Monday, December 28, 2015

Learning From Your Patients

Some of my best learning moments as a clinician came when a patient left me.  They liked me enough, and respected my trying to meet their needs, to let me know personally why they were leaving me.  Early on, one patient listed my faults (which were many!), including not washing my hands before I examined their child.  Another one, later on, told me I was ineffective in dealing with her troublesome child, and had me read "The Difficult Child" by Henry Turecki, which is a great book that I have recommended to all my patients ever since.  It was painful, but I learned.
And then there was the patient I had with repeated bouts of acute abdominal pain.  I had them come into the office, against their will since they thought I should be able to do it over the phone for free.  I looked at the kid, I thought about it, I walked around the room, and I said, "Does he chew sugarless gum?" 

"Why, yes, he does!" they said. 

"It could be the sorbitol," I said. 

They cut out the sugarless gum and no more stomach aches!  One of my best diagnoses.  I had been studiously reading my newsletters in pediatrics, and it paid off.
The next thing I heard from them was a notice requesting that their records be transferred to a doctor nearer their house.  So I called them up to ask why they were transferring.  They said something about the distance.
I said, "What about that diagnosis that cured the abdominal pain?"
They said, "We expect that!"
What a world.  
Budd Shenkin

Tuesday, December 15, 2015

Ta-Nehisi Coates: Between The World And Me

I just read another book I wouldn't have read except for my book club, Norm's Bookies, having assigned it. In a close vote we chose the widely acclaimed Between the World and Me, by Ta-Nehisi Coates.

The last two years have been filled with evidence of the pervasiveness of police terrorism towards African-Americans. It's incontrovertible – Baltimore, Staten Island, Ferguson, Cleveland, Chicago. All together, the picture is of police terrorism toward African-Americans.

What we have seen in these killings is the outside view. What Coates presents us with is the inside view, what terror lurks in the heart of the oppressed. He, and other African-Americans, need constantly to be on the alert, not at the wrong place at the wrong time, not pissing off the wrong cop, staying under the radar. His friend from Howard, Prince, didn't do that. He wasn't offensive, but he probably was obvious and true to his name, princely. An off-duty Maryland cop stalked him into Virginia and killed him and got away with it. That's not an aberrance, that's the standard, there are many like him, this was just the case closest to Ta-Nehisi.

Stay alert, keep your head down, know where you are. That's really no way to live. He looks at the carefree suburbanites and is irritated. Why do they get to live like that, when Ta-Nehisi has to keep his head down? He's right.

He is on less solid ground, I think, when he talks about his body and relates it to history. It's not just in his mind, they can actually kill him, get to his physical self. In slavery, bodies were captured and ruled. Well, yes, it isn't just mind control, that's true. But that is just history, and it isn't just African-Americans, it's everyone in the world. People didn't just assemble and reason together, after all. Gangs got together, ruled the unorganized and fought the other gangs until finally one gang ruled everything. That's the way states began. The treaties came later, within countries and among countries. The Magna Carta was a treaty between the royal gang and the aristocrat gang. In political theory, the sine qua non for a government that works is having a monopoly on violence.

So, yes, it was a brutal world for slaves and a brutal world still for many. But at least now we have regular ways of negotiating differences, and overall, law is a wonderful thing. Perverted in the case of cops and African-Americans, yes, but better than it was, and it will be better still. Not to say that African-Americans need to be patient. Patience is frequently not a virtue, and this is one such place.

But objectivity isn't the strength of the book; the heart of it is Ta-Nehisi's subjectivity. What he remembers so vividly is that his father had a belt up on the mantlepiece, and he lived in fear of that belt. His father used it frequently, saying “better me than the police.” He made sure by stark physical means that his son would not die at the hands of the police by not showing respect, by mouthing off, by not being aware. Ta-Nehisi accepts the explanation of the father he reveres. He gets beaten for his own good.

I hear this with the ears of a pediatrician. And what I hear is, child abuse. When I hear the alert and watchful adult story, I hear in addition to the reality of police abuse, a certain amount of PTSD from child abuse. Maybe it is functional PTSD; maybe it keeps him out of trouble. But it seems all too reminiscent of scars of child abuse.

I am reminded of the sad case of Adrian Peterson, suspended for a year from the NFL for beating his little son. Charles Barkley objected to the league's view, saying they “They don't understand the South.” Maybe it is necessary; maybe it is. It doesn't sound like it's identifying with the oppressor, man kicks boy and boy kicks dog. It might be one way of dealing with police terrorism. But in any case, it leaves a scar.

It is not just a rhetorical device, then, that the book is written as a letter to his son. We serious people take our parenting seriously. We look at our parents, and we look at ourselves as children. We think, how can I do what I need to do with this most important job of my life?

Our parenting has three major influences. Our default is to replicate our own experience; we can't help but do a lot of that. Our major conditioner is our own personalities. We can only do so much, based on who we are. But then the third influence is what we choose to concentrate on, the things that we want to change. We might have to think about it constantly, because it doesn't come automatically. We might make lots of mistakes, and suspect ourselves of not doing it well enough, or constantly enough. But there are things we think we had better do for the good of the child, things we need to correct in our own upbringing, things in which the clay has hardened in ourselves but not yet in our children.

What Ta-Nehisi has decided to do differently is not to beat his son. And he's trying to tell him, look, I'm not beating you, but you still have to be careful, you hear? They are still out there waiting for you. You hear? I don't want you winding up on a slab like Prince, that magnificent presence at Howard. You can excel, I want you to excel, but you be careful. You hear? You hear?

And now in publishing this book, the rest of America – you hear?

Budd Shenkin

Friday, December 11, 2015

Is It Politically Correct To Be Smart?

I had lunch today with a good friend who takes pride in not being politically correct. I always enjoy it.

He told me about a discussion he had with a younger colleague at the University. My friend Bruce was discussing an issue that had come up on constructing a website for a Departmental project. I think it was on a governmental contract. The problem was this: the staff had constructed the website directory and placed the files in a way that a visitor would have trouble finding what he or she wanted. They had divided up the files according to how they had divided them among themselves as they created them, but that didn't accord with the logic of a visitor. No matter the titles they made up for the sections, It's as though one folder could be called “Mindy's files,” another one “Janet's files,” etc. The path to relevant files was impenetrable.

