Friday, March 27, 2009

AIG – too big to succeed

The phrase "too big to fail" is too often used to describe why various companies should receive bailouts from the federal government. Some financial companies are allegedly too big to fail because if they do fail it would create a series of failures as those who do business with the failing companies would be hurt by the failure of the initial company. Some automobile companies are allegedly too big to fail because if they do fail then parts suppliers and dealerships would all fail as well.

Perhaps it is time to introduce a new phrase into the national lexicon, "to big to succeed." A company is too big to succeed if it grows so big that it cannot make a profit anymore, and as a result it must fail.

What about the domino effect of dependent companies. They are part of the "to big to succeed" model, because their success is entirely dependent on a failed company. If someone is betting that a company that is bleeding money will succeed, that someone should lose the bet.

There is no way to turn a failed model into a successful model without changing the model. There is no way to turn a failed company into a successful company without liquidating the losses. Making the company bigger only makes the failure bigger.

A bigger failure needs more bailouts to keep from liquidating, but those bailouts do not change the model – they do the reverse. They save those in charge of the failure from having to adjust their behavior.

Let AIG fail, because it is too big to succeed. Then go on to bigger failures, such as the State of California, and eventually to the United States Government itself.

Friday, March 20, 2009

Healthcare in the United States

A friend of mine works in medicine, and I told her that if she were to write up commentary on the state of healthcare in the United States I would print it for her. I expected an essay, but instead she forwarded to me two emails she had sent to another organization, the second as an addendum to the first.

To: Department of Health and Human Services

Re: Action plan to to prevent healthcare-associated infections

I am responding as an individual, not representing any organization.

Myself, BS, BSN, MPH, formerly CIC

I currently work as an Infection Preventionist (name recently changed from Infection Control Nurse) in a 500+ bed community hospital. I cover all the intensive care units in the facility, so I am aware of the problems faced on the front line of infection prevention.

1. Basics: Make sure government agencies at all levels do not impede best practice.

Research has shown that alcohol-based hand hygiene products can improve compliance in intensive care units. (Maury et. al, Am J Respir Crit Care Med Vol 162, pp 324-327). The hospital I work in has had alcohol based hand sanitizer available for over 8 years. We spent time and effort in selecting a product that was acceptable to all involved. The Georgia State Insurance Commissioner is currently investigating removal of foam sanitizers under pressure for a theoretical fire risk. The last time we were forced to remove our current product from the hallways, our cross transmission of MRSA skyrocketed. Replacing the hallway dispensers stopped the outbreak.

2. Partnership of all involved groups: The patient also needs to be seen as a partner in reducing healthcare associated infections.

Transmission of flora within the hospital does cause healthcare-associated infections, but for SSI (surgical site infection), the patient's own flora can be the source. Aside from complying with preoperative showers for elective surgery, patients need to prepare themselves for the surgery by stopping smoking and controlling blood glucose levels. Smoking has been shown to increase SSI. Post-operative glucose control is important in prevention of SSI, but patients who know they are going to have surgery should prepare themselves.

Patients also need to understand that requiring their physicians to prescribe unnecessary antibiotics also contributes to infection with CD (C diff).

Physicians also need to be involved in getting patients ready for elective surgery. The following is a true story. My mother and the brother of a friend of mine both had knee replacements on the same day. It took a long time to get my mother ready for surgery because her surgeon insisted that she see her primary care physician and her dentist for clearance.. She had to be screened for infection--UTI. Our hospital does nasal screening for MRSA and MSSA on all orthopedic implant surgeries. The brother did not have to do any of this. Within three weeks of surgery, my friend told me that her brother had an infection. My mother is now over one year out from her surgery and doing fine. We switched surgeons early in the course of getting her knee replaced because the first surgeon we went to wanted to basically go from his office to the OR without the preparation the second one required.

3. Focus on MRSA: I find this short sighted.

The worst infections in our facility are caused by Gram negative rods (GNR) for which there are no antibiotic treatments. It is much easier to track MRSA and may be easier to put in interventions. However, GNR are a much worse and growing problem.

4. Futility of Care and End of Life issues: something nobody want to discuss as part of the solution. Strong guidelines on futility of care, and decreased payments for care after such a determination is made need to be in place now.

