Those Crazy Politicians and University Endowments

The Wall Street Journal is reporting that Massachusetts is contemplating a 2.5% state tax on university endowments in excess of $1 billion per university (via Greg Mankiw's Blog). Now personally, I could care less about Harvard's financial concerns. It's hard to worry about a school with a $34 billion endowment. I'd be happy if my net worth was half that amount.

Here's an idea that would take some of the wind out of these legislative proponents' sails. Harvard could take 2% of their endowment each year and give it to their 19,000 undergraduates and graduate students. This is surely a fraction of the annual interest Harvard makes on its investments each year.

This would amount to over $35,000 per year per student and would essentially give them free tuition. Of course the B-school students would still have to cough up about $7,000 more per year but well...they're B-school students. They'll be able to pay that off after their first few weeks of gainful employment.

Massachusetts would have an awfully hard time taxing such "good" citizens as the Harvard administrators for providing a world class education for free.

I don't know. 2.5% going to taxes vs. 2.0% going to their own students? Seems like a no brainer to me. Maybe the legislature is threatening the universities with this tax just to achieve this end. Either way, it seems like an abuse of their authority to me.

More on my thinking about government meddling in the affairs of private universities (non profit organizations) here.

The EMTALA and Inintended Consequences

Edwin Leap wrote a revealing post about one of my personal pet peeves: the EMTALA laws (h/t KevinMD). Read the whole thing.

The EMTALA (Emergency Medical and Active Labor Act) mandates that essentially all patients must be seen regardless of ability to pay. Admittedly, this federal law states that people can be sent away without treatment after they've been properly evaluated. However, the penalties for being wrong are so severe that few hospitals are willing to take the chance. In effect, hospitals see and treat almost all E.R. patients even if they know that they won't be payed for doing so.

People will of course argue that some patients might die after having been mistriaged to home. Unfortunately, it is the nature of things that this is so. Triage nurses will always make mistakes on occasion and as sure as the sun rises in the east, some patients or their families will pay a tragic price.

Inevitably, such cases will become front page headlines, but rare as they may be, the victims will be "named" and therefore worthy of our sympathy and compassion. Consider though, that in California alone, at least 65 E.D.'s have closed in the last decade. Unreimbursed care is at the root of most or all of these closures.

How many more patients will die, however, because of a lack of nearby or conveniently located E.D.'s? Moreover, these patients will not be named but will instead be mere statistics in some as-yet-unperformed observational study.

Again, read Leap's article for more reasons why the EMTALA is a bad idea (as it's currently written).

From Dr. Jill Bolte Taylor: The Most Electrifying Lecture You'll Ever Hear

I've heard a lot of lectures in my life but never one like this. This is neuroanatomist Dr. Jill Bolte Taylor giving a talk on the functional differences between the right and left hemispheres of the brain. She's passionate about her subject as she actually suffered a massive intracranial hemorrhage that trashed her left brain. Dr. Taylor brilliantly describes the experience and sensations both as a stroke victim and as a scientist.

Not that I want to replicate her experience but man do I wish I could teach like her! Check it out and prepare to be riveted by the most amazing 20 minute talk you've ever heard.

It makes me never want to step up to a podium again.

Universities' Endowment Funds and the Federal Government

Here's an idea I hate (via the instapundit). Congress is considering regulating the amount of university endowments that schools may keep for themselves and how much they have to pass on to students (in the form of tuition cuts, financial aid, or scholarships). Do these guys really have this much time on their hands?

Laws such as those being proposed give our legislature the bad name that it has. Why a private, non-profit organization such as a university endowment "needs" to be controlled by the federal government eludes me. Don't get me wrong. When I read that elite schools such as Harvard could pay the tuition of their entire student body on just the interest that their endowments earn, I find that reprehensible and a poor reflection of their governance. But that's their problem, not the fed's.

Surely people will make the argument that as tax-exempt organizations, some limitations on their behavior is appropriate. Really? Is the federal government really so much the paragon of efficiency and insight that they should decide where the Red Cross or Harvard should allocate the contributions they collect? Is that what we want?

Likewise, some will point out that many (most?) students receive some federal aid in the form of grants or federally insured student loans and as such, the government has an overriding interest. To me, this just strengthens the position that the fed should get out of higher education completely.

My guess is that such legislation will probably go nowhere (although some provision for more transparent reporting of where endowment money actually goes may pass). I think though, that the real intent of such debate is to put a chill in the minds of fund managers' minds. The mere threat of such laws may well be enough to "influence" behavior. In my opinion such saber rattling is an immoral use of federal power.

