Is there anything coming up with the Wikileaks that is surprising? I can’t find much at all.
It has already been widely reported that Arab states want the US to get rid of Iran as a nuclear state. What we get from Wikileaks is the names of the Arab leaders, and that’s all.
The fact that Putin and Berlesconi have some common predilections? Trivial and gossipy.
The fact that the Obama Administration reached out to Iran but expected those gestures to fail, and had alternative plans for tightening and extending anti-Iran measures? No surprise.
The fact that no one trusts what Iran says? Now, that’s news!
Yemen complicit with the CIA? Surprise!
Karzai paranoid? Already public knowledge that others think this about him.
Karzai’s brother working for the CIA? Well reported.
Pakistan has poor leadership? Please. ISI is close with the Taliban? Come on, how could that be?
That the US would like to see North Korea implode and join South Korea? Nice they’d like to see that – the essential weakness of North Korea is not news.
The Obama Administration pulling the anti-missile installations under Russian pressure, and perhaps getting cooperation in return? Well reported.
In fact, I wonder if there isn’t a lot of dis-information in the leaks. For instance, is Israel as much of an independent actor as it is reported to be? Isn’t that exactly what the US would want to portray – “Well, you can trust us, but we don’t know what to do with the Israeli’s.” Good cop, bad cop.
What is embarrassing is the reaction of the US diplomatic community. They seem foolish and ingroupy – they are invading our space! How can anyone trust us now? They have crashed our little game! Not much of it seems so serious and intelligent, tell you the truth. But now they react so predictably – OK, people in the government, we’re going to shut it down, OK? Let’s be careful!
Who trusted them before? It all seems like crap to me. It’s scary to think again about how limited our “leaders” are. Sure wouldn’t want to make me join the Foreign Service….
Budd Shenkin
Monday, November 29, 2010
Saturday, November 27, 2010
WARM HEARTS AND COLD MINDS - EDUCATION POLICY
This is a post about education policy. New York Times columnists David Brooks and Tom Friedman, among others, insist that we need to concentrate as a nation on improved educational achievement, because that’s what jobs are requiring. Everyone knows our numbers suck, and Tom and David want us to concentrate on education, and they think parents need to be proactive with motivating and disciplining their children. This is the future, they say, and if we are inattentive, our nation will suffer severely. I agree.
There must be many, many reasons our achievement numbers suck. The outrageous proposition that education is a jobs program, propounded by risk-adverse teachers unions, is an attractive culprit, because they set self-interest against the public good. But I’m wondering if some of the reason lies in what I call the Warm-Heart/Cold-Mind dichotomy (WHCM, which sounds like a radio station.)
WHCM was presented to me most cogently in medical school. As a young liberal, with two classmates I started the Public Health Club, and Dean Robert Ebert assigned Dr. Dieter Koch-Weser to advise us. For our first session he assigned us a couple of articles that presented a dilemma of public health policy that, truthfully, I wasn’t ready for.
It is heart wrenching to imagine or to see babies and children dying from malaria. Some projects eradicated malaria in local areas. What happened when they stopped this suffering? Well, the ultimate results were not so great, it turned out. Evil though it was, malaria kept the population in check. Absent malaria, overpopulation ensued, and the suffering was worse than ever. I don’t remember the details of what actually ensued, but take my word for it – the cure caused more suffering than the disease.
As I say, I wasn’t ready to handle the conundrum – what does one do, then? Koch-Weser didn’t have any specific advice on that either, as I recall. But it was a memorable session – after all, it was 45 years ago and I remember the moral turmoil and policy confusion it caused in me.
Other liberals were confused, too. My Public Health Club co-founder, Carol Wolman, who had actually been to Africa, said that African doctors treated those in the cities and didn’t do public health, which would save ore lives, because they were short-sighted, and couldn’t resist taking care of the sick person in front of them. It could be a case of WHCM, but she probably neglected the fact that Africans who got to be doctors were from the wealthy class, and went back to treat the wealthy. Just a liberal confusion, I guess, with “mirror thinking” that others think the way we do.
In Africa in the late 70’s and early 80’s there was mass starvation. The response was food airlifts. Wrong and fuzzy-thinking, said an article in the New York Review of Books. If you save the children and don’t provide for more food production domestically, it will just happen again and be worse and create even more suffering. As it happened, I think there was more food production, and now AIDS has taken care of winnowing the overpopulation problem. Maybe the article was wrong; maybe too cold hearted and not hopeful enough that the future would actually experience advances that could support a larger population. Or maybe not.
Then as a pediatrician I saw what happened in the Intensive Care Nursery. Severely premature babies had literally a million dollars spent on each one, with profits to the hospitals that built the biggest and best ICN’s, and large salaries for the neonatologists and many pediatricians becoming neonatologists, hundreds of thousands spent for later rehabilitation, only a rare baby without deficits..Triumphs, yes, but lots of failures, and immense total costs, and resources drained from other, less dramatic areas.
So, to education policy. Years ago, they closed our neighborhood, fully-integrated school because it was “too good,” literally. The School Board made it into some kind o a magnet school where no one from the neighborhood goes any more, and where it doesn’t attract envy for being too good. God forbid someone should achieve.
Last year Berkeley High proposed that many math and science AP classes be abolished, the resources to be scattered to the underprivileged and underachieving groups in an unspecified way. It came within a whisker of being passed.
More generally, how much money are we spending on remedial education? A lot. Any Nobel Prize winners emerging from that expensive enterprise? If I were the father of an autistic kid I would certainly appreciate the tens of thousands of dollars that the school districts would be paying for one on one treatment. I can understand the power of the autism lobbying groups who want their children cared for. But still.
Have you had a friend or relative become a teacher for the developmentally delayed (aka, retarded)? A noble enterprise, to be sure. But the apogee of civilized achievement? At what opportunity cost?
So, you can talk about the weakness of the parents who do not value education for their children and make them turn off their cell phones and study instead. You can talk about the importance of caring for each child. You can say that a society is measured by the way it treats its weakest members. As a pediatrician I have a certified warm heart.
But as a cold-hearted public policy analyst, seems to me we most urgently need to support our best, and our next-best, and our third-best, those with the highest potentials. We should be able to do all of it, true. We spend too much on Pentagon waste, true. We could redo our entire educational menu and upgrade the quality for all, true.
That ain’t gonna happen. India isn’t going to do malaria control and agricultural reform and population control and educational upgrade all at once, and we’re not going to do defense reform, governmental efficiency upgrade, health care priority reform, and educational reform all at once, either. No long bombs, only three yards and a cloud of dust. So, when Tom and David tell us where our priorities need to be, are they going to say anything about our caring for the developmentally delayed and the autistic, or are they going to concentrate on getting parents to turn off the TV’s? Are they going to talk about liberal, warm-hearted groups that form what an objective observer would call special interests?
Back atcha, guys.
Budd Shenkin
There must be many, many reasons our achievement numbers suck. The outrageous proposition that education is a jobs program, propounded by risk-adverse teachers unions, is an attractive culprit, because they set self-interest against the public good. But I’m wondering if some of the reason lies in what I call the Warm-Heart/Cold-Mind dichotomy (WHCM, which sounds like a radio station.)
WHCM was presented to me most cogently in medical school. As a young liberal, with two classmates I started the Public Health Club, and Dean Robert Ebert assigned Dr. Dieter Koch-Weser to advise us. For our first session he assigned us a couple of articles that presented a dilemma of public health policy that, truthfully, I wasn’t ready for.
