Businesslike Healthcare

Paul Levy has another interesting post:

http://runningahospital.blogspot.com/2014/12/when-company-is-run-by-droids.html?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+blogspot%2FmJlm+%28Not+running+a+hospital%29.

In it he recounts the the practices of Heartland Regional Medical Center, of St. Joseph, Missouri. Basically, Heartland is the Scrooge of healthcare. They pursue debts with a fervor and an unfairness that is hard to fathom. Someone gets sick and comes to the hospital, fails to sign up for the hardship program that would reduce charges, and thus becomes ineligible to sign up when the program is eventually discovered, because they didn't start out as members of that program. Because there is a cap on how much they can recover from one paycheck, Heartland sues both wife and husband to get a part of each paycheck. Etc.

It's bad enough when corporations in other fields pull this. But in healthcare? Yes, healthcare needs better business methods. But when you think about it, "businesslike" seems to have two separate lines of thought, even two different meanings. On the one hand, good business is knowing your costs and recovering them, producing a better product, increasing efficiencies, etc. On the other hand, business practices can be rapacious, grab the money, go for the gold, do whatever it takes, etc. When people say that healthcare should be “run like a business,” mostly they mean #1, not #2. But if you confronted Heartland, odds are they would say “we need to run it like a business,” and mean #2, not #1.

Reading this reminded me of the dinner I had last Wednesday with two healthcare consultants and my long time close friend, Steven Wright, who is at once idealistic and ethical, and a practical and effective healthcare manager. Steven has run many programs in the mental health and alcohol and drug areas, and inevitably takes a failing program to effectiveness and profitability. He most recently did this with Thunder Road, an Oakland program for troubled youth. He brought this program to effectiveness and profitability, although a program in this field will never be a big winner – just breaking even is an achievement. Unfortunately, bringing the program to profitability was soon met with the declaration from Sutter Health, the owners who inherited the program, that Thunder Road had to be sold, because it didn't fit in with what they were trying to do, maybe didn't fit with their “core competencies.” The health consultants we were dining with nodded with sad and knowing assent. They know healthcare corporations like that.

(It reminded me also of the new owner of The New Republic, a magazine that had never run a profit and was never intended to. Let's go vertical, let's go digital, let's go Silicon Valley, said the billionaire owner who had been the roommate of Mark Zuckerberg at Harvard. Let's make money. Ambitious, arrogant, steeped in the modern digital culture that produces greedy young jerks. But I digress. Let him be a jerk, and I never liked The New Republic that much anyway. Maybe he'll learn something.)

But you just have to think, is profit an objective, or a constraint? If your objective is to help people one way or another, then profit can be a constraint – you can serve people, but only with the constraint that you can't lose too much money doing it, or you will go out of business and help nobody. If, however, it's the reverse, you then want to make as much money as possible, with the constraint that you do have to help some people along the way. Or at least not hurt them too much. Or at least not get caught hurting them too much, which would then start hurting profits.

So, if I look at a healthcare program, I have to think: OK, run it in a businesslike fashion, but is it businesslike #1, or businesslike #2? Are they doing well by doing good, or just doing well? The difference is pretty important.

Budd Shenkin

How Sibelius Lost the Election

Election results are influenced by so many factors that interpretation is always necessary, often contentious, and mostly unprovable. While truth might be elusive, opinions most certainly are not. This is a fortunate circumstance for those who opine for a living, and for those conversationalists and bloggers who opine for a hobby, both of whom can be disbelieved, but neither of whom can be disproved. Or, to put it another way, competing for cleverness in interpreting elections can yield profits for some and lots of fun for others.

Thus it is with some humility but little fear of disproval that I offer my simplification as explanation for the November 2014 election. I believe that the Democrats lost the election more than a year prior to the actual voting, specifically on October 1, 2013 and the ensuing week, when the Obamacare .gov website failed. We can't even say “crashed,” because it didn't get that far. Instead, it just pathetically sputtered in anguish for weeks, and thus confirmed the public's worst fears about government and about Democrats – which is, that for all the reliance that Democrats put onto government, it just doesn't work.

