It’s true – I am negative on the Democrats. But I wonder why. And I believe I’ve said a word or two about poor spending on the Stimulus Bill. I haven’t liked their timidity vis-à-vis the financial industry, and their obeisance to the powerful interests in health reform – nor the kowtow to clinics and nurses. When my friend Michael, returned from a year’s stint in the Defense Department, asked Ann and me how we felt about Obama last Monday night, I said I was disappointed. Why? Lack of apparent leadership, I said. Obama’s inexperience was showing.
But isn’t that terribly short-sighted of me? I thought that the Obama Administration should go for a lot of big goals simultaneously, and not scale down objectives and go one by one. They took my advice, and it has worked out. There has been a spate of articles in the last few days pointing out that the triumphs of Obama puts him in the league of FDR, LBJ, and Reagan for changes made and influence felt. That’s big league, and they are just talking about domestic policy, leaving out the important foreign policy advances such as nuclear reductions, temperature lowering with the Russians if not the Chinese.
Here is a typical quote from Steve Benen, reflecting on how voters tend to vote for and to vote against: “This year, the Democratic Party really hopes that it can benefit from both. On the one hand, they argue, Democratic policymakers have an impressive list of accomplishments, mirroring the platform they ran on -- economic recovery, health care reform, Wall Street reform, student loan overhaul, withdrawing troops from Iraq, restoring the nation's global stature, advances on civil rights, Lilly Ledbetter Fair Pay Act, expanded stem-cell research, new regulation of the credit card industry, new regulation of the tobacco industry, a national service bill, the most sweeping land-protection act in 15 years, etc. On the other hand, the Democratic argument goes, Republicans have moved sharply to the right, and generally act as if the GOP has gone stark raving mad.”
I said a couple of months ago that the Democrats needed to get past health care reform, and then make a very big deal about Wall Street reform, daring the Republicans to stick up for the plutocrats. They are doing that, but in their moderation, the Republicans are able to support it, and not take the bait. Hard to find sympathy for Lloyd Blankfein. So we’ll get some good law, not enough but something – and the problem is that it will not provide an electoral theme.
So, what is the Obama Administration to do? Again, I’ll go back to 1934. Everyone advised Roosevelt that the opposite party always loses seats at the midterm elections. They advised him not to risk his prestige in a lost cause. Roosevelt overruled them, set out aggressively to campaign hard and nationwide, and came up aces. Similarly now, with everyone expecting a Democratic debacle, what really does Obama have to lose? If anybody can make a case, he can.
It’s probably a question of timing. Right now, the Gulf Spill is the problem, and the Administration needs to come out heroes, if they can. Then in the fall, take the one item that the great Spill brings to the fore, energy policy (used to be climate policy, but that doesn’t sell.) Obama can say that his Administration has shown they can be successful, but more remains to be done. We can’t have any more oil spills. We need to completely reform the governmental part of it (the hapless Materials Division of Interior, or whatever it is, the sex and drugs haven), and institute strong incentives for alternative energy generation, and tax carbon.
There has to be more to the campaign, of course, and maybe this isn’t even the main part. But the tone and the energy needs to come forth, even if it seems like a risk. Not playing hard is the real risk.
Budd Shenkin
Sunday, May 23, 2010
Saturday, May 22, 2010
Spending ARRA Money
It’s pretty clear that the government needs to spend money to keep the economy going. That’s basic Keynesian counter-cyclical governmental action – buy when no one else is buying. That’s not the time to worry about the deficit (but at the same time one hopes that in better times the deficit will be worried about – ojàlà). So I’m for priming the pump, and I wish we had another round coming.
But, then, even I have my doubts. I haven’t seen any big exposés of the shovel-ready projects of the original ARRA legislation – where is William Proxmire’s Golden Fleece Award when we need it? It’s really strange, come to think of it, that the Republicans haven’t come out with sensational stories about multiple bridges to nowhere. I wonder why. Maybe it’s mutual respect for each other’s district spending.
So, in lieu of Proxmire, here are my own personal observations of how money is filtering down to be government-spent. Item #1 – two weeks ago we received a notice from our local Contra Costa County Health Department. They had a $1 million grant program that they themselves could not spend directly, but had to divvy up among others (if they could have spent it themselves, knowing that health department, believe me, they would have. A classic health department, bureaucracy and empire building.) Anyway, we were notified about this program with one day turnaround time required – they are not used to involving others in money spending, I guess.
This grant program was a mélange of rules. How to apply, what criteria to meet, how to measure, who would be eligible for what, etc. etc. Just the reason I don’t deal with governments. Half the value of the grant, if received, would have been spent (and not reimbursed) by time and effort filling out the damn grant application. So typical. Then reviewed by the huge brains in the health department.
And what was the object of this million dollars to be spent, and the time of application to be spent on unpaid work, and the time of bureaucratic efforts to conceive the project, make the rules, and review the applications and later the work? Get this. Spending all this money to find the hard to reach populations in Contra Costa County and immunize them against H1N1!! Jesus! Talk about a stupid objective! Where is the evidence that this is a worthwhile objective? Where is the evidence of how much money would be spent per shot delivered? Where is the evidence that this is worth anything at all, especially when so many regular people are declining the H1N1 shots for various reasons of their own? Do we think that H1N1 is that much of a threat now? Anyone there with experience in trying to wipe out smallpox or polio with the CDC worldwide, who would know how uninformed this choice of objective is on so many levels? Government!!!
OK, so that’s only a million dollars. Then a friend of Sara’s who works for the health department in Seattle was visiting last week. Now we’re talking $25 million. What are they looking to spend $25 million on? Tobacco and obesity. What are they going to do about tobacco and obesity? OK, tobacco public health campaigns have been effective, and I love the old ads that were so sarcastic and hardhitting, about the hard-bitten faux advertising guys plotting about how to make kids into cigarette addicts. They probably helped. And it’s true that tobacco is a huge public health problem. Although it’s also true that probably the most important element of the anti-tobacco crusade was the tax policy. But OK, I’ll give them this on tobacco – important objective and a somewhat proven track record. On the other hand, I doubt if this money is going to lead to much increased employment, except maybe for the health department people and some advertising agencies. Not exactly the people I would target to get this country going again.
But obesity? What the hell are they going to spend the obesity money on? There is no proven way to combat obesity. We don’t know anything about advertising about obesity – who and what are going to be the targets? No one knows anything that will work! Gym memberships? Lectures about fast food? Hit squads on fructose-rich corn syrup? General money for the health department personnel so they avoid layoffs? Personally, I’d rather see some Ben Shahn art commissioned – at least that leaves a trace. I smell another Golden Fleece, sorry to say.
Which leads us to taxes. By the grace of God, I am a highly taxed person. I don’t squawk much about taxes, but lots of people do. They might give lots of reasons for their discomfiture, both practical and theoretical, but I think it comes down to this – what are we getting for our tax money? Even if we are borrowing money now and these expenditures might not be coming directly from taxes yet, we still pay interest and we the people will have to pay it somehow sometime. What are we getting for it?
When the money goes out to health departments and they are told, “Spend it in a good cause,” I don’t buy that. Pea brains don’t do well in spending Other People’s Money (OPM). Large brains don’t even do so well. I look at these idiocies and say, why not fix the pot holes on I-880? It turns out that construction projects don’t have a very good multiplier effect in rocketing money around in the economy. But then I have to ask, does giving money to public health agencies and advertising agencies do better?
That's what I see and that's what other people see.