It is heart wrenching to imagine or to see babies and children dying from malaria. Some projects eradicated malaria in local areas. What happened when they stopped this suffering? Well, the ultimate results were not so great, it turned out. Evil though it was, malaria kept the population in check. Absent malaria, overpopulation ensued, and the suffering was worse than ever. I don’t remember the details of what actually ensued, but take my word for it – the cure caused more suffering than the disease.
As I say, I wasn’t ready to handle the conundrum – what does one do, then? Koch-Weser didn’t have any specific advice on that either, as I recall. But it was a memorable session – after all, it was 45 years ago and I remember the moral turmoil and policy confusion it caused in me.
Other liberals were confused, too. My Public Health Club co-founder, Carol Wolman, who had actually been to Africa, said that African doctors treated those in the cities and didn’t do public health, which would save ore lives, because they were short-sighted, and couldn’t resist taking care of the sick person in front of them. It could be a case of WHCM, but she probably neglected the fact that Africans who got to be doctors were from the wealthy class, and went back to treat the wealthy. Just a liberal confusion, I guess, with “mirror thinking” that others think the way we do.
In Africa in the late 70’s and early 80’s there was mass starvation. The response was food airlifts. Wrong and fuzzy-thinking, said an article in the New York Review of Books. If you save the children and don’t provide for more food production domestically, it will just happen again and be worse and create even more suffering. As it happened, I think there was more food production, and now AIDS has taken care of winnowing the overpopulation problem. Maybe the article was wrong; maybe too cold hearted and not hopeful enough that the future would actually experience advances that could support a larger population. Or maybe not.
Then as a pediatrician I saw what happened in the Intensive Care Nursery. Severely premature babies had literally a million dollars spent on each one, with profits to the hospitals that built the biggest and best ICN’s, and large salaries for the neonatologists and many pediatricians becoming neonatologists, hundreds of thousands spent for later rehabilitation, only a rare baby without deficits..Triumphs, yes, but lots of failures, and immense total costs, and resources drained from other, less dramatic areas.
So, to education policy. Years ago, they closed our neighborhood, fully-integrated school because it was “too good,” literally. The School Board made it into some kind o a magnet school where no one from the neighborhood goes any more, and where it doesn’t attract envy for being too good. God forbid someone should achieve.
Last year Berkeley High proposed that many math and science AP classes be abolished, the resources to be scattered to the underprivileged and underachieving groups in an unspecified way. It came within a whisker of being passed.
More generally, how much money are we spending on remedial education? A lot. Any Nobel Prize winners emerging from that expensive enterprise? If I were the father of an autistic kid I would certainly appreciate the tens of thousands of dollars that the school districts would be paying for one on one treatment. I can understand the power of the autism lobbying groups who want their children cared for. But still.
Have you had a friend or relative become a teacher for the developmentally delayed (aka, retarded)? A noble enterprise, to be sure. But the apogee of civilized achievement? At what opportunity cost?
So, you can talk about the weakness of the parents who do not value education for their children and make them turn off their cell phones and study instead. You can talk about the importance of caring for each child. You can say that a society is measured by the way it treats its weakest members. As a pediatrician I have a certified warm heart.
But as a cold-hearted public policy analyst, seems to me we most urgently need to support our best, and our next-best, and our third-best, those with the highest potentials. We should be able to do all of it, true. We spend too much on Pentagon waste, true. We could redo our entire educational menu and upgrade the quality for all, true.
That ain’t gonna happen. India isn’t going to do malaria control and agricultural reform and population control and educational upgrade all at once, and we’re not going to do defense reform, governmental efficiency upgrade, health care priority reform, and educational reform all at once, either. No long bombs, only three yards and a cloud of dust. So, when Tom and David tell us where our priorities need to be, are they going to say anything about our caring for the developmentally delayed and the autistic, or are they going to concentrate on getting parents to turn off the TV’s? Are they going to talk about liberal, warm-hearted groups that form what an objective observer would call special interests?
Back atcha, guys.
Budd Shenkin
Saturday, November 20, 2010
The Giants Win the World Series
I don’t believe in God, certainly not in the old-fashioned sense of a Man on a Throne. But I do think God is a pretty good heuristic.
“Heuristic” means to me “as if.” You don’t really believe this is so, but it’s useful to believe it. Now, that’s not Pascal’s Wager, which tells us to bet on the existence of God, because if God does exist you will be rewarded, and if he doesn’t, well, what have you lost? That’s not a heuristic, that’s a cost-benefit analysis.
Here is a good example of a heuristic: if you play the stock market, it is useful to believe that there is an “operator” who is manipulating the market to draw you in and take your money. There used actually to be operators, but they don’t exist anymore, or so we are told. Still, the market acts as though there were one. It goes down to scare you, and then down again, and then again so you finally sell your stock, and now that the operator has bought your stock at a cheap price, up goes its price with you on the sidelines in frustration. The mythical operator has struck again.
So, I don’t believe in God. But it’s useful to think that “God will provide.” You can’t plan everything, you can’t be sure of everything, sometime you just have to take a chance, move to America and leave the Old World behind, and think that “God will provide.” It might be you yourself who will provide, or the Massachusetts Indians, but it’s useful to think of God up there to help you.
And so it is with baseball, itself the holy of holies. Not that “God will provide,” because anyone who has grown up rooting for the Phillies, the A’s, the Giants – in fact, I guess everyone except the Yankees – you know that God will not in fact provide. You will lose and lose and lose, and be drawn into thinking that this might be the year, and then you will lose again. So I have always figured that if our team is not mathematically eliminated in September and the games still have even theoretical meaning, it was a good year.
It helps to remember Job, and believe that sometime, maybe at an unexpected time, the plagues will finally relent. Maybe. And that great turn of your luck will not depend on any particular virtues of yours, but it will simply be a gift from a heuristical God.
And so it was this year. There was no reason to think this year would be any different for the Giants. None. Excellent pitching, which they had had before. A lack of bats, severe, I thought. So all through the year GM Brian Sabean brought in people and tried them out. Some worked – Aubrey Huff at first – and some didn’t – Bowker in left. Most famously, the “accidental Giant,” Cody Ross, became a Giant off waivers only because the Giants didn’t want him to go to San Diego. And then he comes up with five homers in the playoffs. It’s skill on Sabean’s part, and on manager Bruce Bochy’s part, and luck, and chance, and happenstance, and you could say it just was the fact that God decided to smile on you, for no particular reason that we can figure out.
For me it was particularly amazing, since my beloved brother Bobby is a die-hard Phillies fan and season ticket holder. While the Giants were making their amazing run at the collapsing Padres in September, when it seemed that God was just determined that they should win, Bobby and I faced the prospect of rooting against each other. After 34 years in the Bay Area and being partners in Giants season tickets I am acculturated – the Phillies are my second-favorite team. (Actually, if the A’s recover, that might not be true – but they will definitely be my second favorite team in the National League.) So the best we could hope for would be that the Phils and Giants would not face each other in the first round although the odds were against it. But fie on the odds – God provided, and they faced different opponents in the first round, so we could root for each other’s team, and both teams won. Voilá!
Then our Giants were on to the powerful Phillies, with their winning experience and very solid lineup, featuring the great Shane Victorino (inside joke – he’s from Maui and has a featured box on the Maui News sports page every day, really funny home town boosterism, “Victorino and Phillies advance to League Championship series!”)
How was every desire coming true? Where was this coming from? How was it that every move worked out? The new players produced, Wilson kept saving games, Uribe hit an 8th inning homer to beat the Phillies. How did we beat their great pitchers? Ryan Howard looked at a third strike when he should have been protecting the plate. Bobby and I communicated carefully with each other, since we each knew where we stood. From not believing they could catch the Padres, to the World Series. Why was he smiling on us?
