The World at War - Foreign Policy and Priorities

The attentive reader will recall that I opined on Putin and Marxist thought last week. Today, I'd like to focus on Obama and the United States.

The world now finds itself with violent and dangerous brush fires raging widely – Israel-Hamas, Libya, Iraq, Afghanistan, Iran negotiations, and our friends in the Ukraine. ( Not to mention Ebola in West Africa - wow!  But we'll keep that out of this discussion.)  The role of the President at this time is to sort out priorities – what do you do with whom, in what time frame, and how. The role of all our opponents is to take advantage of the chaos to use the distractions to sneak off and do what they want to do.  So while making priorities is hard under duress, doing so also presents an opportunity to show the world where you will put your resources, and what you care about the most.

The Gaza crisis certainly grabs headlines and strums heartstrings. Kerry is spending a great deal of time there. This is a mistake. Although there is a humanitarian crisis, there is really little for the US to do. If you look at the Middle East, the conservative forces there see the threat of radical Islamism and are starting to act accordingly, as on the other side Turkey and Qatar try to take advantage (a couple of years ago when we were in Turkey we read that Erdogan was doing some Holocaust denying – that's the kind of guy he is.) They will all sort this out. In the meanwhile, it is in our interest to let the Israelis clean out the tunnels and do whatever else they want to do with Hamas. They will live with the results. Even if we were to be fully, fully engaged, who can predict what efforts will yield what result? It's just unpredictable. The Israelis' long term problem is not so much Hamas as the demographic challenge of their own Ultra Orthodox and other Rightist-enablers, and once again, there's not a whole lot we can do about that. So, as a matter of priorities, I would reassign Kerry and leave this firefighting to someone else. Perhaps Susan Rice – why let only the Israelis and Hamas be abrasive? We are concerned, we are willing to be helpful, but it's a little bit down on our list.

Libya is going to pot with internecine warfare. Again, what are we going to do about that? The US has done the right thing by just getting our people out of the line of fire. Again, the Arab world has the most fish to fry in this situation, let them see what they want to do, and if we can help, we will. Our main task should be to avoid making enemies.  This is even further down on our list than Israel-Hamas.

Iraq is another place we can only do so much. We have called Maliki's bluff very well, and the Iraqis are now sorting it out themselves, trying to develop a new government that may or may not be able to govern and to include Sunnis properly. They can't do worse than Maliki. It's true that a new state run by extreme Islamists could in time be a threat, and even if it would not threaten us directly, it is worthwhile blocking Islamic extremists from having a state of their own. But as threatening as it would be to us, it would be much more threatening to the regional powers. We should stand by ready to help, but that's it. I would continue to have this area staffed at the Assistant Secretary level. 

On the other hand, although it is less spectacular than the wars, the Iran negotiations are in reality more important. What is at stake is the balance of power in the region and actually in the world, and how that balance will be addressed. We are trying to maintain the rules as they have been, with nuclear weapons increasingly restricted, not proliferated. It would be very useful if the US could show the importance of this issue by having the President address this personally from time to time, and having Kerry stop running around the world and instead concentrating on the negotiations personally. The Iranians would be pleased. Everyone wants respect, and attention despite the distractions would show them lots of it. The President would certainly be taking a chance with his prestige, but that's the game. It's a better big goal to have than the stupid one that W attempted. This should be the President's very strong priority number two.

Finally, number one priority should be the Ukraine. The stability and prosperity of the world hinges

on a certain level of trust and stability. If a country is going to revert to 19^th or 18^th century land grabs, neither trust nor stability will be possible. Thus, the collective world needs to enforce this modern norm, just as they did when Iraq invaded Kuwait – no land grabs.

What is Putin after? Territory, of course; a sphere of influence; prestige. I believe he can't have been anything but severely stung when Obama dissed Russia as a “regional power” in a Romney debate. “Regional Power, eh?” you can hear Putin saying. How'd you like this Regional Power crawling up your ass?

This is really the most difficult of the tasks. The EU should be concerned, but France still wants to sell Russia the superships, Germany wants to keep trading, and even England doesn't want the Russian money to disappear. It's probably about time for Obama to send them black umbrellas. He should do this with style, making personal visits and instructing Kerry that this is his first priority. Kerry should do what Jim Baker did in the run up to the First Gulf War – globe trot for money and troops. Forget globe trotting for a cease fire – that's for Susan Rice. Maybe Obama himself should visit the Ukraine. Certainly the US should be giving the Ukrainians targets in real time – as long as they do everything we want them to do to construct a government that works and doesn't steal. The risk of a shooting war should be a danger to everyone, and Obama shouldn't do his favorite negotiating with himself to dissuade him from taking the risk.

