I was recalling it from memory. Actually, the Department of Education accountability formula ranked her as 7th percentile, which prevents her from being rehired at that school and probably any New York City school. The confidence interval 0-52nd percentile. Yes, P=95%. She was there 2 1/2 years, and two dozen of her students got into Bronx Science and Stuyvesant.
You can't just rank teachers based on their students' test scores. You have to correct for the students' abilities. (1) Everybody who has studied student achievement (Diane Ravitch for example) agrees that the factor that is most strongly correlated with student test scores is family income. So you have to correct for family income. But how do you do that? Parents aren't required to reveal their income to the school. So they have to use indirect methods of estimating income, which are inaccurate. (2) New York City is trying to correct for the students' past performance, to see how much the teacher improves their scores. But this has a bias against the best students, because if your class has students who already have a 98% average, they don't have any room to go up. So they have to correct for these and many other factors.
They wound up with the complicated formula in the article that tries to incorporate all these factors. The problem is that (1) the formula hasn't been validated and (2) literally nobody understands it.
The fundamental problem is that it's a bad formula that doesn't correlate with teacher ability. In this case, the teacher is obviously qualified, her students do well, her principal loves her, and yet the formula says she ranks at the bottom. How do you know this formula works?
The fact that it ranks this teacher from the zeroth to 52nd percentile demonstrates that the formula doesn't work. Even if you believe the test, the only statistically valid information it gives you is that she's either among the worst teacher or among the top half. The conclusion that she's in the 7th percentile is not statistically valid. You have to understand basic statistics to realize what's going on here. If you have a confidence interval of 0-52, you can't take one point of the distribution.
I think that whoever wrote this summary is being unfairly critical of charter schools, and even more unfair to those rich donors who are actually *trying* to help (as opposed to those who just hoard their money and or just their wealth to buy new Ferraris).
If you read TFA http://www.dissentmagazine.org/article/?article=3781 you'll see what the problem is. These billionaires aren't simply giving money to local innovative schools. They're using their money in a heavy-handed way to shape policy for the public schools used by less-affluent, less-powerful taxpayers.
They promote bad policy, and when the evaluations show they don't work, they ignore the evaluations and keep promoting the bad policy -- in public schools as well.
They've affected federal policy, under No Child Left Behind, so that schools can't get this federal money unless they accept the whole package of "reforms," many of which turned out not to work, such as destroying large neighborhood schools and replacing them with small schools, high stakes testing, and promoting charter schools (which according to major nationwide evaluations http://nces.ed.gov/nationsreportcard/studies/charter/ using the tests they love so much, are worse on average than public schools).
The problem is that billionaires don't free up resources for public schools. As a result of their lobbying, public schools actually lose money, for example through penalties under No Child Left Behind, if they don't implement these "reforms" many of which have been proven not to work.
As TFA says, the billionaires are trying to change the public schools that only get tax money. They're doing it by using their money not so much for direct teaching but for setting up "think tanks", lobbying, and even paying public school educators in ways that might be considered bribery.
My biggest problem is that they're implementing fad solutions, like charter schools, financial bonuses, etc. that haven't been shown to work -- and have sometimes been shown not to work.
I agree that parental involvement is the most important factor, but teachers are fighting the wrong battle by pitting themselves against standardized tests. They will not win because their position defies common sense. Everybody understands the need to measure outcomes and the need to compare those measurements.
These "neutral" tests are also invalid tests. As TFA http://www.dissentmagazine.org/article/?article=3781 mentioned in passing, the National Academy of Sciences and other organizations reviewed the current tests and found out that they don't do what they're supposed to do: They don't tell you whether a teacher is good or bad.
The New York City department of education was using a test to determine whether new teachers would continue on the job. The test had a complicated formula that (literally) no one could understand, to try to correct for things like the students' family income and previous test scores.
The test told one middle school teacher that she was in the bottom 6%, and had to be fired. Her principal didn't believe it, and didn't want her to be fired, because she was a good teacher, her students got into the competitive high schools, etc. But that 6% had a confidence interval -- from 0% to 51%. So actually, she was either among the worst teachers (0%), or among the best half. If you don't know what a confidence interval is, there's no point in my talking to you, but that means the test results are statistically invalid. You might as well fire teachers by throwing dice.
These tests are made under contract by testing companies, and they haven't been tested for validity. There's a huge amount of research on this. They can't distinguish between the effects of family income and effective teaching. It's not common sense to fire teachers based on these tests.
Everybody knows that the one factor that is most strongly associated with grades is family income. If you teach low-income kids, they're going to start with low grades and their grades will rise slowly. Test scores reward teachers for having high-income students.
You make a good point. It's stupid to fire "bad" teachers. If your tests are so good at identifying good teachers, find out why they're good, and teach their techniques to other teachers.
If a teacher is hopelessly incompetent, I don't defend keeping them on, but that's not what Rhee was doing. She was just a right-wing hero who wanted to destroy the union and attack teachers.
Read the USA Today story about Rhee (or the Wikipedia article).
