With Ezra in sunny California, Matt and Sarah gets weedsier than ever as she attempts to explain to Matt the mysteries of ACOs before they discuss a brewing controversy over economic journal citations.
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I guess it sounds like that. That would be totally catastrophic.
Hello. Welcome to another episode of the weeds boxes, policy pod cast on the Panoply network, Matthew Glaziers with me his usual, as my colleagues have cliff Ezra as there is not with us.
he's in California, drawing together whether them, then Washington may know what he's doing the weather's, probably terrible. I hear it's too
He is about to miss what may be the most requested episode of the weeds that we were there. We have absolutely no Ezra has always brought a lot of pressure to make. This show
You know a little more commercial talk more about down
given the cheap radiance,
Syrian. I we believe in the weeds and
You know we mentioned on a previous episode, accountable care organizations, and I think Sarah
We should do in episode, I'm having, as our might have set a new kind of an honored momentum. Now he'll. Never you would never be my and I thought that it might be too crazy, but
demand. Literally three people
around seven out of you can't believe message me on Twitter and emailed me here at seven total
I said this is a great idea. Let's, let's do it, and I thought I guess so
so here's what I know about a camel care organisations, because it's not that much and Sir is going to have to explain
me gears ago, when a bomb care was just a twinkle in MAX boxes. I I was a writer for think progress, which was part of the larger centre for american progress, which was very apt up about the formal care they left. It and
You would see that kind of like the health Wang say where they were on a different floor of the building, but you would do it talk to them sometimes about you know what, but they started, and they were very upset that the congressional Budget Office, which did that the score of how much it would cost.
not crediting the law. With
even as much savings inefficiencies in the system as they felt the Laud deserve
C b, I didn't want to say that highly speculative things work, we're going to work and top on the list of the cap. Monks sort of grievance sheet was that they were not getting credit for the accountable care organizations which they
lived. Would dramatically, or at least would meaningfully reduce the amount of spending in Medicare by, I think
reading organizations that we're gonna be accountable Heath? Yes, that's it. Let's hit a definition here, but I have never yet there stood from what they would eat. My ok yeah, let's start with defining what issues are so easy owes accountable. Characterizations are
really the main way that Obamacare tries to make health care more cost efficient. So the idea is the thing you're, too
To do? Is incentivize providers to provide the right
care, not too much care and ultimately, ideally save money. So if you think about the way or healthcare system works now in Arizona safer vocs about this today, it's very disconnected. You have all these doctors who don't talk to each other,
and you know when you are health long. Can you look at that? You think? Well, you know that might lead to repeat testing or you know, if you have doctors are talking
other one might order an x ray and another one might order an x ray and thereby looking at X rays when really all you need is just that wine,
three and you could see this not only being wistful- could be dangerous where, if you're cardiologist prescribes him,
bugs that have a dangerous interaction with drugs at your primary care, Doktor prescribed
secondly, very dangerous for the patient. So the idea of the accountable care organization,
is, basically all these doctors should be talking to each other. They should be
Council to one another for patients care
so the way that Asia is nobody. Obamacare work is you have some
Kirk Innovation and its really diverse? Who leads them? It could be a hospital could be a group of doctors. Walgreens,
leaving some Asia is kind of like pharmacy led easy owes. You get a network that big enough to care for two busily provide a spectrum of
care for patients, and you get assigned five thousand patients are Medicare minimum and be
you are given a lump sum of money to take care of those patients. If you are able to do their care for less than that, lump sum you get to keep some of the sea
so can create economic manner. The reason it's hard to know what in Asia is it's like its new right? Where were accustomed to the idea that a hospital is a kind of a year and a bright medical practice is kind of a thing, and a farmer.
chain is a kind of a thing and the ideas they want to call into being. Like a new class of institution,
One here is one of the most confusing thing. So one of the things that make Asia is different from each Mose is you're not stuck in ratio to one of the things. I think that
Jason was rightly worried about is
you know, Medicare patient, would you know, get letters and you're in Euro X Y see is a ceo in the EU, can only see the people in the and they would say well.
to better. When I could see all of my doctors, so one of things and Israel
different kind of makes issues a bit invisible is that doctors can't say
okay, you can only see people Maceo because, like I need to save money- and I need you to see these doctors so means that you know the folks working in these have to work extra hard to like try and fun
people to the doctors and Asia knowing full well that they have choice to go where
where they wanted to its even a bit invisible to the patient.
Two doesnt really know the witch doctors part of NATO and may not, even if some
if there are one of the things that nine million Medicare beneficiaries use in an easy all right now, so in case in case of young people, listening,
it's gonna, Bernie, brows and and so far it let's go back to the ninety. Ninety explain what would the age Emma was because I think there is a clear relationship. Both in terms of
the similarity and, as you were saying, the difference ride. So
H. M o stands were health maintenance, organ donation and if we look back at like the Pollack,
Six of the ninety nine is complaining
h, M o is that was what the health care politics consisted. There is twitter,
would have been huge learning about James. You believe me, this is what I mean honestly. I do think this is important because younger people who, like fired up about single pair healthcare, don't understand how basic Democratic Party healthcare for
Those were in the nineties, but like the big thing, was that they wanted to regulate these agent mose better or different.
