When should doctors disclose their relationships with the wider medical industry?
By upholding the Patient Protection and Affordable Care Act, the Supreme Court has ensured that a host of other provisions and attached bills will go into effect. One that affects me personally is the Physician Payments Sunshine Act authored by Sen. Charles Grassley (R) and Herb Kohl (D). It's good legislation overall (If I was getting a knee replacement I'd want to know if my surgeon is a paid shill for the knee device she's implanting) but because the legislation offers no mechanism for doctors to explain themselves alongside the data, in many cases the Act will blow out a lot of suspicious smoke where there's no fire.
Every drug, device or medical supply company must report transfers of value that exceed $10 to the new federal database maintained by the Centers for Medicare and Medicaid Services (CMMS). Last month CMMS announced it's delaying implementation until January 2013 to allow it more time to create the needed infrastructure, but at least twelve companies are already reporting payments in a less uniform and streamlined fashion. A database maintained by ProPublica makes this data easy to search for interested citizens and health care reporters. The ProPublica database has raised important questions for academic medical centers replete with physicians who serve as pharmaceutical company spokespeople. But there are also cases where tight-lipped (or just busy) doctors see their motivations replaced by the reporter's innuendo of malfeasance. I think this genre of information-gap expose will spread like wildfire once Sunshine goes into full effect next year. The CMMS database, like ProPublica's, will list companies, doctors, dollar amounts and payment categories but no context.
"Our research shows hundreds of thousands of dollars in payments for everything from speaking, to travel, to meals from the very companies they could be prescribing to you," reports KOAA in Colorado Springs. The station went on to report from the only two doctors willing to defend themselves. The others "didn't want to talk about it."
Next year there'll be many more physicians in same situation as Dr. Madeleine Hernandez who found herself defending $355 in food she received over the course of a year from Pfizer. When the San Luis Obispo Tribune came calling her excuse went like this: "I don't care what they say or what they feed us -- if the product is not good, I will not use it."
Doctors everywhere had best recognize today that this information is coming to light tomorrow, and they'd better be pro-active in explaining their actions lest they get lumped together or singled out as examples of bad actors too cozy with industry.
As a doctor who sometimes writes about the medical-industrial complex I have a particular interest in holding onto both the reality and image of my own objectivity, but these relationships are everywhere; this is how American medicine works. It's not realistic for me, or in the best interests of my patients, to refuse every industry interaction. Recently I made tentative plans to attend an educational conference about a particular device that would benefit my patients, but I backed out when I realized my attendance would be reported as a gift from the company. Just last week I tried to log onto MerckMedicus.com, a website that offers free access to a few journals, medical news and a few other useful resources. I hadn't been to the site in a while and this time it prompted me to agree to have an educational gift from Merck reported. I clicked no. But at the same time I regularly use sites like Medscape and MedPageToday that are riddled with advertisements from companies like Merck. But because these third-party media companies stand between Merck and me, no reporting is required. If you surf these doctor-media sites you'll see there's no difference in the quality of the information (which often comes from third parties, like Reuters) whether the site as a whole is branded by Merck or Merck is buying a banner ad.
As far as I know, I don't currently show up in any physician payments database. But it's only a matter of time. One day I'll go ahead and click through to see a site like MerckMedicus.com. One day I'll attend the device seminar. I've been thinking about how and when I want to explain myself if somebody decides to inquire about the objectivity of my medical opinion. Will it be to the local paper, to ProPublica, or some other way, on my own terms?
Here's my idea.
Most practices (and individual docs) have websites. I propose that every private practice, hospital and clinic that's interested in how this information gets interpreted take the following measure this year. Simply create a web page called Physician Payments Sunshine Disclosure and update it with a running log of corporate interactions coupled with explanations. Are you consulting for a company? Tell your patients why you decided help that company. Did you attend a device company educational conference? How did this experience add to the care you give? Did you register for a pharmaceutical company educational website? What kind of information are you getting that might help your patients? Did a company support your research or provide free equipment to your clinic? Pro-actively tell the world why you made that choice, before ProPublica starts calling you.
Finally, if you find your explanations are getting a little too long and convoluted that's a good cue that it's time to re-think value of that industry relationship to yourself and your patients. Not everything will survive in the full glare of the sunlight the Supreme Court has forecast for next year.
By antagonizing the U.S.’s neighbor to the south, Donald Trump has made the classic bully’s error: He has underestimated his victim.