Rhee gave large bonuses to certain principals and teachers. Then it turned out that there was massive cheating on the standardized tests that Rhee used to evaluate them. The teachers erased the incorrect answers and filled in the correct answers. The companies that mark the test sheets can read the test answers, but their machines can also read erased answers, because an unusually high number of erasures indicates cheating. That's what happened in DC. When the company warned Rhee about this, she refused to investigate it and covered it up.
Everybody really ought to read TFA. It explains why all of Rhee's reforms, including the performance bonus, have been tried before and didn't work. http://www.dissentmagazine.org/article/?article=3781 I admit it's not easy reading, because it has lots of facts and data, based on actual research and the experience that people had when they tried these things out and looked at whether they worked.
That's exactly the opposite of what the article said. Did you actually read the article you are linking to? If so, then you're deliberately misrepresenting it.
The actual headline is:
"Yes, 47% of Households Owe No Taxes. Look Closer."
The article says that's true only if you define "taxes" to exclude payroll taxes. It says:
"About three-quarters of households pay more in payroll taxes than in income taxes."
I really get pissed off when people try to have an intelligent, informed conversation and you have to spend 15 minutes checking the conservative sources and have their facts turn out to be wrong. Deliberately distorting facts is the worst thing you can do, IMO. Negligently distorting facts is a pretty close second.
It's a waste of time to try to have an intelligent debate with conservatives. The time is better spent reading Paul Krugman http://www.playboy.com/magazine/playboy-interview-paul-krugman and going to Occupy Wall Street to figure out how to organize politically to stop them from destroying the country.
People tell me that I romanticize the UK health care system too much (probably from reading BMJ and Lancet in my younger days), but my understanding was that the NHS gives a lot more emphasis to systematic evaluations than we do in US.
I thought that when they rolled out their health care software, they did a lot of careful testing and evaluation, compared to what we did in the US. True?
Because non-tech people usually don't understand the "computer is a universal tool" thing and have problems stretching the limits of their imagination ("I had no idea a computer could do that for me...")
Because IT evangelists think that every problem in the world can be reduced to computer code, and they create medical systems without understanding how medical practice works.
Then the doctors try the system out, it runs into problems ("It takes me longer to enter a prescription into this computer than it does to write it on a prescription blank by hand"), and they correctly go back to the older manual systems that work better.
Doctors aren't stupid. They use lots of new technology every day. When something works, they use it. When it doesn't work, they drop it.
Medical practice is very complicated. The potential cost of error is very high. The cost of developing electronic medical records properly is very high. It's like developing a medical drug or device (which it is). You have to get back to your users (the doctors) continuously, find out what's going wrong, and fix it. Automating medical practice is a massive job, like automating the aerospace industry. At best, it will be slow and expensive. At worst, developers will take shortcuts, waste even more time and money, and have to scrap it all and start over.
I used to evaluate medical office-based systems about 15 years ago, and I kept an eye on the field ever since.
They made wonderful predictions, about half of which came true. (I made predictions. Mea culpa.)
The billing systems worked very well. When they went to Medicare/Medicaid billing, the investment paid for itself in about 6 months.
The clinical systems didn't always work so well.
Transmitting lab reports worked very well. They substituted a standard paper format for a standard electronic format.
Keeping patient notes is difficult. In the New England Journal of Medicine a year ago, a doctor was complaining about EMRs that automatically insert boilerplate, winding up with a hundred pages that nobody has time to go through. In contrast, the old handwritten notes forced doctors to think it out beforehand, be concise, get to the point, and emphasize what was relevant to clinical decision-making.
There's a tradeoff between a narrative and a structured description. Some systems encourage (or force) doctors to structure their notes. The problem then is that in some systems doctors had to go through pages and pages of menus, many of them with irrelevant choices.
Few doctors are anti-technology, but they don't want an electronic system that takes more time than paper, unless it has significant advantages. (Remember all the Ask Slashdot articles about, "What's the best way to take notes in class?" Lots of techies use wire-bound notebooks.)
Electronic prescribing worked reasonably well. But even so, doctors say that it takes longer. They could quickly write a prescription on paper, but the electronic systems force them to go through pages of menus. In one study, the death rate in a pediatric ICU increased with an electronic prescribing system, because it took so much longer to write a prescription. It would seem that it should reduce drug interactions, but in real-world studies it doesn't do that. (Doctors had better understand what drugs they're giving the patients and how they interact with the other drugs a patient is taking. If they don't, they've got problems that computers won't solve.)
Unexpected problems come up. How do you keep a keyboard sterile?
The fundamental problem (which the Obama administration is perpetuating) is that it requires a lot of testing and evaluation, with controlled studies at every step, to get these systems working right. And there are a lot of steps.
Doctors aren't willing to get a beta release that works right most of the time, but still has a few bugs in it. They're right.
A system analyst can define a scientific problem, or a financial operation, in great detail, and then pass it off to the programmers to write the code. But health care systems, even a small medical office, are much more complicated and unpredictable, with lots of exceptions to the routine. And humans are really complicated.