because people are really mad about them. So I need you,
was like an insurance company, basically near here,
lawyer would say
ok, we want to save money somewhere for signing up for the h m o instead of the old insurance company
and the age Emma was. Basically, it was like a list of doctors. You could go to and to get clear in
to go see a specialist. You would have to go through like a gatekeeper
resources for you to go. You need are a far out. This is like where referrals become super import end where, if you
to see the orthopedic. You need your primary care doktor to write. You are
also essentially it makes primary care doctors, the gatekeepers to the rest of the healthcare system, patients understandably
did not like this. You saw this H. M o do had really slow healthcare costs.
in this era, so where healthcare costs are kind of growing three to four percent things like look
on that level, but patients do not like this system. They don't like that. It's hard to see a specialist
kind of like mid nineties, the each imo backlash and switch to more, like p, p, o products
What probably won't live now preferred provider networks where you can get a cheaper rate at your end network doc
but you can still go out of network. This is more expensive to content
the really expensive doctor is he want to charge a lot of money for standard procedure?
and that's kind of where easy owes you talked like health nerves is,
I have to do some of them will say you know it's just it's just a nature mon disguise that its veto very similar, but I think there are signal
in differences, but their ones that make it a lot harder to control costs thicket.
If the goal you're going for because you're not saying you have to go to these,
zero doctors you're putting the
As on the ceo to kind of convince its patients that these are the best doctors that they should stick with it, and that's it that's a hard our task.
the GMO had sort of like a like two two faces
so like on one side. If you talk to like insurance company veteran of this era, they'll say like let people
tons and tons and tons of unnecessary care than the United States. One reason
health care costs balloons.
hi is people getting medical treatments that they don't really need, or why
didn't. You see a low level
examples of this like people getting antibiotics for com?
cold and any see high levels of this people. Getting tests ordered that don't do anything useful and this they look like the
While we were imposing sound discipline on the system- and we are saying luck, if you really sick- and this is actually a treatment that will help you- the doktor will go
referral to it, but otherwise he can't just have service specialist running around so to drumming up business by getting people that to come in and be like. Oh my knee hurts, so I got your old man. You know
and the other side of it is that the insurance company is a for profit business. You are forking over to them money every month in premiums and then is in their interests. For you do not wear
Eve Healthcare, and so people would always be very suspicious that, like there was useful medical care that they were not being allowed to get by their
gmo, because they were trying to to save money. And that's where these, like patients, rights, type proposals came into the four and so
you had the rationing. The people
Warn you about in a government control system, but the rationing was me:
done by for profit companies with like ceos with Jetson, shareholder meetings and stuff like that. So so people
ugly, I mean, but both people like it and and the political backlash was- was really intense. So now
it is to achieve some of those gains but like with a friendlier
earlier phase face, and also you know when the ways you can see the internet legacy playing into the Asia shows is that their quality metric. So Nazi Medicare says: ok, you have five
Impatience- and you don't say, like thirty,
million dollars to care for them, and they also
certain quality metrics. The easiest way to you know hit your target to say, spend ten million dollars and get some twenty million back is just like, say nobody
thing just like deny say: oh you
That don't worry about this.
one of the things that they see us have. That H has traditionally didn't have a set of quality metrics, and
Rain range from certain physical things. You can measure like how many of your diabetics have their diabetes.
for all, and they includes impatient satisfaction metrics, which can be a little controversial and healthcare.
World whether that actually measure is better care.
nevertheless knew that something that I am ready to eat. Medicare patients are getting more patient, satisfaction surveys to say you know your doctors doing a good job.
Your weight times. I said the idea with these quality metrics way
to veto incentivize more efficient care, but not at the cost of just letting everyone get really sick. So the idea is that with many care that they
believe, or I think we know
There is a lot of health care that is happening. There is not genuinely useful to patients right and the sort of like the the holy GRAIL would be to eliminate that healthcare
without just sort of arbitrarily, because you see in other parts of the formal care I cried, I mean you have people in these like hide it after my plans and the
here there is where you gonna, just like use less health services and a lot of people are gonna, be ok
but Bit Asia is like trying to do that in like a smarter war. Finally targeted way yet
guess putting the onus more on the on the doktor. Then end this gets a go. It gets a complex, you know what is a hospital in what is an insurance company?
this point when you have, but they are hostile
Let s see. Oh, that's, making that's like looking over this global budget and saying like making decisions about what kind of care they're going to provide, but the kind of aid
here the easier it is to put the Disease
in the hands of the caregivers to say: ok, like you guys of this money you're,
actors you of the medical degrees. Are you figure out the best way to provide care and
I think the hope, although you know you kind of sea mixed results, and we can Dudley talk about that in the hope. Is that
poor, get smarter about things like care coordination that you know they will call other doctors to make.
they're not doing the same x rays? Are those check about interactions between different prescriptions?
