Budd's Blog

Election Time!

2012-01-31T21:11:00.000-08:00

There is something about country club business Republicans that stinks. It is the entitled bullying, the use of money not only to keep score, but to batter someone else. First it was Bush II from the country club; now it’s Romney. What jerks.

“I’ll bet you $10,000!” What a threat. “I have $10,000 and it’s pocket change – what about you, Rick?” Nice man, no?

“I made Ted Kennedy take out a second mortgage on his house.” Is he bragging to his Bain friends, his B-School friends, or the other guys at the club bar? Enjoying inflicting pain, using money as the preferred tool. Cruel.

He uses his money to assassinate his opponents, not that they don’t deserve it. In Florida the ads were 13,000 pure negative ads by Romney to 200 against Gingrich. I can see Romney saying, “Just wipe him out.” Not that any of it was untrue, and not that Gingrich is not despicable, and I don’t know what I would have done. But I can just see Romney gloating and bragging. Bullying is his SOP.

What would he do as a President, playing these confrontational games? What kind of bullying would he engage in? He wants a very big military so no one would even dare oppose us. He’s nuts. Size isn’t the issue, Mitt. It’s being smart, not being a big, stupid, giant Empire.

What would he do domestically? Play to his own guys, the way Bush did, another country club guy at the bar. I’ve got mine, Jack, tough on you. Let’s see you guys crawl up from the bottom, he’d say. And he would pretend that that’s what he did.

He exudes a lack of compassion. He’s not at all nice. He doesn’t have a Jewish bone in his body. He’s a jerk.

Budd Shenkin

2012-01-02T15:08:00.000-08:00

Three little observations in this informal post.

One – more anecdotes in the never-ending story of medical pricing transgressions from reasonability.

The nurses at Alta Bates Medical Center are on strike again! They will spare no efforts in their mission to bring better care to patients, as their picket signs proclaim. That has to be their motivation. The logic is inescapable: happy employees produce the best work, and how better to make them happy than to pay an average wage of $138,000, with top earners making $295,000? And in the bargain they get the extra kick of besting their eternal rivals, the physicians. That must really make them happy.

I received my billing information for visiting an ENT doctor to check on my nose bleeds after my surgery. We waited two hours (by the clock, two hours), he spent no more 10 or 15 minutes with me, stuck a fiber optic device up my nose to view it better, finding no specific lesion and a slightly deviated septum. He billed for a new patient visit at the intermediate level – absurd, as he hardly asked me anything at all and they collected no significant history – and for the procedure, which as I said, was only slightly more advanced than looking at ears through an otoscope. He billed a total of $500 and got paid $349.65. That’s a lot of money for a brief visit. I should have billed him more for the 2 hour wait.

Finally, my friend and colleague Charley Woodard told me about a patient who was referred to Alameda Hospital for a basic x-ray of an arm, I think it was. Charge - $1,400, and the insurance paid it.

Reflection on these anecdotes: there are many fancy ideas of how to fix medical costs, how to make things more efficient, etc. I hope a lot of these ideas wind up working. But the heart of it is, so many people charge too much and no one can stop them, it seems. The prime component of increasing medical costs is hospital costs, and 30% of hospital costs are nursing costs. Is anyone up to challenging the nurses? Do we need a Margaret Thatcher? Reagan put it to the air traffic controllers. Who can put it to the nurses? I love a good nurse, and I found my care excellent last August. But there is a right price for everything, and these prices I’ve cited are not the right prices.

Medicare has actually been pretty effective in going after one specialty after another – last hit was cardiology, as I understand it. The ROAD to wealth in medicine is now said to be Radiology, Ophthalmology, Anesthesiology, and Dermatology. That seems to be a pretty good agenda to me.

We need a government with guts. Sure won’t find it with Obama.

Which brings us to item number two, politics. We’re in the middle of the Iowa caucus season. The whole Republican panoply of ignorance and incompetence has been remarkable. I can only believe that the majority of those running don’t expect to win, but hope that their publicity will lead to enhanced speaking fees. What a racket.

The very ordinary Mitt Romney is not certifiably stupid or insane, and thus stands out. Most of the others will fall of their own weight; some, like Gingrich, have needed to be shot down by a healthy airing of the facts.

But what a dispiriting prospect -- the ineffectual Obama facing a fairly empty suit, Mitt Romney. The Days of the Pygmies have arrived. I believe in the economic analysis of Paul Krugman, and all the contenders are still bowing to the convention of let’s try austerity – for everyone else, that is, since all the proponents are pretty well fixed themselves. Dispiriting.

Finally, number three, the role of war in economics. Everyone talks about the causes of the economic decline as due to so many complicated things. Then they add at the end, “And fighting two wars without paying for them doesn’t help.” I’m wondering, aren’t the wars more important than a postscript? Yes, the mortgages and CDO’s and CDS’s and the housing bubble and the smothering of the middle and working classes and the Bush tax cuts and everything else, yes, they are all too true. Too true.

But isn’t war the ultimate wasting of resources? War made sense for Hitler, I was reading in “1938: Hitler’s Gamble,” by Giles MacDonogh. They kept running out of money to finance the war machine, so annexing Austria and absorbing Czechoslovakia and taking their treasuries and their factories, and taking all the assets of the Jews made sense (until they found out that they couldn’t run all those businesses they took over, and the money stopped.) The great Aaron Wildavsky said, “Never do anything for just one reason,” and the Nazis followed that advice. They wanted to get rid of the Jews because they hated them, but they also wanted their wealth. Two reasons added up to a policy.

War also made sense for the Romans, who absorbed the territory, awarded the lands to their generals and others, and reaped the taxes. War can make economic sense.

But our wars in Iraq and Afganistan? It’s pure outgo and no income. When you spend a lot of money and get nothing in return, isn’t relative impoverishment the inevitable result?

I’sn’t that what happened in the 1970’s, the time of stagflation? I forget how much the Vietnam War cost, but it was another fruitless expenditure. When you spend a lot of money and get nothing for it, aren’t you going to suffer economically?

World War II was a war of total necessity, and is praised in economics for getting us out of the Depression by pump-priming, after Roosevelt mistakenly adopted austerity in 1937. We paid wages and manufacturing costs for product that was not exchangeable (war-making), but was necessary. Everyone was amazed that the post-war period did not bring inflation, but instead sustained and orderly growth. What makes that period different from the 1970’s and the present?

I would nominate the spirit of victory, as well as and the foresightedness of the government with the GI Bill and the Marshall Plan, expenditures that would result in increased productivity. That’s what we need now, government investments in education, infrastructure, and technology, to prime the pump now and to yield increased productivity in the future. We also need severe regulation of the financial world, and measures to repair the financial health of banking and mortgaging victims. But with no spirit of victory and no confidence, retrenchment is all the country can come up with, which is bad news.

Anyway, that’s what I think. Bad wars lead to bad economics. If you win a war and get money and territory, that can work. If you win a war and gain confidence and spend money in real investment, that can work. But if you lose a war, or don’t win it, and there is no spirit of victory and no confidence that investment can yield fruit, stagnation is the result, or worse. That’s where we are.

Happy New Year!

Budd Shenkin

Quality Improvement in Medical Practice - Need for Balance

2011-12-18T16:06:00.000-08:00

The quality improvement movement in medicine has been important and fruitful. Nonetheless, many of us have had reservations. The complaints have ranged from the indisputable fact that P4P results reported to our practices are often inaccurate, to concerns that meeting standards and reporting to authorities is often just busy work, to worries that standards often lead to teaching to the test, to the criticism that practices that treat the lower socioeconomic strata (or, practices that treat non-vaccinators) are penalized by the shortcomings of their patient bases. These are all valid. My own concern has been that with a strict emphasis on the measurable, important aspects of quality that are difficult to measure have been neglected. Let me explain.

Two Methods and Two Types of Objectives

There are two methods we can use to effect both clinical and clerical change in our offices. One could be called Systemic Re-engineering (SR); the other would be Professional Enhancement (PE).

SR builds techniques into the office environment with such devices as checklists, explicit protocols, flow sheets, questionnaires, and computerization. SR solutions are “outside the head” and relieve the clinician or staff of the burden of remembering.

PE, on the other hand, happens inside the head, as in, “Remember to….” PE is very familiar to us from our training. We are educated in basic facts, basic procedures, precepts, attitudes, etc.

Just as there are two ways to effect change, there are two types of objectives. Type one is a Quantifiable Objective (QO); the other would be Non-quantifiable Objective (NO).

A QO is generally related to a stereotypical event, such as vaccinating, or diagnosing and treating streptococcal pharyngitis. QO’s are familiar to us as P4P measurements.

An NO may be a non-stereotypical event. Pursuing a difficult diagnosis would be such an event. There is no current way to measure how a clinician pursues signs and symptoms with his or her own acumen, strategic tests, and referrals.

Other NO’s would be based on the human behavior of the clinician. Caring for patients with empathy and compassion would be such a behavior. Another would be attentiveness to a patient’s communication, and patience in eliciting information. A patient satisfaction survey is far too blunt an instrument to capture these qualities accurately, and we have no other applicable means of measurement.

Matching Methods and Objectives

The two methods and the two objectives tend to pair up, SR with QO, and PE with NO. An example of the SR-QO pair would be the stereotypic case of prescribing controllers for asthma and not relying on rescue medications excessively. The PE approach would be to bank on the attentiveness and memory of the clinician when the refill requests come in (“Remember!”). The preferred SR approach might be to institute an office procedure that forbids albuterol refills, and instead compels the staff to schedule a visit when an albuterol refill request is made, and has a flow sheet in the chart that details all prescriptions. The results of this QI effort would be clearly measurable, as we know.

A clerical example of office functioning would be keeping track of vaccine stock. One could admonish clinicians and staff to remember to bill for every vaccine given (PE – remember!), or one could institute a procedure of daily balancing of stock vs. billing sheets (SR). Clearly, for these stereotypical events, SR would be a more reliable and efficient approach resulting in higher quality and less variation.

I have two favorite examples of the PE-NO pair. The first is the issue of pursuing a difficult diagnosis. Perhaps clinical prompts in an EMR would be helpful, but in general it is difficult to think of an SR approach that would arrange a system to help and encourage a clinician to be smart and persistent in pursuing a diagnosis. Yet it is difficult to think of a more important aspect of quality care than this.

A second favorite example is improving the “caring” function. Imagine a possible SR solution: the placing of a sign on the wall reading “We Care!” Clearly, teaching and encouraging how to care for a patient, how to reduce emotional distance is something that still belongs in the realm of PE.

In both of these issues, the PE approach would seem more apt. I can’t think of any fancy and modernistic approaches, but practice conferences with case presentations and feedback (hopefully positive), and in the case of conferences on caring, the presence of professionals from outside the practice with relevant expertise (social work, psychiatry, clergy), could be of great help.

The key is for the practice as a whole to care about these issues, and to make them part of the practice culture. The fact that the effect is not quantifiable should not deter the practice from emphasizing these very important practice characteristics.

Keeping the Balance

As QI has risen in importance in recent years, QO has been emphasized and NO neglected. Perhaps this has occurred because of our scientific prejudice to pay attention only to the measurable and to distrust the impressionistic. Maybe it has happened because of a perceived need to “prove” quality to insurance companies and payers. Both are understandable.

But the imbalance is regrettable. What can be more important than pursuing difficult diagnoses? What can be more important than the caring function? Yet, because they are not easily measurable practices are not paid to excel in these functions. The measurable has pushed out the unmeasurable.

Still, although we are influenced by QI professionals and organizations, and by financial incentives, in the final analysis our practices are ours to shape. If we take steps to improve our practices in these very important but non-quantifiable aspects, we ourselves will feel the richer for it, and it is quite possible our patients will benefit from it. The key is "Not everything that counts can be counted, and not everything that can be counted counts.” (William Bruce Cameron.)

Budd Shenkin

Steve Jobs and My Credit Card Woes

2011-12-04T00:30:00.000-08:00

I think it’s time for a few smaller blog posts. I can’t be hamstrung by trying to make every one better than the last. Even at the risk of triviality. But after all, some of my favorite writers – Dave Barry, say – dwell in that region and thrive.

So, I just read Walter Isaacson’s Steve Jobs biography, which is well worth reading, sports fans. Great story and Isaacson is in a class with David McCullough and Michael Lewis and Alan Furst– you can’t go wrong reading what they write. Steve’s wife, Laurene Powell, said he’s a great man, but great men are not great at everything. So personal relations and being nice to others weren’t his strengths.

But he was frank. There were a lot of gadgets, devices, architecture, a lot of things that he pronounced as shit. The whole music industry didn’t get it as their business went kerplunk. It took Itunes to get it right and save them, and it was an outside agency that did it, not they themselves. Sony had everything together to do an Ipod and they didn’t do it – why? Because they were divided into divisions and the divisions didn’t and couldn’t work together. So an outsider, Jobs, did it.

BTW, this invention is an example of the incorrectness of the description of innovation as “find a need and fill it.” Instead, he visited Toshiba, I think it was, and they said, we invented this 1.8 inch hard drive and we can’t figure out what to do with it. Jobs thought, I can do something with this, and brought together technology, his love of music, and his identification with the general consumer to think, Ipod. The technology advanced and he found the use for it. This is generally what happens – like the telephone, recording devices, the computer itself.

Anyway, let me be inspired by Jobs’ ready indictment of the ignorance of others. About three years ago I made a mid-year’s resolution. I was leaving my credit card behind at too many restaurants, and in my car I was pulling out of my lane without looking too often (all the time, actually). So my resolution was to stop forgetting my credit card, and to look before I pulled out.

Perspective: whenever there is improvement to be made, there are two ways to do it, personal improvement or systematic re-engineering. When I want to make an improvement at Bayside, that’s the choice I have – ask people to try to remember, or build it into the system. Sometimes one strategy is appropriate, sometimes the other. In the case of my credit care forgetfulness woes and my driving woes, since I’m just an individual, only the individual strategy is open to me – be aware, remind myself at the table and at the wheel, take the card and look first.

Jobs was in the position that he could look at a device, how much a customer needed to remember to use it, and say, This is ridiculous, and make a better, more intuitive device. In the Apple stores he realized how inefficient it was for a customer (the customer’s view!) to have to line up to pay for a purchase. Reminds me of the old Soviet stores where you lined up to look at something, lined up again to get the item, and lined up again to pay for it. So Jobs had the employees have those little devices that paid for the item right on the floor – just as in Europe as they do in restaurants.

But what do they do in restaurants here at home? Here, they take your card away, bring it back, and then they HIDE THE CARD INSIDE THE CUSTOMER’S RECEIPT! How many of us want that receipt, for God’s sake? The way they do it now, I have to prompt myself to take the hidden card out and put it in my wallet. It’s just not going to work all the time, but this is the way they keep doing it. Ridiculous. Where is Steve Jobs when I need him?

So, I’m here in Hawaii and the other night I left my card behind again – got it later, but what a pain. This is a stupid system and they’re all doing the same damn thing, hiding the card! At least I can rant and recognize that this is what Jobs was a specialist at, ranting about the idiocy of others. I’m in good company.

Oh, and one more thing – in my new car, an Infinity, there is a little light by the door that lights up when there is a car in my blind spot. All I have to do is remember to look at it. What they need is a bell that goes off when my wheels start to turn and the light is lit.

I read the Steve Jobs book, I understand the power of being right – No More Mr. Nice Guy!

Budd Shenkin

The Desert of Quality of Care in Diagnosis

2011-11-05T10:36:00.000-07:00

The reader will remember the stirring account of my recent neurosurgical adventure. The initial part of the adventure was essentially a misdiagnosis by my ophthalmologist. Despite the facts that, one, my eyesight was clearly deteriorating, and two, the very small cataracts in each eye were unchanged -- nonetheless, my ophthalmologist sent me home with literature on cataract removal, and instructions to tell him when I was ready to have them removed. I struggled with my feeling on the one hand that something was more profoundly wrong than that, versus my respect for a doctor’s opinion on the other. Silly me. Eventually, as I exerted pressure for a better diagnosis, my pituitary macroadenoma impinging on my optic chiasm was revealed as the cause of my progressive blindness.

What I didn’t anticipate was the response of fellow physicians to this misdiagnosis. One friend, plastic surgeon Steve Daane, was outraged: “You were misdiagnosed!” My pediatrician friend Arnie Blustein noted that this is a classic case of the kind of mistake in doctor thinking described in Jerry Groopman‘s book, How Doctors Think. As Arnie said, once they get an idea what the diagnosis is, they twist logic to come to that conclusion and just hang on. In my case, the cataracts had nothing to do with my decrease in vision, and if the ophthalmologist had used his head and gotten a simple visual fields test, he would have discovered my pituitary tumor impinging on the optic nerves. But he didn’t. Funny, I had read the book but it took Arnie’s observation for me to connect my plight to Groopman’s, as recounted in the book. I guess I’m not so smart as I sometimes think I am; I’ll have to reread it.

But what’s even more interesting is the number of doctors who recounted similar incidents in their own medical care! Here is the list:

• One pediatric colleague had had GI symptoms for some months, and his doctor said, you’re just constipated. My colleague didn’t think so, but went along with the suggested remedies. He subsequently arrived in the ER with fecal obstruction. The diagnosis in the ER was constipation. My colleague objected, insisted on and pulled strings to get an MRI, and an obstructing colon cancer was found. (He is now fine, having finally gone to UCSF for treatment.)

• Another pediatric colleague, a runner, was recovering from back surgery when he took a turn for the worse. The diagnosis was that he hadn’t rested enough and was “pushing it.” He objected to the diagnosis, insisted on blood tests, and he was ultimately diagnosed with osteomyelitis at the surgical site.

• Another colleague had had nagging pain in the right buttock and leg. He was advised to get physiotherapy. He insisted on an MRI, got his internist to sign off on it, and a five pound tumor was found in his buttock.

• Just yesterday, a neonatologist colleague told me about his searing right upper quadrant abdominal pain, diagnosed by a GI specialist as a clear case of a spastic gall bladder, which should be removed at once. My colleague suggested an MRI or CT scan, which the specialist refused to order because the case was so clear-cut. My friend went back to his internist to get his wish for a study fulfilled, and the culprit turned out to be a ureteral stone just above the bladder, not a gall bladder case at all.

What to make of these cases? An anecdote is just that, an anecdote, and even multiple anecdotes do not rise to the status of data. But while they don't prove anything, I think these anecdotes really do illuminate a probable truth. I think it i probably true that diagnostic medicine as commonly practiced has a very high rate of errors. This is a sobering thought, but probably true. It’s what my father told me long ago; as a community based neurosurgeon he saw a lot of how medicine is practiced, and it didn’t inspire confidence. His counsel to me was to be very careful whom I chose to be my doctor.

All these anecdotes concern doctors as patients. It’s possible that doctors get worse care than do ordinary patients. Treating physicians might be more nervous with a doctor as a patient, and they might not treat their doctor-patients as they do other patients and leave things out, try extra hard to appear confident, etc. But I think it is more probable that doctors are more alert to physician mistakes than are lay people. We just know more about what goes on, just as a general can tell a bad battle plan and bad commander reactions to enemy actions better than an architect can. I think that there is a lot of this bad diagnostic medicine practiced all the time and everywhere, but doctors get away with it.

From another point of view, it's amazing that such a poor diagnostic landscape exists. After all, there is a very active movement in medical care to measure quality of care. I won’t recount the history here, because it is long and complex. But the amazing thing is this – none of these adventures in misdiagnosis would be caught and cited by any current effort to measure quality of care!!! (That’s right, three exclamation points. After all, what could be more important than these misdiagnoses, and yet they are off the radar screen, by design! OK, now I’m down to one exclamation point.)

In outpatient medicine, it is very hard to measure quality of care, or even to define it. The most recent quality movement has been P4P, or Pay For Performance. P4P uses data from billings – the ease of data acquisition in P4P is its biggest selling point – and assesses to what extent regular, stereotypical procedures have been carried out. For instance – immunizations. There is a regular schedule for giving immunizations to children, and each shot should be billed for. Thus, a quality indicator for a practice is, what percentage of patients in a practice have gotten all the required shots by age 2? Or, another example, in a patient hospitalized for a heart attack, what percentage of patients had a beta-blocker prescribed by the time of discharge? Again, the ideal percentage would be 100%, so the rating is unambiguous. These are stereotypic procedures that should be done for every patient of that age or with that diagnosis, every time.

In the case of my ophthalmologist, a regular, stereotypic procedure would be, does the practice measure intraocular pressure every year, to detect glaucoma? I assure you, in this practice, they measure 100% on this; I have never been there without my intraocular pressure being measured.

But how could there be a method for detecting the timely (let alone early) diagnosis of my problem? How could the diagnostic acumen of the doctors in thes other cases of misdiagnosis recounted above, be assessed? Actually, I can think of several ways, but each would be difficult, expensive, and not possible in the typical small office. Quality assessment is really hard to do.

But, I do have a proposal. It goes against the grain of current quality assurance or quality improvement programs, because it is not quantitative – quantitation has infected medicine worse than MRSA has. You just can’t mention anything in quality assessment until somebody’s left brain kicks in, and someone pipes up as though they had a personal connection to the scientific Taliban, “How can you measure that exactly?” As though they were the smartest ones in the room. Drives me nuts.

Anyway, right now practices get paid extra (actually, their withhold of payment is restored, but that’s not the way the insurer’s portray it) if they meet the quantitative measure of keeping enough patients fully immunized. My proposal is this: the practices should be paid if they can show that they regularly review diagnostic problems within their practices and discuss them with each other.

The scientific measurement Taliban will reject this as “inexact,” but still, what gets talked about and what gets paid gets the attention, and the more we ignore diagnostic prowess the worse it will get. So I say, tell the practices they should have these procedures of diagnostic review, set some criteria for them and pay the practices that set such a review up.

There is a legal problem that would have to be solved for this proposal to work. In the hospital a quality committee’s deliberations are legally non-discoverable. This confidentiality allows true quality work to proceed, for obvious reasons. Without that protection, the quality committee’s work would be adversarial from the start and no one would agree to staff it. The diagnostic quality review committee in outpatient care would need similar legal protection.

So, in summary, I think diagnostic accuracy in community medical care probably is sorely deficient. If my colleagues and I can’t get it, you probably can’t get it, either. Caveat emptor – get that second and third opinion whenever you feel uneasy. And second, I propose that the quality movement change its focus from being exclusively on the repetitive, stereotypic, quantifiable procedures, and start to focus more on the harder to measure but ultimately at least as important area of accuracy of diagnosis.

Note to insurance company – I am available as a consultant, as I am not currently otherwise occupied occupying Oakland.

Budd Shenkin

Bookstores, The Kindle, and a Solution to a Moral Hazard

2011-10-16T14:09:00.000-07:00

My wife is a bookstore junky. We’ll be walking along, or even driving along, and she will spot a bookstore and head for it. Even in the shoppers’ paradise of the Dubai Mall, the main attraction was a great bookstore. She even has destination bookstores at various locations – it used to be the Thunderbird in Carmel, that bookstore near the Metropolitan Museum on Madison in NYC we were in earlier this week, and is it Smith’s in London? And I have to admit, I’m right there with her – she’ll be on her feet more, but I’ll settle into a chair and read a likely candidate for purchase.

There is really nothing like a bookstore. The best stores display books they recommend that you might otherwise not notice, each has its own personality, and you can look the book through in your own way to see if it’s for you. Plus there is the group experience as other book lovers mill about.

So, you want to support bookstores and buy the books you find there, and not run home and order the book you found from Amazon at a cheaper price, often substantially cheaper. You want to discipline yourself to buy the book there where you find it, and keep those stores in existence. Which we do.

But now the Kindle has made it harder. Not only is the book substantially less expensive on the Kindle, sometimes you don’t want the physical book, you want it on the Kindle. I love reading on the Kindle, even though I enjoy the look and feel of real books, the memory of book covers, and the ability to scan back in a way that is better than on the Kindle. But for me somehow I read the Kindle faster and easier, and it travels very, very well. So, there you are in the store, you have found a book you want, but you want it on the Kindle. It’s a harder choice than it has ever been.

Plus, there are probably people less scrupulous than we are, who make it a regular practice to shop actual and buy virtual. They can rationalize that they are pressed for cash, they can make other rationalizations, but the moral hazard still exists.

I don’t know how widespread this problem is, or if anyone knows how widespread it is, but if it is widespread, I have a solution. Here it is:

HAVE AN AMAZON CONNECTED COMPUTER IN EACH BOOKSTORE. IF A CUSTOMER CHOOSES TO ORDER THE BOOK ON THAT COMPUTER RATHER THAN BUY IT DIRECTLY FROM THE BOOKSTORE, THEN SPLIT THE PROFIT BETWEEN AMAZON AND THE BOOKSTORE.

I don’t know how the numbers would work. Would people do it? Would they order right there in the bookstore? Would too many people be tempted to buy it on Amazon, when without this connection in the store they would just have pIcked it up at the store and the store would have enjoyed the whole profit themselves? Would this be an attractive proposition for Amazon?

I don’t know the answers. But I do think it would help me out of my moral dilemma. I see the book, I want it on my Kindle, and what am I going to do? I sure would like to give each of them some profit, and have that book the way I want it.

Budd Shenkin

Welcome to Neurosurgeryland

2011-08-24T12:01:00.000-07:00

WELCOME TO NEUROSURGERYLAND

I thought our big adventure this year would be our trip to East Africa. Well, that trip was terrific, for sure. But our biggest adventure turned out to be our trip to Neurosurgeryland. Be warned: this is a long post, 6,000 words probably. But I’ll do my best to keep it moving along.

My Life as a Neurosurgical Son

I was the eldest child in a neurosurgical family. I say “neurosurgical family” because when your father is a neurosurgeon, that’s the whole deal right there. Neurosurgeons tend to be Ayn Rand hero-types. That’s what my Dad was.

He got to be a neurosurgeon because of his father, who was a general practitioner (and also billiards champion) of Philadelphia. The story goes that one day in 1932 he blew his nose too hard and the infected phlegm went backwards through his ear, causing a cerebral abscess. With no antibiotics and only rudimentary brain surgery, he soon died. My father was 17. The attending neurologist put my Dad to work as a neuropathology technician, and soon doctors were calling him directly for his reading of the slides.

As my Dad was at the end of medical school the first neurosurgeon in Philadelphia, Francis Grant, came to him and asked him what he was going to be. “A neurologist, I guess,” said my Dad.

“Well, you know,” said Dr. Grant, “if you are a neurologist you will have to do psychiatry, too, to make a living. Why don’t you think about being a neurosurgeon?”

Much to the advantage not only of my father but a myriad of patients who would be seeking psychiatric advice, my father became the third neurosurgeon in Philadelphia.

The next part of the family story is that my father could not stay at Penn although he wanted to. He was Jewish. Dr. Grant said to my Dad, “We did it for Rav (Isidor Ravdin, internist), but we can’t do it for you, Henry.” My Dad stuck to that story, but one time years later he said that it might have been his personality, too.

My Dad wound up as Chief of Neurosurgery at Episcopal Hospital in North Philadelphia and perennial President of the Medical Staff. He has a list of “firsts” he accomplished as a nationally and even internationally known neurosurgeon, but his favorite had to be owning the first CAT scanner in Philadelphia. It operated 24 hours a day, and when they called for an appointment from Penn, my mother would be happy to give them the open 2 AM slot.

I idolized my father, but when I was in medical school he put no pressure on me to become a neurosurgeon, and in fact urged me more toward administrative or academic medicine. He rightly saw that if I chose the neurosurgical path, it would have to come from me. But I chose pediatrics. When my father announced this choice to his hospital lunch table colleagues, there was a silence. Someone spoke up, “But, Henry, those guys work so hard and they hardly make any money at all!” Silence. Then, “Can you talk to him?”

Even though I seem to have a “surgical personality,” pediatrics and administration has been great for me, a real mitzvah. But I remained a neurosurgical son, at home in Neurosurgeryland. When my Dad had a reunion of his residents at a Harvey Cushing Society meeting in San Francisco, I was asked to speak. I told the residents that we were all his sons. They loved him.

My Dad died at age 92 in 2007, his last accomplishment having lived to the age of 92. He was a man of objectives. He told me in his 80’s that he figured that the goal now was to live long, so he reduced his diet and made it to 92. “Made it to 92,” was one of his final statements. He observed many times – many, many times, since he was not one to deny himself the pleasure of reiteration -- that he was born when horses were the general mode of transportation in Philadelphia for God’s sake, and that his generation had seen the most amazing transformation in technology not only that the world had ever seen, but much more than anyone could ever have imagined. Just in his own field, my Dad had gone from relative helplessness with his own father’s illness, through the techniques that my Dad and his generation created, and then beyond. (My own view is that advances in medicine and in space and physics exploration are the quintessential advances of our age, even more important than the securitization of mortgages.)

As if to prove the point, just seven months after Dad died, I got my hip resurfaced (slightly more advanced than the traditional hip replacement.) I had told him I was having some trouble with it, and the kindly (he was kindly with me) neurosurgeon said, “Get it fixed.” Spare parts replacement surgery. If you think about it, wow. Star Trek.

Ophthalmology

So that was fine, but then last year I started having some trouble seeing. I had always taken pride in my eyes; even here in my late sixties, in strong light I have been able to read the New York Times without glasses. But I thought Father Time was catching up with me. My prescription hadn’t changed and I got checked up each year, but I was having real trouble seeing. I went to the ophthalmologist in December 2010 with pretty severe complaints. I couldn’t see anything on the eye chart with my left eye, and my right one wasn’t so great, either. My ophthalmologist said that my vision hadn’t changed a lot (that was hard to understand), and the small cataracts I had shouldn’t really affect my vision that much. But nonetheless, he didn’t delve further and gave me a packet of information on cataract surgery.

It didn’t make sense to me, but I thought maybe he just wasn’t paying enough attention to helping my vision. I thought I’d try to do that, so I went to the optometrists at UC Berkeley, who used terrific new technology to map my whole eye on each side – fantastic, granular pictures of just every part of my eyes. Star Trek. I wondered with the optometrist, since the cataracts don’t explain the vision loss, if there was something neurological going on, since the exam of all aspects of the eyes was so normal. But it was left at that, a wondering. He asked me to come back to try one or two things more, but I let it go. I got new glasses for reading and that helped some.

My eyes got worse. I had trouble making out a wall menu when the lettering on the wood was in yellow. I thought the type on some of my books was faint. I felt often the way you do when you have looked at brightness and your eyes have yet to accommodate, but they never would accommodate, and I was just left with the glare. Ann and I took a wonderful trip to Africa, and she could see game that I had to look twice or three times to see. We came home and were about to go on a long-planned trip to Hawaii with my brother and sister-in-law, and I said, “I have to go back to the ophthalmologist. My eyes suck.” Maybe it was just age, but I had try again, even if he might just say, get the cataract surgery.

So I did. The house optometrist asked me why my vision was poor (I said, you’re the doctor! To which he took offense), and then why I hadn’t had my cataract operation. They had only done a partial transition from paper to electronic medical records, but he eventually was using both to trace my history. He refracted me (not sure why). Then he looked at my left eye’s progress over the last few years – 20/40 to 20/60 to 20/80 to 20/100. But the size of the cataract hadn’t changed. My ophthalmologist came in and seemed puzzled. I asked him about neurological disease – I’m too old for multiple sclerosis, but something was happening. I told him many of my symptoms. I was emphatic – when I read I can’t use my left eye at all, and I’m scanning with my right eye. Finally, he said he would do further testing. He looked at me as though I had pushed him enough. I could only make out one of the numbers on the Ishihara color discrimination test – but that’s OK, he said, you’re dilated. He asked if his office could set up an appointment with a retina specialist. He asked me to make an appointment to come back for a visual field test.

I went out front and the staff made the retina appointment with the wrong group until I corrected them. I insisted on giving my cell phone number to the front desk person who didn’t seem to know what to do with it on the electronic medical record. I was about to leave when someone came around the corner and said they could do the visual field testing now after all, if I could wait. Of course I could. The tech came and got me for the tests, chin up and one eye looking straight ahead, thumb clicking on device every time I saw a flash of light in various quadrants. The tech excused himself during each test because it was so boring for him to sit there and watch. I left and ate an early Japanese dinner with my step-daughter Sara, a UCSF pediatrician, and 1 1/2 year old Lola. I told Sara I thought I could have a brain tumor of some sort. Then I went home.

The ophthalmologist had left a message on our home answering machine – call him, he didn’t have my cell number, so he is calling here at home. I called and he said, you have both eyes involved, the upper outer fields in both eyes are cut. So there is something going on at the optic chiasm, where the optic nerves cross, right in the middle of the head above the pituitary gland.

“So I need an MRI,” I said.

“Right,” he answered.

“So I’m not going to Hawaii tomorrow morning, “ I said.

“Right,” he answered.

I called my wife who was already there in Hawaii. I explained what was happening. She said, “I think I’m going to cry.”

I said, “I think it’s going to be OK.” The most common thing for it to be would be a pituitary adenoma, which is operable and non-malignant. I was counting on that. I told her not to take the red eye home, let’s see what happens tomorrow.

She called Sara, who called me and said she wanted to come with me to the MRI. I could handle it alone, but I was grateful and I accepted. My father said that every family should have at least one doctor in each generation.

The MRI

It was Thursday now. The ophthalmologist’s office called at 9 AM. They said they had me scheduled for the MRI on Friday at 7:30 AM. I said, “No.”

She said, “What?”

I said, “I’m getting my MRI today. Who did you call?”

She said, “I called all around.”

I said, “Did you tell them it was for Dr. Budd Shenkin?”

She said, “No, I asked them when they had an opening.”

I said, “Did you call Stuart London’s office?”

She said, “No. I should have thought of that.”

We rang off. At 9:20 she called me back and said, “Dr. London has you scheduled for 12 noon today.” I thanked her. He had bumped somebody less acute, who wasn’t going blind.

I had to get my blood tests to him by noon so I could be injected with contrast. The local blood draw station for Labcorp got stat lab results by the end of the day. I went to my old home hospital, Summit, and they got the super stat labs to Dr. London in an hour.

I went home and did some scanning and shredding – I’m making my home office as paperless as possible, Ann’s too – and Sara and I went down to get the MRI. They did my test while she got a sandwich at Ptomain Heaven, all that is available at 34th and Telegraph in Oakland. When my test was over, Sara and I were escorted back where Stu could review the MRI with us.

Stu looked at me with compassion and professionalism and took us to the computer and said, “You have a macroadenoma of the pituitary. It’s 4 cm by 3.2 cm by 2.8 cm. It has extended first down into the sphenoid sinus and then up to squash the pituitary against the side of the sella turcica (the seat of the pituitary, which has a floor and pillars on each side, so it’s like a throne), and it is putting pressure on your optic nerves. What are your symptoms?”

I told him. Then I asked the obvious question, to which I really knew the answer, but I wanted to reassure both of them, in a way. “Is it operable?”

“Oh, yes, it certainly is,” said Stu.

Ok, then. “Where should be go, Stu?” I asked.

He shrugged, “UCSF. You don’t want to go local with something like this. No disrespect to the local guys.”

Of course. That was my view as well. I knew Charlie Wilson had pioneered the nasal approach to the pituitary years ago right here at UCSF, which was my home institution, and for years I had insisted on PPO insurance so that if something like this happened, I could go there. Charlie Wilson was always my explanation when I signed up for PPO. Not that I planned on it. (See http://www.newyorker.com/archive/1999/08/02/1999_08_02_057_TNY_LIBRY_000018760, for the New Yorker's essay on Charlie Wilson.)

After thanking Stu, Sara and I left with the disk of the MRI and she grabbed my arm above the elbow, in support. I didn’t feel any angst at all. I knew this was doable.

We walked to the car and called Ann on the Bluetooth speaker phone, and told her. She said, “You two aren’t sugar coating it, are you?”

Sara and I looked at each other to make sure. Then we both said, “No, we’re not. It’s really going to be OK.”

Starting with Neurosurgery

I called the ophthalmologist and told him the result. He said that all my vision would return. From his lips to God’s ears, and the ears of his malpractice carrier. I told him that my goal now was to find the best surgeon and be operated on by the middle of the next week. He advised going to UCSF, saying he had had a couple of patients there. I asked him to try to get me an appointment asap, and tell them I’m on the clinical faculty there, etc. But move on it. He agreed.

We checked other sources. Sara pulled up the bio on Sandeep Kunwar, the chief neurosurgeon at the Pituitary Center at UCSF. It said he had the largest series of pituitary adenomas in the country. Another colleague of Sara’s, a neurosurgeon in Sacramento, called her to say there was no reason not to go to Dr. Kunwar. I called other sources, who eventually confirmed the choice. I hoped he was not on vacation.

He wasn’t. I scanned and shredded some more, ate dinner at Asmara, my favorite Ethiopian restaurant, and called my brother to tell him the change in plans. He would have to figure out whether to go to Maui on his own with Susan, or change plans. I talked to Ann a few times. She would head home the next day. I felt fine, although I still couldn’t see very well.

On Friday morning I got a call from Dr. Kunwar’s office, asking if could I come to his office in Fremont at 12 noon. apologizing for the short notice. I said I thought I could make time in my schedule to be there. I scanned and shredded, did email, and left to be on time. I was taken back to the exam room at 12:20 and they apologized for keeping me waiting. Dr. Kunwar arrived and apologized for keeping me waiting.