Bruce said to his friend, “The staff just isn't smart enough to do that job. You need the professors to do it.”

His friend replied, “The staff just doesn't have enough experience in the field.”

No,” said Bruce, “they're just not smart enough. Don't be politically correct. They're staff, not professors.”

His friend couldn't bring himself to agree. For him, it had to be a question of experience. Apparently, under the current rules of political correctness, calling one group “smarter” than another is a no-no.

Well, I could agree with Bruce! Love to be politically incorrect, of course, love being a shit-kicker, but also, like to call a spade a spade.

I told Bruce about my experience when I was a two-year doc in the US Public Health Service in the later 60's. Each year a bunch of us came in as commissioned USPHS officers, Lieutenant Commanders we were, for two years not spent in Vietnam. We did bureaucratic staff work, we worked hard, and in my case it was a high point of my life. We worked side by side with the bureaucracy. We weren't seeing patients, we weren't wearing uniforms, we were doing paper work mostly, looking at the medical stuff that came through Health, Education, and Welfare. It was an eyeopener that gave me knowledge of the ordinary that I have used the rest of my life.

In my experience, the top governmental administrators are pretty smart. They have hard jobs. Imagine trying to get meaningful work out of thousands of employees who are GS-9s or 10s or 12s, who chose government work; that's who you have.

So what would sometimes happen is that a problem would come up that the staff couldn't solve. It would be technical, perhaps, it would be involved, but it wasn't at the level that the administrator him or herself could work on personally. But it had to be solved.

So here is what the savvy administrators would do. They would say, “Get a two-year officer on it!”

But this isn't medical,” the staff would say. “A two-year guy won't know anything about it!”

Doesn't matter,” the administrator would reply. “They'll figure it out.”

And they would. It was a selection issue. Doctors are smart. Some are jerks, some are smug, some are whatever people generally are. But they are smart. They had passed the tests. And they would inevitably solve the problems that the career staff couldn't solve. Because they were smart.

And so are professors. Sure, it's nice to say we're all equal. Just doesn't happen to be true. You could explain to the staff what kind of organization you wanted in the website, you could give examples maybe, but at the end, the professors might as well do it themselves. Incredibly enough, some people are just smarter than some others.

Hope that doesn't constitute a micro-aggression.

Budd Shenkin

Thursday, December 10, 2015

The Obamacare 2014 California Report Card

A couple of years ago I made a bet with my friend Herschel Lessin, a skeptical Republican pediatrician of Poughkeepsie, NY, a graduate of Stanford Medical School and Yale pediatrics residency, and no dummy. Obamacare (otherwise known as the ACA) was just starting, and Herschel believed that the health plans would fail, and that insurance rates would rise significantly the second year.

I didn't think so. I thought that insurance companies would be cautious, since their main lines of business would continue to be non-Obamacare policies, and that they would probably make their rates on the higher side to be safer and not lose money out of the gate, figuring they could gain market share later on when the risks were more knowable.

Herschel won. I don't remember if I have yet ponied up the ten bucks, but still, he won. Rates rose the second year. I supposed that companies had gone for market share after all.

But an article in today's LA Times makes me wonder if the actual culprit for rising rates lies elsewhere. Even though Herschel won (and I will pay up!), I think his win might be tainted.

It turns out that three of California's big four health insurance companies made significant amounts of money last year selling individual policies on the ACA California marketplace. Blue Shield was number one in the country, Kaiser number two, and Blue Cross number seven. So there must be something special about California.

It turns out there is. California mandated that the insurance companies terminate their existing individual policies. According to the article:

Amid a national uproar, Covered California defied the Obama administration and required participating insurers to cancel existing individual policies at the end of 2013.
That move created a healthier, more diverse mix of old and new policyholders at the start of the exchange. About 35 other states allowed consumers to stay longer on health plans that didn't comply fully with the new law.
That decision left many states with a smaller and sicker population signing up for Obamacare. Many new enrollees had been denied coverage previously because of pre-existing conditions.
So that's the story. The problem with the other states is that they didn't really adopt the full ACA as a program; they waffled. As a result it looks like the ACA is a failure, with all those companies losing money, and half the Coop plans going out of business. But in fact, their decisions to let people keep their old policies made the ACA plans victims of adverse selection.

But that's not all there is to the story. In the area of health insurance, it's bound to be complicated. Remember, the biggest wager of the ACA was that insurance companies would reform their sharp practices and compete on quality and price rather than aggressive underwriting and policy denials, that old dogs would find new tricks. Did California health insurance companies learn new tricks?

Well, it seems not. Blue Shield – a chronic offender of sharp practices, according to those of us in the field – benefited by the fact that

consumers had difficulty finding a doctor or getting care during 2014. That could have reduced medical claims, boosting the bottom line for companies.

In fact,

Michael Johnson, a former Blue Shield official and now a company critic, said the San Francisco insurer should issue more refunds to customers. "Blue Shield made this huge profit because they hindered access to care."

And in addition, both BS and BC had inaccurate provider directories, which means that when patients went to sign up and they checked to see if their doctors were in the plan they were signing up for, and they saw that they were indeed on the plan, that information was frequently inaccurate, and after they signed up, they had to switch doctors.

And why were the doctors not on the plan? That's because of the infamous “narrow networks.”

The insurance companies would have us believe that the new plan selected superior clinicians who were most economical in the use of resources, the best and smartest doctors. In fact, however, what happened on the ground was, they circulated a rate schedule to the doctors and said to them, will you take these horrible rates for our new plan? Those that said yes were then christened by the insurance companies as the best of the best.

And meanwhile, let's add one more observation about the insurance companies. There was a ballot initiative last year in California to allow the state Insurance Commissioner to negotiate rates with health insurance companies, as most other states allow their IC to do. It lost with huge insurance company (and organized medicine) advertising campaigns against it. But part of the success of the California ACA state plan is that

Unlike most other states, California negotiates premiums with health plans and doesn't allow every insurer into its exchange.