It was the Republican mantra – largely and shamefully unopposed by the Obama Administration and Democrats in general – that Obamacare wouldn't work, that it was poorly designed, but also that government itself just can't be relied on. So here was the test – rollout! Places, Action, Camera! If it worked the way it should have, the Democrats would have been able to trot around the track in splendid victory, and their abdication of verbal defense would have been excused by the actual demonstration of competence. There would still have been the publicized failures in individual cases (many false), but they would have fallen by the wayside as cascading numbers of signups rolled in. Glory and Triumph!

Instead, the failure was ignominious. Instead, the Democrats were covered with the excrement excreted by website. There were were promises, there were mutterings, there were statements, there were reports that Obama was “really pissed off.” But mostly we awaited the advent of the A-team and the 60 day fix, wondering why the A-team hadn't been there from the start. It was pathetic.

But actually, even then, with the lurid failure that was the rollout, Obama still could have saved the day. If he was as reported “livid” in private, he could have shown it in public and acted on it. Maybe he didn't want drama because it cuts across the grain of his personality; maybe through the years he has learned not to be an Angry Black Man. But whatever it was that inhibited his rising up to the occasion, it's a shame. If he had declared his lividity publicly; if he had fired Kathleen Sibelius by the end of the week; if he had taken the occasion to declare (as I urged at the time in these pages) that governmental cyber-incompetence was intolerable, and that the site would be up and functioning in 60 days no matter what!, and that he was launching a multiyear effort to make the government cyber-competent beyond all suspicion, and that he was asking Silicon Valley to help him in this the way that industry geared up for the World War II, albeit on a more limited scale – if he had raised the stakes that way, he could have triumphed in the end, and maybe even gotten his approval rating up over 50% by election time. I think it would have worked.

And actually, if he had done that, Sibelius could have come out OK. She could have announced her resignation, saying that it happened on her watch and “mistakes were made,” implying “not by me,” and that she was falling on her sword the way a good commander should. She would have been defended and showered with praise for taking the consequences the way a leader should, and she would not have been the dead meat she is now. She would have “taken responsibility.” Obama would have been “tough.” The government would be seen not to have failed, but to have learned and moved forward, and Obama would have made lemonade out of a lemon.

That's what they should have done. But they couldn't do it. Obama is a cool personality, self-protective and cautious, and truthfully, he lacks the necessary decades of experience to be able to pull it off. And Sibelius is just that good little Catholic schoolgirl who also can't rise up and connect and draw us in. So even though the website actually got fixed, and even though Sibelius actually left in a few months, the damage was done. They were fried, and the Democrats up in 2014 were fried along with them.

Damage happened because suspicions were confirmed. Doubts were sown by the super-aggressive Republicans, and government, truthfully, has failed all too often in recent years. Democrats depend on defending governmental action, and Republicans depend on attacking it as incompetent, and thus call for downsizing rather than strengthening. This background made the dramatic narrative of incompetence believable.

There are other features of the election to note. It seems ironic to me that many of the Republicans who won on Tuesday were businessmen, who, like Mitt Romney, trade on their reputations for being able to “do things.” On the one hand, they say that government can't work, but on the other hand they say that they can make it work. But to the extent that the election shows anything beyond turnout of the elderly white and non-turnout of youth and minorities, it is a rejection of the Democrats, who aside from the key failure of Obamacare.gov, ran such poor campaigns, just as they had not spoken up for several years now, even fatuously not stating that they had voted for Obama, or featuring how they could and would oppose Obama policies. Sorry, folks, you can't do that if you're in his party. You all have to hang together and sell the policies and push back at the banalities of the opposition. You were politically quite stupid. Stand up, be smart, be counted, and ooze empathy, and you will win your fair share. Retreat, and you will be enjoying private life. Lesson perhaps learned, let's hope.

So, that's my thesis. My hope is for a Democratic regrouping and rethinking not so much of policies, but of public stances. You just have to be forthright and sometimes dramatic. You have to show emotion and determination, and you have to be 'splainer-in-chief yourselves. Nobody is going to give it to you. Chickens do come home to roost.

