Rational Arguments

A reader points me to a study out in the New England Journal of Medicine this week.  The abstract:

Background When copayments for ambulatory care are increased, elderly patients may forgo important outpatient care, leading to increased use of hospital care.

Methods We compared longitudinal changes in the use of outpatient and inpatient care between enrollees in Medicare plans that increased copayments for ambulatory care and enrollees in matched control plans — similar plans that made no changes in these copayments. The study population included 899,060 beneficiaries enrolled in 36 Medicare plans during the period from 2001 through 2006.

Results In plans that increased copayments for ambulatory care, mean copayments nearly doubled for both primary care ($7.38 to $14.38) and specialty care ($12.66 to $22.05). In control plans, mean copayments for primary care and specialty care remained unchanged at $8.33 and $11.38, respectively. In the year after the rise in copayments, plans that increased cost sharing had 19.8 fewer annual outpatient visits per 100 enrollees (95% confidence interval [CI], 16.6 to 23.1), 2.2 additional annual hospital admissions per 100 enrollees (95% CI, 1.8 to 2.6), 13.4 more annual inpatient days per 100 enrollees (95% CI, 10.2 to 16.6), and an increase of 0.7 percentage points in the proportion of enrollees who were hospitalized (95% CI, 0.51 to 0.95), as compared with concurrent trends in control plans. These estimates were consistent among a cohort of continuously enrolled beneficiaries. The effects of increases in copayments for ambulatory care were magnified among enrollees living in areas of lower income and education and among enrollees who had hypertension, diabetes, or a history of myocardial infarction.

Conclusions Raising cost sharing for ambulatory care among elderly patients may have adverse health consequences and may increase total spending on health care.

Here’s the recap.  Some researchers wanted to see what happened to seniors if you increased their Medicare co-pays a bit for primary care and ambulatory care visits.  This is all based on the moral hazard argument.  It goes something like this: People use too much care if it’s free.  So the more you make them pay for it out of pocket the less they will use.  People who need the care the most will pay for it, but people who don’t need it will avoid it.  We become more efficient shoppers, spend less on needless care, and everyone wins.

Right?

No.

What happened here is that just by increasing the co-pay from $7 to $14 and $13 to $22, about 20 fewer outpatient visits occurred per 100 people.  That’s a huge reduction for just a few dollars increase.  Imagine the reduction you would have seen for a significant increase.  And that reduction wasn’t harmless.  There were an additional 2 hospitalizations per 100 people and an average of more than 13 additional days in the hospital.

This minor additional cost-sharing not only resulted in worse health outcomes, but it might also cost more.

Here’s where it gets worse: The most effects were seen in those who were poor or sick.  That’s exactly what we’re trying to avoid.

You will hear some people say this contradicts the findings of the RAND Health Insurance Experiment, which basically “justifies” the whole co-pay thing.  They will say that the RAND HIE showed you can increase co-pays without negative health consequences.  But that’s because many have always misinterpreted the results.  As I’ve argued before about the HIE:

[H]ere’s the gist of that they found: People in the high deductible plans – those most exposed to health care costs – did spend significantly less and consumed less health care.  And, yes, much of that care was unnecessary, as healthy people did not suffer negative consequences  from forgoing care.  BUT, and this is important, poorer participants with hypertension avoided necessary care, and saw their mortality rates rise significantly.

Removing the moral hazard did no harm in the majority of patients (which is touted often as the result of the study) because they were healthy.  And, of course, getting less care when you’re healthy leads to few short term negative results.  But for those who were unhealthy, who comprised a minority of patients in the study, removing the moral hazard led to significant and dangerous consequences.

This study in the NEJM was of elderly people, who were all excluded from the RAND HIE.  They were inherently sicker.  And the results of the RAND HIE for sicker people held.  They fare poorly.  And it might not even save money.

I know it feels like higher co-pays are a good thing.  It seems right to ask people to have more skin in the game.  It looks like it’s fairer and more likely to reduce waste.  But that’s only true for healthy people.  And they’re not who we need to protect.

There’s a bit of a hubbub about a new study that many are touting as proof that abstinence-only education works.  From the abstract:

Outcome Measures The primary outcome was self-report of ever having sexual intercourse by the 24-month follow-up. Secondary outcomes were other sexual behaviors.

