Open Thread: Speak Softly, Punch Hard

As I may have said before, I {heart} my senior Senator! From that NPR interview:

Because Warren is a woman who holds the press at arm’s length, it might have seemed a touch ironic when Democratic Leader Harry Reid chose her to be the messenger for the progressive wing of the party. Warren stepped into that leadership position barely two years into her first term.

Reid said Warren is simply strategic about when to speak.

“She’s an effective messenger because, No. 1, she doesn’t talk very much,” said Reid. “I find — maybe I’m being judgmental — but I think when people talk too much, their message is lost. She doesn’t talk very much. But when she talks, people listen.”

Reid says even during internal caucus meetings, Warren is very quiet. She speaks up with her colleagues only in deliberate moments.

“People think she’s a big talker. She isn’t,” said Reid. “In our caucus, I have some people who raise their hands all the time. They want to be recognized. But not Elizabeth.”

And her supporters say that strategic use of her influence has made her a powerful validator in the caucus — someone who can breathe new life into a cause simply by jumping on, whether it’s Wall Street reform, expanding Social Security or reducing student debt…

She doesn’t just launch issues. Democrats say she can also launch candidates. Warren is one of the top fundraisers in her caucus. During the 2014 midterms, she raked in more than $6 million for Democratic Senate, House and gubernatorial candidates and party committees.

This election cycle, Warren’s Leadership PAC has given away about a quarter-million dollars; her office says that amount represents just a small portion of her overall fundraising efforts so far, which include fundraising events, campaign appearances and — most important — emails…

Long (Noir) Read: “I know who killed the Black Dahlia: my own father”

A retired LA detective talks to the Guardian‘s Alexis Sobel Fitts:

Shortly after receiving the news of his death, Steve Hodel found himself sorting through his father’s belongings. Though Steve’s father, George Hodel, loomed large throughout his early childhood, their relationship had always been strained. George was a grandiose doctor with a distant personality who abandoned the family shortly after Steve’s ninth birthday, eventually moving far away to the Philippines.

As he went through his father’s possessions, Steve found a photo album tucked away in a box. It was small enough to fit in his palm and bound in wood. Feeling like a voyeur, he perused it. It was filled with the usual pictures – his mom, dad and brothers – as well as portraits of the family taken by the world-famous surrealist artist Man Ray, a family friend.

But towards the back, something caught his eye: two pictures of a young woman, her eyes cast downward, with curly, deep-black hair. Steve still doesn’t know why he had the idea, but as he looked at the images, he thought to himself: “My God, that looks like the Black Dahlia.”…

The personal connection between Short and George Hodel suggested by the album photos seemed outrageous. Hers was one of the most brutal murders in American history, and, after the Zodiac killer’s shooting spree in San Francisco, perhaps the most famous unsolved crime in California. But from this moment on, Steve was hooked…

Cataloguing evidence has been Steve’s life for the last 15 years, during which the quest to connect his father to Short’s murder consumed his life. It brought him back to Los Angeles, where he now spends his days in a modest apartment, documenting his father’s supposed criminal past in a snowballing body of work including four books, a play and a frequently updated blog. And though his first book, Black Dahlia Avenger: The True Story, is little more than hundreds of pages of evidence, listed chronologically like a cop’s case log, it made the New York Times bestseller list after it was released in 2003.

This research has won him fans. It has also made many people uncomfortable given his tone, which blurs the line between obsession and admiration, and his conveniently gripping narrative: a homicide detective, raised in the heart of gritty Los Angeles, finds his father guilty of the city’s most notorious unsolved murder…

The Mushroom Gods Hate Me, and Other Mushroom News

Since I posted a dupe, I might as well bigfoot myself.

First a report on this year’s morel season:


End of report.

Okay, here’s some more detail:

my morels

Foraged by…someone.

I’ve been spending a lot of time outdoors hunting the elusive morel. Last year I searched for a few weeks and got two runty ones. This year I found two good-sized ones, only they were false morels, which are poisonous. (The magic ingredient is monomethylhydrazine, which is also found in jet fuel.) I even attended The National Morel Mushroom Festival in Boyne City, MI (near the top of the mitten), and met many interesting fungiphiles, but alas no morels. (But did get sleeted on – in mid-May! WTF Michigan.)

