Wednesday, April 30, 2014

Jews and the NBA

Yes, of course it is true that Jews have been disproportionately awarded Nobel Prizes (I don't have one, it's true, but lots of Jews do.) And it's true that the 19th century saw seminal figures such as Marx, Freud, Kafka, and Mendelssohn have inordinate influence.  Jews are certainly important.

But often overlooked, even today after the Donald Sterling kerfuffle, is the seminal influence of Jews on pro basketball. Who remembers that the Commissioner was Maurice Podoloff? The Warriors owner was Eddie Gottlieb? That Red Auerbach was Jewish? Who remembers that, I ask you?

Who remembers that the Philadelphia Warriors began as the Philadelphia Sphas – South Philadelphia Hebrew Association basketball team? Who remembers that David Stern was the the league in-house lawyer before he became commish? Look what he did, after all. Guess what religion Adam Silver has to be, although I've never heard it mentioned – that's right, never heard it mentioned!

Back then, way back then, the college game had lots of Southern teams. Kentucky, even with Pat Riley against Texas Western – all white! But blacks were taking their place steadily in the less-established pro game, and Jews knew that discrimination was a bad thing. They also knew quality when they saw it, and they respected the game and the people who played it. And I'm not even mentioning Goose Tatum.

Pro basketball has led the way in so much or race relations, n'est-ce pas? When I wrote my acclaimed freshman essay at Harvard, “Mr. Basketball, or Why I Hate Bob Cousy,” (available on personal request), even then in 1959, I proffered Elgin Baylor as the next superstar, and didn't even think to mention that he was African-American. Of course, unconsciousness, c'est moi. But even so, there he was at the top of the heap in my mind (a Jewish mind, no?). I didn't see that among the many assets that Cousy had going for him in Johnny Most's mind and the editors of Sports Illustrated was his whiteness, but still. The league has been a model for good race “relations.”

So, I ask you, is it a coincidence that the NBA has been a model for race recognition, or race progressivity, and that it has such a Jewish heritage and presence, and I haven't given more than a hint of the Jewish influence, really. Red Holtzman, gotta be Jewish. Dolph Schayes, Lenny Rosenbluth, Wilt Chamberlain in the Borscht Belt. Sheldon Raiken. OK, maybe not Sheldon. Reds Sherr.

Why don't we hear more about that, that you can count on Adam Silver, after all, he's Jewish? Why don't we hear that? Is it because of the overreach of AIPAC? Or, maybe, I guess you gotta say, maybe because Donald Sterling appears to be Jewish? Yeah, maybe good to keep the whole Jewish thing on the low-down.

Well, at least we have to say, we haven't heard anything about Sterling the Jew. I look at Jabbar and Kevin Johnson lavishing praise on Adam Silver and I think, that's great. Matter of fact, do you think Kevin might be Jewish?

budd shenkin

Monday, April 28, 2014

High Deductible Health Plan - Big Article is Published

OK, sports fans, I have opined here at some length on the nefarious character of High Deductible Health Plans – HDHPs. Now, at long last, my definitive article has been published.

And here is the AAP News article announcing the new policy:

High-deductible health plans discourage primary care visits, services for children

  1. Alyson Sulaski Wyckoff, Associate Editor

The federal government should consider restricting high-deductible health plans (HDHPs) to adults because the plans discourage families from seeking primary care for their children, according to an updated AAP policy statement.
High-Deductible Health Plans (Pediatrics 2014;133:e1461-e1470Abstract/FREE Full Text), from the AAP Committee on Child Health Financing, reviews the pros and (mostly) cons of HDHPs and suggests how the plans could be improved.

The economics

More than 5 million people younger than 20 years are enrolled in HDHP plans. A 2013 survey found 20% of small companies and 40% of large ones offered an HDHP plan to its employees, with 20% of all employers having an HDHP as the only choice. In addition, such plans increasingly are used by companies employing mostly low-income workers.
To receive government approval, the 2013 plans required a minimum deductible of $1,250 for an individual and $2,500 for a family. Total out-of-pocket expenses (not including premiums) were capped at $6,250 for an individual and $12,500 for a family. While the Affordable Care Act (ACA) allows for basic preventive services in nongrandfathered plans with no cost-sharing, related services administered during those well visits generally are subject to the deductible.