What are we doing work to get out the redundancies that might happen in health care and unit? That seems like the easy
way to think about saving money like it seems like the lowest hanging fruit is like
limiting the repeat, TAT S like eliminating things that happen as a result of unclear
It care the harder task
is using coordinated care to keep people healthier idea that you can use good preventative
air to stop medical conditions from Prague,
to a very unfortunate and expensive,
a veto crisis moment. I think that's one of the things two issues I would like to be doing, but that works a lot harder than
an electronic system where it says, hey, someone already ordered that x ray the work of actually key
people healthier, is harder, but also kind of necessary,
Ask where these to succeed services like the ideas like
you come in to see the doctor and they check you out and it's like well, ok, you're at risk of heart disease, and you don't doctors will tell you that nowadays, but it's like if the doktor was actually effective in getting to to do stuff right. That would make you
not develop the heart disease then later on, you would be able to avoid very closely treatment.
right now in the sugar like traditional, like Atomizer healthcare system. The idea is that when the doktor just
informs you, you have these health risks and you should do something about them. That you yourself will be highly motivated to not have a heart attack
or to but in theory you could change.
Financial incentives in the system so that, like the whole network of people working with, are motivated to
to really try to make that right. How are you hire different kind of people so and when I'm insane global Budget committee, lump sum of money in health want terminology kind of call that a global budget, where you have one
of money to cover everything? Usually Medicare works as a fee for Serbia.
You have paid for a visit you get paid for a surgery you get paid for doing a lab task in kind of a global budget.
Deal with issues, have more flexibility over how they want to spend money, so its electors cardiologists is primary care, Doktor whoever's, as a patient,
there's you're at risk of heart disease. I am,
I have an appointment with far new case manager who is going to check in on you every week to make sure that you're doing X, Y,
Z or have you monitoring your weight or different Juno factors and
typically and Medicare that kind of case management isn't reimbursed. Like you don't get money, you just think money into this employees salary
global budget. You could say you know what we want to set aside forty thousand dollars for this
manager and we're going to pay their salary, and we think at the end of the day. That's all
mentally, going to generate savings or creates more more flexibility, and definitely you don't talk to seo systems to kind of have those roles are kind of case manner
Where's nurse managers, social workers that they didn't have before they start.
this programme, and generally like, seemed like a good positive part of that
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Of it suddenly like some sense of what this is, we ve had a few years. Does it seem to be
working is money being saved our people healthy, I mean it's on one level, it is working. Organizations have said okay, we want to be easier.
Yes, so nearly a hundred percent- yes clear, it would even happen so
the last count. I looked up and there's a healthcare consulting firm Levitt partners that does the best survey of
they estimate that there is about four hundred and seventy seven eighty owes in the United States. Now a number of those are met.
carries. Yos number them are private insurance companies, so basically private insurers said: oh that's what Medicare is doing. Maybe
try it out to you of both private and public.
he owes it, could actually be the same exact healthcare system and the running one Asia with America,
one when Asia for their private insurance patience- and I think it's in essence,
about nine million Medicare beneficiaries who are in Asia is right now, so definitely you know
the different like levels you could
Michael, isn't working one is participation and guess, there's a lot of participation. The second is already saving money,
and that's one were in others, it's just so mixed and Oliver the board.
just some that are saving a lot of money. You see some that are losing a lot of money at their spending way more than their Medicare target. The way most of these
arrangements are set up with Medicare is most hospitals and surprisingly, have been drawn to financial orange,
it's where, if they save money, they get a small share of the savings, but if they lose money, Medicare just takes
losses, they do have an option to take on more risk, but most of the media, where you could get even more savings, but then you have to say
if I've losses in going after pony up most vetoes
Sums have not been on board for that model. Medicare trying to move the programme in that direction, but it is,
It seems right now, like super super variable in whether this is
working or not to save money. You could tell anyone.
story once with the data right now, the theory
after looking over all that, as there are some scale issues where
possible. You have a handful of systems that, like figure this out like they know how to
do it. There saving money- and you really see this in the first group of Asia as recalled the pioneer ratios and they like that's, really good results
savings or if you look at there's, a study will put in show notes
in the New England Journal of Medicine. That kind of look at Asia that entered and twenty twelve verses, those it entered, and twenty thirteen with the idea being that twelve ones were like more enthusiastically
ready earlier to twenty
of ones in their first year saved an average of one hundred and forty four dollars a patient.
between thirteen one saved an average of three dollars? A patient. Like you see the thing
see when I look at the issue of data is like a handful of tat. Some too are doing this complex thing of
Jeanne CARE really well and then a lot
their systems that are like taken.
best shot at it, really just like not able to make this very different model of health care. What
I mean. We see these kind of like scale questions in a lot of public service
Just wait. A minute reminds me a little bit of charter school debates where I think you have a lot of examples of
but you go in states where it's really hard to start to turn her school of some really good ones, but then in states where you make it easy. You know what
cease have like lots and lots and lots is like the marginal one, is often not that great, because you have like a number of people
who, like have a good idea and a good motivation and like one run these schools or want to work in them and like the real thing, but then this,
with so many to go around
by the same token
It's like this could be a great opportunity for a hand.
Full of like visionary healthcare entrepreneurs by
health care is a super labour intensive, not highly scale of all sort of theirs.
