Friday, September 25, 2009

So, I'm a Jew

We get so much from our parents, don’t we? My mother taught me a lot of things. I remember walking on 52nd street with her and it was maybe a shoe store that was being picketed. We walked around and she said – not being one to avoid a forthright opinion – “Never cross a picket line.” After all, my parents started out being Lefties, although at least my father became much more middle of the road in later years, since he could learn from experience.

And then there was Leon, who was a tall very light skinned African-American as we now say, who would be a bartender – a bartender! – at some of my parents parties. They were modest affairs, and really hardly warranted a bartender, but people drank more then and I think it was far cheaper to get help, and I guess it was classy. We kids loved Leon. What a nice man! We asked my mother if Leon was white or black. She explained that Leon would probably be “passing over.” “Passing over” was leaving the black world and entering the white world. As I understood it from my mother, this was just a process that would bring on a kind of we’re all equal world. What a great way out of discrimination! The blacks would just become white. I didn’t quite know how that would work, but since my mother said it, I had to take it seriously.

Then there was the fact that we were Jewish, but from as secular a background as you could possibly have, befitting political Lefties. My father wasn’t Bar Mitzvahed, his father hadn’t been Bar Mitzvahed, and sure enough neither was I, much to the consternation of my maternal grandfather. The legend is that my father’s grandfather said that all religion brought in the world was strife, so he wasn’t having any of it. A doubtful story that I heard only later on.

We should have some religious training, though. I remember my parents talking about it. “How about RS (Rodolph Sholem)?” asked my mother. So we were trotted off to reformed Sunday School at RS in North Philadelphia somewhere for two years, unwillingly but obediently, where there were kids we didn’t know, and they didn’t seem very manly to me, and a teacher who tried to get people to go to Saturday services by saying, “Who went yesterday?” What dorks, I thought, without knowing the word “dork”. Later on it would be Sunday and we were no longer going to Sunday School and Bobby and I would be out beside our house playing Kicking Goals with a football, and I would look around at the sun and this big beautiful 12 foot hedge that divided us from the street, and I would think, those poor people who have to be inside on a day like today! It’s so beautiful and this is so much fun! And then I’d kick.

Later on, on some Friday afternoons we would go to the home of Itzhak Sankowski and together with about seven or eight other boys, Bobby and I would listen to old Jewish stories. It was something that we couldn’t really get into, tell you the truth, but we did it. It didn’t make us any more Jewish. We had gone to a Quaker school, Friends’ Central, for four years and learned some about Christianity, and later on at Harvard I studied philosophy and history and learned a lot about Christianity, and you pick up that stuff in all sorts of places in America, so in the end I think I know as much or more about Christianity as about Judaism.

I spent one year at Ardmore Junior High in 9th grade, after we moved to the suburbs, and there weren’t many Jews there, maybe a few. But I went out for all sports and probably shattered the stereotype for some of my classmates. In basketball I got the nickname “The Nose,” although my nose isn’t all that prominent. I made a self-deprecating remark at some point, and Charlie Newsome, as Catholic as they come, said to me, “Your nose isn’t any bigger than anyone else’s.” Charlie invited me to come with him to some local church dance where there were no Jews at all. I felt out of place because I didn’t know anyone, but that was OK, at least I wasn’t left out. You just don’t know where you’ll find the righteous gentiles.

At Lower Merion High Jews from Bala-Cynwyd Junior High merged with the gentiles from Ardmore and we had an integrated group of friends, some Jewish and some not, and it didn’t seem to make a whole lot of difference. Sports and intelligence were the issues. I think that age is very central to a certain kind of identity, and I really liked our group and its lack of religious identity. I never have gotten over feeling like a Lower Merion guy. I didn’t want to ever be part of the RS type of crowd, and I didn’t want to go back to the Ardmore kind of crowd. I was very happy where I was, and I was reluctant go to away from high school to college; we had a great class and that is where I felt I belonged, playing sports and playing poker and drinking and trying to get a start with girls. God, it was a great time!

In freshman year at Harvard I remember telling Sandy Stidham, from Episcopal Academy in Philadelpia, that I didn’t identify that much as a Jew. Well, said Sandy, since other people looked on me as Jewish, maybe that was a pretty strong sense of identification. I protested that I didn’t feel it that much, and he just told me the same thing again. Sandy was reputed to be really smart.

