Friday, May 12, 2017

The Emerging Organizational Structure of Health Care

This paper has been brewing in me for some time.  I can't say it's finished, but it is up to a place where I would like to show it to you all and invite your comments.  While it is clearly written from my perspective as a primary care practitioner and as a member of the Section on Administration and Practice Management of the American Academy of Pediatrics, nonetheless, I believe it is widely enough based to have practical applicability.

Warning: 3,500 words (in other words, not publishable in its present form in a journal, alas.)


The Emerging Organizational Structure of Health Care
May 2017 draft

It is a recognized principle that structure and function must go together. Thus, the organizational structure (OS) of our health care delivery system strongly conditions the cost, quality, and experience of care produced by that system. So it is somewhat remarkable that, even as the OS of our system changes profoundly right in front of us, and even as the financing of that system is discussed perhaps more than any other domestic issue, there is little systematic and critical discussion of OS.

This absence needs to be rectified. Not that an ideal OS needs to be identified – indeed, I will argue that there is no such ideal OS. But unless an overt and conscious policy is developed that will encourage an evolution of OS that serves the public well, the evolution will fall prey to ungoverned political and economic forces that will not necessarily respond to the needs of the public. This paper intends to help uncover the conditions that the policy needs to address.


How OS Is Changing

The universal theme of OS change is agglomeration and centralization, and some would say, corporatization. Horizontal Integration (HI) is ubiquitous. “Sixty percent of hospitals are now part of health systems.”i Independent physician offices have become larger single-specialty groups and community clinics. Health insurance companies are fewer, larger, mostly for-profit, and richer.

Vertical integration (VI) has occurred as well. Multi-specialty groups have grown and multiplied, often tied to hospitals. Hospitals currently employ over half of the physician force, and have absorbed aftercare units.ii The completely integrated system (IS) of Kaiser Permanente, continues to dominate California's market and is increasingly emulated elsewhere. Accountable Care Organizations (ACO's) can be viewed as the most recent iteration of VI. Large hospital centers are increasingly partnering with insurance companies or trying to bring the financing arm in-house. Insurance companies are buying practices and investing in clinical services such as nurse advice and telehealth. Ownership of the means of production (which means clinicians and their facilities) has shifted from professional dominance to corporate control.

Agglomeration is clearly a fact. But, is this fact a good thing?


Evaluating Agglomeration

The Pluses of Agglomeration

Mid-20th century liberals derided the traditional decentralized system as a “cottage industry” model, and proposed a more modern industrial model of VI financed by capitation for “prepaid care.” The business-oriented Nixon Administration agreed, renaming “prepaid care” as Health Maintenance Organizations. Alan Enthoven suggested that “the provider community must be divided into competing economic units” with his concept of “managed competition.”iii Today, the argument for larger integrated entities has become orthodoxy.

The agglomeration argument asserts that larger organizations can internalize operations and thus decrease open market transaction costs and rationalize the disparate functions of health care delivery; that if costs are centralized, then priorities will shift to prevention and efficiency; and that larger scale will deliver economies of scale and decrease risk. Rationalization will come from leadership's having more information and control, from recruiting and training physician leadership, from specialized professionals leading corporate functions such as personnel, finance, and information technology, and from allowing most physicians to devote themselves only to the practice of medicine. Larger firms can better adjust to new payment schemes by payers. Innovation will be fostered by larger accumulations of capital, and lower risk of the consequences of failure. Larger firms can integrate lesser-trained professionals more easily into productive clinical roles.

In addition, larger size confers benefits in relations with the world outside the firm. Insurance companies will pay higher rates to larger firms. Larger firms have more power in governmental negotiations. Large firms can afford to advertise, and can recruit high quality personnel more easily.

The minuses of agglomeration

The minuses of agglomeration, however, are just as compelling. “In companies with lots of divisions and product lines, it’s hard for executives to concentrate on the core business.”iv In academic centers the research agenda may trump clinical service, and within VI entities highly profitable specialties can trump the attention paid to primary care. Moreover, large organizations can cushion the competitiveness of individual units – a specialty unit with built-in referrals from the network needs only to be “good enough” rather than outstanding.

Bureaucracies experience careerism, turf battles, and information withholding. Creativity can be stifled; promotion of clinicians can depend on deference to administrative leaders.v Administrative overhead can expand needlessly; profit-driven and power-driven leadership can drive out the medical ethic. Clinicians in large groups can seek approbation from colleagues rather than patients.vi As losing a patient has smaller economic consequences, patient service can become a bureaucratic afterthought.

Lammenais observed that, “Centralization breeds apoplexy at the center and anemia at the extremities.” A more recent observer warns that the ills of VI are so pervasive that that VI should be avoided if possible because of the inherent difficulties of managing a vertically integrated firm, and that the motivation for VI is more often a search for market power rather than improved performance and efficiency.vii

The pluses of decentralization

The conservative American Medical Association was the earliest defender of the decentralized status quo, citing a better doctor-patient relationship, and emphasizing the positives of professional dominance.viii In 1971 a brilliant article by physician Michael Halberstam encapsulated the anti-corporate position of the Left, in surprising support of the AMA position, placing priority on authentic person to person relationships supplied by smaller organizations.ix Today, a contemporary business theory supports decentralization in the form of the Centers of Excellence (COE) model.x

COE envisions competition among smaller independent units of care connected by information and communication technology rather than by VI's ownership and overt direction. In this model, for instance, a primary care Patient Centered Medical Home (PCMH) would unite the patient and primary care provider in choosing referrals among competing centers with varying combinations of cost and quality, be they large or small specialist practices, general or specialty hospitals or procedure centers, etc., rather then being tied into a mandatory network. In theory, the PCMH alliance of PCP and patient makes free market competition practical by circumventing the problem of low patient knowledge, and activates the medical-fiduciary role of the clinician in choosing referrals freely rather than from a constrained list.