Swear, you can just like copy and paste the best hospitals in America into every every
city and we're having some
a book like even articulating
What is working well in the places that are that are doing really well isn't, like obvious, had a repeat the success and like we
Look where things you know I've thought about is that you ve had systems like those that have been really successful for a number of decades. The Kaiser permanent day is known, is kind of one of these
bind, ensure hospital systems where you do you
into their network. All your care is managed at that place. I think we ve talked to them without them before in the show. Some people had their ensure anytime you how many times have we we, both men and, I believe, panoply employees, and then
you're the guy singer, health and which I believe is an Colorado's. You have like a number
Well known, systems have been doing this for decades and then you kind of thinking a wolf. This is working for these systems and has been
since you know, nineteen seventeen nineteen eighties. Why have they not proliferated could be that it's very hard to kind of Adieu issued a box
of model, because so much of what is happening is very much on the clinician level that you, you know, you have a high.
of a plan in the sea sweet, but you also have doctors,
nurses and patience and case managers making all these decisions all the time, and it strikes me that there might be something you know unique and hard to replicate about these
systems that have been very successful, and you know the kind of the issues statistics, those kind of speak to this as well,
Did you see the best results among the earliest and trends? Are there was one thing you know
keep in mind, as you have had there's a pioneer,
is your group that were, unsurprisingly the first Ngos about a third of
I believe, have dropped out of the programmes or who decide. You know this is too hard. This is too much work. We want to focus our care,
elsewhere. So it's not like all the earlier
answer like bananas is great and like did super well, you ve.
They seen for all sign up? You have a number of systems have dropped out and said this is working for us when I've talked.
I'm usually there are participating in some other kind of like incentive programme with medical
and like you, they just can't manage all these different quality metrics they like chosen another one, they think is a better. Is it's not like
they're giving up on the idea of trying to improve the quality of care. But do you know they ve looked at the issue, a program like that's not for us to that's happening.
Should you have a new article out on me? The internet website vocs com hurry, I'm Zaire they do. It is eight journals, daddy, daddy Journalism. I think it's about the amount of work that the conventional healthcare system puts onto the patient,
You know you have doctors who, if you are in their office, they will treat you. You have pharmacists who, if they have the medicine and prescription at their desk, and you shall
they will hand it to you in exchange for money, but the work you have to be your own case manager. When you have any kind of complicated
chronic healthcare condition its on you, as the patient or or at other times a loved one of the patient to be in charge of
talking to the insurance company talking to the pharmacists talking to the different health care providers and constantly doing the leg work of making short,
that things actually get done and an happen because
is to extend its no one's law, us right. If you come to the doktor and they do the exam and they prescribe the right medicine for you that's their job. I beg you
burst for that, unlike whether they are helpful in fine
new pharmacy that will actually fill the prescription or not is like
sort of in their interest, but like not now really whatever one's job, as is defined very narrowly and patients or are doing it needs
pain, and it also seems, though, that its own identity,
we'll driver of health that,
yeah. This is something I've thought about a lot more hours. I've, generally, you know, like thirty one
in kind of the genuine, like a young invincible, sort of category, a person who doesn't spend a lot of time getting healthcare, but the past
Europe is annoying thing that touches on this by gas before my foot, that, just like will not he'll, despite its in a number of
doctors and spending months in a walking cast it just dino. Isn't
working and one of the things you know that struck me, though, probably very obvious to anyone who spent anytime managing a kind of condition is just how much time
I spend like coordinating between different parts of the health care system, so just trying to get a cop
of an MRI report- is like an hour
she won't experience? What you know seems a trivial to complain about, but when you have to do it multiple times
a week in your leg. Managing all these different things- and this is just for like one
specific injury. You know I'm not like many
people are managing multiple chronic conditions are trying to keep diabetes under control
also trying to manage hypertension, unlike train, to work on multiple things. I'd like one specific thing,
that. You know I'm highly motivated to fix and I have like a very flexible job where no one
Is it I'm gone for two hours waiting for the doktor, and I
in any sort of Asia situation, I'm basically
on my own doctors, making sure I felt my prescriptions are sometimes like not getting it done in time, emailing a lot with the medical assistance and when my doctors office is when
Scuse me, who kind of knows everything that's going on, so you know
thinking even as researching this unit will maybe like
ceos are kind of the solution to this, because we talk about coordinated carrots and the name that, wouldn't it be great if there is some like case,
we are working on this and I had a really interesting conversation with them. A doctor, the Mayo clinic Victor Montessori, who does really interesting work, and he either
these issues are on the right track. But where things he pointed out to me that I haven't really thought about, you know you have, I think it's thirty three equality metrics at the issues are judged.
a most them about. Are you getting your patients healthier? And then you know you kind of call this patient centred medicine, where we're making sure the patients are doing that
we're making sure everything is working and the patients health there's, not a single quality metric that
to do with how much time patients are spending managing their own, how he argued, I think it's the right theory, but it's very easy,
that's not one of your metrics, its super easy just to offload the work under patients. That's less work here, people to do that. Those people who have to hire
This kind of rely on people being very motivated to fix their own healthcare problems, so we
he's the kind of in working on this concept that I became interested in of minimally disruptive medicine, where you kind of one other thing
engineer around is how do we deliver health care and away? That's least disruptive too.