Driving back from the Fest, I passed a Grizzly Adams-looking dude parked by the side of the road, selling morels from a cooler. So I finally got my morels. (See pic.)

Unfortunately, however, the Mushroom Gods weren’t done with me. Right after we completed our transaction, Mr. Adams commented in a tone of enormous satisfaction, “Great! Now I can get my hunting and fishing licenses!” (For those who don’t know, I’m vegan.)


In more uplifting mushroom news, Imperial College London recently reported strong positive results in what Nature is calling the first human trials of using psilocybin to alleviate depression:

Researchers from Imperial College London gave 12 people psilocybin, the active component in magic mushrooms. All had been clinically depressed for a significant amount of time — on average 17.8 years. None of the patients had responded to standard medications, such as selective serotonin re-uptake inhibitors (SSRIs), or had electroconvulsive therapy.

One week after receiving an oral dose of psilocybin, all patients experienced a marked improvement in their symptoms. Three months on, five patients were in complete remission.

The New Yorker reported on research at Johns Hopkins and elsewhere on shrooms as a treatment for depression, addiction, and anxiety. (Here’s a great narrative by a guy who used them to cure his smoking habit.) They apparently work by increasing your sense of wholeness and connectedness not just with yourself but the rest of humanity and nature, thus solving this problem:

In Carhart-Harris’s view, a steep price is paid for the achievement of order and ego in the adult mind. “We give up our emotional lability,” he told me, “our ability to be open to surprises, our ability to think flexibly, and our ability to value nature.” The sovereign ego can become a despot. This is perhaps most evident in depression, when the self turns on itself and uncontrollable introspection gradually shades out reality.

Finally, related to the recent wonderful posts by Prescott Cactus on his hospice work: Johns Hopkins and NYU have also done research showing that shrooms help those with terminal cancer meet their end with less anxiety.

Can’t wait for this stuff to be legalized—and for those who are interested, JHU may do a new cancer study in 2016.

Stung by the Bee

I’ll just lay this here:

Obnoxious and ignorant is no way to go through life, son.

Champion’s League Championship Open Thread: Atlético Madrid v Real Madrid

Who do you like? Atletis or Merengues? Have at it!

Saturday Morning Cartoon Character Open Thread

trump tinfoil hat ohman

(Jack Ohman via

Nominated for poltical headline of the week: Gawker, “Clown Recognize Clown”

Nominated for best Trump photo pick of the week: TPM, “Trump Camp Accidentally Emails Politico Its Plan To Hit Clinton On Whitewater”

Nominated for Snark of the Week (even in a week full of eminent contenders): Eric Levitz at NYMag:

We all know Martin Shkreli has his flaws. The former hedge-fund manager turned pharmaceutical CEO — turned exemplar of capitalism’s worst pathologies — tried to make malaria treatment into a luxury good. And he bought that Wu-Tang album. And his last name is easy to misspell.

But this is America, a land of second chances. And on Thursday night, Shkreli took a first step on the path to redemption. Recognizing that his own unpopularity is the most powerful weapon he possesses, everyone’s least favorite hedge-fund hipster delivered a devastating blow to Donald Trump’s candidacy…

Nominated for most predictable news story of the week: NYTimes, “Donald Trump’s Campaign Stumbles as It Tries to Go Big”

BISMARCK, N.D. — A constant stream of changes and scuffles are unsettling Donald J. Trump’s campaign team, including the abrupt dismissal this week of his national political director.

A sense of paranoia is growing among his campaign staff members, including some who have told associates they believe that their Trump Tower offices in New York may be bugged, according to three people briefed on the conversations.

And there is confusion among his donors, who want to give money to a “super PAC” supporting Mr. Trump, but have received conflicting signals from top aides about which one to support.

