Monday, April 27, 2009

Female Desire

My wife tells me I am a product of the 50's, which is not necessarily praise. But I'm sure she is right. A very repressed era. Those who elevate the 50's as the era of muscle cars and cigarette packs on the sleeve or rolled up T-shirts simply elevate repression.

But in my heart I continue to agree with Art Garfunkel in Carnal Knowledge (one of my top 50 films) as he reflects on his affair with Candace Bergen - something to the effect that we should be grateful to women for whatever sex we get, because after all, what do they get out of it?

I also agree with whoever cast Mary Martin as Peter Pan - which I hated at the Philadelphia Academy of Music, named in the days before the rich and the corps got their names plastered on public facilities in what is sure to be exposed as a major symptom of the problem of our era by future historians. Why cast a male in a male's role? After all, how could there be anything sexual going on between Wendy and Peter as they fly away to a magic island and have children in their care, for goodness sake?

When I was in 8th grade in the the pool at Friends' Central I heard a little group of older girls standing in the pool. One said, let's do something. Another said, yeah, between the legs. How puzzling! That couldn't be, I knew. Fact of conversation, belief of Art Garfunkel. Go with the belief!

Besides, how could anyone desire me? Like any adolescent, I realize now as a pediatrician, I looked at myself and found me wanting. My lips are too big. I didn't know then that that was sensual.

What triggered this and other reminiscences too intimate to post - everyone has them, I know - is this charming little piece by my good friend Bob Levin, on the connection of sports, food, sex, and immaturity. I think Bob is such a fine writer.

If anyone wants to hear more in this vein, let me know. Or are my 3 readers aching for more on health care reform?

Budd Shenkin

Sunday, April 26, 2009

Success in the "War on Terror?"

This post has nothing original to say. Even fertile minds sometimes need to get seeds from elsewhere, to mangle a metaphor.

It is easy to dismiss the claims of the far right, Mr. Cheney, clowns on Fox, and various fans of torture. I do it, but I wonder if what we believe is true - is it true that torture is not a useful tool in getting information? Even if it were a useful tool, I would still reject it, because I think the essential strength of this country and all countries is moral. At the end of the day, if countries are not believable I think they will succeed only by force, and if they do that, they may win in the short run but not the long run.

But I am suspicious of myself. It's too much of a goo-goo argument. Everything in the end works out. Let's do what is moreal and ethical and that will be the most successful. Too easy! Yet it is the belief I walk around with. Of course, since I am just a bystander, I can afford to be self-indulgent. Still, I believe.

The other side says, "The Bushies kept us safe." It is an argument that reeks of bullshit to me. I thought, well, yes, we've been safe, but who knows what did that? Where is the evidence? When I hear "It's classified," I just don't believe it. And these guys are inveterate liars.

But what I hadn't thought of is this, from the Washington Monthly:

A TWIST OF THE 'KEPT US SAFE' ARGUMENT.... As the Bush/Cheney administration was poised to end, and there were an abundance of pieces reflecting on the Bush era, the most common defense tended to be that Bush "kept us safe." I've never understood this argument.

Indeed, it's generally offered with a series of pretty important caveats. Except for the catastrophic events of 9/11, and the anthrax attacks, and terrorist attacks against U.S. allies, and the terrorist attacks against U.S. troops in Iraq and Afghanistan, and Bush's inability to capture those responsible for 9/11, and waging an unnecessary war that inspired more terrorists, and the success terrorists had in exploiting Bush's international unpopularity, the former president's record on counter-terrorism was awesome.

Ha! There's the answer. Plus the recent reports of what Cheney was looking for when they were torturing at the start - evidence linking Al Qaida with Iraq, which of course did not exist. Thus, torture the hell out of them because the objective was not truth at all, but convenient evidence.

Just trying to reason it through.

Budd Shenkin

Monday, April 20, 2009

The Wall Street Delusionists

When I was a younger man I joined the Public Health Service and moved to Washington. I had wanted to do something like this, but had stayed on the conveyor belt through medical school and then internship. It was the time of Vietnam, and we had to find a way around that. It seemed so clear at the time, this is what we had to do, and we felt bad about people who were going there, but as I say, it seemed pretty clear at the time

As I say, I had been on the conveyor belt, doing well, but something wasn't quite right. I was in medical school, but I bought (but didn't read) a book called the Nerves of Government. How to combine and interest in politics and being a doctor? Like when I was about 10, maybe, and my parents asked me what I wanted to be. I said, can you be a doctor and a baseball player? Well, there was one, Bobby Brown of the Yankees, third baseman. So I compromised, or didn't make a decision, and said that's what I wanted to be, a doctor and a baseball player.