Dr. Kunwar introduced himself as Sandeep Kunwar, informally, just the way Mike Ries had introduced himself when I had started seeing him for my hip. While being friendly and informal and very warm, he was brisk and practical, with no time for traditional formalities like listening to my heart or even examining me. He had the MRI and didn’t need anything else. He asked me about my UCSF and UCB connections – he graduated at UCB, and had done all his medical work at UCSF. I asked him if he trained under Charlie Wilson. He said yes, he trained with him, and then took over his practice. “Great,” I said. We are part of the same club.

He told me he would go over things I no doubt knew, and I said, right, treat me like a patient. We nodded understandingly at each other. As he started I interrupted briefly. I said, “I have to tell you, I come from a neurosurgical family, so coming here I actually feel right at home.” He was interested. I told him about my Dad, whom he hadn’t heard of. I said, “I remember coming down in the morning and my Dad wasn’t drinking coffee because he had a brain tumor that morning, and he didn’t want his hands to shake. So here we are.” He shook his head in understanding, right. I had been more worried with my hip than here with my brain. (As Woody Allen said, “Not my brain! That’s my second-favorite organ!”)

He then gave me his personalized rap. The facts of the case were straightforward. He said I had probably had this tumor for eight or ten years. Below 45 years of age they usually produce a hormone, over 45 years they are non-productive. Sometimes they are prolactinomas, but not usually. It had expanded down into the sphenoidal sinuses without noticeable symptoms. It had also flattened out the pituitary and doubtless wiped out several of my hormones. He said the first one to go is Human Growth Hormone, but in adults patients don’t notice anything. (I wanted to say I had noticed a loss of power from the right side of the plate, but restrained myself.) Then thyroid goes, then testosterone, and then cortisol. The thyroid and testosterone are easily replaced by a pill and a gel, but the cortisol is harder.

He asked about my symptoms. I told him I had been on supplementary thyroid because my internist had taken a test just on the basis of ageing and found a little deficiency. My libido had been down for some time, which I found to be a relief. He asked me about general vigor. I’m in very good shape, so I turned my palms out and straightened my arms to say, “Look at me. I’m 69.” He said, “But you could be even better!” Some slow wound healing maybe, but I didn’t mention that. Dry skin. Still, basically unnoticeable except for the vision. He said that once squeezed, the pituitary doesn’t recover significantly but we could replace everything, it looked like.

After the tumor had squeezed the gland and grown downward and obliterated the sphenoidal sinus, it started to go up, meeting the optic chiasm. That’s what had brought me to this exam room.

These tumors can be either spongy or more rigid, in a spectrum from about 20% (spongy) to 80% (rigid). They come either like hard-boiled eggs that can be easily peeled out from the shell, or more like cauliflowers that are harder to resect. Problems with resecting come if they have wormed their way into something that it’s hard to get them away from. The cavernous sinuses would be number one. A nerve can also be a problem. But even in these cases we get most of them. They are slow growing, so if there happens to be some left behind we just follow it with serial MRI’s and then if it gets bigger, we cut it with a gamma knife, just tightly-focused radiation.

The approach used be under the lip with Charlie Wilson, and is now through the nose. You break through the sphenoidal sinus, which we won’t have to do here because the tumor has already destroyed it. Then you follow it in, debulk it from the inside, then go carefully with each surface of it and pick it out. Then put some fat he would get from my abdomen into the sella, which the tumor had enlarged, like the foam we use to take up the extra space in packages. He told me he had done over 2,000 of these operations now, and the risks are down to under 1%. That’s a good number. He said I would regain the vision I had lost in the last 3-6 months, but that the endocrine function lost would not likely return, but could be replaced.

He said he operated at both Washington Hospital and UCSF. He went into private practice and operates in Fremont because he has a technology and he wants to do more with it, go different places in the body, and you can do more off-campus. It’s funny, he said, you would think you could innovate more on-campus. But in fact UCSF is great for the science, but off-campus is best for technology. I could choose where I wanted to be operated on, it didn’t matter to him, each has its own strengths and weaknesses. I didn’t ask more about that, I just wanted the earliest date available. That date turned out to be Wednesday, August 3 in Fremont. It would be less than one week from ophthalmology appointment to operation, which was my goal, so long as I got the best neurosurgeon, which it seemed like I did. As I left the front desk to get my blood tests, he left the opposite way, waved and said, “See you Wednesday.” I responded, “Be there or be square.” We smiled at each other.

I got my blood tests, collected my paper work and drove home. It was set. I had my man and I had my op date. I was very comfortable to be back in Neurosurgeryland.

The Operation

I picked up Ann at the airport that night to the relief of both of us and filled her in. Over the weekend I worked out, did some work (scanned and shredded), notified near and dear, decided with this risk level that son Allie didn’t have to come from his home in Panama to stand by, decided to let leadership at Bayside know the prospect but to wait until post-op to let everyone else there know – why worry them? - took grand-daughter Lola to the merry-go-round and the little farm in Tilden Park on Sunday, got the pre-ops on Monday, did more work on Tuesday, scrubbed hard in showers Tuesday night and Wednesday morning and slept in freshly washed sheets and pajamas to minimize infection risk, loaded up my pill boxes for two weeks, got packed up with slippers and pajamas by Ann, and we drove down together on Wednesday morning, all ready.

The anesthesiologist came and we talked. He was a Stanford guy, which was reassuring. I remembered Reagan’s aplomb as he was wheeled into surgery after the assassination attempt, “ Any of you guys Democrats?” So I confessed we were Cal people. He recalled gifts of cases of wine he had received from former patients. Stanford guys…. He shot me some Versed. I said, “I like Versed.” He said, “Who doesn’t?” That’s the last thing I remember before waking up in the recovery room – no ICU, even – and Peter and Ann thought I looked ten years older. I got morphine and was fine.

First thing I did when I woke up was look around and check my vision on signs. My left eye was working fine, already. My right was better, too. It had already worked.

At nine PM Dr. Kanwar came by. I asked him what else he had done during the day. He said, two other cases, a spine and something else, the clinic, and then a gamma knife conference. He’s 44 years old and full of energy – the perfect age, and the perfect intensity. He told me my tumor had come out completely – it was hard-boiled egg, not cauliflower. My tumor was the size of a small tomato, almost as big as they get, and very rigid, almost like cartilage, maybe 90% on the spectrum. It had probably been there for 8-10 years. He said that since it was so fibrous, there were only a handful of surgeons in the country who could have handled it – he wasn’t bragging, he’s not a braggart, it was just fact. Good choice of surgeon. Wow. And here I was just conversing with him after his being in the middle of the brain just a few hours ago. As Ann said, it was scary that he was in the middle of my brain, both literally and figuratively. Ann’s a funny person.

I told him, “I don’t know how much you make, but whatever it is, you deserve a lot more.”

Recovery

The first night was morphine, the second night was hydrocodone, then it was home on Friday. Ann sat with me and 27 year old son Pete did, too. Ann ministered to me as she knows how to do – second major surgery in three years. Over and out, hopefully. She told me not to be abstemious with the hydrocodone, which I tend to be, to keep ahead of the pain.

I told Pete, “I feel fine!”

Pete laughed and said, “Dad, of course you do, you’re on hydrocodone!”

Pete urged me to name the tumor. Didn’t want to do it then. Subsequently settled on “The Tomato.”

The ophthalmologist’s office called to find out what happened, so I called back and told them. We let Bayside know I was fine and they could let out the word. We let near and dear know.

It’s good for a doctor to experience the other side of health care. It makes us better doctors. I noticed the hospital. The room was good size and private; the TV was flat screen with a pretty good cable range of shows, including Giants games. The nursing was attentive, each nurse with his or her own personality. Kim fought playfully with me about how we were going to keep me un-constipated while taking pain meds. Roy said his charge nurse wouldn’t let him leave Mylanta by the bedside because it was a drug, and he hoped I would understand because he didn’t want to get written up. I had my blood drawn at 4:30 AM each day. The default channel on the TV was constantly rotating nursing conferences about their quality efforts, very earnest. The charts on the walls as I took my walks were about steps toward quality. That’s good. Think of how hard it is nationally to get hospitals to take action for quality – very difficult. Large groups of people like American hospitals are, by definition, average. Yet national imperatives have filtered down to hospitals well, and progress is evident to a patient like me.

The night before discharge Sandeep’s PA Joe repeated the rules of recovery again: Two weeks of no work, no lifting, lots of reading, some walking, and no blowing the nose. Then two weeks of limited work. Then done. Expect sinus headaches for a couple of weeks. Use Ocean Spray. Things in my head were rearranged and we needed some time for it all to sclerose in and become settled.

At Home

When I got home Ann brought me meals in bed. I followed her advice on meds and rest. I appreciated her ministrations and other secondary gains. I had thought about cautioning others that I didn’t want a fuss made. Then I thought, what’s wrong with a little fuss? Forget the Mr. Cool. Emails, flowers, cards, books. Food. On Saturday Stu Lovett came by with blueberry pie, and we visited. He said he saw my car out front so he figured I was OK. Ione with a stew. Marjorie and Michael with a great salmon dish. And as with the hip, a sandwich from Andronico’s tasted like no other sandwich ever tasted – last time tuna, this time ham and cheese. Cards from people and group cards from some Bayside offices. I choose to believe that these are real expressions of person to person concern and affection. I’ll take it.

I followed Bobby and Susan’s Maui adventure each day, they came back for two days here, used some Giants tickets and loved the stadium, visited for an hour in the sun with old and very dear friend Bob, and as Hemingway would have said, it was good.

I started feeling better, but then Peter sat me down and lectured me: “Dad! You’re not following the orders! You have to take it easy! I saw you picking Lola up!” He was impassioned, frightened for me, and he was right. I thanked him and pledged to be a better patient. I appreciated his concern and his love

And then there is my vision. I kept checking it out. Would it get better still? I walked around the block with Sara and Lola and I thought everything looked more colorful, and the air was clearer. There was no glare. I can see my cards in Freecell more clearly; I can read the numbers on the squares clearly in the New York Times crossword – still can’t do the puzzle all that well, but at least it’s not because of my eyes. I can read real books. I decreased the font size on my Kindle so I can read it faster. What a gift!

I saw my friend Joel the urologist, and we talked again about our OB friend Hank, who died in May of malignant melanoma. He had told Joel that he felt like he was in a speeding car and couldn’t get out. What an image; I understood it. I wish Hank could have gotten out, but even if he couldn’t, I was thankful that I could. Joel said, retire, man! He recounted those who worked too long. But we love our work. The trick is to keep it in its place, I said. Yes, he said, keep it in its place.

After a week I drove into the Oakland office so they could see for themselves. I was home free.

Endocrine Follow Up

The following week Ann and I drove to UCSF to see my endocrinologist, Lewis Blevins. He told me I looked so young, and we would wait six weeks and take hormone levels and see what needed to be replaced. He said that he has been at three different institutions with different neurosurgeons, and Sandeep is the best. He used to say to patients that post op, 1/3 will have worse endocrine function, 1/3 the same, and 1/3 better. With Sandeep he says 5% will have worse, 10% the same, and 85% better. Neurosurgeons are not fungible.

He said that he didn’t see why neurosurgeons don’t refer all pituitary tumors to UCSF. There aren’t enough of either pituitary tumors or neurosurgeons to make a financial difference. Maybe it’s the neurosurgical personality, the ego. I agreed with him. There are two current theories for organizing health care. One is vertical integration, or integrated networks, like Kaiser. The other, as suggested by the book “Redefining Health Care” by Porter and Teisberg, is centers of excellence, where a primary care doctor or a patient him or herself, could choose among competing centers for quality, cost, and accessibility, for each individual affliction. I’m in the centers of excellence camp. Made sense for my hip, made sense for my pituitary. I found the centers where problems from other docs were referred to for repair, and I just went there straight away. Makes sense to me. Surgeons and centers of excellence are not fungible.

What I Make of All This

So what do I make of all this?

First of all, I’m on Medicare and a Medicare supplement – so notice, not once have I said anything about a network, calls to insurance companies, or cost. I paid only $50 for the refraction done at the ophthalmologists. Medicare has great problems, but they sure aren’t on the patient side. For patients, this is just the way it should be.

But I reflect back to my Dad. This case is such a triumph of modern medicine! In my Dad’s day, he would have had to do a pneumoencephalogram, probably, an excruciatingly painful Xray procedure where the neurosurgeon injected air through a lumbar puncture, the body was tilted this way and that, and the lesion outlined against air in the ventricles of the brain. Instead, we have an MRI with about half an hour of lying on my back, and exquisitely detailed pictures of every aspect of the brain, with millimeters of definition. Tell me that’s not Star Trek.

Then there is the surgery itself. Minimally invasive to the middle of the skull? The pituitary gland is like a pit in the middle of the cranium with the brain curled around it. Go in through the nose and operate on it with fiber optics and microscopic controls with a TV set enlarged to guide the instruments? Are you kidding me??? My Dad would have sawed off half my skull, I guess, looking for the pit. This has to be Star Trek, not earth in the 21st century. Except that it is.

So, as I say, modern medicine, space exploration, the Hubble, cosmology, string theory, not to mention securitization. I mean, think about it.

But beyond that, I take it personally. Look at what everyone had to do to be able to have Sandeep do this for me and in me. Look at what Mary Lasker and Lister Hill did when they started the NIH. Look at what Charlie Wilson did as a pioneer and as a trainer of others. Look what Sandeep has done to prepare himself to help me. Look at the time he took just with me. They did it all through the years so that they could do this for me, and for others like me. It is a person to person service. They did it for me.

Not that I particularly deserved it. I was lucky. I was the recipient of the favors of strangers – except for my father, who was not a stranger, and who also made his contribution.

And look at the people around me and the much-appreciated secondary gains. Succor and attention. Family around me and caring, friends, associates. I have to look at it all and be grateful.

I know the tendency for public health and preventive medicine to take a back seat to spectacular curative medicine, and that the greatest advances in health have been clean water, hygiene, and immunizations. But still, I’m hardly making the same contribution that these giants, including my doctors Mike Ries with my hip and Sandeep Kunwar with my tomato, have made and are making, not only in Neurosurgeryland and Orthopedicsland, but also in Cardiologyland, Oncologyland, and other Medicallands. It’s hard for me to think I’m making enough contributions. But I’ll just do what I can.

There was a study of righteous gentiles who helped the Jews during the Holocaust. Many of them had some experience in their lives earlier where someone had done something for them, more or less without obligation, just to do a good deed out of compassion. They knew how it had felt, and they could do the same in turn with some of these poor oppressed Jews. I think I feel the same way.

I am so grateful.

And finally, finally – it’s great to have personal relationships, and to feel individualized, but I am also part of a group. So, I don’t want to be just a name, I want to be a number! I want to be Kunwar pituitary adenoma patient #2,134! Come on, give me my place in the starry kingdom of Neurosurgeryland! I want my number!

Budd Shenkin

Visiting Africa

2011-07-13T08:05:00.000-07:00

VISITING AFRICA

I’ve been away. On a big trip to East Africa, Kenya and Tanzania by way of Emirates Airlines and Dubai – long live the Dubai Mall! Big, lots of good stuff for people who like fancy stores and fancy stuff, and on the bottom floor I could buy a lithium battery to bolster Ann’s light for her Kindle for 3 bucks. It’s nice to have Arabic dress around, real people who just happen to dress that way, and Pakistanis who drive the taxis and remind us it’s only 3 hours to Pakistan and Afganistan, whereas it’s 15 hours to the U.S. They have lots of money, so they get to choose what lifestyle they want. They choose Arab dress, but it looks like they choose Western stores and goods. They had lots of money to make a Dubai first class, uninhibited by the restrictions of taste. Hoo-hah!

Anyway, that was our stopover before and after Africa, where I had been aching to go for years, but we went elsewhere on cruises and such, but then Ann said, if we don’t go now we’ll never go so we did. With trepidation. What if we get sick. What if we can’t take the rigors of a trip like that. What if. We needn’t have worried.

The hardest part was the packing. Since we were going on safari (Swahili word), we were restricted to one 33 pound small bag apiece, since we were flying on many small planes. We took weeks to get ready. I had to buy shoes, and thank goodness for my shoe guy Cyrus. I called him and he said I needed all terrain shoes, that’s what people going to Africa wore. I went there and he gave me no choice, just fitted me to the shoes he chose and I couldn’t be happier. If someone knows best, all you have to do is listen to him. Not too heavy, laces around hooks, OK!

Several trips to REI, mosquito repellent shirt. The company, Abercrombie and Kent, sent us flashlights that had bright white light, just after we bought mini.-flashlights at Ace. We took the free ones (well, considering the price of all this, not quite free) and were very happy. We used them in our tent cabins at the four lodges we visited, and going to dinner with our askari’s our guardians, who were unarmed, but I guess they knew how to shout at animals that happened our way.

We went on lots of game drives, in open and closed land rovers, looking for and finding game. We were mostly just alone with our driver/guides, or sometimes with others, but always very private, nothing like the tour buses from cruises. Very knowledgeable and very lovely people. We saw tons of animals, starting with zebras and giraffes, which seemed to hang together a lot so the giraffe could spot trouble from on high and warn the band. Giraffes walk with two left feet and then two right feet strides, so they aren’t too fast. But their kicks can kill a lion. We saw baboons warning others from trees about an approaching lion pride. We saw a pride of lions stalk and kill a wart hog, a half hour of stalking and about 5 seconds of jump and kill, after which the other four warthogs wondered what had happened to Henry.

But the animal most admired by our guides was probably the impala. Impalas hang together, but in two different groups. The guides would say, look, there’s the boy’s club or the bachelors club, where all the males are. And close by would be the harem with a couple dozen females and one male, who would be their consort for a few months. They guides would chuckle in admiration and say, he’s very tired. And chuckle again. He was their idol.

One afternoon at the Maasai Mara, where we had a beautiful cabin on the banks of the river where hippos soaked all day and night and made their noises so they sounded about 20 feet away, Ann took a rest and I went for a walk with my guide Richard. We walked through grass and by trees and he waxed eloquent about what was what and what did what. Who knew ebony trees were so skinny? An impala admirer, he had two wives and aspired to four, which was a pretty common aspiration. I couldn’t help thinking that their admiration for the chosen impala consort and their own aspirations were connected. His wealth was counted in cattle, which is common for tribes in Africa. I had studies the Nuer of Sudan in college, and the Dinka, and they were the same. We found hippos and some crocs on our walk, and talked. Talked a little about wives, were just together mostly, taking a walk. Took pictures of each other at the hippo pool.

As we walked I said he was a great walker, and I told him I was older but I was keeping up with him. He said, you are old, but you are strong. I guess that was true. I asked him how old he was and he said 37. Then he asked me how old I was and I said how old do you think? He looked, sized me up, and said 45.

So I said, actually, I’m older than that, I’m 69. He was amazed. He looked at me with wonder. He said, how do you do it?

I looked back at him, drew closer, and said, “One wife!”

He giggled and hit me on the arm and we had a fun time and walked home.

Budd Shenkin

The Re-segregation of health care

2011-05-30T09:12:00.000-07:00

This is very sad. Just as US wealth is being increasingly concentrated at the very top, health care is being re-segregated at the very bottom. The segregation of facilities is primarily by wealth, and then secondarily by race, because that is the way wealth is distributed.

In the beginning, say the 1940’s when my Dad started practicing, the middle and upper classes received their health care in private offices and private hospital rooms, and the poor received their care in public clinics and hospital wards. My Dad told me about it. Back then there were fewer doctors, fewer medicines, fewer procedures, much lower cost, less health insurance, and no Medicare or Medicaid. My Dad and others like him felt a social responsibility - plus there were training needs – and hospitals functioned more for public service rather than for profits. My Dad served at PGH, Philadelphia General Hospital. He pronounced “PGH” with a tone I couldn’t identify, and maybe it was reverence. “This is what we did at PGH,” he said. He was nostalgic. “We treated the patients the same as we treated our private patients,” he said. “We took a day or a half-day a week and worked there for free. It was an honor to be chosen to work there.”

By “the same,” he didn’t mean the same dignity and convenience, but rather the same basic medical care. The clinics were big and impersonal, the ward beds were like you would see on M*A*S*H, no frills, but the treatment was good. The doctors and hospitals didn’t get paid, they just did it.

But of course everything was different back then. I suppose noblesse oblige worked for those times. Poor people were grateful to get the care and there were no complaints about dignity, and few about racism. Different days, to be sure.

But in 1965 Medicare and Medicaid were passed and that changed everything. Medicaid covered many of the poor and gave them to right to be seen in offices rather than clinics, just like middle class patients, if the practitioners agreed to be paid by Medicaid. Most practitioners did take it at the beginning, when payments were fairly competitive. So did most hospitals, which improved their bottom lines. Public clinics and hospital wards persisted, since there were still relatively few doctors and hospital habits were hard to break. Even into the 1980’s at the largest of my local hospitals, private patients on the maternity wards had private or semi-private rooms, and most Medi-Cal patients were placed in larger wards with only curtains walling off the beds from one another. Yet even those larger wards vanished by the 1990’s. Still, the staff sought to place culturally similar patients in semi-private rooms (which was a good thing, I think. Picture yourself as a new mother with a roommate who keeps the TV on all the time, and is on the phone all the time, etc. Cultural clash.)

Coverage vs. Access

But then what happened is what always happens. The money devoted to care for the poor, governmental money, was whittled down. The original fees for doctors weren’t too bad – but they never changed as the years went by and inflation occurred. Is a separate program of health insurance for the poor equal to health insurance for the middle class? Maybe at first, but in time it won’t be. Separate is just never equal.

Gradually, the diminishing fees pushed more and more doctors out of Medicaid. Government didn’t acknowledge this movement, it claimed increased coverage, as more patients qualified for the program. But “coverage” does not equal “access. Here in California, the worst case scenario in the United States, we have extensive “coverage,” but the Medi-Cal fee schedule calls for about 35% of Medicare fees – which many think are already too low. Try to fathom that -- 35%!

Alameda County

Here in Alameda County our primary care pediatricians have been protected to a certain extent. Our Managed Care Medi-Cal, contract allows pays our pediatricians at maybe 80-85% of Medicare rates. These are low rates, but just about manageable to be able to keep serving our Medi-cal patients. At our practice we started with Medi-Cal patients as most practices did, but then instead of abandoning them as we attracted more private patients, we kept the Medi-Cal patients and just got bigger. This is what Medicaid envisioned, I think – one class of care. It takes some forbearance on the part of our private patients, since there are cultural differences that can grate as classes mix, but on the whole, this being the Bay Area, we have been successful.

What do patients want? The Alameda County Medi-Cal population has voted with its feet. Despite an extensive clinic system, 65% of Medi-cal patients choose private practices as their primary care practitioners. This didn’t just happen. The planners of Medi-Cal Managed Care mandated a two-plan system for each county, so the doctors had competitive plans to contract with. It also took a very public spirited Director of Health Care Services, David Kears, who believed in primary care, and believed in giving the choice of provider to the patient, and did not take the usual public health department bureaucratic route of trying to steer all the patients and all the money to their own clinics. And in addition, we primary care pediatricians got together and negotiated ourselves a decent deal, we didn’t just take what they gave us. As a result, many private pediatricians have stayed in Medi-Cal, and the original intent of Medicaid seems to work here locally in pediatrics.

Re-segregation

But it’s not going to last. Time, finances, and the inexorable drive to discriminate is catching up with us. Nationally, the Affordable Care Act (ACA) grants $13 billion to the clinics. There will be a mandate for 2013-2014 to pay 100% of Medicare for certain primary care visits, which might actually stay in the bill, we’ll see, but that may or may not apply.

Locally, the current Department of Health Care Services and the Medi-Cal managed health care plan tied to the county, the Alameda Alliance for Health (AAH), are applying to the Feds to become a County Organized Health System (COHS). They dress up this proposal as “saving money,” although exactly how this would happen is mysterious. They say that if there were a single system they could “coordinate care” better, although the only concrete proposal to do that is to hire more administrative staff. Essentially, the COHS application is an application for county monopoly over the Medicaid program.

We have met with AAH and the County. It’s pretty clear – they want more money and power, they will increase their administrative staff, and they will reduce our payments. Like every other county government, alas. Currently, as we pediatricians negotiate with AAH, we can sign with them or leave them and switch our patients to Blue Cross Medi-cal. With a COHS in place, our new choice will be to sign or leave Medi-cal completely. That’s what a monopoly looks like.

So, add it up -- more federal money for the clinics, more money for the health department, and less money for the private doctors. Most private doctors will bolt; they will have to. The private doctors who remain run offices that you would not want to patronize. “Coverage” will once again not equal “access.”

Once again, the poor will be served in clinics, the middle class in offices. Idealistic liberals, supporters of the clinics -- socialists, really – imagine that the clinics will actually give better care than private offices, no matter patient preference.

But you have to know that their dreams ain’t gonna happen. If you think for one minute that poverty medicine will be superior to private medicine, think again. What will happen is that care will be re-segregated by income, and hence by race as well. This will be congruous with the increasing inequality of wealth and income of the last 30 years as we Latin Americanize our social fabric. I wonder what my Dad would think.

It is such a damn shame. I can only hope I’m wrong, and that things will turn around. We are fighting the COHS proposal, and maybe it won’t happen. I would so hate to see our patients who have come to our office these past decades disappear to the clinics.

Here’s hoping!

Budd Shenkin

Enter the Feds

2011-05-11T08:08:00.000-07:00

We serve Medicaid patients. Always have. It was fairly traditional in our area to start a practice with Medicaid patients and gradually withdraw as the private patients built up. We took a different tack and just kept them and added practitioners. It fit our social responsibility agenda, and I don't think we lost money on it. I think we still manage a very modest margin.

Part of what we do is give vaccines. There, we really lose money. There is no mark up on the Vaccines For Children program "free" vaccines, and the immunization administration fee is only $9.50. By contrast, for private patients we have a markup on the vaccines of a certain percent that covers our overhead for ordering, storing, keeping track of temperature, etc. etc. It's considerable work, and for the Medicaid patients, we get nada for this. The official Medicare values for vaccine administration would be $25 for most vaccines. So giving our Medicaid vaccines is a considerable loser for us.

The problem with government is that you agree to treat Medicaid patients at a very reduced fee and they treat you like a criminal. We just got a notice on Monday that the Inspector General - must be the Feds, I don't yet know for sure - will be coming to our office on Thursday and has a list of 24 policies, temperature logs, etc., that they want on a CD to give to them.

"Will be coming," no "May I." No explanation. No niceties. No nothing. It's a wham-bam without the "thank you, M'am."

The Feds! I'm going to tell them to visit the land where the sun don't shine. Twenty-four items! For the privilege of losing money.

Honest to God. These people.

Budd Shenkin

The Best Ride to the Maui Airport

2011-05-08T15:16:00.000-07:00

Sometimes things just pop out of the ground, it seems like. Our friends the Moes were going to take us to the airport to go home from Maui, but we told them the wrong time to pick us up, so we improvised and walked across the street to the Kia Lani Hotel to catch a cab.

Boy, did we catch a cab. Our cabbie, Jack, was an older guy with white hair in a ponytail and a droopy white mustache. He told us as we left that he liked driving a taxi and was doing it on this Saturday so he be off next Saturday to watch an NBA playoffs double header.

His accent seemed familiar, so I asked him where he came from.

“Outside Philadelphia,” he said.

“Where?” I asked.

“Havertown,” he said.

“Where did you go to high school?” I asked.

“Haverford High,” he said.

“I went to Lower Merion,” I said.

Jack observed that Kobe had gone to Lower Merion, and I assured him that Kobe had learned that crossover move as a legacy from yours truly.

So here we were, 5,000 miles from our mutual original homes, running into each other by chance and finding we went to adjoining, rival high schools. And it seemed that we were both basketball fans, which is not so strange if you come from Philadelphia. (One of my college roommates from Braintree, Massachusetts, didn’t believe us about Philadelphia basketball mania until he came to Philly for a holiday and saw a hoop behind each house and kids walking down the street bouncing a basketball. He capitulated.)

So we had the best time ever talking Philadelphia basketball to each other, Ann watching and listening bemusedly. What is reminiscing about basketball? It’s really a panoply of names, each conveying the physical image, the moves, sometime the games, and an intensity of feeling. Plus personal encounters if they occurred. Talk to me about Philadelphia basketball and it won’t be long until I mention the great Guy Rogers, my hero. How I loved Guy Rogers from the time he was a sophomore at Temple, and then into the pros with the Warriors! God, I thought, I wished, I truly believed he was better than Bob Cousy!! I wrote my greatest freshman year paper “Mr. Basketball, or Why I Hate Bob Cousy” and to this day am convinced that Cousy was ordinary, and that adding Russell to the Celtics was the crucial move, and other guards could have done what Cousy did.

But I digress. I did not leave out in my conversation with Jack that I was in a car on a pretty summer day with Larry Ring when Guy Rogers came off the court at Narberth Playground and said to us, “I want to buy that car!” My God, I said, that’s Guy Rogers! A signature moment of my life. And Jack knew about Narberth Playground, he had played there, and it was just three blocks down the hill from my house.

First Jack and I covered the pros – names, names. Arizin, Johnston, Wilt of course, even Joe Fulks. He passed my test – he knew who Fulks was, and knew he had a jumper. We hit the Big Five college names, every one. Temple, Penn, LaSalle, Villanova, St. Joe’s. Rogers, Lear, Van Patten. Ernie Beck, Sid Amira, McCloskey. Tom Gola. Walli Jones. Goukas and Dr. Jack. Stories, moves, years.

We even hit high school. The Chester teams – he said “Jerry,” I said “Foster, and his brother Billy.” Granville Lash and Emerson Baynard. I told him how we beat Chester when Bob Campbell hit 8 of 10 outside shots before he got a concussion. Mark Dumars from Western Pennsylvania and the 1958 high school state finals.

And then the unbelievable finale. His late ex-wife came from Reading. “Reading,” I said, “Home of my first girlfriend, and the home of beer, pretzels, vice, and Albright College.” “Actually,” I said, “The guard on our high school team went to Albright and played ball, Norman Ruttenberg.” Now, this is the most obscure fact in the known world. But Jack responded, “Ah, Dr. Norm!”

So, as I say, 5,000 miles from home, two very different guys, him from Lackawanna College after a year on an oil tanker to make some money, me a Harvard doctor, and here we were, best friends. We did sneak in some personal stuff. My tenure with the Harvard JV’s and our 23-0 junior year when we beat our own varsity three out of four times. His basketball scholarship to Penn if only he could have qualified academically. Not to mention that he lived in an apartment house a floor down from Billy Cunningham and would run with them if they were a man short. His two artificial knees that are working great. My three knee operations and artificial hip. Hey, the ravages of war.

We reached the airport and he said how short the trip had been, and he said it was the best ride he’s ever had. I said “Me, too.” We took his card. I’ll call him. Maybe we can go to the Maui Invitational together. It would be real fun.

I knew Ann loved it. So I asked her, “What were you thinking while we were talking.”

She said, “I was thinking, when is Budd going to stop talking with taxi drivers?”

She’s so funny.

Budd Shenkin

Was Hank a Dinosaur?

2011-04-30T12:46:00.001-07:00

I have to say I'm absolutely struck by the heartfelt comments on my post about Hank. So I'm wondering, was Hank a dinosaur?

That is, he was in private solo practice. He was with a couple of groups before he went solo - don't know what the story was there, but he finally found himself in a small office by himself and had never been happier. Nothing between him and his patients, except insurance, but he didn't grouse about that.

Medical sociology, mostly Eliot Friedson in his great tome Profession of Medicine, looked at groups of doctors, mostly large groups in New York. He said that the more you are in a group, the more you look for consensual validation from your peers - that is, other doctors - and the less you look to your patients to validate your work and you as a person. I would imagine that the more administration there is, the more you look for validation from the administrators, the more you want to be like them (every doctor I know thinks that administrators have a sweet deal - little do they know). So with larger institutions patients are less patients and the more customers or even consumers.

Maybe I'm wrong. Maybe when a Kaiser doctor leaves the scene for whatever reason, patients feel bereft. Or maybe they shouldn't feel bereft, so personally deserted. Maybe they should feel that there is another one just behind him or her, waiting to take their place. I remember in Sweden when I would talk to people about the impersonality of the polyclinics, some of them said, but isn't that what you want, objective opinions?

But for myself I can't think that medicine should be anything but a real person to person enterprise. Our group, Bayside, is large by Bay Area standards - about 35 clinicians in 10 offices. But the offices are small, intentionally, not one stop shopping but rather pearls on a string. I think my job is to make sure we retain the ideals that Hank personified. We'll see if it's possible - I think it is. The culture comes from the top, they say, and I think everyone knows where I stand. With the dinosaurs.

Budd Shenkin

Welcome Back Budd

2011-04-11T09:14:00.001-07:00

I have been neglecting my readers, and myself, by not posting lo these many weeks. Unlike a columnist, I don't have to churn them out and can lay fallow at times. I hope that's what I've been doing, fallowing. I've been distracted. Two trips to Chicago for AAP meetings, losing my wallet (and having it found) on one trip, losing my favorite belt in the scanning machine when I forgot it and discovered the fact too late when my pants were falling down. Many activities at the Goldman School of Public Policy where we hosted former Senator Bob Graham last week, and then health economist and Obama advisor David Cutler - first time I met him. Losing my Kindle. Worrying about good friend Bob with two heart attacks, my good friend and neighbor obstetrician Hank, who delivered my step-granddaughter with a midnight house call, with recurrent melanoma. As my friend Michael says, as you get older, there is no Yellow Brick Road, you just keep doing what you have always done, coping. Sigh.

Also, there is the tyranny of success. I have been so pleased to get positive responses about my blog from people I respect that I don't want to pollute my product with mediocre posts. Easy enough to do. It can be a killer. One of our employees, after years of underproduction, met with our new Administrator and began to do really well. They then went out with anxiety, and their stupid doctor recommended rest - like a pill, rest. Idiot! The employee finally does well and collapses with anxiety? What about some counseling to make it possible for them to continue to do well, and not worry if they can keep it up? Doctors. Kaiser. Idiots.

OK, so with this prolonged intro, here's my post on health care, my now and forever topic.

Our system of health care sucks. Everyone knows that. Here is another detailed complaint from a primary care doc at the Mass General (sine she is at Mecca, anything that happens must be someone else’s fault.) Then a comment from my friend pediatrician Jon Caine, and finally trenchant comments from me.

A Waste of Money

By Katharine Treadway

Last week, a patient I have known for several years called my office and spoke to my nurse. She said that while she was driving, her vision had gone blank for one second and then she was fine. My schedule was already overbooked: almost all of the slots were filled with patients with the usual array of multiple chronic medical problems for follow up and management of what were, for the most part, stable conditions. Thus my nurse sent her to Urgent Care, a unit set up so that patients can be seen quickly for acute medical problems rather than being sent to the emergency room. The necessity for such a system has developed gradually as the burden of prevention, chronic care, documentation, and paperwork has eroded the flexibility of many internists to squeeze in the extra patient who has an acute problem. The result of this system is that paradoxically, I see my patients when they are well or stable and urgent care sees them when they are sick; the reverse of what should happen. The cost of such a system can be significant, as this story illustrates.
The nurse practitioner who saw my patient in Urgent Care sent her to the emergency room for evaluation of a transient ischemic attack (TIA, characterized by passing stroke-like symptoms) despite the fact that a symptom lasting 1-2 seconds does not fit any definition of a TIA. Once in the emergency room, she was seen by the medical service and then the neurology service who, not surprisingly, ordered magnetic resonance imaging tests which, also not surprisingly, were entirely normal. She was sent home after several hours with instructions to follow up with her primary care physician.
I saw her a few days later and carefully reviewed her history which confirmed the story of a 1-2 second white-out of her entire visual field bilaterally which resolved with complete visual clarity in the time it took to blink. She had no preceding symptoms: no heart palpitations, no lightheadedness, no other focal neurological symptoms. Except for a burst of anxiety, she felt entirely well after the episode and has remained so.
I thought about the close to $10,000 that had been spent ruling out a serious cause of her symptoms. If I had been able to see her, would it have made a difference in her management? I believe it would have for two reasons. After listening to her story in detail, I was confident this was not a significant neurologic event. Because she knows and trusts me, I was able to reassure her with my opinion (which interestingly the normal scans had not been able to accomplish). But equally importantly, because I knew her well, I was willing to take responsibility for my decision. One of the hallmarks of being a primary care physician is to be comfortable with uncertainty. We learn to trust our clinical judgment and not jump to ordering expensive tests “just to be sure.” It is hard to accept the responsibility of decisions when the patient is unknown to you.
It is clear that we need to redesign primary care so that we can see our patients when they are sick, not just when they are well. The medical home is one such model and there are undoubtedly others but whatever the design, it cannot be assumed that medical personnel are interchangeable. The knowledge of a patient gained over years coupled with the trust such a relationship builds for both the doctor and the patient are essential components of cost-effective medical care.
Katharine Treadway, MD is a primary care physician at Massachusetts General Hospital who teaches at Harvard Medical School.
---------------------

Jonathan Caine MD says:

The sequence of events you describe was completely predictable once you made the decision to “turf” the patient to the Urgent Care Center. What your patient experienced was a sequence of defensive medicine decisions. First, the NP was not able to correctly diagnose the patient was not having a TIA. (Those bureaucrats who believe that NPs will save the “system” money because they are paid less for providing services, please take note.) She in turn “turfed” the patient to the ED, who then “turfed” her to neurology. Neurology did what neurology consultants do, that is, order MRIs (and occasionally EEGs). The fact is no one gets sued for ordering too many tests. The number one cause of malpractice suits these days – failure to diagnose. Would the medical home model have prevented this as you surmised? Doubtful. You could have had the highest level of NCQA Certified Medical Home, but if you were fully booked and couldn’t see the patient that day the same outcome would have occurred. If you were truly confident in your impression that she did not have a TIA, you never would have referred her to the Urgent Care Center in the first place. So, your decision was defensive medicine as well. Until we have legitimate tort reform in this state these types of cases will continue to occur on a daily basis in Massachusetts.
Jonathan Caine MD, Pediatrician

• Kate Treadway says:
You are absolutely correct about the problem of defensive decision making and that is the point of my blog – that, as primary care doctors who know our patients, we are much more willing to accept responsibility for these types of decisions. My nurse sent the patient to urgent care without my input so I was not part of that decison making process. However, I also heartily agree that tort reform is absolutely necessary if we are to change medical care and medical costs. Thanks so much

And now, breathless reader, my own comments:

She thinks the problem is "the system," a vague designation. You, Jon, think the problem is defensive medicine. I agree. But although both are correct, I think we should look further.