Anyone ever thought of subsidizing bloggers?
Budd Shenkin
But, then, even I have my doubts. I haven’t seen any big exposés of the shovel-ready projects of the original ARRA legislation – where is William Proxmire’s Golden Fleece Award when we need it? It’s really strange, come to think of it, that the Republicans haven’t come out with sensational stories about multiple bridges to nowhere. I wonder why. Maybe it’s mutual respect for each other’s district spending.
So, in lieu of Proxmire, here are my own personal observations of how money is filtering down to be government-spent. Item #1 – two weeks ago we received a notice from our local Contra Costa County Health Department. They had a $1 million grant program that they themselves could not spend directly, but had to divvy up among others (if they could have spent it themselves, knowing that health department, believe me, they would have. A classic health department, bureaucracy and empire building.) Anyway, we were notified about this program with one day turnaround time required – they are not used to involving others in money spending, I guess.
This grant program was a mélange of rules. How to apply, what criteria to meet, how to measure, who would be eligible for what, etc. etc. Just the reason I don’t deal with governments. Half the value of the grant, if received, would have been spent (and not reimbursed) by time and effort filling out the damn grant application. So typical. Then reviewed by the huge brains in the health department.
And what was the object of this million dollars to be spent, and the time of application to be spent on unpaid work, and the time of bureaucratic efforts to conceive the project, make the rules, and review the applications and later the work? Get this. Spending all this money to find the hard to reach populations in Contra Costa County and immunize them against H1N1!! Jesus! Talk about a stupid objective! Where is the evidence that this is a worthwhile objective? Where is the evidence of how much money would be spent per shot delivered? Where is the evidence that this is worth anything at all, especially when so many regular people are declining the H1N1 shots for various reasons of their own? Do we think that H1N1 is that much of a threat now? Anyone there with experience in trying to wipe out smallpox or polio with the CDC worldwide, who would know how uninformed this choice of objective is on so many levels? Government!!!
OK, so that’s only a million dollars. Then a friend of Sara’s who works for the health department in Seattle was visiting last week. Now we’re talking $25 million. What are they looking to spend $25 million on? Tobacco and obesity. What are they going to do about tobacco and obesity? OK, tobacco public health campaigns have been effective, and I love the old ads that were so sarcastic and hardhitting, about the hard-bitten faux advertising guys plotting about how to make kids into cigarette addicts. They probably helped. And it’s true that tobacco is a huge public health problem. Although it’s also true that probably the most important element of the anti-tobacco crusade was the tax policy. But OK, I’ll give them this on tobacco – important objective and a somewhat proven track record. On the other hand, I doubt if this money is going to lead to much increased employment, except maybe for the health department people and some advertising agencies. Not exactly the people I would target to get this country going again.
But obesity? What the hell are they going to spend the obesity money on? There is no proven way to combat obesity. We don’t know anything about advertising about obesity – who and what are going to be the targets? No one knows anything that will work! Gym memberships? Lectures about fast food? Hit squads on fructose-rich corn syrup? General money for the health department personnel so they avoid layoffs? Personally, I’d rather see some Ben Shahn art commissioned – at least that leaves a trace. I smell another Golden Fleece, sorry to say.
Which leads us to taxes. By the grace of God, I am a highly taxed person. I don’t squawk much about taxes, but lots of people do. They might give lots of reasons for their discomfiture, both practical and theoretical, but I think it comes down to this – what are we getting for our tax money? Even if we are borrowing money now and these expenditures might not be coming directly from taxes yet, we still pay interest and we the people will have to pay it somehow sometime. What are we getting for it?
When the money goes out to health departments and they are told, “Spend it in a good cause,” I don’t buy that. Pea brains don’t do well in spending Other People’s Money (OPM). Large brains don’t even do so well. I look at these idiocies and say, why not fix the pot holes on I-880? It turns out that construction projects don’t have a very good multiplier effect in rocketing money around in the economy. But then I have to ask, does giving money to public health agencies and advertising agencies do better?
That's what I see and that's what other people see.
Anyone ever thought of subsidizing bloggers?
Budd Shenkin
Monday, May 17, 2010
Too much, too soon?
When a baby comes into the family, you start making priorities. As my friend John (Buzzard) Bernard said, before children, you could pretty much fit anything you wanted into your life. Especially if you were as talented as John Bernard. But kids are the killer.
Even when you are expecting a baby, the priorities change, for women more quickly than for men. Women have to change what they eat and drink. We don’t. Women have to learn to sleep on their back. Not me! Women worry about the health of the baby. Men worry about how to support the whole family financially. Everybody has to grow up.
You get a sense that this is the most important thing you have ever been entrusted with. If you disappointed your parents, that was too bad, but still you could say, hey, I’m the one who will really suffer. It’s my life! But with a baby, if you screw up, it’s not just you who suffers. So many people read baby books. Me, I tried to go back and read Jean-Jaques Rousseau’s Emile. Nuts, I know, but at least I was sensible enough not to get very far into it.
Then there’s life style. When Allie was born, I was determined that going out to dinner wasn’t going to be interrupted. Colic fixed that one pretty good. I thought, I would so like to life in another country for a while so the kids could be easily bilingual. Not at the top of everyone’s list, and it turned out that it wasn’t as easy as I thought. Allie’s first word was “Titta!”, which is Swedish, but that was about it as we moved back to the States to stay.
The rich and famous can have more temptations than we do, simply because they have the means. Daughters trotting around with Gucci, sons with Stingrays. Too much, too soon. A real hazard.
All of which brings us to my step-daughter Sara Buckelew, and her daughter, Lola Buckelew. Sara is a wonderful mother and Lola is just over three months old. Luckily, Lola is a very complacent but still very responsive baby, making everything easier. Sara can focus in on her own priorities for Lola.
Sara seems more reasonable that I was, which is probably not that hard to be. But, Sara is a baseball fan. Actually, more of an uber-fan. And Lola doesn’t have colic. As a result, Lola, at just over three months of age, has been to about six major league games already.
One of the things about baseball is its endless variety. They say that every time you go to the ballpark, if you are observant, you will see something you never saw before. Like this last Saturday at the Giants, Brian Wilson of the Giants faced Kazuo Matsui with two out in the ninth, bases full, Giants up 2-1. Fifteen pitches, about six of them strikes thrown one after the other as Matsui fouled them off, finally succumbing to a soft fly to left before a rapturous crowd, Fifteen pitches! And then yesterday, Sunday, it’s Wilson vs. Matsui again, two men on, two out, bottom of the ninth, Giants up 4-3, and it’s a strikeout. Pretty good! Baseball is a game to savor.
But, that’s just me, and I’ve been to hundreds of games. What about Lola?
Lola: three months old, six games. She has already seen the Giants’ Aubrey Huff hit an inside the park homer, saw the Yankees pull a triple play on the A’s, and then last week she saw Dallas Braden’s perfect game – perfect game! – for the A’s. Perfect game!
So, I have to ask. Sara: Too much, too soon?
Budd Shenkin
Even when you are expecting a baby, the priorities change, for women more quickly than for men. Women have to change what they eat and drink. We don’t. Women have to learn to sleep on their back. Not me! Women worry about the health of the baby. Men worry about how to support the whole family financially. Everybody has to grow up.
You get a sense that this is the most important thing you have ever been entrusted with. If you disappointed your parents, that was too bad, but still you could say, hey, I’m the one who will really suffer. It’s my life! But with a baby, if you screw up, it’s not just you who suffers. So many people read baby books. Me, I tried to go back and read Jean-Jaques Rousseau’s Emile. Nuts, I know, but at least I was sensible enough not to get very far into it.