So in summary, it looks like the ACA looks worse nationally than it should because of the adverse selection problem – too high a proportion of the new policyholders represent people who couldn't get insurance before because of preexisting conditions, probably. And in California, it looks like Covered California is a go, although it could do better with regulating the insurance companies and their practices and narrow networks. And it looks like the old dog insurance companies are continuing with their old tricks.

Stupid insurance companies.

Budd Shenkin

Saturday, November 28, 2015

Climate Change, The Nuclear Option, And Organizations

With the Paris conference on climate change beginning in two days, and with many thinking that this is the world's last realistic chance to plot a path toward survival, a venture capitalist named Peter Thiel makes a case for nuclear energy in the NYT.

He is not wrong. The overwhelming issue of our time is, will mankind survive? In my early lifetime the threat was the Nazis – yes, mankind would have survived, but the history would be troubled. Then the threat was nuclear weapons, and truth be told, it still is. On The Beach was not unreasonable fiction, except how beautiful Ava Gardner was, and I guess Gregory Peck. But the threats are accelerating. nClimate change, né global warming, is arguably the most serious of all. James Lovelock sees disaster but not total annihilation. There will still be “mating pairs in the Arctic,” he says, which is less than totally reassuring.

What is behind it all is the exponential expansion of the anthropocene age. ( I have used the image of the beehive before, and it comes to mind again. When humans crawl all over the world and all over each other, they stay alive by an interconnectedness that works for a limited time. But nothing stays the same for long, and if you are precarious you eventually fall, and that's inevitable with our exponential-ness. The only alternative is planning, and restraint, and a sense of all being into it together. Good luck with that.

Nonetheless, we keep trying, and nuclear is an important option, as Thiel says. Years ago, when it became apparent that we had a problem and my Dad had not yet died, he and I discussed it in a couple of words, which was all we needed since we tended to think alike. All of his professional life as a neurosurgeon, my Dad had looked at dangerous operations and unpalatable choices, delayed decisions and followed cases assiduously until a choice became clear and sometimes inevitable. And when we talked, even in his decline, he faced the problems of the earth with the same coldly reasonable calculations that he used in judging the advisability to operate. So when I asked him, “Dad, what do you think about climate change and energy?” he responded, “I think we have to go nuclear.” Which was just what I thought, too. I figured, you just have to be careful, find the right way to do it, and put the radioactive debris in the right spot – I figured, send it to outer space, but then, I tend to be a risk taker.

The problem was, however, that we were both thinking like doctors, like Lone Rangers, which is what old fashioned doctors tend to do. We were thinking, get your best doc and go on in and be careful to do it right, concentrate, do it right.

But that way of thinking is a mistake. Nuclear power can't be operated by a Lone Ranger. Nuclear power has to be run by a large organization; as a matter of fact, since the world is a big place, it has to be run by many large organizations. So it's not an individual challenge, it's an organizational challenge, which is a horse of a different color.

Earlier this year we visited Japan and, as is my custom when traveling, I read the local English language press. There was an article about the Fukushima accident of 2011. I remembered that it was clear early on that Tepco, the utility company that ran it, had disingenuously reported about and dealt with the accident, not to mention having made mistakes with the initial design. It seemed to be a poorly run organization with strong political support charged with what could be a dangerous mission. Now the Japan Times reported that no significant changes in administration have been made. I read that a citizens' committee – a citizens committee! What a sign of entrenched bureaucracy! -- had twice (twice!) recommended that the top officials of Tepco should be tried for ineptitude and negligence. They reasoned that punishment would have a deterrent effect in the future, and thus perhaps change organizational behavior. But the article reported that twice had this recommendation has been dismissed by the establishment prosecutors.

It reminded me of the investigation of Chernobyl, which found that political appointments had so infested the organization that it was non-functional. To the Russians' credit, they made the investigation, just as the Japanese did. But the consequences for personnel were few; after all, these were favored apparatchiks who had been placed there in the first place.

Here's the point: you can build organizations for a purpose and get impressive success. You can win World War II, go to the moon, build the 50's Yankees. But then, over time, organizations decline. They just do. Guardians of nuclear missiles in North Dakota get lazy and drunk and no checks are made on the missiles. NASA leaders dismiss warnings from their intimidated scientists that the O-rings might not work at low temperatures. CDC forgets to safeguard the smallpox vials. Achievement organizations become blame organizations, as incentives shift from high accomplishment to avoiding blame, where personnel shift from dream-seekers to get-a-job-and-get-promoted seekers. It's just the natural history of organizations.

So as the VC Peter Thiel touts nuclear as the answer, he thinks technically, not organizationally. VC's think about starting a company and selling it, usually, not operating it into perpetuity. Could you build nuclear plants all over the world that would never fail, or if they failed, would have damage contained? Maybe. Computers have become very powerful. But there are still operators all over to oversee the plants, and if they are not unqualified apparatchiks, or Tepco bureaucrats, they can still be Homer Simpsons. 

Thiel thinks that the downsides of accidents have been exaggerated, and that side effects can be contained. Maybe he's right. Maybe my father and I were right. Or maybe we need nuclear not as a permanent solution, but as a bridge to a future technology that would truly work automatically. And maybe running the risk is better than simply continuing on as we are on the road to mating pairs in the Arctic. And maybe Space X can take our nuclear debris on a quest to find dark matter.

But in the meantime, if nuclear turns out to be the necessary risk we take, let's not just concentrate on the technology. Let's pay as much attention to advance organizational theory as to engineering theory. That could be the biggest challenge.