I believe in computerized medical records. I think all these problems can be solved. I think they'll be completely digital some day. But medical systems are more difficult to develop than their enthusiasts thought.
We have to try things out in small systems, in small steps, and then large systems, in controlled trials, and make sure they do what you want them to do (save lives), not just what the programmer is able to do (save data), at every stage. If your computer doesn't save lives or improve patient outcomes, doctors won't use it. And rightly so.
Then of course they have to be part of an integrated system. It's bad enough to learn one new system; a doctor doesn't want to learn 20 new systems. They could be reading JAMA, or even seeing patients, in that time.
If you want to find out why computerization is going slowly, talk to some doctors and ask them.
I knew a medical secretary at a major academic medical center. She used to keep index cards for every patient. While she was waiting for the system to deliver their electronic charts, she had a 3x5 index card with the essential information on it. She was actually faster than the younger secretaries, who had never used index cards.
Just because they made an error, that doesn't mean a death resulted from the error. A patient's blood pressure may have shot up or down for a day, but (unacceptable though it is) they might have caught it and it might not have harmed him.
One small distributor, and a large pharmaceutical company, both deliberately sold a dangerous, misbranded syrup as pharmaceutical syrup, resulting in a large number of deaths.
I realize that there are a lot of people who think that the problem is that the market isn't free enough; if only we could get rid of all those government controls, the free market would give us the best of all possible worlds. In my observation of the real world, it doesn't work that way. The Chinese chemical manufacturers cheerfully sold children's cough syrup poisoned with glycerol, and when the children died, the Chinese were protected from tort liability. People support government regulation, because without it, their children die.
Are you referring to this story: http://en.wikipedia.org/wiki/Toxic_cough_syrup ??? If so you kind of mischaracterized what happened. I don't mean the part that glycerol is the poison. Also, the point is not whether or not regulation would prevent these types of errors. It is to compare the cost of government regulation, as well as false positive and false negative rates, to that of other options. Assuming government regulation is the best solution is common, but not necessarily true.
That's the story, or rather, the Walt Bogdanich story in the NYT which it cites. I think the story makes it clear that Chinese chemical manufacturers deliberately mislabeled syrup. They clearly mislabeled industrial grade as pharmaceutical grade. Nobody was able to sue them. I don't know what you think I mischaracterized.
The pharmaceutical industry has very high standards for quality control. The costs of damage from dangerous products is much greater than the cost of inspection. They should never have deaths from cough syrup. Whatever that level of QC costs, that's the cost of manufacturing pharmaceuticals. False positives are part of the cost of doing business. The company needs multiple layers of QC and inspectors. Government regulation is one more layer. Most of the pharmaceutical companies were happy with FDA regulation of their manufacturing process. It's better to have an inspector spot a batch of infected drugs than find out when 100 people around the country develop infections from the drug. It's better to have an independent monitor.
Look what happened when we cut back on government regulation -- by not having enough FDA inspectors to inspect Chinese manufacturers. We got contaminated heparin. Most manufacturers would rather have FDA inspectors than have their business destroyed by a scandal like that.
Yes, there was a good series about that in the New York Times a few years ago.
The Chinese are very capable manufacturers, not only of drugs but also feedstocks to make drugs. Some American and European manufacturers established their own quality control procedures, and they did OK. But most of the American manufacturers put their suppliers under heavy price competition, which lead to a race to the bottom, and there have been a lot of Chinese products (like heparin) that, through carelessness, negligence or outright fraud, were improperly manufactured and caused widespread illnesses and some deaths. The FDA didn't have the resources to inspect Chinese plants, so we've got global competition without the oversight. The Times had difficulty locating manufacturers even when they knew the names. There's a long international distribution chain, and it's usually impossible to trace a Chinese drug back to the source. The Chinese government didn't care, had almost no oversight, and dealt with a few of the worst scandals (in which Chinese were harmed) by executing the suppliers. I think it shows what would happen if the libertarians had their wish of eliminating government regulation and letting the free market take care of it, as we did before 1916. As I understand it, Communism in China meant that drug companies and hospitals were run by the Red Army, which is politically powerful enough to do whatever they want without much oversight. Between the cracks they have wealthy businessmen running drug companies (I assume they have connections with the Red Army). It's like Halliburton and Blackwater under the Bush Administration.
India has a much older pharmaceutical industry, with chemists like Cipla, who have had several generations of European-trained owners running the plant. They go to European and American conferences. They do contract work for American and European companies, so they're FDA-inspected. They supply generics to the third world, so they can do it cheaply. For a long time, Indian law allowed them to manufacture generic copies of drugs that were still under patent in America and Europe, if they could "invent around" the patents, so they were under a lot of pressure to be good chemists. Otherwise, poor Indians would have just died. The Indians seem to understand the whole system, whereas the Chinese are just contract manufacturers.