Then there’s life style. When Allie was born, I was determined that going out to dinner wasn’t going to be interrupted. Colic fixed that one pretty good. I thought, I would so like to life in another country for a while so the kids could be easily bilingual. Not at the top of everyone’s list, and it turned out that it wasn’t as easy as I thought. Allie’s first word was “Titta!”, which is Swedish, but that was about it as we moved back to the States to stay.
The rich and famous can have more temptations than we do, simply because they have the means. Daughters trotting around with Gucci, sons with Stingrays. Too much, too soon. A real hazard.
All of which brings us to my step-daughter Sara Buckelew, and her daughter, Lola Buckelew. Sara is a wonderful mother and Lola is just over three months old. Luckily, Lola is a very complacent but still very responsive baby, making everything easier. Sara can focus in on her own priorities for Lola.
Sara seems more reasonable that I was, which is probably not that hard to be. But, Sara is a baseball fan. Actually, more of an uber-fan. And Lola doesn’t have colic. As a result, Lola, at just over three months of age, has been to about six major league games already.
One of the things about baseball is its endless variety. They say that every time you go to the ballpark, if you are observant, you will see something you never saw before. Like this last Saturday at the Giants, Brian Wilson of the Giants faced Kazuo Matsui with two out in the ninth, bases full, Giants up 2-1. Fifteen pitches, about six of them strikes thrown one after the other as Matsui fouled them off, finally succumbing to a soft fly to left before a rapturous crowd, Fifteen pitches! And then yesterday, Sunday, it’s Wilson vs. Matsui again, two men on, two out, bottom of the ninth, Giants up 4-3, and it’s a strikeout. Pretty good! Baseball is a game to savor.
But, that’s just me, and I’ve been to hundreds of games. What about Lola?
Lola: three months old, six games. She has already seen the Giants’ Aubrey Huff hit an inside the park homer, saw the Yankees pull a triple play on the A’s, and then last week she saw Dallas Braden’s perfect game – perfect game! – for the A’s. Perfect game!
So, I have to ask. Sara: Too much, too soon?
Budd Shenkin
Tuesday, May 11, 2010
Another Thursday
It was a Thursday like any other Thursday. My day of long but productive and important meetings in our Dublin office. We have been operating for over a year now – indeed, for several years – without a well-functioning Administrator, and I have taken that role.
We met all morning, then I went over to ValleyCare Hospital for a Pediatrics Committee meeting, to consider once again how we can combat a hospital intent on using its capital to construct and run its own medical group, and put us out of business. There will be more and more of this – the hospitals have the money.
Then I visited our local Infinity dealer for a second time. My lease ran out on my Lexus GS 430 – four years and out. I lease so that I don’t run a car into the ground until it just breaks up, which means I’ve been driving a fairly crappy car for a long time, no matter how great it was at the start. I have to force myself to get going and make a new choice. I’m not a good chooser – I procrastinate. I think it’s pretty genetic. My son Allie is pretty much the same. I really don’t know if it makes economic sense for me to lease or buy – it’s too hard to figure out, and it can’t be all that different or it would be obvious. They get you coming and going no matter what you do. I guess.
So here I was with the salesman. Not a pushy guy, not a pushy agency. I drove the car around again and liked it, responded to the Joe the salesman that I was ready to buy real soon, saw his eyes light up, and I told him the way I bought my last car – figured out what I wanted and called around to dealerships until I found the best deal, which was $750 above invoice. Said I’d do the same thing this time. I thought I ought to get back to the office, but he said, “Want to come inside and see what we can do?” “OK,” I said, surprising myself.
So we were sitting in his cubicle and Joe checked with his manager – they are all so young! Short wiry guy with a little mustache and nice smile. I’m still getting used to being older and successful, being looked at with respect, I guess, but I’m always surprised not to find envy and resentment. I’m still surprised the way I’m treated with respect. And, to tell the truth, delighted. I’m always friendly back at them, and “a regular guy.” A strength. Why I don’t like to be in situations where I am inferior in some way. Not good with mentors. A weakness.
Strangely, Joe came back and said my offer was just fine with them. He said, my manager felt like dealing today. I figure, either they understood that my story about what I would do made sense, or the car had been sitting, or the invoice isn’t as valid as one would like, or they get manufacturer rebates. So what could I say? I had bought a car. Surprised myself, me, who dithers and channels my late father by second guessing myself. Joe asked if I wanted to take the car home tonight. Couldn’t wait for it that long, I said, the Sharks play at 6. “Go Sharks” came the cry from the salesman at the next cubicle. Such a friendly group. “He has season tickets,” said Joe.
I knew the next step in the familiar dance, visit the financial officer who would try to convince me to lease instead of buy. Another wiry guy, about my height, another guy with a small mustache. Started out the same way as the guy did four years ago when I switched from buy to lease, “Why do you want to buy a wasting asset?” “Why tie up your money?” I guess I reflected that I had danced this dance before, because he made a meta-comment – “I have to do this.” After all, it’s his job. Another low-key guy. And I wound up leasing, just like last time. He acted surprised that I had bought his argument rather than the car.
I think it was the meta-comment, the personal connection, the “Go Sharks” comment, the surprise that they simply accepted my offer, or the relief of actually having made a decision; it was something. But I’m a naturally gregarious guy, not overly shy, and - hey! - I’m a doctor. Maybe I was talking about my wife or my kids. So I must have said, “Are you married?”
He said, “No, I’m not.”
So I said, naturally, “Are you a gay guy?” I mean, we were talking, why pussyfoot around?
So he said no, he wasn’t. “If you’re not married,” he said, “do you have to be gay?” He seemed a little surprised that I asked him.
“No, but it’s the Bay Area,” And I added, “You’re a good looking guy, so I figured you could be married if you wanted to be, so I was just wondering.”
He accepted that (I’m not above a little flattery.) So he said, “I’m not married, but I have a girl friend.”
I asked him how old he was and he said 49 – that’s about what he looked.. “How long have you been going together,” I asked.
“Five and a half years.”
“Wow, I said, that’s pretty long. Why don’t you marry her?”
He said, “Why do you think that?”
I said, “Well, if it’s been that long, and you love her and you think you’re getting a good deal with her, you just have to knock her down and marry her. Otherwise you don’t know what will happen. If you don’t think you’re getting a deal, if you think she’s the one getting a good deal, and you’re doing her a favor, then you probably need to find somebody else.”
Then I told him about Andre Agassi’s book, which I thought was terrific. “You know what happened?” I asked him. “Agassi thought Steffi Graff was terrific, admired her, even idolized her, so he tried to make a date with her.
“She said, ‘I have a boyfriend.’
“He said, ‘how long have you been going together?’
“She said, ‘Six and a half years.’
“He said, ‘That’s a long time. So long that it’s probably not going anywhere. Why not give me a try?’
“She did, and not too much longer, they were together, she was pregnant, and they were married.”
A pretty powerful story (and a great book.) So my new friend said, “There’s something you don’t know.”
“Ah!” I said. “What is it.”
“She’s married.”
“Yup, that explains it,” I said.
“And she’s Chinese.”
Well, that’s not unheard of. I wondered what was coming next.
He said, “You know, I think I’m telling you this because you’re a doctor.” And kind of shrugged.
“Yes,” I said, “it’s OK, I’ll treat it confidentially.”