God smiled again. I was due for tickets to the 6th game but my partner Jim wanted to trade his 1st game tickets for my 6th game. It’s a deal, Jim!
Ann, as my wife, always has first call on the tickets, but usually says that someone else will appreciate it more and gives them up. But this time I prevailed on her to go with me, to both the Phillies game and World Series #1 game against the Rangers. While she was reserved for the Phillies game, she said it was great. Then for WS #1 the reserve evaporated. It was a wonderful night. Balmy. Mellow. Joe Montana was sitting two rows ahead of us across the aisle. Other SF notables popped up here and there. We belonged there; these are our seats, our city. Tony Bennett sang I Left My Heart in the second inning because he was late – took Muni to the ballpark. 83 years old, but the voice is there. It was November, but it was in the 60’s, calm, comfortable, perfect, the whole night. (The next night it was Steve Perry from Journey singling “Lights” about the City, and when they stopped playing that, the crowd kept singing. A sports writer from Texas who repeatedly trashed the Bay Area had to write as he visited here, “I take it back. I love this city.”)
Ann said, “Look at the sky!” It was remarkable. It was like slate, but a bit uneven, blue-black, some parts darker than others, but not moving at all, perfectly still. Aaron, one of my partners with the tickets, turned around and said, “Look at the sky.” Look at the sky.
It was tight, and then the 5th inning happened. We kept scoring and were a couple of runs ahead. Then Uribe hit a three run homer to push us way in front. Everyone around us looked at each other, gave high fives, and then literally said stopped and said to each other, “My God.” There was singing and I was dancing as Ann laughed at me, and laughed with everyone else. In the 7th Tony Bennett sang God Bless America and so did we.
I’ve heard that hospitals are the modern equivalent of medieval cathedrals, but now I think it might be sports stadiums instead. At the ballpark we were one, knit together, being blessed. How else can you look at it? It was just a gift from a heuristial God, and it was our job to take it, to accept it, to appreciate it, to be blessed with it.
It’s probably the best sports experience I’ve ever had, in a lifetime of watching sports. And blessedly, my brother Bobby was good enough to send me a text that said, simply “congratulations.” The Phillies have had three great seasons, and Bobby has been through enough to know that when your games still mean something in September, and you make it through the playoffs to the second round, you, too, have been blessed by a heuristical God.
What a night, what a series, what a set of playoffs, what a season, what a sky, what songs, what a crowd. What a life.
Budd Shenkin
“Heuristic” means to me “as if.” You don’t really believe this is so, but it’s useful to believe it. Now, that’s not Pascal’s Wager, which tells us to bet on the existence of God, because if God does exist you will be rewarded, and if he doesn’t, well, what have you lost? That’s not a heuristic, that’s a cost-benefit analysis.
Here is a good example of a heuristic: if you play the stock market, it is useful to believe that there is an “operator” who is manipulating the market to draw you in and take your money. There used actually to be operators, but they don’t exist anymore, or so we are told. Still, the market acts as though there were one. It goes down to scare you, and then down again, and then again so you finally sell your stock, and now that the operator has bought your stock at a cheap price, up goes its price with you on the sidelines in frustration. The mythical operator has struck again.
So, I don’t believe in God. But it’s useful to think that “God will provide.” You can’t plan everything, you can’t be sure of everything, sometime you just have to take a chance, move to America and leave the Old World behind, and think that “God will provide.” It might be you yourself who will provide, or the Massachusetts Indians, but it’s useful to think of God up there to help you.
And so it is with baseball, itself the holy of holies. Not that “God will provide,” because anyone who has grown up rooting for the Phillies, the A’s, the Giants – in fact, I guess everyone except the Yankees – you know that God will not in fact provide. You will lose and lose and lose, and be drawn into thinking that this might be the year, and then you will lose again. So I have always figured that if our team is not mathematically eliminated in September and the games still have even theoretical meaning, it was a good year.
It helps to remember Job, and believe that sometime, maybe at an unexpected time, the plagues will finally relent. Maybe. And that great turn of your luck will not depend on any particular virtues of yours, but it will simply be a gift from a heuristical God.
And so it was this year. There was no reason to think this year would be any different for the Giants. None. Excellent pitching, which they had had before. A lack of bats, severe, I thought. So all through the year GM Brian Sabean brought in people and tried them out. Some worked – Aubrey Huff at first – and some didn’t – Bowker in left. Most famously, the “accidental Giant,” Cody Ross, became a Giant off waivers only because the Giants didn’t want him to go to San Diego. And then he comes up with five homers in the playoffs. It’s skill on Sabean’s part, and on manager Bruce Bochy’s part, and luck, and chance, and happenstance, and you could say it just was the fact that God decided to smile on you, for no particular reason that we can figure out.
For me it was particularly amazing, since my beloved brother Bobby is a die-hard Phillies fan and season ticket holder. While the Giants were making their amazing run at the collapsing Padres in September, when it seemed that God was just determined that they should win, Bobby and I faced the prospect of rooting against each other. After 34 years in the Bay Area and being partners in Giants season tickets I am acculturated – the Phillies are my second-favorite team. (Actually, if the A’s recover, that might not be true – but they will definitely be my second favorite team in the National League.) So the best we could hope for would be that the Phils and Giants would not face each other in the first round although the odds were against it. But fie on the odds – God provided, and they faced different opponents in the first round, so we could root for each other’s team, and both teams won. Voilá!
Then our Giants were on to the powerful Phillies, with their winning experience and very solid lineup, featuring the great Shane Victorino (inside joke – he’s from Maui and has a featured box on the Maui News sports page every day, really funny home town boosterism, “Victorino and Phillies advance to League Championship series!”)
How was every desire coming true? Where was this coming from? How was it that every move worked out? The new players produced, Wilson kept saving games, Uribe hit an 8th inning homer to beat the Phillies. How did we beat their great pitchers? Ryan Howard looked at a third strike when he should have been protecting the plate. Bobby and I communicated carefully with each other, since we each knew where we stood. From not believing they could catch the Padres, to the World Series. Why was he smiling on us?
God smiled again. I was due for tickets to the 6th game but my partner Jim wanted to trade his 1st game tickets for my 6th game. It’s a deal, Jim!
Ann, as my wife, always has first call on the tickets, but usually says that someone else will appreciate it more and gives them up. But this time I prevailed on her to go with me, to both the Phillies game and World Series #1 game against the Rangers. While she was reserved for the Phillies game, she said it was great. Then for WS #1 the reserve evaporated. It was a wonderful night. Balmy. Mellow. Joe Montana was sitting two rows ahead of us across the aisle. Other SF notables popped up here and there. We belonged there; these are our seats, our city. Tony Bennett sang I Left My Heart in the second inning because he was late – took Muni to the ballpark. 83 years old, but the voice is there. It was November, but it was in the 60’s, calm, comfortable, perfect, the whole night. (The next night it was Steve Perry from Journey singling “Lights” about the City, and when they stopped playing that, the crowd kept singing. A sports writer from Texas who repeatedly trashed the Bay Area had to write as he visited here, “I take it back. I love this city.”)
Ann said, “Look at the sky!” It was remarkable. It was like slate, but a bit uneven, blue-black, some parts darker than others, but not moving at all, perfectly still. Aaron, one of my partners with the tickets, turned around and said, “Look at the sky.” Look at the sky.
It was tight, and then the 5th inning happened. We kept scoring and were a couple of runs ahead. Then Uribe hit a three run homer to push us way in front. Everyone around us looked at each other, gave high fives, and then literally said stopped and said to each other, “My God.” There was singing and I was dancing as Ann laughed at me, and laughed with everyone else. In the 7th Tony Bennett sang God Bless America and so did we.