Budd Shenkin

Everyone Makes Money Off Of Medicine

Last night at the Goldman School of Public Policy at UC Berkeley – my school! – I heard California Insurance Commissioner David Jones, a very engaging and impressive speaker and person, talk about Proposition 45, which will be on the ballot this year. Prop 45 would empower the Insurance Commissioner to review health insurance premiums for reasonableness, and rescind excessive increases for cause. Far from revolutionary, this power already resides in the state insurance commissioners in 37 other states, and a similar power resides in the California Insurance Commissioner for many other policies, such as auto and home owners insurance. Naturally, the health insurance behemoths have raised $37 million to fight against 45.

It surprised me at first that the California Medical Association has lined up with the insurance companies, as has CAPG, the California Association of Physician Groups, since doctors and health insurance companies are such enemies. Jones opined that the docs probably feared that putting pressure on insurance prices would cascade down to their own fees. Makes sense. It's surprising that the nurses are for 45 – good for them, for a change.

Dean Henry Brady puckishly asked why there needed to be regulation at all, since there are four predominant players in California – Kaiser, Anthem Blue Cross, Blue Shield, and Health Net. Isn't that enough to compete? Answer: no, it isn't. With an impressive show of wonkish economic argot, Jones swatted that challenge away with ease, saying that in lots of fields four isn't enough, that the barriers to entry in health insurance are enormous – just the financial requirements are staggering – so regulation is necessary here. He also gave some pungent examples of unwarranted rate increases that included the ill-advised California Blue Cross increases in 2009 that pushed the ACA over the finish line, a true “what were they thinking?” moment.

But that set me to thinking yet again, who exactly is it that is against health costs rising? Consumers, yes, and consumer groups have raised some money to support Prop 45, although not in the ballpark of the corporations with vested interests. But who else? Everyone in the industry wants a piece of the pie. Even some economists observe the support to employment provided by the health care industry, which is kind of stupid if you think about it, since it is disguised unemployment, really, employing people wastefully where they are not needed.

When Detroit was like this, and everyone in the industry was happy to have prices high (and quality low, but that's another matter), the Japanese realized that ships could carry cars and made a bundle as Detroit hollowed out. I have always thought that health care was impregnable to foreign assault. But I'm now wondering, is it really? There is already medical tourism to Asia for surgery – you get the operation, airfare, luxury hotel, and for all I know, a girl to help you through it (speaking as a guy), and save a bundle in the process. Maybe that's just for starters. Telemedicine is coming, and virtual visits. Radiology is being offshored to India, especially during our night and their day. Telemedicine can be pretty bad as it now stands – a testimonial from an enthusiastic woman in a recent SF Chronicle article raved about how her migraine was gone in hours after antibiotics prescribed via telemedicine. Antibiotics for migraine? But that can no doubt be improved. You never know what people will come up with.

High prices leave an industry vulnerable. Price regulation can be their best friend, fight it as they might. But there is no boundary to the shortsightedness of the health insurance industry, let alone private-spiritedness. It is good to hear that at this point Yes on Prop 45 polls 10 points ahead of No. I think I'll distribute some leaflets up and down my block. That's the least I can do for the American economy.

budd shenkin

Pediatrics and the NFL

So much starts at the beginning. As a pediatrician I'm used to looking at the long curve of life, and trying to help people adjust that curve for their kids at the beginning. We promote physical health – exercise! – and we prevent physical disease – immunize! But beyond the body, we try to promote and prevent with behaviors as well as physical health.

So as a pediatrician, I looked at the recent NFL problems of personnel misbehavior off the field with a weary familiarity. Yes, athletes tend to be spoiled by adulation and indulgence by organizations that hope to benefit from their skills. Yes, their sport is violent. But no, these are not just “dumb athletes.” They are people of good intelligence and character who just didn't get the early training – and pediatric guidance – that they should have.

I looked at the Ray Rice video and cringed along with everyone else. It was clear that Janay was coming at him – she had a lot to say, and it didn't look complimentary. She appeared pretty verbal even in a silent video. I saw Ray's bottled up fury. What could he do? I wanted to yell out to him: “Ray, use your words!”

I know that sounds all touchy-feely and nerdy, and to some ears it sounds unmasculine. Women talk and talk and we men drink beer with each other and grunt and laugh, right? Well, no, not right. Women might be naturally more verbal on average, at least in our society, but men can and should learn to use language instead of physical strength. This can be learned! It needs to be learned.