One evening in college I was walking with my roommate Kenny Nahigian and by that time I had my first real girlfriend, Carol King from Reading, PA. Kenny said, “Doesn’t it feel good to have a Jewish girlfriend?” I said, “What do you mean.” He said, “Well, doesn’t it just feel good?” I said, “No, not really.” I loved Carol, but I really didn’t like the fact that she was Jewish so much. I never did marry Carol, thank god, it would have been a disaster. Small town Jews? Not for me. For me it’s smart Jews, funny Jews, Jews with good ethics, urban Jews, I guess.

I wound up marrying an Irish-French girl from Gloucester, Mass. That didn’t work well at all, I’m sorry to say. Then I married an Irish (Irish-American, of course) from Southern California, also very secular, and we live in Berkeley where people are both Jewish and not, and I belong to the Claremont Hotel gym and pool club, where there is the typical Jewish and non-Jewish mixture, pretty much like in Lower Merion or at Harvard. It feels very comfortable to me. I play poker with other pediatricians, and you have to be either Jewish or Asian to play, with one exception, and under 5’10”, mostly, which is what pediatricians usually are. And we have a house in Maui (where I am as I write this), where there just aren’t many Jews. I’d like a few more, but I don’t think about it much, really.

Then the other night Ann and I went out to eat and afterwards I took her to Lappert’s Ice Cream, a Hawaii institution, where the buttermilk percentage is 16-17%, as compared to 10% at Bascom-Robbins, which they advertise proudly. Two scoops of chocolate for Ann to be in heaven. An older lady with a middle-aged couple was ahead of us, and since she was having trouble both hearing and tasting and choosing, the guy of the couple very nicely said, “Why don’t you go ahead of us?” I thanked him and Ann got her chocolate, and we started to amble out to wander and go to the car. Thy guy then looked at me and said, “Shana Tovah!” Surprised, I said the same back to him – as a kid I didn’t know this was what you said at Rosh Hashonna for “Happy New Year,” since it’s Hebrew and not Yiddish, but I learned it later. I had to laugh. Shana Tovah, for Christ’s sake.

Earlier this week Ann and I had found it necessary to get a local lawyer here on Maui, so we hired Joel Richman, an ex-hippie lawyer from Massachusetts. It felt good to have a Jew as a lawyer, I have to say. I told him the Shana Tovah story and he, dumbfounded, said, “Did you have a sign around your neck?”

No, just hadn’t crossed over yet. It’s a good thing I enjoy being Jewish.

Sunday, September 13, 2009

Oaths, Ethics, and Professionalism

Does an oath mean anything? Sometimes it does. Maybe even more than sometimes. Maybe even usually.

The oldest oath that we know of is the Hippocratic Oath. When I stood up and took the oath at medical school graduation, it seemed kind of corny, tell you the truth. What was probably more important was growing up in a medical household where you could see our father's devotion to duty, his pursuing research objectives, his wanting to do things right, his wrestling with the problem of his patient's wanting an operation, his knowing that it probably wouldn't do any good, and his knowing that if he said no, the patient would just go down the street and get it done by somebody else. I think he generally did the operation, figuring that since he was such a good surgeon, at least he wouldn't screw it up. He was in business, after all.

In med school the oath was talked about and as far as we could see, it was practiced. The most important precept then and now was: Do no harm. Primum non nocere. That's a pretty important one. Whatever you do, don't make things worse. Don't take chances when the stake is your patient's welfare. Don't let your own welfare get in the way.

Does it work in practice? I don't really know for sure, but I think so. Doctors seem to be cynical about many things, but not about this. They may talk about business and money and managed care a lot, and about trips and golf and houses and things, and about how stupid some patients can be and what a pain in the ass, and litigious, but I have never heard any joking about how a doctor screwed his or her patient in retaliation or by not caring. I think that aspect of professionalism and ethics remains pretty strong.

The law has oaths also. My friend Bob Levin joked that he wanted to put out a Yellow Pages ad that advertised him as "Graduated Law School Before Mandatory Ethics Course." Pretty funny. There are more unscrupulous lawyers than there are doctors probably, the oath isn't so strong there, but there are judges, there are courts, there are DA's and there are Federal Attorneys, and I have to think that the code of ethics is active.