First, let's not forget incompetence. Was the NP generically over-matched -- that is, no NP could make this diagnosis, and only a doctor could -- or was she as a professional not up to the job?

Then the ER - why could they not deal with this? Not sharp enough?

Then the neurologist. Is the primary care doc smarter than the neurologist in his or her own specialty? Or were they mindless?

So, yes, certainly defensive medicine and the fear of lawsuits pressure all of us in practice. But then there is competence or the lack thereof and courage of convictions.

However -- having said that -- the "system" will not reward any of these professionals who saw the patient for their abstemiousness. No way. So why try if your only reward will be your own knowledge of what you have done? It's not enough.

But then, why has this primary care doctor so overbooked her day that she does not have the capacity to see an acutely ill patient? Why has she set up her practice this way? She blames others, but why? We have the same mix of pre-scheduled and acute patients in pediatrics, and we make sure we have enough capacity every day to see anyone who calls in.

Perhaps the issue is payment. Because we build in the capacity to see patients who might or might not call, we sometimes have unused capacity. We therefore make less money than we might otherwise. If primary care adult doctors had higher payments and thus had more money to play with, perhaps they could do the same thing.

But one still has to ask, why is her practice set up this way, with an urgent care center somewhere else? Wouldn't it make sense for her to have a group practice where they had an urgent care center right on their premises? Wouldn't it make sense for her to employ some nurse practitioners or physician assistants to see some of her regular patients for some of their visits, allowing her to see some of the more difficult patients -- our patient in question -- when warranted? It would be better medicine, and the partners in the practice would make a little more money.

Our physician corps does have many entrepreneurial members, and being entrepreneurs, they often look for the biggest payoff, which is available in areas other than primary care. The entrepreneurs thrive in areas with surgical interventions, or radiological interventions, or some such -- that's what our system pays for. But still, our primary care physicians can build systems that serve patients better and make themselves a little bit of money in the process.

So, yes, it's the system. But this primary care doc let's herself off too easily. Better to ask, "Why have I not set up my practice so that I can serve my patients better?"

And finally from Jon:

“I agree completely that the problem lies with the doctor herself and the way she is scheduling her office visits. I sort of implied that with the term "turf". I didn't want to continue to bash her so as not be accused of assault.”

Budd Shenkin

Dcotors and Nurse Practitioners

2011-02-13T11:05:00.000-08:00

There is a vigorous discussion in medical care organization policy circles on the role of physicians, and the role of “advanced practice nurses” and physician assistants. How much can the role of the doctor be played by these so-called midlevel practitioners? In practices headed by physicians, midlevels already thrive. But the recent ACA legislation has succumbed to the nursing lobby and granted money for independent nurse practitioner clinics where physicians would not be present.

I present here a discussion from our American Academy of Pediatrics administrative listserve that I found interesting. You can’t make these arguments persuasively without looking closely at what actually happens, and what people in the field find. In this listserve exchange we hear first from Seth Kaplan, pediatrician in Texas, on his day where he had to exercise a great deal of his physician prowess. What would a nurse practitioner have done with these patients? Jon Caine of Massachusetts answers puckishly. Finally, David Horowitz of North Carolina makes the case (which I have shortened) that some docs couldn’t have handled this case load as well as Seth did, but that some nurse practitioners could have given it a pretty good shot. David points out, rightly, that a person is not totally defined by his or her training.

First, Seth:

There's been a lot of talk on the listserv about the possibility of mid-level providers replacing general pediatricians over time. I'm sure most of you have had similar days, but this is a synopsis of my day today:

The normal well checks and sick checks, dominated by gastro and a febrile illness without much of a source, with fevers to 103-104 lasting 4 to 6 days.

A 4 month well check with a very depressed mom.

A new sick patient with fever, who, oh by the way, has adrenal insufficiency, growth hormone deficiency, thyroid dysfunction, and some unidentified underlying disorder.

One of the kids with high fever for several days who had some small lymph nodes and mom has been convinced he must have cancer and will no leave without getting a cbc done and the cbc has an ANC of 700 (probable viral suppression - kid otherwise looks good, but we will be rechecking counts).

An 11 year old with poorly controlled asthma due to parental non-compliance and poor understanding who I ended up having to admit.

A well 7 year old with the "oh, by the way, I'm concerned about inattentive ADD".

A teen brought in for concerns about weight loss, "not looking well for 3 months, does he have diabetes?"

A child with arthyrogryposis with growth patterns that are difficult to make heads or tails of.

The sick kid with gastro amongst many who only came in because they wanted Zofran, but their exam sure seemed a lot more like appendicitis and it took 20 minutes to convince the mom that we really did need to image, check labs and get a surgical consult despite the fact in would involve a needle stick and maybe an IV, because "if she doesn't have appendicitis, I don't want her unnecessarily stuck"

The new well visit with an adopted kid who is a victim of sexual abuse both by her birth parents and multiple foster families, who exhibits signs of PTSD and major behavioral problems.

One of the kids with the high fever thing whose mom took him to Minute Clinic after school 3 days ago because "it was right next door" and the NP told them that "she was going to stop taking the temperature because it went up every time they took it and if it is above 103, we have to refer him out."

All of this in ONE DAY. Would love to see a "mid-level provider" handle it all.

Don't really have a question, just venting and thinking that we do is awfully challenging. We should be proud to be general pediatricians and continue to fight for our role in the healthcare system.

Seth D. Kaplan, MD, FAAP
Frisco, TX

Now, Jon’s reflection on Seth’s day (note the increased costs the nurse practitioner’s actions would entail):

No one is saying that PNPs will be effective or even cost-effective replacements for pediatricians. But, as long as Scope of Practice laws continue to be passed allowing independent practice in states where the politicians "think" they will save money, it will continue to progress. How would a PNP in independent practice handle your day?

1. Normal well/sick visits - Piece of cake
2. Depressed Mom - Refer to psych
3. Multiple Endo Pt - Refer to Endo
4. Neutropenia - Turf to Tertiary Children's Hospital ED for workup
5. Asthma Exacerbation - Turf to Local Hospitalist or Children's Tertiary
6. ?ADD - Refer to Pedi Neuro - 4-6 month waiting list
7. Teen with weight loss - Back to Children's Hospital ED
8. Arthrogryposis - Refer to Genetics & Endo
9. R/O Appendicitis - Give Zofran. "If pain worsens go to ED".
10. PTSD - "Call your insurance plan for psychiatrist who is participating in their closed panel".
11. Minute Clinic kid with fever and shockingly no antibiotics - Rx: Antibiotics
12. Lunch Break

Jon Caine MD

Tongue somewhat firmly in cheek.

A quick note from Jeff Couchman of Arizona:
Actually, I think many of the people who are changing scope of practice laws actually ARE saying the PNPs will be effective and cost-effective replacements for pediatricians…
Jeff Couchman, MD
And finally, from David Horowitz (edited):

I have worked with a PNP who could handle all (all right, most) of those kids appropriately. I have worked with real board certified pediatricians who would have handled this list the same way listed (by Jon), or even worse, attempted to treat the complicated kids and do it wrong. IMHO, one of the key attributes of being a good doctor or provider of health care is to know what you don’t know but know where to find the answer to those questions you don’t know. The bad docs I’ve worked with didn’t know that they were doing the wrong thing for their patients. All of the NPs I have hired have freely come to me with questions when they didn’t know the answers and asked very appropriate questions. That is because the structure I provided in my office meant that the NP was never there alone.

The question of the role of NPs is a lot more complicated than “should they replace us”. The first PNP I hired was one of the smartest people I’ve ever met. She was competent enough to work sick call on evening hours by herself and I never felt uncomfortable because I new she would call me if there were issues. She did more work in the running of the office than many hired doctors I have had. On the other hand, I have had an FNP work in my office who I felt I had to look at every ear to confirm if it was a real otitis or not.

…(It is important to note that) not all NPs are created equal and there are several training tracks: Pediatric, Adult, Family, and Neonatal. …There is no doubt in my mind that the ONLY qualified NPs to do any serious pediatric work are PNPs. Adult NPs have no training in kids at all, and FNPs are similar to Family Practice doctors in their training, and I see little to no role for them in seeing quantities of children.

(But) as good as some PNPs are, they are not doctor replacements, they are doctor extenders. While the laws may be structured so that the doctor doesn’t have to be physically present in the building to provide supervision (I am thinking of rural health centers here, not Minute Clinics), there MUST be a supervising pediatrician immediately available by phone. I am against totally independent practice without any MD supervision and this aspect is one area to focus our attention on legislation. I can also see different rules for rural health clinics where there is a lack of other qualified pediatrician services as defined by the government, and Minute Clinics, which are totally different in purpose and orientation.

David Horowitz

My Son Peter - A Reminiscence

2011-02-08T10:57:00.000-08:00

When Peter was small, he was really small. He was born small at 35 weeks gestation when Ann had HELPP Syndrome, which had yet to be described in the literature, so as her blood didn’t clot and her BP was up and her liver enzymes were up and she was very sick and went into labor at 35 weeks, we all weren’t sure what was happening. It turned out all right and Peter more than survived. But he was small. Today he is just a bit shorter than I am and all muscle and very athletic, but when he was younger he was small.

But smart and with an emotional IQ of 150 from the day he was born. Here he would be, about three feet tall, standing by the door and looking straight up at our friends and say, “How was your vacation?” People would say, is that a little kid, or is that a midget? And they would leave saying, “That kid is going to be President.”

But before that, Pete was small and very verbal as a three year old. Having older sibs was a big help because he acculturated readily, and made the expressions of others his own. He taught himself to read by taking baseball cards and finding out where they belonged in the scrap-book by comparing letters in the names. He had no hesitation in parroting. One day he turned over the telephone (let’s all date ourselves), saw the symbol and said, “AT&T – The Right Choice!” Big mouth, my parents would say.

So Ann had passed the bar, worked for a firm she didn’t particularly like, then went to work for a small firm she did like, and we invited the youngest partner and his wife over for dinner, and some lawyer patients of mine that I liked, and we had dinner. It was a nice time, and we were on our good behavior, as one would be in that circumstance. A nice dinner and nice talk as Ann and I tried to find ourselves in our new lives as young professionals.

As the dinner came to an end, who would provide the coup de grace? Peter, of course. So down the stairs he came, our little verbal cherub, as the dinner broke up and we all headed for the door. “Here’s Peter!” we exclaimed, and started to introduce him.

Pete walked down the stairs and surveyed the situation with his 150 emotional IQ. We were so proud, he was so darling. Then he spied in our front hall – we had five kids, after all – a parked bicycle. Well, that happens. But Pete was no doubt conscious of how this violated the image of the young lawyers. His visage clouded over, he became incensed, he approached the bike head on, he glared, he kicked the front tire, and with the impassioned heat of a violated host pronounced: “I told Brian to keep his fucking bike out of the hallway!”

I’m still laughing at Peter – and, I guess, at our little pretensions. I guess I could have sent it in to Reader’s Digest if it were a little less of a family magazine.

Budd Shenkin

The Great Steve Martin

2011-01-16T11:33:00.000-08:00

I’ve always liked Steve Martin a lot, maybe loved him, not exactly putting me in a minority. Remember when he started? Everyone had a beard and was scruffy, but Martin looked like a regular button down guy with prematurely gray hair. “Why do you dress like that?” he was asked. “To be different,” he said, truthfully, with his trademark subtle irony, since of course the first scruffy guys wanted to be different, and then everyone else figured that was the way to do it. He was great, as everyone knew, that wild and crazy guy. My special favorite, the Christmas wishes monologue: (http://www.hulu.com/watch/116204/saturday-night-live-steve-martin-introduces-his-christmas-wish).

I had read some of this New Yorker articles. He could write! Then I read his autobiographical Born Standing Up. Great writing -- direct, vivid, truthful, excellent writing. The picture of him growing up seemed so authentic. He had worked so hard starting at the bottom. I particularly liked how he was different from me, since I was on the track of Ivy League, med school, etc., not just trying something you liked with no guarantee at all. Then I remember especially his recounting his triumphant one-man tour when every event was completely sold out. He trooped people out the door all together as part of the act at one point, amazingly. Then one day, he saw it. Way, way in the back of the balcony, there was an empty seat. He wondered if it would be filled a little later, but no, there was an empty seat. So I knew it was coming to an end, he said. His writing is so intimate that I felt I was his friend. That’s hard to do.

So, I just read his new novel, An Object of Beauty, which I think is just great. I’m prejudiced by loving him, but still, I think the book is great. Surprisingly to me, it reminds me of Richard Ford’s Independence Day, in which Ford’s protagonist, Frank Bascombe, is doing real estate, and the picture of the real estate business makes you understand what it’s like to be in that world. Ford said he hung around with real estate people a lot, just found himself doing it, before he wrote the book.

That’s what Steve does for the art-collecting world in New York. As an art collector himself he clearly knows the people and the business. As with the real estate business after reading Independence Day, I think I know a little something about the art-collecting world now, too.

I like the story, featuring Lucy Yeager, a very pretty girl who becomes upwardly mobile first at Sotheby’s, then with her own gallery, and who is not really likable at all. I read this the same week we saw The Social Network, which we liked, and which doesn’t have many if any likable characters at all. I found shades of sympathy with most of An Object of Beauty’s characters, but still, there was something in common with Social Network. Lust pervades both, money and sex, and at least in the book, beauty. The narrator, a guy who is a friend of Lacey’s and who becomes an art writer, is sympathetic. Some are more and some less sympathetic, and all are real, at least those in the constant trade winds of the art world. They either lust after art, or they are in the business of servicing those who have that lust. You will have noticed that the title is a double entendre, some lusting after art, some after Lacey, many after both. And maybe that’s almost the same thing.

What’s it like to be lusted after all your life, to be an object of beauty? That’s Lacey. She knows she is lusted after by most men she meets – that’s us, men! – so she uses it, and has contempt for those who continue to be used by it. Boy, does she use it. When she rides her bike with a halter top and shorts, she listens behind her for the metal clank of bikes crashing as, she imagines, boys and men are looking at her. I guess this is what many beautiful and sexy women deal with – it’s probably hard to do, to figure out who loves you and who is simply lusting for you. Most people probably feel, as with great wealth, I know there are problems, but I wouldn’t mind that challenge. At the end she has a long affair with an FBI agent, the only one she knows below her station, who she always calls “Agent,” and who she loves because he never tells her he loves her.

It’s interesting that Steve has this agent look at a painting he likes – his line is not art appreciation but following art theft, so if he likes something it’s from a very unprofessional view – and he tells Lacey it might be symbolic, explains what symbolic is (thank you, says Lacey), and then says the sea is reality, the sky is the dream, and art is trying to connect one to the other. Sounds like Steve to me.

Steve writes really good sentences. He writes with structure. We hear it referred to that Lacey came into money, and we think, she did? Did I miss exactly how that happened? But it pops up later. The story doesn’t bog down for a minute, and I like his short chapters. I didn’t want the book to end, but still, when I would look ahead and see that it was only a couple of pages, especially since I’m having some trouble with my eyes, it would be a relief. Steve might have started as a showman, but he is a writer, in every good sense of the word. He is a very good writer, and I’m so glad he is.

All of which reminded me of my brush with the art world. It was 1970 and I was in graduate school at Berkeley, my first wife Mary Jane was an undergrad at Mills College, and we lived at the corner of Arch and Hilgard, just a few blocks walk for me to school. She brought home a fellow student one day who lived just a block up the hill from us, a young lady who dressed in a peasant-type dress, I guess it was, and whose chest was very alluring. I was 29 years old and had as much testosterone as most guys that age, probably at the higher end of normal. Truthfully, I just couldn’t get over her chest just below the scoop neckline as we stood there. She was recently married to a guy who I met probably a few days later, it’s hard to remember the details, but I do remember it was hard to think of anything beyond this young woman’s chest, very hard. Anyway, I guess she and her young husband wanted to be friends. He was a nice enough guy on the small side. He was called Dicken, which in German meant little Dick, because he was junior to his father, whose name was Richard.

So, as part of getting to know each other, they said that Dicken’s father was an artist and did I want to meet him and see his studio? I pictured walking up to his house nearby, looking at the studio, who knows what boring stuff I would be faced with. So I demurred, we never became friends with this young couple, life went on, I never met the father. Face it, I was distracted.

And so it was that I never met Richard Diebencorn.

I am such an asshole.

Budd Shenkin

The Lame Duck That Lost It's Limp

2010-12-31T13:24:00.001-08:00

It was heartening and amazing to see the Lame Duck congress pass a comprehensive tax program for the next year (however compromised by economically unnecessary but politically necessary giveaways), repeal Don’t Ask Don’t Tell, and pass the New Start treaty. After the goddamnest biggest case of legislative constipation anyone can remember. Everyone is asking, why should this be? Lame ducks are usually the weakest legislative animal in the barnyard.

I don’t know either, since I’m not close to the situation, but I do have some thoughts.

Most important has to be the Obama shellacking. Since the Republicans had gotten scorched two elections in a row previously, this evened the score, and the Republicans could now let things go through without seeming weak. They had just won, they had their honor back, so they could compromise from a position of seeming equality. Politically, their Just Say No strategy had won them the election, so there was little to gain by continuing. By the next election no one will remember the Lame Duck much, and a new electoral strategy will be in place.

And besides, both DADT repeal and New Start were not only popular with the public, but the military were strongly behind both, every past Republican Secretary of State and Dick Lugar were strongly behind New Start, so get it out of the way! Get your own new start.

Kyl and the Turtle (McConnell) had got themselves caught out there on the wing, playing the old game, so for them it was best just to vote as if they still believed what they had said (which they couldn’t have, really), and again, get it out of the way.

I wonder, however, if there isn’t something else happening, and some Republican sensibleness now coming down the pike. There might be a generational split developing in the Senate, as revealed by the current maneuvering to redo the rules in the next Senate – make the filibuster a talking filibuster, reform the initial motion to proceed to discuss legislation, and the placement of secret holds. The younger group (see Tom Udall) wants reform – they want action in the Senate. The leadership on both sides would lose some of their power with these reforms, and so are reluctant to proceed. But the Senate as a body is held in derision by the country as a whole at this point, so even the leadership must be sensitive to that, and maybe there will be some reform.

What about the upcoming term – more like the last term, or more like the Lame Duck? I’m an outsider, so I don’t know, but I suspect that Obama has spent two years learning hard lessons, and he will come back more aggressive, more teaching the country and less making a few lofty speeches that open him to charges of elitism and arrogance. I also think that Just Say No will not be much of a strategy from here on in. So, my prediction would be that there will be action. The President proposes and the Congress disposes. Success will depend on what is proposed. We’ll just have to see.

Budd Shenkin

Tales of a German Urologist

2010-12-24T10:10:00.000-08:00

Urology is not where one usually turns for wisdom – humor of a certain sort sometimes, but not wisdom. Still, within humor there is often wisdom, and in a package that is easy to accept.

Enter my colleague Bernd Schmidt of Pleasanton. A tall man with a craggy face hidden by a rather sparse beard and ever-ready grin, he has a strong German accent that demands close attention to understand him. I really don’t know him that well, but I thought he introduced himself as “Ban,” so that’s what I call him at the doctors’ lunch table at ValleyCare Hospital, be it nickname, the pronunciation of Bernd, his accent, or my poor hearing.

Each specialty in medicine has its own stereotype, and as with most stereotypes, there is a core of accuracy. I once introduced myself at a party of lawyers in the City as a pediatrician, and was told that “you guys are all alike.” Yup, I could have replied, and so are lawyers, as typified by that remark by you, asshole.

But I digress. Internists are removed, cerebral or pseudo-cerebral, not the warmest buns on the table. Surgeons are cowboys who can’t wait to cut but can’t think well or broadly. Orthopedists are strong as an ox, and twice as smart. Urologists – well, urologists. They have a very down to earth attitude, shall we say. My med school classmates told me to prepare for a unique experience in my one-week Mass General urology rotation. They were right. My residents gloried in making rounds while smoking cigars, inquiring of their patients amid their smoke, “How you doin’?” Actually, It was refreshing not having to deal with the poseurs the MGH was rife with.

One of my classmates was interviewing for a surgery residency in at MGH with George Nardi, who had some post in the department. He waited for a while for Nardi in his hospital office, a converted exam room. Then Nardi burst in, hustled over to the sink, pulled out his penis and pissed right in the sink, with a gasp of relief saying, “Sometimes you just gotta go.” Nardi should have been a urologist.

My colleague Ban has a typical urologist get-rich scheme, inspired by the plastic surgeons. He wants to use Botox injections to take the wrinkles out of the scrotum. “Wouldn’t they be beautiful?” OK, Ban, good. You’re a urologist, all right. Wish you smoked a cigar. Maybe your scheme will work in San Francisco, who knows?

Ban had two stories yesterday at lunch. He related that in Germany you never, ever, marred the bed sheets of a patient. The German passion for order and cleanliness prevailed. So he was shocked when he came to America in training and saw that the urologists on rounds routinely used the bed sheets to write on as they made rounds. My MGH urologists were too busy with their cigars to write on sheets, but it did seem right in character.
But Ban said it didn’t always work out too well. A few weeks into it he was standing at the foot of the bed as the urology staff was gather on each side of the bed, discussing the case over the patients supine body, his head sticking out from under the sheets as he listened. The urologists drew pictures on the sheets, depicting the anatomy underneath. But what they didn’t notice was the patient. As they drew and discussed, “Then we’ll cut here, and then here, then pull this together,” and so on, the patients face became paler and paler, visible only to Ban at the bottom of the bed, as the others were in heated discussion. Finally, as they agreed, “Right, this is just where we’ll cut,” the patient sat up and vomited everything he had all over the bed sheets, the pictures, the pens, their hands, and their cuffs. Urologists.

But on a more serious note, Ban has another side to him, a really lovely and understanding, which is to say, perhaps a non-urological side. I told Ban that I had always been fascinated by Germany, but that as a Jew I had of course ambivalence, to say the least. Still, my father had been one of the first to buy a VW in the United States, on the grounds that it was pretty cheap. So my family heritage enabled me to be somewhat dispassionate. Ban is from the Hamburg area, and I said I had heard that the real rapid anti-Semitism was in the south, and especially in Austria.

Ban agreed. He reflected that as a German medical student he could change schools each semester within the German community, just so long as he passed all his requirements. So one semester he decamped to Vienna, where he rented a room in a house where the only TV was in the landlady’s living room. So he was watching TV with her one evening and there was a documentary of some sort about the holocaust, and Austria’s experiences. His landlady denied that there was much anti-Semitism in Austria. She said, “All that never happened here in Austria. It’s a lie. This movie must have been made by some Jew.”

Ban has remembered this story a long time. Reminds me of how one of my very favorite authors, Alan Furst, has never written about Austria and Vienna. “Just never wanted to do it,” he said at one of his readings I attended. Probably one of the cities I won’t visit, either.

It’s good to eat In the doctors’ dining room. You meet the most interesting people. Even urologists.

Budd Shenkin

Tales of Worker-Management Cronyism

2010-12-12T15:14:00.000-08:00

The auto industry, civil service, and our old friend health care – three separate very troubled American industries. But if you look at them critically, it seems to me they have a certain sameness, which then makes me think they might reflect a more general American problem.

I have recounted the tale of the auto industry before (see Paul Ingrassia’s book, Crash Course.) The auto industry was a major success of modern industrialization. Three large companies emerged with one large union. The UAW wrested very high wages and benefits from employers, extensive and strict work rules, company pay for union organizing jobs, and a job bank where workers were paid for years not to work. The success that liberals now celebrate was that, thanks to union power, line workers entered the middle class. I, too, like to see people do well, but in this case the collateral damage was really unacceptable.

As the UAW thrived, management didn’t do its job. They not only caved to the UAW, they also pursued their own slothful and self-indulgent agenda. The managers were not unhappy to see workers’ pay improve, because they simply applied a multiple of that pay to compute their own. They exerted no quality and efficiency discipline, they continued to populate their own managerial ranks with the mediocre products of local feeder educational institutions, and they passed costs onto the public. When Japanese competition appeared the American auto industry had so little muscle and so much fat that they simply went lifeless, dead by their own hand and evil constitution.

We are also now facing a crisis in civil service. I don’t know how it arose, but the civil service deal has been a tradeoff of lower wages for better benefits and security. The civil service was supposed to be quiescent and not union organized. The deal started to unravel when unionization was allowed. We are now faced with civil service workers who retain their security, but who now have generous pay and benefits while they work, and pension plans that will soon bankrupt the country. Civil servants can retire after 30 years of service, sometimes even earlier, which lets many retire before they do in France or Greece, at nearly full salary. Not content with that, many have plans whereby they get a percentage, sometimes 100%, of their highest yearly salary. They can accrue vacation time and other bonuses until one year when they get a large spike of salary, and that’s the base they figure from. These retirement benefits are generally unfunded. That is, they need to be paid for by others than those who granted the benefits, because they were future benefits.

Who was on the other side of the bargaining when these deals were struck? Civil servant managers and politicians. The problem was that as soon as you have unions, you have political campaign contributions – the best example in the world being the California prison guards union. In addition, city and county managers responsible for recommending solutions to the political powers are similar to the auto managers. The managers’ financial fate is aligned with that of the other workers, rather than opposed. So, we have had managers who will benefit by caving into union demands, and politicians who can curry present favor in exchange for someone in the future having to deal with it.

As a result, we are in the soup. Unfunded obligations simply hang over us. As with auto management and workers, politicians and civil service workers act more like cronies than adversaries, and the public takes it in the neck.

Finally, the health care industry also has common elements. Hospitals drive health care costs. Hospitals can compete with each other for business, but if they cut costs and become more efficient, what have the managers really gained? The way health care is set up, a lower cost provider doesn’t really gain anything. Because patients and referring physicians do not pay much of the cost directly themselves, it is better for a hospital to be fat with patient amenities, and fat with rich physician “directorships” of various services and departments, and fat by giving into the relentless demands of the nursing unions and SEIU. A larger hospital budget translates into larger manager salaries and perks. Let the pubic pay, now just about to the breaking point.

These three industries seem to have the same dynamic – lack of competition to discipline the managers, and a resultant cronyism between management and workers to the detriment of the public. It would be nice if managerial professionalism led the managers to stand up for the public interest, but people being people, that doesn’t happen. Would that there would be the equivalent of the Hippocratic Oath for professional managers and politicians, but that doesn’t even work consistently for physicians.

In our mixed economy, when a market isn’t working, government is supposed to intervene, and either make rules to create a market that works, or to enforce an administrative solution. You can see how that didn’t work in the auto industry, is not yet working in health care, and government is itself the problem in civil service. My own sense is that government could be made to work in all three instances if we had the will and wisdom. A stronger government more impervious to business influence could adjust cases one and three, and governmentally appointed independent commissions could have warded off the civil service disaster.

Government needs to be better, smarter, more professional, more independent -- just better. We need leaders! We don’t need Plato’s guardians, but do need big guys, smart guys, aggressive guys on our side. Guys like my hero, Elizabeth Warren. We don’t need bigger government, we need better government.

Which is why I support the Goldman School of Public Policy at the University of California, Berkeley, my alma mater. Maybe fine professional schools harbor the long term solution. We should think up a professional oath for them.

So what do we do in the meanwhile? Yesterday my wife and I went shopping in downtown San Francisco. It was a sunny day in the low 60’s with happy crowds. We walked in the sun, we ate lunch, the fries were really good, we laughed. Life goes on.

I was buying baubles at Gumps, where we had somehow wound up, and Ann took little 10 month old Lola outside to wait for me. She is a happy baby, but this time she sat down on the sidewalk and cried. As Ann picked her up, a nice man on the way into the store said wryly, “I wish I could do that, sit down on the sidewalk and cry!”

Sometimes, so do I.

Budd Shenkin

Health Care Costs

2010-12-08T09:06:00.000-08:00

In response to my last post, from a colleague:

Hi Budd,

We all have our stories. I had radiation therapy for cancer. 12 weeks, 15 minutes a day. The charge was $3500. Per day. That’s 60 days treatment at $3500. $210,000. BCBS paid at 100%. I am lucky to get 80% on a $85 office visit.

What is going on here, with these costs? As I've said before, let's forget utilization - what about prices? There is just no curbing them at present, and to my mind no prospect of such. Here in the East Bay, the rising cost of health insurance, which is a consequence of these prices, is simply driving more and more people to Kaiser, which can control its prices. This exodus from private insurance reduces the pool of private patients at Sutter and elsewhere, who respond by raising prices even higher. This is what is called a death spiral.

Nothing goes on forever, so there will be an end to it, but it's hard to see right now what that end will be. I wish I could be brilliant and see it, but I'll leave that for the often-wrong economists. The idea of ACO's, like HMO's before them, is for a group of providers to be able to look at a group of patients and plan rationally for their efficient care, saving money and distributing it to themselves and kicking some back to the government, but it's a speculative program and will take some time to take effect. In the meantime life goes on, trends continue, and anti-trust is silent.

Budd Shenkin

Health Care Costs - What Hospitals Charge

2010-12-07T11:36:00.000-08:00

So, where does our health care money go?

My wife has diabetes and was urged by her doctor to attend a series of self-care classes at our local hospital, part of the Sutter chain. First, she had a half-hour individual consultation. Then she attended a series of four 2-hour classes in a group of 6 or 7 patients on Wednesday afternoons. She was told that they "would bill Medicare." The classes were taught by a nurse.

Billing for the first visit, $280. Billing for each class, $400. Total, $1,880.

Seems like 6 students in a 2 hour class taught by a nurse, billed out as $2,400, or $9,600 for the set of 4 classes, might cover the salary of that nurse plus overhead - even at the inflated rates of pay for nurses at this hospital.

By mistake they sent the bill to our old insurance company, which excluded $470 of the charges, so the private insurance charge would be $1,410. Some hard bargaining there....

This is the same hospital that charged $13,000 for an abdominal CT scan.

So, tell me whether or not we need health care reform???? The market, she not working too well. But, alas, our just-passed health care reform will not touch this kind of billing at all. Health care reform? Not really - mostly enhanced coverage and money for clinics and some experiments in research and organization in health care that gores nobody's ox. A disgrace, really.

Budd Shenkin

OBAMA AS A LEADER AND CAVER

2010-12-06T07:50:00.000-08:00

I have been having major difficulties with the Obama Administration. I really hate to blow in the wind, although truthfully, like the majority of people (by definition!), I catch myself doing that all the time. A careful reader might remember that I blew against the wind last spring when everyone thought the Democrats would do poorly in the fall elections. I bravely stood up and said, “Not so!” I predicted that Obama would rally the troops, show leadership, and pull a Roosevelt 1934. So much for spitting into the wind.

I now find myself blowing with the wind instead of against it. I conclude that Obama is not much of a leader. He has a very small coterie of old friends – who the hell is Valerie Jarrett, and what is she doing in the President’s inner circle, I ask you? – and as my wife says, he really misses Ted Kennedy, who could have steered him right, who knew how to fight and when to cooperate. As Krugman says, he bargains with himself time and time again. And who knows what he really stands for? It’s just not clear. The policies of the Justice Department seen only to veer somewhat from the Bush years, and not bringing to justice the CIA people who destroyed the tapes is just ludicrous. It has become a nation of people and not of laws.

If I had been him, I would have been on TV every Saturday morning after cartoons, up there with a cabinet member or a chief adviser, questioning him or her, making the points about what we are trying to do, how we have to save the system, although we hate to reward people who brought it down. How we need to reach out to the soldiers in the economic field, “Main Street,” and take care of that aspect simultaneously, and how hard it is to do. How we have to find “shovel ready” projects and make sure that we are not shoveling shit, as governments are want to do. I would have gone into it in detail, and not worried if we looked like it was difficult to grapple with – let people feel the problems along with us. That’s what he promised to do, and it wasn’t a bad promise, either ideologically or practically politically. But he wilted.

Maybe I’m wrong. Maybe this “let’s all get along” President will yet turn the tide to civility. Maybe the Republicans, their honor restored by an historic victory, will now be able to deal with a Democratic President without seeming craven. Who knows? Just when I turn and blow with the wind, maybe that’s the capitulation the market was waiting for, to suck me in before it turns.

But here, look at this from the Incidental Economist blog [I have resisted a blog quoting a blog for a long time, but here I am, with the wind again! Oh, my.] The Obama Administration caves yet again:

Obama’s quiet $49 billion gift to America’s Health Insurance Plans
Posted: 06 Dec 2010 01:00 AM PST
America’s Health Insurance Plans (AHIP) is a trade association representing private health insurance companies including those that operate most Medicare Advantage plans. AHIP opposed the Affordable Care Act (ACA), spending heavily on ads that criticized the President and Democrats for supporting cuts in Medicare Advantage payments. These cuts, which Austin and I have shown would fall mostly on plans, not on beneficiaries, were scored by the CBO as worth $136 Billion over 10 years. They are the backbone of the financing for expanding coverage to the uninsured and one of the few real cost control measures in the law.
In the mid-term election the Democrats fared poorly. Many Democratic candidates had difficulty explaining their votes in favor of ACA, particularly to elderly Medicare beneficiaries concerned about Republican and AHIP charges that it will cut their Medicare benefits. On Veterans’ Day, just 8 days after the election, the Obama Administration quietly released a new regulation expanding quality bonuses to Medicare Advantage plans that receive only average quality ratings. Julie Appleby of Kaiser Health News reported a few days later that some analysts interpreted this as a gift to the plans worth about $1.3 billion over 3 years ($5.3 billion over 10 years). Austin and Brad Delong both expressed concern that this could be the beginning of the political unraveling of one of the few cost controls in the ACA.
How could a $5.3 billion give-away make a meaningful dent in $136 billion in savings? It couldn’t. But the $5.3 billion figure is probably wrong. A more realistic estimate is almost ten times larger.
The original quality bonus program written into ACA targeted bonuses to plans receiving 4 or 5 “stars”, representing approximately 23% of enrollees according to Brian Biles and Grace Arnold of George Washington University who analyzed the data last April. The new regulation will grant bonuses to plans receiving 3 or more “stars”, representing 84% of enrollees (3.7 times as many). Biles and Arnold estimated the cost of the original bonus program at $1.4 billion per year as long as plans don’t respond to the bonuses by improving their quality ratings. The details of the expanded bonuses have not yet been released, but if we assume the new program will be similar to the old one, we can make a rough calculation of the cost: 3.7 times $1.4 billion is $5.1 billion per year. Accounting for expected cost growth, that’s a $49 billion difference over 10 years. If plans respond to the incentive, the spending will be higher. That’s a heck of a stocking stuffer.
Do you remember when the President stood firm against withering opposition last year and rallied his party to achieve an historic expansion of health insurance coverage while insisting that the bill be fiscally responsible and reduce the long run deficit? Sure was inspiring. If I were one of those members of Congress who did the right thing, voted for the bill and just lost my seat, I don’t think this latest example of the President’s generosity toward his adversaries would lift my holiday spirits.

Budd Shenkin

WIKILEAKS - MUCH ADO ABOUT NOTHING

2010-11-29T18:20:00.000-08:00

Is there anything coming up with the Wikileaks that is surprising? I can’t find much at all.

It has already been widely reported that Arab states want the US to get rid of Iran as a nuclear state. What we get from Wikileaks is the names of the Arab leaders, and that’s all.

The fact that Putin and Berlesconi have some common predilections? Trivial and gossipy.

The fact that the Obama Administration reached out to Iran but expected those gestures to fail, and had alternative plans for tightening and extending anti-Iran measures? No surprise.

The fact that no one trusts what Iran says? Now, that’s news!

Yemen complicit with the CIA? Surprise!

Karzai paranoid? Already public knowledge that others think this about him.

Karzai’s brother working for the CIA? Well reported.

