The Musculoskeletal Time Bomb

For the past few decades Orthopedic Surgery has been the "jewel" of medicine.  The technological advances in Sports Med,  Microsurgery, Spine surgery, Joint Replacement, and  Trauma Care have been astonishing and well documented.  All of that being said, the looming problem in the US and around the world is  higher and growing demand and not enough providers to keep up.  That is the Musculoskeletal Time Bomb.  According to Steven M. Kurtz, PhD, and Kevin L. Ong, PhD by 2030, the demand for primary total hip arthroplasty (THA) is estimated to grow annually from 209,000 to 572,000 and the demand for primary total knee arthroplasty (TKA) is projected to grow from 450,000 to 3.48 million procedures.  The American Academy of Orthopedic Surgery estimates that the demand for joint replacement will double in ten years and that Total Knee replacement demand will grow by 674% and Total Hip replacement demand will go up by 174% by 2030. 
 Two often overlooked factoids are that new surgeons have different lifestyle expectations i.e. they want to work less and spend more time doing other things, in practical terms they want to do fewer cases.  The second factoid is the trend for older surgeons to retire early.  These two trends come at an inopportune time.
How to increase the supply of qualified Orthopedic surgeons to meet the increased demand is going to demand we, as a society, look at new models for educating surgeons.  It will not be easy.  I anticipate one approach will be to further expand the role of mid-level providers to do more of the office work which will allow the surgeon to spend more time in the OR, but that creates its own problems.  Most patients want to meet their surgeon before they go to the operating room, and who can blame them?  
 As our population ages it is expected to drive the demand for Orthopedics up by at least 50% over the next twenty years or so.  The combination of longer expected life spans, the obesity epidemic, and the progress of the population bubble representing the baby boomers combine into what has been called the perfect storm of unmet expectations for MS care.  Demand for specific procedures like total joints will be even higher if Kurtz and Ong are to be believed.
There are a lot of places to look for numbers on population growth but in very rough terms the Medicare population in the US is projected to increase from around 47 million in 2010 to 80 million in 2030.  Social security numbers indicate that the worker/beneficiary ratio will shrink from 3.4 to 2.3.  The potential instability is hard to overlook.
 

Insulin and Obesity

When speaking about  obesity and type 2 Diabetes insulin resistance is the problem.  Elevated blood sugar is the symptom not the cause.  Much of focus in recent years has been on treating the symptom and not the cause.  The world literature on obesity and diabetes is voluminous and often contradictory. But what is known for sure is that calorie restriction i.e. most diets have a failure rate of around 98%. Any one who has tried any of the fad diets of the last 40 years knows this to be true. Giving drugs to increase insulin production when the real  problem is to much insulin is irrational, sort of liking giving alcohol to an alcoholic to treat their addiction.  Two thousand years of medical progress indicates that the best results are obtained when the cause of a disease is elucidated and treated.  Treating symptoms is sometimes the best that we can do, but to only treat symptoms when the cause of disease is known is poor practice.  High insulin levels that result from insulin resistance are usually associated with metabolic syndrome.  The metabolic syndrome is a group of conditions involving excess weight and girth, high blood pressure, and elevated cholesterol and triglycerides. But insulin resistance is also associated with other problems like Type 2 Diabetes, fatty liver and cirrhosis.  
A few biochemical facts are in order.  Glucose and fat are the main sources of energy for the body.   Insulin is a hormone produced by the beta cells in the pancreas. Insulin circulates in the blood and controls many cellular functions foremost of which is the regulation of glucose as energy.  All carbohydrates that we eat are turned into glucose.  The rate this happens is fairly important and is measured by the glycemic index.  Foods with a high glycemic index get turned into glucose quickly and visa versa.  The Zone diet is one which aims to avoid foods with a high glycemic index.  Trying to smooth out insulin release and avoid spikes in insulin  (which is the response to sudden spikes in glucose levels) is also rational. However it may not be the best way to treat insulin resistance. A lot has been written about the paleo diet.  This is also a low carbohydrate higher protein and fat diet.  What is not mentioned often is that the paleo diet was also characterized by frequent periods of low food availability, i.e. fasting.  There is much to be said about fasting.  Dr Jason Fung has been touting the real and measurable benefits of fasting for some time. 
Fasting is an effective way to decrease insulin levels.  It seems clear that food raises insulin and no food should lower it.  The body turns to fat for energy in as little as 24- 36 hours.  Alternate daily fasting has been proposed as a way to increase insulin sensitivity i.e. lower insulin resistance.  Another benefit of fasting is increased growth hormone production.  GH helps preserve muscle mass and increases the bodies use of fat as fuel. Fasting is an overlooked tool for weight loss and the most effective treatment for insulin resistance I am aware of.  It is of historical interest that most of the worlds religions have included fasting as a tool for enlightenment and practiced by the founders.  