Patients lives and its in some of the EU.
so these Yos, but definitely not like one of the things anyone's being
third on. So there's really not a strong incentive for
Annabelle characterizations to practice medicine in the way that police disruptive to their patients
kind of essentially get free labour out of patience, because you're gonna be the personally
really cares about fixing your problem. You kind of like rely on their motivation,
people have to achieve these metrics without really keeping track of all the work. You are asking them to
He, although I mean one question, is, is like how good our people actually doing this this job
I mean, my guess is that you have gears or experience cover
health care. Your very little red entertain. The terms are probably a pretty good manager of Sarah Cliffs.
Healthcare case, but it seems to me that a lot of people probably are- and I mean particularly,
people in more severe health distress who may be don't have
background, necessarily in the field to like filling bay, where they have a strong
command over the whole thing, and I mean you just keep
all the time in a very low level. Stories about like people who don't take of the pills that are prescribed to them
more like trying to save money and a pen wise pound foolish way by
stretching their medication rather than than using things correctly. So I mean to the extended that's true, even like, without an explicit
make this easier metric organizations that find a way to make it easier for people to actually comply with their.
Regimes should save a bunch of money right,
do these services and this time acts as a counter argument to a conductor. Oratorios argue to me that you should expected
you may healthcare easier your patients or get healthy early easier for them to follow them,
and you can expect some of which be reflected there. The kind of counterpoint to that is you're still kind of like not really thinking about what you're
You have doctors who are very the cognizant of their quest that their make indications
it's very that you're saying like when a doctor rights may prescription, they dislike Henry a piece of paper if they ve
given me the prescription and then like I'm on my way- and you know a lot
These kind of patients to veto aren't on taking them occasion on time are saving
tells you know our kind of labelled and compliant
and so you are not complying with the doctors order. Any that feels like after reporting this peace and kind of like,
these issues like a real misnomer, like maybe there, people who have like very inflexible jobs that they have to go to and like the job of going to work like pays them and the job of being a patient does not pay them. What they thought about
writing this is. I don't know it doesn't really make sense to me that, like doctor should be taking over this work, I kind of like circles. A lot of them talked about
a tonic records and innovation like it really seems like a place where a computer should steal a lot of this work, but for somebody
and fax machines still seem to be the mode of communication in the medical system, and you know no doctors feeling very overburdened by all the work that they're doing behind the scenes that I'm probably not even seeing
it seems like there's space for this to be true,
and maybe maybe the ratios well will change that.
There is some research on kind of patient satisfaction and, as you know, and it seems to be about the same as regular Medicare, where patients
There's one survey where patients report Ed easier access to their primary care doc
Is there an uneasy oversees, not NATO? Otherwise, it seems to me
at the same, and I think you if these
are saving money and you know their quality. Metrics are the same. That's pretty good mark to head. I guess you are you like
should be doing even better because it providing us coordination better. I think they're doing this
services for a lower price, that's like a decent scientists,
yeah I mean that's like the goal and some level if you can reduce costs without impairing either like to help out.
Or the patient experience. That is definitely a policy win, even if it's kind of a kind of a modest
and beyond, like a pig people, sort of wild dreams there sitting that that I'm fascinated with about this is simply the
quantitative limits on the number of primary care: physicians that exist in the United States
Italy's strikes me that if you go see like a regular doctor,
seem like really busy like their schedules really for and they feel like their working alive and then from up patients. As customer perspective didn't seem like that interest
in like new business in the in the way that most people are
You know, like it
billion ordinarily till I get service provider there like ours
like they're, like excited to haven't who client and they like wanna, make you happy with this words. I've always
in Washington DC I mean, maybe things are different, but the impression I have gotten from almost every doctor that I've ever been to hear
is kind of like easy, come easy go.
they don't really care, like the schedules full
like always, if you call them
you like wanna, get an appointment there like wow I'll. Do you this favor of? Like you come see me for money, then I wonder to what extent that kind of just like persistence, scarcity of primary care positions,
drives some of that state like they are shuffling people in an outbreak
Quickly, till I get the billing, I mean they have neither the time nor the incentive to like really put the work in hand.
I mean I just personally but like as an office right that, like a lot of the assistance in these services, are not super helpful and nothing because their bad people
cause. It's just somehow seems to be a business where, like making people feel taken. Care of is not that important to the success of the endeavour.
In a way that a little odd yeah, I know I mean I think you re actually is unlike an even higher level and specialty care where you like? All this demand you the other day I was in the doctors office
I waited ninety minutes to see my doctor in what one doesn't one, why twenty minutes is complains about it
Twitter is a quick they, at least just like call me, and we like he's running an hour late, just like come an hour later and there are equal. Why did they care
If you don't show up those dislike failure with another patient there
demands of doesn't really matter of. Like I'm upset about my weight, they will just have someone.
and like this waiting room was full of people just all over.