Then there is the world of business. I remember sitting at a Goldman School of Public Policy Board of Advisors meeting next to a Board member who works at the Haas School of Business. I said to him about some business practice, "That isn't right." Now, this is a very good guy, but he said to me kind of incredulously, "But it isn't illegal!" He didn't even want to engage on right or wrong, his only standard was legality. That retort is so foreign from what a medical response would be, I was incredulous myself.

This was after Enron. What amazed me so much about Enron was how many of the participants came from Harvard Business School. Yet they were pulling all this crap. I thought, what those guys need is a Hippocratic Oath. Sure enough, pretty soon there were calls for mandatory ethics classes in business schools. I think that kind of died on the vine.

The world of business is so bad, ethically speaking, that it's not only people conducting business that's so bad, it's the regulators. Yesterday's paper had an article about the ongoing failure to reform the financial world. There were new accounting standards that had been proposed by the accounting world itself, with transparency a prime objective, and some marking to market. These are failing under political pressure, and arguments that if you don't intend to sell an asset, you can value it at what it used to be worth, or what you think it might be worth in the future. I can see how day to day marking to market can lead to disaster, essentially margin calls that accelerate a downturn, but after a period of time, reality is realitiy. Behind this political pressure is business money.

Now today the redoubtable Gretchen Morgenson in the NYT, in "Who is Watching the Regulators," tells of the ongoing regulatory failures, and how the failed bodies want more power. Shades of Bush awarding the Medal of Freedom to those who failed us most! She cites suggestions from Edward J. Kane, of the Boston College Business School, in a paper called "Unmet Duties in Managing Financial Safety Nets." He says that the public needs protection from bureaucratic self-interest, and the power of large institutions the regulators are supposed to police. He suggests -- an Oath of Office! Yes, an oath of office for regulators!

I think it might have an influence, especially if there were to be anything resembling ethics imbued in business school students in class after class. He sees four parts to the oath. One - Duty of Vision. See what is going on in the creative minds of business institutions. Two - Take Prompt Corrective Action. Not like with Bernie Madoff, I guess, nor with mortgages that the Fed knew or should have known were a problem - everybody else seemed to. Three - Perform Regulatory Work Efficiently. It's a business issue, so they should understand that. And Four - Put the Interest of the Community Ahead of Your Own. Bureaucratic self-interest is indeed a scourge.

It is this last part, Kane says, that is going on now. The regulatory bodies are taking advantage of the crisis to try to enlarge their power, and working with the institutions so that nothing will really change. Cynicism. Kane suggests Inspectors General for all the regulatory institutions, so the watchers would be watched.

Personally, I'm pessimistic that anything important will really change. I think these institutions are the heart of our current system, that this is where the high priests are. This could all be changed by a real depression or an atomic attack instead of symbolic airplanes into towers, that really killed them all. But I hope neither of these things will happen,

The closest we can get to really getting to the point where business people experience a real fiduciary responsibility for Other People's Money would come from electoral reform. If political elections were funded by public money, the financial clout of these institutions would be somewhat blunted. Not completely, because they would still be the refuge that the Tony Coelho's and Tom Daschel's and Phil Gramm's and Larry Summers' would repair to after a political career to "make their money." That's not going to change. But at least at the start, if someone wanted to be idealistic in politics, it would be more possible than it is now. It's still possible - Wellstone and Feingold proved that, among many others. But it's pretty hard.

And my friend Larry at the UCB Business School? He and others like him, the good guys in business, should take a page from the medical tradition, and think about it seriously. If the Great Age of Capitalism is to do better, ethics needs to be on the table.

Budd Shenkin

Monday, September 7, 2009

Understanding the Health Insurance Exchange

OK, I'm getting repetitive, but I can't resist posting this short item focused just on the issue of the HIE. I've made all these points before, but here it is shorter and sweeter:

As a practicing pediatrician and long-time health policy analyst, it has been very painful for me to see how little my very intelligent and engaged friends understand what is being proposed for health care reform. True, some of it is complex – mostly the funding, which I grant you is not straight-forward, and I, too, worry about cost and the deficit. But to me the most important part of the reform is the Health Insurance Exchange (HIE). Even if the Public Option were not adopted, even if the funding for the lower middle class were not generous, the HIE would be extremely important just in and of itself.