Just as with the Iranians, making this the highest US priority would give Putin the center stage as a World Power, not a Regional Power. Respect is a precious commodity, but unlike other commodities, it doesn't deplete any coffers. Like love, there is always more available. So give it freely. You don't need to protect your resources of respect. And in giving respect, be prepared to receive it as well – after some more violence, probably and a minor game of chicken.

So that's my recommendation. Make your priorities, Mr. President, and don't bargain with yourself the way you did domestically. Maybe it's very simplistic. As my friend Michael Nacht, who actually did negotiate with the Russians, likes to say, "What do I know?"  But that's what I think.

Budd Shenkin

The Corrupt Idiocy of Blaming the Victim for Emergency Department Use

This note explains once again that poor people go to Emergency Departments for sick care:

CQ Healthbeat:  More Medicaid Families Sought Emergency Room Care, Statistics Show
Three-fourths of children treated in emergency rooms in 2012 were taken at night or on weekends, according to federal statistics released Thursday. The figures also showed that families on Medicaid were more likely than those with private insurance or without any coverage to use the emergency department. The frequency with which people use pricey emergency department care is getting attention as policymakers struggle to find ways to lower federal health spending. Lawmakers want to persuade people to use less expensive outpatient care whenever possible. The Centers for Disease Control and Prevention statistics released Thursday suggests that families still use the emergency room in part because of convenience, and that Medicaid families may need help in finding a primary care physician or understanding when an emergency visit is necessary (Adams, 7/25).

What would you do if you wanted to really change this situation? It's not so hard. Would you try to change the behavior of poor patients whose kids get sick? They can't change their behaviors for everything in their lives, or they wouldn't be on Medicaid, I guess you could say. What are they supposed to do when their kids get sick and they're worried? They can't regulate when they do things, and where else are they going to go, especially since they have been doing this for years and years?

No, you wouldn't try to change their behavior. What you would do is have services available when and where they are needed, and you wouldn't have them in the emergency department, you would have a clinic very near the ED where they were taken care of by primary care physicians and advanced practice nurses under supervision. It wouldn't be in the most expensive facility imaginable, it would just be a clinic. Unless you wanted it to be the most expensive facility imaginable, because you want to get paid for it at the highest prices available.

Could you afford to run a clinic and get paid Medicaid rates? Probably, yes. If not, you could cut a deal with Medicaid – not that it would be easy dealing with that government bureaucracy, not at all, but it could most frequently be done.

But if you are a hospital, of course, that is not in your interest. In fact, Children's Hospital Oakland years ago had an urgent clinic set up just like that. But they shut it down in order to send the patients to the ED, because they would make more money that way.

Is it the case that hospitals need the Medicaid patients to come to the ED to subsidize maintenance of high intensity services that are not extensively used? Well, the truth is probably that nobody knows. The famous Harvard Business School professor Michael Porter has pointed out that hospitals have such poor accounting that they don't know what anything costs, actually.

No, this whole trope is utter BS. It is a problem that produces nothing but money for the hospitals. Hospitals do what the hell they want and they blame high costs on everyone else, even the poor. It doesn't stop. It is such crap.

Budd Shenkin

Putin's Weltanschauung, Putin's Gamble

Is Putin still a Marxist? We don't officially know. We know that he is a Russian nationalist-imperialist, but that could skip back over the Soviet time to the Czars. We know he is not a socialist, but then were the Soviets? Kleptocrats, that's more down Putin's line.

But let's ask this question: how does Putin explain the world to himself? Does he still look at the world through Marxist glasses, at least partially? All young Russians from his generation were subject to very detailed, very long schooling on Marxist theory. Marxist theory presents an entire way of looking at the world, much as do religions. The Jesuits said, “Give me a child for his first seven years and I'll give you the man.” World views stick.

Which brings us to today. Putin has embarked on a very risky campaign in the Ukraine. He has invaded a country and ripped off part of it, and is in the process of trying to rip off more. He has to think, will the Western powers try hard to stop him?

The Western powers are capitalistic. Marxist theory tells us that the state is governed by economic forces, and even if it appears that the official leadership is making decisions, it is really the capitalistic forces behind the curtain that are pulling the strings. Their motivation, Marxism tells us, is profit, pure profit.