It's not because the Chinese are stupid. There are some pretty smart Chinese scientists, many of them trained in the U.S. It's because of the system and the accountability. I'm sure the Chinese will be major players in the pharmaceutical industry in the next few decades. If you gave them a well-defined drug manufacturing task to do, and established good quality control, they can do it. I'm looking forward to seeing what Chinese scientists will contribute to molecular medicine in the years ahead.
But I don't understand why the Indian and Chinese manufacturers can't produce methotrexate to FDA standards.
So you've got a drug that just doesn't have enough volume to justify maintaining an expensive production line. Switching a production line from one drug to another has to involve basically taking it apart and reassembling it differently, then going through the inspection and correction cycle, then running for a week or two, then doing it all again for another drug.
That's the way the chemical processing industry works.
Take the total cost of production, add a reasonable profit, divide that by 3,500, and that's the price.
The main cost of producing a pharmaceutical product is the quality control to make sure it's safe.
You could produce tech grade methotrexate cheaply. The pharmaceutical grade is a lot more expensive.
There are a lot of drug companies in China and India who could easily manufacture methotrexate. Making it to QC standards, and documenting it, is expensive. The FDA has to inspect the plants.
I don't know whether they have the same problem in Europe. I would trust drugs that had passed the European (or Australian, or Japanese) regulatory system. There was some talk about making it easier to import drugs.
The textbook I read was Wei et al, Structure of the Chemical Processing Industry, which had a chapter on two-party and three-party competition, with game theory and other mathematical models. What's the cost of production, considering economy of scale, when 1, 2, 3... manufacturers are producing a given chemical? Plus I used to read Chemical Week, which was written for the guys who owned the chemical companies, and (with a heavy commitment to the free market) described how those things played out.
I can't think of any place in the world that has a pure free market. If you went to Somalia, where there is no effective government, the warlords would want a cut of your business. The government regulates everything to some degree, the only question is how much. The chemical processing industry has a lot of externalities, so they should be regulating it. You don't have a right to put your chlorinated hydrocarbons and dioxins in my drinking water.
I realize that there are a lot of people who think that the problem is that the market isn't free enough; if only we could get rid of all those government controls, the free market would give us the best of all possible worlds. In my observation of the real world, it doesn't work that way. The Chinese chemical manufacturers cheerfully sold children's cough syrup poisoned with glycerol, and when the children died, the Chinese were protected from tort liability. People support government regulation, because without it, their children die.
True, methotrexate has some horrible side effects, particularly the destruction of short-term memory. I knew somebody who was taking methotrexate for brain cancer, and by the time she got to the end of the conversation, she couldn't remember what I said at the beginning of the conversation. However it's great when you want to selectively destroy B cells and T cells. Oncologists love to run randomized controlled studies, and if there was anything better than methotrexate, they would use it. For several cancers, such as childhood leukemia, there isn't. When something better comes up, they'll phase it out fast. How many parents do you know who want their children to grow up with cognitive defects? Why would an oncologist use it if there were something better?
The chemical processing industry is as close to a free market as we will get (especially when you define it to include home methamphetamine manufacture).
The free market will always work within some government constraints, but if we don't have a free market in the worldwide chemical processing industry, then a free market is impossible.
According to the economic textbooks, competitors should be moving into the methotrexate market right now. They're not. I wonder why they don't follow the textbooks.
The supply of methotrexate isn't exactly limited by the government.
As I recall, there were 2 companies with the capacity to make methotrexate in the U.S., but they both had problems meeting the good manufacturing standards for pharmaceutical drugs. Injected methotrexate can be fatal if it's not manufactured properly. Yes, they weren't meeting federal standards, but no pharmaceutical manufacturer in his right mind would manufacture these drugs without meeting the same standard.
I know a bit about the chemical processing industry, and according to the textbooks, when you have 2 manufacturers producing an unreliable supply of a specialty chemical with inelastic demand, and shortages develop, a third company is supposed to move in to the market and produce that chemical at a price which is slightly higher than the old, unsustainable price but less than the monopoly price of a patented chemical.
Not only are there U.S. manufacturers capable of manufacturing methotrexate, but there are also capable foreign manufacturers in Europe, India, China, Israel, etc. who are regularly FDA-inspected and approved for other drugs, and even do contract manufacturing for major brands here.
I don't understand why the free market isn't working, and why additional manufacturers aren't jumping into the market for drugs like methotrexate.
Slashdot Mirror
Here's the article.
http://www.nytimes.com/2011/03/07/education/07winerip.html
On Education
Evaluating New York Teachers, Perhaps the Numbers Do Lie
By MICHAEL WINERIP
Published: March 6, 2011
I was recalling it from memory. Actually, the Department of Education accountability formula ranked her as 7th percentile, which prevents her from being rehired at that school and probably any New York City school. The confidence interval 0-52nd percentile. Yes, P=95%. She was there 2 1/2 years, and two dozen of her students got into Bronx Science and Stuyvesant.