Why does our current health insurance system not work? It’s because competition in capitalism is supposed to result in better and better deals for the consumer, as with cell phones, for instance, yet it doesn’t in health care. Health insurance competition works against the customer rather than for him or her. How do health insurance companies make their money? By excluding those likely to be costly from purchasing a policy, by driving policy costs higher for those with little choice, by rescinding policies from those who get sick, andby confusing buyers with policy details that are nearly impossible for the ordinary customer to fathom.

This is a situation tailor-made for government intervention. If the rules of play work against the customer, it is the role of government to reset the rules, so that the game works differently.

The HIE would do just that. The government would set the minimum standards for offering policies at three or four different levels. Rules for all levels would be: all applicants would be accepted, premiums would vary by age within limits, no policies would be canceled retrospectively, there would be no lifetime money limits to coverage, conditions covered would be standard, mental health coverage would be equal to physical health coverage, etc. The major difference among the levels would be how much out of pocket the policy-holder would be at risk for.

So, the problem of policy availability would be solved. The problem of understanding details and being hit with large bills that the consumer thought would be covered would be solved.

How, then, would the health insurance companies compete and make profits? They would have to be efficient and they would have to be creative. Efficiency in claims processing speaks for itself. Creativity – maybe some companies would create networks of only the best and most efficient physicians and split the savings with them, so that a customer would pay less yet get more efficient service. Maybe companies would partner with hospitals and see them run with increased efficiency. Maybe companies would contract with primary care physicians to pay special attention to their patients (with higher payments) and avoid costly referrals. There would be innumerable ways to compete – and in this competition, consumers would reap better care and cheaper prices, just as we have with cell phones.

It might be, on the other hand, that these hide-bound companies might not be able to transform themselves to innovators. Some might die. Others might be able to conform to the efficient claims-processing model, and miss the creativity, but they would at least lower the cost.

Because technical health care quality is harder for consumers to detect than cell phone quality, government would have to arrange for professional quality assessment, so consumers could have that knowledge in choosing health plans. Or maybe Consumer Reports, the Institute of Medicine, and US News and World Report could compete in assessing quality.

As this competition among health insurance companies continued, what would be the role of the Public Option? I think the PO would offer plain vanilla care, and would become a safety net of health insurance – if a competing company went belly-up, the PO would be there to pick up the customers immediately so that coverage would not be interrupted. (Actually, I believe that it would be better if we had at least two PO companies per region, one Federal and one state, to compete with each other and the private companies.)

One of the biggest problems with the health insurance market is that, over 90% of markets in the United States are oligopolistic. To perfect this competitive market, beside providing its own sponsored entity, government might have to do one more thing - ensure easier access to the marketplace for other private companies. I don't quite know how to do it now, but it needs to be done. Truth to be told, that's really the essence of the PO at this point, killing oligopoly.

Of course, as in all capitalistic competition, there will be corner-shavers. Companies will try other angles that I can’t now predict to attract customers that are not really in their interest – who knows where the tailfins of health insurance policies will arise? But I would think these problems would be minor and transient.

The only problem I see with the HIE is that it is too slow to come – 2013 would be the target date - and too limited in scope – open only to the uninsured or the very smallest groups. It should come earlier, and be open to everyone – why not?

Kaiser's fantastic innovation

Clearly, one of the greatest assets of large groups is the ability to innovate. I take as a case in point the Kaiser system, as detailed in the current Wired Magazine, in an article on low tech disruptive innovation. Check out pages 117-118:

"...Kaiser has long relied on a simple strategy of building complete, self-sustaining hospitals - employing 50 doctors or more - in each region it serves. 'It's an efficient model,' says Michele Flanagin, Kaiser's vice president of delivery systems strategy. 'It offers one-stop shopping: pharmacy and radiology and everything you want from health care in one building.' But that approach forces patients who don't live near a hospital to drive a long way for even the most routine doctor's appointment.

"As it happens, though, Kaiser has become one of the most technologically advanced health care providers in the country, digitizing everything from patient records and doctors' notes to lab data and prescriptions and putting it all online. The system is networked, so patients can email their doctor, check lab results, and make appointments from their PC or mobile web device. Getting a referral doesn't mean carrying medical records from one doctor to another, as it does at many hospitals.