Decentralized units reduce bureaucracy and administrative overhead, and modern information and communication technology make it possible for smaller units to be exquisitely efficient. Unlike in an IS, lower performing units are not coddled, and competition for patients drives high performance and innovation. Smaller units tend to be more personal for both employees and patients, so important in the caring function, and so helpful in easing communications within the organization and from the organization to patients.

Owners are incentivized both financially, by professional pride, and by the caring connection to the patient. The more direct financial and personal connection to the patient may provide increased incentives for patient-centered care. Smaller units can be more flexible than larger bureaucracies in serving patient needs, can focus attention more acutely on their narrower missions, and can foster creativity rather than stifle it by demanding conformity.

The minuses of decentralization

On the other hand, smaller units can become isolated and slow to adopt new knowledge, have less capital available for investment in innovation, less expertise available for administrative and clinical functions, and may have poor quality oversight. Excellent staff may need to leave a practice to be promoted. The need to retain patients can lead to poor medical practices in order to maintain popularity (e.g., prescribing unnecessary antibiotics.) COE advantages might not be realized if the patient-PCP unit does not search well for superior referrals. Communications and information flows might be inhibited by lack of community inter-operability. Leadership may be dispersed instead of centralized, and network coherence might then not be realized. Individual units may suffer by their lack of market power.

Theory vs. Reality

The point is this: with so many pluses and minuses for each model, the key to success will not be adopting a single model everywhere, especially given America's taste for variety. Rather, most areas will need artful adoption to the strengths of each area, capitalizing on strong organizations and capable leaders wherever they are found. Most solutions will be hybrid, combining the virtues of the VI model and the COE model, and often using intermediate organizations such as IPAs for coordination and leadership.xi Although highly specialized services will generally be centralized and primary care will most often be decentralized, it will be hard to prescribe whether it is better to put them in the same organization or keep them separate. Rather than any specific OS being ideal, practical implementation and even improvisation will be most important.

The case for more than one system in an area is strong, because people and preferences are different: both patients and professionals differ in their tastes for smallness or for bigness, professionals differ in their preferences for employment or entrepreneurial ownership, etc. There must be room for the brilliant individualist as well as the consummate leader, and often these shining lights will not fit into the same system.


Policy Implications

The traditional role of government is not to choose winners, but rather (1) to ensure that the playing field for competing solutions is level, (2) to protect against undue concentration resulting in oligopolies and monopolies, and (3) to establish regulation where concentration is desirable. In health care, where government has been intimately involved and has been the ultimate funder for perhaps 2/3 of healthcare provision, it has also appropriately (4) encouraged improvements by various grants and programs, (5) given feedback on performance, (6) actively established and run health systems on its own (Veterans Affairs, local safety net hospitals and clinics, public health departments, etc.), (7) affected care policies through its payment policies (DRG's, etc.), and done other things as well.

Even while government aims at the public good, however, like other entities, it is subject to its own prejudices. It is particularly difficult to establish policies where an industry is in flux, as is the case with healthcare. Established organizations typically attempt to use their expertise, money and power to extend their current predominance into the future, not only by making legitimate progress on their own, but also by suppressing other organizations. Government itself often tends to support larger organizations because they are easier to deal with than decentralized systems, and governmental officials might incline to the orthodoxy that larger is better. That has certainly been the case with health care. Because of these potential prejudicial factors, specific and overt policies are necessary for non-prejudicial competition to prevail.

The OS policy task is then to determine:

  • Which policies can best support the development of local institutions nationwide, giving each area full freedom to develop its own pattern of organizational structure, without prejudice for which structures should be centralized and which decentralized?
  • How can the interests of patients be placed as the central focus of organization?
  • How can the interests of individual providers, as workers in the system and as representatives of a traditionally idealistic profession, be respected as well?

The following suggestions for policy are aimed at those targets.

Acknowledging, refereeing, self-assessing

Government needs forthrightly to acknowledge that different solutions will be appropriate for different areas of the country, and thus to declare a neutrality policy for preference of scale of institutions, understanding that larger organizations will need regulation is they are oligopolistic.

To operationalize this principle, government needs to take the position that it will actively take steps to seek to establish a level playing field for the contending forces, and that it will continuously monitor and adjust the conditions of engagement.

Government should then examine the implications of all of its present program policies with regard to the agglomeration of organizations, and adjust policies which are not neutral. (For instance, the ACO program supports centralization without any balancing program for decentralization; the Medicare Alternative Payment Models regulations favor large organizations, and FTC regulations allow integrated systems to negotiate with insurance companies, but does not allow negotiation by more loosely aligned groups.)

