Read Your Own Stats

It is generally said--but really not believed--that most American jobs are created by small business. 75% of all U.S. businesses have no payroll; they mostly are self-employed people in unincorporated businesses. They account for 3.4% of reported national business receipts.

Small businesses with a payroll are a different matter. The Huffington Post recently reported that small business was responsible for 93% of the jobs in the last 15 years. A Census report examining from 1988 to 2004 showed that businesses with fewer than 20 employees accounted for 90% of all firms and 97% of all new jobs. But these numbers have a twist: Nearly all net job creation from 1980 to 2010 were in companies less 5 years old. If you guess that that number was a dot com bubble, in the collapse from 2007 to 2010 it was 67%.

More. Immigrants with graduate degrees make up 8% of immigrants annually. But, according to the WSJ, immigrants founded or co-founded 25% of all American high-tech firms from 1995 to 2005 and 24% of U.S. patents.

These are pretty shocking numbers and one would think the topic on every one's lips would be how the society could take advantage of these dramatic observations. And encourage them. The first thing that comes to mind is the tendency of communities to fight over the relocation of existing industries. By these numbers, that is the last thing they should be doing. They should be finding small start ups and fostering them. They should be making taxes easier, funding easier and recruiting easier. But one never hears of any of this. Instead we hear that the new Dodd bill intends to decrease angel investing by 75% and delay successful funding for start ups by 3 months.

We seem wrong more often than chance would allow. Perhaps there is some self-destructive thing hidden in success. Or perhaps these incredibly bad decisions are the subtle work of some patient enemy who has wormed his way into our governmental processes. More likely it is the work of Mediocrity, that persistent hanger on, feeding mindlessly off the achievements of others, fussing about the workplace like so many sorcerer's apprentices.

A Song

In response to the complaint that this blog is preoccupied with politics, medical care, government and similar arcana, .....a song!


The Falconer

I always hoped that we would live forever,
And if not us then our devotion be
A point of permanence amide the chaos
But you see...

There is no center, all things drift and ride;
Opinions seem the depth of newsprint on a page;
Men bend to standards, perhaps one just renounced,
And Proteus is now a sage.

Our future soars away from us on falcons' wings,
A subject to the hidden currents of the skies,
What easy thought will swing our minds around?
What upstart winds blow ancient infantries?

And white clothed candidates tell us they will lead,
And I'm Candide with deja vu;
They say that we control our destinies
And I am Merlin passing through.

And so with you, my dear, your love for me is fad;
Last year I sang a solitary song;
But now, like love, I am in style this year
And like a dress can be put on.

Obama is Innocent!

Obama, Dodd, Barney Franks, Pelosi...all these "leaders" are under attack for our problems in the economy. That anger is misplaced. There are several basic errors that have led to this current mess. The people involved made decisions based on their own gain without any regard for the social implications. "Material abundance without character." People took 125% on a house knowing they would never uphold their end of the bargain. Second, the ingenuity of people--especially dishonest people--will always outstrip that of the regulators. The regulators will always be a half a generation behind; they will always be fighting the last crisis. Finally, the debt/deficit crisis is not contemporary, it is the result of errors that are several generations old and these problems have been faced and deferred every year since. Political errors voraciously accepted by the public. These foolish efforts at undergraduate economic manipulation and social engineering--aside from the corruption--are founded on obvious, obvious demographics that would never allow them to be successful. That does not excuse the current leaders who will continue the errors, if allowed. But the point here is that these errors have become institutionalized. They must be solved, the byzantine mess must be unwound carefully and with control. Otherwise they will be unwound haphazardly and in chaos.

Health Care, Medical Care and Managers

Several articles have appeared, conveniently, raising the question of the possible shortage of medical personnel in the next years. Some state that disaffected medical people will leave the profession, some that the increase of patients will overwhelm a stable physician population. One article suggests the rise of "physician extenders" (PA's, nurse practitioners) to make up the deficit.