Parents teach kids to use words instead of fists. Even if the parents themselves lack the verbal and personal skills needed, they can send the kids to preschools to learn to use their words. My own children got a full dose of using words at a preschool that was decidely unacademic, but instead stressed social skills and talking with one another, and conflict avoiding strategies. If Ray Rice had been my kids' classmate, he would have had his teacher's voice in his mind. He would have heard her saying, “Ray, use your words!” And he would have had those words to use right there in his mind.

Then we got the grim news about Adrian Peterson, that wonderful running back whom I had always thought a fine man. My God, hitting his four year old with a tree branch? And then Charles Barkley saying that that's just the way of the South? Did your families never go to a pediatrician? Did you never hear about not hitting children, and in fact not hitting anyone? Hitting with a switch? My pediatrician (OK, also Northern and Jewish) mind just boggles.

Gentlemen, hitting begets hitting. Hit a kid and he will kick a dog, and when he gets older, he will in turn hit a kid and who knows whom else. Do you think fear of bodily harm is what keeps people in line? I'm not advocating guilt and shame, understand, but there are other things that work. Most people turn out like their parents, so setting an excellent example is the most important job of parenting. Discipline can be exacted by direction and attention and by setting proper incentives. The most important of all is positive reinforcement. Catch your kid doing something good, and praise him! Show him. Set expectations, set up consequences of bad behavior that withdraws privileges, give him a time out if you want. There are lots of things to do. But Adrian, and Charles, please, hitting is not the right way.

As pediatricians we try to get things right at the start, to set the curve of life in a positive direction. We try to direct our parents and their kids to positive interactions, to positive child rearing, to verbal self defense and explanation. Maybe it seems wimpy, maybe it does. But maybe some wimpiness is just what the doctor ordered. It sure beats cold cocking the girl you're going to marry.

Budd Shenkin

A Well Child Physical for Two Sisters

I had two little girls for check ups, ages 3 and 6, and their efficient-appearing mother. When sibs appear like this I generally do “double physicals” – that is, sisters together. That's always a nice thing to do, do it together. You can cover the things that apply to both, you can take a topic and make one comment for age 3 and another for age 6.  This is the way a mother thinks, anyway: column A for one and column B for the sister.  You can compare and contrast.  You can watch how the family interacts. It's a nice family thing.

So I didn't hurry; I felt like doing a really good job. They were nice little girls.  The 6 year old maybe wants to be a doctor, so I showed her how to wash her hands before you see your patients. I talked to them quietly and with some humor, as is my wont. I had them jump together. I asked the 6 year old to show the 3 year old how to hop, which she did quite well. I did some developmental queries, which were normal. I asked them both if they pooped every day, and if they had belly aches – they did, and they didn't. We looked at the growth charts, which were normal.

I imparted wisdom. I told the mother how we can say all we want to, but most of our children's behavior will mirror our own. If we are nice to people, they will be, too; if we are mean, so will they be. In the end, our knowledge of our impact on our children is a prime motive force for us to clean up our own act.

I asked them if they could swim – a prime safety concern. They can't yet. The mother can, however, which is good. I sympathized how it is hard to mobilize to get to a pool, lessons, etc., but opined that it was worth doing, and why. I asked about physical activity, which they get a lot of. I asked about screen time, which is limited in their house.

The mother objected when I tactfully examined the 6 year old's pubis while she lay down, saying she didn't want males to look there with her kids, and she didn't know why she had been assigned a male doctor. I told her that I get a little edgy examining the older girls myself, and usually urge them to switch to a female sometime after 11 years old. But while it's important to be careful – Uncle Phil might not be a safe babysitter – here we were with a doctor and being chaperoned by her, the mother. I thought it would be important for the girls to be able to feel safe with a trusted male, for their own future benefit. I hoped the point got across.

I took my time with the visit, not rushing, although you can never cover everything. I felt that I was really doing a good job with them. And then I said, “Is there anything else you would like to talk about?”

To my surprise, the mother responded, “Actually, I didn't know it would all take so much time. I thought I would just get the form signed and get out of here. Are you done?”

“Yes,” I said, “sure. I do think it's important for you to feel that you have a trusted source of care to come to here at Bayside.” In other words, there is something at stake in making a personal connection here.

And she said, “I do.”