Pakistan has poor leadership? Please. ISI is close with the Taliban? Come on, how could that be?

That the US would like to see North Korea implode and join South Korea? Nice they’d like to see that – the essential weakness of North Korea is not news.

The Obama Administration pulling the anti-missile installations under Russian pressure, and perhaps getting cooperation in return? Well reported.

In fact, I wonder if there isn’t a lot of dis-information in the leaks. For instance, is Israel as much of an independent actor as it is reported to be? Isn’t that exactly what the US would want to portray – “Well, you can trust us, but we don’t know what to do with the Israeli’s.” Good cop, bad cop.

What is embarrassing is the reaction of the US diplomatic community. They seem foolish and ingroupy – they are invading our space! How can anyone trust us now? They have crashed our little game! Not much of it seems so serious and intelligent, tell you the truth. But now they react so predictably – OK, people in the government, we’re going to shut it down, OK? Let’s be careful!

Who trusted them before? It all seems like crap to me. It’s scary to think again about how limited our “leaders” are. Sure wouldn’t want to make me join the Foreign Service….

Budd Shenkin

WARM HEARTS AND COLD MINDS - EDUCATION POLICY

2010-11-27T11:51:00.000-08:00

This is a post about education policy. New York Times columnists David Brooks and Tom Friedman, among others, insist that we need to concentrate as a nation on improved educational achievement, because that’s what jobs are requiring. Everyone knows our numbers suck, and Tom and David want us to concentrate on education, and they think parents need to be proactive with motivating and disciplining their children. This is the future, they say, and if we are inattentive, our nation will suffer severely. I agree.

There must be many, many reasons our achievement numbers suck. The outrageous proposition that education is a jobs program, propounded by risk-adverse teachers unions, is an attractive culprit, because they set self-interest against the public good. But I’m wondering if some of the reason lies in what I call the Warm-Heart/Cold-Mind dichotomy (WHCM, which sounds like a radio station.)

WHCM was presented to me most cogently in medical school. As a young liberal, with two classmates I started the Public Health Club, and Dean Robert Ebert assigned Dr. Dieter Koch-Weser to advise us. For our first session he assigned us a couple of articles that presented a dilemma of public health policy that, truthfully, I wasn’t ready for.

It is heart wrenching to imagine or to see babies and children dying from malaria. Some projects eradicated malaria in local areas. What happened when they stopped this suffering? Well, the ultimate results were not so great, it turned out. Evil though it was, malaria kept the population in check. Absent malaria, overpopulation ensued, and the suffering was worse than ever. I don’t remember the details of what actually ensued, but take my word for it – the cure caused more suffering than the disease.

As I say, I wasn’t ready to handle the conundrum – what does one do, then? Koch-Weser didn’t have any specific advice on that either, as I recall. But it was a memorable session – after all, it was 45 years ago and I remember the moral turmoil and policy confusion it caused in me.

Other liberals were confused, too. My Public Health Club co-founder, Carol Wolman, who had actually been to Africa, said that African doctors treated those in the cities and didn’t do public health, which would save ore lives, because they were short-sighted, and couldn’t resist taking care of the sick person in front of them. It could be a case of WHCM, but she probably neglected the fact that Africans who got to be doctors were from the wealthy class, and went back to treat the wealthy. Just a liberal confusion, I guess, with “mirror thinking” that others think the way we do.

In Africa in the late 70’s and early 80’s there was mass starvation. The response was food airlifts. Wrong and fuzzy-thinking, said an article in the New York Review of Books. If you save the children and don’t provide for more food production domestically, it will just happen again and be worse and create even more suffering. As it happened, I think there was more food production, and now AIDS has taken care of winnowing the overpopulation problem. Maybe the article was wrong; maybe too cold hearted and not hopeful enough that the future would actually experience advances that could support a larger population. Or maybe not.

Then as a pediatrician I saw what happened in the Intensive Care Nursery. Severely premature babies had literally a million dollars spent on each one, with profits to the hospitals that built the biggest and best ICN’s, and large salaries for the neonatologists and many pediatricians becoming neonatologists, hundreds of thousands spent for later rehabilitation, only a rare baby without deficits..Triumphs, yes, but lots of failures, and immense total costs, and resources drained from other, less dramatic areas.

So, to education policy. Years ago, they closed our neighborhood, fully-integrated school because it was “too good,” literally. The School Board made it into some kind o a magnet school where no one from the neighborhood goes any more, and where it doesn’t attract envy for being too good. God forbid someone should achieve.

Last year Berkeley High proposed that many math and science AP classes be abolished, the resources to be scattered to the underprivileged and underachieving groups in an unspecified way. It came within a whisker of being passed.

More generally, how much money are we spending on remedial education? A lot. Any Nobel Prize winners emerging from that expensive enterprise? If I were the father of an autistic kid I would certainly appreciate the tens of thousands of dollars that the school districts would be paying for one on one treatment. I can understand the power of the autism lobbying groups who want their children cared for. But still.

Have you had a friend or relative become a teacher for the developmentally delayed (aka, retarded)? A noble enterprise, to be sure. But the apogee of civilized achievement? At what opportunity cost?

So, you can talk about the weakness of the parents who do not value education for their children and make them turn off their cell phones and study instead. You can talk about the importance of caring for each child. You can say that a society is measured by the way it treats its weakest members. As a pediatrician I have a certified warm heart.

But as a cold-hearted public policy analyst, seems to me we most urgently need to support our best, and our next-best, and our third-best, those with the highest potentials. We should be able to do all of it, true. We spend too much on Pentagon waste, true. We could redo our entire educational menu and upgrade the quality for all, true.

That ain’t gonna happen. India isn’t going to do malaria control and agricultural reform and population control and educational upgrade all at once, and we’re not going to do defense reform, governmental efficiency upgrade, health care priority reform, and educational reform all at once, either. No long bombs, only three yards and a cloud of dust. So, when Tom and David tell us where our priorities need to be, are they going to say anything about our caring for the developmentally delayed and the autistic, or are they going to concentrate on getting parents to turn off the TV’s? Are they going to talk about liberal, warm-hearted groups that form what an objective observer would call special interests?

Back atcha, guys.

Budd Shenkin

The Giants Win the World Series

2010-11-20T14:42:00.000-08:00

I don’t believe in God, certainly not in the old-fashioned sense of a Man on a Throne. But I do think God is a pretty good heuristic.

“Heuristic” means to me “as if.” You don’t really believe this is so, but it’s useful to believe it. Now, that’s not Pascal’s Wager, which tells us to bet on the existence of God, because if God does exist you will be rewarded, and if he doesn’t, well, what have you lost? That’s not a heuristic, that’s a cost-benefit analysis.

Here is a good example of a heuristic: if you play the stock market, it is useful to believe that there is an “operator” who is manipulating the market to draw you in and take your money. There used actually to be operators, but they don’t exist anymore, or so we are told. Still, the market acts as though there were one. It goes down to scare you, and then down again, and then again so you finally sell your stock, and now that the operator has bought your stock at a cheap price, up goes its price with you on the sidelines in frustration. The mythical operator has struck again.

So, I don’t believe in God. But it’s useful to think that “God will provide.” You can’t plan everything, you can’t be sure of everything, sometime you just have to take a chance, move to America and leave the Old World behind, and think that “God will provide.” It might be you yourself who will provide, or the Massachusetts Indians, but it’s useful to think of God up there to help you.

And so it is with baseball, itself the holy of holies. Not that “God will provide,” because anyone who has grown up rooting for the Phillies, the A’s, the Giants – in fact, I guess everyone except the Yankees – you know that God will not in fact provide. You will lose and lose and lose, and be drawn into thinking that this might be the year, and then you will lose again. So I have always figured that if our team is not mathematically eliminated in September and the games still have even theoretical meaning, it was a good year.

It helps to remember Job, and believe that sometime, maybe at an unexpected time, the plagues will finally relent. Maybe. And that great turn of your luck will not depend on any particular virtues of yours, but it will simply be a gift from a heuristical God.
And so it was this year. There was no reason to think this year would be any different for the Giants. None. Excellent pitching, which they had had before. A lack of bats, severe, I thought. So all through the year GM Brian Sabean brought in people and tried them out. Some worked – Aubrey Huff at first – and some didn’t – Bowker in left. Most famously, the “accidental Giant,” Cody Ross, became a Giant off waivers only because the Giants didn’t want him to go to San Diego. And then he comes up with five homers in the playoffs. It’s skill on Sabean’s part, and on manager Bruce Bochy’s part, and luck, and chance, and happenstance, and you could say it just was the fact that God decided to smile on you, for no particular reason that we can figure out.

For me it was particularly amazing, since my beloved brother Bobby is a die-hard Phillies fan and season ticket holder. While the Giants were making their amazing run at the collapsing Padres in September, when it seemed that God was just determined that they should win, Bobby and I faced the prospect of rooting against each other. After 34 years in the Bay Area and being partners in Giants season tickets I am acculturated – the Phillies are my second-favorite team. (Actually, if the A’s recover, that might not be true – but they will definitely be my second favorite team in the National League.) So the best we could hope for would be that the Phils and Giants would not face each other in the first round although the odds were against it. But fie on the odds – God provided, and they faced different opponents in the first round, so we could root for each other’s team, and both teams won. Voilá!

Then our Giants were on to the powerful Phillies, with their winning experience and very solid lineup, featuring the great Shane Victorino (inside joke – he’s from Maui and has a featured box on the Maui News sports page every day, really funny home town boosterism, “Victorino and Phillies advance to League Championship series!”)

How was every desire coming true? Where was this coming from? How was it that every move worked out? The new players produced, Wilson kept saving games, Uribe hit an 8th inning homer to beat the Phillies. How did we beat their great pitchers? Ryan Howard looked at a third strike when he should have been protecting the plate. Bobby and I communicated carefully with each other, since we each knew where we stood. From not believing they could catch the Padres, to the World Series. Why was he smiling on us?

God smiled again. I was due for tickets to the 6th game but my partner Jim wanted to trade his 1st game tickets for my 6th game. It’s a deal, Jim!

Ann, as my wife, always has first call on the tickets, but usually says that someone else will appreciate it more and gives them up. But this time I prevailed on her to go with me, to both the Phillies game and World Series #1 game against the Rangers. While she was reserved for the Phillies game, she said it was great. Then for WS #1 the reserve evaporated. It was a wonderful night. Balmy. Mellow. Joe Montana was sitting two rows ahead of us across the aisle. Other SF notables popped up here and there. We belonged there; these are our seats, our city. Tony Bennett sang I Left My Heart in the second inning because he was late – took Muni to the ballpark. 83 years old, but the voice is there. It was November, but it was in the 60’s, calm, comfortable, perfect, the whole night. (The next night it was Steve Perry from Journey singling “Lights” about the City, and when they stopped playing that, the crowd kept singing. A sports writer from Texas who repeatedly trashed the Bay Area had to write as he visited here, “I take it back. I love this city.”)

Ann said, “Look at the sky!” It was remarkable. It was like slate, but a bit uneven, blue-black, some parts darker than others, but not moving at all, perfectly still. Aaron, one of my partners with the tickets, turned around and said, “Look at the sky.” Look at the sky.

It was tight, and then the 5th inning happened. We kept scoring and were a couple of runs ahead. Then Uribe hit a three run homer to push us way in front. Everyone around us looked at each other, gave high fives, and then literally said stopped and said to each other, “My God.” There was singing and I was dancing as Ann laughed at me, and laughed with everyone else. In the 7th Tony Bennett sang God Bless America and so did we.

I’ve heard that hospitals are the modern equivalent of medieval cathedrals, but now I think it might be sports stadiums instead. At the ballpark we were one, knit together, being blessed. How else can you look at it? It was just a gift from a heuristial God, and it was our job to take it, to accept it, to appreciate it, to be blessed with it.
It’s probably the best sports experience I’ve ever had, in a lifetime of watching sports. And blessedly, my brother Bobby was good enough to send me a text that said, simply “congratulations.” The Phillies have had three great seasons, and Bobby has been through enough to know that when your games still mean something in September, and you make it through the playoffs to the second round, you, too, have been blessed by a heuristical God.

What a night, what a series, what a set of playoffs, what a season, what a sky, what songs, what a crowd. What a life.

Budd Shenkin

ON THE WAY TO MAUI

2010-11-11T20:42:00.000-08:00

My wife Ann is never late. I have learned a lot from her. And she has learned a lot from me, about how to tolerate being late. Opposites attract.

But when it comes to going to the airport, she wins. In fact, she has won so much that I try to be very early even when I’m not with her. We don't just make compromises when we get married, we change.

So today we left super-early for the San Francisco Airport to drop off Ann, Sara, and nine month old the magnificent Lola – up at 6:30, out the door at 7 for the maybe 40 minute drive to SFO for the 9:15 flight. We almost made it; probably would have if we had left 10 minutes earlier. Just not quite.

Maybe you have to feel sorry for the guy afterward, but most people had trouble ginning up sympathy at the time. KCBS reported that a heavy set guy in his 50’s in white pants and a tank top, with his 16 year old daughter in the van where he had apparently been living, decided to express his frustration with his straying, divorcing wife by calling KCBS, saying he had a gun and a bomb, and that he was going to stop traffic on the upper deck of the Bay Bridge, which is of course our route to SFO. He succeeded even if he really didn't have the gun and bomb he said he did. He was on the suspension span, we were not far behind on the East Bay side of Yerba Buena Island. We stayed on the bridge not moving for one and a half hours; people got out of their cars just to look around, look down at the Bay, and kind of look at each other. That's what we did, too.

It was the KCBS story of the day as we listened to what we couldn't quite see -- the man threatening to jump, being talked back onto the bridge, handcuffing himself, and the bridge lanes finally opening up, just in time for us to arrive at SFO at 9 AM, and the flight to go bye-bye without wife, step-daughter, and magnificent grand-daughter. They rebooked on the 2 PM flight and faced 5 hours in SFO with a magnificent 9 month old who loves to walk holding on to two fingers a few inches to the side and above her head. Much better than napping. Oh, joy!

We did well, even though leaving early was supposed to prevent this. No one panicked, although it was gruesome to try to reach United Airlines on the phone – could only get someone in India who couldn’t understand our telling her the number of our tickets, much less call ahead about our predicament, etc. Telephone answering trees are carbuncles on the body of the modern world. "Which of the following services best describes what you want...." How about, "none of the above, we're sitting on the Bay Bridge not moving?" Sitting there, time moving but not us, with the wonder of cell phones and smart phones and internet connections, but United Airlines cocooned off and unreachable. Couldn’t get SFO itself either. Not that it would have mattered.

I just heard from them, 14 hours after we left this morning. Lola was good, but slept only 15 minutes and spilled four different liquids the ladies were trying to drink. I had said, why not wait for tomorrow? But Ann said, no, I’m going today, if we have to go on any airline, if we have to go through Honolulu; we’re going. The lure of Maui is just too great. Maui is warm, the pool is warm, the surf and beach are beautiful, and the Sports Page beckons. Maui is something special for Ann, beyond the obvious. There is something that draws her, something that makes her relax, feel good, flow through the day. Probably because she was there all the time as a girl when her father consulted for Chevron and there was nothing at all where our house now stands. We are sometimes asked what we do there. We say, mostly wait for repair men. But it doesn't matter, there's something in the water.

So, I’m wondering – we left home in plenty of time under normal circumstances. I’ve been a very good boy. I have taken her habits and made them my own. We’re not going to leave any earlier next time, are we? I guess not. Being early is sensible, if you think about it. We're not nuts, just prudent. Took a long time for me to get there.

Budd Shenkin

Maui Stories

2010-10-17T13:20:00.000-07:00

Maui is a small island with a population around 160,000, I think. A small county in a small state. Lots of the permanent residents know each other, or of each other.

We have our celebrities. I hear Oprah has a place or two, but I haven’t seen her and I don’t know if she really comes. I know that Arnold and Maria were looking for a place and looked in Makena, but I don’t know what they finally did because someone else bought that beachfront house for about $29 million, I heard. Cute little place.

So, I’m flying over from Oakland last month and who is sitting behind me but Don Nelson, long time coach of the Warriors. He is an island notable and has a place in Kihei, Hale Nelson. We walked off the plane together and struck up a conversation. I was mindful that he had been fired the day before and might be sensitive, but on the other hand he collected $6 million buyout, I think, so not all has been lost.

So after a few remarks back and forth, including my telling him that I had seen the first NBA game where Russell faced Chamberlain, I said,”Don – I saw you play!” He said, “I thought everyone who saw me play was dead.”

He is 70, not much older than I am, and vigorous, which I am, too. But obviously mindful of that horrendous number. Actually, except for the loss of my parents and one particularly upsetting and dysfunctional relationship with a loved child, I am as happy as I have ever been. Secure and still excited by my work. It’s like autumn back in Philadelphia. I used to think, this is really the best time of the year, fresh aur and beautiful foliage and football, except that we know that winter is coming.

Anyway, Don (he became “Don” to me) said that he was renting Hale Nelson out now and had moved up to Paia, where it’s cooler and rains more. I know he is a member of an island-fabled poker game with Willie Nelson and I think with Kris Kristofferson. Also with local notable Steve Goodfellow, I heard. And then he said that he was busy investing his whole “fortune” -- a word he emphasized in a way that made me think that here’s someone who came from a non-fortune background, and thus doesn’t take it for granted, but still looks at it with a little amazement that he did it -- his whole fortune on Maui. He is constructing some kind of place in Kihei for weddings. And up in Paia he has a coffee shop, where he invited to come up and visit. Would have done it, but I was only going to be on island for 6 days.

So I thought, he might be done with basketball – it looks that way – but he’s not through with action. Basketball had become a business for him, a special business but a business, and he isn’t about to give this attitude to life he has adopted for decades.

OK, that’s my Don Nelson story. Now here’s my Gordon story. Gordon is an Aussie by birth and speech, but an American by residence and business and American son since the age of 20, which was a few decades ago. Gordon lives in our condo complex and is as people-oriented as God makes us. Gordon knows everyone. We have a mutual friend, Anne, who lives in the complex also with her husband. So, Anne got a mattress for their bed. She tried and tried, but after six months she just couldn’t get herself to like it. So she decided to sell it and put an ad on Craig’s List. She got a call for the used mattress from a guy who lives up country, and he naturally wanted to come down and try it out. OK, Anne said, let me tell you where we are and how to get here. She told him the condo’s name and he said, “Hey, isn’t that where Gordon lives?”

“Why, yes it is.”

“Well, I know how to get there. In fact, I know the entrance code!”

This is a true story. As I say, it’s a small island, and Gordon knows everyone. But I have to say it reminded me of the famous story that ends with the narrator standing with the throng outside St. Peter’s and asking a bystander if she knows who is up there. The bystander says, “Of course I do. But who’s the guy in white standing next to Hymie?”

Pretty funny. I had to laugh.

Budd Shenkin

The Culture of Enabling

2010-10-09T16:10:00.000-07:00

Dear readers, please permit me a dyspeptic screed.

There is a conspiracy of silence in this country. No one assigns responsibility. We enable failure. It starts early, when everyone on the kids’ team that went 0-14 for the season gets a trophy. And that’s just the start.

Pop psychology has no doubt played a part. “Positive reinforcement” is what we operate on. Look only at the positives.

Our Berkeley mothers say in dulcet tones, “Now, Joshua, Mommy needs you to take the knife away from your little sisters throat, right now.”

“I’m going to kill the little bitch!” says Joshua.

“Joshua, don’t you think you would be sad if Kelsey wasn’t here, and wouldn’t Mommy be sad?”

Well, maybe that’s an exaggeration. Somewhat. Maybe it's off the point - OK it probably is. It was just on my mind.

But seriously, what about responsibility? For instance, anybody know who screwed up the O-ring? We know that the Challenger went down because of a faulty O-ring design, that a defective NASA culture enabled it, that Morton Thiokol was the designer, and that NASA ignored warnings of engineers that low temperature was especially dangerous for the O-ring. But I want to know some names. Who did it? Who was on the team of designers? Who in NASA ignored the warnings? Why the anonymity?

We know the heroes well enough. Sully heroically saved a plane after a collision with birds, and showed up at every significant event afterwards for a year, and I felt as good about him as anyone. We know it was Francis Kelsey at the FDA who blocked approval of Thalidomide – in fact, go to Wikipedia and you will find a photo of her with President Kennedy. Success has a name.

But where are the anti-heroes? America needs them!

Who the hell was it that confused inches with centimeters in 1999 when NASA lost the $125 million Mars Climate Orbiter spacecraft after a 286-day journey to Mars, when thrusters used to help point the spacecraft had, over the course of months, been fired incorrectly because data used to control the wheels were calculated in incorrect units? The company was Lockheed Martin, which was performing the calculations, but who was the stupid engineer who did it? Why can’t we know?

Who screwed up the Hubble? Remember that? A small defect in one of the two mirrors was caused by a 1mm error in one of the machines that made it. This error made the telescope worthless, and only scientific heroics in 1993, at great cost, saved this treasure. The company at fault was Perkin Elmer in Connecticut. OK, we have a state and we have a company. But who, I want to know, made the error? It was somebody. Anyone got names? I don’t. What’s the theory, that they have suffered enough? Not in my book. I doubt that this achievement appears on his CV.

And who was the idiot that drove his truck off Interstate 880 and tied up the East Bay for months when he drove his oil-laden truck too fast in the middle of the night, crashed, and burned the freeway up? If we can’t have his name, can we at least have his ethnicity? Give us something!

In sports a lot is out in the open. Poor Bill Buckner – a long and distinguished career, but we remember the ball trickling through his legs at first base. We know that name. His error is a measuring stick for all other errors. It's painful, but it serves a function, and has a name. But even in sports the don’t-put-a-name-to-failure affliction has begun to infect commentators. In a Giants game a week or so ago, bottom of the ninth and two runs behind, I think it was Freddy Sanchez who was thrown out trying to get to third when he could just as easily stayed on second, since his run was meaningless – they needed two. It was only a rather amateurish new hire commentator who pointed out the mental error. Someone had forgotten to issue him the requisite rose colored glasses, or rather microphone. The regulars didn’t criticize anyone. Freddy’s a good guy, but this willful look the other way attitude debases the sport and our intelligence.

And just yesterday in the SF Chronicle we read that the California Air Resources Board overestimated diesel pollution by 340%. It was due to “a faulty method of calculation.” This comes on top of a miscalculation last year that overestimated the number of diesel-related deaths. Needless to say, we are given no idea at all who is responsible. “I think somehow some very poor decisions have been made,” says a Board member. Jesus. “Who” is a person, not an organization, a system, a process, or a culture.

Does it matter? It actually probably does. The culture of positive reinforcement has all but extinguished taking responsibility. And what about the entertainment value? Just as medicine has named syndromes after someone who described them first, we are missing the opportunity to name specific types of errors after their most prominent perpetrators. Wouldn’t such terms as “The McCarry Miscalculation” elevate our cultural heritage?

So, let’s stop the cover up! Here is a modest proposal to get the ball rolling: the esteemed non-profit organization, the Center for Responsive Health Policy, should offer a trophy to any individual reporter who succeeds in placing a specific name with a specific error in a major publication or blog. The name of the prize will be the Yudunit Award, or a Yuddy. You can imagine the image of the trophy – an enormous pointing index finger. You want trophies? You got’em. I know just where to get them, from Mary and Joe’s Sports Store down on San Pablo. They sell them by the dozens.

Other proposals are invited.

Budd Shenkin

Top 10 List of Physician complaints about insurance companies

2010-09-28T19:30:00.001-07:00

I know we have covered much of this same ground before, but I thought it might be worth posting this listing of complaints that we developed on the SOAPM listserve.

Health Insurance Companies vs. Doctors
The Top Ten Outrages

From an idea of Jon Caine, MD
With the aid of unindicted co-conspirators from the SOAPM Listserve
Written by Budd N. Shenkin, MD, MAPA

The outrages perpetrated by health insurance companies against their policy-holders – people we physicians call, perhaps anachronistically, “patients” – were aired and to some extent repaired in the run-up to and passage of the Affordable Care Act (ACA) this past year. What went largely unremarked and unaddressed, however, are the outrages perpetrated by health insurance companies vis-à-vis the physicians they contract with to serve these selfsame patients. Here, for your wonder, perhaps your outrage, or if you are a health insurance company executive, your amusement, is a top-ten list of these outrages.

1. Unequal anti-trust policy. The biggest outrage, the ur-outrage from which all other outrages spring, is condoned and supported by the laws and enforcement of the government of the United States and the various states. Health insurance companies operate in largely monopolistic and oligopolistic environments in local areas. Physicians practice in much more atomized small group practices. The playing field is severely tilted – insurance companies can do without an individual physician practice, yet the physicians cannot do without the insurance companies. Governments have allowed anti-trust laws to accommodate insurance company consolidation, but have enforced the law on physicians, and will not allow them to negotiate as groups, even when members of IPA’s and other groups. The predictable result is that insurance companies continue to lower payment rates to physicians to the point of near extinction, and to commit outrages to decency such as those listed below. In reaction, physicians are now themselves conglomerating into corporate entities, not because this is a better way for them to serve their patients, but simply to protect themselves from the oligopolistic insurance industry. Coming soon to your community – Large Corporate Physician, your doc in the corporate box. The ACA could have given a anti-trust waiver to allow doctors in organizations such as IPA’s to bargain collectively with oligopolitic insurance companies.

2. Payment for vaccines. Vaccines are the greatest life-saving advances contributing to the health of the public since safe drinking water. Medical practices, amazingly, have overhead – a typical primary care group practice has an overhead rate of 65-70%. But many of our friendly health insurance companies have declared it their policy that “physicians should not make a profit on vaccines.” Therefore, when a physician administers a vaccine, a company with this policy will pay the physician only a few percentage points above the acquisition cost of the vaccine. How long would Macy’s survive if it sold a shirt for 5% above purchase price? The ACA could have required insurance companies to pay for vaccine cost plus overhead plus margin.

3. Adherence to the Payment Code Policy. There is a codebook called the CPT codebook. Whenever a physician does something, there is an official code on how to describe the service, with a Relative Value assigned to this code. Physicians are required to adhere to this codebook; no deviations are allowed. Insurance companies, however, often deviate. There are codes, for instance, for administering a vision test, a hearing test, a urinalysis, etc., to a child. These are separate services recognized by the code book. But many companies “bundle” these separate services and simply declare that “these services are included in the payment for the visit.” Which they clearly aren’t, which is why they are listed separately and have their own codes. The ACA could have said, “Insurance companies need to recognize all CPT codes and pay according to their relative value.”

4. Up To Date Codes. In a related vein, when new services such as new vaccines appear and are approved, health insurance companies lag for months in inputting the codes “into the system.” This leaves the physician in the lurch, wanting to give the service to the patient, but not being able to get paid for it by the health insurance company. Amazingly enough, when time comes that they decide to delete a code, the health insurance companies can accomplish this immediately. The ACA could have fixed this by requiring the code addition to be timely.

5. Double dealing in eligibility. When a patient comes to the office, physicians need to know if the patient’s insurance is in force. The insurance companies, keepers of the data, have websites that the physicians can check. But this information is sometimes out of date. If a website says a patient has insurance in force and the physician accordingly serves the patient and sends the bill to the insurance company, but the information turns out to have been false, the health insurance company commonly reneges on its responsibility, and doesn’t pay the physician. The ACA could have compelled the heatlh insurance companies to honor their own information, and to pay the physician for service rendered in good faith.

6. Payment for services on capricious criteria. A prime principle of prevention is early detection of illness. An important way to do this is to screen all patients. For instance, pediatricians use scientifically-validated screening procedures to detect developmental delay, autism, hearing loss, or high cholesterol. But some health insurance companies pay for these screens only if the patient actually has the disorder in question! Talk about unclear on the concept. The ACA could have compelled the health insurance companies to pay for the screens when applied at the officially indicated age intervals.

7. Takebacks. Since the health insurance companies are constantly sending doctors payments, if they want to they can simply debit a current payment for a past problem they detect, with no form of mutual adjudication. From a fellow physician: “Last week I had a takeback from BCBS for a patient visit one year ago. The problem was not that the patient was no longer eligible, but they had never responded to the BCBS inquiry about other insurance coverage.“ That’s right, the insurance company sent an inquiry to the patient asking if they had additional health insurance coverage, the patient didn’t respond, so the insurance company retroactively voided their payment to the physician. The ACA could have mandated no takebacks without mutual adjudication.

8. The Lapsed Coverage Waltz. A colleague reports: “Patient's coverage lapses in error. They call the plan to get reinstated. The plan reinstates the patient from the date they called, not back to the erroneous termination date. Doctor still does not get paid.” The ACA could have fixed this, too.

9. The Myth of Timely Payments. From another colleague: “State law mandates payment of "clean claims" within, say, 30 days. On day 28 they send an inquiry to the patient (with a copy to the doctor), requesting ‘information on any other health care coverage’ and the claim is pended until that information is received. Since it takes the patient some finite time to respond, if they bother to at all, the doctor is left waiting for payment.” Surely the ACA could have obviated this tactic as well.

10. Show Us Your Documentation. One of the most wasteful practices of the health insurance companies is excessive documentation demanded from the physician. Before paying for a service, the health insurance company can require the physician to send copies of the patient record. The number of such requests can amount to harassment. Some health insurance companies will require documentation for every single instance of a service, such as a screening for autism. In our own practice, with some companies and some codes we have now resorted to the extra work and expense of submitting such records expectantly. What a waste of effort. The ACA could have regulated the number of such requests.

11. Rudeness and Mendacity. As a bonus, for #11, let us mention my own personal favorite. Industries tend to attract certain personality types, and to take more malleable personalities and mold them to a common image. The capacity of health insurance company executives to misstate facts and demean inquisitors is legendary. Virtually all my colleagues who manage practices have been told that they are the only one in the state, region, or country to protest or be dissatisfied. I myself have been told that the American Academy of Pediatrics supports the position of the health insurance company on an issue, when I myself have been part of the committee that sets the policy. Whoever invented the word “chutzpah” couldn’t have had a strong enough imagination to envision its embodiment by the health insurance industry.

Colleagues have requested that our list go on, but in deference to David Letterman, we will stop at ten plus the bonus. We all know that the American health insurance system, even after ACA, needs revision. In the grand scheme of things, this list of grievances might seem small potatoes, but to those of us in the system day after day, it is major. Since the Federal Government has shot its bolt with the ACA, which failed to address these issues, we most likely cannot expect any relief from this or any prospective Congress or Administration. Our best hope, then, would be the states. As practitioners, we can fight the good fight on our own, but realistically, only government has the capacity to curb such bad behavior.

Budd Shenkin

Adventures in Primary Pediatrics

2010-09-18T11:06:00.000-07:00

Leave it to medical couples to have interesting children.

I have a lovely, low-key family in my practice with a three year old in for a check up. He is a quiet child, non-obstreperous, maybe even diffident, much like his charming and engaging very low-key nephrologist Dad. He has had a little trouble with constipation and is not enthusiastic about the potty, which he seems to fear. But his development is great – very verbal, draws a cross on the exam table paper with no hesitation. He thinks I’m funny (true, I am). A nice, smart little boy.

So as I was examining him with his parents seated over by the window, and his Mom, Laurie, said, “He says he doesn’t want to grow up.” Now, I haven’t heard this symptom very much, and from a three year old! But child psychology is something I enjoy. It gives me room for imagination and creativity, and it’s something many pediatricians are a little deficient in. So, a chance to engage! And with a boy who thinks I’m funny, especially when I do my Donald Duck talking.

So I said to little Grayson, “Well, that’s OK. I didn’t want to grow up, either.” A little tittering from the parents in the Peanut Gallery, but actually it’s true, I didn’t. Why grow up? It’s great being a well-loved little boy, and in my case, the #1 son, as my father used to say, recalling the Charlie Chan movies of his youth. I’ve always regarded development as a double-edged sword, and maybe little Grayson does, too.

Did Grayson feel too much pressure to “grow up” from these accomplished parents? Were they more striving and directive than I thought they were? Was being #2 son too much for him, and he was retreating from the competition? What would they be demanding of a three year old boy, after all?

So, follow the logic. What would the developmental challenge be to a three year old, this three year old? Toilet training, of course. But why would he not want to toilet train? They said he was afraid of the potty. Why would he be afraid? Projective fears (see Bettelheim)? I asked him – are you afraid that the potty will eat you up? He looked mystified at that. Well, it was a try, I thought.

But then why would he fear the potty? Which potty did they use, one on the ground (preferred) or one on the adult toilet? The sound of that toilet gurgling can be intimidating. They use the ground-based potty, and he didn’t seem to have any reaction as I talked to him about it.

Then the “Aha!” moment. He’s constipated! What does constipation mean? Pain, torture. (With Portnoy’s father, I believe that colonic health is the doorway to happiness.) So what does he hear about growing up? Big boys use the potty. I don’t want to use the potty, he thinks, it hurts! So, the intelligent solution for this verbal and intelligent three year old doctor to be, specialty yet unchosen? “I don’t want to be a big boy. I don’t want to grow up.”

A chuckle of appreciation from John in the Peanur Gallery. “Of course,” said in appreciation. I felt so good, the triumph of discovery. Of course, it should have been obvious from the start, it’s pretty basic pediatrics, and as I enjoy and congratulate myself, it’s really quite elementary. Still, I’ll let myself enjoy it.

I had a long, hard time finding pediatrics as my vocation. And I still feel humbled by the task. But you have to admit, this was pretty cool.

Now to fix that constipation.

Primary Care - My KALW Interview

2010-08-29T12:01:00.000-07:00

It wasn’t the prospect of a hanging that did it in my case. For me, my mind was concentrated by my being interviewed for KALW by a very intelligent journalist on the subject of primary care. I’ve always said, if you can’t explain something so that an intelligent layman can understand it, you probably don’t understand it enough yourself. I don’t know how it will be for the listeners, but for me it was a very good educational experience. It clarified my thinking.

Being me, I found the interview an opportunity to disagree with all three of the other interviewees for this project, all of whom I know and like: Tom Bodenheimer, MD, of UCSF internal medicine; Kevin Grumbach, MD, of UCSF family practice, and Richard Scheffler, PhD, of UCB School of Public Health. Interestingly, I found myself to the traditional Right of the two academic docs, and skeptical of Richard’s traditional economics view of medical care, although let me say, not dismissive of any of them. They are all smart and thoughtful and worthy on all levels.

Tom has published great articles on the plight of primary care, and accurately focused on money as the biggest problem. Some people say primary care is too difficult to do, not professionally rewarding enough as compared to specialities, etc. Tom doesn’t buy this and neither do I, and neither does Kevin for that matter. For a person-oriented physician, noth other specialty provides the long term relationships of primary care. But faced with the prospect of primary care for $120-$190K a year, vs. anesthesiology for $600K a year – is this a choice? Not to mention cardiology, ENT, ortho, various surgical specialties, etc. You don’t have to be an economist to figure this one out. But my interviewer said, do primary care doctors need more money, or as Tom Bodenheimer says, are the primaries getting enough, it’s the specialists that need to get less, so the choice of a medical student is less economically based?

Time to disagree with Tom. I’m reminded of one of Martin Amis’s books on Russia, when the young people are parading around saying, No One Should Be Rich! An old lady says, I remember when we said, No One Should Be Poor!

Tom (and Kevin) represents a strand of medicine that I call the missionary strand. We do have a priestly role, but I personally have no desire to wear a hair shirt, and neither do most doctors. I don’t ask for poverty, I ask for an even playing field. It’s true that doctors in the US make more than in other countries, but that’s not true of primary care docs. If all doctors were to make less money, medicine would be less attractive to the elite, and I’m for as many smart and aggressive and entrepreneurial and progressive and inventive minds as possible in medicine. Economics works.

My interviewer said, but given more money, would the doctors just bank it? I said, to some extent, but then what we see now is primary care doctors with insufficient resources to bulk up the office with nurses and other personnel – we train the staff, then they leave for hospitals and specialists offices, where the money is. We are asked to be a medical home, calling patients on the phone to see how they are doing, and directing patients and spending more and more resources for patients, but to do this we need more money to spend. It has to stop all going to hospitals and specialists – but I guess I’ve mentioned that.

Would primaries do that, spend some money on the practice as well as bank some of it? They would if there were a fair market. Patients appreciate these aspects of care, they aren’t hidden as are some aspects of quality. So patients would choose to visit the doctors who had beefed up their offices with the enhanced payments they receive. In this case, the market would work.

Kevin says that hankering for the past security of your friendly neighborhood doctor is passé. He says that much of primary care can be accomplished by midlevels (nurse practitioners and physicians’ assistants), nurses, and others, so we should husband our physician resources and save money and be more efficient by having independent nurse clinics and much more clinical work done by others than doctors. I disagree.

First of all, the problem of medical cost does not stem from primary care, it stems from the money pit of hospitals and specialist services, and IMHO it is more a price problem than a volume problem. So you’re going to fix a money problem occurring elsewhere by economizing in primary care? I think this is a very poor solution. Since I tend to be sometimes belligerent, I say – Don’t give in to those schmucks!

At Bayside we have NP’s and PA’s and we love and respect them, definitely. My own step-daughter often chooses to go to a PA for her own care. But our PA’s often go over to our lead FP MD and ask him questions, seek assistance and direction, etc. They are not doctors, and they don’t think they are.