Government should also require itself to inspect all proposed health care policies for their organizational agglomeration implications, and issue an agglomeration impact statement for each policy as a prerequisite for its being adopted.

Distinguishing Centralized Effectiveness from Market Power

Operational advantages of size – such as economies of scale, administrative specialization, decreased transaction costs and ease of internal coordination, investment in innovation and quality enhancement – benefit both the company and the public and need to be retained. Market power advantages of scale, however, may redound only to the benefit of the organization, and against the public interest. Government needs to assess these differences and regulate the marketplace so that only the former accrue to the advantage of the large scale organizations. Examples follow.

Clinical service pricing

Large predominant organizations – often hospitals – can be “must haves” for networks, which results not only in high payment rates for in-hospital services, but also in payment rates for outpatient services by in-network clinicians that are much higher than those obtainable by independent practices with less market power, not to mention added on “facility fees” obtainable only by hospital-based practices. Analogously, Federally Qualified Health Centers (FQHC's) are paid much higher rates for their services than independent practitioners. These economic rents are then translated not only into profit and high administrative and clinical salaries, but also into inducements for independent entities to be acquired (clinician capture).

One solution to establish a level playing field would be to establish all-payer rates for equivalent services in a locality or state, and to allow balance billing so that more desirable practices could benefit from a market. Allowing patients in IS's to access out of network services and requiring the IS's to pay a discounted fee to the accessed service provider would also be part of that solution. Another solution would be to allow non-integrated clinical associations to negotiate collectively.

Communication and information

The Electronic Medical Record (EMR) is becoming the keystone modality not only for patient record keeping, but also for communication and coordination of care. Adoption of EMRs will soon be near universal. Full inter-operability of EMRs, technically quite feasible, will enable all providers to operate equally with one another, no matter their ownership or affiliation. It is tempting, however, for larger medical centers or (in theory) insurance companies to purchase an enterprise-level EMR and restrict operability to network membership, thus steering patients preferentially to network members and restricting competition on price and quality (patient capture), thus compromising the ability of PCPs in a PCMH to fulfill their medical-fiduciary responsibility to their patients, and pressuring practices to join the network (clinician capture).xii Ensuring full interoperability of EMRs should be a governmental level playing field responsibility.

Free substitution of services

Large systems also practice patient capture by not paying for services that patients access outside their networks. This is deleterious to patients, who might prefer alternative services for various reasons, and protects elements within the large systems which may be cushioned from competition and thus not be impelled to seek improvement. Government should consider requiring that all systems of care, including IS's, provide free substitution of services. An IS patient might need to pay more to go out of network, but that would be a choice the patient could make.

Equalizing Governmental Developmental Support

Government has concentrated its system development support programs on large systems. To level the playing field, government needs to fund development of diverse systems equally, and not to decide prematurely that large systems are the winners. For instance, grant programs to areas to establish COE systems would balance the attention given to ACOs. Another instance would be to offer support for decentralized systems to help them accept non-fee-for-service Alternative Payment Models.

Enforcing Anti-trust

Governments at both state and federal levels have been complicit in allowing large hospital chains to emerge, with the expressed belief that larger size will bring improvements in cost and quality, despite the lack of evidence that this has actually occurred. Simple enforcement of the law with assiduous and astute evaluation of data should remedy the deficiency.

Improving Evaluation and Feedback

A prime element that distinguishes the health care market from the market for more mundane goods and services is lack of the ability to evaluate the health care product. Quality measures are now far more robust than in the past, but much more improvement will be necessary for patients and payers to be fully informed. One persistent problem, however, is that no simple measures reflect the quality of a practice as a whole, yet collecting an extensive set of measures is impractical, establishing cost data is particularly difficult, and many important aspects of care still remain unmeasurable. In addition, insurance companies assembling narrow networks continue to conflate acceptance of low rates of pay with high quality.

Government would be well advised to set in place procedures to make public sets of measures as are illustrative, to be clear as to the limitations of the implications of these measures, to practice good data hygiene in making the data simple and clean to obtain, and to make it mandatory for all EMRs purchased with government money to incorporate standard data collection modules for these data. It would also be important for the data to reflect multiple factors of care, and to incorporate private social media techniques in gathering and communicating information. Once again, it will be important to ensure that evaluation does not preferentially favor large organizations, either by the measures chosen, or by the data collection requirements imposed.

Building leadership capacity for the future

Finally, systems are dependent on personnel. Industrial theory has recommended for a century that workers in the system be tapped for their mental contributions to the industry they work in, from suggestion boxes to workers councils to promoting from within. It is actually scandalous that practicing medical professionals, one of the most highly selected sets of personnel in the country, and one of the most idealistic set of professionals willing to contribute to the common good, are so often outsiders in the formation of policy.

Tapping this potential resource of experience, knowledge and judgement needs to be a prime objective of national policy. Potential leaders need to be identified and nurtured, and rank and file professionals need to be taught the basic principles of organizations and organizational behavior so that they may better contribute to ongoing shaping of policy. Government would be well advised to utilize both law and funding to help teaching institutions and professional societies to provide this important education, and to include this source of practicality in their councils more fully immediately.