The last three infections I identified (2 BSI and 1 VAP) were all in patients in whom it had been acknowledged that there was no hope of recovery and all medical interventions were futile. DNR discussions had been ongoing with the families for as long as three weeks prior to the infections. All three patients died of their underlying conditions within three weeks of the onset date of the infection. The infection was not the immediate cause of death, even if it might have hastened the inevitable. Physicians discuss the problem openly during our intensive care rounds. The family will be around after the patient's death and might bring a law suit if their wishes (the family's) are not carried out. The wishes are usually expressed as "Do everything for Mama" even if they have been told that everything will not work and that Mama is going to die anyway. We have discussed the reason for families not to withdraw care. Sometimes it is just too soon. It because apparent today that the patient was beyond hope. Sometimes it is the level of education and sophistication of the family. When you talk to them, they are very nice but they just don't seem to understand the issues. Guilt can play a part also. Having neglected Mama for the past year (nursing home patient, living with a friend, not family), the family wants to make amends. We see cultural differences. African American families seem less able to withdraw care. Sometimes we find out that there is a financial reason.. Mama's Social Security check is going into a family member's bank account.

What ever the reasons are, physicians are not comfortable withdrawing care and instituting palliative care measures if the family still states they want everything done, even if it prolongs death and does not lead to life.

5. Payment issues: The assumption appears to be that hospitals control doctors. I wont' even go there.

We ask, we coax, we nag. We already use a Foley catheter reminder sticker for physicians. It is usually ignored, even though it is part of the chart. Some physicians sign the reminder without indicating why the Foley is to continue and without giving an order for its removal. Physicians have not reason to listen. I recommend that payment for physicians whose patients develop a healthcare-associated infection (HAI) also be reduced, just as payments for hospitals are. The payments are reduced to the extent that hospitals used to get reimbursed for care of infections. Yes, hospitals need good systems to ensure timely care, but physicians have to do their part by responding in a timely fashion.

In my introduction, I noted that I was formerly CIC. One of the most important things that you can do is make sure that all front line workers are adequately prepared. I dropped CIC for three major reasons: my current employer does not pay for the test and it is expensive, I do not get any pay differential for it, and CIC ensure entry level competence. I have been in infection control for over 20 years now. I will have to pass the new requirements for getting my NHSN certificate so I can continue to use the CDC computer-based reporting system. Hospitals should be supported in efforts to make sure that employees are qualified.


1. Best practice. The Office of Insurance and Safety Fire Commissioner has denied the request of the hospital that I work in to keep the foam hand santizing product. The reason that is stated is that the "State is bound by contract to meet the requirements of CMS 211, which supersede those of the State of Georgia..." This ruling was given by the Regional Director for CMS.

If CMS will not pay for HAI then CMS must allow the use of the best products to prevent infection. Changing hand hygiene products is not as simple as it sounds. Not only do the products have to work, but the employees must use them. The products must not cause redness, skin breakdown, stickiness or other problems. The hospital did evaluate gels the last time it looked at hand hygiene products. The end users preferred the foam.

2. Please add to your reserach list: the best way to wean a patient from the ventilator. We have six Intensivists. Each has a way to do this. Each tells us the other ways won't work. ATC trials should not be done more than once a day. ATC does not work at all. Do ATC trials three to four times a day before considering extubation. PLEASE HELP. Meanwhile, we are having a difficult time decreasing our ventilator days and getting patients off the ventilator is the best way to prevent VAP.

3. Patient as partner: All patients should know that it is not a good idea to keep drinking patterns a secret. It can be a major problem when a patient comes in for elective surgery and goes into DTs three days post-op. The patient may wind up on the ventilator with central lines and then is at risk for hospital associated infections. DTs prolong stay no matter what.

Friday, March 13, 2009

Accurate Predictions

Senator Bernie Sanders wants a congressional investigation of what caused the economic meltdown. His investigation, even if it happens, will not uncover what caused the meltdown due to the intrinsic conflict of interest in a politician investigation the political causes of the meltdown.

The popping of the housing bubble, the devaluation of the mortgage backed securities, the defaults and foreclosures of the mortgages, were all predicted accurately. Given that those were predicted accurately it is fair to say that the cause of each of those is already known.