So it was scary for me to actually do something off the conveyor belt. But it was great. Choosing something. And one thing I could always do was learn on my own. That's the way I learned to play chess, from books, and a little teaching from my parents' friend Irv Kagan from around the corner. So I arrived in Washington and I started learning for myself.

Which is a long way and very circuitous and I guess irrelevant to what I'm getting around to. Which is the virtue of the magazine that Charlie Peters started, the Washington Monthly. I started reading this in Washington, a place I had moved to voluntarily, on my own, and I decided, on my own and voluntarily (getting the idea I had led a sheltered life?), that this was a great magazine. I'm not sure how you would describe its politics, very realistic, non-ideological, very practical about politics, smart - I guess I'm not really a political scientist since I can't categorize it. But it was the kind of thing that Moynihan understood and did, and other realists.

But lately I have discovered that even if people like Charlie Peters were realistic and non-ideological, I think they were at heart goo-goo's, which means Good Government people, which is what I have discovered that I am. OK, be hardbitten and cynical, but at heart, you hope and believe that you would do "the right thing," and you expect others to do it.

Which is the opposite of the Bushie's, who captured government and raided it. The stark opposite of goo-goos.

Which brings us to the exact present, and what I'm going to post here as a quote from the blog that the Washington Monthly runs. BTW, two years ago I bought a subscription for my son Peter to the Washington Monthly. That's the way generations replicate their views, I would say ideology, but how can you have the ideology of a non-ideological publication?

So here is what the Washington Monthly quotes about the personal views of those on Wall Street, members of that subgroup of society who have captured a part of the economic system and profited by it the was the Bushies captured government. It's quite a point of view. And the view of the quoter, the Washington Monthly, is pretty much as it always has been, goo-goo. Now that I'm older and have some money, maybe I can't share everything with the commentator's point of view, but the Wall Street guys are really clueless. Who the hell do they thing they are??

By: Hilzoy

Mr. DeMille, They're Ready For Their Closeups!

New York Magazine has what Felix Salmon calls "an astonishing concatenation of moans and whines from New York's monied classes". It's truly surreal. For example:

""Without exception, Wall Street guys have gotten accustomed to not being stuck in the city in August. So it becomes a right to have a summer home within an hour or two commute from Manhattan," says the Goldman vet. "There's a cost structure of going with your family on summer vacation that's not optional. There's a cost structure of spending $40,000 to send your kids to private school that is not optional. There's a sense of entitlement, that you need that amount of money just to live, that's not optional."

"You can't live in New York and have kids and send them to school on $75,000," he continues. "And you have the Obama administration suggesting that. That was a very populist thing that Obama said. He's being disingenuous. He knows that you can't live in New York on $75,000.""

And yet, strange to say, in 2007 the median family income in New York City was $52,871. Maybe New York takes in floods of new residents every year, and so many of them die of starvation that the median income is actually below the level needed to survive. Maybe over half of the families in New York are zombies. Or maybe -- just maybe -- over half the families in New York live well below the level this "Goldman vet" thinks you just can't live on.

Likewise (this is a different speaker):

"That said, he continues, "We're in a hypercapitalistic society. No one complains when Julia Roberts pulls down $25 million per movie or A-Rod has a $300 million guarantee. We have ex-presidents who cash in on their presidencies. Our whole moral compass has shifted about what's acceptable or not acceptable. Honestly, you can pick on Wall Street all you want, I don't think it's fair. It's fair to say you ran your companies into the ground, your risk management is flawed -- that is perfectly legitimate. You can lay criticism on GM or others. But I don't think it's fair to say Wall Street is paid too much.""

Wrong. People at firms that would not have survived without government assistance might have been Julia Roberts a couple of years ago. Now, they're Norma Desmond.

If you want to say that whatever the free market in its wisdom dictates that people are paid is fair, then the fair wage for people at AIG, Citi, and any other firm that would not have survived without government assistance is zero. If you want to use some other metric, then Julia Roberts et al are irrelevant. But you do not get to appeal to the marvels of the market to justify your exorbitant salary when times are good without accepting its conclusions when it implies that the fair value for your work is nothing.

And I don't even know what to say about this:

"There is rage at Obama for pushing to raise taxes ("The government wants me to be a slave!" says one hedge-fund analyst)"

If raising the marginal tax rate to 39.6% counts as "slavery", then I suppose that the fact that top marginal tax rates during the Truman, Eisenhower, and Kennedy administrations were over 90% is a Holocaust. Or, you know, maybe not.

