Flaw in ranked-choice voting: rewarding extremists

 In November’s midterm elections, control of the U.S. House of Representatives will be determined by the thinnest of margins. 

One of the most closely contested races is in Alaska, an election that is unusual for two reasons. First, the election is essentially a rematch of a special election held in August. Second, the election will be conducted using ranked-choice voting, a system for conducting elections with more than two candidates whose popularity in the United States is quickly spreading.

In August’s special election, Democratic Party candidate Mary Peltola defeated Republicans Nick Begich III and Sarah Palin and, as a result, she is favored to win again. However, Peltola’s victory was the result of an extremist bias that is inherent to the method used by ranked-choice voting to select winners. It is thus entirely possible that the fate of the House will turn on a flaw in the ranked-choice voting system rather than the preferences of the Alaskan voters.

The popularity of ranked-choice voting stems from the fact that it permits candidates with extreme political views and narrow bases of support to run in elections without acting as a spoiler for one of the major party candidates. For example, in the 2000 presidential election, Democrat Al Gore lost to Republican George W. Bush in Florida by a smaller margin than the total number of voters who voted for Green Party candidate Ralph Nader.

In ranked-choice voting, if no candidate gets a majority of the vote, candidates are iteratively dropped from the election and their support is reallocated among the remaining candidates until one candidate has a majority. In Florida in 2000, then, Nader would have been eliminated in the first round and his support reallocated between Gore and Bush. If most Nader supporters preferred Gore to Bush as their second-place choice, these votes would have swung Florida, and the presidential election, to Gore.

However, ranked-choice voting makes it more difficult to elect moderate candidates when the electorate is polarized. For example, in a three-person race, the moderate candidate may be preferred to each of the more extreme candidates by a majority of voters. However, voters with far-left and far-right views will rank the candidate in second place rather than in first place. Since ranked-choice voting counts only the number of first-choice votes (among the remaining candidates), the moderate candidate would be eliminated in the first round, leaving one of the extreme candidates to be declared the winner.

This is exactly what happened in the special election in Alaska. Peltola was declared the election winner under a ranked-choice voting system, but the more moderate Begich was preferred by more of the electorate. In the official election results, Begich received just 52,536 first-place votes, compared with 74,817 for Peltola and 58,339 for Palin, and was therefore eliminated after the first round.

However, we analyzed the anonymized voter data made public by the Alaska Division of Elections, a dataset that includes the complete ranking of candidates for every scanned ballot in the election and comprises over 99 percent of the total votes counted. We found that Begich won head-to-head contests against Peltola by over 8,000 votes (86,385 to 78,274) and against Palin by over 38,000 votes (99,892 to 61,606).

What should be done? Locales interested in holding elections with more than two candidates should use a different vote counting system. There are many voting methods that ensure moderate candidates will tend to beat extreme candidates in the presence of a polarized electorate. 

Three well-known and well-studied methods are Borda’s rule (where voters allocate points to candidates based on their ranking of candidates), Copeland’s rule (which gives candidates points for the number of times they beat another candidate in a one-on-one competition) and Kemeny’s rule (which reverses as few votes as possible to produce unanimity among the voters). There are many other vote-counting systems that share a similar tendency toward moderation when the electorate has many voters with extreme, countervailing views.

Consider Borda’s rule, which in a three-candidate election would assign 2 points to a voter’s top-ranked candidate, 1 point to candidates ranked second, and 0 points to candidates ranked third or not ranked at all. Adding the points from all of the voters, the candidate with the most points wins. After removing write-in candidates, Begich would receive 186,277 points under Borda’s rule, Peltola would receive 168,238 points, and Palin would receive 145,435 points, meaning that Begich would have won the special election.

In fact, Copeland’s rule, Kemeny’s rule, and a wide variety of other well-studied rules would all have selected Begich as the winner.

The ranked-choice system that is being used around the country to conduct elections with more than two candidates is biased towards extreme candidates and away from moderate ones. This is just as important of an issue for the future of American democracy as the other important policy concerns surrounding voting in our country. 

When there are more than two candidates, it is not just about counting votes accurately. How you determine a winner from the tallied votes matters too. Given our current polarized political environment, Alaska and the other states that have adopted ranked-choice voting are doing it wrong.

Nathan Atkinson is an assistant professor at University of Wisconsin Law School. Scott C. Ganz is an associate teaching professor at Georgetown University’s McDonough School of Business and a research fellow in economic policy studies at the American Enterprise Institute.

https://thehill.com/opinion/campaign/3711206-the-flaw-in-ranked-choice-voting-rewarding-extremists/

Hillary Clinton suggests conspiracy surrounding Paul Pelosi attack

 Elon Musk on Sunday responded to a tweet by Hillary Clinton tying an assault on Paul Pelosi to Republican rhetoric by espousing a conspiracy theory surrounding the circumstances of the incident.