So he continued: “She has a 16 year old son. They are traditional (!). They think a teenage son should be raised by a father and a mother. So she’s there in the day, but every night she comes over to my house and sleeps with me.”
Well, I thought this was an unusual solution to wanting to be traditional, but people do solve dilemmas in unusual ways.
Then he said, “I used to be married. We had a son. He was 13. Then one day he was with a bunch of kids and they were up in a tree. We found him up in that tree hanged by the neck. We don’t know how it happened.” He shrugged. He just shrugged.
I told him about Peter. Peter was 17 and on a trip with his school and they slept overnight in an open campground on the American River. In the middle of the night a 4,700 pound live oak tree fell in the midst of the group and crushed Peter’s abdomen. He lost a kidney, 18 inches of bowel, severed all the lateral processes of the lumbar spine, broke a hand, and was in the ICU for many days and in the hospital for 3 weeks, and went from 132 pounds to 112 pounds and months of rehab and recovery. He came back. He narrowly escaped paralysis and death. We were lucky. We were just lucky. My auto financial advisor wasn’t.
It was just about then I got call from Grant, our IT guy at Bayside. “Dr. Shenkin, are you coming back to the office today?”
I said, “Yeah, Grant, I figure I will, but I’m buying a car. What’s up?”
Grant giggled in wonder, “You’re buying a car??”
“Yeah, I just figured I would. What’s up?”
“Well,” Grant said, “I have a contract with ATT that we really should have signed today and sent in, and they are in the Central Time Zone.”
“Grant, it’s twelve minutes of four o’clock.”
“Yes, we have about twelve minutes. They’re waiting for it.”
“Grant, it’s just not going to happen today. I’ll be back there in about half an hour.”
So I signed the lease and shook hands with my friend, who I figured I would look up when I brought the car in for service (I had negotiated three free servicings), arranged to have the salesman deliver the car to our house on Friday night, drove back to the Dublin office reviewed the terms of the contract, thanked Grant for doing all the work of getting the price of revision of service down from the $150,000 that our three months and out Administrator had negotiated to a more manageable $2,750, but told Grant that we need to exert some leverage at this point to recoup some of the losses we had sustained in switching services, and getting a better deal on the monthly charges.
Grant said, “But it’s a time-limited offer!”
“That’s OK, Grant. You’ve done a great job. Now let’s hand it over to Flora. Don’t worry.”
On the way home Flora called me and said she had negotiated a $41,000 check to reimburse us for the ATT deficiencies. At the end of the day at home Flora emailed me that she had negotiated the monthly fee from what Grant wanted me to sign down by a third. Good job Flora.
Another Thursday come and gone. When I get my car serviced, I think I’ll drop by to visit the guys and say hello. The Sharks are still in it.
Budd Shenkin
We met all morning, then I went over to ValleyCare Hospital for a Pediatrics Committee meeting, to consider once again how we can combat a hospital intent on using its capital to construct and run its own medical group, and put us out of business. There will be more and more of this – the hospitals have the money.
Then I visited our local Infinity dealer for a second time. My lease ran out on my Lexus GS 430 – four years and out. I lease so that I don’t run a car into the ground until it just breaks up, which means I’ve been driving a fairly crappy car for a long time, no matter how great it was at the start. I have to force myself to get going and make a new choice. I’m not a good chooser – I procrastinate. I think it’s pretty genetic. My son Allie is pretty much the same. I really don’t know if it makes economic sense for me to lease or buy – it’s too hard to figure out, and it can’t be all that different or it would be obvious. They get you coming and going no matter what you do. I guess.
So here I was with the salesman. Not a pushy guy, not a pushy agency. I drove the car around again and liked it, responded to the Joe the salesman that I was ready to buy real soon, saw his eyes light up, and I told him the way I bought my last car – figured out what I wanted and called around to dealerships until I found the best deal, which was $750 above invoice. Said I’d do the same thing this time. I thought I ought to get back to the office, but he said, “Want to come inside and see what we can do?” “OK,” I said, surprising myself.
So we were sitting in his cubicle and Joe checked with his manager – they are all so young! Short wiry guy with a little mustache and nice smile. I’m still getting used to being older and successful, being looked at with respect, I guess, but I’m always surprised not to find envy and resentment. I’m still surprised the way I’m treated with respect. And, to tell the truth, delighted. I’m always friendly back at them, and “a regular guy.” A strength. Why I don’t like to be in situations where I am inferior in some way. Not good with mentors. A weakness.
Strangely, Joe came back and said my offer was just fine with them. He said, my manager felt like dealing today. I figure, either they understood that my story about what I would do made sense, or the car had been sitting, or the invoice isn’t as valid as one would like, or they get manufacturer rebates. So what could I say? I had bought a car. Surprised myself, me, who dithers and channels my late father by second guessing myself. Joe asked if I wanted to take the car home tonight. Couldn’t wait for it that long, I said, the Sharks play at 6. “Go Sharks” came the cry from the salesman at the next cubicle. Such a friendly group. “He has season tickets,” said Joe.
I knew the next step in the familiar dance, visit the financial officer who would try to convince me to lease instead of buy. Another wiry guy, about my height, another guy with a small mustache. Started out the same way as the guy did four years ago when I switched from buy to lease, “Why do you want to buy a wasting asset?” “Why tie up your money?” I guess I reflected that I had danced this dance before, because he made a meta-comment – “I have to do this.” After all, it’s his job. Another low-key guy. And I wound up leasing, just like last time. He acted surprised that I had bought his argument rather than the car.
I think it was the meta-comment, the personal connection, the “Go Sharks” comment, the surprise that they simply accepted my offer, or the relief of actually having made a decision; it was something. But I’m a naturally gregarious guy, not overly shy, and - hey! - I’m a doctor. Maybe I was talking about my wife or my kids. So I must have said, “Are you married?”
He said, “No, I’m not.”
So I said, naturally, “Are you a gay guy?” I mean, we were talking, why pussyfoot around?
So he said no, he wasn’t. “If you’re not married,” he said, “do you have to be gay?” He seemed a little surprised that I asked him.
“No, but it’s the Bay Area,” And I added, “You’re a good looking guy, so I figured you could be married if you wanted to be, so I was just wondering.”
He accepted that (I’m not above a little flattery.) So he said, “I’m not married, but I have a girl friend.”
I asked him how old he was and he said 49 – that’s about what he looked.. “How long have you been going together,” I asked.
“Five and a half years.”
“Wow, I said, that’s pretty long. Why don’t you marry her?”
He said, “Why do you think that?”
I said, “Well, if it’s been that long, and you love her and you think you’re getting a good deal with her, you just have to knock her down and marry her. Otherwise you don’t know what will happen. If you don’t think you’re getting a deal, if you think she’s the one getting a good deal, and you’re doing her a favor, then you probably need to find somebody else.”
Then I told him about Andre Agassi’s book, which I thought was terrific. “You know what happened?” I asked him. “Agassi thought Steffi Graff was terrific, admired her, even idolized her, so he tried to make a date with her.
“She said, ‘I have a boyfriend.’
“He said, ‘how long have you been going together?’
“She said, ‘Six and a half years.’
“He said, ‘That’s a long time. So long that it’s probably not going anywhere. Why not give me a try?’
“She did, and not too much longer, they were together, she was pregnant, and they were married.”
A pretty powerful story (and a great book.) So my new friend said, “There’s something you don’t know.”
“Ah!” I said. “What is it.”
“She’s married.”
“Yup, that explains it,” I said.