What is it that makes me value a doctor so much? Is it because I am one? I don’t think so. Mid-levels do well on measurable quality parameters, but quality assessment is still rather rudimentary. The deeper considerations a doctor makes, the questing after difficult diagnoses, the balancing of judgment calls – doctors weren’t highly selected and highly trained for nothing.

Kevin is right that we need to beef up our offices with personnel other than physicians – the medical home is a good and important concept. But he needs to be a little less enthusiastic in calling for a substituting for primary care doctors and economizing. In our country we should be able to afford primary care doctors, and we should be able to afford a first-class primary care system.

Kevin also seems to represent a potent line of thought that the Obama Administration has mindlessly adopted – that we need to have larger systems of care – Kaisers and other large entities – and primary care needs to get out of the communities and into the large organizations. I couldn’t disagree more. The local doctor’s office is personal, and the best doctors in these offices care for their patients, and moreover, care about their patients in a way that an employee of a large organization just won’t. Sorry, they won’t. And anything that a primary can do in a large organization with quality enhancement, we can do in our local offices. I personally think the offices need to be larger than just one office, but the best offices can do it even with three or four docs. They just can.

An example of caring: my friend Bob Shimizu is a long time pediatrician at Lamorinda Pediatrics in Lafayette. He recently cut back his hours markedly and feels much more relaxed. I asked him what the big difference was. He said, “The worrying. I would get so worried about some of my patients. That was really getting me down.” Worrying outside the office. Caring about his patients, not just caring for his patients. Think that’s happening at Kaiser? Betcha not.

Richard had not yet been interviewed so whom I couldn’t comment on what he had said. But I had read his interesting book, Is There a Doctor in the House, and my interviewer was sharp enough to anticipate some of what he would say –do you agree with Scheffler that it is all right to have to wait to see a doctor?

My answer is no. In this respect, medicine is not like other goods and services. It is OK to wait for cable installation, but it is not OK to wait to be evaluated for sudden feelings of weakness and arm pain that could be musculo-skeletal, or could be heart. Urgent care and ER care are not substitutes for good primary care by your own doctor whom you know, and who care about you and you know cares about you, and who is good and competent, and you know is good and competent. There is no substitute, and waiting is not OK. As I said, I like and respect Richard, but his strength is also his weakness, which is that he is an economist. Waiting might be fine in economics because it is cost sparing, but add into early detection the issue of patient anxiety, and you have to be better staffed than what is envisioned by economics. Plus, it’s all because of the horrendous rents paid to monopolistic systems of care at the hospital and specialist levels that we even contemplate savings in primary care, which is so inexpensive by comparison.

I loved being under the pressure of this interview, but typical of me, I found a way to disagree with everyone else on the panel. But hey – I still think I’m right. Don’t you?

Budd Shenkin

Carpe Diem

2010-08-26T08:30:00.000-07:00

In pediatrics there is a syndrome called the “vulnerable child.” This occurs when a child has a severe illness, such as prematurity, a severe accident, a severe event. Parents are scared out of their wits, and when the child recovers they wonder,, is he OK? Was damage done that isn’t apparent? Supernaturally, is there some fatality at work that will emerge later, a tainted future?

When I was just starting in practice I covered for a colleague on his day off. I saw a teenage boy, big and strapping, six feet tall and muscled, probably played on his football team. I examined him and told his worried mother, “He looks OK. Nothing serious.”

She said, “Are you sure?” Pause. “Doctor, he was a premie, you know.”

Luckily, I knew about Vulnerable Child Syndrome. I had to laugh, and told her that her fears were understandable, because she had been through a trauma that left her considering her football player as somehow vulnerable. I said, “But look at him! Don’t worry.”

In our house we have our own vulnerable child. Peter had his birthday yesterday. The little tyke is now 27 and a third year law student. He was a premie himself, 35 weeks, five pounds seven ounces, while his mother had HELPP Syndrome, which was then a month or two short of being described in the literature, which left us to fend for ourselves in diagnosis. She presented with a nose-bleed that wouldn’t stop because her blood was coagulating within her veins. Luckily she went into labor and had Peter – in those days a trained nurse or technician didn’t attend every delivery, and it was left to me as the father to resuscitate Peter, which I did, but he was in the hospital for over a week, I guess, looked like a drowned rat, and Ann had a bone marrow aspiration and clotting tests for days in the ICU as she recovered, which she did, since pregnancy is the cause of HELPP.

Then at age two Pete needed heart surgery to close a hole, called an ASD. But not before the insurance company tried to revoke our policy, on the grounds that we failed to reveal when we got the policy that Pete might need surgery, which of course we didn’t know. This insurance company practice, called rescission, was just outlawed by ACA (Obamacare). That operation went well. He was up and in the halls saying “Pitch to me!” just a few days later, amazingly, on the same floor that I had done my residency on.

Then at the beginning of his junior year of high school Pete was on a camping trip to foster class solidarity. In the middle of the night a 4,500 pound tree fell in the midst of the sleeping group and Pete was only saved because, to the amusement and derision of his classmates, he had brought a very puffy air mattress along with him – he apparently shares his mother’s and father’s attitude to roughing it. The tree fell right on him, but the air mattress cushioned the blow enough that he escaped with losing a kidney, 18 inches of small bowel, five broken transverse processes of his lumbar spine, a broken wrist, and no trauma to the spinal cord. It was weeks and months of recovery, and the scars of the heart surgery and the tree trauma now form an anterior zipper line from neck to pelvis, almost. You can imagine the trauma his parents endured as well, with the 4:30 AM phone call of your son is in critical condition, and the days afterward.

Pete now has a truly existential view of life. He knows that we all die, and that we could do so at any moment. He is not afraid, but carpe diem is definitely for Peter.

And so it was that we received word yesterday of how Peter celebrated his birthday. Peter went sky diving from 18,000 feet and loved it.

He told his parents afterward. That was thoughtful of him.

Budd Shenkin

The Week of an Administrative Physician

2010-08-24T09:33:00.000-07:00

Last week I went to our Dublin administrative office to console our staff about the sudden death over the weekend of our 32 year old beloved co-worker Preneet; conducted three clinician office meetings on Monday, Tuesday, and Wednesday; saw patients; delivered a eulogy at Praneet's funeral before 400 attendees; interviewed a candidate for Administrator; visited the Berkeley office and consulted with our lead FP there about our office direction and his staffing problems; conducted our weekly business office meeting, while signing checks and reviewing our final contract offer to our Administrator candidate, and contacting the CEO of Children’s Hospital about poor care in the ER and trying to schedule a meeting with him; attended the Children First IPA Board meeting; consulted withe the CEO of San Ramon Regional Medical Center about a new office for us and recent movements of other doctors in the area; gave a day long deposition on a totally bogus wrongful termination and assault and battery lawsuit brought by a wretched former employee; consulted with experts, lawyers, another clinician, our HR Manager and an office manager about what to do with a physician who was possibly impaired; contacted our probably not impaired clinician and worked our way through our course of action; had a radio interview on the subject of primary care; and prepared for a meeting the following week with a physician who was not meeting expectations in various behaviors and documentation. Among other things.

Then over the weekend I asked our scheduler for rounds and call, the beloved Tina Hong, MD, my co-author on a recent Pediatric Puzzler in Contemporary Pediatrics, to do a little rescheduling of rounds and call to account for the temporary absence of our also beloved possibly probably not impaired physician, which she expertly and happily did. So Tina said, “Where have you been, on a cruise? I haven’t seen you!”

Such is the work of administration.

I had to laugh.

What's It Gonna Take?

2010-08-15T20:26:00.001-07:00

I was on vacation the last two weeks of July, cruising. When we cruise, we read. My first book was City of Thieves by David Benioff. During the 900 day Siege of Leningrad two young men have adventures, including an encounter with cannibalism (true), in searching for a dozen eggs. Good book, excellent even. Recommended.

But the big book I read was Winston’s War by Max Hastings, obviously about WW II and Churchill, from his accession to Prime Minister to his electoral defeat during the Potsdam conference. Hastings says, btw, that the defeat was warranted – not rejecting his wartime leadership, far from it, but with the war just about over the focus would be on domestic policy, and Churchill had scant interest in domestic issues, and what interest he had was retrogressive. This is not hagiography, but lots of warts as seen by others, and with full range of the doubts of people of the time, large and small people and doubts.

What struck me very forcefully, although I knew it before, was how Americans and the British for years denied the existence of the Nazi threat, or minimized it, or in the case of the British upper class, sympathized with it. It took so long for people to come to terms with it! In retrospect it is so obvious. It’s not in this book, but if the Allies had only stopped the Germans from occupying and remilitarizing the Rhineland in 1934, the Nazis would have backed down and history would have been different. That’s fact, not surmise. From then on it was a progressive steamroller, Chamberlain’s famous dance of appeasement, and war without Western preparation.

Then the Americans – even with much of Eastern Europe, the Netherlands, Belgium and France occupied, even with Britain under siege, most people in the US thought they could and should keep out of it. Just amazing.

Yes, there were mitigating circumstances. Britain and France had lost a generation in WWI and were loathe to re-engage. Americans did not like nor admire the British. “Toffs,” they were regarded as. Poor fighters (with reason.) Enslavers of the Colonies. Plenty of reason not to like them. Plenty of reason not to admire the French military as well.

Who saw the necessity of opposing Hitler? In Britain, Churchill first and foremost. In the US, Roosevelt for sure. But leaders are not dictators and it took time for the countries to catch up, to see more and more clearly what they were up against. No one wanted to change what they were doing, no one wanted to think of war again. So they denied it.

Denial is an essential part of life. We generally don’t think much about our own mortality, a kind of denial. If you look at yourself and think about it, right now, I bet you can think of things you are denying right now. Just not thinking about it, and going on as if it didn’t exist. It allows you to be functional. But sometimes it’s not a good idea.

In the case of WW II, it took Pearl Harbor for America to stop denying. That did the job pretty well. We still don’t know what would have happened with Europe if Hitler hadn’t declared war on us later that week. But he did and denial was over.

I do recommend this fine book. As a journalist, Hastings is able to take us back in time so vividly, to abolish knowledge of the ending just for a little, and see what the atmosphere really was at the time. He shows us that retrospective clarity is an illusion.

How does this apply to the present? We all know Santayana’s comment that those who don’t know history are doomed to repeat it. That’s essentially a hopeful statement, implying an ability to form the future through reasoned action. But it’s also possible that those who do know history are just as doomed to repeat it as those who don’t. In John Steinbeck’s redo of the Arthurian legend (another book recommendation from Budd) Merlin is asked: “If you can know the future, why didn’t you look ahead and see that this woman would be the death of you?” Merlin replies, “Oh, yes, I can foresee it, but that doesn’t mean I can avoid it.” Makes sense to me.

So here’s the question: Given the power of denial, what’s the biggest issue we are not facing now? What is the equivalent of the brewing Nazi and Japanese crisis of the 1930’s?

Islamic terror? Nah. We are spending huge time and money on it, but it’s really just an annoyance – what can they really do, how many of them are there really? It’s mostly drama. Even if they got a WMD. Even if Iran went nuclear.

Islamic expansionism? Maybe – look at France and especially the Netherlands. Look at how Islam took Kosovo from the Serbs by sheer procreation of the Albanian-Islamic minority become majority. But while a problem, it will be handled more or less, and I don’t think that’s it.

Rising countries with non-democratic governments? Maybe. We used to like to think that liberal democracy was ascendant since the demise of Communism in the USSR and Eastern Europe. Certainly something to contend with – Fukayama’s “End of History” was ridiculous when it was published and is now risible. I love liberal democracy and the Bill of Rights, but that’s a product of our specific Western culture, and its ascendancy was based on our economic and organizational power, which will soon be matched. So, it’s a problem, and it’s true that most people are not conscious of it. But I don’t see it as an impending crisis, just a persistent challenge. Competitive coexistence is most likely.

No, my candidate for major pending crisis in denial, crisis in the same league as Nazi Germany and WW II, is the environment. It’s not an unknown issue, but neither was Nazism. It seems quite clear that overpopulation and industrialization are burning up our planet. Ever since we discovered all that fuel below the surface of the Earth we have been burning it up, and in the process burning ourselves up. We use some of it well, but the “externalities” (to use economist-speak for pollution and carbon dioxide accumulation) come back to bite us, as the lobster-pot we live in heats up, more and more obviously. It’s an impending crisis, but it just won’t explode in the next year or two, so it’s possible to deny it, especially if you are over 50, where the power lies.

I see the Nazi parallel. Hitler built the military month by month, people saw it, but most preferred to think one could reason with Herr Hitler, or thought he was pretty far away in space and/or time. Our decade of the aughts has gotten hotter and hotter, but what the hey! Maybe it’ll stop! Maybe it will be a good thing? Who cares what happens to Bangladesh and the Maldives? Not our problem, is it? Do we really want to change our habits and economy substantially? Or do we say, like St. Augustine, make me chaste, but not quite yet?

As in the 1930’s, the forces of inertia are still in control. Greed is in place – oil and coal interests pay “scientists” to deny global warming. They pay Congress not to tax carbon. Developing countries are also resistant. They say, why should the West have the good standard of living and not us? Politically, it’s a game of chicken. China and Brazil say, we’re going to make progress – why should you always be ahead of us? We say, hey, we’re already here, don’t you realize you will make it worse for all of us? Why are you burning coal? You are making it worse for all of us. It’s a game of chicken.

A gradual approach now, like rearming would have been in the 30’s, would be to hitch profits to moderating climate change, by government incentives. But governments are weak. Corporations and sovereign funds rule the world, and they make money by doing the same thing they have been doing, time after time. There is even an ideology that these entities should not be looking for the common good, that “the market” will take care of it, and technology will “appear.” These are arguments of convenience. We are dealing with economic externalities, and as I understand it, such effects by their very definition do not enter the market. So the ideological market argument is specious. We need strong governmental intervention, and not only are our governments weak, but populations are in denial.

No one really wants to change. Psychologically, it’s just denial. Morally, it’s selfishness of the current generation. Intellectually, it’s often just stupidity and ignorance of science. And as we look for leadership, George Packer tells us, don’t expect much from the Senate. Our institutions fail us just as much as the British ruling class and our own isolationists in the 30’s.

To be educated, to see the future to some extent, to know some steps we should be taking now, to see little happening, is to feel like Merlin.

So, I ask --What’s it gonna take? What will our Pearl Harbor be, or our invasion of Poland? Nobody knows. I don’t know. But if this really is the brewing crisis that is being denied, then it might take something dramatic.

The environment is not my field, so I can’t speculate intelligently about what it will take. Hunger and thirst, rising sea levels and tides? Maybe. Maybe even as the Earth gets more and more depleted of forests, would it be possible that the oxygen level in the air, at 21% for millions of years, would drop, and we would all be living as though we were high in the Andes and Himalayas?

This is as far as I can get. History allows us to reason by analogy, but it is never exact. I know we are denying something that is important, and if we prevented it, that would be better than fighting it later. And I think it’s the environment. And I think it will take something dramatic to move us. And I think there will be a lot of conflict, that it won’t be peaches and cream. I wonder what it will be.

Budd Shenkin

ICU's, interesting cases, and Primary Care

2010-08-14T11:08:00.000-07:00

Atul Gawande is a genius writer in my book, or rather in his books and articles. But, even though I think his mother was a pediatrician (in Ohio), he is still a Boston-based high powered endocrinologic surgical specialist. So, in his latest New Yorker article on the depredations of high powered specialities ICU care and end of life expense and torture, I think he steps on his lede.

In the article Gawande writes very approvingly about hospice care, and recounts the torture inadvertently administered by the ICU doctors to dying patients. At the very end of the article - every article he writes is more than worthwhile reading - he mentions a case where the primary care doc had kept in touch with the patient and with the prospect of ICU care the primary doc gets the patient turned off, then quietly exits stage left.

Hey, Atul! That's the whole ffing point!! It's primary care, man! It was also the point in your South Texas article of the best little medical money machine in Texas. Stop stepping on your lede.

He and the other New Yorker doctor-writer, Jerry Groopman, also generally quite well worth reading, especially on EMR's in the NEJM, come from the background of intellectual (I'm not using that word in a good sense here) pompous (also not in a good sense) Boston specialist doctors (also not in a good sense) on rounds saying, "Hmmm. A very interesting case indeed!" And then they trot off the the next. Some decades later, Groopman says, in the face of caring for his own medical needs - hey! There are people in there with these "interesting" diseases!

No s... Dick Tracy! There are others of us, who I can only think very often wound up in primary care, who from the very first said, "What are these guys doing?" Don't they realize they are dealing with people? Is this part of the God complex? So removed? Then they come back to see, post-seduction, what the game is really about.

For a great comment from a pediatrician turned health policy guy, and classmate and friend of my step-daughter Sara, see http://www.huffingtonpost.com/aaron-e-carroll/its-the-life-in-end-of-li_b_664152.html?ref=email_share.

While I'm on this rant, might as well take on the academic liberal primary care establishment who take the position that those who look nostalgically to the family doctor of the 50's are doomed to disappointment. They say, we can't do that in this day and age. We need to cut costs and be efficient! We need to have Nurse Practitioners, and they should be independent! We need clinics with teams for all our patients! And, btw, doctors are people, too, so they need a very definite work week so they can be with their family and have enjoyable lives - so that means they can't be tied down to patients, rounds, call, etc.! (Okay, that last one is unfair, but I'm leaving it in anyway.)

Well, as my old roommate from Caribou, Maine used to say, bulldiggy. With all the money going to the money pit of hospitals and anesthesiologists (starting at $600K around here) and cardiologists and ortho and imaging (many with millions each year), what we want to economize on is primary care? You've got to be out of your mind!! We're great, we are what's needed, and the system needs to be based on us! We are the biggest bargains in the medical care arena, and you want to cut us??? We love our PNP's - they are great - but they ain't doctors, buddy. We're going to direct all the doctors to be these same specialists who are causing all the ICU problems, those emotionally dead souls, or at least confused? Give me a break!

OK, I know, I shouldn't be on the fence so much, you should know where I stand. OK. Next post I'll take a stand.

Budd Shenkin

Turkey and Anti-Semitism - It Could be Scary

2010-08-08T11:45:00.000-07:00

I’ve never been one to spot anti-Semitism near and far. Nor to overlook it.

I was raised a secular Jew and remain one, married twice, each time to a shiksa, and my kids view themselves as half-Jewish, which you can be if Judaism is a nationality and a cultural heritage rather than a religion. I try to be dispassionate in matters concerning Israel, but I have to admit I feel a rush of nationalism with each war or skirmish. I do know where my loyalties lie, but I am critical of the political structure of Israel, their policies, the predominance of religious conservatives, personal arrogance of many Israelis, and cruelty towards Palestinians by troops and some policies, even given the obvious provocations. I support the Gaza incursion – rockets cannot be disregarded. So I tend to hang with J-Street, the alternative to the very conservative, very nationalistic AIPAC.

I’m just trying to locate myself as a reporter for what I have just found in our trip to the Black Sea and to Istanbul.

When traveling, I like to read the local English language press. It usually is boosterish, often amateurish and provincial, and I’m never sure where it comes from, but I read it. At least you get to hear what’s in the air. Last year I read the English language newspaper in Dubai, which were boosterish. Didn’t say much about sovereign funds, as I remember. Last week we were in Istanbul for a couple of days, and I read the Hürriet Daily News. They covered Recip Tayyib Erdoğan, Prime Minister since 2003, head of the Islamist Peace and Development Party. From his Wikipedia entry:

As prime minister, Erdoğan implemented numerous reforms within a period of time. After 45 years, the negotiations for Turkey's accession to the EU started during Erdoğan's tenure. A great deal was achieved in democratization, attaining transparency, and preventing corruption. Parallel to this, inflation, which had for decades adversely affected the country's economy, was taken under control and the Turkish Lira retrieved its former prestige through the elimination of six zeros. Interest rates for public borrowings were pulled down; per capita income grew significantly. The AK party won the elections of 2007 making it the first time in 52 years that a party in power has increased its votes for a second term.

Of course, what isn’t mentioned is that he was an apparent supporter of the very provocative Gaza flotilla last month that Israel botched so terribly, succumbing to the provocation. Where has that vaunted Israeli ability gone, anyway? On the way to becoming just another Middle East country, I hope not?

The Hürriet Daily News featured an apparent ongoing conflict between the government and the armed forces. Turkey it has often been said, is not a country with a military, but a military with a country. Since the time of Ataturk, the military has led in modernization and secularization – so I’ve always been for it. Now, however, the Hürriet Daily News reports that the government wants the military to be led by civilian government, which would be ho-hum in any other country. That’s the way it seemed to be treated by the Hürriet Daily News, but this is Turkey, and Turkish civilian-military relations cannot be treated that way. So it was curious that the Hürriet Daily News seemed to be treating it that way.

What, in fact, is Erdoğan’s deal? His party is Islamist. He won power partly because of the former ruling coalition’s incompetence and corruption, but there is an Islamist tide in the world. There is more Islamic dress observed in Turkey than previously, and more religious orthodoxy.

Is the Erdoğan government pushing for geopolitical advantage from its crossroads position and it’s 8% economic growth per year? Or is there some true ideology involved? Was the posing with Ahmadinijad and voting against UN Iranian sanctions geopolitical, internal political, or ideological? Or reaction to being turned down by the EU, especially by France, which is having its own Islamic problems now?

Nothing is simple. After all, A.J.P. Taylor, perhaps the greatest English historian of the past generation argued that Hitler was actually a traditional politician in his aims and means – minus the Holocaust, I would assume – I have to reread that book, which I just saw in my bookshelf yesterday, actually. So the best leaders mix their aims and goals for maximum advantage. As Aaron Wildavsky used to say, never do anything for one reason only, even though he was only talking about academics.

But here is what else I saw in the Hürriet Daily News. Erdoğan declared that Turkey, Hamas, and others could not get their true story told because the worldwide media is controlled by Jews. He also said that the PKK, Kurdish separatist guerillas which has resisted Turkish repression for years, are agents of their Jewish and Israeli paymasters.

This material is unreported in our press, as far as I can see. If it has some validity, that this is what he is really saying, this is really some serious anti-Semitic shit. Next thing we’ll be hearing is the Protocols of Zion, the notorious Russian forgery of the secret Jewish plot to take over the world. Next thing we’ll be hearing is Holocaust denial from him.

As I say, I’m a secular Jew, and I’m pretty assimilated. I don’t look for anti-Semitism under every stone. I support Israel but only with reservations. But I also know, anti-Semitism is always there, ready to be reinvigorated. It lives and thrives in the European Left Wing and academia. And I know you can’t let anti-Semitism just burn itself out, because it won’t. Just like in a political campaign, you have to hit back early and often.

There is always more than meets the eye. The Israelis sure know what is going on, and they are in negotiations with Turkey, their best partner in the Muslim world. If Turkey really wants to grow, being able to trade with Israel and benefit from that vibrant economy is a better deal than the stagnation in other places, such as Iran. So I’m not jumping to conclusions.

But if this is accurate reporting, and this is really what he said – isn’t this dangerous? If this is true, if he is really saying these things, if the Hürriet Daily News has any validity at all – this is very scary stuff.

Budd Shenkin

Health Care - If I Could Change Just One Law

2010-07-29T06:18:00.000-07:00

My wife and I are on a very nice summer cruise on the Seabourne Odyssey in the Black Sea. The main celebrity on the cruise is former Governor and Senator Bob Graham (Dem - Fla.) We had dinner with him and his wife last night, and a very nice couple from Santa Monica, one of whom sits on the Board of Cedars-Sinai Hospital in LA. We discussed many things, among them health care. Aaron, the Board Member, said that foundations seemed like a nice solution to him, especially since it was a good deal for the doctors, who got to have a salary. It was an amiable dinner and no noses were bloodied. But as I objected to corporate medicine, I was asked by the Senator if I could point to any examples of what I would favor in the US currently. I had to admit I couldn't.

As I thought about it, I thought I could respond to him with a short letter, what I couldn't say in the context of a nice dinner. Although it is repetitive of what I have cited here before, I thought it might be worth posting.

Here 'tis:

Dear Senator Graham:

Thank you for having dinner with us last night. It was a treat.

I was embarrassed to admit to you that I couldn’t cite an example of a good model of care somewhere in America that could be emulated. I had to retreat to “three yards and a cloud of dust.” So let me take just a minute to explain why I couldn’t come forth with a trenchant answer.. In brief, the structural problems of American medicine currently set a very unequal playing field that makes it difficult for excellent and adaptive new entities to form. As it stands now, the playing field is tilted toward large corporations to run medical care, which I don’t think will serve our interests well in the long term. So I think the rules of play need to change before we can get to really good systems of care that meet the objectives of patients and doctors alike.

Current Examples

Many analysts, most popularly Atul Gawande in the New Yorker, have cited the examples of the Mayo Clinic, Geisinger, etc. The problem with these examples is that they are elite and special examples, which have taken decades and more to evolve, and have very selected doctors and administrators. They are not going to be able to be replicated elsewhere – in fact, the experience of the Cleveland Clinic and Kaiser and Mayo is precisely that they find it hard to replicate themselves in other parts of the country.

But even if they could be replicated, would we really want that? They are highly structured and corporate entities. This kind of entity usually does not deliver the kind of personal care that our people are used to and want. Large institutions just can’t. As sociologist Eliot Freidson pointed out years ago in “Profession of Medicine,” as you get larger groups, the doctors are more keyed into the opinions and norms of their fellow professionals and even administrators, and less to the patients they serve. It’s only human. So we get what we call “institutional care” rather than personal care. Many patients really wonder if their doctors in these settings really care about them personally, and know them for who they are.

Current Forces

But even if these models are not replicable, we are getting more and more large medical entities forming as American medicine evolves very quickly. Conglomeration has gripped the industry, as hospitals have formed large chains and local monopolies, some large multi-specialty groups have formed, and these large conglomerations have become price-givers instead of price-takers vis-à-vis insurance companies. Using the RBRVS Medicare price system, hospital monopoly and large group contracts have been at a rate of 160% or even 200% of Medicare. Typical physician practices by contrast are at from 100% to maybe 130% of Medicare tops.

As an additional problem, the RBRVS Medicare system (their price list) grossly underpays primary care and non-procedural specialists, and overpays hospitals and procedural specialists. Since the private insurance companies also use the Medicare RBRVS as the basis for their payments, this payment imbalance reverberates throughout the system.

These two forces, hospital and specialist conglomeration and RBRVS payment imbalances, shape our current system. Prevention and primary care practices languish while hospitals and large systems are awash in money. They use this money to pay themselves, and to invest in themselves. Hospitals vertically integrate by employing doctors (in California through foundations), and specialty groups add ancillary services (physical therapy, MRI scans, etc.) Some think that foundations are a good deal for doctors since they don’t have to do the administration themselves and they get paid salaries, but this is only attractive based on the alternative of being starved by the current system of payment. The playing field is very uneven.

What HCR Could Have Done

While the Health Care Reform law successfully attacked many insurance practices that disadvantaged patients, it is completely silent on the insurance company practices that disadvantage small scale physician practices – exactly the practices that people are used to getting their care from, and exactly the practices that are least responsible for the rise of health care costs.

It is quite understandable that the Reform did not reach to the provider-side and stayed only on the patient-side. It was hard enough to get the bill passed as it was. But if political realities were different, what could the law have done?

Perhaps most importantly, the HCR law could have taken steps to even playing field. Currently, only the large conglomerated groups can negotiate with the insurance companies as a single entity. If a group of doctors want to negotiate the same way as these conglomerations, they too need to conglomerate themselves. That would mean, however, that they would lose the very individuality they are seeking to retain. The HCR law could have mandated an exemption from anti-trust law that would enable groups of doctors to negotiate as one with the insurance companies, just like the big boys. This would have leveled the playing field, at least somewhat. There are other steps that could be taken, but this would be the big one.

Personally, this is precisely the situation that we pediatricians find ourselves in the San Francisco East Bay. We have a fairly smoothly functioning group of pediatricians and pediatric specialists, and we would like to bargain collectively with the insurance companies. But because we are forbidden from doing this, we are picked off one by one by the insurance companies, while at the same time they are richly rewarding the large groups such as Sutter Foundation (tied to a dominant hospital chain), and Palo Alto Medical Foundation, which is allied with Sutter. In the oft-repeated words of my step-daughter, “Not fair!” These large clinics have no apparent superiority in services, they simply have more market power, delivered to them by federal anti-trust law.

Is It Just a Retrograde Dream?

Is this a retrograde dream, yearning only for the old, professionally rather than corporate dominated days? Maybe. But there is a theoretical work from the Harvard Business School, Redefining Health Care, that points out that an ideal system would not be an integrated network such as Kaiser or Mayo. At Kaiser, for instance, if the primary care doctor is acting as an agent for the patient, there is little choice of specialist – the patient is sent to the Kaiser cardiologist, or Kaiser neurosurgical clinic. It might be good or not, but it’s theirs. The HBS study says that it would be much better if the primary care doctor could choose among multiple specialty alternatives that compete with each other. This is not so much different from the system we are used to, but that is rapidly disappearing.

[Here is an example (not exactly what I was talking about, but close) close to my home: ValleyCare Hospital in Pleasanton, California, has recently established a Foundation, employed all the obstetricians who practice at the hospital, brought in new pediatricians (all new to the area and graduated in medical schools in foreign countries), and ordered the OB’s to refer all newborns to these new pediatricians. Patient interest? Not really. It’s corporate power interest.]

What the HCR Law Does Do

The HCR Law does look for some experimental changes, most notably the formation of Accountable Care Organizations (ACO’s). The ACO would get paid a set amount for various episodes of care, both within and outside the hospital. The major target for the ACO would be cost reduction by stimulating more coordination among providers. It might work, but there will be major fights among hospitals and doctors for control, and the hospitals will most likely win. If costs are actually reduced, good. We certainly need cost reduction. But this is an untried and slender reed to base major health reform on.

Many analysts have said, however, that the major underlying problem of our current system is the weakness of primary care. The average age of primary care doctors is constantly rising as younger doctors choose the better paid specialties. The HCR law funds more training slots and forgives some loans of graduates who choose primary care and practice in underserved areas. But to make an analogy, they are funding swimming lessons (training) but they are not warming up the pool (the practice of primary care) so that people actually want to go there. So these efforts are likely to be of small value.

The new HCR law does give more power to MedPAC, the agency that sets Medicare payments. They now can set rates that Congress would have to veto, rather than simply making suggestions to Congress, which is susceptible to special interest (hospitals, specialists) pressures. But, of course, this is simply one element.

Summary

In summary, I can’t point to a model that will work. I can only say that the course we are set on – large scale corporate control of medicine with emphasis on specialist care – will be a radical departure for American medicine, and will turn out to look far more like socialized medicine (very large scale, clinics, etc.) than most of us, patients and providers, would really want. There are some steps that could have been taken, and still could be taken, to allow us to evolve in a way that might give Americans and American doctors care with a human instead of a corporate face. To choose this path, the field must be leveled, and only government can do this.

Budd Shenkin

Lying Scumbags and Health Insurance

2010-07-05T11:03:00.000-07:00

Some of you will recall that we had health reform earlier this year. Some of it eliminated egregious practices by health insurance companies, which is very good. Who could believe that in the United States of America a company could rescind a health insurance policy once the patient became ill? Maybe that tells us more about our country than we would like to know.

But insurance companies don’t just interface with patients; they also interface with us, the doctors. Health insurance companies are equal opportunity companies – they treat us just the way they like to treat patients, and this side of the pathology of American medicine went completely untouched by Health Reform. Alas. Just this week a fine example of insurance pathology visited itself upon me. It has been uncomfortable.

The issue in question is this: immunizing children with vaccines has always been important, but in recent years many new vaccines have been introduced. These new vaccines are not only numerous, they are costly. When I first started in practice a vaccine cost about $5 apiece; now some are in the $100-$200 price range, some of them requiring three shots for the series.

Happily, the new vaccines are very effective. In fact, they are so effective that pediatricians and hospitals now care for many fewer illnesses. Financially speaking, I’m not certain of the ultimate effect for health insurance companies and pediatricians. Health insurance companies pay for vaccines, but they also have to pay for fewer sick office visits and hospitalizations. They don’t win on the new vaccines that prevent genital warts and subsequent cervical cancer years later, but I bet they are winners for vaccines that prevent pneumonia, septicemia, and meningitis. I used to have several cases of meningitis per year, now not at all. My intuition tells me that they make money on the deal, but I can’t be sure.

I’m also not sure of the financial balance for us as practitioners. We can make money on giving the vaccines (if the insurance companies allow us to – that’s one of the points of this post), but we certainly care for fewer sick children – thank God, of course. It really depends on how well we are paid for our vaccination services. (Children’s hospitals, on the other hand, simply lose the income of caring for sick kids. But I never feel sorry for those inefficient, union-bedeviled, nurse-bedeviled financial sinkholes called hospitals.)

Thus, our work as pediatricians has changed. Vaccines have become less of a sideline for us, and more of the main show. In business terms, they have become a full-fledged service line for pediatricians. It’s good – getting paid for keeping kids healthy rather than tending to them when they are sick. But this substitution has changed the business model of pediatrics. If we don’t make money on this important business line, we will be out of business. Most pediatricians are not great business people, and most pediatricians don’t yet realize this. The more savvy pediatricians do realize this, and our section of the American Academy of Pediatrics put together “The Business Case for Vaccines.” This paper calculated that paying us 117-128% of the vaccine cost would cover overhead. That calculation is certainly too low (leave it to pediatricians to shortchange ourselves), because they neglected important elements of vaccine loss, which happens in every office – from omissions in billing, lost vials, parents deciding at the last minute they don’t want the vaccine after all even after it has been prepared, a kid grabbing the dose and throwing it away, just kicking a dose under a table, whatever. But even if the number is too low, there it is, a number to be respected.

In contrast to pediatricians, however, Insurance companies, understand their business pretty well, at least in the short run. They are, after all, pretty much exclusively business enterprises, rather than professional care givers plus businessmen as pediatricians are. Insurance companies see the increased price of vaccines and try to figure out how to lower their costs. It’s not their business to figure out how to keep pediatricians in business – it is up to pediatricians to take care of themselves and their incomes. The insurance companies also don’t figure it’s their business to fix the American health care system, which is very deficient In primary care mainly because primary care docs don’t get paid nearly as well as specialists. For insurance companies, if they can economize on the cost of vaccines and still reap their benefit of fewer sick bills, it’s a wonderful life.

Bad as they are, health insurance companies have their own pressures. They are being squeezed by consolidated hospital systems that are price-givers rather than price-takers, and by large integrated multi-specialty groups, such as Sutter Foundation and Palo Alto Medical Foundation here in Northern California. The insurance companies figure that they need those contracts, and as a result they pay those providers very, very well. In addition, I think corporations like to do business with other corporations, rather than a different kind of entity completely, which doctors in private practice are.

So, the health insurance companies give here and take there. Private practice primary care docs, however, are prevented from negotiating together by antitrust laws, despite the fact that the health insurance companies on the other side of the table are very consolidated. The results of these negotiations are then predictable.

Right now, this business drama is playing itself out with a new vaccine, called Prevnar-13. The old version, Prevnar-7, protects against 7 types of pneumococcus, a virulent pathogen that causes pneumonia, sepsis, meningitis, and ear infections. The new Prevnar-13 adds six more serotypes of the bacteria to the protected list. Pediatricians buy the new version for 30% more. Most insurance companies are raising their payments appropriately. Anthem Blue Cross – that’s right, the same company that proposed 39% premium increases to patients right at the end of the health care debate, thus helping immeasurably to pass the legislation – wants to pay us 5.6% less for this more expensive vaccine.

The decrease in payment is partly because we have had a pretty good contract for the last three years after some very tough negotiating. But it’s also because Blue Cross has been bought out by Anthem, and Anthem plays even harder ball than Blue Cross used to, and they were very bad boys and girls indeed.

Clearly, since our new business model depends on vaccine delivery as a major service line, we can’t accede to this new fee schedule. They will hit us first for Prevnar-13, and then come after the rest of the vaccines. So we have to be strong in negotiating, and possibly even terminate our contract. This would be a major step to be taken only with lots of forethought, but if they are persistent, it may be necessary. It’s uncomfortable, but it’s business. In fact, for me personally, it’s very uncomfortable, not my favorite part of the business. But on the other hand, I’m not one to back down. Quite the opposite. You don’t screw around with Budd Shenkin.

All companies are not the same. There is no one way to do business. A company can be businesslike and aim for profit, but also be civil, honest, and look for common elements. In the negotiation three years ago, I emphasized how common our interests are. They sign the patients up and we have to make sure they are well served and happy. Together, the insurance company and Bayside have the common competitor of Kaiser – we both have to give patients a reason to come to us. They listened then, maybe bought it, maybe didn’t. I heard that what really clinched it was they were convinced that if we didn’t get a decent deal we were going to terminate.

On the other hand, a company can be dirty and demeaning. Guess where this story is going now.