Budd Shenkin

Friday, November 20, 2015

United Health Care Might Exit The Exchanges

There is some consternation today over United Health Care's considering exiting the field of the Health Insurance Exchanges – the Affordable Care Act's policies for individuals. Does this mean that the ACA is not working?
Well, it's a complicated situation. I am indeed afraid that the ACA is not working in a very significant way: the ACA has incorporated High Deductible Health Plans into its midst, and they suck, as both the NYT and the Boston Globe (below – quoting me!) have pointed out graphically this week:
The worse the plans are for people the more enrollment will fall, and I have to think that the high deductibles make people feel they are not getting much for their money, so some don't enroll or reenroll.
But I think the UHC issue is different, and doesn't indicate ACA failure as such. UHC is very big and the exchange programs are a relatively small part to their business. They can probably make a profit on them, even though they say they can't, but the profit might not be big enough for them to want to concentrate on it. GE's strategy under Jack Welch was to make sure that every GE unit was #1 or #2 in the industry, and if they weren't, they either had to be built up or sold. From a corporation's point of view, you need to have some focus. And as we appreciate that point of view, I guess it's not such a bad thing to see them exit from this business segment. It's just a decision that there are more profits to be had elsewhere, and a corporation can't do everything. Is it such a bad thing for us that UHC can't find that much profit in Exchange programs? I think it's fine.
Looking back, the idea of the ACA was to make insurance companies make money a different way from the way they did it before, which was largely by excluding subscribers by underwriting, and writing tricky policies. Instead, insurers would have to make money by efficiency and service. That was a big gamble for both sides -- can insurance companies reform themselves? Can corporate cultures change? If not, then better to exit the field, concentrate on traditional markets, and other health-related fields like Optum.
Here is the way I put it six (!!!) years ago:
There will have to be a period of time where old companies try to adapt, and where new companies could even come into being to meet the new standard. The new companies might emerge from health care delivery models themselves, I would think. We'll just have to see.

Budd Shenkin

Saturday, November 14, 2015

EMRs, Government, and Capitalism

I wrote in my last post how the government screwed the pooch on Electronic Medical Records by not requiring interoperability as it invested $30 billion in the enterprise. With that kind of money going to by EMRs and equipment, surely the proviso that they be interoperable could be included. Was it corruption or incompetence that omitted that proviso? I couldn't be sure. Maybe a mixture

So here's a follow up from JAMA, September 22/29, pages 1213-1215, a medical news article: “On the Road to Interoperability, Public and Private Organizations Work to Connect Health Care Data.” The reporter, Julie Jacob, interviews the Office of the National Coordinator for Health Information Technology (ONC) spokesperson, Erica Galvez MA. The article states:

Although the ONC road map presents the movement toward interoperability as a smooth, straight road, in reality it's more like fitting together the pieces of a giant jigsaw puzzle. Several public and private organizations are working on different pieces, including organizations creating technical standards, establishing health information exchange (HIE) networks, connecting those HIEs, and developing principles of governance and usage. The hope (emphasis added), according to health care information technology experts, is that all the pieces eventually will interlock.

Because the Feds have basically opted out of direct action and laws requiring interoperability, several organizations have formed to try to fill the breach, one from the AMA called Healtheway, another called CommonWell Health Alliance which was spawned by the EMR industry sans Epic, and which requires a fee from participating institutions. Another older one is the Indiana HIE. Epic has their own system called Care Everywhere, available for a fee when you buy Epic and which was charging for each chart searched when Epic was presented to me, which links together Epic systems and some others who choose to join (for a fee which has been waived for five years, I guess under some pressure.)

Why all the flailing around? The JAMA reporter:

The highest barriers are financial and policy ones, not technical ones, noted those with expertise in health care technology.

Technology is almost never the obstacle,“ noted Indiana HIE's (John) Kansky. “It is really the governance of the data and getting organizations with different agendas to agree on what you are going to do.”

In other words, it is precisely the role of government that is not being well filled here. Government has taken a hike. Amazingly, this is the ONC goal:

...electronic exchange of health information among clinicians, health facilities,and patients should be widely available within 10 years.

Holy moley – 10 YEARS!! Let's see: Kennedy's speech, 1961; moon landing, 1969. ONC is not what we would call, let's say, overambitious.

I was interested that the spokesperson from ONC JAMA interviewed had only an MA degree, so I googled her, and got a hit from four days ago. From Healthcare IT News:

Former ONC Interoperability Manager Erica Galvez joins Aledade.”

What is Aledade?

Aledade was founded in 2014 by Mostashari with a focus on supporting independent, primary care physicians creating and or running ACOs. They provide healthcare technology, business transformation services and upfront capital.

More from Forbes:

Farzad Mostashari, who was formerly national coordinator for health information technology, raised $30 million in series B funding for Aledade. ARCH Ventures Partners led the round, with participation from return investor Venrock, bringing total funding to $35 million.
Mostashari, an internist, oversaw the nationwide implementation of electronic health records in the initial stages between 2011 and 2013. Last June, he founded Aledade to help doctor practices, as small as one, band together in so-called accountable care organizations (ACOs).
...By the end of the year, Aledade expects to have more than 100 physician practices in its ACOs, managing 75,000 Medicare patients. Practices pay a membership fee of $500 per general practitioner per month. They keep 60% of savings, with 40% going to Aledade.
In other words, the former head of ONC left to raise money for a private venture and hired a former staffer for him at ONC to come to the private venture. Let me note, however, that Aledade actually is interesting in that it focuses on private practices and has software that is designed to keep them independent of large hospital networks. Still, as they used to say, is this any way to run a railroad? But I have to say that I myself was in government early in my career, and looking around at what took place there, I decided that it was not a good place for me in the long run, much as I learned and loved some of my years there. I can't criticize others for making the same decision.

So, here is the picture. There are so many loose ends in the current non-system, it's not at all clear that this puzzle can be put together. To my mind, the Federal government has never looked so bad. They fail to look forward to see where private enterprise – here, EMR development – needs some help, some regulation if you please, to pave a road ahead so that companies can innovate and compete, but still develop a system that works together for the public's benefit. Companies themselves put a low priority on working together, as would be expected; that's why government is needed, as a convenor. Even when the Feds have a $30 billion windfall from ARRA, which would ensure they had the clout to enforce standards, they fail to exercise it. ONC continues to be meek and silly, setting a 10 year horizon for something that has governance and political impediments rather than technical ones. Government continues to fail to see, or at least talk about, the implications for the system as a whole, where some large capitalistic systems will benefit from lack of interoperability to the detriment of true competition and progress. Government accepts the role of bystander and beggar. Private companies seek to fill the government void of data coordination and interoperability. The problem of rotation of personnel from government to private business continues in health care as with other fields. Given the toothlessness and fecklessness of government, one can hardly blame them, although I'm sure there is much connivance from the private world. In fact, perhaps I am blaming the victim as I blame government. Who knows?