A 42-year-old man allegedly broke into the San Francisco home of Speaker Nancy Pelosi (D-Calif.) and her husband, Paul, early Friday morning and assaulted the Speaker’s husband with a hammer, leading him to undergo surgery for a skull fracture.

Clinton lambasted the GOP while sharing a Los Angeles Times article that reports the suspect echoed QAnon conspiracy theories.

“The Republican Party and its mouthpieces now regularly spread hate and deranged conspiracy theories,” Clinton tweeted on Saturday afternoon.

“It is shocking, but not surprising, that violence is the result,” Clinton continued. “As citizens, we must hold them accountable for their words and the actions that follow.”

On Sunday morning, just a few days after he took over the social media platform, Musk tweeted at Clinton by sharing an article detailing an unfounded, right-wing conspiracy about the circumstances of the attack. 

“There is a tiny possibility there might be more to this story than meets the eye,” Musk wrote.

There is no evidence to back up the claims made in the article by a website known for repeatedly publishing stories that are false, including one in 2016 that claimed Clinton had died during that year’s presidential campaign and that a body double was sent to debate then GOP-candidate Donald Trump.

After taking over the platform, Musk quickly made moves to determine content decisions, which comes as many of the Tesla CEO’s critics express worry about the spread of misinformation on the platform under more relaxed content moderation policies.

The specifics of future content moderation on Twitter under Musk’s ownership remain unclear, and he has also vowed to implement significant changes to the platform, like layoffs and the lifting of lifelong bans, including that of Trump.

“Twitter obviously cannot become a free-for-all hellscape, where anything can be said with no consequences!” Musk wrote in a statement posted on Thursday.

The assault on Paul Pelosi has drawn condemnations from both sides of the aisle, and it marks the latest in a long series of attacks and threats against lawmakers and prominent government officials that has grown in recent years.

The Speaker said on Saturday that her husband’s condition continues to improve, calling the alleged altercation “life threatening” and “traumatizing.”

“Please know that the outpouring of prayers and warm wishes from so many in the Congress is a comfort to our family and is helping Paul make progress with his recovery,” she wrote in a Dear Colleague letter.

https://thehill.com/homenews/house/3711430-musk-tweets-at-hillary-clinton-suggesting-conspiracy-surrounding-paul-pelosi-attack/

Fresenius Medical cuts outlook on slower recovery, rising costs

 

Kidney dialysis provider Fresenius Medical Care (FMC) on Sunday revised down its forecast for 2022, expecting net income to decline this year, dragged down by rising labour costs and a slower than expected recovery in North America business.

The company now expects net income to decline in the high-teens to mid-20s percentage range this year, down from its previous outlook of a high-teens percentage drop. It still expects revenue to grow at a low single digit percentage rate.

FMC said net income dropped 16% in third quarter to 230 million euros ($229.15 million) while operating income fell by 7% to 472 million euros in the quarter.

https://www.marketscreener.com/quote/stock/FRESENIUS-MEDICAL-CARE-AG-436087/news/Fresenius-Medical-cuts-outlook-on-slower-recovery-rising-costs-42132026/

Innumeracy is a big giveaway

..one the press likes to overlook because there are so many 'patients' among them... [emphasis ours]

In his latest gaffe, the 'most popular president in US history' claimed that Democrats campaigned in "54 states" in 2018 to defend Obamacare.

 "And, of course, they’re going try for their 499th time, or whatever the number is — they’re still determined to eliminate the Affordable Care Act. And, by the way, if they do, that means — not a joke, everybody," said Biden, not jokingly. "That’s why we defeated it in 2018 when they tried to do it. We went to 54 states."

"The reason is people didn’t realize that the only reason anybody who has a pre-existing condition can get health care is because of that Affordable Care Act," Biden continued, warning that "these protections will be gone as well if Republicans get their way."

Amazingly, Biden has his defenders - including this self-described 'attorney and animal lover' who claims Biden must have been referencing US territories, while talking about Dems campaigning for Obamacare.

Of course, even if Biden was talking about US territories - their residents can't vote in US elections and have non-voting representation in Congress.

https://www.zerohedge.com/political/biden-claims-there-are-54-states-latest-gaffe

Senate Republicans want the SEC to explain why staff are quitting

 

Senate Republicans want the SEC to explain why staff are leaving the nation's corporate watchdog at the highest rate in 10 years amid a flurry of proposed rules, according to a letter seen by Reuters on Sunday.