First of all, at the beginning of the year Anthem Blue Cross stopped paying us for an emergency care code (a billing code is how we get paid), 99058. They just said they weren’t recognizing that code anymore. Can you believe they can do that unilaterally? I actually don’t think they can, and maybe we can take them to court over that – just the kind of diversion from our main business of running our practice that we need. Doesn’t it sound like the way they have treated patients, with rescissions, etc.? Then I just found out this week that, at the same time they stopped recognizing the 99058 emergency code to all their contractors, they raised the amount they are paying for vaccine administration (we get paid separately for the vaccine itself and for administering it). Amazingly, while they took away our emergency fee, they didn’t revise our payment for this fee upward. Dirty pool.

So now we’re fighting over payment for the new vaccine. Here is how it is going. You know how doctors complain about the part of managed care where they have to justify their plan of treatment for patients to an under-educated insurance company employee? It’s an insulting process to the doctor, not only because of the educational discrepancy – why should a doctor have to get permission from a clerk? - but even more because of the social power discrepancy. The usual roles have been reversed in a sociological anomaly. It’s like my objection when I go to a doctor’s office and some 25 year old high school grad comes to the waiting room and shouts out, “Budd?” It’s Dr. Shenkin, you twit.

So, this is what I have been going through. There is the local Anthem Blue Cross employee, a not very nice young woman who declares their policy to me in imperious tones. When I object in writing and declare myself insulted, she becomes more fearful and conciliatory and we consult superiors, I make phone calls that go unanswered, and finally reach someone, who sets up a call with the VP of Reimbusement Strategies, a man whom I will call John Doe, because my attorney wife informs me that identifying exactly in writing the person I will refer to as the Lying Scumbag might lead to legal troubles, despite the unquestionable accuracy of the charge.

So in my quest for fair payment for Prenar-13, I have to endure a one-hour conference call with the young imperious rep, the nicer superior who is unaware of these issues but wants peace, and the Lying Scumbag. The Lying Scumbag then proceeds to lie like a scumbag. He tells me that the American Academy of Pediatrics has approved of their payments – a claim made earlier by the young imperious rep. “Oh, yeah?” I say. I was elected to the Board of the AAP Section on Administration and Practice Management (SOAPM), and selected for the Committee on Child Health Financing (COCHF). Who exactly gave that OK?

The Lying Scumbag gives one source as the California Pediatric Council. Another is the national AAP representative for private payers. I know he is being mendacious. I have made sure to inquire, and they have assured me that’s not so. The Lying Scumbag tells me that of the 14 states he covers, I am the only pediatrician who has complained and been dissatisfied. That’s a pretty amazing claim, and clearly counterfactual. He sidesteps my assertion that every other insurance company (except one, CIGNA, so far at least) pays a lot more. I tell him I know he feels this is a triumph for his company, to pay less than others.

The Lying Scumbag quotes our own Business Case on Vaccines to the effect that if you add together the payment for vaccine and administration and get up to 117-128%, that’s enough. The wording of the Business Case could be clearer, but that’s not the case at all. He tells me, “Let me explain to you how this works,” about our own Business Case. The Lying Scumbag then deigns to instruct me on the economics of our practice and how it works. He wonders if he can explain to me the RBRVS system, which governs our payments. He is a young man, full of himself but not very smart, it seems. He tries to snow me. I tell him, stop being patronizing. I’m more of an expert on this than he is. I tell them all that their policy is self-defeating. If they starve us and let the corporate practices thrive, that’s all they will have left to deal with, and how will that be for them? Long silence. They have a mission, which I view as search and destroy. I’m not at the right level of Anthem Blue Cross employee. I’m stuck with someone whose role is to be a Lying Scumbag.

The Lying Scumbag repeatedly refers to a “neutral party” that they consulted that recommended their proposed payment rate. He also tells of the approval he got from the AAP national when he proposed to inform pediatricians how to buy vaccines more cheaply (he’s telling me?) so that Anthem Blue Cross could then pay us less. The Lying Scumbag and his confederates on the phone all inform me that Anthem Blue Cross considers vaccines “just a commodity.” “We’ll pay you for your work, but not for a commodity,” they tell me pointedly. That’s the tone, from these jerks.

So, as I say, market power reigns, corporations take over, pipsqueaks and Lying Scumbags come to the fore, and this is what we have to deal with. There is a market imbalance, and Health Care Reform did not address it. The power imbalance is too much to deal with, since there are a few powerful health insurance companies, and private practitioners are forbidden to combine in negotiations. In addition, while some elements of the AAP are supportive, the Board and the President of the AAP maintain a distance from the fray – God forbid they should get involved with the financial viability of their constituents.

With this kind of market economics prevalent, it’s hard to see how the health care system can improve on the foundation of primary care. And me – I’m trying to stop steaming. I think I’ll try to hire someone to do this negotiating. It’s just too wearisome. I can’t ruin my life dealing with Lying Scumbags and Jerks. And that’s all too much the story with this most heinous of industries, the health insurance industry.

Budd Shenkin

Corporate Medicine

2010-06-27T22:57:00.000-07:00

I had lunch with a pediatric specialist in a field that doesn't have a lot of procedures, and so like those of us in primary care, is relatively poorly paid. She is currently employed by the Sutter Health Foundation.

She makes pretty good money there. Sutter is rolling in cash, being a corporation based on a hospital system that has a very powerful position, little reason to economize, and is a price giver rather than a price taker with insurance companies. This specialist bills an unholy amount for office appointments and gets paid accordingly, because the contracts that Sutter extracts from payers are, well, rich. So she makes money.

But, are the patients well served, and is she well served? As in many corporations, the staff are not directly responsible to the doctors. She can still be seeing patients and if it's lunch time, adios! A patient became unresponsive in the waiting room and luckily someone brought this to the doctor's attention and she could administer to him, because the staff had vacated the premises for lunch.

If she wants a chair to sit in - a chair! - it has to go through innumerable levels for authorization, if the site administrator deigns to send the request in. Administrators tell her where her office will be without asking her first. They just tell her, they don't care about her. Administrators come and go, no one caring very much. It's corporate and it's large.

I am currently looking for an Administrator at Bayside and our headhunter has told me several times that she understands, I started this practice and it's my baby. Well, sure, I thought. But now it really hits me what she meant. When she searches for a corporate client, it's much less serious business. The level of performance matches the level of caring. Good enough is really good enough. Me, I really care.

In capitalism, the theory is that competitors with superior efficiency and customer satisfaction should rule the roost. But look how that isn't true here. The market really isn't working. Sutter gets big contracts and makes big money, pays the doctor probably more than I can - I'm hopeful that maybe I can match, but it will be hard - and it sure ain't because of efficiency or customer service. It's market power, pure and simple.

And why market power? It's partly because of size - Blue Cross needs to contract with Sutter or close up shop in Northern California. But I'm wondering if it's also because of like liking like. Big corporations seem to like each other. The minions get together and they are in it together. So they scratch each others back? Is corporate medicine what they are both most comfortable with?

Corporations, administrators. It reminds me when I worked for government. People would talk about "government," and said that it was inherently unresponsive and rather evil. When I was on the inside, I looked around and saw what people did, and I thought they weren't capable of much, and/or they didn't care. The few who got something done took themselves off in a corner with a few other good people and actually got good things done. Management to good effect was scarce. I always thought, yes, the structure allows them to do this, but then, they are the ones who did it. If they were more ethical and less immature and self-indulgent, they could do the right thing. If they cared. I guess I still feel the same way. But now I also think, that's the way people are. It's really a shame.

Budd Shenkin

Missing Old Times

2010-06-07T06:49:00.001-07:00

I thought time was supposed to dull missing departed people. So I thought. I was always touched when we still had the San Francisco Examiner and each Christmas publisher Randy Hearst published a long poem of his father’s on the editorial page, about the renewal of life, and how water rolls down to the sea and returns as rain. Then he said that he missed his father and he always would. I hadn’t lost my father yet, but I was forewarned.

My father died in December, 2007 – he missed the big financial meltdown, he missed Obama, he missed a much-wanted great grandchild. And I miss him. It isn’t getting any better. I kinda knew I idolized him when he was alive, and fought against him, but it’s just gotten worse since he left us.

I think about how we used to be. I remember when I was in high school, and when I was away at college and knew my parents were there, even when I called home reluctantly on Sunday night – no cell phones, he kinda missed that, too, he was too old when they came – and my Mom and my Dad were on the phones and I said some of my courses were hard, and Dad said, “Well, it’s long distance, so, ….”

And my Mom said, “Henry! He needs you!”

And then my Dad said, “Well, everyone knows that math and science are the hardest.”

I hadn’t even known that I needed him. I never thought I did before. Just knew that I needed to please him or I’d feel crappy. Not that I ever did displease him, so far as I knew. Displease my mother, that seemed easier. I still remember the call; it must have helped, I’m sure it did. Nothing had been particularly hard before, I guess. Except mechanical drawing, and I could always just spend more time on that. But in college we were steaming ahead.

And I remember sitting with my parents and with Betty Jane Lipshutz from up the street, whose daughter Margie was friends with my sisters. Who was it on the TV? It must have been the Beatles, because Elvis came on Ed Sullivan when I was in high school, and this must have been later, when I was older. It doesn’t matter. I just remember they were watching the old 21-inch black and white TV in my parents bedroom, and we heard them screaming, like girls were supposed to do, probably a replay of the bobby soxers. And the parents looked at each other and laughed.

Why does that make me cry? I just don’t know. I do know I miss them.

My first play was Our Town. I was in 7th grade and played Wally Webb, Emily’s little brother. My whole family came to see my one line, “Aw, Mom, by 10 o’clock I have to know all about Canada!” Wrung every emotional note out of it I could. Emily gets to go back and look at the past, against the advice of the Stage Manager. Don’t do it, he says. Oh, but I want to, says Emily.

I can see why. I can imagine myself there right now, just like Emily. I look down on the parents, on me, and I want to say, I’m right here! I love you all! You were so wonderful! Can you hear me?

I love Thornton Wilder. It’s just what I want to say. I can see us all, I really can – and I’m not stoned. True, I’m listening to Beatles music and 50’s music and 60’s music, but I’m not stoned, really I’m not.

Time is such a pisser. We just can’t beat it. I hope they knew how much I would appreciate them, how much I loved them. I know they loved me. And I just realized a couple of days ago how young they were. My Dad was 26 when I was born, my Mom I guess just shy of 24. So when I was 20, they were just 46 and 44, already had 4 kids whom they had sent to private school until we moved to Lower Merion, a summer house down the shore (who knew that “down the shore” was a localism?), a succession of cars, etc. Rock and roll had just come and no one knew how to treasure it yet. No one knew Mad Magazine was a classic. No one knew we’d be flying on jets, listening to IPods, and the world would be getting less dangerous from H-bombs but more dangerous from terrorism. No one knew that the US would get better and better. Now we know. Too late, man! That doesn’t help them now! They couldn’t plan on that, and now they’re fucking dead!

All we have is the present, but I sure miss the past, and I miss my mommy and daddy.

Budd Shenkin

Health Care Evolution as Seen From the Bottom

2010-06-06T21:28:00.000-07:00

We know that the money in health care is going to the hospitals. If you are half-decently managed and you have a half-decent payor mix, you will be making a lot of money. Non-profit has no meaning in health care; it was shown long ago that for-profit and voluntary hospitals act equivalently. The money they make goes for very handsome executive salaries and retained earning to be spent on system development. “System development” for hospitals can mean more and more technology. It can also mean buying up doctors and controlling the field, vertical integration.

Here’s what this process can look like on the ground. There is a voluntary hospital in Pleasanton called ValleyCare. The CEO is a firebrand named Marcy Feit, who began life as a nurse, but who has now been in Pleasanton for over a decade and is very well entrenched. She decided a couple of years ago to construct a Foundation. In other states the hospitals simply hire doctors; in California it is illegal for non-doctors to hire doctors, so instead there are Foundations, which are non-profit entities governed by Boards, which are essentially run by the hospitals that establish the foundations.

In forming the Foundation, Marcy and her aides identified a primary care doctor well-schooled in previous medical care wars, John Yee, to head the group, and I understand he is being paid $1.5 million over three years to be Medical Director. Between these two and some others, they rule the Foundation without opposition. Their view seems to be that anyone who hasn’t joined the Foundation is the enemy.

Two pediatric practices were approached about joining the Foundation on what they judged were unfavorable terms, so they declined. Outraged, Marcy vowed to hire pediatricians on her own, which she proceeded to do, and hired all the obstetricians practicing at ValleyCare, and ordered the obstetricians to refer exclusively to the newly hired pediatricians. It was essentially a got-out-of-town verdict for practices that had been there for 30 years and who had done much to build the hospital’s pediatric program.

Marcy and her associates, I understand, are insisting that most prominent Medical Staff positions be held by Foundation members, although so far the staff as a whole has managed to remain independent. They sought to vote democratically for their member on the hospital Board, but their nominees were disqualified by Marcy and a Foundation doctor appointed.

There are two large radiology groups in the East Bay, one of which holds the ValleyCare contract. Marcy informed the group holding the contract that if they wished to continue to do so, they would be required to discharge two of their radiologists there, both competent and very long standing members of the staff, whom she judged disloyal. The group is now in a condition similar to Google in China – important market, but mindful of their ethics. Not easy.

It’s an interesting story, and an extreme. But to my mind the ValleyCare situation highlights the forces in medicine as they are being played out currently. It’s hard to know how it will play out, but if people are interested, I’ll keep you posted.

Budd Shenkin

Budd's Advice to the Democrats

2010-05-23T22:55:00.000-07:00

It’s true – I am negative on the Democrats. But I wonder why. And I believe I’ve said a word or two about poor spending on the Stimulus Bill. I haven’t liked their timidity vis-à-vis the financial industry, and their obeisance to the powerful interests in health reform – nor the kowtow to clinics and nurses. When my friend Michael, returned from a year’s stint in the Defense Department, asked Ann and me how we felt about Obama last Monday night, I said I was disappointed. Why? Lack of apparent leadership, I said. Obama’s inexperience was showing.

But isn’t that terribly short-sighted of me? I thought that the Obama Administration should go for a lot of big goals simultaneously, and not scale down objectives and go one by one. They took my advice, and it has worked out. There has been a spate of articles in the last few days pointing out that the triumphs of Obama puts him in the league of FDR, LBJ, and Reagan for changes made and influence felt. That’s big league, and they are just talking about domestic policy, leaving out the important foreign policy advances such as nuclear reductions, temperature lowering with the Russians if not the Chinese.

Here is a typical quote from Steve Benen, reflecting on how voters tend to vote for and to vote against: “This year, the Democratic Party really hopes that it can benefit from both. On the one hand, they argue, Democratic policymakers have an impressive list of accomplishments, mirroring the platform they ran on -- economic recovery, health care reform, Wall Street reform, student loan overhaul, withdrawing troops from Iraq, restoring the nation's global stature, advances on civil rights, Lilly Ledbetter Fair Pay Act, expanded stem-cell research, new regulation of the credit card industry, new regulation of the tobacco industry, a national service bill, the most sweeping land-protection act in 15 years, etc. On the other hand, the Democratic argument goes, Republicans have moved sharply to the right, and generally act as if the GOP has gone stark raving mad.”

I said a couple of months ago that the Democrats needed to get past health care reform, and then make a very big deal about Wall Street reform, daring the Republicans to stick up for the plutocrats. They are doing that, but in their moderation, the Republicans are able to support it, and not take the bait. Hard to find sympathy for Lloyd Blankfein. So we’ll get some good law, not enough but something – and the problem is that it will not provide an electoral theme.

So, what is the Obama Administration to do? Again, I’ll go back to 1934. Everyone advised Roosevelt that the opposite party always loses seats at the midterm elections. They advised him not to risk his prestige in a lost cause. Roosevelt overruled them, set out aggressively to campaign hard and nationwide, and came up aces. Similarly now, with everyone expecting a Democratic debacle, what really does Obama have to lose? If anybody can make a case, he can.

It’s probably a question of timing. Right now, the Gulf Spill is the problem, and the Administration needs to come out heroes, if they can. Then in the fall, take the one item that the great Spill brings to the fore, energy policy (used to be climate policy, but that doesn’t sell.) Obama can say that his Administration has shown they can be successful, but more remains to be done. We can’t have any more oil spills. We need to completely reform the governmental part of it (the hapless Materials Division of Interior, or whatever it is, the sex and drugs haven), and institute strong incentives for alternative energy generation, and tax carbon.

There has to be more to the campaign, of course, and maybe this isn’t even the main part. But the tone and the energy needs to come forth, even if it seems like a risk. Not playing hard is the real risk.

Budd Shenkin

Spending ARRA Money

2010-05-22T10:38:00.000-07:00

It’s pretty clear that the government needs to spend money to keep the economy going. That’s basic Keynesian counter-cyclical governmental action – buy when no one else is buying. That’s not the time to worry about the deficit (but at the same time one hopes that in better times the deficit will be worried about – ojàlà). So I’m for priming the pump, and I wish we had another round coming.

But, then, even I have my doubts. I haven’t seen any big exposés of the shovel-ready projects of the original ARRA legislation – where is William Proxmire’s Golden Fleece Award when we need it? It’s really strange, come to think of it, that the Republicans haven’t come out with sensational stories about multiple bridges to nowhere. I wonder why. Maybe it’s mutual respect for each other’s district spending.

So, in lieu of Proxmire, here are my own personal observations of how money is filtering down to be government-spent. Item #1 – two weeks ago we received a notice from our local Contra Costa County Health Department. They had a $1 million grant program that they themselves could not spend directly, but had to divvy up among others (if they could have spent it themselves, knowing that health department, believe me, they would have. A classic health department, bureaucracy and empire building.) Anyway, we were notified about this program with one day turnaround time required – they are not used to involving others in money spending, I guess.

This grant program was a mélange of rules. How to apply, what criteria to meet, how to measure, who would be eligible for what, etc. etc. Just the reason I don’t deal with governments. Half the value of the grant, if received, would have been spent (and not reimbursed) by time and effort filling out the damn grant application. So typical. Then reviewed by the huge brains in the health department.

And what was the object of this million dollars to be spent, and the time of application to be spent on unpaid work, and the time of bureaucratic efforts to conceive the project, make the rules, and review the applications and later the work? Get this. Spending all this money to find the hard to reach populations in Contra Costa County and immunize them against H1N1!! Jesus! Talk about a stupid objective! Where is the evidence that this is a worthwhile objective? Where is the evidence of how much money would be spent per shot delivered? Where is the evidence that this is worth anything at all, especially when so many regular people are declining the H1N1 shots for various reasons of their own? Do we think that H1N1 is that much of a threat now? Anyone there with experience in trying to wipe out smallpox or polio with the CDC worldwide, who would know how uninformed this choice of objective is on so many levels? Government!!!

OK, so that’s only a million dollars. Then a friend of Sara’s who works for the health department in Seattle was visiting last week. Now we’re talking $25 million. What are they looking to spend $25 million on? Tobacco and obesity. What are they going to do about tobacco and obesity? OK, tobacco public health campaigns have been effective, and I love the old ads that were so sarcastic and hardhitting, about the hard-bitten faux advertising guys plotting about how to make kids into cigarette addicts. They probably helped. And it’s true that tobacco is a huge public health problem. Although it’s also true that probably the most important element of the anti-tobacco crusade was the tax policy. But OK, I’ll give them this on tobacco – important objective and a somewhat proven track record. On the other hand, I doubt if this money is going to lead to much increased employment, except maybe for the health department people and some advertising agencies. Not exactly the people I would target to get this country going again.

But obesity? What the hell are they going to spend the obesity money on? There is no proven way to combat obesity. We don’t know anything about advertising about obesity – who and what are going to be the targets? No one knows anything that will work! Gym memberships? Lectures about fast food? Hit squads on fructose-rich corn syrup? General money for the health department personnel so they avoid layoffs? Personally, I’d rather see some Ben Shahn art commissioned – at least that leaves a trace. I smell another Golden Fleece, sorry to say.

Which leads us to taxes. By the grace of God, I am a highly taxed person. I don’t squawk much about taxes, but lots of people do. They might give lots of reasons for their discomfiture, both practical and theoretical, but I think it comes down to this – what are we getting for our tax money? Even if we are borrowing money now and these expenditures might not be coming directly from taxes yet, we still pay interest and we the people will have to pay it somehow sometime. What are we getting for it?

When the money goes out to health departments and they are told, “Spend it in a good cause,” I don’t buy that. Pea brains don’t do well in spending Other People’s Money (OPM). Large brains don’t even do so well. I look at these idiocies and say, why not fix the pot holes on I-880? It turns out that construction projects don’t have a very good multiplier effect in rocketing money around in the economy. But then I have to ask, does giving money to public health agencies and advertising agencies do better?

That's what I see and that's what other people see.

Anyone ever thought of subsidizing bloggers?

Budd Shenkin

Too much, too soon?

2010-05-17T12:29:00.000-07:00

When a baby comes into the family, you start making priorities. As my friend John (Buzzard) Bernard said, before children, you could pretty much fit anything you wanted into your life. Especially if you were as talented as John Bernard. But kids are the killer.

Even when you are expecting a baby, the priorities change, for women more quickly than for men. Women have to change what they eat and drink. We don’t. Women have to learn to sleep on their back. Not me! Women worry about the health of the baby. Men worry about how to support the whole family financially. Everybody has to grow up.

You get a sense that this is the most important thing you have ever been entrusted with. If you disappointed your parents, that was too bad, but still you could say, hey, I’m the one who will really suffer. It’s my life! But with a baby, if you screw up, it’s not just you who suffers. So many people read baby books. Me, I tried to go back and read Jean-Jaques Rousseau’s Emile. Nuts, I know, but at least I was sensible enough not to get very far into it.

Then there’s life style. When Allie was born, I was determined that going out to dinner wasn’t going to be interrupted. Colic fixed that one pretty good. I thought, I would so like to life in another country for a while so the kids could be easily bilingual. Not at the top of everyone’s list, and it turned out that it wasn’t as easy as I thought. Allie’s first word was “Titta!”, which is Swedish, but that was about it as we moved back to the States to stay.

The rich and famous can have more temptations than we do, simply because they have the means. Daughters trotting around with Gucci, sons with Stingrays. Too much, too soon. A real hazard.

All of which brings us to my step-daughter Sara Buckelew, and her daughter, Lola Buckelew. Sara is a wonderful mother and Lola is just over three months old. Luckily, Lola is a very complacent but still very responsive baby, making everything easier. Sara can focus in on her own priorities for Lola.

Sara seems more reasonable that I was, which is probably not that hard to be. But, Sara is a baseball fan. Actually, more of an uber-fan. And Lola doesn’t have colic. As a result, Lola, at just over three months of age, has been to about six major league games already.

One of the things about baseball is its endless variety. They say that every time you go to the ballpark, if you are observant, you will see something you never saw before. Like this last Saturday at the Giants, Brian Wilson of the Giants faced Kazuo Matsui with two out in the ninth, bases full, Giants up 2-1. Fifteen pitches, about six of them strikes thrown one after the other as Matsui fouled them off, finally succumbing to a soft fly to left before a rapturous crowd, Fifteen pitches! And then yesterday, Sunday, it’s Wilson vs. Matsui again, two men on, two out, bottom of the ninth, Giants up 4-3, and it’s a strikeout. Pretty good! Baseball is a game to savor.

But, that’s just me, and I’ve been to hundreds of games. What about Lola?

Lola: three months old, six games. She has already seen the Giants’ Aubrey Huff hit an inside the park homer, saw the Yankees pull a triple play on the A’s, and then last week she saw Dallas Braden’s perfect game – perfect game! – for the A’s. Perfect game!

So, I have to ask. Sara: Too much, too soon?

Budd Shenkin

Another Thursday

2010-05-11T08:18:00.000-07:00

It was a Thursday like any other Thursday. My day of long but productive and important meetings in our Dublin office. We have been operating for over a year now – indeed, for several years – without a well-functioning Administrator, and I have taken that role.

We met all morning, then I went over to ValleyCare Hospital for a Pediatrics Committee meeting, to consider once again how we can combat a hospital intent on using its capital to construct and run its own medical group, and put us out of business. There will be more and more of this – the hospitals have the money.

Then I visited our local Infinity dealer for a second time. My lease ran out on my Lexus GS 430 – four years and out. I lease so that I don’t run a car into the ground until it just breaks up, which means I’ve been driving a fairly crappy car for a long time, no matter how great it was at the start. I have to force myself to get going and make a new choice. I’m not a good chooser – I procrastinate. I think it’s pretty genetic. My son Allie is pretty much the same. I really don’t know if it makes economic sense for me to lease or buy – it’s too hard to figure out, and it can’t be all that different or it would be obvious. They get you coming and going no matter what you do. I guess.

So here I was with the salesman. Not a pushy guy, not a pushy agency. I drove the car around again and liked it, responded to the Joe the salesman that I was ready to buy real soon, saw his eyes light up, and I told him the way I bought my last car – figured out what I wanted and called around to dealerships until I found the best deal, which was $750 above invoice. Said I’d do the same thing this time. I thought I ought to get back to the office, but he said, “Want to come inside and see what we can do?” “OK,” I said, surprising myself.

So we were sitting in his cubicle and Joe checked with his manager – they are all so young! Short wiry guy with a little mustache and nice smile. I’m still getting used to being older and successful, being looked at with respect, I guess, but I’m always surprised not to find envy and resentment. I’m still surprised the way I’m treated with respect. And, to tell the truth, delighted. I’m always friendly back at them, and “a regular guy.” A strength. Why I don’t like to be in situations where I am inferior in some way. Not good with mentors. A weakness.

Strangely, Joe came back and said my offer was just fine with them. He said, my manager felt like dealing today. I figure, either they understood that my story about what I would do made sense, or the car had been sitting, or the invoice isn’t as valid as one would like, or they get manufacturer rebates. So what could I say? I had bought a car. Surprised myself, me, who dithers and channels my late father by second guessing myself. Joe asked if I wanted to take the car home tonight. Couldn’t wait for it that long, I said, the Sharks play at 6. “Go Sharks” came the cry from the salesman at the next cubicle. Such a friendly group. “He has season tickets,” said Joe.

I knew the next step in the familiar dance, visit the financial officer who would try to convince me to lease instead of buy. Another wiry guy, about my height, another guy with a small mustache. Started out the same way as the guy did four years ago when I switched from buy to lease, “Why do you want to buy a wasting asset?” “Why tie up your money?” I guess I reflected that I had danced this dance before, because he made a meta-comment – “I have to do this.” After all, it’s his job. Another low-key guy. And I wound up leasing, just like last time. He acted surprised that I had bought his argument rather than the car.

I think it was the meta-comment, the personal connection, the “Go Sharks” comment, the surprise that they simply accepted my offer, or the relief of actually having made a decision; it was something. But I’m a naturally gregarious guy, not overly shy, and - hey! - I’m a doctor. Maybe I was talking about my wife or my kids. So I must have said, “Are you married?”

He said, “No, I’m not.”

So I said, naturally, “Are you a gay guy?” I mean, we were talking, why pussyfoot around?

So he said no, he wasn’t. “If you’re not married,” he said, “do you have to be gay?” He seemed a little surprised that I asked him.

“No, but it’s the Bay Area,” And I added, “You’re a good looking guy, so I figured you could be married if you wanted to be, so I was just wondering.”

He accepted that (I’m not above a little flattery.) So he said, “I’m not married, but I have a girl friend.”

I asked him how old he was and he said 49 – that’s about what he looked.. “How long have you been going together,” I asked.

“Five and a half years.”

“Wow, I said, that’s pretty long. Why don’t you marry her?”

He said, “Why do you think that?”

I said, “Well, if it’s been that long, and you love her and you think you’re getting a good deal with her, you just have to knock her down and marry her. Otherwise you don’t know what will happen. If you don’t think you’re getting a deal, if you think she’s the one getting a good deal, and you’re doing her a favor, then you probably need to find somebody else.”

Then I told him about Andre Agassi’s book, which I thought was terrific. “You know what happened?” I asked him. “Agassi thought Steffi Graff was terrific, admired her, even idolized her, so he tried to make a date with her.

“She said, ‘I have a boyfriend.’

“He said, ‘how long have you been going together?’

“She said, ‘Six and a half years.’

“He said, ‘That’s a long time. So long that it’s probably not going anywhere. Why not give me a try?’

“She did, and not too much longer, they were together, she was pregnant, and they were married.”

A pretty powerful story (and a great book.) So my new friend said, “There’s something you don’t know.”

“Ah!” I said. “What is it.”

“She’s married.”

“Yup, that explains it,” I said.

“And she’s Chinese.”

Well, that’s not unheard of. I wondered what was coming next.

He said, “You know, I think I’m telling you this because you’re a doctor.” And kind of shrugged.

“Yes,” I said, “it’s OK, I’ll treat it confidentially.”

So he continued: “She has a 16 year old son. They are traditional (!). They think a teenage son should be raised by a father and a mother. So she’s there in the day, but every night she comes over to my house and sleeps with me.”

Well, I thought this was an unusual solution to wanting to be traditional, but people do solve dilemmas in unusual ways.

Then he said, “I used to be married. We had a son. He was 13. Then one day he was with a bunch of kids and they were up in a tree. We found him up in that tree hanged by the neck. We don’t know how it happened.” He shrugged. He just shrugged.

I told him about Peter. Peter was 17 and on a trip with his school and they slept overnight in an open campground on the American River. In the middle of the night a 4,700 pound live oak tree fell in the midst of the group and crushed Peter’s abdomen. He lost a kidney, 18 inches of bowel, severed all the lateral processes of the lumbar spine, broke a hand, and was in the ICU for many days and in the hospital for 3 weeks, and went from 132 pounds to 112 pounds and months of rehab and recovery. He came back. He narrowly escaped paralysis and death. We were lucky. We were just lucky. My auto financial advisor wasn’t.

It was just about then I got call from Grant, our IT guy at Bayside. “Dr. Shenkin, are you coming back to the office today?”

I said, “Yeah, Grant, I figure I will, but I’m buying a car. What’s up?”

Grant giggled in wonder, “You’re buying a car??”

“Yeah, I just figured I would. What’s up?”

“Well,” Grant said, “I have a contract with ATT that we really should have signed today and sent in, and they are in the Central Time Zone.”

“Grant, it’s twelve minutes of four o’clock.”

“Yes, we have about twelve minutes. They’re waiting for it.”

“Grant, it’s just not going to happen today. I’ll be back there in about half an hour.”

So I signed the lease and shook hands with my friend, who I figured I would look up when I brought the car in for service (I had negotiated three free servicings), arranged to have the salesman deliver the car to our house on Friday night, drove back to the Dublin office reviewed the terms of the contract, thanked Grant for doing all the work of getting the price of revision of service down from the $150,000 that our three months and out Administrator had negotiated to a more manageable $2,750, but told Grant that we need to exert some leverage at this point to recoup some of the losses we had sustained in switching services, and getting a better deal on the monthly charges.

Grant said, “But it’s a time-limited offer!”

“That’s OK, Grant. You’ve done a great job. Now let’s hand it over to Flora. Don’t worry.”

On the way home Flora called me and said she had negotiated a $41,000 check to reimburse us for the ATT deficiencies. At the end of the day at home Flora emailed me that she had negotiated the monthly fee from what Grant wanted me to sign down by a third. Good job Flora.

Another Thursday come and gone. When I get my car serviced, I think I’ll drop by to visit the guys and say hello. The Sharks are still in it.

Budd Shenkin

A Game the Self-Critical Can Play

2010-04-26T22:34:00.000-07:00

It’s important to be self-critical. It’s a worry my wife has about the always-positive-reinforcement give-everyone-a-trophy modern don’t-let-anyone-feel-neglected world. How do you know if you’re any good, she says?

Well, my parents would sure go along with that. They were proud of me and the other kids, very proud. But tell us? Don’t want to do that. Might cut down on effort. So I was raised to be self-critical. Was it enough? Was it any good? Would you be able to keep it up for next time when “the others let down.” How would someone not inclined to favor you look at it? (The old Jewish problem, you have to be better to succeed.)

That’s not such a bad thing if you’re going to do something worthwhile. For instance, I haven't posted lately because as I write something, it just doesn't seem up to snuff. I hope you all appreciate that. So that's the good part. But, the bad part is that relentless self-criticism can make for depression, tension, anxiety. That’s a high price.

There are many ways to deal with this family legacy. Some are expensive. But I am here to recommend one I have come up with for your evening pleasure. Jeopardy, the old Merv Griffin stable. Jeopardy. ABC, Channel 7 at 7 PM every night. In Hawaii it’s on at 4 PM, with a rerun of an older game at 4:30. Jeopardy, not running as frequently as Law and Order, but enough for a near daily dose, if you want.

But not standard Jeopardy. Standard Jeopardy is tough. In standard Jeopardy you have to be careful. Are you sure you know the answer? How sure do you have to be to ring in? If you’re wrong, it’ll cost you with deducted cash. But you have to act fast, with instant calculations. Standard Jeopardy is nerve racking.

Instead, I play Budd-Jeopardy. Budd-Jeopardy is refreshing. Budd-Jeopardy releases you from the worry throughout the game. You don't have to wonder if your account is going up or going down. Budd-Jeopardy only goes up, never down. It’s an upper!

What is Budd-Jeopardy? It is non-critical Jeopardy. In Budd-Jeopardy, there are no deductions. You get a point only when you know the answer, and no one else on the panel on the show does. If you get it and they don’t, you get to shout, “Budd!!” Or, if your name is not Budd, you get to shout your own name, let's be clear. Maybe I should insist that it's always "Budd!" you shout, but I doubt this rule would catch on, so you can use your own name. If it is a Daily Double question, and thus only one panel member gets to guess, and you get it and he or she doesn’t, you still get a “Budd!” If you are playing with someone else in the room, and you both get it, you both get a score, and you both get to shout your names.

Budd-Jeopardy gives you only positives! For every answer you can guess the question. If you’re wrong, no problem! You can be self-critical if you want, and of course I can’t help it. I should have gotten that! I knew that! I just couldn’t pull that one out, but I did know it! The full boat of disappointments can be uttered.

But, that’s only an undercurrent. Budd-Jeopardy is an upper. You’re only adding up the pluses. In Budd-Jeopardy, par for a game is two “Budd’s!” The best I’ve ever done is about six, I think. Sometimes it’s only a one, or very occasionally zero.

Budd-Jeopardy is the opposite of golf. Why would you play a game set up for frustration?

Try Budd-Jeopardy instead! You can use your own name, but be sure to shout it in triumph. At least twice a game. It helps to throw your arms up over your head, and to look around for admiration. Or, if you’re alone – and if you do this too much you might well find yourself alone – be sure to admire yourself. You deserve it.

OK, I confessed that I have hit a little dry patch for my posting, and this might not be up to par. OK. I agree. But if I get a bunch of complaints, I'll just erase it. I can't worry about the misses; let's only count the hits. One of these days, I'll get another "Budd!" Maybe tomorrow.

Budd Shenkin

Hospitals Employ Doctors

2010-04-12T20:05:00.001-07:00

A few articles have recently appeared in the New York Times and elsewhere, saying that newly graduating doctors are choosing to be employed by hospitals, In addition, doctors and groups in practice are choosing similarly. Locally, a large group down the Peninsula recently chose to join Palo Alto Medical Foundation (PAMF). I don't know why they did this, but at least now I can say for sure that Bayside, our group, is the largest private primary care group in the Bay Area. But I guess that's off the point. Again.

Anyway, why is this happening? People talk about the new work ethic of new grads - more leisure, more "just a job," etc. Maybe so. But, that's nothing an economic determinist would accept.

Let me be economic determinist, then. To quote "Deep Throat" in All The President's Men (the movie only - line does not appear in the book): Follow the Money.

Hospitals and large health systems command monopoly rents. They not only enrich themselves as monopolies, but by taking more of the health care dollar, they leave less for smaller, physician owned practices. The systems then use their extra money to purchase the factors of production that they have starved - the doctors.

The hospitals and systems claim, as do all expanding monopolies, that they provide higher quality (often for a hypothetical future) and better technology that only they can afford. Sometimes it may be true, unless you include as part of the quality equation personal relationships, human scale, and human trust. Patients probably prefer small offices, but the lack of a true market prevents them from voting with their feet and wallets.

But the telling point will be, who can offer the new doctors entering practice a better deal, the starved personal practices, or big, rich systems that thrive on monopoly rents? Follow the money.

Budd Shenkin

Is Kaiser the Answer?

2010-04-01T14:44:00.000-07:00

The question is, how is health care to be organized in the United States? One answer by the health cognoscenti has been, why not Kaiser for everyone? It is less expensive than other care, and its quality is high by all measures. So, why not Kaiser?

Since I am in the biggest Kaiser neighborhood in the country, Oakland, and since Kaiser with probably 70% or so of the private market is our biggest competitor, I’m hardly a disinterested bystander. We lose patients to Kaiser all the time, and there is not much we can do about it. They’re cheaper, and they are not out and out bad. So, grain of salt is indicated.

But, believe it or not, I have a Kaiser card myself! Why I have that card sheds light on the travails of health insurance for a business, the business in this case being Bayside Medical Group, that fine leader in primary care in the East Bay.