“And she’s Chinese.”
Well, that’s not unheard of. I wondered what was coming next.
He said, “You know, I think I’m telling you this because you’re a doctor.” And kind of shrugged.
“Yes,” I said, “it’s OK, I’ll treat it confidentially.”
So he continued: “She has a 16 year old son. They are traditional (!). They think a teenage son should be raised by a father and a mother. So she’s there in the day, but every night she comes over to my house and sleeps with me.”
Well, I thought this was an unusual solution to wanting to be traditional, but people do solve dilemmas in unusual ways.
Then he said, “I used to be married. We had a son. He was 13. Then one day he was with a bunch of kids and they were up in a tree. We found him up in that tree hanged by the neck. We don’t know how it happened.” He shrugged. He just shrugged.
I told him about Peter. Peter was 17 and on a trip with his school and they slept overnight in an open campground on the American River. In the middle of the night a 4,700 pound live oak tree fell in the midst of the group and crushed Peter’s abdomen. He lost a kidney, 18 inches of bowel, severed all the lateral processes of the lumbar spine, broke a hand, and was in the ICU for many days and in the hospital for 3 weeks, and went from 132 pounds to 112 pounds and months of rehab and recovery. He came back. He narrowly escaped paralysis and death. We were lucky. We were just lucky. My auto financial advisor wasn’t.
It was just about then I got call from Grant, our IT guy at Bayside. “Dr. Shenkin, are you coming back to the office today?”
I said, “Yeah, Grant, I figure I will, but I’m buying a car. What’s up?”
Grant giggled in wonder, “You’re buying a car??”
“Yeah, I just figured I would. What’s up?”
“Well,” Grant said, “I have a contract with ATT that we really should have signed today and sent in, and they are in the Central Time Zone.”
“Grant, it’s twelve minutes of four o’clock.”
“Yes, we have about twelve minutes. They’re waiting for it.”
“Grant, it’s just not going to happen today. I’ll be back there in about half an hour.”
So I signed the lease and shook hands with my friend, who I figured I would look up when I brought the car in for service (I had negotiated three free servicings), arranged to have the salesman deliver the car to our house on Friday night, drove back to the Dublin office reviewed the terms of the contract, thanked Grant for doing all the work of getting the price of revision of service down from the $150,000 that our three months and out Administrator had negotiated to a more manageable $2,750, but told Grant that we need to exert some leverage at this point to recoup some of the losses we had sustained in switching services, and getting a better deal on the monthly charges.
Grant said, “But it’s a time-limited offer!”
“That’s OK, Grant. You’ve done a great job. Now let’s hand it over to Flora. Don’t worry.”
On the way home Flora called me and said she had negotiated a $41,000 check to reimburse us for the ATT deficiencies. At the end of the day at home Flora emailed me that she had negotiated the monthly fee from what Grant wanted me to sign down by a third. Good job Flora.
Another Thursday come and gone. When I get my car serviced, I think I’ll drop by to visit the guys and say hello. The Sharks are still in it.
Budd Shenkin
Monday, April 26, 2010
A Game the Self-Critical Can Play
It’s important to be self-critical. It’s a worry my wife has about the always-positive-reinforcement give-everyone-a-trophy modern don’t-let-anyone-feel-neglected world. How do you know if you’re any good, she says?
Well, my parents would sure go along with that. They were proud of me and the other kids, very proud. But tell us? Don’t want to do that. Might cut down on effort. So I was raised to be self-critical. Was it enough? Was it any good? Would you be able to keep it up for next time when “the others let down.” How would someone not inclined to favor you look at it? (The old Jewish problem, you have to be better to succeed.)
That’s not such a bad thing if you’re going to do something worthwhile. For instance, I haven't posted lately because as I write something, it just doesn't seem up to snuff. I hope you all appreciate that. So that's the good part. But, the bad part is that relentless self-criticism can make for depression, tension, anxiety. That’s a high price.
There are many ways to deal with this family legacy. Some are expensive. But I am here to recommend one I have come up with for your evening pleasure. Jeopardy, the old Merv Griffin stable. Jeopardy. ABC, Channel 7 at 7 PM every night. In Hawaii it’s on at 4 PM, with a rerun of an older game at 4:30. Jeopardy, not running as frequently as Law and Order, but enough for a near daily dose, if you want.
But not standard Jeopardy. Standard Jeopardy is tough. In standard Jeopardy you have to be careful. Are you sure you know the answer? How sure do you have to be to ring in? If you’re wrong, it’ll cost you with deducted cash. But you have to act fast, with instant calculations. Standard Jeopardy is nerve racking.
Instead, I play Budd-Jeopardy. Budd-Jeopardy is refreshing. Budd-Jeopardy releases you from the worry throughout the game. You don't have to wonder if your account is going up or going down. Budd-Jeopardy only goes up, never down. It’s an upper!
What is Budd-Jeopardy? It is non-critical Jeopardy. In Budd-Jeopardy, there are no deductions. You get a point only when you know the answer, and no one else on the panel on the show does. If you get it and they don’t, you get to shout, “Budd!!” Or, if your name is not Budd, you get to shout your own name, let's be clear. Maybe I should insist that it's always "Budd!" you shout, but I doubt this rule would catch on, so you can use your own name. If it is a Daily Double question, and thus only one panel member gets to guess, and you get it and he or she doesn’t, you still get a “Budd!” If you are playing with someone else in the room, and you both get it, you both get a score, and you both get to shout your names.
Budd-Jeopardy gives you only positives! For every answer you can guess the question. If you’re wrong, no problem! You can be self-critical if you want, and of course I can’t help it. I should have gotten that! I knew that! I just couldn’t pull that one out, but I did know it! The full boat of disappointments can be uttered.
But, that’s only an undercurrent. Budd-Jeopardy is an upper. You’re only adding up the pluses. In Budd-Jeopardy, par for a game is two “Budd’s!” The best I’ve ever done is about six, I think. Sometimes it’s only a one, or very occasionally zero.
Budd-Jeopardy is the opposite of golf. Why would you play a game set up for frustration?
Try Budd-Jeopardy instead! You can use your own name, but be sure to shout it in triumph. At least twice a game. It helps to throw your arms up over your head, and to look around for admiration. Or, if you’re alone – and if you do this too much you might well find yourself alone – be sure to admire yourself. You deserve it.
OK, I confessed that I have hit a little dry patch for my posting, and this might not be up to par. OK. I agree. But if I get a bunch of complaints, I'll just erase it. I can't worry about the misses; let's only count the hits. One of these days, I'll get another "Budd!" Maybe tomorrow.
Budd Shenkin
Well, my parents would sure go along with that. They were proud of me and the other kids, very proud. But tell us? Don’t want to do that. Might cut down on effort. So I was raised to be self-critical. Was it enough? Was it any good? Would you be able to keep it up for next time when “the others let down.” How would someone not inclined to favor you look at it? (The old Jewish problem, you have to be better to succeed.)
That’s not such a bad thing if you’re going to do something worthwhile. For instance, I haven't posted lately because as I write something, it just doesn't seem up to snuff. I hope you all appreciate that. So that's the good part. But, the bad part is that relentless self-criticism can make for depression, tension, anxiety. That’s a high price.
There are many ways to deal with this family legacy. Some are expensive. But I am here to recommend one I have come up with for your evening pleasure. Jeopardy, the old Merv Griffin stable. Jeopardy. ABC, Channel 7 at 7 PM every night. In Hawaii it’s on at 4 PM, with a rerun of an older game at 4:30. Jeopardy, not running as frequently as Law and Order, but enough for a near daily dose, if you want.