Conclusion

One of the prime tasks of policy-making is to decide on the target. Too wide becomes ineffectively diffuse; too narrow misses the forest for the trees. Focusing on OS as the general area, and honing in on the specifics of propelling development forward would make for effective health policy. Critical thinking about the salient issues of OS would lead to more even-handed governmental actions, and to accelerated progress on achieving higher quality, lower costs, and improved patient service. Beyond the passive leveling of the playing field that I have stressed here, active governmental involvement in cooperation with the private sector in devising regional solutions would be salutary.

While I have concentrated this discussion on OS as centralization vs. decentralization, other criteria are certainly germane. Not-for-profit vs. for-profit is a perennial subject, as is medical versus business ownership. These and other criteria are certainly worthy of evaluation. The overall message of this paper, however, is this: it is difficult to believe that there is a single OS to apply everywhere in the United States. If there were ever anything that looked ready for state and regional experimentation and evaluation, it is the Organizational Structure of health care delivery. Making haste to focus on OS would be prudent

Budd Shenkin

iCutler DM, Morton FS, Hospitals, Market Share, and Consolidation. JAMA 2013;310(18):1964-1970.
iiIbid.
iiiEnthoven AC, Managed Competition: An agenda for Action. Health Affairs: 7 (3), 25-47, 1988.
ivWilliamson OE, Corporate Control and Business Behavior: An inquiry into the effects of organization form on enterprise behavior. Prentice Hall, Englewood Cliffs, NJ, 1970.
vMarsh H, Do No Harm, St. Martin's Press, 2014.
viFreidson E, Profession of Medicine: A study of the sociology of applied knowledge. New York, Dodd Mead and Company, 1973.
viiStuckey J, White D, When and When Not to Vertically Integrate. McKinsey Quarterly, August, 1993
viii Alford RR, Healthcare Politics: Ideological and Interest Group Barriers to Reform. Chicago, U of Chicago Press, 1975
ixHalberstam MJ, Liberal Thought, Radical Theory, and Medical Practice. NEJM, 284: 1180-1185 1971
xPorter ME, Teisberg EO, Redefining Health Care: Creating Value-based Competition on Results. Boston, Harvard Business School Publishing, 2006.
xiShenkin BN, The IPA in Theory and Practice: Notes from the Field. JAMA, 273 (24), 1937-1942, 1995.
xiiJayanthi A, Epic Under Investigation for Information Blocking in Connecticut. Health IT & CIO Review. http://www.beckershospitalreview.com/healthcare-information-technology/epic-under-investigation-for-information-blocking-in-connecticut.html. Accessed May 11, 2017.

Thursday, May 11, 2017

Three Poems


My Mother's Family

They're dead now.
They weren't, once.
Once they walked down the steps, smiling.
They cackled, they laughed at each other,
They softly competed and defended.

They were five sisters and three brothers-in-law,
And some were fathers and mothers,
And grandfathers and grandmothers.
They went down the shore in the summer.
They arranged it, to assemble, to be all together.
To me, it just happened. I was the little boy.

Bea arranged the gladiolas.
Tilly sang soprano, very soprano.
Sadye played cards with us.
Dorothy was a grumpy New Yorker.
And Rose was Grandmom.

Sam woke me up at 4 o'clock to go fishing.
I didn't want to go even though it had sounded like a good idea the night before,
But I went.

They walked down the stairs on a sunny afternoon
And smiled and talked and strutted for my mother's Super Eight with Kodacolor.
I just looked at it the other day.

They're dead now.
I miss them.
I miss me.

They're dead now.


Book Club

I'm older now.
I must look it.

Richard was effusive.
I'm so glad you came!”
What's the big deal?
It's only me.

He and Susan put out a big effort, and it showed,
Cooking for the book club.
They're the best.
Not salmon or beef, but salmon and beef,
and carrots of many colors.

When I spoke people looked at me with expectation.
I'm smart, I know that,
But I must be looking older, although nobody says it.
They are looking older too, of course,
But I'm the oldest, class of 1941.
I know the skin around my eyes is baggy in the morning,
Saggy, lax. This must be what they call rings.
I eat too much and have trouble with my weight,
But I guess appetite is, all in all, a good thing.

I left early.
What a crappy day I had.
But at least it was a day.

Will I be the first to die?
No, Tyzoon already did, of idiopathic pulmonary fibrosis.
And then Tom's wife, Ida Jean, died last year of Crohn's Disease and sepsis and full body multiorgan shutdown.
So I won't be the first,
But I won't be the last, either.

I was quieter than usual last night,
Although quieter than usual for me isn't that quiet.
Maybe that was age?
Nah, it was just a long, crappy day.
But at least it was a day.


Time

We are men
And we are women.
I'm glad we are.
But that's all we are.

Time giveth
And time taketh away.
Time really sucks.
I hate the Second Law of Thermodynamics.

We live in memories.
And then not even that.

Monday, May 1, 2017

UC Berkeley and Free Speech, Redux


So, it was the first Giants game of the year for me, and we made it a grandmaster attendance game with besties David, Michael, and Larry. Bound to be lots of conversation, and sure enough it started right in the car as we set out. For some reason I seemed even more declarative than usual, although that's a pretty high standard to meet. First topic: the Milo Yiannopoulos disruption (https://www.wsj.com/articles/university-of-california-berkeley-cancels-speaker-after-violent-demonstration-1486010255) and Ann Coulter challenge to free speech at the home of the Free Speech Movement.