Zero Bound: A limit on limts?

The idea of money, the kind you can carry around in your wallet, has served civilization well.  It makes exchange a lot easier than barter for most transactions and seems to be coupled with the idea of "stored value".  After all if you can by frugality save money you are retaining something of value since you can use the unspent money to buy things you want or need at a later time.  Thus the idea of "money" as stored value seems to be intrinsic to its existence.   In the current economic universe, what many have called a "race to the bottom" interest rates have gotten so low that they bump up against the so called zero bound problem.  What is the zero bound?  On line resources like Investopedia suggests the following definition.  The zero bound problem is a limit on monetary policy that occurs when a central bank lowers interest rates to zero and effectively goes to negative rates when the set rate is less than the rate of inflation.  A simple thought experiment demonstrates the problem.  If inflation is 2% and interest rates are say 1% then the effective interest rate is -1%. That is you invest say a thousand dollars at 1% for a year and get $1,010 back But with 2% inflation your purchasing power is only $989.80   You have just hit the zero bound limit.  It is clear that this will limit the actions of a central bank in terms of its choices in stimulating a moribund economy. This has been called a liquidity trap.  The lack of liquidity is caused by hoarding cash which is rational if putting it to work gives you back less purchasing power than if you just held onto the cash.  Japan discovered this in the 90's and more recently the US Fed has been drifting toward it too.  Paul Krugman has argued that the United States is in a liquidity trap now since the monetary base has tripled between 2008 and 2011 and this failed to produce any real effect on US domestic prices or on dollar denominated commodities.  More recently Mario Draghi president of the European Central Bank pushed interests rates below zero to a minus 0.2% in Sept of 2014. Countries like Denmark that peg their currency to the Euro were forced deeper in negative interest rates.  Negative interest rates are punitive to savers since you get less back than you put in.  By the end of the first quarter 2015 about a quarter of all debt issued by Eurozone governments had negative yields. The spiral of competitive devaluations and ever lower rates seems to spread like the flu virus and most of the worlds economies are acting as if a currency war is in progress.  Even China has been lowering interest rates recently. It is unclear that lowering interest rates below zero for a significant period of time will actually stimulate a credit based economy since the incentive is to hold onto cash rather than pay someone to hold it for you.  It could bring about a monetary and fiscal destruction of the banking system and return us all to a barter economy.  Facing retirement in a sub zero interest world is challenging to say the least.  I think I need to get to work on my sandwich board,  Will Operate for Food.

Obamacare Economics

A quick review of the new taxes associated with the  ACA (Now SCOTUS Care) is revealing.  No matter that John Benedict Roberts has now saved Obamacare twice, the law is bad economics as Larry Kudlow points out in a recent editorial.  There is now an extra 0.9 percent Medicare tax on salaries and on self-employment income.  There is a 3.8 percent tax increase on capital gains and dividends.  There is now a cap on healthcare flexible spending accounts and a higher threshold for itemized medical-expense deductions.  And now there is a stiff penalty on employer reimbursements for employer reimbursements use for individual employee health-policy premiums.
The penalties for a business owner for moving from 49 employees to 50 are onerous.  Similarly keeping an employee at 29 hours a week is avoids costs associated with going to 30 hours a week.  The higher percentage of people reported by the Bureau of  Labor Statistics doing part time work is no surprise during this so called recovery.  There is no disputing the low labor-force participation rate, but why should anyone be surprised.  " Obamacare is a tax on full-time work. After-tax, people working part time yield more disposable income than working full time."