I have the card because we had to get Kaiser insurance for our group. We used to have a pretty good plan, although too expensive because all health insurance is too expensive. It was an exchange program run by the Pacific Business Group on Health, very much like the Health Insurance Exchange to come under Obama care. Under the exchange, we had several different levels of care, HMO’s and PPO’s, and several health insurance companies competing at each level. Most of our employees chose Kaiser, mostly because it was the least expensive alternative, and probably also because with one stop bureaucratic shopping, it is a pretty transparent system to the patient.

Anyway, it was fine, but then the system died, mostly because the health insurance companies didn’t need it and it exposed them to too much competition and squeezed them into categories of care. So it died. So we were back to choosing a plan for our group. But how to choose? We are a disparate group, from file clerks to physicians, and one plan won’t fit all. Moreover, we are a medical group, and medical groups are avoided by health insurance companies because of a perception that they are high utilizers. And, here’s the killer – the health insurance companies insist that we go all with them, or not at all with them.

Because so many of our employees were already with Kaiser, it would be very hard not to choose Kaiser. And luckily, Kaiser has a plan whereby employees can choose the classic closed panel Kaiser plan, or opt for a so-called point of service plan, which is like a PPO. It’s expensive for both premium and deductible, a rather crappy plan to be sure, but at least it’s a plan that I can use and a few of my colleagues as well. Under this plan, I get two cards – the POS card, and a regular Kaiser card. So, here I am, a prime Kaiser competitor, someone with a distaste for large institutions such as Kaiser, a pretty independent person, and I’m a card-carrying Kaiser member. Who’d a thunk it.

So there I was with a Kaiser care, so I figured, why not make a site visit? So last year I got the first annual physical of my life – I’m not a big utilizer, and I just programmed my own preventive program – at Kaiser. Then this year I returned for my second site visit, following up with the same doctor I saw last year.

What was it like? Did Kaiser appear to me to be a possible answer to the question? That is, we know that introducing a model is not easy and often impossible, so just because something works here doesn’t mean it will work there – there are all kinds of cultural questions involved. But, that’s not the question for the site visit. The question is, if it were possible to work toward something like this, would that be a good idea, in my eyes?

I have to say that the website worked well for me. I could find a doctor who was open and find out credentials, if not much more – see our website, www.baysidemedical.com, for what is possible with a personal touch. And I could make my appointment on line, which was great, just great.

But when I got there, it’s a visit to what socialized medicine would look like. Big institutions, big hallways, big buildings, milling crowds, big parking lots with lots of cars one after the other and you’re just another one of them, and a full dose of the hoi polloi. No matter what you had achieved in life, there you were with everyone else on an equal footing. We have to expect that Kaiser will never be the answer for everyone, just as all the socialized systems have alternatives of private care for those who can pay. Hoi polloi doesn’t work for everyone. Probably not for me. But, if I got past that and found a system and people who worked well, it could be for me. I’m opened minded enough for that, maybe.

Although maybe not. If I or a family member get something severe, I want choice. For most non-medical people they can’t use choice very well, but for me, I can use it and will – and actually did, for my hip resurfacing, for instance. But for primary care and run of the mill, I could do Kaiser, I think. Maybe. If it were good.

Overall, I did get promptness for my primary care visit. I got Oakland African-American sullenness from my first Medical Assistant – they are unionized, and no one can really fix this – but the one at my second visit was better. They take weights with clothes on, but I guess that’s just adult care. Doctor promptness was good, although the second time I went the office was almost empty of patients, so I had to wait almost 15 minutes in the exam room for my doctor. As everywhere, work expands to fill the time, and if things are slow, the staff are likely to go slower as well.

Promptness does not apply to waiting for lab tests or immunizations – I had to wait 15-30 minutes for both, and the shots are given at a separate clinic rather than at your primary care doctor’s, with another hoi polloi exposure. And waiting for labs is as slow as on the outside. Everyone there knows about it and deals with it.

The website helped right at the doctor’s office where she could make a dermatology appointment on her computer for me later the same week – great convenience. And after the visit I got emails pointing me to my lab results on the website. I could email my doc to ask for her reaction to the lab tests.

But of the vaunted Kaiser health system, that’s kind of it. It was up to me to inquire about the lab tests, she didn’t do anything about them unless I asked, even when my Vitamin D the second time was much lower than the first time, when she put me on a supplement for it. I had to remind her this year to check my level, and also the thyroid level, which she forgot she was monitoring and had supplemented. When I reminded her to order it, she even forgot she had had me on it for a year and treated it as a new prescription. She told me to come back in three months the first time but there was no prompt for me to do so – saving money, probably (I think that’s what most of Kaiser is geared toward.) Same with the yearly physical – up to me.

Kaiser is supposed to emphasize prevention. (They are prepaid, so they advertise with a slogan “Thrive!” They probably would like to add, “If you’re sick, why not enroll elsewhere?”) So, as my doctor sat on her little cart performing data entry with her Electronic Medical Record in front of her, she attempted to perform some prevention. She said, “You’re watching you weight?” I said, “Actually, I’ve gone up in my weight lately.” I think my BMI had gone up from 27 to 30 as they measure it, after my knee surgery, which knee she didn’t think to examine. So she looked at me and kind of shrugged. That was it for weight control, despite the fact that I have arthritis and am on statins and blood pressure medicine.

You would think that Kaiser would make a point of screening for depression, given that it is so widespread and treatable. But I don’t think their much into minds and feelings. I was surprised they don’t administer questionnaires. Maybe the hoi polloi won’t fill them out, but I would have. So she screened me verbally. She looked at me and said, “You’re OK, right?” I said, yeah, pretty much. Well, it was quick.

I actually can’t remember if she did a full body physical exam or not. She sure didn’t look at the sites of my operations, or ask how my hip was doing since the resurfacing operation. I do have to tell you, however, that my prostate got a good working over. Oh, yeah.

She did check this time to see if I had had my Adacel and pneumovax shots, which I guess we had skipped the first visit for some reason. The EMR at Kaiser does work well for that.

Actually, I like her. She’s a young woman from Haiti and went to a good medical school and seems nice enough. But I tend to like people. And if there were some big issues I would bring them up, I suppose. But to me, it just seems like working in these clinics is a killer. It’s institutional. What we want is really another human being taking care of us. Can I look at Marie as taking care of me? Only if she followed up the labs, asked me to come in again, gave me a roadmap of my health care, took time to ask about me and my family and my happiness or my plans to retire – I guess she did ask about that, actually. She’s a lot younger than I am and after all, I’ve only met her twice. And I’m prejudiced, hoping that Bayside can give better care than this system. But I have to say, you can put technology into the equation – and you should – but you have also got to find a way to get institutional feel out of the equation. Institutional feel kills the essence of care, and we have to be cared for. That’s what people want, to be cared for. We’re a long way away from being able to be cared for by a HAL.

I always tell our group, the key to being a successful clinician is for your patients to feel that you are competent, that you care, and that you are reliable. It’s hard to say that any of these criteria have been met by my experience at Kaiser. The quality measures cited by the cognoscenti, indicating that Kaiser’s care is of high quality? They are just markers that can be measured. Being cared for? They don’t really measure that, just as they don’t measure the competence of a clinician or a system in chasing down difficult diagnoses, following up orthopedic issues with physical therapy, and a myriad of other aspects of quality of care. Measurement of health care quality isn’t to the point where we can rely on it to indicate good care, just where it can indicate bad care.

But I also have to say, I still have the remnants of my depression-scarred father in me, and I appreciate that Kaiser cost less than other alternatives – all I had to do was pay the copay for the visit, which was reasonable, and nothing extra for the labs. I guess it’s good enough for the hoi polloi.

So, it's an interesting site visit. We can't get more out of it than that. Just one experience, just one doctor dealing with a difficult patient, another more-senior doctor. No big conclusions. It seems as though I could find another doctor if I wanted to.

But I have to say, as a system meeting the needs of a nation, leaves me unimpressed. But then, I'm a tough critic.

As for me, looks like I'll be taking care of myself for a while longer.

Budd Shenkin

Songs for Lola

2010-03-21T22:57:00.000-07:00

As readers of this blog will recall, on Superbowl Sunday we added another member to our family, one Lola Elizabeth Buckelew. My step-daughter Sara found herself getting to the end of her fertile age and was without a partner, as so often has happened with high achieving professional women, alas. Sara is a double-boarded pediatrician and preventive medicine specialist, with a subspecialty in adolescent medicine, and is director of the UCSF eating disorders program. We’re very proud of her, but it does seem she has paid a price.

So Sara bravely decided to have a baby on her own, and the happy result was Lola. For the first six weeks Sara and Lola have been staying with us, which is just fine with us. It’s been a long time since a baby has been in the house, our youngest, Pete, now being 26. And thankfully Lola is a very good baby, no excessive crying, regular habits. She does grunt a lot in a very unladylike fashion, and is a regular fart and poop machine, but as grandparents, we figure that’s mostly Sara’s problem, and we just chuckle at little Lola.

Both my wife Ann and I have regained our newborn skills. We do well with soothing. Lola likes to be held, and we hold her. Lola looks askance and we jump. We each take her and walk her and keep going, terrified if we stop she will wail, but she never really does. When Lola poops we hand her to Sara. We are, after all, grandparents.

So as Lola has matured in these six weeks, she has demanded songs. Babies without songs are bereft indeed. Ann and I have had to go back into our memories and come up with songs. It has been a long, long time since we sang to babies. Not sure we did such a good job of it with our own. But now with all our years of experience, and the luxury of having just one baby and three adults, we can search for the proper songs.

It was hard at first. I came up with “Ten Thousand Men of Harvard Want Victory Today.” Dunno, just trying to come up with a song. Sara objected and tried Roar Lion Roar, her Columbia fight song, but could remember only that line. We looked it up on Google and got some other lines, but she couldn’t quite get the tune. Sara isn’t that musical.

Ann came up with the California fight song. It was more like a response to my Ten Thousand Men of Harvard than a real solution. A counter-non-solution, I guess you could call it.

Farmer in the Dell was OK, and seemed to capture some attention, but that’s pretty dull. When the Bough Breaks did it for a while, but it’s hard to continue that one.

So, I made up a song. I kind of like it. It goes like this: “Lola is a good girl, a good girl, a good girl, Lola is a good girl,” and then you add any final line that you want. Like, for instance, “She has very cute nose.” Or, “She poops all of the time.” Or, “She loves me better than you.” It’s a good song for improvising. Its downside is that it’s one of those songs that sticks in your head, so you have to be careful with it.

Anyway, that’s a pretty good solution for right now. But it didn’t quite fit Ann. She had to come up with her own, which she did.

Now, you have to know Ann a bit to understand that she is not in the least saccharine. She always looks at life a little aslant. You’re never quite sure what she will come up with. But I have to say, her solution to the song for the grandchild took even me by surprise. I think it took even her by surprise.

Picture Ann with Lola lovingly in her arms, as she purrs to Lola, The Theme From “Cops.” “Whatcha gonna do when they come for you – bad boys, bad boys!” “Whatcha gonna do???” “When they come for you????”

We just had to laugh with the power of the unconscious. It’s just pretty funny. Her version of Rockabye Baby isn’t everyone’s. Could it be coincidence that we have two sons in law enforcement, do you think?

Just had to laugh.

Budd Shenkin

What's Up With Kucinich?

2010-03-19T21:43:00.000-07:00

Dennis Kucinich was dead set against the health care reform legislation because it didn’t meet his criteria. Then he met with President Obama. Afterwards, Kucinich says he’ll vote for it. He says that he was offered nothing by Obama that would account for his vote change. Then, completely uncharacteristically for Kucinich, he started recruiting colleagues to follow his lead and vote for the bill.

What gives?

I have absolutely no inside information, and haven’t even followed the commentary very closely lately. But here’s what I think.

I think Obama told him that he needs to pass health care reform or his presidency is effectively dead. The bill is not completely repellent; it’s good enough not to be ashamed of. It will be very significant domestic legislation. It can be improved later on. And as Axelrod says, at this point they are all in. It’s now success or failure.

And then, here is what I think Obama said next. I think he said, after we pass health reform, I’m not stopping. I’m going to use this as a springboard for the next thing- financial reform. I’m going to double down – I’m going to be more aggressive, not less. And I’m really going after the banks. We gave enough money to them to stabilize the system – now we’re going after them.

It makes perfect sense for policy. Pivot away from Summers/Gaithner, over to Paul Volcker. Resurrect separation of deposit and investment banks, Glass-Steagall. Institute controls and transparency. Start a consumer financial protection agency. Dodd’s bill isn’t strong enough, but maybe they can get the House to be stronger, the way it was before Barney Frank went soft on us.

Then push the hell out of it and gain popular, populist support. Go for a 1934 – the only time beside 2002 that the incumbent party picked up seats in the off year election. Be very aggressive, which is what Roosevelt did. Take a chance. Say, we tried to be bi-partisan and what did we get? We tried to get some support by incorporating some of their ideas, and what did we get? We tried to include them, and what did we get?

I might have been a little naïve, but I’m not dumb. If we’re going to do something, we going to have to be aggressive. And we do have to do something. This country hasn’t been in this kind of a mess for a long time, so these are things we have to do. We won’t exclude them, and if they want to be part of this, they’re welcome to join us and weigh in. But we’re not going to wait around the way we did for health care. I’m not that dumb.

Then, see if the Republicans can be goaded into defending Wall Street. They will support “free markets” and decry “socialism,” but if they do, we can say – why are you defending the banks? And we’ve got them.

In other words, they went all in for health care – now double down.

How could Kucinich resist this?

It could be a hot summer and into the fall. Here’s hoping.

Budd Shenkin

Dreams and Déjà Vu

2010-02-23T11:16:00.000-08:00

I thought I had a dream last night, I’m sure I did. I kind of remember it was about Nick, son number two. What was he doing? Hard to remember. But it was something that mystified me at the time, and even more now, since I can’t remember it.

And then there is déjà vu. Others thing that this is a malfunction of the mind, but in my case, I’m not so sure. I think if I could only get one extra piece of memory to function, it would actually work, and I could see what was going to happen, because it happened before. Really, I do.

Wonder of wonders, amazingly and incredibly, so satisfyingly, we are going to see more of exactly why these things happen in the near future (if we haven’t already and I’m unaware of it.) Functional MRI – we see what areas of the brain are working when the person can tell us, or we can just see as someone calculates, for example, what the brain is doing. Shades of Wilder Penfield, who opened up the brain and stimulated it and asked the person what they were thinking! It’s just a miracle. The computer companies put chips in with the intention of performing tasks; the brain scientist looks at the bio-chips already in there and figures out what they do. What a world of wonder. That plus the universe opening up to the Hubble. That plus anthropology unraveling the evolution of great apes and people, how there were other humanoid species that died out, and some of them recently on an Indonesian island, and great ape anthropology showing us that chimps have culture, that they use tools one way in West Africa and another in South Africa, and that it’s culture, not genes. What a world!

OK, that was a diversion.

But there is also another way of thinking about brain functions besides functional MRI – evolutionary, teleologic thought. If it works this way: there must be a reason however our brain works, it must give us an advantage, because we’re here and we had to survive competition. So, why does it work that way?

Here’s what I think. Dreams have lots of functions. They have symbolic thought that somewhere in our brain, where exactly I don’t know, they picture meanings to us and work out our problematic areas. OK, that’s pretty general, but let’s leave it there. What I really want to say is this – why are these dreams hard to remember, in our conscious minds? (Except for Ingmar Bergman, who claimed to remember them all in detail.) I think I know. We have to keep our conscious minds very clear. If we are to work our way through the world and eat – always my primary preoccupation – we have to be pretty clear about what is and what is not factually and objectively true. So, we can’t have the airy fairy dreams cluttering our minds while we are about our work. Someone who remembers his or her dreams and – here’s the important point – can’t distinguish them from objective reality, will wind up not eating. They will be too confused. So the best way to make sure that there is no confusion is to make dreams unrememberable in the conscious world. So, not remembering your dreams is functional.

Of course, that doesn’t mean they are forgotten. They are just not recoverable by the part of your brain that is conscious. There’s a whole lot more of your brain, and lots of the processing is “subconscious” and “unconscious.” These areas of metaphor will no doubt be further subdivided as the functional MRI gets more capacity and other technologies come on line.

So what about déjà vu? Well, I think déjà vu is a lot of fun. I really treasure those moments. But what is the function of déjà vu, what is the evolutionary advantage? I don’t think there is one. I think it’s a malfunction. I don’t know where it comes from, and it sure is like a dream. I think it’s an overflow from somewhere that is dream related. It’s to our benefit that these malfunctions are transitory. I always want them to last longer, but if they did, I would think I could find something to eat just the way I did before, but then I would become befuddled. I wonder if there is a mental disorder that features prolonged and repeated episodes of déjà vu? Haven’t heard of it, but you would think it could happen. I wonder.

You heard it here first.

Or maybe not.

Budd Shenkin

The President's Health Reform and CHC's

2010-02-22T09:32:00.001-08:00

Since the President’s health care reform proposal has just appeared two hours ago, there may be some items that have not come to light. But it appears that the new proposal remains a huge windfall for the Community Health Centers:

“Community health centers play a critical role in providing quality care in underserved areas. About 1,250 centers provide care to 20 million people, with an emphasis on preventive and primary care. The Senate bill increases funding to these centers for services by $7 billion and for construction by $1.5 billion over 5 years. The House bill provides $12 billion over the same 5 years. Bridging the difference, the President’s Proposal invests $11 billion in these centers.”

At the same time, while Medicaid eligibility is extended, the House’s proposal that Medicaid payments rise to the level of Medicare over three years simply goes unmentioned. In other words, the uneven playing field between private practitioners seeking to give care to the poor on the one hand, and the CHC’s on the other, will become a mountainside, not a playing field at all.

In addition, the CHC’s say that they see many patients now who are uninsured. What will happen now, as many uninsured become insured, and the CHC’s can now collect from them, but they retain their giant funding? It will be a double win.

As a side note, I saw Chris Van Holland, Congressman from Maryland and the Chairman of the Democratic Congressional Campaign Committee, last week. I explained to him the inequity of funding, and how CHC’s got so much more per visit than practitioners. “I did not know that,” he said. “But the House Bill has a rise of Medicaid payments to the Medicare level,” he said. “It will never pass,” said I. Boom goes the dynamite!

Well, why are CHC’s so popular? They have their claque, to be sure. But also, think of this. The Democrats like them because they are for the poor, and they are governmental entities, essentially. Organized, bureaucratic, just like the doctor ordered.

And why do Republicans like them? Even Mike Enzi came out for them last week. I can only think, they like them because the Republicans like the idea of not infringing on the paying population. It’s two class care, very separate, and you can say that you’re doing a lot for the poor, but the waiting rooms of private practitioners won’t be cluttered with them.

But who knows? Maybe CHC’s will turn out better than I think they will. Maybe they will be so successful that they will spread to middle class medical care. But I don’t think so, tell you the truth. I’ll relate my field trip to Kaiser in a post in the next day or two – Kaiser, the great success story that health policy analysts point to – and tell you why I think they are not our future.

At least, that’s what I think today. Who knows, as I always say, I make mistakes every day, and all I can hope for is that they are not big ones.

Budd Shenkin

Clinics vs. Private Practice

2010-02-16T21:24:00.000-08:00

From a friend who has experience in several different venues, commenting on post citing the uneven playing field:

"I couldn't agree more.
The FQHC vs private practice debate has occupied my mind ever since Hurricane Katrina, when the FQHCs received all kinds of federal assistance and bonus payments, while private practitioners received nothing. Not "next to nothing"--I mean absolutely nothing. The Gulf Coast now has what is basically a two-tier system for primary care--community clinics for the poor, and private practices for the insured. It wasn't the most egalitarian system before the storm, but it's certainly far more stratified now (which, as we know, also utterly violates the equal-access provision which was part of Medicaid's original intent)."

Budd Shenkin

My Superbowl Weekend

2010-02-12T06:40:00.000-08:00

My last weekend. Start with home internet (DSL) going out Friday - major disruption for both wife and me. Finish day, call tech support (ATT), figure out it's the modem. Go to Best Buy, get new modem. Connect. Not plug and play. Call tech support. Spend hours on phone with several techs who it seems were competence challenged. Give up. Our in-office IT guy will help, but has gaming tournament on Saturday - so I say, go, relax, see you Sunday. Go to office on Saturday for 3 hours just to do email work. Call Comcast and arrange for Tuesday visit by cable guy to change from ATT internet to cable internet. Take wife to lunch by waterfront and forget about internet. Next day is not only Superbowl Sunday, but stepdaughter's (prospective single Mom, with out full support, by choice) due date. Stepdaughter to stay at our house tonight. She has back ache. 12 midnight water breaks. Call OB, friend. Get set to go to hospital. OB calls, he is outside our front door, house call, just to be friendly. Go to hospital, wife up all night with laboring step-daughter. Anesthesia screws up, epidural becomes spinal, anesthesia to level of jaw. Baby comes well, 8# 2 oz., at 7:30 AM, in time for Superbowl. Stepdaughter with lots of bleeding, pain. Take sleepless wife to breakfast. IT guy comes to house, fixes internet. Go with wife back to hospital. Power steering on car goes out in parking lot. Baby still fine, step-daughter in good spirits, although bled a lot and on high pain meds for very tough labor. Tow truck comes. Go in tow truck to dealer. Saints narrowly behind, haven't seen game yet. Wife walks home from hospital to get car to pick me up at car dealer. Wife calls me, you wouldn't believe this. Her car blocked by step-daughter's car, but step-daughter's battery dead - probably left a light on. Car salesmen supervisor hears me on phone, no customers in showroom on Superbowl Sunday, asks salesman to drive me home and then go home himself. Salesman is thrilled, I get home. Triple A comes to charge step-daughter's battery. Everyone so thrilled by baby none of above matters. Baby very cute. Get to see second half of game, wonderful game. Call brother in Philadelphia to ask about snow, and how many storms of the century you can have in two months time. Brother amused, keeps asking if baby can be named after him. Wife sleeps for 12 hours. I go back to hospital to help step-daughter and hold baby for 2 hours. All still thrilled. Suggest football name for little girl, DeBrickashaw. Suggestion refused but laughed at. Next day name chosen, Lola. All still thrilled. Driving step-daughter's car while power steering fixed, Mini too small for me, but it's a car. Hear from dealer late on Monday, power steering module was recalled, so whole fix will be free. Baby still fine, hardly cries, step-daughter's spinal headache bad, but blood patch works, she can now sit up. Anesthesiologist makes two bedside visits in one day. OB pissed at him. Comcast guy comes at 6 PM, takes 2.5 hours to install new internet. Works slightly better than ATT DSL, hope for reliability, not have to talk to ATT tech support again. Package of cable, internet, and phone will be less than what we were paying for just internet, no more DSL charge, unlimited long distance. Pick up car at dealer Wednesday morning, they throw in car wash and full tank of gas, which was near empty. Feel that life is good. Step-daughter and Lola home from hospital, got own car back, wife resuscitated, wife so thrilled she can't stand it, step-daughter thrilled and amazed. Me, too. Turn back to AAP SOAPM listserve and find 140 items received.

From saga above, have omitted days in office, clinician meetings, meeting with new Administrator to counsel and direct, four perfect circumcisions, interview peds candidate. Who says we can't multi-task?

Budd Shenkin

Health Reform and Medicaid: Clinics vs. Private Practice (2)

2010-02-03T20:55:00.000-08:00

I left a point out of yesterday's post on the consequences of granting $10 billion (that's ten thousand million dollars!!?) to the Community Health Centers, while leaving private practices that treat Medicaid patients severely underfunded and headed out of the business of treating the poor.

Some might argue that granting this money to the CHC's will improve care for the poor. But in the end, that is an unlikely event. By pushing private practice out of the Medicaid picture, Health Reform will in effect be creating a very separate system for the poor, and we know enough now to understand that separate is inherently unequal, with the advantage to the overclass, not the underclass.

It is clarifying to look at the looming situation from the viewpoint of graduating primary care residents. They will have to choose - will I serve middle class patients, or will I serve the poor? There will be no middle ground, no practices like Bayside (our practice), that serve both. Medical schools and training programs do a surprisingly good job of indoctrinating their charges with the mantra of equal care for all, and the precepts of the Hippocratic Oath. Graduating residents tell me in job interviews that they really very much like that they will get to serve everyone. After Health Reform? Not so much.

Obama is right in saying that getting health care for all is a moral issue. It is. This under-appreciated part of the the Health Reform legislation, however, cuts exactly the opposite way. Alas.

Budd Shenkin

Within Health Reform - The Clinics vs. Private Medicine

2010-02-02T08:27:00.000-08:00

I am a member of a probably dying breed – a pediatrician in private practice who sees Medicaid patients. Although it has been coming for a while, the proximate agent of our extinction is Health Insurance Reform.

Within the 2,000 pages of the reform bills lurks a big issue the public doesn’t hear about – will Medicaid patients be served in the mainstream of medical care, or will they be served in clinics? Many simply assume that Medicaid patients always go to clinics, but they don’t. Medicaid is like a voucher system – a Medicaid card allows you to choose clinic care or a private office that accepts Medicaid. In Alameda County, California, where I practice, despite a multitude of clinics, two-thirds of pediatric Medicaid patients choose private practitioners. So my colleagues and I are actually our county’s “safety net.”

Nationwide, Medicaid’s major problem is that fewer than 50% of primary care doctors accept Medicaid, not surprising given the abysmal payments offered – on average only 72% of Medicare’s already marginal rates. We try to tell the Federal and state governments, “Coverage does not equal access.” You can spread out the money to make more and more patients eligible, but it doesn’t help them if payments are too low to draw doctors in. With low payments, the Medicaid voucher doesn’t give much choice.

By contrast, governmental support of clinics has continually increased. If the non-profit clinic qualifies as a Federally Qualified Health Center, it is required to provide certain extra services (e.g., nutrition counseling), and will often provide services for the uninsured. The FQHC clinic receives the same Medicaid payment as we do, but on top of that, they receive supplemental government payments to “cover their costs.” After this payment, the clinics receive from two to three times as much payment per visit was we do, no matter if the costs are due to extra services, high salaries, or inefficiencies inherent in such entities. Not to mention the charitable gifts the clinics receive from the public and health care institutions.

The Heath Reform bills slant the playing field even further. The House bill would increase Medicaid payments in steps over three years to 100% of Medicare. The Community Health Clinics would receive direct grants of $6.5 billion over 5 years. The Senate’s approach is even more skewed – no increase for Medicaid at all, but $10 billion for clinics over five years (so high reportedly in order to garner support from Senator Bernie Sanders of Vermont.)

It is always difficult for outsiders to know why decisions are made. The clinics have a great beneficent image, the clinic lobby is strong, the numbers seem to work if Medicaid pay is kept low (notwithstanding patient preferences, and notwithstanding that “coverage” does not equal “access,”) and most legislators are generalists who don’t understand the issues in depth.

But we private doctors on the front lines understand the issues all too well. Medicaid starves us, even though so many patients choose us. Unlike many of the doctors at our competitors the clinics (not all), we take nighttime and weekend call, do hospital rounds, see patients on weekends, and work hard on productivity since we are business entities. If the clinics receive the projected huge Health Reform grants, the already tilted playing field will be a mountainside. We will barely survive, and will certainly not be able to attract new practitioners to replace us. And for what? An ideology that pronounces clinics good for the poor, and private medicine bad. Not that the clinics don’t have some wonderful people – they do. But are the clinics better than we are? Not according to patient choice.

Our preferred solution would be simple, straightforward, and less expensive. Raise Medicaid fees to equal Medicare – or above Medicare to attract even more practices and provide us a competitive wage – and let the best model win. Fund us, and we will come.

Budd Shenkin

Education of a Negotiator (2)

2010-02-02T07:57:00.001-08:00

Aaron Estis has a nice comment on the January 10 entry, on the nature of do-gooder organizations, how typical it is to be "unselfish," and how that really doesn't work. Spoken like a true graduate of the Goldman School of Public Policy.

Aaron is right-on. It's interesting to note that Mike Crichton made the opposite point in his book (diatribe) against the do-gooder global warming groups. His do-gooder leaders were self-aggrandizers, and his members of the organization were blind hypocrites. Mike (OK, I'm name dropping - old friend from college and med school) wasn't exactly on their side.

Interesting to note, speaking of organizations, by the way, that the Health Reform debacle has revealed the essential weakness of physician organizations. The AMA had no claims of substance to pursue (the sustainable growth pay formula is a dead-letter anyway, and their quest to get it eliminated once and for all really was de minimus, since it is voted down every year anyway, and if it weren't, there would be a nationwide doctor strike). The docs had no standing against the real corporate powers,pharma, hospitals, device-makers, and insurance companies. All in all, it was just a pitiful sight, although you've got to say, they made no enemies - the weak seldom do. And the specialty societies were just as pitiful, it seems. Marking the end of the era of professional domination, and revealing that the corporate era is here in full force.

Budd Shenkin

Ways & Means Testimony!?

2010-02-01T08:32:00.000-08:00

The hidden hand - you just never know.

I got a Google Alert yesterday that my name had come up in a House Ways and Means hearing last June. Scratched my head, followed the leads, and sure 'nuff, there it is, my blog post from last June, when I was in Hawaii and gave myself the task of figuring out Health Reform, and how insurance companies made their money, and how the process would change under the Health Insurance Exchange, and how important the Public Option might be. Figured it out as best I could, wrote it down, entered blogosphere, felt good, a few people liked it, on to other things.

Then, here it is! http://waysandmeans.house.gov/Hearings/Testimony.aspx?TID=8154,

I wondered if Don Madison had passed it on to Jon Oberlander who passed it on, but Don says no. Maybe it was Phil Lee. Just don't know.

What a hidden hand!

Love it.

Budd Shenkin

Stories We Tell

2010-01-30T08:57:00.000-08:00

Every culture has stories. So does every age. The Ancient Greeks, who I suspect did not think of themselves as ancient, had stories about an age ancient to them, of battle in and then voyage from Turkey, which they kept adumbrating with new meanings, and illuminating with focus on minor characters – Ajax comes from the wings of Homer’s stage to the center of Euripides’. Kids tell great stories that we pediatricians will ascertain as “age appropriate,” and as adults we keep telling them, maybe or maybe not age appropriate.

My friend Fred Gardner recounted the course of a love affair years ago, saying “And then I was telling her the story of my life. You do that, right?” Yeah, I had never thought about that, that’s what we do. Sometimes it's accepted and sometimes not. In my own case, I get correctives from my wife who puts her own interpretations on things - all stories are interpretations - and makes me think. Often I think, hmmm, I look at things the way my parents did, and sometimes I adjust, and sometimes not, or sometimes I change and then change back.

I thought of Fred’s story, from Horace Mann in New York, or before that, his mother comparing little Fred to Lenin – now there’s a recipe for psychological disaster. Somebody should tell Fred’s story – not Fred. So much ability, so much there, and so much water under the bridge. Anyway, Fred was right, we tell our life stories to those closest to us, differently to different people, trimming to fit. How much bravado, how much triumph, how much Rodney Dangerfield – the art of the story. I catch myself doing it. If it’s bravado, we have to look and see how much we can get away with. Or sometimes if I'm self critical, someone will say, why do you do that to yourself?

I like it when guys trade stories. It’s simpler. John King is my physical therapist – I tried five others until I found John – and we trade stories of the past and present as he pushes and stretches me. Yesterday I told him the story of my Harvard junior year JV basketball team that went 23-0 – 23-0!! What a year! And the first game, before our coach appreciated how good I was, and it was tied with about 2 minutes to go, and he had to put me in, finally, and I scored five points and had an assist and we won by five. The whole team came out to meet me as we walked off the court. I especially remember John Raezer, my high school classmate and four year Harvard roommate, smiling as he came, so pleased and proud, even though he had been the high school hero and me not. A basically generous and nurturing guy. Then last year at my 50 year high school reunion, John said to me, remember that game? John King said, so you said, “What game? I think so. How did that go?” We just laughed. Guys together. I said, if I were talking to Ann I’d have to say the highlight of my life was the day we got married – and John King added, or the day the kids were born – but we know, guys know, that that game was really the highlight of my life.

Which prompted John to talk about the high school football game where he was a free safety and stepped in front of a receiver, intercepted and took off for a touchdown. Then, at the end of the half his team took over with two minutes to go and the coach signaled for time out, and John as quarterback ignored the coach, told the team that taking time out would only give time for the defense to get set and “we knew what we wanted to run,” and they scored. That’s 14 points for John, and they won by two. John and I just smiled at each other. Guy stories, nothing like it.

So, I’m reading “A Traitor to His Class,” a biography of Franklin Roosevelt by H. W. Brands. Brands is a good biographer, not as great as Walter Isaacson, but more than serviceable. I know the story of FDR, Doris Kearns Goodwin’s “No Ordinary Time” is one of the best books I’ve read. There was a great PBS biography a few years ago – just great. The PBS story showed the centrality of FDR’s polio, how in those days you took a cripple and put him in a back room to hide the shame, but FDR tried and tried to walk, then took himself to Warm Springs Georgia where he met the local people, ordinary people whom he wouldn’t know in Hyde Part or Washington or New York, how he made his hotel into a haven for the afflicted, like him. From encouraging himself he went to encouraging others. He was a true hero then, really. That’s when he knew that we all have a common maker. And from this book I learned that he almost exhausted himself financially to do it, until he was rescued by a rich friend who wanted him in politics.

So then he went back to politics and greatness. Without polio he still probably would have been terrific, but no polio, no hero, probably. Maybe. Washington, Lincoln, Roosevelt, our panoply.

I came across this speech extract on page 512:

“Storms from abroad directly challenge three institutions indispensable to Americans, now as always. The first is religion. It is the source of the other two – democracy and international good faith. Religion, by teaching man his relationship to God, gives the individual a sense of his own dignity and teaches him to respect himself by respecting his neighbors. Democracy, the practice of self-government, is a covenant among free men to respect the rights and liberties of their fellows. International good faith, a sister of democracy, springs from the will of civilized nations of men to respect the rights and liberties of other nations of men. In a modern civilization, all three – religion, democracy and international good faith – complement and support each other.”

I hadn’t put it together just this way, certainly not the religion part, but boy, does it make sense. Hitler was a huge bully, and didn’t have any of the three characteristics of what we see as a better-than-natural order. Of course there is huge culture boundedness in what FDR saw as good and desirable. But what of it? The underlying sense is, let’s get along, let’s respect each other, and let’s try to make things good for everyone. It’s not cynical, it’s very English, just expanding it to the heathen.

If you read what he had to do with Congress, and the isolationists, and the Wall Street crowd, you see how he came to understood how one has to deal with people as their minds and situations evolve. He was just ahead of events more than they were, and had a high-mindedness that probably was very Episcopalian, but I’ll take it.

Now today, we are again (or still) faced with a new challenge abroad, testing whether this nation, or any other nation so conceived and so dedicated can long endure. The non-Western nations are certainly not so conceived and so dedicated. Maybe they will be like Hitler – it always surprises me, after my Jewish upbringing, to think that Hitler wasn’t Catholic, but was non-religious – and conceive themselves not with a common creator, a good father, and not with a directive to get along and help each other. Maybe they will nurse grievances and dare us to stop them from spoiling our common Earth, while they don't desist. The nature of man is not pacific. But even with as low as Congress has sunk, the Congress of the 30’s can’t have been much better. It seems like a similar struggle.

But what a leader we had! FDR! My mother really loved him.

Budd Shenkin

Education of a Negotiator

2010-01-10T12:58:00.000-08:00

I have been a little thorn in the side of the American Academy of Pediatrics lately, not an uncommon spot for me, over the issue of how they view themselves and their mission, and their conception of what their stances mean.

Here is the essence. There is a division of opinion within the AAP. Historically, they have tended to view themselves as advocates for children rather than looking out for their membership. Other professional societies may have a similar division, but probably none to the extent that the AAP does. Most are more like the surgical societies, that think what's good for them is good for the nation and the patients.

Within our section, the Section on Administration and Practice Management (SOAPM), many voices have been raised on our Listserve and in private counsels - how about standing up for us? If we don't get our margin, there will be no mission. Etc.

Earlier in this decade the AAP had a proposal called Medikids. This was a proposal for universal health insurance for children, and part of the proposal was for pediatricians to be paid at Medicare rates - which suck. In other words, the AAP's proposal would screw its own members - and that was the opening position! I and others excoriated their naivete and indeed, inadvertent malevolence in their self-conception as medical missionaries within our own country.

We just couldn't get rid of this proposal - we would protest, they would say they would change it, and then it would reappear. I'll leave out the AAP internal bureaucratic politics, but that was the result.

Then, last month, a set of articles came out as a supplement to our journal, Pediatrics, evaluating costs of giving vaccines to our patients. The pay rates of insurance companies in paying us for vaccines has been problematic. These articles were commissioned by the AAP to try to give pediatricians some backing in getting paid better. But, just as I had feared when I heard these articles were coming, the articles did a classic pediatrician, AAP preemptive surrender. Instead of viewing these articles as an opportunity to establish a negotiating position, they relied on trying to find an unassailable, reasonable, conservative position. They underestimated the costs - and this is going to be our opening position. Just like Medikids, I thought. They just haven't learned.

Anyway, so I protested on the Listserve, and then I wrote this reminiscence on how I learned to negotiate. Kinda.