I’ve heard that hospitals are the modern equivalent of medieval cathedrals, but now I think it might be sports stadiums instead. At the ballpark we were one, knit together, being blessed. How else can you look at it? It was just a gift from a heuristial God, and it was our job to take it, to accept it, to appreciate it, to be blessed with it.
It’s probably the best sports experience I’ve ever had, in a lifetime of watching sports. And blessedly, my brother Bobby was good enough to send me a text that said, simply “congratulations.” The Phillies have had three great seasons, and Bobby has been through enough to know that when your games still mean something in September, and you make it through the playoffs to the second round, you, too, have been blessed by a heuristical God.
What a night, what a series, what a set of playoffs, what a season, what a sky, what songs, what a crowd. What a life.
Budd Shenkin
Thursday, November 11, 2010
ON THE WAY TO MAUI
My wife Ann is never late. I have learned a lot from her. And she has learned a lot from me, about how to tolerate being late. Opposites attract.
But when it comes to going to the airport, she wins. In fact, she has won so much that I try to be very early even when I’m not with her. We don't just make compromises when we get married, we change.
So today we left super-early for the San Francisco Airport to drop off Ann, Sara, and nine month old the magnificent Lola – up at 6:30, out the door at 7 for the maybe 40 minute drive to SFO for the 9:15 flight. We almost made it; probably would have if we had left 10 minutes earlier. Just not quite.
Maybe you have to feel sorry for the guy afterward, but most people had trouble ginning up sympathy at the time. KCBS reported that a heavy set guy in his 50’s in white pants and a tank top, with his 16 year old daughter in the van where he had apparently been living, decided to express his frustration with his straying, divorcing wife by calling KCBS, saying he had a gun and a bomb, and that he was going to stop traffic on the upper deck of the Bay Bridge, which is of course our route to SFO. He succeeded even if he really didn't have the gun and bomb he said he did. He was on the suspension span, we were not far behind on the East Bay side of Yerba Buena Island. We stayed on the bridge not moving for one and a half hours; people got out of their cars just to look around, look down at the Bay, and kind of look at each other. That's what we did, too.
It was the KCBS story of the day as we listened to what we couldn't quite see -- the man threatening to jump, being talked back onto the bridge, handcuffing himself, and the bridge lanes finally opening up, just in time for us to arrive at SFO at 9 AM, and the flight to go bye-bye without wife, step-daughter, and magnificent grand-daughter. They rebooked on the 2 PM flight and faced 5 hours in SFO with a magnificent 9 month old who loves to walk holding on to two fingers a few inches to the side and above her head. Much better than napping. Oh, joy!
We did well, even though leaving early was supposed to prevent this. No one panicked, although it was gruesome to try to reach United Airlines on the phone – could only get someone in India who couldn’t understand our telling her the number of our tickets, much less call ahead about our predicament, etc. Telephone answering trees are carbuncles on the body of the modern world. "Which of the following services best describes what you want...." How about, "none of the above, we're sitting on the Bay Bridge not moving?" Sitting there, time moving but not us, with the wonder of cell phones and smart phones and internet connections, but United Airlines cocooned off and unreachable. Couldn’t get SFO itself either. Not that it would have mattered.
I just heard from them, 14 hours after we left this morning. Lola was good, but slept only 15 minutes and spilled four different liquids the ladies were trying to drink. I had said, why not wait for tomorrow? But Ann said, no, I’m going today, if we have to go on any airline, if we have to go through Honolulu; we’re going. The lure of Maui is just too great. Maui is warm, the pool is warm, the surf and beach are beautiful, and the Sports Page beckons. Maui is something special for Ann, beyond the obvious. There is something that draws her, something that makes her relax, feel good, flow through the day. Probably because she was there all the time as a girl when her father consulted for Chevron and there was nothing at all where our house now stands. We are sometimes asked what we do there. We say, mostly wait for repair men. But it doesn't matter, there's something in the water.
So, I’m wondering – we left home in plenty of time under normal circumstances. I’ve been a very good boy. I have taken her habits and made them my own. We’re not going to leave any earlier next time, are we? I guess not. Being early is sensible, if you think about it. We're not nuts, just prudent. Took a long time for me to get there.
Budd Shenkin
But when it comes to going to the airport, she wins. In fact, she has won so much that I try to be very early even when I’m not with her. We don't just make compromises when we get married, we change.
So today we left super-early for the San Francisco Airport to drop off Ann, Sara, and nine month old the magnificent Lola – up at 6:30, out the door at 7 for the maybe 40 minute drive to SFO for the 9:15 flight. We almost made it; probably would have if we had left 10 minutes earlier. Just not quite.
Maybe you have to feel sorry for the guy afterward, but most people had trouble ginning up sympathy at the time. KCBS reported that a heavy set guy in his 50’s in white pants and a tank top, with his 16 year old daughter in the van where he had apparently been living, decided to express his frustration with his straying, divorcing wife by calling KCBS, saying he had a gun and a bomb, and that he was going to stop traffic on the upper deck of the Bay Bridge, which is of course our route to SFO. He succeeded even if he really didn't have the gun and bomb he said he did. He was on the suspension span, we were not far behind on the East Bay side of Yerba Buena Island. We stayed on the bridge not moving for one and a half hours; people got out of their cars just to look around, look down at the Bay, and kind of look at each other. That's what we did, too.
It was the KCBS story of the day as we listened to what we couldn't quite see -- the man threatening to jump, being talked back onto the bridge, handcuffing himself, and the bridge lanes finally opening up, just in time for us to arrive at SFO at 9 AM, and the flight to go bye-bye without wife, step-daughter, and magnificent grand-daughter. They rebooked on the 2 PM flight and faced 5 hours in SFO with a magnificent 9 month old who loves to walk holding on to two fingers a few inches to the side and above her head. Much better than napping. Oh, joy!
We did well, even though leaving early was supposed to prevent this. No one panicked, although it was gruesome to try to reach United Airlines on the phone – could only get someone in India who couldn’t understand our telling her the number of our tickets, much less call ahead about our predicament, etc. Telephone answering trees are carbuncles on the body of the modern world. "Which of the following services best describes what you want...." How about, "none of the above, we're sitting on the Bay Bridge not moving?" Sitting there, time moving but not us, with the wonder of cell phones and smart phones and internet connections, but United Airlines cocooned off and unreachable. Couldn’t get SFO itself either. Not that it would have mattered.
I just heard from them, 14 hours after we left this morning. Lola was good, but slept only 15 minutes and spilled four different liquids the ladies were trying to drink. I had said, why not wait for tomorrow? But Ann said, no, I’m going today, if we have to go on any airline, if we have to go through Honolulu; we’re going. The lure of Maui is just too great. Maui is warm, the pool is warm, the surf and beach are beautiful, and the Sports Page beckons. Maui is something special for Ann, beyond the obvious. There is something that draws her, something that makes her relax, feel good, flow through the day. Probably because she was there all the time as a girl when her father consulted for Chevron and there was nothing at all where our house now stands. We are sometimes asked what we do there. We say, mostly wait for repair men. But it doesn't matter, there's something in the water.
So, I’m wondering – we left home in plenty of time under normal circumstances. I’ve been a very good boy. I have taken her habits and made them my own. We’re not going to leave any earlier next time, are we? I guess not. Being early is sensible, if you think about it. We're not nuts, just prudent. Took a long time for me to get there.
Budd Shenkin
Sunday, October 17, 2010
Maui Stories
Maui is a small island with a population around 160,000, I think. A small county in a small state. Lots of the permanent residents know each other, or of each other.