What I do know is, this really sucks.

Budd Shenkin

Sunday, November 8, 2015

How the Government Screwed the Health Care Pooch

When I get angry, I've learned to think, who do I think should be doing something that they're not doing? Then I can think, is that expectation valid? Sometimes it is, sometimes it isn't, and even when it is valid, thinking about it still kind of tempers my anger. At least, after a little bit. Personal anger management.

And so it is with our Federal government and Electronic Medical Records (EMRs). I complained to my brother Bob, who said, “What do you expect? Who do you think is in the government? The best? What kind of person wants to become a government employee?” He did not reference Donald Trump, but he could have, because that's one thing Trump is right about.

It's a well recognized phenomenon. When the ACA website imploded, veteran official Leon Panetta was thunderstruck: “Obama left that to the bureaucracy to do???” In other words, if it's important, make sure the government doesn't do it. Or, as I read in the WSJ yesterday about how Medicare doesn't check on the possible validity of claims before it pays them, as a modern credit card company would: “The government – yesterday's technology tomorrow.”

“The government” is a collective noun. It is composed of lots of people and agencies, and also the “advisers,” outside of government, often in academia, often in industry, who are supposed to be supplying the intellectual power. Maybe they're the ones I should be complaining about.

Anyway, here's the thing. When Obama came into office he needed to stimulate the economy with ARRA, the American Recovery and Reinvestment Act of 2009. Good, it was needed; in fact, more money than what they put into ARRA was needed, and he could have gotten more if he hadn't negotiated with himself, which I notice he has stopped doing, his current philosophy being, “I don't give a fuck.” Good; nice philosophy. But I digress.

So the health care “experts” thought that a program that put Electronic Medical Records into hospitals and medical offices would be just the ticket – marry the needs of the economy with the needs of health care. They claimed too much for what EMRs would do, they didn't really know much about them, and they didn't think they needed to know much about them. They had their theories, they had their analogies to other industries, they didn't need to get their hands dirty actually seeing what these programs were like. Details, details. The fact that EMRs generally suck didn't have to be addressed. The fact that it would slow down rather than speed up health care didn't have to be addressed. The fact that EMRs turned doctors into data input clerks didn't have to be addressed. Those were mere facts. In theory, it was brilliant.

My San Diego colleague Stu Cohen pointed out that the now-billionaire owner of Epic, Judy Faulkner, the major EMR system adopted in America, was a major Democratic donor and on the committee that inaugurated HITECH, the ARRA EMR program. A little self-dealing, seems like. What else is new?

When the Feds shelled out the money to get these EMRs into hospitals and offices, they unforgivably stupidly or cravenly or somethingly, (I don't know really how it was done so I don't know who to hate) didn't mandate that all the computer programs be standardized enough to be able to talk to each other., which is called interoperability. So here they all are all over the place, and they can't cooperate with one another.

In the words of North Carolina colleague Graham Barden:

What is even more WTF is that the Rand Report that was often quoted as saying how EMR’s were going to save vast amounts of money for the country, stated in the paragraph just above the often quoted figure something to the effect, “Once interoperability is achieved, ….” Unfortunately our 20 something leaders either did not read that paragraph or did not understand the big word…”

And more from Pasadena colleague Glenn Schlundt:

Over the years, there certainly appears to be a recurring and persistent, not improving theme about EMRs. Whereas a few people on this list sing their praises, and can't appear to imagine life without them, a significant fraction of posts speak to legitimate, persistent, and meaningful limitations that many EMRs presently appear to impose.

Here's my "off-the-top-of-my-head" list:

1. They don't talk to each other, so communication between them is essentially impossible.
2. They are absurdly expensive, and the return on investment on balance, while debatable in some instances, is pretty negligible.
3. They are expensive to maintain. The initial capital costs lead to monthly maintenance costs.
4. They are inefficient in that it takes doctors longer to do the same tasks, usually with little if any apparent benefit to the quality of clinical care provided.
5. Liability costs resulting from security risks, including HIPAA violations, may be considerable.
6. Some young physicians are declining to take employment positions where they will have to use hospital EMRs because they are unwieldy, inefficient, and time consuming (this from a
    previous post to this listserv).
7. They purport to allow doctors to collect data that will improve both patient care and cash flow, but other than auto-correcting doctors' previous undercoding, or allowing other doctors
    to purportedly "game the system" by clicking a few additional boxes,  well-publicized data or evidence for clinical or economic improvement appears lacking. Little convincing data suggests
    the financial benefits of EMR outweigh its costs, when measured directly, indirectly, or both.
8. They can weaken the doctor-patient relationship because some patients feel the doctor spends so much time looking at their computer screen, the doctor does not even know what their
    patient looks like. This has been used as a selling point for telemedicine, where, in a bizarre and peculiar twist, patient have reported they prefer telemedicine because "at least the doctor
    knows what I (the patient) looks like."
9. They can alter the way doctors are audited to include only data that supports downcoding or an insurer's interpretation of a clinical encounter based on data that is displayed. Several
    members of this listserv have noted that the medical decision making portion of their documentation, as measured by the software they use, drives payments, even when this does not
    appear to be the only or best criteria for medical work using CMS criteria.
10. The companies that sold or maintain them can decide to go out of business or change the terms of their contracts, creating additional access and liability issues

When one takes a Corporate Management of Risks in law school, one is taught that one frequent source of liability is over-commitment to a project or plan based on the time, effort, and resources that have already been invested. In short, one is taught that people and organizations find themselves in hot water because they are unwilling to objectively re-evaluate projects as they progress. At some point it is time to cut bait.