Results The participants’ mean age was 12.2 years; 53.5% were girls; and 84.4% were still enrolled at 24 months. Abstinence-only intervention reduced sexual initiation (risk ratio [RR], 0.67; 95% confidence interval [CI], 0.48-0.96). The model-estimated probability of ever having sexual intercourse by the 24-month follow-up was 33.5% in the abstinence-only intervention and 48.5% in the control group. Fewer abstinence-only intervention participants (20.6%) than control participants (29.0%) reported having coitus in the previous 3 months during the follow-up period (RR, 0.94; 95% CI, 0.90-0.99). Abstinence-only intervention did not affect condom use. The 8-hour (RR, 0.96; 95% CI, 0.92-1.00) and 12-hour comprehensive (RR, 0.95; 95% CI, 0.91-0.99) interventions reduced reports of having multiple partners compared with the control group. No other differences between interventions and controls were significant.

Here’s the deal.  They randomized group of young African Americans in 6th and 7th grade to receive one of a number of different types of sexual education.  One centered on “abstinence-only”.  Another group got a “safer-sex” intervention.  Yet another got a combination of the two.  There was also a control group that got none of this.

It’s important that you understand just what was meant by each of these.  So I’m giving you their descriptions (may be behind a paywall for you):

Abstinence-Only Intervention

The 8-hour abstinence-only intervention encouraged abstinence to eliminate the risk of pregnancy and STIs including HIV. It was designed to (1) increase HIV/STI knowledge, (2) strengthen behavioral beliefs supporting abstinence including the belief that abstinence can prevent pregnancy, STIs, and HIV, and that abstinence can foster attainment of future goals, and (3) increase skills to negotiate abstinence and resist pressure to have sex. It was not designed to meet federal criteria for abstinence-only programs. For instance, the target behavior was abstaining from vaginal, anal, and oral intercourse until a time later in life when the adolescent is more prepared to handle the consequences of sex. The intervention did not contain inaccurate information, portray sex in a negative light, or use a moralistic tone. The training and curriculum manual explicitly instructed the facilitators not to disparage the efficacy of condoms or allow the view that condoms are ineffective to go uncorrected.

Safer Sex–Only Intervention

The 8-hour safer sex–only intervention encouraged condom use to reduce the risk of pregnancy and STIs, including HIV, if adolescents had sex. It was designed to (1) increase HIV/STI knowledge, (2) enhance behavioral beliefs that support condom use, and (3) increase skills to use condoms and negotiate condom use. It was not designed to influence abstinence.

And, when all was said and done, the abstinence-only program resulted in fewer adolescents having intercourse in the three months before they did follow-up.  In essence, it resulted in less sex than the other interventions.  It also didn’t result in less condom use, which has been found in previous studies.

You should note that the abstinence only program described above is not the same as many other abstinence only programs.  It didn’t recommend no sex until marriage; it recommended waiting until you are “more prepared to handle the consequences of sex”.  It also was factually and theoretically based.  It also presented data on condoms accurately.  It also did not moralize.

And it worked.

That’s right.  If we’re going to hold with science, then we have to accept the results.  This study showed that this abstinence only program worked.  It should receive further funding and more investigation.  We should consider this type of curriculum as an option to implement.

You can’t ignore it because it doesn’t fit your ideology.

That said, you also can’t extrapolate further than the findings.  This study does not mean that all abstinence-only programs work.  In fact, many other studies have shown that other abstinence-only programs fail.  This was a specific, theory-based abstinence-only program.  It doesn’t vindicate one administration any more than it condemns another.

When you do science, you agree to accept the results.  We should acknowledge that this type of abstinence-only program may have a place in sex education for children in 6th and 7th grade.  And, we should do more research to make sure those results hold in other populations and other settings.  That’s how it goes in research.

Buckle in, because this will be a long one…

Although this does not seem like a fact that most people would commit to memory, somehow the average American has come to know that, not only is it insanely expensive to create a new drug and bring it to market, but it is expensive to the tune of $800 million dollars. Why is this important?  It is the reason most often cited for why medications are so expensive in the United States.  And no one can doubt that they are expensive; we spent over $950 per person on drugs in 2007, and that number is going up every year. Many drug company executives claim that if we didn’t pay so much, then the $800 million dollars needed to create each new drug would prevent us getting any new scientific advances.  Even if you didn’t remember this number, it is reinforced repeatedly in advertisements, news reports, and campaign speeches.  It is so widely accepted that few people challenge the figure, at least not in public.  The truth, however, is a different story.