There are so you don't seem good, anecdotal evidence. For that theory. I think
out of what motivated the changes and easy a new easy owes, our kind of like this kind of feeling of patient and, like you know, I'm just like there
and they get paid for seeing these are like they try and see me as quickly as possible. In a kick me out the door
any idea of issues to really change that experience to actually make it worth
providers while to keep you healthy and if there are going to be, if you're gonna be more
welcoming and when you ve healthcare problem. If you're going to be more compliant cause you actually like your doktor. That's all
becomes like the wise financial thing to do, but the way that
in general is practised there just,
Forcing doctors are paid for adjusting just as many patients as they can you end up with these, like super crammed rushed feeling. Schedule
at the time, the idea of delivery system reform, which is kind of a fancy way
changing the way we pay for healthcare and really something Obama's healthcare.
you see often needle gets tied up in the entrance expansion, but there's also been as the easier does really big movement
towards kind of paper, quality healthcare
Menstruation Senegal, recently of moving the healthcare
down to fifty percent paper performance by twenty eighteen and thirty percent between sixteen, which they ve already already hit it put to by the end of the year and in turn
Levin there is none of us. We started zero, were thirty percent, now hope of getting to fifty percent in the truck
Clinton administration, so they really
I've been trying to change these payment methods and it really is a big part of kind of the above
Obama, administrations, health legacy that doesn't get as much attend,
in general duly is addressing this exact sort of problem or still saying. If it's it's gonna work. Let's unwilling even nerdy,
man, we're going so far in the weeds? This is this. Is the controversy over a week last
We talked about what I had thought might be the nervous thing of all
Some exciting new swedish administrative data, which you gotta listen to the episode if it was hot,
data excited. I knew what it was you who really was a because this is relevant. You know he was a paper whose, whose I'd conclusion was kind of interesting,
was about if a pregnant woman has I got relative,
who dies. This has noticeable impact on the baby's should have later use of of certain mental health prescription drugs, but was fascinating about. It was actually the dataset which
unusual, and it was that clever. There was just a lot of good record keeping in Sweden that less
really match say. As I record here, I mean it. I'm gonna go deeper and undermining data one day because
Erica Growth at the door of labour statistics. She's she's got some
ideas. Unless that that I would love to go deeper right now that I would I would love to bring to light. But the interesting thing is that, after we went to air with our episodes, we found that there was actually
controversy about this paper veil bond retraction washed out com, a website that I do not know existed, did you great work, what they do?
they kind of look out for papers that are being retracted from journals, kind of keeping an eye and a lot of the unfortunate fraud that happens in science. So often a lot of science. Research is what their monitoring, but they picked up a hot Tipp on the
wealth, the somewhat obscure work
the econ job. Rumours a blog, but I have learned from my economist Fiance- is frequented by
the economist across the: U S as a school of gossip
rumour trading, and so what what they found here is that essentially
this paper: it emitted citations, it would have undermined the papers, claims to novelty and contributions to the field right. Yes,
what essentially arises on equal job rivers and then is grown into a bigger strand. Retraction watch is that there are two papers
one for nineteen. Seventy eight and one from twenty eleven that used pretty similar data sets
came to pretty similar conclusions and these papers
kind of nowhere to be found in the citations of the initial
in the end, be our paper that we talked about last week. It seems accents
This was brought to the authors attention they have added in a paragraph that
in citations. They said you do. We
and see these we're doing our research. We still believe we add novel.
findings. I'm excellency to the research. Other economists, however, have cried,
saying if you are so in the way of Swedish administrative data, how could you possibly
miss this research. You know it was ended,
I think, a lot of the blame and criticise
is going towards editors. If these paper this paper arena Brandon, it was published by the National Bureau of Economic, shoot
messing up there. We are,
everyone, economic research and also the american Economic review. So either you kind of sea some economists, Ngos
flax poorly on the reviewers on the journal. Auditors, who you know, should have been the ones to say how this this is not as new as you. I think it is
and so to the main thing here, because it feels we are to talk about it. But I've been honestly. This podcast is probably one of the most prominent
places in which this research was picked up or discussed, and the dispute here to be clear is not about the conclusions of the pay
words about the originality of the research, so that just why in particular like, I feel the need to correct the record,
this paper that we that we discussed with
largely duplicating work that was done in nineteen, seventy eight by multi, oh, who tannin and Pack Agnes Cannon who ads
like a finnish people who may well have access to Nordic administrative data and also to a twenty eleven paper by courts, are a class credit where, due to the
but who were pioneers in this. If you look at the footnote settlement
they say, for example, that the statistical approach that the nineteen seventy eight paper road suffers from energy and eighty concerns which, as you know, statistical quibble. The reason this seems striking to raise it in this way is that their conclusion does
differ from the nineteen seventy eight conclusion and
doesn't seem like there had been some raging controversy over the nineteen seventy eight paper
because sometimes there is wide, sometimes people will come out in the late seventies. It all be interesting.