The private letter dated Oct. 27 from Senate Republicans to the chair of the Securities and Exchange Commission, Gary Gensler, adds to mounting criticism that the U.S. regulator lacks the internal firepower it needs to accomplish its ambitious rulemaking plans.

Gensler, a veteran Wall Street regulator who was chosen by President Joe Biden, a Democrat, has already clashed with Republicans over the watchdog's proposals on corporate climate-related disclosures. 

Gensler has previously contended that his new rules are critical to ensuring the U.S. capital markets remain the global "gold standard."

Republicans have claimed he has overstepped his authority and adopted a hostile stance toward the financial industry.

The SEC has introduced 26 new rule proposals in 2022, more than double the number in 2021 and the highest total of any year in the last five years, the Republican letter says.

The letter, signed by six of the 12 Republicans on the Senate Banking Committee, references a public Oct. 13 report posted on the SEC's website from the Office of the Inspector General, the SEC's own internal watchdog, detailing staff attrition and reports of discontent.

Republicans want Gensler to explain how he will address the concerns in the report and also to allow more time for industry feedback on the new rules.

The SEC was not immediately available for comment.

Employees interviewed for the internal watchdog report said they received little feedback on rules they had written, according to the report.

Staff feared an increased risk of litigation because of shortened industry comment periods, the report said.

The SEC is losing employees at its highest pace in 10 years, said the Inspector General's report. The agency expected attrition in senior officer positions to be 20.8% this fiscal year and 8.4% for attorney positions, it said.

The letter concludes that "efforts to ram through hurried rulemaking without proper analysis, deliberation or consideration of downstream negative impacts is nothing short of regulatory malpractice."

Senate Republicans Thom Tillis from North Carolina, Mike Crapo from Idaho, Tim Scott from South Carolina, Michael Rounds from South Dakota, Bill Hagerty from Tennessee and Steve Daines from Montana signed the letter.

https://www.marketscreener.com/quote/stock/HAGERTY-INC-130269453/news/Senate-Republicans-want-the-SEC-to-explain-why-staff-are-quitting-42131971/

Welcome or Patient Look Out: Evaluation and Management Code Changes Starting January 1

 Medical professionals aren't always thrilled by Current Procedural Terminology (CPT) code revisions, but the changes the American Medical Association is making for 2023 will result in less work for physicians.

The application of a revised evaluation and management (E/M) office visit framework from 2021 to E/M services defined by history, exam, medical decision-making, and time is good news. These changes, which physicians with office-based practices have already implemented, will soon extend to hospital services, nursing facility services, and home and domiciliary visits. Hospitalists and medical and surgical specialists will use the ht_221017_betsy_nicoletti_120x156.pngnew guidelines for hospital care.

What's New, and What Are the Advantages?

In addition to benefiting physicians who care for patients in hospitals, nursing facilities, and at home, extensive history and exam requirements from the 1995 and 1997 Documentation Guidelines are gone. CPT states that E/M services include a "medically appropriate" history and exam, but neither history nor exams are key components in visit selection. Instead, the nature and extent of history and exams will be determined by the practitioner.

Starting January 1, no physician will have to hear, "It would have been a level 3 admission, but you only had nine systems in the review of systems and it requires 10. It audits as a level 1 admission without that tenth system." Or, "You can't bill that code without an eight-organ-system exam." The new regulations allow physicians to document a more clinically relevant history and exam.

Although American Medical Association (AMA) administrators have said that most code selections should be based on medical decision-making, there are instances in which using time to select a code level is beneficial.

Say, for example, you were with a patient for 20 minutes, but it took you another 45 minutes to arrange for the needed follow-up. Beginning in 2023, counseling and coordination of care no longer need to dominate the visit. Instead, practitioners can select a code based on the total time devoted to a patient on the day of service — including time when the patient wasn't present. This includes pre-visit time, time spent reviewing history obtained by a staff member; time with the patient; and time spent doing documentation, care coordination, and review that is not separately billed.

CPT specifically says the practitioner can include time spent "reviewing separately obtained history." This lets a staff member obtain and document the history of the present illness, which was not allowed under the old guidelines.

Medical groups can use these changes to significantly revise templates. The 1995 and 1997 guidelines spawned templates that supported a high-level code. For high-level visits, family history was required, whether relevant or not. Groups and electronic health record vendors built templates that included a review of systems and a comprehensive exam. For some specialties, the comprehensive exam was difficult to do or justify. Now, these templates can be updated for clinical relevance.