In order to understand why this is a myth, we must first understand how this number came to be.  In 2001, a group known as the Tufts Center for the Study of Drug Development released the results of a landmark study performed by Joseph DiMasi, MD and colleagues.  They claimed that, after exhaustive work and unprecedented access to company data, the average cost of developing a new drug was $802 million. Unfortunately, the methods of that study were not released until sometime after that, so no one could analyze their figures for over a year. When the paper describing the work was finally released, the $800 million number had already become branded into the American psyche.  So much so that a number of subsequent books and studies attacking the findings not yet been able to change the public consciousness.

So what is wrong with the figure?  A number of things.  First, let’s just approach the study from an economic standpoint.  The actual out of pocket costs for developing a drug in the Tufts study were about $400 million, half of the final number.  How did it get to $800 million then? Through a fancy piece of economic sleight of hand known as “opportunity costs of capital.” You see, when a business chooses to invest money in one area instead of another, it takes a gamble.  The drug industry could spend $400 million on research or, for instance, put it in the bank.  If they put money in the bank instead, they would have earned interest on it.  That interest income was sort of “lost” since they didn’t get to put it in the bank.  Perhaps they could have made even more money if they had invested that $400 million in the stock market.  Or in baseball cards.  The Tufts authors calculated that the drug industry “lost” another $400 million in potential money that they could have earned if they had done something different with the money.  So, they added that up and arrived at $800 million.

The problem with this line of thinking is that research and development is not an investment option for the pharmaceutical industry.  It is a necessary expense — at least it is if they want to stay profitable.  If they want to take their money and invest it in cars that’s fine, but then they are in the auto industry, not the drug industry.  Ironically, when they do their taxes, research is categorized as an expense, not an investment, so any argument about capitalizing costs is rendered moot by the actions of the drug companies themselves.  Research is not a cost to be capitalized.

Which brings us to the other economic trick.  Research is an expense; it is listed as such on tax forms and is, therefore, tax deductible.  This means that the $400 million bill found in the Tufts study was in pre-tax dollars.  Since it is tax-deductible, and the corporate tax rate was about 35%, the actual after-tax cost would be less than $270 million.

While that’s still a lot of money, it is far less than $800 million.  But there are even more problems with the Tufts study.  When drugs go in for approval from the U.S. Food and Drug Administration (FDA), they are classified according to their perceived importance and novelty.  A small percentage of the drugs seeking approval are what are known as “New Molecular Entities” (NMEs.)  Most of the drugs the FDA reviews are just slightly different versions of drugs that already exist on the market.  It makes intuitive sense that it would cost more to make an NME than to merely change an existing drug into a slightly different molecule.  Not only did the Tufts study only look at NMEs, it only included NMEs where the entire cost of development was born by the drug company itself.

As I discussed yesterday, the government, not the drug companies, supports many of the costs of developing drugs. A very, very small number of drugs are developed entirely by industry.  So by taking only NMEs and taking only NMEs that were entirely and solely paid for by companies, the study selected the most expensive drugs for analysis.  This does not yield an “average” cost, no matter what the New York Times says. It provides a cost for the most expensive and rarest types of drugs around — NMEs developed entirely in house.

Even that result is suspect, however.  To this day, no one outside of the study has been permitted to examine the data that the drug companies provided secretly to the Tufts group.  And while we would like to believe the best about everyone, we would be naive to ignore the desire of the pharmaceutical industry to make the costs of research and development seem as high as possible.

Are there any other studies out there to help us arrive at the true cost?  Of course there are.  In 2001, Public Citizen, a consumer safety group known best for its founder Ralph Nader, published a detailed analysis attacking the findings of the Tufts group.  They made a compellingly simple argument: to calculate the average research and development costs to bring a drug to market, you only need to know the total amount spent on research and development and the total number of drugs that obtained FDA approval. Dividing the costs by the number of drugs yields the average cost per drug.

Since total costs are available through publicly available data, and drug approvals are available through the FDA, the group was able to analyze data from 1994 to 2000. They found that the average cost to develop a drug all the way through FDA approval was $161 million pre-tax, and $110 million in after tax dollars. Again, not chump change, but not $800 million.