“And I hope that the girls feel secure with their source of health care also.”

“Yes, they do,” she said.

So that was it. Kinda funny. There are forms people need filled out, and we take advantage of that obligatory visit to foist good health care upon them. Who knows, maybe I did some good. Who knows?

Budd Shenkin

On the impertinence of others

My lifelong friend is Bob Levin.  He always says that when we were young we didn't like each other. I always answer, Well, I liked you.  He is actually a sweetheart.

Today Bob has written in his new blog about his adventures in local establishments trying to stand up for order, as others push themselves forward in competition over very little.   Check it out at http://www.theboblevin.com/?p=245.

I have had my own difficulties with the trespasses of others. I have always thought that saving a place - like, coming down at 7 AM and plopping your bags onto a couple of poolside lounges that you will then occupy physically from 10 AM to 11 AM and 2 PM to 3 PM, was typical New York (or LA) behavior, and that resorts should be forced to post, much as McDonald's has to post calories, a New Yorker Quotient, so we could avoid high NYQ hotels.

My belief in this thesis, I believe, conforms also to my seeking to identify gender and ethnicity of the latest terrible driver, driving 50 MPH in the left lane so it's all clear ahead and people driving a normal speed have to pass on the right.

It seems, however, that the NYQ and the bad-driver identification do not provide usable results.  The reserve a seat behavior spreads to all groups because it works, since most hotels don't enforce a limit -- some do, and good for them!  Likewise, police enforce mostly a speed limit rather than competence and courtesy.

So there you are.  I believe this lack of enforcement is lamentable and anti-social.   By the broken windows thesis, it's a short step from these misdemeanors to ISIS. 

Such a world!

budd shenkin

Racial Makeup of Police Departments -- Check Out Berkeley

The Ferguson, Missouri problem has located an underlying problem of American society that many of us whites were not well aware of.  Police departments are predominantly white, and are not changing in step with the demographic changes of the country. 

I see this as a problem with two dimensions: employment and authority.  Immigrants cluster in specific places according to their homelands -- you go to where you have friends and family who paved the way, so that, for instance, Ethiopian communities are strong in Washington, D.C., Seattle, and Oakland, and Jews came to the Lower East Side.  Employment patterns are similar -- Merrill Lynch, for instance, was well known as the Irish financial institution.  So police departments recruit the familiar as well -- whites (but I don't know why they all appear to be so beefy).  Especially in days of an employment squeeze such as we now have, these corridors to employment will be especially prized and difficult for outsiders to penetrate.

But there is also the authority dimension.  Official America and moneyed America is still pretty white.  Keeping the "other" in their place is still the role of law enforcement.  Official America is thus very happy with a white police force.  It seems that police forces act in the expected way, with covert racial profiling hassling the "other."  I'm not sure I accept all the statistics about who gets stopped, since minority populations are generally poorer and possibly less inclined to follow the law and thus more liable to be the subject of a righteous stop.  On the other hand, the accounts of black men being pulled over many times and having to keep their cool are very convincing.  Very.  So the authority function of white cops keeping minorities in subjugation seems pretty obvious.

I hadn't focused on all this well because I am looking to relax, to say that things are much better than they used to be.  But Ferguson has helped me see that I was just being lazy.  In fact, there is so much racism in our country, and it is so unfair, that it makes me depressed to think about.  OTOH, I am more and more satisfied that I insisted that our practice, Bayside Medical Group, serve all groups equally and with respect, taking Medi-Cal patients unlimitedly.  At least to a certain extent, we were part of the solution and not part of the problem.  I remember that one of my patients said about me, "Dr. Shenkin is a good doctor!"  By emphasizing the word "good," she divided the profession into two, and if you were "good," it meant you were someone who cared and gave patients respect.  I'm hoping not all of that goes down the drain now that I have sold Bayside.

My wife and I often ridicule the city of Berkeley, where we have chosen to live.  There are so many idiots, and so much trendy crap, and so much PC.  But we choose to live here.  And here below is one of the reasons why.  In today's NYT there is a wonderful article that exhibits the racial statistics of police departs throughout the country.  It's generally pretty dreadful.  But here in Berkeley the PC influence has actually worked.  It makes me happy and proud.  And sad to see the rest of the Bay Area lagging behind, perhaps more in tune with the rest of the country than with us.  The statistic "+__%" in the list below describes how much more the police force is white than is the community they serve.