I'm not suggesting there is no role for EMRs; clearly in some cases they work, and work well. Nor do I mean to be either indiscreet or provocative here. What I don't understand is why, if having adopted a system that clearly has so many flaws and that it impedes efficiency, tarnishes one's balance sheet, increases liability and diminishes quality of life, why, at some point, the whole system doesn't find its way into the trash, and doctors don't just go back to the good ol' days (which, based on the animus transparent in many of the posts on this list, really are perceived as the good ol' days), until something genuinely better really comes along?

Why not just go back to paper for the time being?”

OK, that's bad, there was self-dealing, the programs are not ready for prime-time, and they don't talk to each other. Lots and lots of waste, and worse.

But, here's the deeper point of this post (sorry it took so long to get here.) There is an under-appreciated implication of the horrible omission of not requiring interoperability, which is brought out in a recent post from Boston health policy colleague Paul Levy:

Short look back: before the computer revolution, one of the foremost thinkers in health care organization was economist and ex-McNamara Whiz Kid Alain Enthoven. He proposed the model he called Managed Competition (MC). He envisioned many ICNs competing for business. He was a corporatist, and in those pre-computer days, the transaction costs of communication and information gathering were intimidating. Managed Competition was an attractive model.

The current incarnation of MC is called the Integrated Clinical Network (ICN) model, examples of which would be Kaiser, or the VA. In an ICN, when you are in the network, that's where you stay. Need a referral to neurosurgery? Off you go to the Redwood City Kaiser, where all their neurosurgery gets done. Need a neuro MRI? Off to Richmond, or wherever. It's all in-network. In theory, such specialization is good, more efficient, expert. But, if you are a clinician in a network, you don't have overt competition. The plan's members are a captive audience. You have to do well, maybe, but you really don't have to be the best. Each individual unit is shielded by the collective – the patient might choose Kaiser knowing there are some substandard units she hopes she won't need.

But now, with computers, another patient-centered model is possible. This is called the Centers of Excellence (COE) model. In a COE, you come to me, your primary care doctor. You need a referral. My job as your doctor is to get you to the very best place possible, and I have not just my in-network choice, but a full choice of the whole Bay Area, or even beyond. Several centers are competing for my business, and that's good for the patient. If they start to screw up one way or another, they will lose my business.

This is the real significance of interoperability of EMRs. The Mother Jones article cited above by Stu, written by an author with complex medical problems, points this out in great detail. To deliver the best care most efficiently, the primary care doctor and the referral unit need to have the same medical record in front of them. If the EMRs are interoperable, problem solved, COE feasible. If not, we have the same old difficulties of coordination, cooperation and efficiency.

If the EMR is not interoperable, referral within the system is easy, but referral to a possibly superior or more convenient center for x or y specialty is hard. But if patients might suffer, the same is not true of the ICN institutions at all. Although our economic system is based on competition, the role of individual corporations is to try to escape that discipline as much as possible, by combining with others to form oligopolies, or by fencing customers in to your network (as Apple does, for instance). So Epic won't cooperate with other systems – they sure don't want a small computer company that is great for a primary care doc networking into their system – God forbid! And for the integrated networks like Kaiser as well, interoperability is a threat rather than an opportunity.

The consequences of the Feds' decision not to require interoperability when they allocated $30 billion for EMRs are clear, then? This decision skewed the fight in favor if the ICN model, when the COE model has much to recommend it from the patient's point of view.

Maybe this situation is an example of LUC – the Law of Unintended Consequences. But “unintended” doesn't mean “unforeseeable.” The Feds, and if not them then their advisers, should have foreseen this consequence. Is this an example of inside dealing? Is this an example of selling out to corporate interests? Were the Feds convinced by others that “it would be too difficult” for them to insist on interoperability, and they settled for something less so they could “get the money out there?”

I don't know how it came about. They say when you need to choose between ignorance and malice, choose ignorance. Maybe. But at this time in our history, there is a very strong trend of increasing concentration within every industry, of corporate domination of government, of weaker and weaker government ability, and more and more violation of individual rights and welfare.

Sometimes it makes me mad, and sometimes it makes me sad. But either way, it sucks.

Budd Shenkin

Saturday, October 31, 2015

Hollywood Violates History Once Again

Hollywood and its apologists continue on their merry, hubristic, and for me, at least, ultimately dispiriting quest to bend facts to their predilections. The latest lamentable lapse into factual revisionism, perhaps the least significant of a series of misrepresentations, is “Steve Jobs.” Joe Nocera, for one, has taken great offense. A financial columnist before arriving at his Oped post at the NYT, he knew Jobs personally. Nocera says that virtually nothing about the movie is actually true. Instead, the very talented Aaron Sorkin has appropriated Jobs' persona and fills him with thoughts and feelings that never existed. “Is it a biopic?” he is asked. “I'm not sure what to call it,” he answers. Nocera knows what it is: “That's easy. Fiction,” he says.

When it comes to truth and history, what a sordid history Hollywood has! I just read that before our time, in the 1930's, Louis B. Mayer changed film elements that offended the Nazis – this really happened, even before the blacklisted 10. (reference: Philipp Blom, Fracture –
Those were instances of Hollywood's bending to political pressures. In our time Hollywood bends to the “artistic sensibility” of the auteur. Oliver Stone alleges conspiracies that never were. Kathryn Bigelow glories in the fruits of torture that never existed. Ava Duverney libels one of the greatest enactor of civil rights who ever lived – the white man Lyndon Johnson – as a cynical bigot. Why?

Here is their defense: UCLA professor of Theater, Film, and Television Richard Walter writes in the NYT letters that Nocera displays the “the height of arrogance” for thinking he knows the truth about Jobs – Nocera, who knew him, vs. Sorkin, who didn't! The fatuous Professor Walter adds: “The role for the creator of dramatic narratives is not to catalog an inventory of 'facts,' but to engage, indeed to provoke, upset, discomfort and disturb audiences.” He refers to “the lie that tells the bigger truth.”