But not standard Jeopardy. Standard Jeopardy is tough. In standard Jeopardy you have to be careful. Are you sure you know the answer? How sure do you have to be to ring in? If you’re wrong, it’ll cost you with deducted cash. But you have to act fast, with instant calculations. Standard Jeopardy is nerve racking.
Instead, I play Budd-Jeopardy. Budd-Jeopardy is refreshing. Budd-Jeopardy releases you from the worry throughout the game. You don't have to wonder if your account is going up or going down. Budd-Jeopardy only goes up, never down. It’s an upper!
What is Budd-Jeopardy? It is non-critical Jeopardy. In Budd-Jeopardy, there are no deductions. You get a point only when you know the answer, and no one else on the panel on the show does. If you get it and they don’t, you get to shout, “Budd!!” Or, if your name is not Budd, you get to shout your own name, let's be clear. Maybe I should insist that it's always "Budd!" you shout, but I doubt this rule would catch on, so you can use your own name. If it is a Daily Double question, and thus only one panel member gets to guess, and you get it and he or she doesn’t, you still get a “Budd!” If you are playing with someone else in the room, and you both get it, you both get a score, and you both get to shout your names.
Budd-Jeopardy gives you only positives! For every answer you can guess the question. If you’re wrong, no problem! You can be self-critical if you want, and of course I can’t help it. I should have gotten that! I knew that! I just couldn’t pull that one out, but I did know it! The full boat of disappointments can be uttered.
But, that’s only an undercurrent. Budd-Jeopardy is an upper. You’re only adding up the pluses. In Budd-Jeopardy, par for a game is two “Budd’s!” The best I’ve ever done is about six, I think. Sometimes it’s only a one, or very occasionally zero.
Budd-Jeopardy is the opposite of golf. Why would you play a game set up for frustration?
Try Budd-Jeopardy instead! You can use your own name, but be sure to shout it in triumph. At least twice a game. It helps to throw your arms up over your head, and to look around for admiration. Or, if you’re alone – and if you do this too much you might well find yourself alone – be sure to admire yourself. You deserve it.
OK, I confessed that I have hit a little dry patch for my posting, and this might not be up to par. OK. I agree. But if I get a bunch of complaints, I'll just erase it. I can't worry about the misses; let's only count the hits. One of these days, I'll get another "Budd!" Maybe tomorrow.
Budd Shenkin
Monday, April 12, 2010
Hospitals Employ Doctors
A few articles have recently appeared in the New York Times and elsewhere, saying that newly graduating doctors are choosing to be employed by hospitals, In addition, doctors and groups in practice are choosing similarly. Locally, a large group down the Peninsula recently chose to join Palo Alto Medical Foundation (PAMF). I don't know why they did this, but at least now I can say for sure that Bayside, our group, is the largest private primary care group in the Bay Area. But I guess that's off the point. Again.
Anyway, why is this happening? People talk about the new work ethic of new grads - more leisure, more "just a job," etc. Maybe so. But, that's nothing an economic determinist would accept.
Let me be economic determinist, then. To quote "Deep Throat" in All The President's Men (the movie only - line does not appear in the book): Follow the Money.
Hospitals and large health systems command monopoly rents. They not only enrich themselves as monopolies, but by taking more of the health care dollar, they leave less for smaller, physician owned practices. The systems then use their extra money to purchase the factors of production that they have starved - the doctors.
The hospitals and systems claim, as do all expanding monopolies, that they provide higher quality (often for a hypothetical future) and better technology that only they can afford. Sometimes it may be true, unless you include as part of the quality equation personal relationships, human scale, and human trust. Patients probably prefer small offices, but the lack of a true market prevents them from voting with their feet and wallets.
But the telling point will be, who can offer the new doctors entering practice a better deal, the starved personal practices, or big, rich systems that thrive on monopoly rents? Follow the money.
Budd Shenkin
Anyway, why is this happening? People talk about the new work ethic of new grads - more leisure, more "just a job," etc. Maybe so. But, that's nothing an economic determinist would accept.
Let me be economic determinist, then. To quote "Deep Throat" in All The President's Men (the movie only - line does not appear in the book): Follow the Money.
Hospitals and large health systems command monopoly rents. They not only enrich themselves as monopolies, but by taking more of the health care dollar, they leave less for smaller, physician owned practices. The systems then use their extra money to purchase the factors of production that they have starved - the doctors.
The hospitals and systems claim, as do all expanding monopolies, that they provide higher quality (often for a hypothetical future) and better technology that only they can afford. Sometimes it may be true, unless you include as part of the quality equation personal relationships, human scale, and human trust. Patients probably prefer small offices, but the lack of a true market prevents them from voting with their feet and wallets.
But the telling point will be, who can offer the new doctors entering practice a better deal, the starved personal practices, or big, rich systems that thrive on monopoly rents? Follow the money.
Budd Shenkin
Thursday, April 1, 2010
Is Kaiser the Answer?
The question is, how is health care to be organized in the United States? One answer by the health cognoscenti has been, why not Kaiser for everyone? It is less expensive than other care, and its quality is high by all measures. So, why not Kaiser?
Since I am in the biggest Kaiser neighborhood in the country, Oakland, and since Kaiser with probably 70% or so of the private market is our biggest competitor, I’m hardly a disinterested bystander. We lose patients to Kaiser all the time, and there is not much we can do about it. They’re cheaper, and they are not out and out bad. So, grain of salt is indicated.
But, believe it or not, I have a Kaiser card myself! Why I have that card sheds light on the travails of health insurance for a business, the business in this case being Bayside Medical Group, that fine leader in primary care in the East Bay.
I have the card because we had to get Kaiser insurance for our group. We used to have a pretty good plan, although too expensive because all health insurance is too expensive. It was an exchange program run by the Pacific Business Group on Health, very much like the Health Insurance Exchange to come under Obama care. Under the exchange, we had several different levels of care, HMO’s and PPO’s, and several health insurance companies competing at each level. Most of our employees chose Kaiser, mostly because it was the least expensive alternative, and probably also because with one stop bureaucratic shopping, it is a pretty transparent system to the patient.
Anyway, it was fine, but then the system died, mostly because the health insurance companies didn’t need it and it exposed them to too much competition and squeezed them into categories of care. So it died. So we were back to choosing a plan for our group. But how to choose? We are a disparate group, from file clerks to physicians, and one plan won’t fit all. Moreover, we are a medical group, and medical groups are avoided by health insurance companies because of a perception that they are high utilizers. And, here’s the killer – the health insurance companies insist that we go all with them, or not at all with them.
Because so many of our employees were already with Kaiser, it would be very hard not to choose Kaiser. And luckily, Kaiser has a plan whereby employees can choose the classic closed panel Kaiser plan, or opt for a so-called point of service plan, which is like a PPO. It’s expensive for both premium and deductible, a rather crappy plan to be sure, but at least it’s a plan that I can use and a few of my colleagues as well. Under this plan, I get two cards – the POS card, and a regular Kaiser card. So, here I am, a prime Kaiser competitor, someone with a distaste for large institutions such as Kaiser, a pretty independent person, and I’m a card-carrying Kaiser member. Who’d a thunk it.
So there I was with a Kaiser care, so I figured, why not make a site visit? So last year I got the first annual physical of my life – I’m not a big utilizer, and I just programmed my own preventive program – at Kaiser. Then this year I returned for my second site visit, following up with the same doctor I saw last year.