Budd Shenkin

San Francisco

Minorities make up more than half of suburban San Francisco towns like Daly City, Hayward and Fremont, but their police departments are heavily white. Berkeley has more black officers than white, and the share of white officers in the department is on par with the share of whites in the city.

San Francisco

Department	WHITE BLACK HISP. ASIAN OTHER
Daly City, Calif. Pop. 101,123 108 police officers	Residents Police	Police Dept. +52 pct. pts. more white than residents
Hayward, Calif. Pop. 144,186 191 police officers	Residents Police	+50 pct. pts. more white
Fremont, Calif. Pop. 214,089 185 police officers	Residents Police	+48 pct. pts. more white
San Bruno, Calif. Pop. 41,114 48 police officers	Residents Police	+47 pct. pts. more white
San Mateo, Calif. Pop. 97,207 114 police officers	Residents Police	+45 pct. pts. more white
Sunnyvale, Calif. Pop. 140,081 207 police officers	Residents Police	+36 pct. pts. more white
Santa Clara, Calif. Pop. 116,468 137 police officers	Residents Police	+34 pct. pts. more white
Redwood City, Calif. Pop. 76,815 91 police officers	Residents Police	+33 pct. pts. more white
San Jose, Calif. Pop. 945,942 1,386 police officers	Residents Police	+31 pct. pts. more white
Richmond, Calif. Pop. 103,701 161 police officers	Residents Police	+31 pct. pts. more white
San Rafael, Calif. Pop. 57,713 73 police officers	Residents Police	+26 pct. pts. more white
Albany, Calif. Pop. 18,539 27 police officers	Residents Police	+25 pct. pts. more white
Alameda, Calif. Pop. 73,812 99 police officers	Residents Police	+23 pct. pts. more white
Oakland, Calif. Pop. 390,724 725 police officers	Residents Police	+18 pct. pts. more white
El Cerrito, Calif. Pop. 23,549 42 police officers	Residents Police	+18 pct. pts. more white
San Francisco, Calif. Pop. 805,235 2,303 police officers	Residents Police	+12 pct. pts. more white
Palo Alto, Calif. Pop. 64,403 87 police officers	Residents Police	+9 pct. pts. more white
Berkeley, Calif. Pop. 112,580 181 police officers	Residents Police	+1 pct. pts. more white

Obama's Foreign Policy Makes Medical Sense

In medicine, sometimes we have to wait. “Tincture of time” is a traditional strategy. You have to let the body react, you have to see what is going to happen, you have to resist the temptation to treat right away, because it might not be necessary, and because treatment later on might work better. Yes, it's most often best to catch an ailment early, but when you do, the judgement of the clinician is sometimes just to wait. And when the time comes to act, sometimes the best intervention is not dramatic, but just a well-aimed lance, perhaps; boom boom and it's done.

And sometimes you just don't know what you're dealing with. When I was a senior medical student I made rounds with infectious disease specialist Sam Katz. He would be called in for a case of infection on the wards of Children's Hospital in Boston. Often it wasn't clear what the infection was. So he would say, take the child off all antibiotics and reculture in three days. The housestaff (residents) would protest – this kid's sick! I know, Sam would say, but we need to know what we're dealing with. Take him off all antibiotics (it would take time for the antibiotics to clear from the system so we could get a good culture) and we'll see if we can find the bug after three days. Have some confidence here that the kid is not going to expire – if he gets a lot worse, we can restart early.

Which is a roundabout way of saying that I am one of the apparently few defenders of Obama's foreign policy. Everybody's dumping on the guy with I told you so's. As though it's obvious that an earlier intervention would have prevented the ISIS Syria-Iraqi insurgents from coming this far this fast, and as though it's obvious that this is far too dangerous a place for us to be. Hillary opened her big mouth to distance herself from a sensible policy once again – she claims to have learned the lesson of Iraq, but I doubt it.

Myself, I think Obama, in his very understated way, did the subtly courageous thing to do, he let the infection come to a boil that could be lanced. While doing it, he effectively got rid of the noxious Maliki side infection. Don't want us? Fine, we're out of here. Let's see what will happen. Let's be confident we can handle it in the future. Let's not let ourselves be wagged by the noxious tail.