And my God, it's not only Hollywood. Lying science takes a bow in today's NYT: “Take, for example, Prof. Diederik Stapel of Tilburg University in the Netherlands, who in 2011 faked experiments to show, among other things, that eating meat made people selfish. (He later said that his work was “a quest for aesthetics, for beauty — instead of the truth”).”

OK, my own aesthetics are offended, because for some reason I like truth. But is this only an aesthetic preference, or something greater? Does truth matter, even though so many people think that there is no real discoverable truth, that everything is just stories, since even historical facts are selected to make a story out of events? Am I just old-fashioned?

Yes, I learned about the problem of selection for history in my very first semester of being a history major. And yes, I'm for provoking and challenging and making people think. Good. But so we really want to consciously lie to provoke and to seek a self-defined “higher truth?”  Go ahead, call me old-fashioned, call me stuck in the conventional mud, but I'm opting for factual truth over the calculated lie. 

What an age where one has to defend that proposition!  But here goes.  An honest inquiry into factual events needs to deal with explanations and facts that contradict an overall narrative. Doing so is one of the major disciplines of finding truth. Let me fall back on medicine, as I tend to do. In medicine, when you are looking for a diagnosis, and when treatment depends on that diagnosis, there is no “higher truth.” There is only an understanding of the disease process as it actually is, complex though it may be. And in arriving at a diagnosis, there is every chance for error. The Institute of Medicine, a really great organization (and you all know how skeptical I am, so when I praise an establishment organization, it's noteworthy) sees diagnostic error as a huge problem. At the core of diagnostic error are errors in cognition.

What are errors in cognition? There is a huge number of them – An example is confirmation bias, where you have an opinion on the diagnosis, say, and if contrary information comes in, you ignore it as a “testing error,” or “weak indicator.” Or there is the recent case error, whatever that is officially called, where you tend to see the diagnosis as the same as a case you recently saw, or heard about in a lecture. These errors happen all the time, and that's when you are trying to stick to the truth, not lying intentionally! But in medicine, you get to see the result of your error in the course of your patient. There is a final accounting.  In Hollywood, what you get is a "higher truth."  What horseshit.

So, history is harder, because there is no therapeutic test that will judge objectively. But that doesn't mean that truth isn't available and important. There are rules, like prolonged civil unrest brings out the crazies. You learn from the rules you find by searching for truth in history. You avoid undue civil unrest if you can, to avoid the crazy consequences. You try. Truth matters, and if you don't think so, start painting, but don't talk rationality.

If you want to screw around with facts, that's your right as an individual. And if we were talking about some obscure e-book, well, who would care? But movies are something else. To quote myself in “Selma,” movies “shuts you in a room, dampens any other sensory distractions, focuses your attention on colors and giant images that are as clear as can be, and envelopes you in surrounding sound. There is nothing like a movie. Movies are the most persuasive, impactful, and indelible of any media ever invented. Movies are not only powerful, they are so easily accessible; more people see movies than read books or see plays by orders of magnitude.”

Since movies are the most powerful and accessible medium we have, what people learn at the movies is most often the full amount a person will know about the subject in question. So a lie, no matter how well intentioned, is really a sin against human understanding. Unless you are so arrogant that you think you are the one with the higher truth. But guess what – nobody is that great.

What has been gained by Stone's lies about the Kennedy assassination? What about Bigelow's? What about DuVerney, who when confronted with her character assassination of Johnson replied, “Well, that's my truth.” These are the higher truths of the Hollywood geniuses?

What they have in common besides their lies is one big thing – they all made money. You never found one of these guys violating the truth for something less remunerative, did you? Or is it the thrill of aesthetics? Hmmm. I wonder.

Color me outraged.

Budd Shenkin

Wednesday, October 7, 2015

Hillary Is Better Than Obama On Health Care

My opposition to High Deductible Health Plans is well known to readers. (See for the ineluctable conclusion that they suck on a multitude of levels.) I have also condemned the general heedlessness of Obama to the finer points of health care financing, and his administration's concern with only the poor, to the exclusion of the working class that they purport to be very concerned about. In this case, policy does not meet up with words. In general, I think the Obama health team's health approach has lacked, shall we say, fine tuning.

At the same time, if Obama's political approach has been marked by preemptive surrender, Hillary's 1990's approach erred on the other side. With disastrous results, the Clintons treated Washington policy makers as they would have treated the Arkansas legislature, as a bunch of rubes, which they weren't, especially the insurance lobby. But if Hillary lacked astuteness of political approach in those early years, she did know policy. She and Bill basically knew what they were talking about.

Hillary is a lot older and one can only hope, wiser, if not a better candidate. Hey, I wish she were, but one person can only do so much. She is married to Bill, but she isn't him – and that's OK. At least she is smart and good on policies. (I just wish she could stop being so reactive with her propensity for declarations. I wince when I hear “MY PLAN WOULD ….” She can't get away from a tone of preemptive hectoring, that I feel is yelling at me the audience, borne of criticisms I haven't leveled at her. But at this point, I'm just hoping the polls turn around for her.)

What she is saying now on health policy is needed and smart. Apparently her guru is Neera Tanden, who seems smart. See:

Basically, she is attacking the HDHP program, and proposing to take on the drug industry. Good! Limit the out of pocket, and include three visits a year without a deductible. Excellent. Lower the advantages that accrue to pharma – they have enough, and lowering margins won't inhibit innovation.

I also think she's right to plump for rescinding the coming penalties on Cadillac plans, even though it might be a stance directed on gaining union support. I say, let people have as much insurance as they can get, and forget about their “having skin in the game.” You need other ways to reduce expenditures than making people feel pain when they are sick. She doesn't have a program to decrease the in-hospital and procedure costs yet, but no one does. I would think that that would come; it's the logical extension of less reliance on HDHPs. Maybe she has something in her back pocket, but you don't have to talk about that yet, unless in general terms when pressed to speak about cost.

So, I write this as a note of celebration. Good for her! Health is one area that a Clinton II administration would improve the Obama approach. Maybe we'll get to see how the rest of her agenda goes. However it goes, hers would certainly be better than a Rubio-Kasich approach. God, the risks we are running....