The physician problem is already here. Every office offers anecdotal reports with significant declines in insurance reimbursement. Inefficient offices will be collapse; physicians who are already burdened because of time demands, age detriments or simple morale fatigue will likely leave. This new health scheme was created with little input from anyone (it would be interesting to know who wrote the bill) but physicians had the least input of any involved group (other than patients.) The reason, of course, is that this plan is not concerned with medical care, it is concerned with health costs. When confronting costs, as Wal-mart can testify, quality is the first to go.

A generation ago I spent some time in what was then East Germany and met a number of medical students. They were all in a two year program out of high school. All were women. When I asked where the male students were I was told, "The men here go into engineering. Medicine is women's work." This is the product of one of government's fondest wishes: The belief in incrementalism. If there are varying levels of expertise in any system, there must be a very high and a very low quality that is necessary. Thus much of the routine medical work can be done by low quality personnel. After all, medics are superficially educated and they see a lot of serious injuries first. So do EMT's. Consequently the belief that the lower rung of medical complexity can be managed by lower rung personnel. The problem in medicine is that the first encounter usually determines the complexity. And stabilization is a lot different than management.

We are entering a very different time in medicine, the time of the manager. Medicine is extremely complex. It is a true profession; its foundation is vows. It is only incidentally a product. It now will become primarily a product, subject to all the stresses and pressures of others. That will solve a problem for the managers as a profession will not allow compromise in quality or motive. If the profession is destroyed or diminished, everything is negotiable. Soon medicine will be less available; then good medicine will be less available.

Finally real medicine will be scarce and available only to our betters.

The Tyranny of Good Ideas

I hope to read the new Ferris book; he's more than informative, he is educational. His current book argues that science has been the engine of Liberal democracies, wealth and freedom. Inherent is the development of experimentally confirmed beliefs in contradistinction to beliefs developed by logic or reason. The scientific method emerged and then replaced the belief system that had been the focus of philosophical thought since the Golden Age of Greece. No longer would an idea have merit because of its thoroughness, its symmetry, its depth or its elegance. From now on, mankind would be freed of the tyranny of "good ideas". Now we would demand proof before we would commit our lives and our children to a notion--however clever. Good ideas would remain just that, ideas, without proof of the hypothesis. The divine right of kings will go the way of the geocentric universe.

At least usually. We still have the Lamarckian dialectic materialism with its weird cult leaders like Lysenko, Keynesian economics still presents itself as law, and foods are periodically banned like books on The Index. And the hallmark of liberal democracies, the bureaucracy, is immortal; it staggers on regardless of the value or effectiveness of the notions that created it.

We are in thrall to opinions, heartfelt sometimes, but opinions. Talk radio has made an industry of them. Politicians are fond of mixing them with some moral imperative to buttress them and infuse the audience with a bit of righteous fervor. But they are no longer charming national anecdotes and quirks; we are too big. Now when things fail there are giant implications. War. Economic collapse. Doom. Despair. We have forgotten the Enlightenment, the most important period between the Renaissance and the physics/industrial age. We still are seduced by dogma, by a coherent and lovely argument. Particularly an argument that purports to be kind.

Dogma has its place in those areas we cannot explore or answer. Dogma used to have some protective qualities too. The fear of dragons and the flat earth kept men from the dangers of the sea (and also the adverture's rewards.) But we are more confident now. Now we follow the dogmas that promise to improve our lives, right our wrongs, balance our bank accounts.

They call these dogmas "projects", "programs" and "change"; I call them uncontrolled experiments. Wear protective clothing and goggles. Put the dog in the basement. Hide the women.

The Future of Medical Care (And Health Care)

The current problems regarding medical care in this country has become obscured. Even the topic is unclear. We have a "health care" problem which implies a slightly different problem than the problem most people are experiencing. The problem is not about "health care." Regardless of the publicity and the debates, the problem with medical care is what it costs.

Availability of medical care is not the question. I have never once seen a person deprived of medical attention because of money. The care is always available because the people who practice medicine--the physicians, the nurses, the PA's--have taken a vow to take care of sick people. The vows they take specifically prohibit the abuse of the inequality that exists between patient and caregiver, the vulnerability that his illness gives him.