Now the body has reconstituted itself, we have started to mobilize our forces with a better constituent body to wage the counter-war, and we'll supply some medicine while that tail won't be wagging us any time soon. We also found another functional organ to support in the north, the Kurds. They want us, they have a state that is working (Erbil has a Jaguar dealership), their army will fight. Obama has been quite right to say that they have to want it at least as much as we do – we'll just have to see if the Iraqis do or don't.

Meanwhile, for the situation just a little north of there, Obama refuses to speak out dramatically against the posing-against-the-sky-as-background Putin. Patiently and privately, he says, you don't want to do this. He counters every bishop move with a pawn blocker, and moves his pieces behind the lines of attack to more powerful positions. He has a sense of proportion.

I have been quite critical of Obama in the past, and maybe I'm just the kind of guy who looks for an opportunity to take the other side. Nonetheless, let's see what happens. My sense is that his caution and his subtle risk taking will prove in the end to be admirable and effective.

Budd Shenkin

An Electoral Strategy

Yes, there are huge questions facing our country. War or peace, renewal of the cold war? Immigration? Economics? All important. But we know enough to understand that elections don't often hinge on important questions; they hinge on feelings, emotions, and immediate concerns. As in, abortion, gay marriage, giveaways to the lazy poor.

Thus comes my proposal for a cogent electoral strategy. Hear me out.

Last week, my security was breached. My bank was contacted for a transfer of funds to a third party. All my financial institutions were contacted in a similar manner. Later, all my email contacts were spammed for information, and false invoices were mailed to them (and to me.) And yesterday my bank was presented with a check with my wife's forged signature that was cashed at a Southern California credit union (my corporate account was defrauded via a credit union too, some years ago. What is it with credit unions?) The fraudsters have not received any money from me that I know about, and I have taken the laborious but necessary steps of changing my bank account number, changing all passwords and User ID numbers, cleaning up my computer, etc. A pain, and emotionally disorienting, but so far, so good.

I am not alone. Everyone I have talked to has told me I am only one in a long line. Many of my friends who have been spammed have recounted their own family's misadventures. Anyone who has visited Target knows the feeling. The amount of resources expended by institutions on this sort of fraud must be enormous. I wonder what the total population impact and total cost is. It's got to be huge.

At the same time, it is excruciatingly difficult to identify the miscreants in these frauds, and difficult even to report them. I can't find a way to tell Google that someone created a new email address called budshenkin@gmail.com – one “d,” such an insult and abomination! There is no fraud unit ready to jump into action. The bank said originally that their major function would be to deny payment on the fraudulent check, and leave it at that. They said I could do something personally if I cared to. I demanded to see a senior officer who said he would contact the FBI. I doubt that this will lead anywhere; after all, I haven't even lost money. My wife's identity was stolen last year. Amazingly they caught the people involved trying to charge on her account in a Sacramento store – and the Sacramento police let them go! WTF?? In essence, there is precious little enforcement.

Now let's look somewhere else in the public policy sphere. We know that the prisons are overflowing, and needlessly so. The failed War on Drugs is a major source of all the incarceration; everyone knows that. Why the War on Drugs has not been able to be shut down and replaced is a mystery of the usual public policy and bureaucratic stagnation. (In my own field of pediatrics, the self-maintenance of the bureaucracy around lead poisoning – an affliction that sank to very low levels decades ago as soon as gasoline was made unleaded – has been absolutely astonishing. The public health bureaucracy employs thousands. But I digress.) But there is clearly movement as marijuana is being legalized, despite the entrenched interests who benefit from maintenance of its illegality.

So, let's put this all together. My proposal is this: Let's take the money from the War on Drugs and devote it to the War on Credit Care and Online Fraud. And let's do a Prisoner Exchange – let the marijuana offenders out of the clink, and refill it with the Fraudsters. That should keep the Prison Guard Union happy. I'd call it The Great Pivot, “Out of drugs and into fraud!”

Sounds like good public policy to me. If someone were to run on this platform, can there be any doubt it would be an overwhelming winner? Any doubt at all?

I thought not.

Budd Shenkin

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