I had seen the Coulter brouhaha from afar, since Ann and I were having a great time traveling in Europe. I had seen on Facebook that Bob Reich had condemned Cal's cancellation of the Coulter event and their attempt to reschedule it for the following week at a much more disadvantageous time. Let people listen to her idiocies, he said. Later, he relented, saying the new time was fine. I disagreed, since the new time looked like it was like consigning them to an outback court, but since I was traveling, I probably let my natural suspicion of University actions sway my view. All bureaucracies are pretty stupid, and university bureaucracies are particularly so. (I'm currently dealing with my Harvard Medical School 50th reunion, and although the “opportunities to donate” messages come through regularly, persistently, and cliché-edly, they cannot respond to a simple request to schedule times and places for attendees simply to get together and talk to each other, while doing so would no doubt foster good will and boost contributions – stupid educational bureaucracy, but I repeat myself.)

Anyway, I thought Cal had blown it, again. Michael disagreed; he thought the provocations were real, that it was a set up, especially obvious since the young Republicans who had announced the schedule hadn't even had a room committed to them for the event. Right, I said, of course. But it's the tone. Cal administrators were mealy-mouthed and defensive; they couldn't make a proactive case, they couldn't take it to the opposition, they couldn't seize the initiative and put the provocateurs on the defensive. We agreed to disagree, although David supported me and Larry was non-committal. But it stayed with me and I went home and wrote what I think they should have said, in the tone they should have said it.

Then I researched it a little, since I had been away and hadn't read everything that came out, and found that they had actually made a statement that had some elements of what I wrote, although naturally not as good, and not really with the tone that was required – too whiny, too much “look at what those meanies are doing to us!” I wrote Michael and said that I now thought he was right. He wrote me back and said that he had been talking to some others, and they were also critical of Cal administrators, so he now agrees with my original position. OK – I'll take it! I am now back to my original position, too.

Then today in the WSJ I read about the University of Chicago's position in 2015: “'It is not the proper role of the University to attempt to shield individuals from ideas and opinions they find unwelcome, disagreeable, or even deeply offensive.'” You bet!

So, here's what I wrote that is what I thought a good administration with leadership skills could have written.

The University of California at Berkeley, and indeed the city of Berkeley, are the proud and famous inheritors of the spirit of the Free Speech Movement. The FSM changed the behavior and beliefs of UCB forever; we have evolved from trying to direct students to trying to enable the university community to enjoy the benefits of the First Amendment of the Constitution of the United States to the fullest. We firmly believe that everyone in the University community deserves the right to be heard, and the right to invite viewpoints from the outside to be heard. We will never budge from our commitment to the First Amendment.

At the same time, we are just as firmly committed to keeping violence in any form away from our University community. We will not budge from our commitment to keep our community safe from bodily harm and property harm, come what may.

Recently, we have been challenged to maintain both these commitments. Some elements from both within our university community, and from outside as well, have conspired to threaten and actually to commit violence as a way of curtailing free speech. Seeing our dilemma, some elements have then pursued provocateur agendas, to portray us as not enabling free speech fully. Indeed, this seems to have been exactly the scenario with the latest Ann Coulter incident.

It is clear that when a speaker may be an incendiary force, we are challenged to maintain order and safety. In such a circumstance, we need to have timely notice of the proposed events. It is our responsibility not to use this requirement to fetter free speech, to use safety as a pretext to curtail free speech. We are totally committed not to be duplicitous in our citing safety concerns with a secret agenda of curtailing free speech.

In this Coulter case, the campus group gave the University scant notice about the proposed schedule. They simply scheduled the talk without even having any speaking place committed to them. They did not seek our cooperation at all in providing a place and time and protective resources for this speaker. We would certainly honor our pledge to provide free speech opportunity if we were given the opportunity. Instead, we have reasons to believe that several of the agents involved in this proposed talk worked together to place the University in a trap of seeming to renege on its mission of providing free speech.

Let us restate our commitment: When a duly authorized unit of the University wants to hold a meeting and/or invite a speaker, we at the University will work with that unit to provide a time and place and security to ensure that free speech is exercised. We will not use the necessity of securing space and security to consign the speaker or meeting to unpopular times or spaces as a pretext for compromising free speech.

But we will also not allow ourselves to be set up by malign forces to appear to be taking sides in the exercise of free speech. That is why we are speaking out now, recommitting ourselves to our responsibility, and also letting any and all know: ensuring both free speech and safety from violence can sometimes take management, and we will assert our responsibility to manage our grounds and our time to ensure both objectives.

We could generalize the discussion to Middlebury and other scandalous suppression of free speech on campus and the contentions of the ignorant left that “they have the freedom to speak and we have the freedom to stop them,” but maybe I should just leave it there with what I wrote. Universities need to stand up and be counted, and it is a problem that we have bureaucratic administrations with few real leaders, but rather those committed to raising money, not ruffling feathers, pleasing disparate constituencies, and keeping their jobs. Such is life, and such are bureaucracies.

And as a side note, it was a beautiful and warm night at the ballpark, So, the Giants won, which was a treat, although they still have the third worst record in the majors as I write, and I am looking at the games I have in the future and wondering how many of them will take place before they are mathematically eliminated.