On Thursday, Mr. Trump secured the Republican Party’s nomination for president, a remarkable achievement for a political newcomer. But inside his campaign, the limits of his managerial style — reliant on his gut and built around his unpredictable personality — are vividly on display, according to interviews with nearly a dozen Republicans inside and outside of the operation…

… [O]fficials in battleground states have complained for weeks that the Republican committee has not delivered the promised resources for field organizations. Mr. Trump has also been dismissive of data analytics, suggesting in interviews that his showmanship and rallies will continue to be effective. He has suggested that he will compete in new states, despite the scant resources he has devoted to the traditional Republican map so far. And he has been adamant to aides that he intends to try to compete in New York, which no Republican has captured since Ronald Reagan, and has held discussions about hiring an additional pollster for the state.

Despite his and his aides’ talk of unification, Mr. Trump himself has so far proved unable and unwilling to rally the entire party around his candidacy. On Tuesday, he deliberately attacked Gov. Susana Martinez of New Mexico — a Hispanic rising star and head of the Republican Governors Association — in her home state, saying she was “not doing the job.” And he hit Mitt Romney, the 2012 Republican nominee, calling him a “choker” and mocking his gait, saying he walked “like a penguin.”…

Apart from cheap laffs & tasty schadenfreude, what’s on the agenda for the day/weekend?

Lift Off! Donovan Livingston Inspires

Text of his spoken word poem:

Education then, beyond all other devices of human origin,
Is a great equalizer of the conditions of men.” – Horace Mann, 1848.
At the time of his remarks I couldn’t read — couldn’t write.
Any attempt to do so, punishable by death.
For generations we have known of knowledge’s infinite power.
Yet somehow, we’ve never questioned the keeper of the keys —
The guardians of information.

Note to self, NEVER read the comments at YouTube.

I was in the 7th grade, when Ms. Parker told me,
“Donovan, we can put your excess energy to good use!”
And she introduced me to the sound of my own voice.
She gave me a stage. A platform.
She told me that our stories are ladders
That make it easier for us to touch the stars.
So climb and grab them.
Keep climbing. Grab them.
Spill your emotions in the big dipper and pour out your soul.
Light up the world with your luminous allure.

To educate requires Galileo-like patience.
Today, when I look my students in the eyes, all I see are constellations.
If you take the time to connect the dots,
You can plot the true shape of their genius —
Shining in their darkest hour.

We were born to be comets…. (full text here)

I thought we could use a little inspiration to go into the weekend.

Open thread.

ETA: Regarding Authors In Our Midst, I have enough for one more post, but as I was reading through the previous posts there were quite a few others who mentioned their projects in the comments. It was too overwhelming to pull them from the comments, but if anyone wants to be highlighted in the next post, send me cover art, blurb of your work and link to where we can find it. Email is Whats4DinnerSolutions (at) live (dot) com.

Obscenity Prayer (Open Thread)

My sister and I met for drinks recently at a pirate-themed bar, and this is where the hostess put us:


It’s almost like she knew us or something. Weird!

I’m trying to reach a state of Zen-like calm about Election 2016, which, contrary to my earlier predictions, has become even more fraught than 2008. I’ve come up with this Obscenity Prayer to keep my blood pressure within normal parameters and reduce the urge to reach through the screen and throttle random strangers:

FSM, grant me the indifference to ignore brainless, provocative drivel,
The patience to endure well-meaning nonsense politely,
And the motherfucking wisdom to tell one form of bullshit from another.

Here’s where I’m at: I voted for the person I thought would make the best president. I’ll work my ass off to elect the Democratic Party ticket this fall. And that’s all I can control and/or should worry about.

See how easy that is? I predict this state of enlightenment will last at least an hour or so — maybe even half a day if I don’t read comments.

What are you up to this long weekend (in the US)? Hubby and I are taking a little vacation to celebrate our anniversary, so I’ve got that going for me!

Friday Recipe Exchange: Memorial Weekend Grilling

Bourbon Chicken Appetizers

A little early tonight because it looked like we could use a new thread. Apologies for any errors. I’ve spent most of the afternoon with agents, mortgage brokers and inspectors. There were no brain cells left for proof-reading. It has been a whirlwind of activity since the moment the house went under contract. I had forgotten how fast it all moves. So from the recipe blog:

I was going to post the recipes I’d picked out for guests next week, but then realized it was Memorial Day weekend and decided to switch it up for that occasion. There won’t be a recipe exchange next week, we’ll catch up after that.