We have our celebrities. I hear Oprah has a place or two, but I haven’t seen her and I don’t know if she really comes. I know that Arnold and Maria were looking for a place and looked in Makena, but I don’t know what they finally did because someone else bought that beachfront house for about $29 million, I heard. Cute little place.
So, I’m flying over from Oakland last month and who is sitting behind me but Don Nelson, long time coach of the Warriors. He is an island notable and has a place in Kihei, Hale Nelson. We walked off the plane together and struck up a conversation. I was mindful that he had been fired the day before and might be sensitive, but on the other hand he collected $6 million buyout, I think, so not all has been lost.
So after a few remarks back and forth, including my telling him that I had seen the first NBA game where Russell faced Chamberlain, I said,”Don – I saw you play!” He said, “I thought everyone who saw me play was dead.”
He is 70, not much older than I am, and vigorous, which I am, too. But obviously mindful of that horrendous number. Actually, except for the loss of my parents and one particularly upsetting and dysfunctional relationship with a loved child, I am as happy as I have ever been. Secure and still excited by my work. It’s like autumn back in Philadelphia. I used to think, this is really the best time of the year, fresh aur and beautiful foliage and football, except that we know that winter is coming.
Anyway, Don (he became “Don” to me) said that he was renting Hale Nelson out now and had moved up to Paia, where it’s cooler and rains more. I know he is a member of an island-fabled poker game with Willie Nelson and I think with Kris Kristofferson. Also with local notable Steve Goodfellow, I heard. And then he said that he was busy investing his whole “fortune” -- a word he emphasized in a way that made me think that here’s someone who came from a non-fortune background, and thus doesn’t take it for granted, but still looks at it with a little amazement that he did it -- his whole fortune on Maui. He is constructing some kind of place in Kihei for weddings. And up in Paia he has a coffee shop, where he invited to come up and visit. Would have done it, but I was only going to be on island for 6 days.
So I thought, he might be done with basketball – it looks that way – but he’s not through with action. Basketball had become a business for him, a special business but a business, and he isn’t about to give this attitude to life he has adopted for decades.
OK, that’s my Don Nelson story. Now here’s my Gordon story. Gordon is an Aussie by birth and speech, but an American by residence and business and American son since the age of 20, which was a few decades ago. Gordon lives in our condo complex and is as people-oriented as God makes us. Gordon knows everyone. We have a mutual friend, Anne, who lives in the complex also with her husband. So, Anne got a mattress for their bed. She tried and tried, but after six months she just couldn’t get herself to like it. So she decided to sell it and put an ad on Craig’s List. She got a call for the used mattress from a guy who lives up country, and he naturally wanted to come down and try it out. OK, Anne said, let me tell you where we are and how to get here. She told him the condo’s name and he said, “Hey, isn’t that where Gordon lives?”
“Why, yes it is.”
“Well, I know how to get there. In fact, I know the entrance code!”
This is a true story. As I say, it’s a small island, and Gordon knows everyone. But I have to say it reminded me of the famous story that ends with the narrator standing with the throng outside St. Peter’s and asking a bystander if she knows who is up there. The bystander says, “Of course I do. But who’s the guy in white standing next to Hymie?”
Pretty funny. I had to laugh.
Budd Shenkin
We have our celebrities. I hear Oprah has a place or two, but I haven’t seen her and I don’t know if she really comes. I know that Arnold and Maria were looking for a place and looked in Makena, but I don’t know what they finally did because someone else bought that beachfront house for about $29 million, I heard. Cute little place.
So, I’m flying over from Oakland last month and who is sitting behind me but Don Nelson, long time coach of the Warriors. He is an island notable and has a place in Kihei, Hale Nelson. We walked off the plane together and struck up a conversation. I was mindful that he had been fired the day before and might be sensitive, but on the other hand he collected $6 million buyout, I think, so not all has been lost.
So after a few remarks back and forth, including my telling him that I had seen the first NBA game where Russell faced Chamberlain, I said,”Don – I saw you play!” He said, “I thought everyone who saw me play was dead.”
He is 70, not much older than I am, and vigorous, which I am, too. But obviously mindful of that horrendous number. Actually, except for the loss of my parents and one particularly upsetting and dysfunctional relationship with a loved child, I am as happy as I have ever been. Secure and still excited by my work. It’s like autumn back in Philadelphia. I used to think, this is really the best time of the year, fresh aur and beautiful foliage and football, except that we know that winter is coming.
Anyway, Don (he became “Don” to me) said that he was renting Hale Nelson out now and had moved up to Paia, where it’s cooler and rains more. I know he is a member of an island-fabled poker game with Willie Nelson and I think with Kris Kristofferson. Also with local notable Steve Goodfellow, I heard. And then he said that he was busy investing his whole “fortune” -- a word he emphasized in a way that made me think that here’s someone who came from a non-fortune background, and thus doesn’t take it for granted, but still looks at it with a little amazement that he did it -- his whole fortune on Maui. He is constructing some kind of place in Kihei for weddings. And up in Paia he has a coffee shop, where he invited to come up and visit. Would have done it, but I was only going to be on island for 6 days.
So I thought, he might be done with basketball – it looks that way – but he’s not through with action. Basketball had become a business for him, a special business but a business, and he isn’t about to give this attitude to life he has adopted for decades.
OK, that’s my Don Nelson story. Now here’s my Gordon story. Gordon is an Aussie by birth and speech, but an American by residence and business and American son since the age of 20, which was a few decades ago. Gordon lives in our condo complex and is as people-oriented as God makes us. Gordon knows everyone. We have a mutual friend, Anne, who lives in the complex also with her husband. So, Anne got a mattress for their bed. She tried and tried, but after six months she just couldn’t get herself to like it. So she decided to sell it and put an ad on Craig’s List. She got a call for the used mattress from a guy who lives up country, and he naturally wanted to come down and try it out. OK, Anne said, let me tell you where we are and how to get here. She told him the condo’s name and he said, “Hey, isn’t that where Gordon lives?”
“Why, yes it is.”
“Well, I know how to get there. In fact, I know the entrance code!”
This is a true story. As I say, it’s a small island, and Gordon knows everyone. But I have to say it reminded me of the famous story that ends with the narrator standing with the throng outside St. Peter’s and asking a bystander if she knows who is up there. The bystander says, “Of course I do. But who’s the guy in white standing next to Hymie?”
Pretty funny. I had to laugh.
Budd Shenkin
Saturday, October 9, 2010
The Culture of Enabling
Dear readers, please permit me a dyspeptic screed.
There is a conspiracy of silence in this country. No one assigns responsibility. We enable failure. It starts early, when everyone on the kids’ team that went 0-14 for the season gets a trophy. And that’s just the start.
Pop psychology has no doubt played a part. “Positive reinforcement” is what we operate on. Look only at the positives.
Our Berkeley mothers say in dulcet tones, “Now, Joshua, Mommy needs you to take the knife away from your little sisters throat, right now.”
“I’m going to kill the little bitch!” says Joshua.
“Joshua, don’t you think you would be sad if Kelsey wasn’t here, and wouldn’t Mommy be sad?”
Well, maybe that’s an exaggeration. Somewhat. Maybe it's off the point - OK it probably is. It was just on my mind.
But seriously, what about responsibility? For instance, anybody know who screwed up the O-ring? We know that the Challenger went down because of a faulty O-ring design, that a defective NASA culture enabled it, that Morton Thiokol was the designer, and that NASA ignored warnings of engineers that low temperature was especially dangerous for the O-ring. But I want to know some names. Who did it? Who was on the team of designers? Who in NASA ignored the warnings? Why the anonymity?