Really, I’m just a nice Jewish boy from Philadelphia, sheltered in the suburbs, and put into the college and medical school pipeline. I was brought up to be truthful, fair, and idealistic. I went to medical school, not business school, not law school. How could I be a negotiator?

And in fact, I don’t think I am such a good negotiator. Maybe I’m OK, I don’t know. But my objective is generally just not to be taken advantage of, and not to take too much risk, and not to be stupid. Pretty minimal objectives. Or maybe I’m better than I think. Dunno.

But there I was, right out of internship, a so-called “Two Year Officer” in the US Public Health Service. “Two years,” because that’s what it took to count our time in a uniformed service as service time and avoid Vietnam. (Although I didn’t really have a uniform, although I was issued an instruction booklet on how to dress in one, and how to call on senior officers and leave “my card” with them.) I had always had an interest in administration and politics, and here I had an opportunity, stepping off the clinical treadmill, to participate. I was stationed in Washington, D.C., with a unit that underwent numerous name changes, but the most descriptive might be the Community Health Service. It was deep in the bowels of HEW, under the Health Services and Mental Health Administration, then HHS, etc.

Leadership was at a premium, and somehow in these days of expansion of health services, despite my youth and inexperience, I was given leadership and responsibility for first Neighborhood Health Centers, and then the Migrant Health Program.

(Side note. The NHC’s were started by the Office of Economic Opportunity, and copied by the so-called 314 (e) program of HEW. David Blumenthal, currently HIT czar in the Obama Administration, wrote a summa [I think] Harvard political science thesis on the 314(e) program. He was following the example of his brother, Richard, currently slated to succeed Chris Dodd as Connecticut senator, who wrote his Harvard summa thesis on OEO, which was the primary document for Senator Pat Moynihan’s famous book, Maximum Feasible Misunderstanding. End of side note.)

Anyway, to the point. There I was at a meeting on Migrant Health, which I was taking charge of, and across from me was the lady who had had lobbied for this program to get started, and then had been in charge of it for years and years. The only background I had was college, medical school, and being a nice boy, taught to be reasonable, and not to get caught out by an attending on rounds making stuff up. I forget the exact points that were being made, but I know that I started to make a proposal that sounded reasonable and acceptable to me.

I had just started and someone else was talking, when I felt a tap on my shoulder. The owner of the finger was Tom Uridel, 6’3” 225 lbs., then and now a hero of mine. Tom was a genius. He came from Medford, Oregon, heard jazz on the radio station and was entranced, went to Mexico to have experience and now spoke great Spanish, came back and settled for a while in Alviso, California, down by San Jose, a poor Mexican community. Tom had no health background but he saw the need for community health services, and built one of the first ones in the United States, from scratch. And when I say built, that includes building the building himself with other community people, literally. Plus recruiting doctors and a dentist, and getting some funding, and running it. Building and running it from scratch, with no models to guide him. The man was a genius.

After Alviso was up and running, Tom was recruited as a consultant for our unit by higher-ups who wanted us to at least to have someone around who knew something. So there he was, sitting just behind me, tapping on my shoulder.

Tom said to me, “Budd, is that what you want, what you are saying?” I nodded yes. Then he said, “Then you had better get out on the wing, so you can compromise to that.” So I made a proposal that an attending physician on rounds would tell me was self-centered and ludicrous, and we compromised to the center, where I had figured it from the start it would be fair to be.

The next year, we had a similar situation, except I was in Tom’s chair, and I was the person tapping on the shoulder of my new Deputy, telling him not to make his “reasonable” proposal, but to get out on the wing, if that is where he wanted to wind up. Many of you probably know my then-Deputy, who was Jim Perrin, now Chief of Pediatrics at Mass General in Boston.

See one, do one, teach one. Except in this case, do one, teach one.

Now let’s leap forward to that misbegotten proposal known as MediKids. Remember that, sports fans? Proposing what – universal childhood health insurance coverage, paying 100% of Medicare? And remember our SOAPM outrage at this proposal that wouldn’t go away? Was it “reasonable?” I would say not, others would say it was marginally so. But it was a proposal that no attending physician would attack as self-centered and outrageous. It was certainly “good for the children.”

And where are we now? The current health reform proposal gives close to universal coverage of children, all the programs considered, in a total program of Medicaid, CHIP, etc. And what is our payment from this? They have compromised down to the “middle,” which is far below what we think is acceptable, which was where we seem to have started from. We will, in short, be screwed.

To be fair, I really doubt that pediatricians had any input at all in health reform; if we did, then it certainly wasn’t to our advantage. If we did, I doubt there was a Tom Uridel, tapping on someone’s shoulder, trying to get to the wing so we could have an acceptable compromise. But if we had any influence, I would say it came from MediKids to start with, where the framers of the legislation noted that pediatricians would be happy with 100% of Medicare, put it in the original House legislation, and whittled it down from that starting point. Where was Tom when we needed him?

So let’s finish up with vaccines. We have a couple of articles that are supposed to support our claims to “fair” payment for vaccines. Like the good little boys and girls we are, not wanting to be called out by our attending physicians for being self-centered or outrageous or God forbid, giving ourselves benefit of any doubt, we go for valid “scientific” data. If there are assumptions to be made, we make them in favor of our opponents in the negotiations – no wastage assumed! Fully efficient practices, such that we can in reality only aspire to! Medical Assistants that only God could really deliver to us, uniformly! Marginal instead of average costs, not asking vaccine payments to bear any of our basic costs of doing business, or to assume pediatricians get more than minimum wage. (OK, I exaggerate – don’t call me out on this, attending sir!)

We assume that our modest figures, already giving the insurance payers all they should fairly want, will simply be accepted. And where will we settle? Where is the middle? We’ll find out.

As I say, I don’t hold myself out as a great negotiator. I would much rather be fair and reasonable. I’m just a nice Jewish boy from Philadelphia. But I would wager that the health insurance companies will not be represented by nice boys or girls. I would wager that they will be real negotiators. I would wager that given our articles, they will try to negotiate us down to a fraction of what we have honestly underestimated as our basic costs. I would wager, in short, that we will be screwed.

Where was Tom when we needed him?

Budd Shenkin

Enthoven Destroys Gawande

2010-01-03T11:43:00.000-08:00

I have always kind of resented Alain Enthoven, although I'm not sure why. I think it's the air of infallibility he carries, not unlike the McNamara boys at DOD, which I think he was a part of, before he turned his attention to health care. Maybe it's because of his corporatism, and his sense that he uses the Palo Alto Medical Clinic and it's fine for him, so why shouldn't it be for everyone? I can give him several reasons why not - he is an insider, for one, so he's going to get care that's different, and just because he likes it.... Anyway, he is a cold fish. He doesn't have a humanitarian background. I'm such an independent guy that I just bridle at the thought of having to be contained in a corporation and to answer to corporate politicians. And he's at Stanford with their red shirts. Who knows?

But that doesn't obscure the fact that he is quite smart and often right. He is clearly one of the 5 top health care economists/policy experts. If we had adopted his Managed Competition proposals decades ago, American medicine would be in infinitely better shape than it is now.

And now I agree with him completely in his commentary on the insufficiency of the current health reform bills and their really pitiful proposals for pilot projects. Yucch!

Here is his commentary in the cloak of a response to the New Yorker article by Atul Gawande that assets the pilot projects might work in the way that the agricultural extensions worked a century ago in our rural areas. I love Gawande, but smart as he is, he's not a policy guy. Enthoven takes him apart.

http://healthaffairs.org/blog/2009/12/22/would-reform-bills-control-costs-a-response-to-atul-gawande/

Budd Shenkin

United Health Care and Telehealth (2)

2010-01-02T14:17:00.000-08:00

Well, I'm having trouble posting a comment to my own blog. Pretty amazing.

So, here's my response to Donna Cusano, who posted a comment:

Thanks for the comment, Donna. Interesting to see the other side of innovation. We know that innovations come from invention of the technology first, and use second. The inventors of telephones, phonographs, and radios had no idea of the wide usages that would come.

Seems to me that telehealth will be the same. Invent, and then see who can come up with the perfect usages. I’d say that the most obvious use would be in the Third World, and the rural parts of first world. The problem would be money – the same reason there are no doctors in the Third World is why the prospect of profit would be difficult. But there are donors, there is some money somewhere, and maybe that would work.

I think the problem of adult acute but probably not serious care is a problem of organization. Pediatrics isn’t so much of a problem, usually, although more could be done. I think most pediatric practices are like ours – acute illness will be seen on the same day, even on weekends. The main problem is with adults – why adult practices are not set up to see same day sick patients escapes me! Also, why hospitals can’t set up urgent care better is not clear. Hospitals are generally just poorly run, as we all know. Also, they can charge so much for an ER visit and get it – so why settle for an urgent care visit? So, I guess the Retail Based Clinics really do rely on just low cost.

But if that’s the case, would telehealth be low cost and thus competitive? I can’t see how that would be the case.

I agree 100% that the UHC demos of telehealth were based on PR for impressionable Reps and Senators. I agree it was part of their strategy as they won the Health Reform fight. So, I wonder why you think that UHC will be toast with health non-reform? Seems to me the insurance companies are going to get lots and lots of new subscribers with no significant limits on profit. Their problem will be what to do with all the money.

If I owned the UHC zoo, I think I would identify areas that could potentially be like Intermountain, and the Grand Junction Colorado system. I would partner with some, buy some, and then try to spread like ink spots. If I got a great team together, pretty soon I would be predominant in health care in a large part of the country. It would not be easy, it would take real investment and team building, it would take creativity – all of this would be alien to UHC as presently constituted. But that’s what I would do.

Budd Shenkin

Health Care Reform - Proclaim Victory and Go Home

2009-12-27T14:47:00.000-08:00

Call it a victory, and move on. They couldn’t do it in Vietnam, can’t do it in Afganistan, but they’re doing it in health care.

Not that nothing has been done. I don’t agree with the crowing politicos that this is the change of the millennium, but getting 30 million people into the health insurance system is clearly important. I wouldn’t call it a progressive move so much as an anti-regressive move. How America has tolerated this for so long shows the innate pathology of the system and of our politics, the weakness of government and the strength of the corporations with no consciences. Since this is the heart of the health reform legislation, I’d call this not health reform, but inclusion reform. It will be important.

But it’s a lot like the financial bailout. We’ll change some current conditions, but we need to remember, it was the system that got us into this, our set of institutions and practices. We will get more inclusion, but the high-cost low-efficiency high-profit low-fairness system that got us into this will remain. Them that has is them what will get more. More meat on the bones, but the bones still hopelessly misaligned.

What I’m talking about is not the failure of the public option. I thought the public option could have been very helpful, but the main event was always the Health Insurance Exchange. If there had been a good and viable and extensive HIE, one of the pillars of the current system -- the health insurance companies-- would have had to do their business in a different way. They would have had to compete, with their competitive drives redounding to the benefit of the public. (For more details on this, see http://buddshenkin.blogspot.com/2009/09/understanding-health-insurance-exchange.html.)

The key is this. There are two ways of running a system responsibly, competition and regulation. Most American industries have a combination of both, some more regulated and some more competitive, but most a mixture of both. How do corporations operate within these systems? What it wants to do, what it fights to do, plots to do, is to escape both and either. Any self-respecting corporation will espouse the holy cause of competition and try to escape it to become a monopoly. What any self-respecting industry wants to do is to capture the regulators and make rules that favor business rather than the public. That’s what they are born to do. The role of the government is to prevent both from happening. Capturing the regulators and crushing and excluding the competition is the strategic function of the corporation.

The health insurance companies have not been heavily regulated, despite their claims that they have been, and 90% of the population have had a choice of health insurance companies so sparse that they qualify as either oligopolies or monopolies. That has been part of the tragedy of the health insurance industry. How much will this be changed now? In the service of increased coverage, some important regulation will be introduced – excluding prior conditions, excluding rescissions, etc. That’s not nothing. But the essential conditions of competition will not be introduced, because HIE will apply to so few applicants for insurance, maybe a couple of million. There will be some increased regulation as mentioned, but only a couple of provisions, really. In the end the system will not be essentially changed.

As an employer of about 150 people, I was hoping to cut some exorbitant health insurance costs, and to be able to offer my employees a better insurance plan than we have now, with more choice and value. Now, we’re frozen for the foreseeable future, and the present sucks. Our people would like to choose, but I can’t offer them a choice, because there are very few insurance companies I can contract with, and all of them insist that I make them exclusive to Bayside, so I have to choose one only. I can't choose Kaiser and others, it's either/or. It’s not if you like your present insurance you get to keep it; rather, you’re stuck with your present insurance like it or not. Thanks a lot.

How would anyone be violated if we could just choose freely in a market, where the prices and services were clear to see? Ah, but then the monopoly would be violated, the companies would not be in control. The health insurance industry beat that back, little by little, until nothing was left. They have the money, they have the influence, and the goddamn Senate sucks.

In addition, as a company that is still small but not very small, I think we will be required not only to cover our employees, but also to offer to pay for 65% of our employees’ families’ insurance. Probably the cost of each individual policy will increase, and our corporate responsibility to provide health insurance will massively increase. To me, it’s very discouraging.

Other Notes on the Legislation

The new legislation will establish some pilot projects on Accountable Care Organizations, and boards for assessing comparative effectiveness of treatments. These are bureaucratic arrangements designed by the health policy intellectuals that I am very pessimistic about. They will lead to regulation rather than competition. Not worth the big fight that health reform entailed. Minor.

The nurses have signed on to reform because they got what they wanted, support for more training (jobs and power!) and independent nurse clinics without the need for their nemeses, doctors. Nurses are on the move!

Other big winners are Community Health Centers. They will get $6.5 billion – billion – over five years for increased operations, trying to go from serving 15 million people to over 30 million. They will get $1.5 billion – billion – just for construction. Plus they will be getting over $800 million from stimulus funds to introduce IT.

Many of a liberal persuasion will be tempted to applaud the new money for the CHC’s. Not me. The alternative ways of funding care for the poor are (1) to establish and support various clinics, such as CHC’s, and (2) to give the poor funding to obtain care in the mainstream system. Notice that we are dealing with “separate but equal” arguments here. We at Bayside are providers for Medicaid and every private insurance company you can shake a stick at. Where would our patients and potential patients rather go? Now, that’s good competition.

I say, give me a level playing field. But what the legislation does is give gobs of money to the CHC’s and starve us in the private sector. Not only do the CHC’s get all that money, they get paid two or three times what we get per visit, as they always have (outrageous!) But also, Medicaid eligibility is expanded, and the dreadfully low payments to doctors will not be raised, according to the Senate bill. (The House bill actually raises payment to the level of Medicare – that’s right, even though Medicare rates are quite low, Medicaid is considerably lower! But I doubt the House Medicaid levels will survive the conference committee.)

Thus, the private sector will continue to be excluded from serving the poor, simply because they won’t be able to afford to do so. The CHC’s, on the other hand, will be funded separately and thus relied upon. The die is thus further cast – there will be separate systems for the poor, clinic care. Forget the vision of Medicaid, to serve everyone with the same system. Gone. Two classes of care, more than ever. Those of us who try to serve all with one class of care, adios!

Well, these last are just my personal observations of some of the less noticed aspects of the legislation. There are others I won’t mention, all tending in the same direction.

This is what the systems now allows to be done. So what can the Democratic Party do? Proclaim success and move on. It’s pathetic, really.

Budd Shenkin

United Health Care and Telehealth

2009-12-27T14:09:00.000-08:00

What does a corporation do when it is wildly successful financially and has lots of cash?

We in the medical field have looked on bemused at the plans of United Health for “telehealth.” I understand that United even set up demonstrations in the halls of Congress during the recent health care reform activities, wowing the Congress people.

What is telehealth? The use of communication and other technology to have a virtual visit with a patient. The patient is seen at a distance, miles or hundreds of miles away. It’s a pretty glitzy prospect, and who knows, maybe useful in some instances. Rural and remote areas, perhaps, if they can’t be manned by real people. Specialist visits, perhaps. We already have interpretation of imaging studies on line, so that doesn’t count as a new phenomenon.

Naturally my primary care colleagues are upset. It attacks our business, and it demeans what we do, in a way. People who think telehealth substitutes for a real caring person are unclear on the concept – but that’s so typical these days, techno-types think they can deconstruct and understand, when they can’t.

I understand this from a corporate point of view. United is an ultra-successful health insurance company, and has amassed billions. No wonder they didn’t want to be reformed, and the prospect is for even more billions under the health care non-reform legislation. When this happens to a company, they look for the next "disruptive technology," or they find a way to buy other companies in their field and make themselves bigger and even more predominant and successful.

Apple was good as far as it got, but what does it do for an encore? Ipod. Iphone.

Microsoft and Google were excellent, what do they do for an encore? Buy other adjacent companies, compete in adjacent markets like the iphone, for instance.

So what will United do to maintain its dynamism? It's hard to go around buying hospitals, medical groups, other insurance companies, etc. So instead it looks for a disruptive technology, and it thinks telehealth might be it. Gotta do something.

Personally, I think it will be a big failure. I think an insurance company cannot be the linchpin of medical services. Seems to me that it will be very hard for what is essentially a fiscal intermediary to make real substantial improvements in the medical care system, and if they were to do so, it wouldn’t be through technology. I think that transformation and disruption need to come from real providers of care, docs and hospitals, not financial intermediaries. But of course, first they have to get the money.

Budd Shenkin

The Moral Pain of Health Reform

2009-12-18T03:06:00.000-08:00

First, a caveat about this post. I’m 36 hours post left knee arthroscopy with partial meniscal removal, and just took my first oxycodone and it’s about 2 AM. The first 24 hours were pretty good pain-wise, but now I’ve got some ache, enough to drive me to the pills. So here I am awake and a little alert, enough to drive me to blog. So, we’ll just have to see how it turns out.

I’m so mad I can’t see straight or think straight. The subject – health care reform, which, as you know, I’ve been paying a fair amount of attention to. I’m just so mad at the industry payoffs that the Senate bill has in it. Pharma, hospitals, and health insurance companies, such an unholy trio. The first two do some good, the last one not so much, but all three then become what they call “stake-holders.” My god, what a term. Stakeholders. As in, I’ve got my claim to possession of a territory that yields money. Why does that offend me? Is it my mother’s and father’s voices from their Commie past in the 30’s that eroded to realism, but an idealism of “should’s” that never did really recede? I try to think, “That’s the way people are” and not use the term “should,” because I see how that moves quickly to anger. But I guess this is the operative process as I get so mad I agree with Howard Dean, and I say “Pull the bill – don’t pay the ransom.”

Realistically, I know it has to be passed. It’s more than deeply flawed, it’s morally offensive, and offensive in a practical way as well, because we know from history that any angle that can be played, any trick that can be conjured, any grand hypocritical avenue that can be traveled, these industries will do it. “Public good” never passes their lips that it is betrayed before hitting the listener’s ear.

Still, it needs to be passed, because people need the coverage, some of the insurance tricks are done away with, and the logjam of health care organizational stasis is broken. OK, I know that. But it is so outrageous to see the players, preening, representing so few thinking people, paid off in so many ways. What a system.

Maybe in the end this is what it takes. We know the Churchill quote that it’s a terrible system, but there is no better. Plato called for wise men, and anywhere that something like that has been tried it hasn’t worked. Maybe moving millions of people in a direction takes this. Maybe watching sausage or legislation be made is not for the weak of stomach.

But it’s hard, it’s just so hard.

Budd Shenkin

Financial populism

2009-12-12T19:29:00.000-08:00

I've been predicting that the big election cycle push by the Democrats will probably have to be over financial reform, faut de meilleur issues. The fact that Wall Street has lacked remorse is just so tempting. The problem has been that they have been watering down and watering down what they are prescribing. But it appears that the Republicans are falling into the trap. From the Washington Monthly blog:

"Not one Republican voted for the financial regulatory reform and consumer protection bill in the House. Not one," Woodhouse said. "One year after nearly the worst financial collapse in our nation's history -- a collapse brought on by the excessive greed and risk taking of Wall Street and by the anything goes regulatory environment put in place by Republicans -- not one Republican in the House thinks that consumers deserve additional protections or that the practices of Wall Street should be curbed. Do the Republicans not get that one of the reasons they lost so badly in 2006 and 2008 is because the public believed that the GOP had just become shills for oil companies, Wall Street financiers and insurance companies? Apparently not -- because here they go again."

The goal, apparently, is for Republicans to actually suffer some electoral consequences for this one. DCCC Chairman Chris Van Hollen (D-Md.) told reporters that GOP opponents of reforming the way Wall Street does business "are going to pay a very heavy price."

And in his weekly White House address this morning, President Obama reminded Americans, "Just last week, Republican leaders in the House summoned more than 100 key lobbyists for the financial industry to a 'pep rally', and urged them to redouble their efforts to block meaningful financial reform."

Is this the issue on which Democrats take the offensive?

I'll stick with my prediction and analysis. At least for now.

Budd Shenkin

Obama Nobel

2009-12-11T18:11:00.001-08:00

It's never quite clear what the Nobel Peace Prize means. Remember that Arafat got one? When I lived in Sweden, my friends there explained it by pointing to the awarders: "They're Norwegians, don't forget!"

Unlike the science prizes, the Norrmen use their prize as a way to influence events, not just recognize past achievement. I'm sure this is part of what the Norrmen tried to do here, that and as others have said, to compliment America in finding someone who is not George Bush.

But more profoundly, this year I think the Norrmen have made another error - they have forgotten that they are the MVP committee, and instead found the Rookie of the Year.

Budd Shenkin

Nutrition is the way to good health

2009-12-01T08:49:00.000-08:00

First a quick note on the ongoing health reform debate. Can you believe that a plus for the Senate bill is that premiums will not go up??? The mind boggles. After the unthinkable rises in health insurance costs, we're supposed to feel good that the exorbitant current costs for employer provided health insurance will not rise?

OK, it brings in the uninsured; OK, it gives needed support to many of what we used to call the "medically indigent," too much money to get Medicaid, not enough to buy insurance. OK, that's good, very good and very important, well worth doing. But "no rise" in health insurance costs is supposed to be good? Our group got hit by 20% rises two years running, and "only" 4% this year for Kaiser HMO insurance, or really lousy Kaiser sponsored POS insurance -- where is our relief, Mr. Man? Stinko, guys, just stinko.

OK - now the meat of this post. Nutrition - that's really the road to lower costs! If we ate right (and exercised right, and took our statins and blood pressure meds right), we'd really lower costs. See the Safeway plan, commented on many months ago here as I undertook the serious job of health reform analysis probably last spring.

But for nutrition, it's not just eating at home. Americans like to eat out - just look around the city, and if you're looking for it, you can't help but be struck by how society has built itself around the biological imperative that we need to eat. We have found a way to make it a social glue, and an economic boon.

So, how do we domesticate this proliferation of places to eat? How do we turn it to our advantage? How do we make these places Mecca's of good nutrition and good health, yet not abstemious?

Here, in lowly Fremont, California, is the modern answer to our nutritional and social needs.

http://www.yelp.com/biz/the-deep-fried-twinkie-and-pastrami-shop-fremont

I rest my case.

Budd Shenkin

ObamaNeeds to Move on the Financial World

2009-11-29T23:09:00.000-08:00

Politically, the Obama Administration is in trouble, although they probably think they’re not. People are getting impatient; I’m getting impatient. Yes, there is change, and this isn’t the Bush Administration – that is what has given the Administration so much slack, we still remember the WAH (Worst Administration in History). We now have some people who have some brains and some basic humanity.

But we’re not really going to see too much positive for quite a while, the way we’re going. Let me count the deficiencies.

Guantanamo – maybe not as grim as it was, we don’t really know. It’s just taking a while to wrap it up.

Torture. He did well at first saying we won’t torture, but we’re still going to do special renditions.

Justice Department. Still incompetent, and still double-dealing with Spiegleman. Still taking some Bush positions.

Greg Craig. All pundits agree, a good man wronged by bureaucratic infighting and failure of Obama himself to stand up.

Health care. Not going to go so well. Some things will be better, but not clear how soon, and not really clear if it will be a lot better in the end. Meanwhile, the perhaps necessary strategy of letting the Congress lead has not been pretty.

Afganistan. Will not a pull out, will readjust objectives and management, it will look competent, but it will take time.

Pakistan. A very most improvement, but the area itself is so difficult, who can expect much? If it doesn’t blow up, we will be well served.

Iraq. Certainly much better, but Obama can’t take credit for this; most people think that by our staying in there, it finally will be somewhat better, although it was done in the least effective way imaginable.

Middle East. No particular competence shown here.

All the public appearances. Regular guy, OK, but too many appearances. Watching basketball games, the turkey, enough, give me a break. It would be different if things were going well.

Which leaves the big boy, the economy, joblessness, low growth, the specter of more and more loss of homes, more financial upsets. The stimulus package was necessary, of course, but it’s controversial and since it’s just cushioning a fall, there is no one there to shout “whoopee!”

Which leads us to Wall Street. If there is one leaking sore, this is it. The other items above may not be solved, but many are somewhat better, and none demonstrably worse. Wall Street, the major miscreant in the most major problem we have, is awash in money and notably devoid of contrition. Quite the opposite. And their facilitators, their enablers, Geithner and Summers, are insiders.

So, here’s what I have been thinking for the past month or so. Get health care out of the way, one way or another. Just get it done, call it a victory, and move on. Say the results will take some time to see, although there will be a special near-term fund from the government for the uninsurable to buy insurance.

Get Afganistan set, say it will take time, we are not bugging out, but our strategy will be intelligent, and hope it recedes some in prominence.

Then, attack the financial problem head on. First, say that the system has been rescued. We had to prop it up so there wouldn’t be a liquidity crisis and there wouldn’t be a meltdown. Unfortunately, in the process of doing this, we have found out that the denizens of the Street are profoundly unconscious people. They have revealed themselves as who they are, and it’s not a pretty picture. It’s time for the extortion to end.

So, here’s what we’re going to do. We’re going to push for really big regulations on the Street. We’re going to reintroduce Glass-Steagall, which never should have been repealed – thanks, Clintons and thanks, Phil Gramm et al. We’re going to take measures to break up the big banks so that nothing will be too big to fail.

And we’re going to take the money from the banks and make them start lending to small business. We will start with gentle persuasion. If that doesn’t work, we’re going to take them over one by one. And we’re going to make the mortgages go back to the original interest rates of the ARM and not let them vary upward. Too bad, lenders; you’ll survive.

Now, a lot of what I suggest is untutored – I don’t know 5% as much about this as I know about health care. I’ll follow this up in a while with something more accurate. But I’m trying to indicate what I think is the tone they need to strike -- we’re kicking ass and taking names.

OK, it’s populist. But politically, this is what they have to do. Let the Republicans start to defend Wall Street. Isn’t that what the Administration needs?

Budd Shenkin

Health Reform (for a change)

2009-11-28T10:30:00.000-08:00

OK, this is very repetitive, but I'm now restating my position on health care reform, as I wrote to my old mentor, Phil Lee:

Hi, Phil:

Hope you're having a good Thanksgiving and are hale and hearty.

A couple of decades ago you said to me that it seemed to you that there is so much money in the game that it's hard to change. I didn't have the wisdom to reply at the time. But it is just so obvious you were right then, and would be even more right now if you made the statement again.

It's pretty clear to me that should health care reform pass in its current state, and for Obama's and the Democrats' sake it had better do so, who would be sitting pretty? The same ones who are sitting pretty now. Pharma, no problem. Hospitals? All those newly insured patients and minor inconveniences of making their services non-infective, no new prohibitions on local and regional monopolies, no problem. Insurance companies? No more underwriting, continue to write up policies with big premiums, few if any assurances of breaking their oligopolies (I assume the retraction of insurance company immunity from antitrust will not go through), no problem. Training programs, with more money for nurses and more places for trainees? No problem. Nurses, now able to head medical home installations without physician direction or participation? No problem. FQHC's, with $1B growing to $4B increased funding over 5 years? No problem. Everyone with a strong lobby, no problem.

Primary care? Only a possible promise of a MedPac in the executive that might or might not dodge the specialty interests and help redress the RBRVS inequities. A policy to lure people in with debt forgiveness and more training slots, not to make the ultimate destination more palatable. No strong lobby, no place at the table.

And have you seen the plans for the Primary Care Extension Program? Pure public health, no involvement of the professional primary care givers at all! The Feds through AHRQ will dish out grants to states who will set up "Hubs" of the state health departments who will send out who, RN's and MPH's, to tell us in practice how to practice medicine in a medical home, with no money promised to fund it all, just another unfunded mandate? That'll sure be well received!

And patients, what kind of health insurance are they getting? The terrible kind of insurance that the insurance companies have come up with over the years, high deductible and high out of pocket costs up front, with no restraints on insurance payments at the back end, where the consults and the hospitals sock it to them, and will be fully funded. Reminds me of Goldmine Sachs and AIG - 100% on the dollar, while Main Street (Primary Care Street), takes it on the chin. I didn't know Larry Summers and Tim Geithner designed health insurance also.

There is so little about cost control, really. I don't know about funding the ACO's, but I would hope it could help. The biggest fights will be political -- who controls these babies, I guess. It would be great if they worked, just a muscled up version of the old DRG's.

Why is all this happening? Why is the government so weak? One, Senate representation of two Senators per state, no matter what the population. Two, election finances, with so much money necessary and corporate interests thus foremost except for the Obama national campaign. Three, the difficulty of fixing election finances, because of the First Amendment, and because of the long-standing confusion of treating corporations as persons with the same First Amendment rights as real persons. We can pin it on individuals, and on the weaknesses of the political class, but it's really structural.

What forces can be mustered for real reform? It's got to be the profession itself. Professional ethics really do exist, goodwill toward man really does exist in so many ways throughout the profession, if the professional societies and organizations could be mobilized. To me, that's our best hope.

I'm still for health reform on the basis that ethically, Americans need to be able to insured, and on the basis that at least the logjam will be broken. Breaking the logjam will be only the first step, but a necessary one.

Anyway, that's my hit on things.

Again, Phil, I hope this Thanksgiving greeting finds you well, and I would love to come down to Palo Alto and take you out to lunch.

Best as always,

Budd

Budd Shenkin

The Reid bill in the Senate

2009-11-25T15:03:00.000-08:00

It's true, dear Blog, I have been neglecting you. I think of it as a fallow period. After all, before just signing in and blogging away, it's good to think first. So I guess I have been.

I have read most of the Reid bill in the Senate, and earlier this year I read the two house bills, especially HR 3962. All I can say is, deficient as I think the bills are, and I think they are grossly deficient, at least they will break the logjam in health and get change moving. I'm trying to be optimistic. My essential pessimism comes from realizing that the powers that be, are the powers that will be. It's not only the rules of the Senate, it's the makeup of the Senate with over-representation of the West, the South, and the rural, and the lack of electoral reform that makes money talk. None of this is going to be fixed in my lifetime, and perhaps in yours. And this situation conditions events strongly.

But, given that, here are some observations on the Reid bill.

The problem of primary care, that there are a diminishing number of primary care physicians and the field is economically uninviting, remains unaddressed. The House bill had a 5% primary care bonus, and it had more people on Medicaid (150% of the poverty line), but increases of Medicaid payments over 3 years to 100% of Medicare. That's all gone in the Reid bill. What remains is nothing to make primary care a more attractive destination, but to make entry more attractive by loan forgiveness and more residency places - not an ideal solution to my mind. In fact, pretty poor.

There is a chance that the changes envisioned for MEDPAC, the body that recommends payment levels in Medicare, would change that. I do think that separating MEDPAC from the special interests, which is what insulation from Congress means, is very good. But I still doubt that they will go ahead and pull compensation for primary care up. So, I think the primary care issue, grounding the system in primary care, is very poorly addressed.

I think the hospitals are going to make out like bandits, because their uncompensated care will now be compensated and they will have given up nothing. The quality measures under Medicare (not getting paid for patients who are readmitted, not paying for hospitalizations for infections acquired in the hospital, etc.) is something they should do anyway, and can do, and in the end it will cost little. Most of them, for all their complaining, do very well with local monopolies, pay SEIU very well (for all their complaining), pay nurses far too much (for all their complaining), pay the administrators phenomenally well, and don't do basic management well (clearing OR's so the next case can follow, etc.) Instead of being efficient and kicking some butt they just raise their rates. Can't see that changing. Hospital rates are so unbelievable, it is surprising there is not more focus on that. This is such a core problem, and it is very poorly addressed.

Pharma will do just fine, thank you, as has been well documented. They will sell more than ever and not much competition will ensue. This issue, festering since the Kefauver investigations, remains poorly addressed.

Insurance companies still will have little oligopolies and no ceiling on rates. Yes, they will get rid of exclusion and rescissions, but they will reduce their underwriting expenses, have many more people enrolled, government money, and yes they will have to report their medical loss ratio, but what games will they play? They will still torture us, the doctors with their contracted rates and quibbling over bills we send in, etc. This problem is better addressed than hospitals and pharma, but where will the competition come from? The Public Option has withered on the legislative vine. They will all still probably retain their monopolies.

So, where will the savings occur? Can't really see it, despite the optimism of the economists. Some will come from us (physicians, especially primary care), where we don't need it. There are the beginnings of ACO's (Accountable Care Organizations), of course, but they will take a while to work if they do. Of course care has to be organized and coordinated, it's a scandal that it isn't. But the major story with ACO's will be political control. Will this further the corporatization of medicine? Almost inevitably. Who will be in control, hospitals? Dunno. This will be the story to follow, I guess.

Some tidbits from the bill: nurses do well, as they will now be empowered to run medical home practices with them in charge, no doctors, just a back up institution like a medical center or FQHC. Nurses are getting their autonomy! Plus the academics get more training money. What they should do is resurrect the hospital nurse schools, get more LVN's, and break the RN strangle hold on the hospitals. Not going to happen.

I think there is further movement to separate and unequal health systems, as the FQHC's get billions, from $1B to $4B over 5 years, I think, while their colleagues in private practice get squeezed instead, and FQHC's already get 2-3 times as much payment per visit. An inevitably high cost and low customer service solution.

There's also $50 million for school health centers - great jobs! No nights, no weekends, just hang out around the school without anyone checking your productivity - a county job! Sorry I can't be enthusiastic, because on paper it's a good idea. In practice? Not so much. Without productivity measures, people just don't work so hard, they just don't.

Then there's this: "The Primary Care Extension Program shall provide support and assistance to primary care providers to educate providers about pre-ventive medicine, health promotion, chronic disease management, mental and behavioral health services including substance abuse prevention and treatment services), and evidence-based and evidence-informed therapies and techniques, in order to enable providers to incorporate such matters into their practice and to improve community health by working with community-based health connectors (referred to in this section as ‘Health Extension Agents’)."

I can't wait until I meet the little MPH graduate who comes around to my office telling me how to practice medicine!! On the positive side, maybe we could capture this program and become the "hub" and the "agents," but I've been around long enough to be able to spot a disaster in the making. "What are you doing now, Barbara?" "I'm a Health Extension Agent. I get to tell stupid doctors what they should be doing." "Oh, that must be fun! Are any of them cute?"

Well, take away my misogyny, and you get the picture.

Budd Shenkin

The Joy of Sex

2009-11-13T12:13:00.001-08:00

Readers of a certain age will remember Alex Comfort's classic, the Joy of Sex. Appearing in the 1970's, Comfort presented a humanistic rendering of what was approached as a very natural process that should be viewed as a pleasure for humankind. The commentary was vivid and loving, the illustrations illustrative.

It turns out that Comfort produced this book with the help of his long time mistress, and that the embarrassment caused to his wife led to divorce, which is a sad story. But the book lives on. I understand it has been updated for a new generation and reissued.

This is a good thing. But what of the old generation that started with his book? We have progressed in age and we have our own new perspective. Can the publishers refocus their concerns on this loyal, now older generation?

I would suggest that new book be prepared. The title would be, The Joy of Regularity. I'm still struggling with the illustrations.

Budd Shenkin

Health Reform Endgame? or Foreplay?

2009-11-11T21:27:00.000-08:00

Crunch time in health care reform. Public option or not, we'll just have to see. The Catholics, with the same wonderful sense of timing that started the Inquisition, try to retard abortion by extortion - waddya want, health care reform or not? Terrific.

Pharma does great selling more brand named drugs and patents on biotech go up to 12 years, hospitals get all those paying patients and hardly any nonpayers, and health insurance? Some costs go down, actually, because they don't have to underwrite, they keep administering the big time ERISA accounts, and look at all those new policies! With no limits on prices. Wow.

The nurses get a lot! They don't need to be beholden to doctors (their dream!) to head a Medical Home project, and they have some other kind of project they can head that I forget right now. Plus educational money for the academic nurses. The Public Health people get billions, and Community Health centers get $1 billion now and up to $4 billion in four years. Not a bad haul.

The academics always get something - money for training in primary care, a pursuit that they continue not to make more attractive by simply raising the take.

OK - that's the facts, pending the Senate. But we just have to look at it this way -- the logjam is being broken. Health care has been so impacted that nothing has moved for years as the pressure has built up from behind. So, this is the beginning. Who knows how it will come out? But the clear need for reform just from the standpoint of cost, forget quality, will make sure that stuff happens. What is happening now will be enough to set the forces free. I'll try to figure out where a little later.

Figured I had to write something. Been too long.

Budd Shenkin

Health costs? Nothing right now, something maybe