Starting things out, Stuffed Jalapeno-Cheddar Burgers and Sweet Potato Fries, complete menu, recipes and shopping list can be found here.

Grilled Potato Packets come in two flavors here.

Click here for Citrus Glazed Baby Back Ribs.

DSC_6256 [1600x1200]

Searching for rib photos this week, I came across several yummy recipes from JeffreyW (along with obligatory mouth-watering photo series).

Spare ribs (pictured above) are here.

Braised Baby Back Ribs are here.

Click here for Country Ribs

Each one has a different rub or sauce, something for everyone.

What’s on the menu for your holiday weekend? As with every year, my father and brother will be helping to put up the impressive display of flags around town (they are flags presented at a veteran’s funeral and donated by the families for display). What summer flavor are you looking forward to most? What are some of your favorite holiday weekend recipes?

Finally, tonight’s featured recipe:

Bourbon Chicken appetizers1

I have a bottle of very fine and expensive whisky in my house. I’ve been having fun experimenting with it in many recipes, finding it really brings out the flavors in beef and adds a complex appeal to chicken and desserts.

With this recipe, it’s all about the bourbon and bacon.

Grilled Bourbon Chicken Appetizers

12  servings

  • 1- 1/2 lbs boneless skinless chicken breasts
  • 3/4 cup firmly packed brown sugar
  •  1/4 cup chopped Chipotle peppers in adobo sauce
  •  1/4 tsp cayenne pepper
  • Bourbon whisky (how much you use and what you do with the leftover is between you and your bottle)
  • 8 oz pineapple chunks
  • 12 strips of sliced bacon (should be a pound)
  • 12 short wooden skewers, soaked in water for 30 minutes before assembling and grilling*

Cut chicken breasts into 1-inch x 2-inch cubes, you should have 36 pieces (you can soak in bourbon if you like)

Mix together Chipotle peppers, brown sugar, cayenne pepper and add enough whisky and pineapple juice to make a thick sauce. Set aside about 2-4 tbsp for mopping during cooking. For the remainder, cover chicken cubes on all sides with the sauce and let marinate for at least 1 hour.

To assemble: Start with a pineapple chunk, add one end of full bacon strip, add chicken cube, then wrap bacon around the top of the cube and skewer, add another cube of chicken, wrap bacon around the bottom of that piece of chicken, then skewer, add a third and repeat with the bacon strip, you’re creating a ribbon with the bacon. Finish with a pineapple chunk.

Grill over medium high heat (if using coals, start over hot coals, then move away from direct heat for the remainder of cooking time), turning frequently. Add more sauce as desired. Cook until chicken is 160-165 degrees. Shouldn’t take more than 10-15 minutes, don’t overcook or you’ll have dry, rubbery appetizers. Serve hot.

*please don’t forget this step or all you’ll have for appetizers is flaming skewers.

That’s it for this week. I hope you have a safe and fun holiday weekend. But take a moment and remember those who have served – TaMara

No One Could Have Predicted- Trump/Sanders Debate

To the surprise of no one but and some clown from Vermont, Donald Trump is not going to debate Bernie Sanders:

“Based on the fact that the Democratic nominating process is totally rigged and Crooked Hillary Clinton and Deborah Wasserman Schultz will not allow Bernie Sanders to win, and now that I am the presumptive Republican nominee, it seems inappropriate that I would debate the second-place finisher,” Mr. Trump said.

“Likewise, the networks want to make a killing on these events and are not proving to be too generous to charitable causes, in this case, women’s health issues. Therefore, as much as I want to debate Bernie Sanders — and it would be an easy payday — I will wait to debate the first-place finisher in the Democratic Party, probably Crooked Hillary Clinton, or whoever it may be,” Mr. Trump said in his statement.

Mr. Sanders is trailing Mrs. Clinton by hundreds of delegates and has repeatedly said he would look forward to debating Mr. Trump. Mrs. Clinton declined an invitation from Fox News to debate Mr. Sanders ahead of the California primary. Mr. Sanders is locked in a tight race with Mrs. Clinton in California and has been trying to generate free media in the state, where it is expensive to advertise.