Even if you think Ralph Nader should not be trusted any more than the drug companies, anyone can reproduce this experiment using more recent data.  According to the 2005 Pharmaceutical Research and Manufacturers in America (PHRMA) Industry Profile, drug companies spent about $121 billion on research and development in 2000-2003. In that same time period, 314 drugs obtained FDA approval. This comes to about $385 million per drug in pre-tax dollars, and assuming a corporate tax rate of 35%, a total of $250 million per drug.

All of this information may leave you with a spinning head. After all, we want the drug companies to spend more time developing NMEs because odds are that most breakthroughs in healthcare will come from these types of drugs.  Far too many new drugs are just copies of drugs that already exist and are really no better than the originals.  It is also likely that NMEs cost more to create than copycat drugs.  However, since NMEs represent such a small percentage of new drugs, it is unfair and dishonest to represent the costs of these drugs as the average costs of new drug development.

Is $250 million a more accurate, and up-to-date, average cost for bringing a drug all the way to market?  Likely, yes.  Some will argue with this.  In fact, Bain & Company, a consulting firm, made headlines by claiming that the cost per drug is really $1.7 billion. However, they argue that the costs of marketing and advertising, which are 2 to 3 times higher than research and development costs, should be included in the cost of creating a new drug.  That’s ridiculous; truly amazing new drugs need no marketing or advertising, only copycat drugs do.

Ultimately, the truth will never be known until the drug companies open up their books and allow us to examine their data ourselves.  That’s not likely to occur soon.

I learned so much of this from Marcia Angell’s The Truth About the Drug Companies: How They Deceive Us and What to Do About It that I’m going to plug it again.  Go buy it.

Yesterday I addressed the relative amounts that the pharmaceutical industry spends on research and development as opposed to other expenses.  But there’s still another way to address the veracity of their claim that we need to give them massive amounts of money in order to create novel, important drugs.

In the last part of my previous post, I explained how FDA data shows that the vast majority of newly approved drugs are not real improvements over what we already have.  How much work do pharmaceutical companies devote to those drugs in terms of research, however?

In 2001, Darren Zinner published a study in Health Affairs that addressed this very question.  Here’s what he did in plain English.  He looked at all clinical patent applications in 1998, and carefully examined all the scientific research cited in those applications.  It’s important to remember that this would include all research, not just those for approved drugs, so it even includes the research for drugs not getting to market.  He then classified where that research was done.  Here’s what he found:

The majority of research cited in patent applications was done in academic centers.  Some more was done in other non-profit or government research centers.  Only 15% of the research was done by industry.  That’s not a very compelling argument for the indispensable contribution of industry to research.

This work has been repeated in slightly different ways.  In 2001, Public Citizen got their hands on an internal study done by the NIH, where they had looked at the top five selling drugs from 1995.  For completeness sake, these included Zantac, Zovirax, Capoten, Vasotec, and Prozac.  Please note – I’m not disputing the importance of those drugs.  The NIH then looked at the relevant published research for the development of those drugs (and their sources).  Can you guess what they found?

NIH found that “NIH-funded research played a critical role in drug discovery in each of these cases.” In all, U.S. taxpayer-funded researchers conducted 55 percent of the published research projects leading to the discovery and development of these drugs (and foreign academic institutions 30 percent). “Researchers at U.S. universities and at NIH contributed by discovering basic phenomena and concepts, developing new techniques and assays, and participating in clinical applications of the drugs.”

In the case of the hypertension drugs captopril and enalapril, the NIH concluded that the drugs were developed thanks to public U.S. research projects and five foreign academic studies. Only three significant studies were conducted by the drugs’ patent holders, Squibb and Merck.

Furthermore, four of the taxpayer-funded studies were deemed “key” and six of the studies were referenced in the industry’s work. The studies sponsored by the patent holders for these two drugs were of less consequence – none were considered “key” by the NIH. In fact, for the five drugs it studied, the NIH deemed only one industry study “key.” (Public Citizen acknowledges the fact that academics generally have greater incentive to publish research than industry scientists.)

The similarities from the two studies are convincing.  About 15% of research comes from industry.  Over half was from NIH-funded labs.  If you drill down even more, and look only at key papers for discovery or development, only one of the seventeen papers in this category came from industry.  Again, it’s hard to make an argument that the industry contribution is so terribly important that it justifies never reducing the amount we’re spending on drugs at all.