The facts are that the Western states have extended their markets into Russia. The oil companies especially are intertwined with Russian oligarchs in projects to extract wealth from the Russian land. In addition, something like 40% of Germany's foreign trade is with Russia. The Netherlands (home of Shell oil) are likewise intertwined. London has benefited mightily from capital infusion of Russian oligarchs into the City. Will state interests of geopolitics trump the short term profitability of the companies that make up the backbone of Europe? Will Europe risk recession and a very cold winter or two, simply to protect the interests of a country far, far away, with little to offer them in terms of profits?

Putin might no longer believe in socialism, but I would wager that his world view remains shaped by Marxist precepts. I think he doubts that when push comes to shove, the capitalistic powers will forego profits in favor of the state's geopolitical interests. I think Putin holds the concept of democracy in contempt when it comes to action and power. I believe that Putin is ready to bet his political life on his Marxist precepts. I think Putin will push and push, and gradually concede only a little at the end.

And who can say it isn't a good bet?

Budd Shenkin

Innovation in American Medicine: the Case of RBCs

I was asked to do a review of this paper: Parents’ Experiences With Pediatric Care at Retail Clinics: Garbutt JM, Mandrell KM, Allen M, Sterkel R, Epstein J, Kreusser K, O'Neil J, Sayre B, Sitrin H, Stahl K, Strunk RC. JAMA Pediatr. 2013 Sep;167(9):845-50.

Retail Based Clinics (RBCs) are a great example of innovation in our system, and thus worth examining not only in themselves, but for what they illustrate.  Here's what I came up with.

American health care is clearly in a state of profound organizational transition. In contrast to countries with socialized medicine, organizational innovation in our private system should in theory be more dynamic, with many innovators trying many new things (some of which fail,) and more attuned to the wishes of the public. On the other hand, individual initiatives and the profit motive can lead to innovations that do not necessarily integrate with other parts of the system, and which may not improve quality in those aspects of care that cannot be evaluated by the patient. In addition, since the American system has very large vested interests in the hospital, insurance, and pharmacy sectors, it is possible that profit-seeking oligopolistic behaviors will predominate. It is obvious that many current innovations are both vertical and horizontal conglomerations. In a quest to improve true value, it is not clear whether the American or the more socialized systems will prove superior.

Retail Based Clinics (RBCs) are one of the most recent American organizational innovations. Ready access to acute care, especially during evenings and weekends, has long been neglected by our health care system. Large pharmacy companies have taken advantage of their access to capital and their high visibility in communities to establish RBCs on their premises to fill that access gap. While they appear to have become financially successful, serious questions surround RBCs. Do they further fragment an already fragmented system? Do they provide high-quality care? Do they succumb to the temptation to drive further profits by prescribing too many medicines to be bought at the parent company's store where they are located?

This simple but wonderfully direct study looks at some of these questions in the St. Louis area by simply asking patients who they find in the waiting rooms of 19 private practices about their RBC visits. They find that an amazing percentage of patients have been seen in RBCs – 25%. They find that they use them because of “convenience,” although almost half the visits were at times the private offices were open. There were virtually no efforts made to integrate with the medical home, by either the RBCs or the patients. And perhaps most strikingly, there is prima facie evidence that the quality of care appears to be quite poor, although presumably profitable to the sponsoring company.

The high utilization of the RBCs should be a wake up call for pediatricians in practice. In areas of the country where competition among practices is high, many practices have established extended office hours on evenings and weekends, and many practices have instituted drop-in times to avoid the hassle of appointment-making. These innovations have apparently not been seen in the St. Louis practices – perhaps the offices are full already and they see no need to please patients with more convenience.

The RBCs lack of integration into the system is dismaying but not surprising. Beyond their fragmenting effect, RBCs also undercut the viability of primary care practices by siphoning off the most profitable segment of their business (not that the practices do not contribute to their own difficulties by not being adaptable to consumer needs.) Thus, when primary care is under such pressure that few graduates are choosing that pursuit, RBCs exacerbate that problem.

Most dismaying, however, is the finding of how many antibiotics were prescribed in clearly inappropriate clinical situations, if the parents' accounts can be believed. 67.7% of patients with colds or flu were treated with antibiotics! 28.6% of patients with a negative rapid strep test were treated with antibiotics! This is clearly not a definitive study, but informal reports nationwide make this finding disturbingly not unexpected.