We know the heroes well enough. Sully heroically saved a plane after a collision with birds, and showed up at every significant event afterwards for a year, and I felt as good about him as anyone. We know it was Francis Kelsey at the FDA who blocked approval of Thalidomide – in fact, go to Wikipedia and you will find a photo of her with President Kennedy. Success has a name.
But where are the anti-heroes? America needs them!
Who the hell was it that confused inches with centimeters in 1999 when NASA lost the $125 million Mars Climate Orbiter spacecraft after a 286-day journey to Mars, when thrusters used to help point the spacecraft had, over the course of months, been fired incorrectly because data used to control the wheels were calculated in incorrect units? The company was Lockheed Martin, which was performing the calculations, but who was the stupid engineer who did it? Why can’t we know?
Who screwed up the Hubble? Remember that? A small defect in one of the two mirrors was caused by a 1mm error in one of the machines that made it. This error made the telescope worthless, and only scientific heroics in 1993, at great cost, saved this treasure. The company at fault was Perkin Elmer in Connecticut. OK, we have a state and we have a company. But who, I want to know, made the error? It was somebody. Anyone got names? I don’t. What’s the theory, that they have suffered enough? Not in my book. I doubt that this achievement appears on his CV.
And who was the idiot that drove his truck off Interstate 880 and tied up the East Bay for months when he drove his oil-laden truck too fast in the middle of the night, crashed, and burned the freeway up? If we can’t have his name, can we at least have his ethnicity? Give us something!
In sports a lot is out in the open. Poor Bill Buckner – a long and distinguished career, but we remember the ball trickling through his legs at first base. We know that name. His error is a measuring stick for all other errors. It's painful, but it serves a function, and has a name. But even in sports the don’t-put-a-name-to-failure affliction has begun to infect commentators. In a Giants game a week or so ago, bottom of the ninth and two runs behind, I think it was Freddy Sanchez who was thrown out trying to get to third when he could just as easily stayed on second, since his run was meaningless – they needed two. It was only a rather amateurish new hire commentator who pointed out the mental error. Someone had forgotten to issue him the requisite rose colored glasses, or rather microphone. The regulars didn’t criticize anyone. Freddy’s a good guy, but this willful look the other way attitude debases the sport and our intelligence.
And just yesterday in the SF Chronicle we read that the California Air Resources Board overestimated diesel pollution by 340%. It was due to “a faulty method of calculation.” This comes on top of a miscalculation last year that overestimated the number of diesel-related deaths. Needless to say, we are given no idea at all who is responsible. “I think somehow some very poor decisions have been made,” says a Board member. Jesus. “Who” is a person, not an organization, a system, a process, or a culture.
Does it matter? It actually probably does. The culture of positive reinforcement has all but extinguished taking responsibility. And what about the entertainment value? Just as medicine has named syndromes after someone who described them first, we are missing the opportunity to name specific types of errors after their most prominent perpetrators. Wouldn’t such terms as “The McCarry Miscalculation” elevate our cultural heritage?
So, let’s stop the cover up! Here is a modest proposal to get the ball rolling: the esteemed non-profit organization, the Center for Responsive Health Policy, should offer a trophy to any individual reporter who succeeds in placing a specific name with a specific error in a major publication or blog. The name of the prize will be the Yudunit Award, or a Yuddy. You can imagine the image of the trophy – an enormous pointing index finger. You want trophies? You got’em. I know just where to get them, from Mary and Joe’s Sports Store down on San Pablo. They sell them by the dozens.
Other proposals are invited.
Budd Shenkin
There is a conspiracy of silence in this country. No one assigns responsibility. We enable failure. It starts early, when everyone on the kids’ team that went 0-14 for the season gets a trophy. And that’s just the start.
Pop psychology has no doubt played a part. “Positive reinforcement” is what we operate on. Look only at the positives.
Our Berkeley mothers say in dulcet tones, “Now, Joshua, Mommy needs you to take the knife away from your little sisters throat, right now.”
“I’m going to kill the little bitch!” says Joshua.
“Joshua, don’t you think you would be sad if Kelsey wasn’t here, and wouldn’t Mommy be sad?”
Well, maybe that’s an exaggeration. Somewhat. Maybe it's off the point - OK it probably is. It was just on my mind.
But seriously, what about responsibility? For instance, anybody know who screwed up the O-ring? We know that the Challenger went down because of a faulty O-ring design, that a defective NASA culture enabled it, that Morton Thiokol was the designer, and that NASA ignored warnings of engineers that low temperature was especially dangerous for the O-ring. But I want to know some names. Who did it? Who was on the team of designers? Who in NASA ignored the warnings? Why the anonymity?
We know the heroes well enough. Sully heroically saved a plane after a collision with birds, and showed up at every significant event afterwards for a year, and I felt as good about him as anyone. We know it was Francis Kelsey at the FDA who blocked approval of Thalidomide – in fact, go to Wikipedia and you will find a photo of her with President Kennedy. Success has a name.
But where are the anti-heroes? America needs them!
Who the hell was it that confused inches with centimeters in 1999 when NASA lost the $125 million Mars Climate Orbiter spacecraft after a 286-day journey to Mars, when thrusters used to help point the spacecraft had, over the course of months, been fired incorrectly because data used to control the wheels were calculated in incorrect units? The company was Lockheed Martin, which was performing the calculations, but who was the stupid engineer who did it? Why can’t we know?
Who screwed up the Hubble? Remember that? A small defect in one of the two mirrors was caused by a 1mm error in one of the machines that made it. This error made the telescope worthless, and only scientific heroics in 1993, at great cost, saved this treasure. The company at fault was Perkin Elmer in Connecticut. OK, we have a state and we have a company. But who, I want to know, made the error? It was somebody. Anyone got names? I don’t. What’s the theory, that they have suffered enough? Not in my book. I doubt that this achievement appears on his CV.
And who was the idiot that drove his truck off Interstate 880 and tied up the East Bay for months when he drove his oil-laden truck too fast in the middle of the night, crashed, and burned the freeway up? If we can’t have his name, can we at least have his ethnicity? Give us something!
In sports a lot is out in the open. Poor Bill Buckner – a long and distinguished career, but we remember the ball trickling through his legs at first base. We know that name. His error is a measuring stick for all other errors. It's painful, but it serves a function, and has a name. But even in sports the don’t-put-a-name-to-failure affliction has begun to infect commentators. In a Giants game a week or so ago, bottom of the ninth and two runs behind, I think it was Freddy Sanchez who was thrown out trying to get to third when he could just as easily stayed on second, since his run was meaningless – they needed two. It was only a rather amateurish new hire commentator who pointed out the mental error. Someone had forgotten to issue him the requisite rose colored glasses, or rather microphone. The regulars didn’t criticize anyone. Freddy’s a good guy, but this willful look the other way attitude debases the sport and our intelligence.
And just yesterday in the SF Chronicle we read that the California Air Resources Board overestimated diesel pollution by 340%. It was due to “a faulty method of calculation.” This comes on top of a miscalculation last year that overestimated the number of diesel-related deaths. Needless to say, we are given no idea at all who is responsible. “I think somehow some very poor decisions have been made,” says a Board member. Jesus. “Who” is a person, not an organization, a system, a process, or a culture.
Does it matter? It actually probably does. The culture of positive reinforcement has all but extinguished taking responsibility. And what about the entertainment value? Just as medicine has named syndromes after someone who described them first, we are missing the opportunity to name specific types of errors after their most prominent perpetrators. Wouldn’t such terms as “The McCarry Miscalculation” elevate our cultural heritage?
