Sunday, June 27, 2010

Corporate Medicine

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

Monday, June 7, 2010

Missing Old Times

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

Sunday, June 6, 2010

Health Care Evolution as Seen From the Bottom

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