In a system that is so entrepreneurial, defining the role for government is especially difficult and crucial. Gathering and evaluating information would seem to be very important to help people make individual choices, and to help policy makers choose wisely. In the case of RBCs, government should stimulate studies that further explore the provocative findings of this study to see to what extent it reflects nationwide conditions. Deciding what to do about it can be a joint concern of the profession of pediatrics, federal and state governments, and the larger entities that are so powerful in our system.

Budd Shenkin

Oligopoly in Massachusetts

Some years ago – OK, many years ago – Ann and I attended my Harvard College 25^th Reunion. The highlight was an Evening at the Pops, when we were escorted to Boston Symphony Hall en masse by the police with all roads blocked off on the way. Wow. I couldn't believe it. It was great to be among the chosen. I doubted the same treatment was extended to Boston University, nor to Brandeis. Wow.

I never liked New England much. It was the kind of place that would block off streets from ordinary citizens to honor Harvard alumni. For all the hard scrabble George Higgins books and Matt Damon movies, there was the other side of small time squalor. Big time squalor, perhaps. I did admire Boston medicine, even more so since I have left Boston, and in probably no other city would victims of a marathon bombing receive such unbelievably well thought out and well executed care. But still.

Now I have been following Paul Levy's excellent and thought provoking blog at runningahospital.blogspot.com. Paul is the former CEO of the Beth Israel Deaconess Medical Center, and has a strong ethical, idealistic bent and a firm intelligence. He regularly calls attention to the ethical lapses among medical officials as they extoll the virtues of robotic surgery with their right hand and receive various favors from Intuitive Surgical Inc. with their left hand. The University of Illinois had an incredible run their in Paul's blog for a while – in the end, of course, the ensconced vested interests didn't move much, which is what happens with ensconced vested interests most of the time.

Now Paul has turned his attention to Partners Healthcare of Massachusetts, founded by Mass General and Peter Bent Brigham Hospital (whose president years ago was my good friend Jim Mongan.) Partners has been more than successful. They have formed an oligopoly of health care. There are many other providers in Massachusetts but I guess none who had the great ability to run a corporation the was Partners has done it. As a result of their success, they get terrific rates from their insurance plans – Blue Cross is predominant in Massachusetts, I think. With lots in the kitty, they are trying to expand, which is what successful companies do. They want to pick up some hospitals on the South Shore. But to do so, they need the blessing of the Massachusetts Attorney General – there is such a thing as anti-trust in Massachusetts law, and apparently the responsibility for enforcement is lodged in the office of the AG.

Unfortunately, the current AG is the redoubtable Martha Coakley, last heard from nationally as she ingloriously handed over the Kennedy senate seat to Scott Brown – that Martha Coakley, who took a vacation during the campaign, didn't she, and didn't see the point of going out and greeting workers. Now she has given Partners a free pass to expand. It was even freer until there was a tiny little outcry and she got a tiny amount of money from them to do something or other as the price of her acquiescence. Tiny. She's that kind of AG, running for Governor, God help Massachusetts. I hold a grudge, Dear Reader.

The powers that be – think police escort to the Pops – have declared that big is good. It leads to cooperation within the firm, care coordination, higher quality. They don't say it leads to lower prices, note. They say that this is just what national policy is calling for, more firms like Kaiser, Geisinger, Rocky Mountain Healthcare. One of their chiefs, arrogant as always, has declared in the past that “this is what quality costs.” He could be in the first limo headed to the Pops, I guess.

Maybe Partners does have very high quality health care, although there is no evidence that they give better care than other organizations.  Maybe they do.  But it looks much more like simple oligopoly rents.  

Government, however, can't take self-declaration as fact.  The role of government needs to be to lay out the playing field so that it is fair, and referee the game so that it is in the public interest – not like the referee in Brazil vs. Colombia, for instance, who let Brazil intimidate without correction, and look where it led. It is a hard role, because being a referee is hard. After all, your role is not to be the star, and the stars are more popular than you are. But good referees are the key to good and fair conduct. If Partners really does have something better to sell, it has to be a case that can be made for all to see and agree on, and for buyers to agree to buy what they are selling.  This case looks more like a wink and a nod among the passanoventi. (That's as close as I can spell it without a copy of The Godfather to look at.)

Unfortunately, in health care the anti-trust referees have been extremely negligent, letting hospitals merge as they will until they can price themselves as oligopolies will. It is this current tradition, and the evidence of the Coakley decision simply extends this tradition, that makes me very fearful that Accountable Care Organizations – ACOs – sponsored by Obamacare, will lead to big organizations that price-fix and don't add much quality.