So, let’s stop the cover up! Here is a modest proposal to get the ball rolling: the esteemed non-profit organization, the Center for Responsive Health Policy, should offer a trophy to any individual reporter who succeeds in placing a specific name with a specific error in a major publication or blog. The name of the prize will be the Yudunit Award, or a Yuddy. You can imagine the image of the trophy – an enormous pointing index finger. You want trophies? You got’em. I know just where to get them, from Mary and Joe’s Sports Store down on San Pablo. They sell them by the dozens.
Other proposals are invited.
Budd Shenkin
Tuesday, September 28, 2010
Top 10 List of Physician complaints about insurance companies
I know we have covered much of this same ground before, but I thought it might be worth posting this listing of complaints that we developed on the SOAPM listserve.
Health Insurance Companies vs. Doctors
The Top Ten Outrages
From an idea of Jon Caine, MD
With the aid of unindicted co-conspirators from the SOAPM Listserve
Written by Budd N. Shenkin, MD, MAPA
The outrages perpetrated by health insurance companies against their policy-holders – people we physicians call, perhaps anachronistically, “patients” – were aired and to some extent repaired in the run-up to and passage of the Affordable Care Act (ACA) this past year. What went largely unremarked and unaddressed, however, are the outrages perpetrated by health insurance companies vis-à-vis the physicians they contract with to serve these selfsame patients. Here, for your wonder, perhaps your outrage, or if you are a health insurance company executive, your amusement, is a top-ten list of these outrages.
1. Unequal anti-trust policy. The biggest outrage, the ur-outrage from which all other outrages spring, is condoned and supported by the laws and enforcement of the government of the United States and the various states. Health insurance companies operate in largely monopolistic and oligopolistic environments in local areas. Physicians practice in much more atomized small group practices. The playing field is severely tilted – insurance companies can do without an individual physician practice, yet the physicians cannot do without the insurance companies. Governments have allowed anti-trust laws to accommodate insurance company consolidation, but have enforced the law on physicians, and will not allow them to negotiate as groups, even when members of IPA’s and other groups. The predictable result is that insurance companies continue to lower payment rates to physicians to the point of near extinction, and to commit outrages to decency such as those listed below. In reaction, physicians are now themselves conglomerating into corporate entities, not because this is a better way for them to serve their patients, but simply to protect themselves from the oligopolistic insurance industry. Coming soon to your community – Large Corporate Physician, your doc in the corporate box. The ACA could have given a anti-trust waiver to allow doctors in organizations such as IPA’s to bargain collectively with oligopolitic insurance companies.
2. Payment for vaccines. Vaccines are the greatest life-saving advances contributing to the health of the public since safe drinking water. Medical practices, amazingly, have overhead – a typical primary care group practice has an overhead rate of 65-70%. But many of our friendly health insurance companies have declared it their policy that “physicians should not make a profit on vaccines.” Therefore, when a physician administers a vaccine, a company with this policy will pay the physician only a few percentage points above the acquisition cost of the vaccine. How long would Macy’s survive if it sold a shirt for 5% above purchase price? The ACA could have required insurance companies to pay for vaccine cost plus overhead plus margin.
3. Adherence to the Payment Code Policy. There is a codebook called the CPT codebook. Whenever a physician does something, there is an official code on how to describe the service, with a Relative Value assigned to this code. Physicians are required to adhere to this codebook; no deviations are allowed. Insurance companies, however, often deviate. There are codes, for instance, for administering a vision test, a hearing test, a urinalysis, etc., to a child. These are separate services recognized by the code book. But many companies “bundle” these separate services and simply declare that “these services are included in the payment for the visit.” Which they clearly aren’t, which is why they are listed separately and have their own codes. The ACA could have said, “Insurance companies need to recognize all CPT codes and pay according to their relative value.”
4. Up To Date Codes. In a related vein, when new services such as new vaccines appear and are approved, health insurance companies lag for months in inputting the codes “into the system.” This leaves the physician in the lurch, wanting to give the service to the patient, but not being able to get paid for it by the health insurance company. Amazingly enough, when time comes that they decide to delete a code, the health insurance companies can accomplish this immediately. The ACA could have fixed this by requiring the code addition to be timely.
5. Double dealing in eligibility. When a patient comes to the office, physicians need to know if the patient’s insurance is in force. The insurance companies, keepers of the data, have websites that the physicians can check. But this information is sometimes out of date. If a website says a patient has insurance in force and the physician accordingly serves the patient and sends the bill to the insurance company, but the information turns out to have been false, the health insurance company commonly reneges on its responsibility, and doesn’t pay the physician. The ACA could have compelled the heatlh insurance companies to honor their own information, and to pay the physician for service rendered in good faith.
6. Payment for services on capricious criteria. A prime principle of prevention is early detection of illness. An important way to do this is to screen all patients. For instance, pediatricians use scientifically-validated screening procedures to detect developmental delay, autism, hearing loss, or high cholesterol. But some health insurance companies pay for these screens only if the patient actually has the disorder in question! Talk about unclear on the concept. The ACA could have compelled the health insurance companies to pay for the screens when applied at the officially indicated age intervals.
7. Takebacks. Since the health insurance companies are constantly sending doctors payments, if they want to they can simply debit a current payment for a past problem they detect, with no form of mutual adjudication. From a fellow physician: “Last week I had a takeback from BCBS for a patient visit one year ago. The problem was not that the patient was no longer eligible, but they had never responded to the BCBS inquiry about other insurance coverage.“ That’s right, the insurance company sent an inquiry to the patient asking if they had additional health insurance coverage, the patient didn’t respond, so the insurance company retroactively voided their payment to the physician. The ACA could have mandated no takebacks without mutual adjudication.
8. The Lapsed Coverage Waltz. A colleague reports: “Patient's coverage lapses in error. They call the plan to get reinstated. The plan reinstates the patient from the date they called, not back to the erroneous termination date. Doctor still does not get paid.” The ACA could have fixed this, too.
9. The Myth of Timely Payments. From another colleague: “State law mandates payment of "clean claims" within, say, 30 days. On day 28 they send an inquiry to the patient (with a copy to the doctor), requesting ‘information on any other health care coverage’ and the claim is pended until that information is received. Since it takes the patient some finite time to respond, if they bother to at all, the doctor is left waiting for payment.” Surely the ACA could have obviated this tactic as well.
10. Show Us Your Documentation. One of the most wasteful practices of the health insurance companies is excessive documentation demanded from the physician. Before paying for a service, the health insurance company can require the physician to send copies of the patient record. The number of such requests can amount to harassment. Some health insurance companies will require documentation for every single instance of a service, such as a screening for autism. In our own practice, with some companies and some codes we have now resorted to the extra work and expense of submitting such records expectantly. What a waste of effort. The ACA could have regulated the number of such requests.
11. Rudeness and Mendacity. As a bonus, for #11, let us mention my own personal favorite. Industries tend to attract certain personality types, and to take more malleable personalities and mold them to a common image. The capacity of health insurance company executives to misstate facts and demean inquisitors is legendary. Virtually all my colleagues who manage practices have been told that they are the only one in the state, region, or country to protest or be dissatisfied. I myself have been told that the American Academy of Pediatrics supports the position of the health insurance company on an issue, when I myself have been part of the committee that sets the policy. Whoever invented the word “chutzpah” couldn’t have had a strong enough imagination to envision its embodiment by the health insurance industry.