There is no upside to Trump debating Sanders, just as there is no upside for Hillary standing on stage graciously being yelled at and having Bernie wag his finger at her. Why? Because he LOST. It’s over.

At this point Sanders is just making an ass out of himself while making Joe Manchin look like a good Democrat. Well played, Bernie. You just got rickrolled by a douchebag and probably still doesn’t even realize it.

Open Thread: Nice — Sandra Fluke Is Still Punishing Rush Limbaugh

Per Politico:

[T]here are signs that all is not well in the Limbaugh radio empire. Because even as his influence is sky high and his dominance at the top of talk radio remains unchallenged, as a business proposition, Limbaugh’s show is on shaky ground. In recent years, Limbaugh has been dropped by several of his long-time affiliates, including some very powerful ones: He’s gone from WABC in New York, WRKO in Boston and KFI in Los Angeles, for example, and has in many cases been moved onto smaller stations with much weaker signals that cover smaller areas.

Why? Because four years after Limbaugh called Georgetown law student Sandra Fluke a “slut” on air, spurring a major boycott movement, reams of advertisers still won’t touch him. He suffers from what talk radio consultant Holland Cooke calls a “scarlet letter among national brand advertisers.” And for someone who has said that “confiscatory ad rates” are a key pillar of his business, that spells trouble. (Limbaugh ignored multiple interview requests.)

Limbaugh’s extremely lucrative eight-year contract—estimated to be worth roughly $38 million a year—is up this summer. What will happen to “America’s Anchorman,” as Limbaugh quasi-ironically refers to himself, once the contract is up, is anybody’s guess. Because as he is learning, political power does not necessarily a stellar business make…

Paying for expensive cures

The Incidental Economist at Academy Health  is examining the next wave of very expensive therapies that could be cures for rare but extremely expensive diseases:

most diseases which are the focus of gene therapy research are relatively rare. Most of these conditions affect children. In addition, gene therapy is more like a procedure than a drug. You perform it once, and potentially achieve a lifetime cure. There’s no way that, like many pharmaceutical products, profits can be made on volume.

It’s important to note that at this time, we still don’t have a lot of promising results in human subjects. But we’re getting close – close enough that it’s best we consider how we might pay for this now, rather than wait until it’s here and we all start fighting about it.

We may expect that prices for gene therapy might approach previously unseen amounts. The only gene therapy currently approved for use in Europe is Glybera. It treats lipoprotein lipase deficiency, a rare illness. It’s now priced at more than $1 million per patient, even though, as the authors point out, its efficacy is not without doubt….

The authors offer some ideas on where to start. First, they present some estimates on the current cost of managing genetic disorders. Cystic fibrosis costs almost $6 million per patient over a lifetime. Gaucher disease about $5 million, sickle cell disease $1 million, and Hemophilia A between $5 and $10 million.

In the United States, the current regulatory regime has the current insurer of a patient with a rare, extremely high cost disease pay for ongoing treatments.  There is an obligation that insurers pay for medically necessary non-experimental treatment regimes.  FDA approved gene therapy regimes that promise a high probability of a cure instead of a lifetime of maintenance treatments, acute crisis response and symptom alleviation would  easily qualify as a medically necessary treatment.  This would produce a major collective action problem and a game of hot potato.

Let’s make some major assumptions.  Let’s assume there will be a Cystic Fibrosis genetic therapy regime that offers a high probability of a cure and once the regime is completed, the individual’s medical expense profile goes from $200,000 to $300,000 per year to a profile that is indistinguishable from their age-group cohort.  Let us also assume that the gene therapy is fairly priced (let’s not argue what “fair” means) at the cost of several years of alternative treatment (think $1 million dollars or more).   Let us also assume there are multiple insurers and people with cystic fibrosis can change insurers (from Employer Sponsored coverage to Exchange to CHIP to Medicaid) with fairly low costs compared to the alternatives of cure or ongoing maintenance treatments.  And finally, let us assume that insurers can’t directly and legally deny coverage for people with cystic fibrosis.

What are the incentives for insurers under the current regulatory regime?