Here is the link to one of the Not Running a Hospital posts that quotes yours truly:

http://runningahospital.blogspot.com/2014/07/what-scott-and-martha-got-wrong.html.

And a later post by Paul, on the subject of quality of care at Partners:

Leading? Hardly.

Posted: 11 Jul 2014 02:08 PM PDT

Well, we could scarcely expect him to say something else, but the CEO of Partners Healthcare System really went out on a limb when he told the Boston Globe:

“The formation of Partners has been a great thing. Care has gotten so much better.”

Well, no, it has not.  Here's a more accurate description from Dr. Eugene Lindsey, the former head of the state's largest multi-specialty group, which has referred patients to Partners for two decades:

If the motivation of Partners over the last twenty years has been to use its market power to really integrate care and lower the cost of care, they have failed monumentally. The care within Partners is no more integrated, and certainly much more costly than in any other healthcare system in the state, the nation, on this planet, and therefore presumably anywhere in the universe. Partners offers spectacular care in specific areas at a high cost.

Partners’ performance on some of the metrics of care that is routine in the community arguably falls short from being unequivocally “the best,” although its price never reflects that reality. What it does succeed at is finance, marketing, government relations and intimidation of other members of the healthcare industry. There has never been a credible analysis that shows that Partners' care significantly exceeds in technical quality, access, patient satisfaction, patient-centeredness, or safety when compared with the other less generously paid academic medical centers in Massachusetts.

Referring to a New York Times editorial, he adds:

Given this reality and the reality that it is the most expensive provider of care in the Massachusetts healthcare market, the Times has made an egregious error to suggest that Partners has been a leader in collaborating to control costs and improve care.

Gotta be suspicious of situations where the cops are on your side, I guess.

Budd Shenkin

Budd Joins NIMBY Nation

OK, I admit, the real villain is United Airlines, which puts the seats so close together even in business class. It's the situation.

But still. Let me tell you what happened yesterday.

As background, I have to say that I haven't been very sympathetic with San Franciscans railing against the influx of the techies. Yes, the rents have gone way up, and my cousin Allison and her roommate found it very hard to buy a house because the selling price kept being so far above the asking price. I didn't quite get the protest against the Google Bus, because I figured that UCSF has dedicated busses, and there are other shuttles, and I figured that having a dedicated bus just made other transportation less congested. And after all, tech was what has been powering the Bay Area forward all these years, what makes us prosperous.

In these unsympathetic thoughts, I erred, as I found out yesterday in row 4 of the United Airlines Business Class flight back from Philadelphia. In row 3 in front of us were two of the above-mentioned techies, I have to think. The Asian girl was in front of me, the white boy with stubby beard in front of Ann. As soon as we took off, poof! Their seat backs went back as far as they could almost in our laps, even in Business Class. Other people in other rows seemed to understand the predicament that UA had placed us in, and moderated their recline, with the exception of one heavy blond lady with too much makeup in row 3 on the other side. But most people understood.

In this situation I naturally paid some increased attention to the young people in row 3. My little lady had her legs crossed yoga style with her laptop resting on everted knee to everted knee. Her back and the back of her seat made a 45 degree angle, so it wasn't completely clear how necessary her intrusion into my knee space really was. Although she had on a dirty sweatshirt that read “California girl” - not clear who would wear such a sweatshirt – and some nondescript jeans, I think I remember, I did notice a very big rock on the ring finger of her left hand, very big. Very big. Quite a sartorial combination.

She went through her email for hours and made a phone call or two. She looked about 17 years old, so she was probably 26.

Her husband looked about 28 years old, and looked pretty much as you would expect. He lounged with legs akimbo much of the time, and actually read a book, but I couldn't see what it was. Then he attacked his cell phone for a long while. As he climbed over his wife to go to the bathroom he bestowed a quick kiss on her, although it looked like something he was just trying to learn to do casually.

It doesn't help that United Airlines sucks so bad. Crappy movies on offer, and they all run on their own schedules, not yours. When Ann had to get out from her window seat, I was happy to grab the seat in front of me and shake it a little, but Little Miss Big Rock didn't deign to notice that we couldn't get out with her rearward seat back thrust. She was too happy sitting like a little fucking princess.

So, now I think the techies are like Euro-trash. Or maybe like the princes and princesses of a conquering army. I say, fuck them, and let's trash the Google Bus. Tax the hell out of Twitter. Little shits.

OK, call me NIMBY.

Also, fuck United Airlines.

Budd Shenkin