You can't just rank teachers based on their students' test scores. You have to correct for the students' abilities. (1) Everybody who has studied student achievement (Diane Ravitch for example) agrees that the factor that is most strongly correlated with student test scores is family income. So you have to correct for family income. But how do you do that? Parents aren't required to reveal their income to the school. So they have to use indirect methods of estimating income, which are inaccurate. (2) New York City is trying to correct for the students' past performance, to see how much the teacher improves their scores. But this has a bias against the best students, because if your class has students who already have a 98% average, they don't have any room to go up. So they have to correct for these and many other factors.
They wound up with the complicated formula in the article that tries to incorporate all these factors. The problem is that (1) the formula hasn't been validated and (2) literally nobody understands it.
The fundamental problem is that it's a bad formula that doesn't correlate with teacher ability. In this case, the teacher is obviously qualified, her students do well, her principal loves her, and yet the formula says she ranks at the bottom. How do you know this formula works?
The fact that it ranks this teacher from the zeroth to 52nd percentile demonstrates that the formula doesn't work. Even if you believe the test, the only statistically valid information it gives you is that she's either among the worst teacher or among the top half. The conclusion that she's in the 7th percentile is not statistically valid. You have to understand basic statistics to realize what's going on here. If you have a confidence interval of 0-52, you can't take one point of the distribution.
Get back to me when you've read the article.
I think that whoever wrote this summary is being unfairly critical of charter schools, and even more unfair to those rich donors who are actually *trying* to help (as opposed to those who just hoard their money and or just their wealth to buy new Ferraris).
If you read TFA http://www.dissentmagazine.org/article/?article=3781 you'll see what the problem is. These billionaires aren't simply giving money to local innovative schools. They're using their money in a heavy-handed way to shape policy for the public schools used by less-affluent, less-powerful taxpayers.
They promote bad policy, and when the evaluations show they don't work, they ignore the evaluations and keep promoting the bad policy -- in public schools as well.
They've affected federal policy, under No Child Left Behind, so that schools can't get this federal money unless they accept the whole package of "reforms," many of which turned out not to work, such as destroying large neighborhood schools and replacing them with small schools, high stakes testing, and promoting charter schools (which according to major nationwide evaluations http://nces.ed.gov/nationsreportcard/studies/charter/ using the tests they love so much, are worse on average than public schools).
I read that article.
I'm not going to respond to a comment that calls me an asshole.
TFA http://www.dissentmagazine.org/article/?article=3781 doesn't have a problem with billionaires helping poor kids get an education.
The problem is that billionaires don't free up resources for public schools. As a result of their lobbying, public schools actually lose money, for example through penalties under No Child Left Behind, if they don't implement these "reforms" many of which have been proven not to work.
As TFA says, the billionaires are trying to change the public schools that only get tax money. They're doing it by using their money not so much for direct teaching but for setting up "think tanks", lobbying, and even paying public school educators in ways that might be considered bribery.
My biggest problem is that they're implementing fad solutions, like charter schools, financial bonuses, etc. that haven't been shown to work -- and have sometimes been shown not to work.
For example, some charter schools have been evaluated by the NAEP http://nces.ed.gov/nationsreportcard/studies/charter/ in rigorous studies, and overall they did worse than public schools.
Tell me -- if the evidence demonstrates that something doesn't work, why would you want to roll it out across the whole school system?
It's a neutral test made by a third party.
I agree that parental involvement is the most important factor, but teachers are fighting the wrong battle by pitting themselves against standardized tests. They will not win because their position defies common sense. Everybody understands the need to measure outcomes and the need to compare those measurements.
These "neutral" tests are also invalid tests. As TFA http://www.dissentmagazine.org/article/?article=3781 mentioned in passing, the National Academy of Sciences and other organizations reviewed the current tests and found out that they don't do what they're supposed to do: They don't tell you whether a teacher is good or bad.
The New York City department of education was using a test to determine whether new teachers would continue on the job. The test had a complicated formula that (literally) no one could understand, to try to correct for things like the students' family income and previous test scores.
The test told one middle school teacher that she was in the bottom 6%, and had to be fired. Her principal didn't believe it, and didn't want her to be fired, because she was a good teacher, her students got into the competitive high schools, etc. But that 6% had a confidence interval -- from 0% to 51%. So actually, she was either among the worst teachers (0%), or among the best half. If you don't know what a confidence interval is, there's no point in my talking to you, but that means the test results are statistically invalid. You might as well fire teachers by throwing dice.
These tests are made under contract by testing companies, and they haven't been tested for validity. There's a huge amount of research on this. They can't distinguish between the effects of family income and effective teaching. It's not common sense to fire teachers based on these tests.
That's what TFA is all about. http://www.dissentmagazine.org/article/?article=3781
Everybody knows that the one factor that is most strongly associated with grades is family income. If you teach low-income kids, they're going to start with low grades and their grades will rise slowly. Test scores reward teachers for having high-income students.
You make a good point. It's stupid to fire "bad" teachers. If your tests are so good at identifying good teachers, find out why they're good, and teach their techniques to other teachers.
If a teacher is hopelessly incompetent, I don't defend keeping them on, but that's not what Rhee was doing. She was just a right-wing hero who wanted to destroy the union and attack teachers.