Pros and cons

Among the positive features, the plans are simpler to implement; offer lower premiums than conventional plans; may be an incentive to living healthier; and can be combined with a health savings account (HSA) or a health reimbursement arrangement (HRA) to allow consumers to pay for qualified out-of-pocket medical expenses on a pre-tax basis. Overall, HDHPs result in lower use of health care services.
Dr. Shenkin
For families with young children, however, many aspects of these plans pose “significant concerns,” according to the policy, because parents have an incentive to avoid doctor visits.
“They’re reluctant to come in, they seek more telephone care, they’re reluctant to complete referrals, and they’re reluctant to come back for appointments to follow up on an illness,” said Budd Shenkin, M.D., M.A.P.A., FAAP, lead author of the policy. “So it really interferes severely with continuity of care.”
The result can be unexpected consequences, particularly for children with chronic conditions, said Thomas F. Long, M.D., FAAP, chair of the Committee on Child Health Financing. He worries about all the care required by children with congenital abnormalities or other special needs.
Dr. Long
“If it’s going to cost them out-of-pocket money, they may say, ‘Well, it’s just a cold, I don’t need to see the doctor.’ And ‘just a cold, turns into ‘just pneumonia,’” Dr. Long added.
Some families who do not qualify for Medicaid but cannot afford the deductibles can be caught in the middle.
“If you’re in the working class … you’re just making it. Your kid gets sick, and you really have to think, ‘Is my child $150 sick?’ Because that $150 has a huge meaning to you,” said Dr. Shenkin. He believes the plans place families in a “terrible position” and conflict with principles of the patient-centered medical home.
There also is concern about families of children with special needs who forego chronic care management if it’s not covered, said Dennis Z. Kuo, M.D, M.H.S., FAAP, member of the AAP Council on Children with Disabilities. That could include critical medications, outpatient lab testing, imaging services and specialty care visits, depending on the plan.
Dr. Kuo
“It needs to be recognized that for children with special needs, their families will likely have little to no control over the amount of care they need,” said Dr. Kuo.
For many of them, a medical event or diagnosis could be unexpected, he added. “Their child may seem healthy at first and if they elect to utilize a high-deductible plan, they’re going to get hit financially very hard if something does happen.”

Other concerns

Pediatric offices face administrative burdens when families don’t understand the plans’ payment structure, said Jill Stoller, M.D., FAAP, chair of the AAP Section on Administration and Practice Management Executive Committee.
Dr. Stoller
“Most insurers don’t have computer systems where we can … find out ahead of time what the parents should owe for that visit. So you end up submitting your claims and having to wait to find out how it gets adjudicated, then billing it out to parents. So there’s a big delay. It impacts cash flow in the practice.”
Dr. Stoller also worries about parents holding back on physician visits: “It’s scary,” she said. “How much are parents going to decide to put off because of cost-sharing?”


If HDHPs continue to be offered to families with children, AAP policy recommendations include the following:
  • Permit a generous number of primary care visits without the deductible and exempt some key procedures.
  • Eliminate deductibles for children with special needs.
  • Require employers to fund HSAs and HRAs at high levels.
  • Include all elements of the medical home in the benefit package.
  • Insurance companies should devise procedures to allow offices to determine the complete bill at the time of a visit; issue debit or credit cards to patients with HSA and HRA accounts; compensate practices for the additional overhead; and encourage preventive visits.
  • Primary care offices should assign a staff member to answer parents’ questions.
  • Policymakers should pursue alternative strategies to reduce health care costs without affecting primary care.

Budd Shenkin

Sunday, April 20, 2014

A Sad Tale in a Teaching Hospital

My father's friend was Sy Axelrod. Sy was a doctor like my Dad. Their third doctor friend was George Silver, and all three were Lefties from Philadelphia who trained in the 30's and 40's when the most basic ideologies had yet to be settled. Sy established the University of Michigan School of Public Health and the field they called “medical care,” to distinguish it from things like sanitation and epidemiology. “Medical care” was about the organization of medical care services. Most of the Medical Careniks wanted socialization of medical care, but they never got that far. As far as they could get was prepaid care, which became HMOs, which entailed large organizations instead of small offices.

Sy had a bracelet he wore, which said, “In case of illness, take me to the nearest teaching hospital.” That was the best way he thought one could deal with the variation of health care quality one finds in the field. Or, as my father used to say, “Every family needs at least one doctor in each generation, to protect them from all the bad care out there.”

Sy was a good Dean; he looked out for his professors and his students. He had a sense of mission, and he realized that the products that he sent forth would be his legacy. One of his professors was Avedis Donabedian, who devoted himself to the issue of quality of care; no one had done much on this until Donabedian. I remember Sy saying, “He's got his handle on this now; he finally understands it.” It was Donabedian who distinguished three levels of quality ascertainment: structure, process, and outcome. Without the structure – like properly trained clinicians – you were unlikely to produce good medical care; without good processes – doing a strep test before you decide whether or not to treat – you were unlikely to be producing good results; but of course the ultimate value of care was in the outcome, but that was very hard to measure.

They believed that the pinnacle of excellent medical care was at the great teaching hospitals; for them, it was the University of Michigan University Hospital. They had all the structural elements necessary to produce great care. Their professors were excellent and did great research. They were intelligent people who could discuss concepts and who agreed with Donabedian's concepts of quality. The house staff were highly selected and motivated. Everything was in place at the University of Michigan.