And while insurance is a problem, it is not the main problem. It is not even the problem it is cracked up to be. According to the Census Bureau there may be up to 47 million people without health insurance. Of those, 18 million come from households with incomes of over $50,000 annually (more than the medical resident who would see him), 10 million from households of over $75,000. 10 million are not American citizens. Another 10 million are eligible for Medicaid but have not applied. Their reasons for not having insurance may be interesting, may be sad or even stupid. They may stimulate many tax deductible conferences. But the noble goal of having these people insured is not the point. The high cost of medical care is the point.

And there is the conceit that the government (the government!) might be able to improve medical care. The government! Some point to those strange studies from the U.N. that rank states on medical care quality. Aside from credibility questions (Castro, Chavez, Mugabe have great ability to apply statistical analysis to their electricity-free nations and would never lie) these studies have some fascinating assumptions. For example, a nation that does not have a central medical service is automatically downgraded. Ditto large nations. If you have high expectations of your medical system and are disappointed that nation is downgraded, if you expect little and are pleasantly surprised, upgraded. And there is no standardization. A newborn death in the first 24 hours of life is a death in the U.S., a miscarriage in Britain and France. The major non genetic cause of infant death is prematurity and low birth weight; these are functions of smoking, teenage mothers and race (Afro-Americans have a very high prematurity regardless of circumstances). These are social factors, not medical.

But even if the government could improve medical care, it is a side point. The problem in this country is the cost of medical care.

This country has developed highly selected, well educated people to apply complex surgery, expensive devices and advanced pharmaceuticals quickly to ill people. There are few wards; there are many private hospital rooms. The nurses are extremely well educated and available. Transport to plentiful facilities is managed from anywhere in the country to any select institution. In short, this is an expensive system. All of this comes at a cost. And many think that cost is too high. I do not know how that is determined; we have an older population, they want care and are willing to pay for it. Ewe Reinhold thinks that uncontrolled health costs can digest the whole economy. These theoretical questions are interesting and peripheral; medical costs in this country are too high.

The answer here is not to improve insurance, not to make medical care more available, and not to have the government bring its version of "expertise" to the science of medicine. Medical cost are high and increasing because the medical care those costs support is of high calibre and growing. Soon we will all be priced out of the Maserati medical market. The answer will be to build a Chevy. The effort to increase the number of people covered by insurance is cynically deceptive. The answer to high health care costs is to have less medical care. The government knows this and will start the process by simply paying less and less for more and more of what it receives. The consequences of decreasing price paid for a product or service without consideration of underlying costs is simple as well: The product or service goes away. That will result in medical care that is less available, less prompt, and less good. That will cause some major changes, but decreasing medical costs will not occur in any other way.

Canadian Breakthrough

A few years ago, when the Provence of Quebec took over the financial responsibility for medical care, one of the changes the government instituted was to forbid patient families from calling pediatricians after office hours--and pediatricians from calling their patients during the same period. Calls were handled instead by a call center manned by nurse practitioners. The logic was that strangers who were not emotionally involved with both the patient and the family were less likely to pursue investigations of complaints. They had some experiential evidence for this. They had some support from physicians, who generally hate the unpaid for time and inconvenience of on-call schedules. The patients initially objected but eventually did not complain much. Change in quality was difficult to assess.
That this idea was somewhat successful is an example of bad concepts becoming first tolerable and then laudable. Imagine the notion that encourages indifference to the patient. Only the coldest organization could consider it.
The relationship between physician and patient is unique: The physician pledges to put aside all considerations in dealing with the patient other than the patient's illness and how the physician can help. The patient will never be a client, a customer, a sexual target. The patient will always, always, be primary. This placement of the patient in the center of medical care is the one aspect of medical care that makes it different; it can never become anything other than medical care. The relationship can never become commercial, can never be entrepreneurial or seductive. And it is this specialness that government must destroy in order to control price.
If the patient is of primary concern, an outside agent will never be able to manage medical care. If the patient is to be replace as the focus of care, there is only one way to do it: The physicians will have to change. Those who cannot change, will have to leave.