Another issue under reported is the fall off in healthy millennial signups.  The risk pool appears to be shrinking which will force insurance companies to raise rates yet again.  According to the consulting firm Avalere many exchanges are raising rates from 20 to 36 percent for 2016.  This is in addition to the higher deductibles hitting the consumer pocket book.  

As a practicing Orthopedic Surgeon and knowing something about health care finance, things are upside down.  More people are coming to caregivers with Medicaid cards but in our state of Illinois payments are delayed and are less than half of the average commercial carrier.  Not surprisingly fewer and fewer Dr's are not taking medicaid.  It won't be long before that is not an option and states will demand all doctors see medicaid.  I predict it will be tied to state license renewal.  

 

The law remains unpopular. " In the latest NBC/Wall Street Journal poll, 65 percent of Americans think Obamacare needs either modifications or a major overhaul, just 8 percent say it is working well, and 25 percent say it should be eliminated."

 http://www.newsmax.com/Finance/LarryKudlow/Obamacare-Economics-Supreme-Court-Taxpayer-bailout/2015/06/26/id/652475/#ixzz3eUcyOiiA
 

Thoughts on the Caliphate and ISIS

I have not found any close associates or friends who were able to answer a question I posed today. The question; "When was the end of the last Caliphate in the Levant?"  The answer by the way is 1924 when Mustafa Kemal Ataturk (the leader of  the 'young Turks') put an end to the Ottoman Empire. This fact was brought to my attention in an article in The Atlantic: What  ISIS Really Wants by Graeme Wood . Although 1924 is  technically correct it leaves out the fact that the Caliphate was largely a toothless tiger for roughly a thousand years before that. The Ottoman empire was on the decline since the 16th century and after aligning itself with Germany in WWI it suffered the ignominy of defeat and dismemberment by the victorious Allies.  The modern states of Syria, Iraq, Saudi Arabia, Jordan etc. were created by fiat out of the rubble of the Ottoman Empire and Turkey was reduced to a much smaller state.
ISIS has proclaimed Abu Bakr al-Baghdadi as Caliph.  It is sad that very few in the west have any idea what this means.  The Caliph is duty bound to institute Sharia law. "In theory, all
Muslims are obliged to immigrate to the territory where the caliph is applying these laws." Without a caliphate most of Sharia is not applicable ie it is in abeyance.  With the caliphate in place the amputation of hands of thieves will resume along with all of the rest of the above horrors.  The prospect of seeing a complete execution of this body of jurisprudence contained is Sharia is about to play out in our living rooms nightly. The West has only had a taste.  The full meal will follow.
The eschatology of ISIS is all about accelerating the Day of Judgement.  The path they follow according to Wood is "the Prophetic methodology."  This means putting some 7th century Islamic teachings into literal actions.  It means following the "prophecy and example of Muhammad, in punctilious detail."   ISIS is a religious millenarian movement that believes that be-headings, crucifixions, slavery, and rape, are proper and necessary to purify a world that has ignored the actual words of the Prophet.  Another quote is appropriate here; " The Islamic State differs from nearly every other current jihadist movement in believing that it is written into God’s script as a central character. It is in this casting that the Islamic State is most boldly distinctive from its predecessors, and clearest in the religious nature of its mission."
Wood's major point I think, and it is an important one, is that ISIS is in fact very Islamic albeit in a medieval literal way.  Those who doubt this are invited to read Dabiq, the official rag of the Islamic State which condones and certifies these horrors as permissible even required  by Sharia and whats more if one objects to the horrors he is denying or mocking the Koran and thus is himself apostate and deserving of death. 