Colleagues have requested that our list go on, but in deference to David Letterman, we will stop at ten plus the bonus. We all know that the American health insurance system, even after ACA, needs revision. In the grand scheme of things, this list of grievances might seem small potatoes, but to those of us in the system day after day, it is major. Since the Federal Government has shot its bolt with the ACA, which failed to address these issues, we most likely cannot expect any relief from this or any prospective Congress or Administration. Our best hope, then, would be the states. As practitioners, we can fight the good fight on our own, but realistically, only government has the capacity to curb such bad behavior.
Budd Shenkin
Health Insurance Companies vs. Doctors
The Top Ten Outrages
From an idea of Jon Caine, MD
With the aid of unindicted co-conspirators from the SOAPM Listserve
Written by Budd N. Shenkin, MD, MAPA
The outrages perpetrated by health insurance companies against their policy-holders – people we physicians call, perhaps anachronistically, “patients” – were aired and to some extent repaired in the run-up to and passage of the Affordable Care Act (ACA) this past year. What went largely unremarked and unaddressed, however, are the outrages perpetrated by health insurance companies vis-à-vis the physicians they contract with to serve these selfsame patients. Here, for your wonder, perhaps your outrage, or if you are a health insurance company executive, your amusement, is a top-ten list of these outrages.
1. Unequal anti-trust policy. The biggest outrage, the ur-outrage from which all other outrages spring, is condoned and supported by the laws and enforcement of the government of the United States and the various states. Health insurance companies operate in largely monopolistic and oligopolistic environments in local areas. Physicians practice in much more atomized small group practices. The playing field is severely tilted – insurance companies can do without an individual physician practice, yet the physicians cannot do without the insurance companies. Governments have allowed anti-trust laws to accommodate insurance company consolidation, but have enforced the law on physicians, and will not allow them to negotiate as groups, even when members of IPA’s and other groups. The predictable result is that insurance companies continue to lower payment rates to physicians to the point of near extinction, and to commit outrages to decency such as those listed below. In reaction, physicians are now themselves conglomerating into corporate entities, not because this is a better way for them to serve their patients, but simply to protect themselves from the oligopolistic insurance industry. Coming soon to your community – Large Corporate Physician, your doc in the corporate box. The ACA could have given a anti-trust waiver to allow doctors in organizations such as IPA’s to bargain collectively with oligopolitic insurance companies.
2. Payment for vaccines. Vaccines are the greatest life-saving advances contributing to the health of the public since safe drinking water. Medical practices, amazingly, have overhead – a typical primary care group practice has an overhead rate of 65-70%. But many of our friendly health insurance companies have declared it their policy that “physicians should not make a profit on vaccines.” Therefore, when a physician administers a vaccine, a company with this policy will pay the physician only a few percentage points above the acquisition cost of the vaccine. How long would Macy’s survive if it sold a shirt for 5% above purchase price? The ACA could have required insurance companies to pay for vaccine cost plus overhead plus margin.
3. Adherence to the Payment Code Policy. There is a codebook called the CPT codebook. Whenever a physician does something, there is an official code on how to describe the service, with a Relative Value assigned to this code. Physicians are required to adhere to this codebook; no deviations are allowed. Insurance companies, however, often deviate. There are codes, for instance, for administering a vision test, a hearing test, a urinalysis, etc., to a child. These are separate services recognized by the code book. But many companies “bundle” these separate services and simply declare that “these services are included in the payment for the visit.” Which they clearly aren’t, which is why they are listed separately and have their own codes. The ACA could have said, “Insurance companies need to recognize all CPT codes and pay according to their relative value.”
4. Up To Date Codes. In a related vein, when new services such as new vaccines appear and are approved, health insurance companies lag for months in inputting the codes “into the system.” This leaves the physician in the lurch, wanting to give the service to the patient, but not being able to get paid for it by the health insurance company. Amazingly enough, when time comes that they decide to delete a code, the health insurance companies can accomplish this immediately. The ACA could have fixed this by requiring the code addition to be timely.
5. Double dealing in eligibility. When a patient comes to the office, physicians need to know if the patient’s insurance is in force. The insurance companies, keepers of the data, have websites that the physicians can check. But this information is sometimes out of date. If a website says a patient has insurance in force and the physician accordingly serves the patient and sends the bill to the insurance company, but the information turns out to have been false, the health insurance company commonly reneges on its responsibility, and doesn’t pay the physician. The ACA could have compelled the heatlh insurance companies to honor their own information, and to pay the physician for service rendered in good faith.
6. Payment for services on capricious criteria. A prime principle of prevention is early detection of illness. An important way to do this is to screen all patients. For instance, pediatricians use scientifically-validated screening procedures to detect developmental delay, autism, hearing loss, or high cholesterol. But some health insurance companies pay for these screens only if the patient actually has the disorder in question! Talk about unclear on the concept. The ACA could have compelled the health insurance companies to pay for the screens when applied at the officially indicated age intervals.
7. Takebacks. Since the health insurance companies are constantly sending doctors payments, if they want to they can simply debit a current payment for a past problem they detect, with no form of mutual adjudication. From a fellow physician: “Last week I had a takeback from BCBS for a patient visit one year ago. The problem was not that the patient was no longer eligible, but they had never responded to the BCBS inquiry about other insurance coverage.“ That’s right, the insurance company sent an inquiry to the patient asking if they had additional health insurance coverage, the patient didn’t respond, so the insurance company retroactively voided their payment to the physician. The ACA could have mandated no takebacks without mutual adjudication.
8. The Lapsed Coverage Waltz. A colleague reports: “Patient's coverage lapses in error. They call the plan to get reinstated. The plan reinstates the patient from the date they called, not back to the erroneous termination date. Doctor still does not get paid.” The ACA could have fixed this, too.
9. The Myth of Timely Payments. From another colleague: “State law mandates payment of "clean claims" within, say, 30 days. On day 28 they send an inquiry to the patient (with a copy to the doctor), requesting ‘information on any other health care coverage’ and the claim is pended until that information is received. Since it takes the patient some finite time to respond, if they bother to at all, the doctor is left waiting for payment.” Surely the ACA could have obviated this tactic as well.
10. Show Us Your Documentation. One of the most wasteful practices of the health insurance companies is excessive documentation demanded from the physician. Before paying for a service, the health insurance company can require the physician to send copies of the patient record. The number of such requests can amount to harassment. Some health insurance companies will require documentation for every single instance of a service, such as a screening for autism. In our own practice, with some companies and some codes we have now resorted to the extra work and expense of submitting such records expectantly. What a waste of effort. The ACA could have regulated the number of such requests.
11. Rudeness and Mendacity. As a bonus, for #11, let us mention my own personal favorite. Industries tend to attract certain personality types, and to take more malleable personalities and mold them to a common image. The capacity of health insurance company executives to misstate facts and demean inquisitors is legendary. Virtually all my colleagues who manage practices have been told that they are the only one in the state, region, or country to protest or be dissatisfied. I myself have been told that the American Academy of Pediatrics supports the position of the health insurance company on an issue, when I myself have been part of the committee that sets the policy. Whoever invented the word “chutzpah” couldn’t have had a strong enough imagination to envision its embodiment by the health insurance industry.
Colleagues have requested that our list go on, but in deference to David Letterman, we will stop at ten plus the bonus. We all know that the American health insurance system, even after ACA, needs revision. In the grand scheme of things, this list of grievances might seem small potatoes, but to those of us in the system day after day, it is major. Since the Federal Government has shot its bolt with the ACA, which failed to address these issues, we most likely cannot expect any relief from this or any prospective Congress or Administration. Our best hope, then, would be the states. As practitioners, we can fight the good fight on our own, but realistically, only government has the capacity to curb such bad behavior.
Budd Shenkin
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