Well, we've have some good years.

Budd Shenkin

Tuesday, April 25, 2017

An Evening With Philip Kerr





Sometimes 15 bucks can buy a lot. Here in London we are staying at the Langham Hotel, which is close to Regent Street, Oxford, Piccadilly, and across the street from the BBC. But the real reason we stay here, I think, is that it is close to Daunt Books on Marylebone High Street, which might be my wife's favorite book store. We checked in on Monday and the very next day we found ourselves perusing the shelves at Daunt Books – that is, she was perusing the shelves. I was sitting in a chair reading the first chapter of a book that started with the sentence something like this: “When I was fifteen I decided what I wanted to be when I grew up: French.” It seemed like a good book but I wondered if I would really read it when there was so much else on my night table and thought about how fully packed we already were, so I let it be as we went for lunch next door. But then a poster caught my eye: on Wednesday night Philip Kerr was coming to Daunt Books!

Philip Kerr is a favorite author, one of those for whom I don't think, I just get the latest book that comes out and read it and follow his character, Bernie Gunther, ex-Berlin policeman and eternally semi-compromised, hopefully not totally so since he is trying to do good, Nazi collaborator-underminer. I just buy every book, as I do with John Le Carré and Alan Furst, and probably like David McCullough, although I think I've missed one or two of his – but not Furst, Le Carré, or Kerr. With them it's every single one. They do spy stories, but that seems insufficient a description to me. These are intelligent and extremely literate narratives of imaginary people among real situations in the WWII and the Cold War. One learns a lot and one doesn't put the book down. If that “one” is me, anyway.

Ann was tired so I went to the talk alone, only a 12 minutes walk. I didn't know what to expect – book, yes; talk, no idea. But it turned out that the man is a real mensch. He doesn't waste sentences, he's full of thought and information, but he is also warm, intimate, frank, and interesting. A smart guy. Maybe he was especially warm because he felt at home here in London, where he looked forward to going home to his own bed, instead of a book tour hotel bed and up at 4 to leave for the plane at 5 and another city. The only thing worse than an American book tour, he said, would be not being asked to do an American book tour. Funny thing, though; here he was on Marylebone High Street, waxing intimate among friends and neighbors, but three of the questions came from Americans. We're everywhere!

So, since he is such a favorite author and this was such a newsy, informative talk, I thought it was worth recapitulating. And, it will come as no surprise to readers, adding in my own question to him and comments to him afterwards.

Interesting how he got into this line of work. He qualified as a lawyer, but didn't look forward to being a barrister – you have to choose your course pretty early in the UK. So he got an advanced degree in German jurisprudence – I think he went to school in Germany for a while when he didn't mesh exactly with English education, imagine that – and then went into the advertising business. But while others were taking the three hour advertising business lunch, he was researching and writing. First it was the London library, and then when he worked for Saatchi, he'd go to the British Museum Library in the morning and order some books that would take a few hours to arrive. So then he'd go to work – “work,” he said, with air quotes, “looking out the window for a few hours, it was the advertising business and that's the way it was then,” and then go back to the library instead of going to lunch. What a wonderful experience for him! The high ceilings, the desks, the heritage! And of course, access to everything.

He had also tried painting at one point. He taught himself, by going to the masters – the modern masters, not the old ones, they were too hard – and copying them. He said that if anyone came to visit him now they would find a lot of Miro's and Picasso's on the wall and think, “This fellow's doing pretty well.” It made me think about his writing, and how it's inevitable that we read and copy, and I'm sure that entered into his growth as an author.

What he thought was that the British authors who bookended the century in Germany were Isherwood – he loved Cabaret, and the interesting fact that you couldn't do the Horst Wessel song because that was forbidden in Germany, but the guy who wrote the substitute for the film did such a good job that everyone who listened thought it was authentic, and he was Jewish. And then Le Carré. Why hasn't Le Carré gotten the Nobel Prize, he wondered. God, the plots! They click together like a fine watch. Bob Dylan getting it, surely Le Carré is more worthy (I differ with him here – I think the Dylan award was great.) I think Kerr's admiration of the Le Carré plots is a nod from a professional to the ultimate master, like Klay Thompson admiring Steph Curry – you know the field very well, what it takes, and you can understand better than non-practitioners what mastery means, in detail. High praise indeed.

So what Kerr wished for in his heart of hearts, was to be sandwiched in between Isherwood and Le Carré. And guess what, amazingly, a few years ago he was in France, I think, or maybe Germany, not sure, and right there on a table in a book display was Isherwood on the left, Le Carré on the right, and there he was in the middle, Phillip Kerr. Dream come true. He took a picture and sent it to his mother.

An inevitable question came from the audience, Why write about that time, the war years, and why about Germany? Kerr answered that this was a time when you could easily tell the good guys from the bad guys. Hell, the bad guys wore black and had a skull and crossbones on their caps – how hard can it be? Which led him to remember a cartoon of two Nazis standing together in their uniforms, and one says to the other, “Is it possible we're the bad guys?” He said that when he started there wasn't that much written about that time, but now it's exploded. The last clear war with goodies and baddies.