When Donald Trump first made sport of thumping Mexico—when he accused America’s neighbor of exporting rapists and “bad hombres,” when he deemed the country such a threat that it should be contained by a wall and so clueless that it could be suckered into paying for its own encasement—its president responded with strange equilibrium. Enrique Peña Nieto treated the humiliation like a meteorological disturbance. Relations with the United States would soon return to normal, if only he grinned his way through the painful episode.
In August, Peña Nieto invited Trump to Mexico City, based on the then-contrarian notion that Trump might actually become president. Instead of branding Trump a toxic threat to Mexico’s well-being, he lavished the Republican nominee with legitimacy. Peña Nieto paid a severe, perhaps mortal, reputational cost for his magnanimity. Before the meeting, former President Vicente Fox had warned Peña Nieto that if he went soft on Trump, history would remember him as a “traitor.” In the months following the meeting, his approval rating plummeted, falling as low as 12 percent in one poll—which put his popularity on par with Trump’s own popularity among Mexicans. The political lesson was clear enough: No Mexican leader could abide Trump’s imprecations and hope to thrive. Since then, the Mexican political elite has begun to ponder retaliatory measures that would reassert the country’s dignity, and perhaps even cause the Trump administration to reverse its hostile course. With a presidential election in just over a year—and Peña Nieto prevented by term limits from running again—vehement responses to Trump are considered an electoral necessity. Memos outlining policies that could wound the United States have begun flying around Mexico City. These show that Trump has committed the bully’s error of underestimating the target of his gibes. As it turns out, Mexico could hurt the United States very badly.
“Somewhere at Google there is a database containing 25 million books and nobody is allowed to read them.”
You were going to get one-click access to the full text of nearly every book that’s ever been published. Books still in print you’d have to pay for, but everything else—a collection slated to grow larger than the holdings at the Library of Congress, Harvard, the University of Michigan, at any of the great national libraries of Europe—would have been available for free at terminals that were going to be placed in every local library that wanted one.
At the terminal you were going to be able to search tens of millions of books and read every page of any book you found. You’d be able to highlight passages and make annotations and share them; for the first time, you’d be able to pinpoint an idea somewhere inside the vastness of the printed record, and send somebody straight to it with a link. Books would become as instantly available, searchable, copy-pasteable—as alive in the digital world—as web pages.
A boring juice product sold itself as the next great technology phenomenon. There was only one way things could go.
Juicero is a startup that sells a $400 machine that squeezes packets of diced fruit and vegetables to produce fresh juice. A person might assume that a product so simple and boring, yet weirdly expensive, couldn’t possibly attract the entire internet’s derision. A person would be wrong.
It’s best to begin this story in March of last year, when the New York Timespublished a profile of the company’s founder Doug Evans, a former Army paratrooper who had already started and sold the successful Organic Avenue line of cold-pressed juices and healthy snacks. Evans was not a Silicon Valley veteran, but he spoke like one, rhapsodizing his product with quasi-religious grandiosity. “Not all juice is equal,” he told The Times. “How do you measure life force? How do you measure chi?”
The early results out of a Boston nonprofit are positive.
You saw the pictures in science class—a profile view of the human brain, sectioned by function. The piece at the very front, right behind where a forehead would be if the brain were actually in someone’s head, is the pre-frontal cortex. It handles problem-solving, goal-setting, and task execution. And it works with the limbic system, which is connected and sits closer to the center of the brain. The limbic system processes emotions and triggers emotional responses, in part because of its storage of long-term memory.
When a person lives in poverty, a growing body of research suggests the limbic system is constantly sending fear and stress messages to the prefrontal cortex, which overloads its ability to solve problems, set goals, and complete tasks in the most efficient ways.
Will you pay more for those shoes before 7 p.m.? Would the price tag be different if you lived in the suburbs? Standard prices and simple discounts are giving way to far more exotic strategies, designed to extract every last dollar from the consumer.
As Christmas approached in 2015, the price of pumpkin-pie spice went wild. It didn’t soar, as an economics textbook might suggest. Nor did it crash. It just started vibrating between two quantum states. Amazon’s price for a one-ounce jar was either $4.49 or $8.99, depending on when you looked. Nearly a year later, as Thanksgiving 2016 approached, the price again began whipsawing between two different points, this time $3.36 and $4.69.
We live in the age of the variable airfare, the surge-priced ride, the pay-what-you-want Radiohead album, and other novel price developments. But what was this? Some weird computer glitch? More like a deliberate glitch, it seems. “It’s most likely a strategy to get more data and test the right price,” Guru Hariharan explained, after I had sketched the pattern on a whiteboard.
For the first time in modern French history, neither candidate is from a major party.