Read the USA Today story about Rhee (or the Wikipedia article).
Rhee gave large bonuses to certain principals and teachers. Then it turned out that there was massive cheating on the standardized tests that Rhee used to evaluate them. The teachers erased the incorrect answers and filled in the correct answers. The companies that mark the test sheets can read the test answers, but their machines can also read erased answers, because an unusually high number of erasures indicates cheating. That's what happened in DC. When the company warned Rhee about this, she refused to investigate it and covered it up.
Everybody really ought to read TFA. It explains why all of Rhee's reforms, including the performance bonus, have been tried before and didn't work. http://www.dissentmagazine.org/article/?article=3781 I admit it's not easy reading, because it has lots of facts and data, based on actual research and the experience that people had when they tried these things out and looked at whether they worked.
What, as opposed to the 47% of citizens that now net zero federal taxes at all? That the top 1% already pays 40% of the national tax burden?
That's exactly the opposite of what the article said. Did you actually read the article you are linking to? If so, then you're deliberately misrepresenting it.
The actual headline is:
"Yes, 47% of Households Owe No Taxes. Look Closer."
The article says that's true only if you define "taxes" to exclude payroll taxes. It says:
"About three-quarters of households pay more in payroll taxes than in income taxes."
I really get pissed off when people try to have an intelligent, informed conversation and you have to spend 15 minutes checking the conservative sources and have their facts turn out to be wrong. Deliberately distorting facts is the worst thing you can do, IMO. Negligently distorting facts is a pretty close second.
It's a waste of time to try to have an intelligent debate with conservatives. The time is better spent reading Paul Krugman http://www.playboy.com/magazine/playboy-interview-paul-krugman and going to Occupy Wall Street to figure out how to organize politically to stop them from destroying the country.
People tell me that I romanticize the UK health care system too much (probably from reading BMJ and Lancet in my younger days), but my understanding was that the NHS gives a lot more emphasis to systematic evaluations than we do in US.
I thought that when they rolled out their health care software, they did a lot of careful testing and evaluation, compared to what we did in the US. True?
Because non-tech people usually don't understand the "computer is a universal tool" thing and have problems stretching the limits of their imagination ("I had no idea a computer could do that for me...")
Because IT evangelists think that every problem in the world can be reduced to computer code, and they create medical systems without understanding how medical practice works.
Then the doctors try the system out, it runs into problems ("It takes me longer to enter a prescription into this computer than it does to write it on a prescription blank by hand"), and they correctly go back to the older manual systems that work better.
Doctors aren't stupid. They use lots of new technology every day. When something works, they use it. When it doesn't work, they drop it.
Medical practice is very complicated. The potential cost of error is very high. The cost of developing electronic medical records properly is very high. It's like developing a medical drug or device (which it is). You have to get back to your users (the doctors) continuously, find out what's going wrong, and fix it. Automating medical practice is a massive job, like automating the aerospace industry. At best, it will be slow and expensive. At worst, developers will take shortcuts, waste even more time and money, and have to scrap it all and start over.
I used to evaluate medical office-based systems about 15 years ago, and I kept an eye on the field ever since.
They made wonderful predictions, about half of which came true. (I made predictions. Mea culpa.)
The billing systems worked very well. When they went to Medicare/Medicaid billing, the investment paid for itself in about 6 months.
The clinical systems didn't always work so well.
Transmitting lab reports worked very well. They substituted a standard paper format for a standard electronic format.
Keeping patient notes is difficult. In the New England Journal of Medicine a year ago, a doctor was complaining about EMRs that automatically insert boilerplate, winding up with a hundred pages that nobody has time to go through. In contrast, the old handwritten notes forced doctors to think it out beforehand, be concise, get to the point, and emphasize what was relevant to clinical decision-making.
There's a tradeoff between a narrative and a structured description. Some systems encourage (or force) doctors to structure their notes. The problem then is that in some systems doctors had to go through pages and pages of menus, many of them with irrelevant choices.
Few doctors are anti-technology, but they don't want an electronic system that takes more time than paper, unless it has significant advantages. (Remember all the Ask Slashdot articles about, "What's the best way to take notes in class?" Lots of techies use wire-bound notebooks.)
Electronic prescribing worked reasonably well. But even so, doctors say that it takes longer. They could quickly write a prescription on paper, but the electronic systems force them to go through pages of menus. In one study, the death rate in a pediatric ICU increased with an electronic prescribing system, because it took so much longer to write a prescription. It would seem that it should reduce drug interactions, but in real-world studies it doesn't do that. (Doctors had better understand what drugs they're giving the patients and how they interact with the other drugs a patient is taking. If they don't, they've got problems that computers won't solve.)
Unexpected problems come up. How do you keep a keyboard sterile?
The fundamental problem (which the Obama administration is perpetuating) is that it requires a lot of testing and evaluation, with controlled studies at every step, to get these systems working right. And there are a lot of steps.