Afterwards, when I chatted with him as he signed my book – typically, I again forgot to ask for the “For Budd” inscription and just got his scrawl, I always forget – I offered my preferred explanation to that question. My view is that WWII is the modern equivalent of the Trojan War, and they were still writing and singing about that 500 and 800 years later. Total war – they don't say “world war” for nothing. So, I told him, it's possible that he will be even more famous than he imagines. Kind of took him aback, but I just left him with that and left – although I did manage to say that I thought his books were terrific, and that he was terrific, “Not to be over the top,” I added.

He reflected on book tours a lot. His itinerary calls for him often to be met at the plane by “an escort.” Hmmm, said his wife, “An escort?” “Not that kind of escort,” he had to reply, of course. These escorts are usually ladies of a certain age, he said, often retired with wealthy husbands and looking for things to do. They pick you up. Remember, he said, you have to sit in the front in the passenger seat, not the back. “Very democratic.”

One of the things he does is ask escorts who they have escorted before, and who was the worst one and why. The lady he had in mind said, “Mitt Romney.”

Really? Why is that?”

Well, first of all, he sat in the back. And then he said, “Do you have a dog?”

No, why?”

Well, I see the leather is all scratched up and I wondered if you had a dog.”

The lady took great offense, putting down her car. I thought, So Mitt! Awkward to the end. Gets in the back because he is a plutocrat. But quite probably was trying to show he was as astute as Sherlock, and also to find common cause with his hostess because we all remember that Mitt likes dogs, and took Seamus to Canada on the roof of his car, to the endless delight of Gail Collins in the NYT. And all he comes off as, is an asshole. Poor Mitt. I guess.

But the worst pick up was Oliver Sachs in Germany, who was very quiet in the car until they came to a complete stop on the autobahn because of traffic. All of a sudden he shrieked, opened the car door and ran out onto the autobahn. Traffic picked up and his hosts tried to chase him down so he wouldn't get killed in traffic and to lure him back into the car. Which they did. He explained that he suffered from claustrophobia and had had an attack. Then the hosts had to rearrange the doors to his hotel room so he didn't feel constricted. Well, he could write.

Kerr talked about the talks he gives. Don't prepare, that's his advice. It will come across as cold and boxed up; instead, just let it flow. I think he's exactly right. This talk was that way, things came to mind, he has a very active mind, free associates well, is very fluent, and the enthusiasm is there as he discovers himself where he's going next.

Sometimes it leads to surprises. When he was in Lyon, he was asked if he would pick a picture in the art museum and talk about it. Sure, he said – always say yes, that's another thing he's found out. He figured that he'd go to the museum and talk for 5 or 10 minutes into a recorder or something like that. On the way there, he asked how long they would like him to talk. “An hour would be good,” they said. And there would be about 200 people there to listen.

He had prepared exactly nothing. So what he included us in was his facing the abyss and having to talk is way out. Which he did. He gave us the particulars, how he built up a case in figuring out why this picture interested him, and the one right next to it for that matter, the details of which I pretty much forget now, but it was memorable.

There was a lot of talk about Brexit. Kerr averred that he had been a Remain voter, but observed that this was not the first time England divorced itself from the continent, the first being 400,000 years ago as it floated away. I forget what he cited as the second time, probably Napoleon's time. He observed that all the separation comes from the hinterlands, which typically hate the central capital. As Roger Cohen writes in the NYT, The fracture between globalized metropoles and depressed regions.” Berlin is very different from the rest of Germany, they have a mordant sense of humor similar to the Brits, and the rest of Germany hates them. Same in France, same in the US, although he cited Washington rather than New York. Brexit is on everyone's mind, and at the time it wasn't clear what was going to happen in France. Today as I write this, it seems pretty clear that Macron and continuity will reign in the near future. Near term crisis averted, long term crisis still very much in play.

He also talked about the Germany-Greece nexus. Was it just after WWI that Greece went in hock to the German bankers? So this isn't the first time. And he cited the horror of Salonica that exported 98% of its Jews to Germany for killing, when the concentration of the Jewish population there was second only to Poland. Another overlooked horror. He's almost done with his next book – that was fast! - and it's about that.

Germany tried several times to dominate Europe. The first was at the time of Martin Luther – who, Kerr said, was a terrible man, a terrible anti-Semite. The Reformation led to German domination of the continent, in Kerr's view. More directly, they used their military in 1870, 1914, and 1939. But they learned. What they learned is that it's much easier to do it with finance. Germany calls the tune in Europe. What is it about the Germans, we always wonder? Kerr didn't go into it, but I remember a letter to the editor from a psychiatrist who had lived in Germany, concerning reunification. His observation was he would only start to trust the Germans when they changed their child rearing practices – they are brutal and unfeeling, just watch any German playground, and we know what that leads to

He was also asked about which Nazis he found most interesting. “Who's my favorite Nazi?” he asked, observing that it was a common question. “Who would I like to have dinner with?”

The first name was Goering. People forget what a hero he was, dating from from WWI, and he was very popular and charismatic. He would walk around Berlin and people would give him beer and wurst and he'd eat it – all the others would be afraid of being poisoned, but not him. He had a way with people, which paid off when he convinced a guard to smuggle him some poison at Nuremburg.