Budd Shenkin

Sunday, September 27, 2015

Perhaps I Am Not A Liberal

I'm not really sure if I'm a liberal. I honor warm feelings for others; I certainly support the First Amendment very strongly; I believe in collective action as represented by government. But I'm also pretty practical. I don't believe in feckless charity; I don't believe in sloppy thinking; I honor some of the principles of conservatism, as in Edmund Burke and his Reflections on the Revolution in France. But I'm not in bed with anything like what passes for conservatism currently in America – no, siree Bob!

In medical school two friends and I founded the Public Health Club. Dean Robert Ebert assigned Dieter Koch-Weser as our advisor. It was then I learned about the Law of Unintended Consequences (LUC). For our first meeting he assigned readings about what happened in areas where doctors and public health authorities abolished malaria. LUC prevailed in these articles. With malaria conquered, population increased, with a resultant increased suffering from human congestion and increased poverty, if that were possible, all from the best of intentions.

Decades later I read about Western beneficent organizations alleviating the suffering during African famines by importing food. Critics pointed out that the LUC would then ensure that the next famine would be even worse, with even greater suffering, since core problems would not be addressed.

So, with that attempt at an exculpatory introduction, what about the refugees descending on Europe? You could say that the refugees are consequent to an awful civil war in Syria, as well as unlivable conditions in other countries. Certainly that is true. But civil wars do not erupt out of nothing. The refugees are fleeing with their pitiful families, which number how many? Six, eight, ten? We pity them the more for their numbers, but what are they doing with all these kids? It's their culture. (I've said for a long time that the Palestinian strategy is to have as many kids as possible and then don't educate them, but that's another matter.) Yes, that's their culture. They have overpopulated their home country, which became manifest when the severe drought came and they fled the rural areas for the cities. They countries are not cohesive, but rather divided into religious tribes who get along sometimes, but when push comes to shove, they fight each other. Overpopulation plus lack of cohesion equals misery.

While the civil war might be the proximate cause of the mass flight, the deeper cause is overpopulation resulting from a culture of human fecundity. In the natural world we see bees overwhelming the hive and then a group leaves to form a new hive elsewhere. It's not a stretch to recognize the same dynamics at work here, even as the outcasts tug at our hearts.

It is only natural to think Europe should be generous and take the refugees in. But, are the refugees say that they want to become Europeans? Maybe some are. But I think most are saying that they want a better and safer life for themselves and their large families, not that they want to change themselves. They don't want to give up their culture. They want room to create a new hive.

I remember the story of Kosovo. It used to be Serbian (I hold no brief for the Serbians, btw, but I believe that this is the fact.) Then fecund Albanian Muslims moved in, proliferated, became a majority, and now they rule, as they and others feel they have every right to do, because they are now a majority. Without firing a shot (at least initially), they gained new land.

As I write this, Ann and I are on the Silver Seas Shadow traversing the North Pacific. We sat with some Brits the other day and conversation turned (not on my initiative, as it happens) to Muslims in Britain. Our new friends told us that in their neighboring towns between Manchester and Leeds, five times a day, loudspeakers blast out call to prayers, invading the auditory space of what used to be quietly Christian towns. And we also read in the papers a day or so ago that in France Islamic prayer services are spilling out onto the streets surrounding mosques in various towns, leading to proposals that this not be allowed. This can be uncomfortable for some; I certainly would not like it; others might feel more at peace with this increase in diversity. Opinions vary, I guess. I think I'm just pretty conservative here.

For many centuries now, after the terrible consequences of wars based on religion, the European tradition has been for religion to be a private affair, and for disparate religious groups to interact with common understandings in quotidian life. The United States has shown how possible it is to benefit from the influx of other cultures; the intention of most immigrant groups to the US has been, however, to become Americans. They have been able to keep their religions and still fit in comfortably, and make the US better. So the big question is this: how does that apply to the would-be Muslim immigrants to Europe? Would it be their intention to fit in? Could they do it? And would the Europeans allow it, and even facilitate it?

To my mind, these aren't easy questions. I think of the Iraqi immigrants to Sweden, who came because of Sweden's commitment to human rights for all. One result of the influx was that a Davis Cup match between Israel and Sweden could not be freely played in Malmö because of anti-Israel protests by the immigrants. The match was played to an empty stadium. Others might think a five time daily call to prayer over loudspeakers in their hometown is acceptable. Would they also think that this imposition of Iraqi prejudice is also acceptable?

France hasn't been able to handle Algerians, who have been banished to the banlieus, from which emanated the assassins of Charlie Hebdo. Cast blame where you will, but isn't that a foreseeable result from warm feelings of wanting to help the refugees? We might say that France should “do better” by the refugees, but maybe they just can't. You have to know your own capacities. Should they willingly admit the refugee bees from the Middle Eastern hive when the foreseeable result is more empty stadia when Israel comes to visit, or more assassins for those who exercise free speech?

I don't think the Syrian civil war is the fault of the West; it's an internal problem. Still, you can't just let people suffer when they appear at your doorstep. I don't have great alternatives.

I wonder if it would be possible with strong united military power to establish a safe zone in Syria to which civilians could flee – but who would govern it? What rules would there be for separating factions? What would the future be, when we know that the highest birth rates on earth occur in refugee camps in the Middle East? This can't happen, I'm sure.

So what about asking the refugees to choose one of two options:
  1. Choose to apply for permanent citizens in the new country, adopting it as their home, and obligating themselves to learn the language fully, to educate the children in the country's schools, to educate themselves about the new country's customs and laws, and to keep their own customs and religion in their private life only. The host country would be obligated to help in seeking a job for at least one of the parents of the family and providing the integration services, and the welfare costs, etc. It would be expensive.
  2. Or they could choose to be a temporary visitor who will be required to migrate back to the home country when the host country would deem it safe. In the meantime they could take welfare or jobs might be found, and the kids educated in the Western style, not in madrassas.

There is a reason the world in agog with what to do here, because it certainly is not easy. I'm not hard hearted, but I've seen enough to respect LUC. You don't have to be a fascist Hungarian to be careful to preserve what you have.

Budd Shenkin