The most basic incentive is to make someone else pay and do as much as possible to be as ugly for the cure regime possible.

When there are multiple payers, whomever pays for the cure is producing massive social benefits and massive individual benefits through better health and  quality of life.  They are spending several years or more of the alternative treatment costs to eliminate future costs of the alternative treatment because the patients’ lungs now work well.  They pay out a million dollars in Year 1 so that the member with CF does not have ten or twenty more years of $300,000 a year treatments.  On net, society is savings $5 million dollars in net present value treatment costs ($1 million for a cure vs. 20 years @$300K/year for $6 million).  However due to churn, the insurer that pays for the cure won’t capture the long run savings.

With that incentive structure in place, every payer has a strong incentive to get someone else to pay for cures.

How do we solve this problem?

There are two very plausible solutions.  The first would be to nationalize the costs of genetic cures for rare and very high cost diseases much like how we nationalize end stage renal disease costs.  Medicare would pay for these genetic cures at a very early age and any needed follow-up care that is specifically tied to the cure.  After the cure period is over, the treated individual would be placed back into the regular insurance world.  The federal government would pay out the million dollars for a cure but society as a whole would capture the multi-million dollar long run benefits.  This works because the government has an extremely long shadow of the future and can wait to capture dispersed benefits.

The other method would be a tweak on my idea to create property rights and income streams from pushing prevention:

Make it worth the while of an insurer to actively push good long term preventative care even accepting churn will and should happen. Follow-on transfer payments could be made by future insurers to the insurer that paid for the preventative care that has immediate costs but long run pay-offs.

The size and duration of the payments would differ depending on the pay-off period and either the cost of the preventative care or the net costs avoided….

An IUD is a bit different. Here the immediate treatment cost is fairly high and the duration of the benefit is three to ten years. Insurer B could conceivably make preventative care benefit payments back to Insurer A of $20 a month if the calculation is based solely on the cost of oral hormonal contraception. If there is calculation of averted pregnancies, transfer payments of $40 or $50 per month could be justified under some assumptions. These payments would stop after a reasonable calculated life span of an IUD or the actual removal of the device.

Finally, the HPV vaccine has a very different profile. It’s main cost saving function is avoiding cancers a decade or more after the administration of the vaccine. There is massive churn in a decade, especially among teenagers who become young adults. Two payment schemes could be created. The first would be the vaccine avoidance payment of a few dollars per month until an individual is 18. Then a decade later a second payment stream would be created. This stream would be a small monthly sum for cancer treatments avoided.

In a CF genetic cure scenario, the insurer who pays for the cure of CF could receive a payment each year from other insurers equal to either a lifespan adjusted cost of the cure (for instance annual $50,000 payments for 20 years) or a larger annual payment based on the averted costs of the next best alternative ($300,000/year for 20 years). Doing that would prevent a game of hot potato, intentional ugliness and cure avoidance as curing now becomes either net revenue neutral for an insurer or a net revenue generator for insurers that aggressively long term cost efficient cures even as there is a massive short term cost.

The Puke Funnel In Action

It never ends with our media:

To some, the comparison to Clinton’s case may appear strained. Clinton has said none of the information on her server was marked classified at the time. In many cases, it was marked as unclassified when sent to her by people in the State Department more familiar with the issues involved.

By contrast, sailors are trained early on that the engine compartment of a nuclear sub is a restricted area and that much information relating to the sub’s nuclear reactors is classified.

Still, it’s far from obvious that the information Saucier took photos of is more sensitive than information found in Clinton’s account. Court filings say the photos were clear enough that they reveal classified details about the submarine that could be of use to foreign governments, such as the vessel’s maximum speed.

However, the Navy says the photos are classified “confidential,” which is the lowest tier of protection for classified information and is designated for information that could cause some damage to national security but not “serious” or “exceptionally grave” damage.

Intelligence agencies claim that Clinton’s account contained 65 messages with information considered “Secret” and 22 classified at the “Top Secret” level. Some messages contained data under an even more restrictive “special access program” designation.

Clinton and her campaign have disputed those findings, calling them a result of “overclassification” and urging that the messages be released in full.

