics. Those who perform well receive cash bonuses. But what to do about complex patients with multiple medical problems? Forty-eight percent of Medicare beneficiaries over 65 have at least three chronic conditions. Twenty-one percent have five or more. P4P quality measures are focused on acute illness. It isn't at all clear that they should be applied to elderly patients with multiple disorders who may have trouble keeping track of their medications."
"With P4P doling out bonuses, many doctors have expressed concern that they will feel pressured to prescribe "mandated" drugs, even to elderly patients who may not benefit, and to cherry-pick patients who can comply with pay-for-performance measures. And which doctor should be held responsible for meeting the quality guidelines? On average, Medicare patients see two primary-care physicians in any given year, and five specialists working in four practices. Care is widely dispersed, so it is difficult to assign responsibility to one doctor. If a doctor assumes responsibility for only a minority of her patients, then there is little financial incentive to participate in P4P. If she assumes too much responsibility, she may be unfairly blamed for any lapses in quality."
"Nor is it clear that pay for performance will actually result in better care, because it may end up benefiting mainly those physicians who already meet the guidelines. If they can collect bonuses by maintaining the status quo, what is the incentive to improve? Doctors have seldom been rewarded for excellence, at least not in any tangible way. In medical school, there were tests, board exams and lab practicals, but once you go into clinical practice, these traditional measures fall away. At first glance, pay for performance would seem to remedy this problem. But first its deep flaws must be addressed before patient care is compromised in unexpected ways."
Jauhar, Sandeep. 2008. "The Pitfalls of Linking Doctors' Pay to Performance." New York Times (8 September).
http://www.nytimes.com/2008/09/09/health/09essa.html
Two Vignettes of Regulation: II
Arthur Samish was a lobbyist who ran California in the 40s and 50s. Senator Estes Kefauver described him: "He is a combination of Falstaff, Little Boy Blue and Machiavelli, crossed with an eel."
Samish recalled in his autobiography:
"One time a reporter asked me how I was getting along with the governor. "I am the governor of the legislature," I told him. "To hell with the governor of California."
His most important client was the sellers of alcoholic beverages. Samish had a keen understanding of the way that economy works. Here is his economic analysis:
"I operated on the theory that only by regulation and enforcement could the alcoholic beverage business thrive and prosper. Cutthroat competition could have been ruinous .... only by regulation and enforcement could the alcoholic beverage business thrive and prosper. Cutthroat competition could have been ruinous. So I put through fair-trade laws to protect wholesalers, distributors and retailers. All of them make a profit in California, and they always have."
"But look what happens in states that don't have fair trade. New York, for instance. When the fair-trade laws were in effect there, a liquor license could have been worth $250,000. Then the state removed fair trade and the license is worth virtually nothing. The liquor business started competing so fiercely that it was tough for anyone to make a profit."
See Samish, Arthur H. and Bob Thomas. 1971. The Secret Boss of California: The Life and High Times of Art Samish (New York: Crown).
Samish recalled in his autobiography:
"One time a reporter asked me how I was getting along with the governor. "I am the governor of the legislature," I told him. "To hell with the governor of California."
His most important client was the sellers of alcoholic beverages. Samish had a keen understanding of the way that economy works. Here is his economic analysis:
"I operated on the theory that only by regulation and enforcement could the alcoholic beverage business thrive and prosper. Cutthroat competition could have been ruinous .... only by regulation and enforcement could the alcoholic beverage business thrive and prosper. Cutthroat competition could have been ruinous. So I put through fair-trade laws to protect wholesalers, distributors and retailers. All of them make a profit in California, and they always have."
"But look what happens in states that don't have fair trade. New York, for instance. When the fair-trade laws were in effect there, a liquor license could have been worth $250,000. Then the state removed fair trade and the license is worth virtually nothing. The liquor business started competing so fiercely that it was tough for anyone to make a profit."
See Samish, Arthur H. and Bob Thomas. 1971. The Secret Boss of California: The Life and High Times of Art Samish (New York: Crown).
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