One Set of Codes for Inpatient and Observation Services

You will need to use the same codes for patients who are admitted to the hospital and patients receiving observation-level care (when the patient's condition is changing quickly, but it's not yet clear whether hospitalization is required). Use codes 99221-99223 for the initial service, 99231-99233 for subsequent visits, and 99238-99239 for discharge care.

These will now be "inpatient or observation care" codes, not "hospital care" codes. The claim will still need to be submitted with the correct place of service code. Use place of service 21 for inpatient claims. Observation is considered an outpatient service, so use place of service 22.

Definitions for Initial and Subsequent Services

The AMA has added definitions for initial and subsequent services provided in hospitals and nursing facilities. For the admitting physician within a group and specialty, one initial service is allowed per admission. A covering physician or nonphysician practitioner within that same group and specialty can bill for follow-up services.

Consulting services provided by a different specialty physician are defined as initial services. For Medicare and other payers that do not recognize consultations, the initial consultation service is billed with codes 99221-99223. If the payer recognizes consultation codes, use codes 99252-99255. Follow-up services for both the admitting and the consulting physician are billed with codes 99231-99233.

Admission in the Course of Another Encounter

One of the more surprising guideline changes is this one: "When the patient is admitted to the hospital as an inpatient or to observation status in the course of an encounter in another site of service (eg, hospital emergency department, office, nursing facility), the services of the initial site may be separately reported. Modifier 25 may be added to the other evaluation and management service to indicate a significant, separately identifiable service by the same physician or other qualified health care professional was performed on the same date."

That is, if a physician sees a patient in the emergency department or office and admits the patient to the hospital on the same day, both E/M services can be billed. It is doubtful that Medicare or other payers will agree with this change from the current guidelines.

What Else Do You Need to Know?

• Observation codes 99218-99220 for initial services and 99217 for discharge will be deleted in 2023. Use initial hospital care codes 99221-99223, subsequent hospital care codes 99231-99233, and discharge visit codes 99238 and 99239 for both observation-level care and inpatient encounters.

• Patient admissions and discharges on the same date will still be reported with codes 99234-99236.

• Emergency department services may be based on medical decision-making only, not time.

• Home visit codes are redefined as home and residence services and will be used for patients seen at home or in domiciliary or boarding care.

• The section on consultations was edited for the 2023 CPT book. Codes 99241 and 99251 have been deleted. Consultations are defined as services provided at the request of another physician, other qualified healthcare professional, or a source who is qualified to recommend care for a condition or problem. The consultant may initiate diagnostic or therapeutic services. The consultant's opinion must be communicated in writing to the professional requesting the consult.

The hope is that these changes will be able to reduce some of the burden that physicians wrestle with and will be considered a positive development for the task of coding.

https://www.medscape.com/viewarticle/982550

COVID-19 Tied to Increased Risk for CV Events and Death

 COVID-19 infection is associated with an elevated risk for incident cardiovascular disease events and death compared with those with no history of COVID-19, a retrospective analysis shows.

The risk for adverse outcomes and death was highest among those hospitalized for COVID-19, but, in those not hospitalized, there was still an increased risk for venous thromboembolism (VTE) and mortality after infection.

Notably, events with the largest risks for those hospitalized for COVID were stroke, VTE, and heart failure, but increases were also seen in incident atrial fibrillation (AF), pericarditis, and myocardial infarction (MI), Zahra Raisi-Estabragh, Queen Mary University of London, United Kingdom, and colleagues reported.

The risk for cardiovascular disease events and mortality was "almost entirely confined to those requiring hospitalization and [was] highest in the first 30 days post infection but remained augmented for a prolonged period thereafter," the authors concluded.

The results were published online October 24 in the journal Heart.

The study team set out to assess the relationship between incident cardiovascular events and COVID-19 using data from the UK Biobank.

They evaluated 35,742 propensity score-matched uninfected controls and 17,871 participants with a history of COVID-19. Females accounted for 55.3% of the whole UK Biobank cohort, and their median age was 69 years. The researchers followed the patients from March 2020 to the time of a cardiovascular event, until a patient died, or until March 2021.

Of the 17,871 COVID-19 cases included in the study, 14,304 didn't require hospitalization, 866 patients were found to have COVID-19 but were hospitalized for other conditions, and 2701 required hospital admission for their COVID infection.

The investigators identified COVID-19 cases with health record data. They then propensity score–matched each Biobank case to two uninfected controls based on high cholesterol, smoking, sex, age, ethnicity, diabetes, deprivation, smoking, body mass index, and hypertension.