What was it like? Did Kaiser appear to me to be a possible answer to the question? That is, we know that introducing a model is not easy and often impossible, so just because something works here doesn’t mean it will work there – there are all kinds of cultural questions involved. But, that’s not the question for the site visit. The question is, if it were possible to work toward something like this, would that be a good idea, in my eyes?
I have to say that the website worked well for me. I could find a doctor who was open and find out credentials, if not much more – see our website, www.baysidemedical.com, for what is possible with a personal touch. And I could make my appointment on line, which was great, just great.
But when I got there, it’s a visit to what socialized medicine would look like. Big institutions, big hallways, big buildings, milling crowds, big parking lots with lots of cars one after the other and you’re just another one of them, and a full dose of the hoi polloi. No matter what you had achieved in life, there you were with everyone else on an equal footing. We have to expect that Kaiser will never be the answer for everyone, just as all the socialized systems have alternatives of private care for those who can pay. Hoi polloi doesn’t work for everyone. Probably not for me. But, if I got past that and found a system and people who worked well, it could be for me. I’m opened minded enough for that, maybe.
Although maybe not. If I or a family member get something severe, I want choice. For most non-medical people they can’t use choice very well, but for me, I can use it and will – and actually did, for my hip resurfacing, for instance. But for primary care and run of the mill, I could do Kaiser, I think. Maybe. If it were good.
Overall, I did get promptness for my primary care visit. I got Oakland African-American sullenness from my first Medical Assistant – they are unionized, and no one can really fix this – but the one at my second visit was better. They take weights with clothes on, but I guess that’s just adult care. Doctor promptness was good, although the second time I went the office was almost empty of patients, so I had to wait almost 15 minutes in the exam room for my doctor. As everywhere, work expands to fill the time, and if things are slow, the staff are likely to go slower as well.
Promptness does not apply to waiting for lab tests or immunizations – I had to wait 15-30 minutes for both, and the shots are given at a separate clinic rather than at your primary care doctor’s, with another hoi polloi exposure. And waiting for labs is as slow as on the outside. Everyone there knows about it and deals with it.
The website helped right at the doctor’s office where she could make a dermatology appointment on her computer for me later the same week – great convenience. And after the visit I got emails pointing me to my lab results on the website. I could email my doc to ask for her reaction to the lab tests.
But of the vaunted Kaiser health system, that’s kind of it. It was up to me to inquire about the lab tests, she didn’t do anything about them unless I asked, even when my Vitamin D the second time was much lower than the first time, when she put me on a supplement for it. I had to remind her this year to check my level, and also the thyroid level, which she forgot she was monitoring and had supplemented. When I reminded her to order it, she even forgot she had had me on it for a year and treated it as a new prescription. She told me to come back in three months the first time but there was no prompt for me to do so – saving money, probably (I think that’s what most of Kaiser is geared toward.) Same with the yearly physical – up to me.
Kaiser is supposed to emphasize prevention. (They are prepaid, so they advertise with a slogan “Thrive!” They probably would like to add, “If you’re sick, why not enroll elsewhere?”) So, as my doctor sat on her little cart performing data entry with her Electronic Medical Record in front of her, she attempted to perform some prevention. She said, “You’re watching you weight?” I said, “Actually, I’ve gone up in my weight lately.” I think my BMI had gone up from 27 to 30 as they measure it, after my knee surgery, which knee she didn’t think to examine. So she looked at me and kind of shrugged. That was it for weight control, despite the fact that I have arthritis and am on statins and blood pressure medicine.
You would think that Kaiser would make a point of screening for depression, given that it is so widespread and treatable. But I don’t think their much into minds and feelings. I was surprised they don’t administer questionnaires. Maybe the hoi polloi won’t fill them out, but I would have. So she screened me verbally. She looked at me and said, “You’re OK, right?” I said, yeah, pretty much. Well, it was quick.
I actually can’t remember if she did a full body physical exam or not. She sure didn’t look at the sites of my operations, or ask how my hip was doing since the resurfacing operation. I do have to tell you, however, that my prostate got a good working over. Oh, yeah.
She did check this time to see if I had had my Adacel and pneumovax shots, which I guess we had skipped the first visit for some reason. The EMR at Kaiser does work well for that.
Actually, I like her. She’s a young woman from Haiti and went to a good medical school and seems nice enough. But I tend to like people. And if there were some big issues I would bring them up, I suppose. But to me, it just seems like working in these clinics is a killer. It’s institutional. What we want is really another human being taking care of us. Can I look at Marie as taking care of me? Only if she followed up the labs, asked me to come in again, gave me a roadmap of my health care, took time to ask about me and my family and my happiness or my plans to retire – I guess she did ask about that, actually. She’s a lot younger than I am and after all, I’ve only met her twice. And I’m prejudiced, hoping that Bayside can give better care than this system. But I have to say, you can put technology into the equation – and you should – but you have also got to find a way to get institutional feel out of the equation. Institutional feel kills the essence of care, and we have to be cared for. That’s what people want, to be cared for. We’re a long way away from being able to be cared for by a HAL.
I always tell our group, the key to being a successful clinician is for your patients to feel that you are competent, that you care, and that you are reliable. It’s hard to say that any of these criteria have been met by my experience at Kaiser. The quality measures cited by the cognoscenti, indicating that Kaiser’s care is of high quality? They are just markers that can be measured. Being cared for? They don’t really measure that, just as they don’t measure the competence of a clinician or a system in chasing down difficult diagnoses, following up orthopedic issues with physical therapy, and a myriad of other aspects of quality of care. Measurement of health care quality isn’t to the point where we can rely on it to indicate good care, just where it can indicate bad care.
But I also have to say, I still have the remnants of my depression-scarred father in me, and I appreciate that Kaiser cost less than other alternatives – all I had to do was pay the copay for the visit, which was reasonable, and nothing extra for the labs. I guess it’s good enough for the hoi polloi.
So, it's an interesting site visit. We can't get more out of it than that. Just one experience, just one doctor dealing with a difficult patient, another more-senior doctor. No big conclusions. It seems as though I could find another doctor if I wanted to.
But I have to say, as a system meeting the needs of a nation, leaves me unimpressed. But then, I'm a tough critic.
As for me, looks like I'll be taking care of myself for a while longer.
Budd Shenkin
Since I am in the biggest Kaiser neighborhood in the country, Oakland, and since Kaiser with probably 70% or so of the private market is our biggest competitor, I’m hardly a disinterested bystander. We lose patients to Kaiser all the time, and there is not much we can do about it. They’re cheaper, and they are not out and out bad. So, grain of salt is indicated.
But, believe it or not, I have a Kaiser card myself! Why I have that card sheds light on the travails of health insurance for a business, the business in this case being Bayside Medical Group, that fine leader in primary care in the East Bay.
I have the card because we had to get Kaiser insurance for our group. We used to have a pretty good plan, although too expensive because all health insurance is too expensive. It was an exchange program run by the Pacific Business Group on Health, very much like the Health Insurance Exchange to come under Obama care. Under the exchange, we had several different levels of care, HMO’s and PPO’s, and several health insurance companies competing at each level. Most of our employees chose Kaiser, mostly because it was the least expensive alternative, and probably also because with one stop bureaucratic shopping, it is a pretty transparent system to the patient.