Ideology and Anthropology

It has been said that "every ideology assumes an anthropology".  What this means in a nutshell is that our idea about the nature of man has a controlling influence on our social theories, philosophies,and favored forms of government. If we assume as does a strict materialist that man is without a "divine spark" ie no soul then we may conclude that life has no meaning and our moral choices are arbitrary at best and have no real consequences now or in the future.  If we assume that man is created "in the image of God", we tend to place great value on life, and live as if our moral choices have very real consequences now and in the hereafter.  Bad behavior tends to increase when no one is watching.  Nietzsche's famous observation that God is Dead was more than a theological construct it was an observation that 19th century European society lived as if their was no cosmic judge.  Many feel that he was prophetic in foreseeing the tragic consequences in the 20th century of the rise of Nationalism and the death of man.     
Much has happened in Europe since Dr. Pangloss stated in Voltaire's classic that  "all is for the best" in the "best of all possible worlds."  We have even more reasons to doubt the optimism of Leibniz than had Voltaire, but we still shrink from the outright pessimism of Schopenhauer. The rise of post modernism is one way to deal with the problems of modernity, but it has it's own issues.  The reemergence of radical Islamofascisim  and the conflict with liberal democracy is a radical conflict of world visions. It is politically incorrect to talk of current events as a holy war, but what other explanation exists for the atrocities that are paraded on You Tube, Facebook, and the evening news?  
 Modern political discourse has left us sharply divided along a progressive/liberal/Democratic vs. traditional /conservative/Republican axis.  I discussed in an earlier blog Sowell's book about different visions.  When discourse is limited by our ability to use language that we agree upon it is impossible to change another s views  on any matter of import.  There seems to be no way out of the impasse. 

Visions and Conflict part 3

Visions and Conflict part 3

 

In part two of his essay Sowell applies his ideas of the constrained vs. the unconstrained vision to various topics that frequently cause conflict in social discourse.  

The first topic addressed is EQUALITY.  It should be obvious that equality is viewed differently by those of different visions.  For the constrained view the important issue is PROCESS oriented.  For the unconstrained view the issue is RESULTS.  

Burke, Hayek, and Alexander Hamilton are quoted in support of the constrained vision.  Hamilton's words are apt.  "All men are entitled to a parity of privileges "but he anticipated that economic inequality "would exist as long as liberty existed". That is the rub.  Equal opportunity never guarantees equal outcomes.  When government forces equal outcomes there is a corresponding loss of autonomy and freedom.  Conservatives generally hold the constrained vision, that sees social processes that give equal treatment as fair and just, even when outcomes are NOT equal for any particular group.  In this view the words of Jesus when he comments that "the poor you will have with you always" are taken to imply that we are not able to create a heaven on earth, but must learn to accept and live with maldistributions of economic resources.  How to rationalize this comment with others such as "it is harder for a camel to pass thru the eye of a needle than for a rich man to enter heaven" has kept theologians busy for the last two thousand years.  

Conservatives would generally agree with Hayek that "irremediable inequalities" exist and will frustrate any effort to remove them.  It is the constrained vision that sees man's capability as limited.  The unconstrained vision see's no such fundamental limits and sees results as the only fair and just way to measure equality.  It assumes more intellectual and moral capacity than can be shown to exist. 

 There is a particularly significant quote from Milton Friedman that bears repeating. " A society that puts equality-in the sense of equality of outcome-ahead of freedom will end up with neither equality nor freedom.  The use of force to achieve equality will destroy freedom, and the force, introduced for good purposes, will end up in the hands of people who use it to promote their own interests."  It seems that SCOTUS ignored that wisdom in finding the mandate to purchase health care insurance constitutional.  When you have the force of the IRS, which includes the right to place a citizen in prison,  used to enforce obamacare the possibility of misuse by those in power seems all to real a possibility.

The Unconstrained vision held by most progressives sees no such fundamental limitations in man.  When results are the measure of equality the existing order is seen as unjust.  This drives the progressive to find ways of "redistributing" resources.  The small fact that the only way to do this is to steal from someone else is seen as acceptable. Providing "compensatory advantage" such as reparations or affirmative action is thus a major goal of progressives, and influences all discussions of public social policy. 

A major point made by Sowell is that causation is part of the unconstrained vision.  Some groups have so little BECAUSE other groups have so much.  The rich are seen as taking from the poor.  For this reason alone redistribution is fair.

Neither vision denies the existence of the poor.  It is how society should deal with the problem that brings conflict.  The constrained view is that capitalism and free markets bring about a rising tide that lifts all boats including the poor.  The unconstrained view is that the "ill gotten wealth" of the rich should be taken from them and given i.e. redistributed to the poor.  This is the language of socialism.  Margaret Thatcher famously said once that the biggest problem with socialism is that you eventually run out of other peoples money.  That is the dilemma facing Greece and for that matter Illinois and California.  No better example of the results of the unconstrained vision exist than in the fiscal mess of these two blue progressive states.