Marine Le Pen, the candidate of the far-right National Front, is through to the second round of the French presidential election, where she will face Emmanuel Macron, the independent, who won Sunday's first round with 23.7 percent of the vote. Le Pen won 21.7 percent. It's the first time in French history that neither candidate from a major political party is in the second round runoff. It's also the first time a far-right candidate is in the second round since 2002 when Le Pen's father, Jean-Marie Le Pen, lost to Jacques Chirac.
Macron and Le Pen’s strong showings Sunday, which saw an approximately 77percent voter turnout (slightly lower than the 79 percent who voted in the first round in 2012), signaled a rebuke of the political establishment that has dominated French politics for decades. Macron launched his centrist party in August 2016 after he quit his role in President François Hollande’s Socialist government, and despite the party’s youth it boasts a quarter of a million members. Meanwhile, Le Pen’s FN secured the most votes it has ever received in its nearly half-century history, surpassing the 18-percent first-round finish it saw in 2012.
Thursday’s terrorist attack in Paris did not “help” Marine Le Pen.
Following Thursday’s terrorist attack on the Champs-Elysees in Paris, which killed one police officer and wounded two others, Donald Trump made a prediction. “The people of France will not take much more of this,” he wrote on Twitter. “Will have a big effect on presidential election!” It seemed like the American president was implicitly backing one of the leading candidates in that election, the National Front’s Marine Le Pen, who has campaigned on rooting out Islamic extremism from the Republic and practices a Trump-like brand of populist-nativist politics.
Then Trump dispelled any doubt about his message. The attack, for which ISIS has claimed responsibility, will “probably help” Le Pen’s chances, the American president told the Associated Press, “because she is the strongest on borders and she is the strongest on what’s been going on in France.” (This despite the fact that the Champs-Elysees attacker was a French citizen ensconced well within French borders.) Trump didn’t explicitly endorse Le Pen. But he effectively endorsed her sales pitch to voters. “I believe whoever is the toughest on radical Islamic terrorism and whoever is the toughest at the borders will do well at the election,” Trump said.
The 45th president’s journey of discovery could be a public service, if it helps bring his supporters to greater understanding of the complexities of governing.
Let the betting pools begin: What will be the next policy issue that Donald Trump suddenly discovers is way more complicated than “anyone” ever imagined?
Already, the aggressively policy-ignorant president has marveled that dealing with touchy issues such as North Korea, China, the Ex-Im bank, Syria, and health care, requires more than trash talk and an itchy Twitter finger. And, while he has yet to break the bad news to the dying coal towns that backed him, Trump has been meeting with energy execs, some of whom have had to gently explain that, when it comes to saving the industry, there’s not all that much he can do. Because—all together now!—it’s complicated.
As it turns out, no matter how much reality TV experience one brings to the table, one cannot simply snap one’s fingers and instantly solve the nation’s most vexing problems.
Inside Walmart’s curious, possibly ingenious effort to get customers to build up their savings accounts
Late last summer, Dawn Paquin started keeping her money on a prepaid debit card from Walmart instead of in a traditional checking account. The wages from her factory job—she works from 9 p.m. to 5 a.m., inspecting blades on industrial bread-slicing machines—now go directly onto the Visa-branded card, which she can use like a regular debit card, though unlike most debit cards, it is not linked to a checking or savings account. She made the switch after a $4 check she wrote to buy coffee for herself and a friend tipped her checking account below the required minimum and triggered $100 in overdraft fees.
This was before she got the factory gig, and she wasn’t working full-time. Paquin lives in Salem, Illinois, where, she told me recently, if you don’t have a college degree, your job choices are “fast food or factory.” Money was extremely tight. “I kind of had a bit of resentment about banks after that,” she said dryly.
Tracking the controversies, allegations, and investigations into the president and his administration
Donald Trump entered the White House as one of the most scandal-tarred presidents in American history—what his imbroglios may have lacked in depth, they made up in variety, encompassing legal, ethical, and sexual controversies. (In a twist, one of Trump’s few competitors for the crown was his rival, Hillary Clinton.) They ranged from race discrimination to mafia connections, from petty hypocrisies to multimillion-dollar alleged frauds.
Now that Trump is president, some of those controversies have continued to shadow him. But the presidency has also occasioned a whole new set of disputes. Looming largest is the question of whether his campaign colluded with Russian agents to interfere in the election, a question being investigated by the FBI as well as panels in both houses of Congress. They also include ethical and legal questions surrounding members of his cabinet, his allegation that Barack Obama spied on him before the election, and various conflicts of interest.