Doctors aren't willing to get a beta release that works right most of the time, but still has a few bugs in it. They're right.
A system analyst can define a scientific problem, or a financial operation, in great detail, and then pass it off to the programmers to write the code. But health care systems, even a small medical office, are much more complicated and unpredictable, with lots of exceptions to the routine. And humans are really complicated.
I believe in computerized medical records. I think all these problems can be solved. I think they'll be completely digital some day. But medical systems are more difficult to develop than their enthusiasts thought.
We have to try things out in small systems, in small steps, and then large systems, in controlled trials, and make sure they do what you want them to do (save lives), not just what the programmer is able to do (save data), at every stage. If your computer doesn't save lives or improve patient outcomes, doctors won't use it. And rightly so.
Then of course they have to be part of an integrated system. It's bad enough to learn one new system; a doctor doesn't want to learn 20 new systems. They could be reading JAMA, or even seeing patients, in that time.
If you want to find out why computerization is going slowly, talk to some doctors and ask them.
I knew a medical secretary at a major academic medical center. She used to keep index cards for every patient. While she was waiting for the system to deliver their electronic charts, she had a 3x5 index card with the essential information on it. She was actually faster than the younger secretaries, who had never used index cards.
Just because they made an error, that doesn't mean a death resulted from the error. A patient's blood pressure may have shot up or down for a day, but (unacceptable though it is) they might have caught it and it might not have harmed him.
http://en.wikipedia.org/wiki/Yuri_Gagarin
http://www.independent.co.uk/news/science/yuri-gagarin-the-man-who-fell-to-earth-2257505.html
Best thing that ever happened to American science education.
To discussions of literature containing the word "fuck"?
That's right. No more Alan Ginsberg, Ezra Pound, Chaucer.
No, read the NYT article.
One small distributor, and a large pharmaceutical company, both deliberately sold a dangerous, misbranded syrup as pharmaceutical syrup, resulting in a large number of deaths.
Are you referring to this story: http://en.wikipedia.org/wiki/Toxic_cough_syrup ??? If so you kind of mischaracterized what happened. I don't mean the part that glycerol is the poison. Also, the point is not whether or not regulation would prevent these types of errors. It is to compare the cost of government regulation, as well as false positive and false negative rates, to that of other options. Assuming government regulation is the best solution is common, but not necessarily true.
That's the story, or rather, the Walt Bogdanich story in the NYT which it cites. I think the story makes it clear that Chinese chemical manufacturers deliberately mislabeled syrup. They clearly mislabeled industrial grade as pharmaceutical grade. Nobody was able to sue them. I don't know what you think I mischaracterized.
The pharmaceutical industry has very high standards for quality control. The costs of damage from dangerous products is much greater than the cost of inspection. They should never have deaths from cough syrup. Whatever that level of QC costs, that's the cost of manufacturing pharmaceuticals. False positives are part of the cost of doing business. The company needs multiple layers of QC and inspectors. Government regulation is one more layer. Most of the pharmaceutical companies were happy with FDA regulation of their manufacturing process. It's better to have an inspector spot a batch of infected drugs than find out when 100 people around the country develop infections from the drug. It's better to have an independent monitor.
Look what happened when we cut back on government regulation -- by not having enough FDA inspectors to inspect Chinese manufacturers. We got contaminated heparin. Most manufacturers would rather have FDA inspectors than have their business destroyed by a scandal like that.
Yes, there was a good series about that in the New York Times a few years ago.
The Chinese are very capable manufacturers, not only of drugs but also feedstocks to make drugs. Some American and European manufacturers established their own quality control procedures, and they did OK. But most of the American manufacturers put their suppliers under heavy price competition, which lead to a race to the bottom, and there have been a lot of Chinese products (like heparin) that, through carelessness, negligence or outright fraud, were improperly manufactured and caused widespread illnesses and some deaths. The FDA didn't have the resources to inspect Chinese plants, so we've got global competition without the oversight. The Times had difficulty locating manufacturers even when they knew the names. There's a long international distribution chain, and it's usually impossible to trace a Chinese drug back to the source. The Chinese government didn't care, had almost no oversight, and dealt with a few of the worst scandals (in which Chinese were harmed) by executing the suppliers. I think it shows what would happen if the libertarians had their wish of eliminating government regulation and letting the free market take care of it, as we did before 1916. As I understand it, Communism in China meant that drug companies and hospitals were run by the Red Army, which is politically powerful enough to do whatever they want without much oversight. Between the cracks they have wealthy businessmen running drug companies (I assume they have connections with the Red Army). It's like Halliburton and Blackwater under the Bush Administration.
India has a much older pharmaceutical industry, with chemists like Cipla, who have had several generations of European-trained owners running the plant. They go to European and American conferences. They do contract work for American and European companies, so they're FDA-inspected. They supply generics to the third world, so they can do it cheaply. For a long time, Indian law allowed them to manufacture generic copies of drugs that were still under patent in America and Europe, if they could "invent around" the patents, so they were under a lot of pressure to be good chemists. Otherwise, poor Indians would have just died. The Indians seem to understand the whole system, whereas the Chinese are just contract manufacturers.
