Tuesday, February 23, 2010

Dreams and Déjà Vu

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

Monday, February 22, 2010

The President's Health Reform and CHC's

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

Tuesday, February 16, 2010

Clinics vs. Private Practice

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

Friday, February 12, 2010

My Superbowl Weekend

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

Wednesday, February 3, 2010

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

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

Tuesday, February 2, 2010

Within Health Reform - The Clinics vs. Private Medicine

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)

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

Monday, February 1, 2010

Ways & Means Testimony!?

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