Please not that I am not asking for us to abolish drug companies, nor minimizing their potential importance in certain areas.  As infrastructure for bringing research from the lab to the real world, they do reasonably well.  They also obviously make and transport the drugs well.  But let’s not over-emphasize their importance in research and development – which is always what they do to justify the expense of drugs.

Medical R&D at the turn of the millennium.  Zinner DE. Health Affairs. 2001 Sep-Oct;20(5):202-9.

Rx R&D Myths: The Case Against The Drug Industry’s R&D “Scare Card” by Public Citizen (2001).

I just came back from a conference in Cambridge where I got to hear a number of fascinating talks.  One of the best was given by Marcia Angell.  If you don’t know who she is, Dr. Angell was a past editor of the New England Journal of Medicine, and pretty much wrote the book on the inner workings of the pharmaceutical industry.  I mean that literally.  Go buy her book right now.  It changed my (professional) life.

Dr. Angell was, of course, talking about the pharmaceutical industry in the context of health care reform.  She updated some of the data in her book for the talk, and I’m going to present two important points.  The original work and methodology is explained in more detail in her book, but I’m going to give you updated information.

The first bit of data has to do with the amount of money the pharmaceutical industry spends on research.  You will often hear that the real reason that drugs cost so much is that companies need to spend so much on research.  Compelling argument.  After all, think of all the lifesaving drugs we get, right?  We have to fund that research.  But it’s just not that clear.

According to Fortune Magazine, the top ten pharmaceutical companies earned about $269 billion in sales in 2008.  That’s just the top ten.  You can also look up their public annual reports.  This is how they spent that enourmous sum:

Here’s what we’ve got.  Those companies spent a whopping $41 billion on research and development.  That’s a lot of money.  But it’s significantly less than the $49 billion in profit they made.  Just so you know, the average Fortune 500 company in 2008 made 0.9% of sales in profits.  So in a recession, pharma did very, very well.  See that blue wedge, though?  Those pharmaceutical companies spent $83 billion on marketing and administration. That’s more than twice as much as they spent on research and development.  That’s an insane amount.

So it’s a little disingenuous to claim that Americans must continue to spend so much to fund R&D when you could make cuts to either profits (which are big) or to marketing and administration (which is gargantuan).  R&D just isn’t that big a piece of the pie.  There’s plenty of fat to trim in there before research and development.

Why do they need to spend so much on marketing?  I’m glad you asked.  Let’s enjoy more of Dr. Angell’s investigative skills and turn to FDA approval data:

The pie represents all new drugs approved by the FDA from 2000-2007.  The first thing to note is the difference between New Molecular Entities (Blue wedges) and non-New Molecular Entities (Green wedges).  See, the FDA will classify a drug as a totally new molecule (NME) or a copy/tiny change from an old molecule (non-NME).  New molecular entities need more research and development.  It takes much less money and work to make a slight change to an already existing compound.

The FDA further classifies a drug by the type of review it necessitates:

Priority Review – Significant improvement compared to marketed products in the treatment, diagnosis, or prevention of a disease.

Standard Review – The drug appears to have therapeutic qualities similar to those of one or more already marketed drugs.

In other words, priority review drugs are much better than what we already have. Standard review drugs are similar to what we’ve got.

From 2000-2007, 667 new drugs were approved by the FDA.  Of those, only 75 (11%) were new molecules that were much better than what we already had.  In fact, over 80% of all drugs approved were no better than what we already had.  Those are “me-too” drugs.

Why do the pharmaceutical companies spend so much on marketing?  Because you have to really promote drugs that really have no benefit over others that already exist.  You have to convince people to buy those.

You know what needs no promotion?  Awesome new drugs that save lives.  When was the last time you saw a commercial for chemotherapy?  For epinephrine?  For steroids?  Those drugs need no promotion – doctors just know to use them.  But I bet all of you know about Nexium.  Or Cialis.

You only need to market drugs which aren’t obviously better.  If drug companies really committed to research and development of new molecular entities that were deserving of priority review, they could really reduce their marketing and administration budgets and cut the prices of drugs dramatically.  They need a better argument against charging less for drugs.

More on where research gets done (Part 2) tomorrow.

The Truth About the Drug Companies: How They Deceive Us and What to Do About It, by Marcia Angell.

Lots of you ask why I’m skeptical of the ability of a public option to truly effect massive change on the US health care system.  I give lots of answers, but – perhaps – many of you assume that I’m making a leap of faith instead of looking to the literature.