However, Clinton’s critics and some former intelligence officials said she should have recognized the sensitivity of the information. They’ve also noted that about 32,000 messages on Clinton’s server were erased after her lawyers deemed them personal.

“The DOJ is willing to prosecute a former sailor to the full extent of the law for violating the law on classified material, in a situation where there was no purposeful unsecured transmission of classified material,” conservative blogger Ed Morrissey wrote last year. “Will they pursue Hillary Clinton and her team, at the other end of the power spectrum from the rank-and-file, for deliberate unsecured transmission of improperly marked classified nat-sec intelligence? Will they pursue the same kind of obstruction of justice charges for Hillary’s wiping of her server as they are for Saucier’s destruction of his laptop?”

From the fever swamps of wingnut blogs to Wolf Blitzer’s mouth. Seriously, how long before this is on CNN?

Cost savings, reform and interest groups

Stat News has a report from last month on opposition to the Medicare Part B drug payment reform scheme that highlights the challenge of any reform effort that attempts to line incentives up to more cost effective but clinically similar care.

Under the Part B program, doctors, and hospitals buy a medicine, and the government reimburses the average sales price plus 6 percent. But the experiment, which would run five years starting this fall, would pay physicians the average price, plus another 2.5 percent and a flat fee of $16.80, not including reductions required by sequestration, or automatic spending cuts. The program would also pursue ways to pay for medicines based on different definitions of value….
The missive from the senators is not surprising. Even before the administration unveiled its program last month, there was heated opposition. Since then, more than 300 groups representing physicians, drug makers, and patients also released a letter that encouraged the administration to withdraw its proposal. And many of these groups have been lobbying Congress.

“The proposal, which was rushed through review without physician or patient input, lays out an experiment (that is) not based on quality metrics,” said the Community Oncology Alliance, a trade group that represents smaller cancer clinics, at the time the program was unveiled last month.

Right now there if there are two drugs that have identical expected clinical outcomes for a patient, the Medicare Part B payment regime gives the prescriber a very strong incentive to prescribe the more expensive drug. If Drug A costs $2,000 a dose and Drug B cost $100 a dose, the doctor makes $180 from prescribing Drug A while he only makes $6 from prescribing drug B. The new reform tweaks that a bit. Drug A would give the prescriber a fee of $66.80 while Drug B would have a fee of $18.80. There is still a gap where prescribing Drug A is better for the doctor than the clinically identical Drug B but the gap is smaller.

This is supposed to be provider level budget neutral. Prescribers who mainly prescribe low cost drugs will see higher reimbursement. Prescribers who prescribe mainly high cost drugs will see much lower reimbursements.

The area of cost savings that may occur is if there is a composition shift in the drugs prescribed. If prescribers switch from high cost Drug A to lower cost Drug B because the gap in their reimbursement is far smaller, then the system as a whole saves money and the patients save money as their co-insurance and deductibles are not tapped for as much cash.

This is fairly dry technical policy writing. The point of opposition is from prescribers who currently prescribe high cost drugs (even if there are no low cost substitutes) as this policy change will take money out of their pockets which means their mistress might have her allowance cut. Concentrated losses lead to far more opposition than dispersed gains lead to support.

Medicare Part B drug payment reform is not a huge deal in the scheme of things. It would be a step in the right direction in a marathon of cost control. But that step illustrates the difficulty of taking money away from incumbent recipients to rejigger incentives so they are a bit less perverse.

Friday Morning Open Thread: Cat Funding Bleg

diffbrad binkley

Balloon Juice lurker, former Sadly, No! regular, and founder of FireMeganMcArdle has a bleg:

My 17 year old snowshoe siamese Binkley has been very sick the last few months. The good news is he’s going to be ok, the bad news is his treatment so far has cost more than my rent at a time when that alone is not so easy for me to cover, and he’s probably not done yet. So I’ve swallowed my pride and started a gofundme

I just tweeted a good shot of him looking at Obama on tv in 08, if you’re curious about the fuzzball in question.

GoFundMe page here, if you have a soft spot for meezers.

What else is on the agenda, as we wrap up the week and/or prepare for the holiday weekend?