Anyway, it was fine, but then the system died, mostly because the health insurance companies didn’t need it and it exposed them to too much competition and squeezed them into categories of care. So it died. So we were back to choosing a plan for our group. But how to choose? We are a disparate group, from file clerks to physicians, and one plan won’t fit all. Moreover, we are a medical group, and medical groups are avoided by health insurance companies because of a perception that they are high utilizers. And, here’s the killer – the health insurance companies insist that we go all with them, or not at all with them.
Because so many of our employees were already with Kaiser, it would be very hard not to choose Kaiser. And luckily, Kaiser has a plan whereby employees can choose the classic closed panel Kaiser plan, or opt for a so-called point of service plan, which is like a PPO. It’s expensive for both premium and deductible, a rather crappy plan to be sure, but at least it’s a plan that I can use and a few of my colleagues as well. Under this plan, I get two cards – the POS card, and a regular Kaiser card. So, here I am, a prime Kaiser competitor, someone with a distaste for large institutions such as Kaiser, a pretty independent person, and I’m a card-carrying Kaiser member. Who’d a thunk it.
So there I was with a Kaiser care, so I figured, why not make a site visit? So last year I got the first annual physical of my life – I’m not a big utilizer, and I just programmed my own preventive program – at Kaiser. Then this year I returned for my second site visit, following up with the same doctor I saw last year.
What was it like? Did Kaiser appear to me to be a possible answer to the question? That is, we know that introducing a model is not easy and often impossible, so just because something works here doesn’t mean it will work there – there are all kinds of cultural questions involved. But, that’s not the question for the site visit. The question is, if it were possible to work toward something like this, would that be a good idea, in my eyes?
I have to say that the website worked well for me. I could find a doctor who was open and find out credentials, if not much more – see our website, www.baysidemedical.com, for what is possible with a personal touch. And I could make my appointment on line, which was great, just great.
But when I got there, it’s a visit to what socialized medicine would look like. Big institutions, big hallways, big buildings, milling crowds, big parking lots with lots of cars one after the other and you’re just another one of them, and a full dose of the hoi polloi. No matter what you had achieved in life, there you were with everyone else on an equal footing. We have to expect that Kaiser will never be the answer for everyone, just as all the socialized systems have alternatives of private care for those who can pay. Hoi polloi doesn’t work for everyone. Probably not for me. But, if I got past that and found a system and people who worked well, it could be for me. I’m opened minded enough for that, maybe.
Although maybe not. If I or a family member get something severe, I want choice. For most non-medical people they can’t use choice very well, but for me, I can use it and will – and actually did, for my hip resurfacing, for instance. But for primary care and run of the mill, I could do Kaiser, I think. Maybe. If it were good.
Overall, I did get promptness for my primary care visit. I got Oakland African-American sullenness from my first Medical Assistant – they are unionized, and no one can really fix this – but the one at my second visit was better. They take weights with clothes on, but I guess that’s just adult care. Doctor promptness was good, although the second time I went the office was almost empty of patients, so I had to wait almost 15 minutes in the exam room for my doctor. As everywhere, work expands to fill the time, and if things are slow, the staff are likely to go slower as well.
Promptness does not apply to waiting for lab tests or immunizations – I had to wait 15-30 minutes for both, and the shots are given at a separate clinic rather than at your primary care doctor’s, with another hoi polloi exposure. And waiting for labs is as slow as on the outside. Everyone there knows about it and deals with it.
The website helped right at the doctor’s office where she could make a dermatology appointment on her computer for me later the same week – great convenience. And after the visit I got emails pointing me to my lab results on the website. I could email my doc to ask for her reaction to the lab tests.
But of the vaunted Kaiser health system, that’s kind of it. It was up to me to inquire about the lab tests, she didn’t do anything about them unless I asked, even when my Vitamin D the second time was much lower than the first time, when she put me on a supplement for it. I had to remind her this year to check my level, and also the thyroid level, which she forgot she was monitoring and had supplemented. When I reminded her to order it, she even forgot she had had me on it for a year and treated it as a new prescription. She told me to come back in three months the first time but there was no prompt for me to do so – saving money, probably (I think that’s what most of Kaiser is geared toward.) Same with the yearly physical – up to me.
Kaiser is supposed to emphasize prevention. (They are prepaid, so they advertise with a slogan “Thrive!” They probably would like to add, “If you’re sick, why not enroll elsewhere?”) So, as my doctor sat on her little cart performing data entry with her Electronic Medical Record in front of her, she attempted to perform some prevention. She said, “You’re watching you weight?” I said, “Actually, I’ve gone up in my weight lately.” I think my BMI had gone up from 27 to 30 as they measure it, after my knee surgery, which knee she didn’t think to examine. So she looked at me and kind of shrugged. That was it for weight control, despite the fact that I have arthritis and am on statins and blood pressure medicine.
You would think that Kaiser would make a point of screening for depression, given that it is so widespread and treatable. But I don’t think their much into minds and feelings. I was surprised they don’t administer questionnaires. Maybe the hoi polloi won’t fill them out, but I would have. So she screened me verbally. She looked at me and said, “You’re OK, right?” I said, yeah, pretty much. Well, it was quick.
I actually can’t remember if she did a full body physical exam or not. She sure didn’t look at the sites of my operations, or ask how my hip was doing since the resurfacing operation. I do have to tell you, however, that my prostate got a good working over. Oh, yeah.
She did check this time to see if I had had my Adacel and pneumovax shots, which I guess we had skipped the first visit for some reason. The EMR at Kaiser does work well for that.
Actually, I like her. She’s a young woman from Haiti and went to a good medical school and seems nice enough. But I tend to like people. And if there were some big issues I would bring them up, I suppose. But to me, it just seems like working in these clinics is a killer. It’s institutional. What we want is really another human being taking care of us. Can I look at Marie as taking care of me? Only if she followed up the labs, asked me to come in again, gave me a roadmap of my health care, took time to ask about me and my family and my happiness or my plans to retire – I guess she did ask about that, actually. She’s a lot younger than I am and after all, I’ve only met her twice. And I’m prejudiced, hoping that Bayside can give better care than this system. But I have to say, you can put technology into the equation – and you should – but you have also got to find a way to get institutional feel out of the equation. Institutional feel kills the essence of care, and we have to be cared for. That’s what people want, to be cared for. We’re a long way away from being able to be cared for by a HAL.
I always tell our group, the key to being a successful clinician is for your patients to feel that you are competent, that you care, and that you are reliable. It’s hard to say that any of these criteria have been met by my experience at Kaiser. The quality measures cited by the cognoscenti, indicating that Kaiser’s care is of high quality? They are just markers that can be measured. Being cared for? They don’t really measure that, just as they don’t measure the competence of a clinician or a system in chasing down difficult diagnoses, following up orthopedic issues with physical therapy, and a myriad of other aspects of quality of care. Measurement of health care quality isn’t to the point where we can rely on it to indicate good care, just where it can indicate bad care.
But I also have to say, I still have the remnants of my depression-scarred father in me, and I appreciate that Kaiser cost less than other alternatives – all I had to do was pay the copay for the visit, which was reasonable, and nothing extra for the labs. I guess it’s good enough for the hoi polloi.
So, it's an interesting site visit. We can't get more out of it than that. Just one experience, just one doctor dealing with a difficult patient, another more-senior doctor. No big conclusions. It seems as though I could find another doctor if I wanted to.
But I have to say, as a system meeting the needs of a nation, leaves me unimpressed. But then, I'm a tough critic.
As for me, looks like I'll be taking care of myself for a while longer.
Budd Shenkin
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