Yet all have an interest in conclusion, but then some people will raise a methodological. Kids
about, if I say, oh there's, an energy, ninety problem with this statistical technique, so you'll do a new page
looking at the same dad, but with a slightly different angle that addresses that concern and he'll say no. They were right after all and that's a good contribution to a growing literature.
talk about before there's a million minimum wage studies that often look at similar things, but there
making new statistical approaches and that's I got a progressive debate in the literature and so
see citations, there's a reason why similar research is happening again and again and again, that's a little bit different because there's like an ongoing programme here in the case of this paper. What's
fishy about it. Is it s not really the case? What was interesting about this paper was
like hey here's, this dataset, that we can analyze, but it turns out that other people had already come done. The hay,
it's his dataset there? We can analyze paper, no one
as far as I know, is disputing the analysis,
an ongoing debate to contribute to here by doing a slightly different take on it. I mean, on the other hand, like it's good for the world. I,
I've seen this edges and hey paper. I did see the new one we talked about it. I think it's interesting. It changes, I think about things a little bit, but is evenly bad manners and think it speaks to some other
kind of challenges and academic publishing and of our co workers. Julia balloons and buying Resnick do really interesting work on this wearied. There is such a push
Words, originality that that you have to come up with something like super cool and interesting kind of more so than replica.
showing that someone else's findings. You could find them too, because
You try and replicate alot of certain when China,
it allowed research and managed ending as in psychology. This is an especially acute problem settlements
this can sometimes you know a study that kind of like they dispassionate media. Someone else tries to do the same thing. You can do
so either in a way definite citation should have been there, but there actually is value, unjustly replicating research of its
something as important as understanding the relationship between prenatal stress in future health harms. I could
totally see saying you know. We ran a similar analysis by similar findings like this really brings more gravity to these conclusions. However, they probably wouldn't
not in into a are, they had showed up,
hey, we did the same work that someone else did
even though the scientific community there's a lot of value in replica
buddy. So it's hard problem for academic publishing the way you're going to kind of like a slash and the media. I would like to think locks is like a little.
Guilty of this with the new Julia's, our health reporters very conscientious, helped. The porter text, like signalled,
view of research, but often the studies that are going to get the most
where are the ones that kind of say something like totally,
new and different from the body of research. The incentives of research become a little bit divorced from what we want.
Aren't like a really rigorous scientific discovery process one. This is something we think about. I think advice we have made. Some sums rides and this, but just a general question in the media is why are we always so interested in? What's new raid, when, like we re talking,
It raises like, according quote new analysis, but the children who were in this study were born a long time ago, one way or another, but it was. The alleged newness of the paper is like how it got on the front page of the envy our website, which is why I cite
why I wrote about like, I would say I didn't get us talking about it,
because it was new, but had it
We knew, I wouldn't have seen it and had not seen it. We wouldn't have talked about on the podcast, unlike one Bagua also wrote about
paper, and we know because it was on the front page of this website eminent obscure website, but not in
scared, but still a website. The world is full of knowledge that just because
doesn't happen to be on the front page of a and b are, as our end on any given day doesn't happen to be a blog post written about it. So it's like not ricocheting around
and what we really struggle with till I read an article about is like be like new,
steady slightly reinforces my confidence that something that other things has also shown is still true red. That's like a bad that
although the exact researcher you? U wine, trade like if there is a big finding, you want to be able to show like. Oh it wasn't
one researcher doing something weird in there
lab or doing something you know that you are not able to replicate you
do want those studies that produce other people's findings, but no one's gonna fund. Those
is Keziah. We're going for grant to say hey! I want to do this thing. The other researcher did like give you like: tough luck and even tougher look getting published anywhere,
where'd. You say like we want to do this. This study that we saw from Sweden. We wonder the exact same study, but we want to do it for Norway right, wait, it's like it's not that interesting
but there's actually value, but there. Yes, it will be enormous value in actually going through finding a handful of the sort of most in
bringing small study is I'm just trying to do as close as you can do that same thing, but slightly different to actually see if it hold
up or not right, because we're getting good at generating dissertations and new
journal articles and then new. Like wonky news stories about Journal article,
but we're not necessarily generating like solid knowledge by having everything be as different as possible from areas that any incentives are defined as different as
possible. Representatives are like two not specifically do not replicate year
it's like how can I buy
studying a similar topic in a totally different way, which are contradictory conclusion like that's what you really want to take the
take machine of arms of how could you know I mean I think it's it's. It's too unquestionably truer like that's that,
you get and then it's very. It makes it hard
to say like what have we actually learned as society about about how things work when people down don't try hard enough to replicate
swedish administrative data who knew what controversy could be got well
as the time to get into another.
controversial research paper of the weak. Absolutely absolutely. This was an interesting. I think not that you know. Methodological contentious
setting out the economic innovation group put out and they
kind of looked pretty casually at the geography of the current.
I'm a recovery in the United States compared to the first four years of the last few growth expansions and
You know one thing: they show it just. Overall, it's been a less robust economic recovery. We ve
bushmen sleds like a physical location at which people work and fewer new jobs created than you saw, em, we gonna do that
I mean it was clearly going to be the case. The economy has grown. My strong those members overall job creation, so also obviously few Fiona establishments issue is at the geographic pattern. Is, is really really different that in the
pass to recoveries. We saw small towns, add new establishment, small and medium sized towns,
in the current one. The smallest counties, the lowest population counties to be clear, have actually seen it continued loss of establishments, where is the biggest highest population places have seen the most robust growth and there's like the charge is like a little
stepladder right, smallest county, shrinking medium sized little big candies alive,
and in terms of overall job growth, you got a basic
a similar kind of story where it used to be that places with a low population base sawdust in percentage terms, the biggest increase they were. You know growing fast went when people are growing.