The other had to be Goebbels. Joey, after all, was actually a novelist, unpublished at first, but when he became Reich Minister of Propaganda, he got published in a hurry. Kerr imagined what that particular interview with the publisher was like. I actually was surprised because Bernie Gunther's boss was Heydrich at one point, and there's a lot of him in all the books. But I admit it's hard to be fond of Heydrich, or any of them of course. Cute they were not.

It's not well known, but Hitler was lazy as hell, never even walked anywhere, got driven around the Eagle's Nest at Berchtesgadan, which Bormann had set up for him because he was too vulnerable and unpopular in Berlin, and he hated Berlin and Berliners. Confiscated all the property around, sometimes at gunpoint and tank point, making him locally unpopular.

And, there was this, which Kerr was so emphatic about. There was a paper in Munich, the Munich Post, which just prior to Hitler's taking power had a Deep Throat source to the top Nazis. They were constantly publishing scoops, although they only had about 60,000 readers, and in those days news didn't travel the way it does now. They got a real scoop in 1932 – they got wind of the Final Solution, and it was pretty much everything that came out of the Wannsee Conference 10 years later. The thought that Hitler was a Zionist and wanted to expatriate the Jews and only later came upon the Final Solution is completely wrong, and there is the document to prove it, says Kerr, convincingly. The editors debated whether or not to publish it, but since Hitler was on the verge of power, they figured this was their last shot to keep him out. Didn't work, and one of the first things the Hitler government did was to clean out the Munich Post, brutally.

It's true that Hitler met with Mohammed Amin al-Husseini, the Grand Mufti of Jerusalem, a more than virulent anti-Semite. As I remember it, and this might be wrong, the leader said that if Hitler sent the Jews to Palestine he would want to kill them all, but then Hitler decided to do it himself. Al-Husseini was a fascist ally, and Hitler needed all he could get at that point. You could feel Kerr's choler rising as he recounted this. This is a guy who knows intimately what happened, and he's not letting it go. Good for him!!

It will come as no surprise to my readers to hear that I ventured an observation-question during question time. I said first how much I appreciated his work and that his books were more than enjoyable, that “enjoyable” might not be the right word, I guess. But then I said, look, Hitler's guys were a bunch of thugs, clearly. Do you remember Godfather II and Hyman Roth – Kerr nodded yes, he sure did – “Michael, we are going to get what we've always wanted, a partnership with a government. Now the observation-question: do you think this describes the Putin government as well? Lots of reaction from the crowd behind me – they didn't see this coming – kind of amazed chortle-bemusement.

Kerr also hadn't made the connection, and you could see he liked it. He said, of course that's right, and made the obvious points. Putin was KGB chief in Dresden and took over from Yeltsin in return for leaving the Yeltsin family alone, and they thought they could control him, which turned out to be a bad bet. Kerr said that he would be brave in saying this, hoping that it wouldn't lead to a rendezvous with thallium or radioactive rubidium. He remembered visiting with the Chief of Police in St. Petersburg in the early 90's and wanting to interview and get lots of data. The Chief was very cooperative, and Kerr paid about ₤200 to rent a car from the KGB! He said that he was probably the only Brit who paid the KBG for information instead of the other way round. He asked the Chief why he was doing this, and the Chief said, to get the truth out. He said glasnost, he said perestroika. Kerr said, you sure don't hear those words anymore. I wondered if this was the same Chief who was good friends with my friend Victor, who actually saved his life by exiling him as a penalty for his samizdats on the real health statistics of St. Petersburg, instead of having him sent to the gulag.

In other words, he took my point and supported it. Later, there was a guy in front of me in the audience who asked the first question, and we traded cards. He is a principal in the firm Grant & Gutsell – Customs, Tax and Border Control Consulting in the UK. He brought up Kaliningrad, né Konigsberg, an old Prussian City now a hotbed of Russian military and spy activity, an active and festering abscess on the Baltic between Poland and Lithuania. He referred me to Martin Cruz Smith recent book, Tanya. “It's all true,” he said, “It's not fiction!”

He was amazed when I said I had read it, and indeed Bill Smith was a friend of mine, and he had joined us at a baseball game a couple of years ago, and that he was from Reading, PA. Actually, the friend I have is Nelson Branco, his son-in-law, a fellow pediatrician. I overplayed it a little, but it seemed too sweet to pass up. My father would have said of me, “Bigshot!”

There were a few other points. Kerr said that Churchill had gotten it exactly right when he rallied the British and said they were looking into the abyss. “Absolutely right!” That was Churchill's genius. He said he was asked by Americans about “his process” of writing his books. He pooh-pooed the question, saying, “Well, I start working at 8 o'clock....” He was asked why Bernie moves to different areas for the books – “I thought it would be boring if he just stayed in one place.” I agree. Part of the reason we stayed at Cap Ferrat for four days during this trip is that this is Bernie's locale lately, at the Grand Hotel, which we walked around in since our new friends Marty and Ellen stayed there. He also alluded to Bernie's being a unreliable narrator, which as we know is a literary allusion. I don't think I ever thought about that, myself.

He finds it interesting and ironic that Hitler's bunker in Berlin is located where there is now a car park. Likewise, it is interesting and ironic that you can go to Berchtesgaden and have tea and biscuits as you you look out at the beautiful view.

So, that was my evening with Philip. Full of thought, full of action! Just like the books. What an exciting time! Came home and told Ann all about it. So, so sweet.

Budd Shenkin