It's not because the Chinese are stupid. There are some pretty smart Chinese scientists, many of them trained in the U.S. It's because of the system and the accountability. I'm sure the Chinese will be major players in the pharmaceutical industry in the next few decades. If you gave them a well-defined drug manufacturing task to do, and established good quality control, they can do it. I'm looking forward to seeing what Chinese scientists will contribute to molecular medicine in the years ahead.
But I don't understand why the Indian and Chinese manufacturers can't produce methotrexate to FDA standards.
So you've got a drug that just doesn't have enough volume to justify maintaining an expensive production line. Switching a production line from one drug to another has to involve basically taking it apart and reassembling it differently, then going through the inspection and correction cycle, then running for a week or two, then doing it all again for another drug.
That's the way the chemical processing industry works.
Take the total cost of production, add a reasonable profit, divide that by 3,500, and that's the price.
The main cost of producing a pharmaceutical product is the quality control to make sure it's safe.
You could produce tech grade methotrexate cheaply. The pharmaceutical grade is a lot more expensive.
There are a lot of drug companies in China and India who could easily manufacture methotrexate. Making it to QC standards, and documenting it, is expensive. The FDA has to inspect the plants.
I don't know whether they have the same problem in Europe. I would trust drugs that had passed the European (or Australian, or Japanese) regulatory system. There was some talk about making it easier to import drugs.
Make sure it doesn't turn you blue. http://en.wikipedia.org/wiki/Argyria
Unless you want to be blue.
The textbook I read was Wei et al, Structure of the Chemical Processing Industry, which had a chapter on two-party and three-party competition, with game theory and other mathematical models. What's the cost of production, considering economy of scale, when 1, 2, 3... manufacturers are producing a given chemical? Plus I used to read Chemical Week, which was written for the guys who owned the chemical companies, and (with a heavy commitment to the free market) described how those things played out.
I can't think of any place in the world that has a pure free market. If you went to Somalia, where there is no effective government, the warlords would want a cut of your business. The government regulates everything to some degree, the only question is how much. The chemical processing industry has a lot of externalities, so they should be regulating it. You don't have a right to put your chlorinated hydrocarbons and dioxins in my drinking water.
I realize that there are a lot of people who think that the problem is that the market isn't free enough; if only we could get rid of all those government controls, the free market would give us the best of all possible worlds. In my observation of the real world, it doesn't work that way. The Chinese chemical manufacturers cheerfully sold children's cough syrup poisoned with glycerol, and when the children died, the Chinese were protected from tort liability. People support government regulation, because without it, their children die.
True, methotrexate has some horrible side effects, particularly the destruction of short-term memory. I knew somebody who was taking methotrexate for brain cancer, and by the time she got to the end of the conversation, she couldn't remember what I said at the beginning of the conversation. However it's great when you want to selectively destroy B cells and T cells. Oncologists love to run randomized controlled studies, and if there was anything better than methotrexate, they would use it. For several cancers, such as childhood leukemia, there isn't. When something better comes up, they'll phase it out fast. How many parents do you know who want their children to grow up with cognitive defects? Why would an oncologist use it if there were something better?
"Free market" is a term of the art.
The chemical processing industry is as close to a free market as we will get (especially when you define it to include home methamphetamine manufacture).
The free market will always work within some government constraints, but if we don't have a free market in the worldwide chemical processing industry, then a free market is impossible.
According to the economic textbooks, competitors should be moving into the methotrexate market right now. They're not. I wonder why they don't follow the textbooks.
The supply of methotrexate isn't exactly limited by the government.
As I recall, there were 2 companies with the capacity to make methotrexate in the U.S., but they both had problems meeting the good manufacturing standards for pharmaceutical drugs. Injected methotrexate can be fatal if it's not manufactured properly. Yes, they weren't meeting federal standards, but no pharmaceutical manufacturer in his right mind would manufacture these drugs without meeting the same standard.
I know a bit about the chemical processing industry, and according to the textbooks, when you have 2 manufacturers producing an unreliable supply of a specialty chemical with inelastic demand, and shortages develop, a third company is supposed to move in to the market and produce that chemical at a price which is slightly higher than the old, unsustainable price but less than the monopoly price of a patented chemical.
Not only are there U.S. manufacturers capable of manufacturing methotrexate, but there are also capable foreign manufacturers in Europe, India, China, Israel, etc. who are regularly FDA-inspected and approved for other drugs, and even do contract manufacturing for major brands here.
I don't understand why the free market isn't working, and why additional manufacturers aren't jumping into the market for drugs like methotrexate.
Gee, it worked so well in the Soviet Union.
Good point. There are some good arguments for that.
When antibiotics wipe out your gut bacteria, does that include the appendix too? I assume it does, but I don't know for sure.
There are also a lot of immune tissue in the appendix. I wonder what's going on in there.
TFA is about a peer-reviewed article that just demonstrated again that doctors overprescribe antibiotics.