Not so!

One of my main concerns is that I don’t necessarily believe that when you put a public plan alongside a private plan, that you won’t wind up with unequal risk pools.  On the theoretical side, I would point to the different missions of those two types of outfits.  The public plan is focused on distributing funds for care; the for-profit plan is focused on, well, profit.  Those are not the same thing.

On the empirical side, I could point to the fact that Medicare Advantage has failed to deliver the same Medicare product for a cheaper amount (which was it’s mission), but we’ve done that before.

And there is more peer-reviewed research.

In an important paper in the New England Journal of Medicine in 1997, researchers examined how people moved in and out of Medicare HMO plans and traditional Medicare.  See, back in the 1990’s there was a swing to “managed care”.  Private HMOs began to offer their services to Medicare recipients.  If you were over 65, you could choose a Medicare HMO or regular Medicare on a month-to-month basis.  If you chose the Medicare HMO, you had to use their providers and hospitals, but otherwise it should be similar.  So, here were the rules if you were eligible for Medicare:

• You could choose the public or private system
• You could switch up and back
• No one could deny you access to their plan
• The benefits in the private plans could be more than the public, but not less

Got that?  No cherry picking allowed.  This looks very similar to how a public plan would function against private plans on the exchange.  So what happened when this was set up and let loose?  Guess:

Methods We used Medicare enrollment and inpatient billing records for southern Florida from 1990 through 1993 to examine differences in the use of inpatient medical services by 375,406 beneficiaries in the Medicare fee-for-service system, 48,380 HMO enrollees before enrollment, and 23,870 HMO enrollees after disenrollment. We also determined whether these differences were related to demographic characteristics and whether the pattern of use after disenrollment persisted over time.

What did the researchers do?  They looked at Medicare billing records for over 375,000 elderly Americans over a number of years.  This allowed them to look at how much inpatient care those people used.  They also looked specifically at how much care they used in the year before anyone went to an HMO and the three months after they left an HMO.  If there is no cherry picking, then they should find that the amount of care used should be the same in all of those groups and times.

Results The rate of use of inpatient services in the HMO-enrollment group during the year before enrollment was 66 percent of the rate in the fee-for-service group, whereas the rate in the HMO-disenrollment group after disenrollment was 180 percent of that in the fee-for-service group. Beneficiaries who disenrolled from HMOs re-enrolled at about the time that their level of use dropped to that in the fee-for-service group.

What did the researchers find?  People who wound up joining the (private) HMOs used 66% less care before joining than those who stayed in the (public) Medicare group.  Somehow the private insurance HMOs figured out a way to get the healthy people to jump ship out of the public plan into the private one!

Not only that, but people who left the (private) HMOs and went back to the (public) Medicare used 180% more care after leaving than the people who stayed.  Somehow the private insurance HMOs figured out a way to convince the sicker people to jump ship back to the public plans.

So we had a system where a private system and a public system were in an exchange like environment.  Regulations prevented cherry-picking.  And yet – somehow – the private plans figured out a way to do it.  And this was competing with a giant government program.

Can you understand my limited faith in the ability of a wimpy, tiny public plan to do any better?

The Medicare-HMO revolving door–the healthy go in and the sick go out. Morgan RO, Virnig BA, DeVito CA, Persily NA. N Engl J Med. 1997 Jul 17;337(3):169-75.

I’ve been sitting at an out-of-town meeting all day.  It’s part of my job, though I actually complain about it quite a bit.  I’ve never had a long attention span, and the idea of sitting around listening to other people talk never appeals to me.

There are times, however, when I hear a really good presentation, one that relies on evidence and data and constructs a well-supported argument.  It’s what I hope to achieve here. I want to explain to you why my hypothesis or statement is correct, and supported by good evidence, in such a way that I persuade you to think about what you believe.  Perhaps I will get you to change your mind; perhaps I will help you to strengthen the foundation of your beliefs.

I haven’t been playing to my strengths enough.  I should be bringing you more original work, more original research.  I’m going to commit to try and bring you posts, hopefully every day, highlighting a certain paper, study, or analysis.  I will try and explain what the authors did, and what I think about the quality of their work.

I welcome feedback on this.  Tell me what I’m doing right and wrong.  More importantly, feel free to send me work you think deserves highlighting or explanation.  I will endeavor to get as much as possible on the site.