"In 2007, Flanagin and her colleagues wondered what would happen if, instead of building a hospital in a new area, Kaiser just leased space in a strip mall, set up a high tech office, and hired two doctors to staff it. Thanks to the digitalization of records, patients could do to this 'microclinic' for most of their needs and seamlessly transition to a hospital farther away when necessary. So Flanagin and her team began a series of trials to see what such an office could do. The cut everything they could out of the clinics: no pharmacy, no radiology. They even explored cutting the receptionist in favor of an ATM-like kiosk where patients would check in with their Kaiser card.

"What they found is that the system performed very well. Two doctors working out of a microclinic could meet 80 percent of a typical patient's needs. With a hi-def video conferencing add-on, members could even link to a nearby hospital for a quick consult with a specialist. Patients would still need to travel to a full-size facility for major trauma, surgery, or access to expensive diagnostic equipment, but those are situations that arise infrequently."

My God, what an innovation!! Only Kaiser could do it! It looks like they have invented, wait, let me name it myself -- a doctor's office! It just goes to show you what good old American know-how can do. I am so proud to live in an area serviced by Kaiser. This Dr. Flanagin must be a genius.

Next up - the receptionist who smiles at you! (Oh, wait, they are eliminating that. Forgot.)

(Thanks to my friend Bob Levin, who gave me this issue of the magazine, actually for the article that follows on placebos, but I got sidetracked. I was telling Bob how much fun I was having with the blog. He said, "I wonder who suggested to you that you so it." Oh, yeah, it was him - forgot that for the moment.)

Budd Shenkin

Saturday, September 5, 2009

Government: Volume purchaser or monopsonist?

You just have to wonder at the Lefties in health care reform who, in calling for a Public Option (a version of which I think would be a good idea), say, “Let’s take advantage of volume purchasing.”

Volume purchasing? I can understand if you call a computer seller and say, “Hey, instead of just sending me one computer for $1,000, how about sending me 20 for $925?” It’s cheaper for them to write up one bill and send out twenty than to take 20 separate orders, so let’s share the savings.

But it’s a lot different if you say, “Hey, there is one big buyer in this market, and it’s me. So I’m offering you a 20% discount on your services. You won’t save any money, because you will still see, treat, and bill each patient individually. But since I’m the only buyer, if you don’t sign up, you are SOL.” That’s monopsony in action.

Now, it is very true that health care is rife with inefficiencies and, basically, overcharging. So if pressure and guidance are properly applied, the system should deliver better care more cheaply. But is just taking a forced discount the best way to do it? Maybe not.

There is a difference between competition that brings savings, and market power that extorts advantage. Maybe there are more sophisticated arguments and understandings that could be brought to bear, but as I see it now, the Lefties are just looking for market power, and talking about the “power for volume discounts” is disingenuous.

Budd Shenkin

Thursday, September 3, 2009

My Wife's Brush With Greatness

It was the summer of 1960 and my wife Ann was 14 years old. Her family lived in San Marino, close to Pasadena, and the Democratic Convention was in Los Angeles. Ann’s family was Irish; her father had risen from being a newsboy in Hell’s Kitchen in New York, had been awarded a Pulitzer Scholarship to Columbia, and had become president of his own successful chemical company. It was another Irish Catholic family, the Kennedy’s, that was contending for a larger Presidential nomination at the Democratic convention in Los Angeles. So John Morrisroe decided to take some of his five kids down to Los Angeles to experience that convention.

Who knew that this would be the day that Ann would have a brush with greatness? As I understand it, the family Morrisroe was milling around the convention headquarters hotel. There was a little stir, and coming toward them was a young man, in a hurry, resembling the candidate, but younger. It was Ted Kennedy. He came closer. He approached Ann. Ann, it must be said, was a gangly teenager who had not yet claimed her ultimate great beauty, but her intelligence must have shown through. Ted then uttered to her his immortal words: “Outta my way, kid!”

From such greatness, these words could only be metaphorical. The future was beckoning, surely. Ann must have represented the great future unknown, the horde of future admirers who would benefit from his untiring pursuits of goodness for all. Let the future beware!

Or perhaps it was the entire weight of the Kennedy future that would torture him again and again, unbearable burdens that he would have to fight through and throw off. Outta my way, indeed.

Or could it have been the Democratic orthodoxy that denied him to crown that would have enabled him finally to realize the goals of a generation, thwarted by Carter, and then by the Republican reaction of thirty years?

“Outta my way.” And to think it was my future wife, Ann, who received those words of foreshadowing and, dare I say it, inspiration. Outta my way, indeed.