Ischemic heart disease death, VTE, all-cause mortality, pericarditis, cardiovascular mortality, MI, AF, heart failure, and stroke were all among the incident outcomes assessed. Over a mean prospective follow-up period of 141 days, the researchers estimated the relationships between COVID-19 and each outcome using Cox proportional hazards regression.

In nonhospitalized cases of COVID-19, they found an increased risk for death (hazard ratio [HR], 10.23; P < .0001) and incident VTE (HR, 2.74; P = .004) compared with matched uninfected controls.

Patients hospitalized primarily for their COVID-19 infection (2701) had increased risk for "all outcomes considered," the authors write. The largest effect sizes were seen for stroke (HR, 17.5; P < .0001), VTE (HR, 27.6; P < .0001), and heart failure (HR, 21.6; P < .0001), but higher risks were also seen for incident AF, which was increased by almost 15-fold, they note. Pericarditis increased by 14-fold, and there was a 10-fold increase in MI in the hospitalized COVID patients compared with uninfected controls. 

Finally, among patients hospitalized for other issues and found to have COVID-19 as a secondary diagnosis (n = 866), there was an increased risk for all incident outcomes compared with those without infection. While their risk for all-cause death was lower than for those hospitalized primarily for COVID-19, the risk for death from cardiovascular or ischemic heart disease was higher, as was incident MI and AF risk.  

"Currently, the National Institute [for] Health and Care Excellence recommends prophylactic low molecular weight heparin for VTE prevention in hospitalized patients with COVID-19 and in patients who would otherwise be admitted to hospital (eg, hospital at home) for a minimum of 7 days," the authors note, consistent with similar recommendations from the British Thoracic Society and the American Society of Hematology. "Our results indicate that the risk of VTE is also increased in non-hospitalized individuals," they write.

Limitations of the study include residual confounding from comorbidities not accounted for in the matching method, lack of consideration for the effects of cardiovascular prescription drugs like angiotensin-converting enzyme inhibitors or statins, and possible underestimation of adverse cardiovascular risk given the relatively healthy UK Biobank cohort, the study authors noted.

Further, the study does not account for other possible modifying factors like multiple infection exposures, effects of COVID-19 vaccinations, and new variants, the investigators added.

More investigation is needed to determine the timeframe over which cardiovascular risk is elevated after COVID-19, the study authors noted.

"Future studies are needed to address whether specific interventions are needed to mitigate the risk of venous thromboembolism associated with COVID-19," they conclude.

Expert Commentary

These results fall into line with the existing literature, noted Anda Bularga, MD, David Newby, MD, PhD, and Andrew R. Chapman, MD, all from The University of Edinburgh, United Kingdom, in an accompanying editorial.

Before the COVID-19 pandemic, systemic inflammation due to respiratory tract infections was a well-known risk factor for stroke and incident MI, with a four-time greater risk reported in an assessment of 5 million patients within 3 days of diagnosis of lower respiratory tract infection as documented in the UK General Practice Research Database, the editorialists noted.

Comparable results have been reported in numerous contexts, such as infective exacerbation of chronic obstructive pulmonary disease, where there is a noteworthy risk for early cardiovascular events that is also elevated in hospitalized patients, they added.

"The prothrombotic effects of COVID-19 do raise the question of whether antithrombotic strategies are required to prevent this large excess of events."

Perhaps a larger question to consider is if the use of antithrombotic treatments, including anticoagulant or antiplatelet therapies, should be considered in all patients, they write.  

"Clearly, duration of therapy is relevant, and these data do question whether 7 days of prophylactic anticoagulation is sufficient for patients with COVID-19," the editorialists concluded.  

Srihari S. Naidu, MD, professor of medicine at New York Medical College in Valhalla, who was not involved in the study, commented on the results for theheart.org | Medscape Cardiology.

"We have to be much more vigilant about these patients even after 30 days," he said. "For the more common cardiovascular events that we may ascribe to just normal underlying cardiovascular disease but really, based on this data, it is being heightened or increased because of an ongoing likely inflammatory prothrombotic effect that has lingering consequences after 30 days."

Naidu noted that future research should look at more recent waves and variants of COVID-19. "My suspicion is that the risk will be much lower," he added. "That would provide some reassurance that if you didn't get COVID-19 during that first year, that COVID now is a more benign disease."

Heart. Published online October 24, 2022. Full text, Editorial

Naidu reported no relevant financial relationships.

https://www.medscape.com/viewarticle/983210