And the most recent one that has been the case. Small low population counties have an added jobs at a very, very low rate. High
Population counties have grown at a pretty robust wade, but there's this relatively few of them, so we ve
specially seem growth in Brooklyn in Miami David in San Francisco. You know what a handful of sort of big city places and not much like out there, and that the vast yonder of the country,
indeed seem just important a recognised like that is a change. I saw some people look at just like the map a bit like while that's where people live, which is true, buddy. Those were also big city, so you, you think, a lot about urban development in all these artificial. What's a different about this report very like, why do you think we're saying this particular pattern this time around? So I think a few different things are are going on. One is that you have the structural decline of physical
retail, more and more Amazon type things is is how people are shopping and,
not necessarily seeing physical stores like vanity
there have been some more closures. Things like that, but people are building new ones at the kind of rate that they used to. It used to be just taken for granted that, like
the economy is growing. That means we're gonna, need more stores and stores by their nature, very geographically scattered and, like the big city already has storms
so it's on the fringe of where you're going to add new ones, people not adding it at that same rate. A related point is that, because we specifically had some,
from a crisis. In the house, building industry people are,
adding new new homes at a rate that they used to
that again used to be like a high growth area for for low population kinds of places right sprawl bills build new exit.
and we ve seen very very very little home building of over the past four years, but in the last factor.
Is that you see this in it in a whole bunch of different ways, but the economy just seems to have shifted to put more emphasis on the sort of hottest, big city hub, sweat, if you think about where
Dynamism, I mean it's technology start ups, earn big cities, but also restaurants and nightlife and entertainment, food service and hospitality, and the like official government classification sectors have been growing. Allow people
ask, like you know like? Where will the jobs come from? You know whatever, whatever like that's. What people want to do with their spare time and in their spare money is like fine place.
eat, go, stay in hotels, things like that in those are varied, like central City focused kind of things bullshit
striking to me. Is that not only do you see this serve shift away from small population centres to big city centres,
But the big cities are not growing back fast either. It's like mostly just been bad news.
right and like an overall like decline and in dynamism and growth. That is really bad about it. If what happened was that like
Small towns were doing poorly, but big cities we're having like an insane boom, the likes of which we'd never seen you'd say like wild, maybe too bad for small towns,
I think, the disparity matters right in the sending one of her co workers. Timli wrote about where I would guess most people setting policy are those living in big cities. You kind of look around them and think, like I like it's not great, but it's not terrible.
a kind of aid. It seems a good changes. The perception of what the recovery looks like
like ways that could potentially,
really how we think about what happens kind of next in whenever policies we,
yeah, I think, especially the media rights, so that one of the
industry is that has become more concentrated in a handful of big cities. Is the media right? There is a much much less employment and much less audience.
should have regionally based new sources and much much more concentration of jobs in New York, Washington, LOS Angeles, but to accept San Francisco and
those are places that not only have relatively robust labour markets. For me, a people but just in general, are seeing growth and places opening
and and things like that. So when you look around you're looking at a place where isn't it
People living in New York don't see that there are economic challenges, but they ten.
to be very focused on things like housing, affordability, which is like a big big problem for people living in giant coastal cities and
We talk about before how the media is really obsessed with gentrification, because as a lot of codification and these because two cities where's like Midwestern,
central city is continued use like empty out right and just like that
in population they're, losing jobs and its its bottom, more severe set of economic problems are
getting smaller towns, small communities and there are,
so different, both
in terms of your overall emotional state, a little bit skew
and then specifically, what you're paying attention to that big. A typical communities problem is like
hundred places closed during the recession and
a lot of them, just nothing. Nothing at all has opened in those spots, radishes vacant and
that's gonna, whereas if you're, looking like a large steady, your annoyed by the giant condo building
That's more like you know, like stores that used to sit
I read a lot of articles about people law,
time residents of the mission district in San Francisco, who are upset that
they themselves or maybe working class people living in when when stabilize, but they used to go to like the barber barber here, the Toggery there and those places are closing and are being replaced by new, much more expensive places,
cater to the yuppies living in one hour and not to say, like. I feel bad for this.
but that is a person living in San Francisco looking for
an economic problem afflicting working class person living in San Francisco find me
the real problem that is affecting like a general
you know it's not just like privileged people whining where we are finding we'll economic struggles of struggling people, but they turn out to be very idiosyncratic right and not reflective of the kinds of problems that you are seeing, unlike mainstream
community is which is just a sort of general slowdown in milk. Statistically at this point, job losses.
Occurring at a very low level. Businesses are not failing. People are not getting laid off, but there's much as much as the creation of new jobs and creation of new companies. People are not moving is much like all the whole like metabolism of the american economy seems to afflict slowed too to a kind of crawl, and that's not ever,
in the biggest cities, which have always been the fastest moving most dynamic places and seem to be plugging along like a kind of normal level,
so its leading people to sort of miss. This is big story. Well now they ve heard it on the weekends thanks for listening thanks
bond citizens or producer Easy Valdez back for better this week. No thanks to israel- and maybe we also neck three. Maybe so, and you should read- is an item you s, you struck by how much, how awesome switching industry that is share with your friends,
the earlier that is yes
ok, creates and applicable in and tell us now really and will I will see you next week.
Transcript generated on 2021-09-14.