Bad law. It's contagious.

Gonzo Medical Blogging

Periodically, I will add a new blog to my "blogroll". Unlike many bloggers that maintain such lists, I try to post only the ones I like to read frequently. Some bloggers maintain huge alphabetized lists of blogs, a practice I've never really understood. Perhaps these lists grow because of quid pro quo (you link to me and I'll link to you, a practice I hate) or perhaps some people just like the look of really unwieldy, completely unfiltered lists.

Personally, when I look at someone else's blog, I enjoy looking through their blogrolls to see just what they like to read. Being an avid reader, I'm always curious about such things. When my patients or their families have books with them in the hospital or exam room, I invariably ask what they're reading. Huge blogrolls don't really give me that kind of insight into the compiler's tastes.

At any rate, this post is to announce an addition to my blogroll. That we are judged by the company we keep concerns me as I add a link to Panda Bear MD but what can I say? The guy is hysterically funny and says things that many of us think but are unwilling to express in polite company. Panda is a resident in emergency medicine. I'm sure he is a bit older than his fellow residents as he's described a wide variety of prior life experiences.

This added age undoubtedly gives his writing a level of sophistication extremely unusual in someone the age of a typical resident. If I had to pigeonhole him, I guess I'd call him the Hunter S. Thompson of medical writing, an appellation I'm sure he'd understand as a compliment.

I enjoy his observations, his insights, and his style very much and have pointed colleagues, nurses, and residents towards selected posts to much hilarity.

Truthfully, I sometimes worry about Panda. My hope is that his posts are put-ons and that the darkness, even bitterness, imbued in his writing is more for shock value than anything else, sort of like Ann Coulter's subtle style. But I have my doubts. His writing is too authentic and fluid.

I think that while most of us will occasionally laugh at the peccadilloes of our patients and their families, most of us don't define such people by them. I hope he is happy in what he does and that if so, medicine continues to sustain him. Unfortunately, my suspicion is that his cynicism has been acquired at far too early a stage in his career. He has all the markings of someone headed for premature burn-out. Hopefully by turning others' attention to his writing, I'm not reaffirming his world view and somehow facilitating such burn-out.

One last point Panda, if you're reading this. You should give some serious thought to posting your name and your institution. Not because I want to know who you are but instead, to protect yourself. While I don't recall reading anything you've written that's frankly libelous or in violation of HIPAA or terribly likely to get you into trouble, some of your posts definitely push the envelope. I think that writing without the imagined security of anonymity helps ensure just enough caution to prevent saying things that can have tremendous legal or professional repercussions. Internet anonymity is fleeting. Just ask the Flea.

My two cents.

Service in Medicine, Has it become a quaint anachronism from a bygone era?

Bob Wachter has posted some great points regarding the "service" of radiology.

The last paragraphs are priceless:

In my NEJM article on dis-location, I described the growing teleradiology trend, driven by the fact that the same technology that allows me to read my films without going to the radiology department also allows a radiologist in Banglaore to read a film as easily as a radiologist in Bangor. The Indian radiologist earns one-tenth of what the U.S. radiologist earns. If my experience in visiting Radiology World tends to be of the positive, collegial sort, I’ll fight like hell to keep the radiologists in the hospital. If it feels like I’m distracting them from their “real work,” then (assuming comparable technical competency) there’s no reason for me to care whether they are in the building.

Or the country.

I feel the same way about so many aspects of modern medicine. If primary care physicians want better reimbursement, they need to "add value" to their interactions with patients. Otherwise, why not have a nurse practitioner or physician assistant grab their business at a discount (e.g. at CVS Pharmacies)? If emergency medicine docs want more respect from their colleagues and to not render themselves useless, then they have to do much more than act as glorified triage nurses. In the same way, if radiologists want to avoid having their jobs outsourced, let them raise their standards of service.

The list of examples could go on and on. Read Arnold Kling's recent article in tcsdaily to see one reason why quality has declined so frequently. Hint: imagine what happens to a service when the recipient pays for it rather than someone else like a third party payer.

Who says big government is inefficient?

Courtesy of the InsureBlog: A little USA article on your government at work. So it seems that the NIH can't keep track of the potential conflicts of interest between grant recipients and the companies they shill consult for.

I was going to ask myself how the General Accounting Office (GAO) could allow this to happen and then I realized...