It is important to say "predicted accurately" because simply saying "predicted" will get the response of "if you predict doom and gloom often enough, eventually you will be right." The meltdown was predicted accurately on the pages of Lew Rockwell and other libertarian websites. The details were all laid out for those willing to read what would happen.

Back in 2004, it was noted that there was a housing bubble and that the bubble would pop and prices would fall dramatically. People responded with "oh no, this is a normal market condition." Later, when it was obvious that the rise in prices was unusual, people responded with "oh no, this is a new economy." Then people said "maybe the rise in prices will slow down but prices will continue to rise." Then people said "prices will level off, but they won't fall." Then they said "they'll only fall a little, not a lot." Then the prices fell, a lot.

Fancy subprime loans were identified as a problem. Not to worry, since prices will always rise, and of course the banks know what they are doing. Prices dropped and the fancy mortgages went into default. These fed into accurately predicting that mortgage backed securities would be a problem as the banks would lack sufficient assets to maintain their value. It was considered "doom and gloom" and nobody would listen.

The underlying cause, the inflationary policies of the Federal Reserve, were identified as an ultimate culprit. People proclaimed Greenspan a genius for bringing permanent prosperity. Greenspan was wise enough to leave office before the consequences of his policies caught upwith him.

At every stage, and for every factor of the recession, people saw it coming. So the causes of this are known. Those who saw it coming weren't believe then and they aren't credited now, even though the proof is available in the archives of several libertarian websites. That's why it is important to say "predicted accurately" because that accurately describes what happened.

Those who foresaw this accurately know what caused the meltdown, therefore there is no need for an official investigation. Those who wish to know what happened only need to ask those who were proven right.

So why an official investigation from a Senator? Several possible reasons present themselves.

First, the government is responsible for this, so the investigation is meant to clear the government of responsibility for its actions.

Second, very few people in government know anything about Austrian Economics, and those who actually are seeking answers are completely ignorant of how to find them.

Third, there is a strong desire for an external scapegoat, with more concern for finding someone to blame than to find someone to accurately blame. This is the most dangerous because people are already blaming the free market for actions caused by an absense of the free market.

It is very unlikely that the investigation will find those actually responsible, since very few congressmen enjoy investigating themselves

Friday, March 06, 2009

The California Crisis

The California government, faced with a budget deficit of unprecedented proportions, chose the only option that a politician thinks is available. The legislators voted to raise taxes instead of learning to live within their means.

Because all tax increases in California need a 2/3 majority to pass, this required that three Assembly Republicans and three Senate Repubilcans join with the Democrat majority and vote to raise taxes.

While it may be tempting to consider those six Republican legislators to be rogues who betrayed their party, that is not the case.

Radio Personalities John and Ken of KFI 640 AM have through their investigative journalism discovered that these six were not acting in opposition to their fellow legislators. Instead they were picked at caucus meetings to be the ones to take the fall because they were (most of them) on their final term and could not be re-elected anyway. Their fellow Republican legislators knew that they were going to vote to raise taxes long before they actually did, and supported them in it.

This arrangement was made so that those who did not vote to raise taxes could say to their constituents that they did not break their promise to not raise taxes. While it is true that they did not cast the votes themselves, they are guilty of "aiding and abetting" the raising of taxes.

If the person who drives a get-away car after a bank robbery is considered to be guilty in part of the robbery, these Republican legislators are guilty in part of raising taxes. They could have at any time stood up to their caucus and opposed the tax increases. They did not. They went along with the deal, and in some cases asked favors from those who were the selected fall guys to get pet projects into the budget.

Now the budget deal has been put on the ballot for the voters. There is no option to vote against this deal as a whole. Proposition 1A has two options - a "no" vote raises taxes, while a "yes" vote raises taxes for two more years but gives a phony budget cap.

Those who are aware that the budget cap is fake and that by voting for 1A tax increases are extended are against 1A. The problem is that not everyone knows that because the ballot arguments - for and against - both fail to mention that. They were selected in a corrupt deal so as to prevent the voter from knowing the facts of this deal.

Fortunately the Howard Jarvis Taxpayer's Association is filing suit. While a referendum on the budget is not possible, it is reported they are working on a ballot proposition to overturn teh budget deal. The State of California is in a death-spiral. The best option is for the state to go bankrupt and have a judge cancel contracts so the state can balance its budget.