Then Donabedian got sick. I forget what his affliction was, but he was cared for at, naturally, the University of Michigan. What he found there as a patient was a disaster. Every element of process quality that he defined was violated. Coordination? Forget it. Continuity? Non-existent. Etc. He and Sy were vexed and bemused, but it was too late in their careers to think much more about it.

My Dad, on the other hand, had left the University of Pennsylvania setting early in his career, unhappily so. He was told that there was no room there for a Jew, and he found his place elsewhere in Philadelphia, getting his revenge by living well, and getting research grants and heading a teaching program independently. He bacame a world-renowned neurosurgeon with an attitude problem. Like, he thought all the NIH grants went to friends of the reviewers, although my Dad got his share. Nonetheless, he was right, there is a problem of safety-first with peer-reviewed grants. He also got his revenge by having a CT scanner before the less-nimble University got theirs, and giving them middle of the night appointments.

One time, my Dad was brought in as visiting professor in neurosurgery at the Cleveland Clinic for a week. He came back and said, “That's where you should go if you get sick!” Their secret? “They don't have any residents!” All they did was focused on patient care; that was their proclaimed goal, not the traditional three-legged academic medicine stool of teaching, research, and (lastly) patient care. As a clinician, my Dad's opinion differed from Sy's. My Dad got his coronary bypass operation at the Episcopal Hospital where he had led the staff for years, and got his atrial ablation at the Lankenau Hospital outside Philadelphia, and his aortic valve fixed there as well. His final caretaking institution was the long term care unit right in his retirement home. No academia for my Dad.

My Dad was a sensitive and argumentative sort, and very much the neurosurgeon. Sy on the other hand, had pride in his academics. Sy thought my Dad didn't understand all the relevant points, and my Dad wasn't going to take any shit from an academic. They parted ways in acrimony. It was really a shame; the three couples, the Axelrods, the Shenkins, and the Silvers, had spent many good times together, and it just ended like that. Dad said how can you take my views so unseriously and disrespect me, and Sy said if you're going to say mean things, how can we be friends. It ended.

Now, years later and here on the West Coast, you would think the medical care issues would be different, but they're not. My wife's ex-husband Bruce, the father of my step-children and the grandfather of Lola, a very nice man who has been an attentive father and grandfather and a thoughtful ex-husband, unfortunately has esophageal cancer. After local oncologic treatment he had his surgical excision at UCSF in an eight hour procedure. I have no doubt that the surgery was excellent, but five out of ten nodes were positive for cancer, and there was local invasion. Such a disappointment.

He went home and lost weight, and then after a few weeks started retching uncontrollably. He went for care back to UCSF and got … a resident, wouldn't you know. A pompous resident. A resident who didn't see why he had to be admitted; after all, it wasn't something that needed an operation right away, I guess he thought. A resident who while he talked turned away from Sara, Bruce's daughter, who is the physician for this generation of the family. It was hard to contact the attending physicians who had operated on Bruce; they were signed out to the residents.

But Bruce was eventually admitted, after spending an interminable time in the dark interior holding area next to the ER, with curtains separating four patients, the others having to listen to Bruce's retching. After two days, on Friday no one rounded on him. Sara discovered by looking at the chart that his sodium was down to 130, too low. She tried to contact the residents who were taking care of him but was unsuccessful. Today on Sunday the sodium is down to 128 and he had not been rounded on by the time Sara finished her own rounds on her patient. Sara had the nurse on the floor page the residents three times and they finally responded that they had 40 patients to round on, had been going since 6:30 AM, and he just wasn't their highest priority. The nurses told Bruce's wife that he might be discharged today. Sara told them not to accept discharge with a sodium so low. Besides which, Bruce has a jejunal tube inserted for feeding and no one has taught his wife how to use it. And of course there is still little discussion of a diagnosis – why is he retching? There appears to be no game plan. Bruce had been scheduled to see the oncologist at UCSF to see if any further chemotherapy would be helpful, but that was the day he was admitted, and there has been no contact from that office.

American medicine is sick, clearly. The system is unarticulated. UCSF doctors are great in what they do, for the most part, but as an institution they don't take care of patients very well. My Dad had it right – we need more Cleveland Clinics. There are calls for “centers of excellence,” and they would be great. But large institutions can go off on their own tangents for their own purposes and lose track of the individual mission of medicine. Residents need to be trained, but throwing them in the pool as asking them to swim might not be the best training regimen. I could go on about academic institutions, I guess, by why do that? Just to say, my Dad probably had it right, and here we are with the same problem all these years later. I feel so bad for Bruce, and for all the other patients who have to endure the ill effects of poor organization.

Budd Shenkin