Seriously: I recognize that it's tough when the world you've known disappears. It's less tough when that means that you have to figure out how to survive on a six-figure salary than it is when your house gets foreclosed on, but still. That said, the degree of self-delusion on display in this article is just astonishing.

They don't get the fact that it is abnormal when people right out of college or business school can command more money than most people will ever see in their lifetimes. They don't get the fact that the firms for which they worked produced an economic catastrophe that has reduced people all over the world to genuine poverty (as opposed to living on $75,000 in New York.) They don't get the fact that the compensation at those firms had a lot to do with that catastrophe. They don't get the fact that because of their greed and stupidity, we had to rescue those firms -- which means that their lifestyles are being supported by truckdrivers and pharmacists and primary school teachers across the country, many of whom would love to try to scrape by on $75,000 a year.

And they really don't seem to get what's wrong with this:

""I'm not giving to charity this year!" one hedge-fund analyst shouts into the phone, when I ask about Obama's planned tax increases. "When people ask me for money, I tell them, 'If you want me to give you money, send a letter to my senator asking for my taxes to be lowered.' I feel so much less generous right now. If I have to adopt twenty poor families, I want a thank-you note and an update on their lives. At least Sally Struthers gives you an update.""

How fortunate for that analyst that most of us don't feel the same way. Writing three hundred million thank you notes would take an awfully long time.

Budd Shenkin

Sunday, April 19, 2009

What to do with one kidney

As a pediatrician I am a member of the American Academy of Pediatrics SOAPM - Section on Administration and Practice Management. We have a terrific listserve for SOAPM. Remember when you were a kid and it was exciting to get mail? There was a terrific New Yorker cartoon of a middle aged man in midflight off a diving board into his pool of jello - his face is turned to the few spectators in his yard and he says, "I promised myself when I was a kid!" Well, my SOAPM listserve is the equivalent of that for kids who really loved to get mail. I have a whole mailbox devoted just to SOAPM, and if I let it go a few days, there are a hundred unopened posts. How quickly we adjust to technology! It's now just part of life.

Anyway, a current question brought up by a pediarician and commented on by others is, what do you tell parents and kids if the kid has only one kidney? Special restrictions? There is a special survival value in paired organs - eyes, kidneys, cajones. Do you take special precautions if there is only one?

This brought to mind a signal event in our lives - when Peter, our youngest, had his accident. I weighed in to the discussion and thought some readers might find some interest:

I have been dealing with the question from the parent's point of view. In 2000 my son Peter, a junior in high school, was on a camping trip with the school and a 4,700 oak tree fell on him while they were sleeping. He lost a kidney, had many lateral processes of the lumbar spine severed, lost 18 inches of bowel, etc. That's certainly a 5 AM call you don't want to get.

Pete was taken on a very bumpy ride to the trauma center in Roseville, just east of Sacramento. The trauma surgeons put Pete on a "to follow" schedule as they operated on a classmate who was more severely hurt, let the elective cases go forward, and let the back up team sleep in. They also didn't transfer him to the nearby academic center where they could have tried to save the kidney. Then we found out that, despite the fact that this is the state mandated trauma center, the surgeons didn't have a contract with Blue Shield, so they were out of network - we got Blue Shielf to pay as an emergency case where we didn't have an option, but still. What a system we have....

Anyway, Pete is an athlete. Thankfully he recovered. We were 1 inch from paraplegia, and about 6 inches from death. So we are grateful and count ourselves lucky. But we were then faced with the one kidney dilemma. There are no real guidelines to go on. He is a roller hockey devotee, so we asked him to wear pads around his middle. He did, at least for a while. I don't know everything, of course. It's just hard to tell what to do. I was in the stands in the 90's when Eric Davis of the Cincinnati Reds fell on his flank in left field and was taken to our hospital - he lost his kidney, playing baseball. So we are left with, Peter, please be sensible! Thankfully he has now reached the age of 25 when the frontal lobes are supposed to fully kick in and give him judgment.

Budd Shenkin

Friday, April 17, 2009

Health Care Reform (3)

So, what are we going to do with this furshtunkina health care system? Look at it in any aspect, and it just sucks. Where is it fat? Like a fat person, everywhere. (Disclosure, as a primary care pediatrician, I have my own views, and at this point will not point out fat in my area. Not that it’s not there.) Some dysfunctional industries can be tolerated and everything can’t be fixed at once, but Obama is right when he says that the health care system is so dysfunctional and so big, it affects everything. We can’t let it fail completely, because health care is too important for human life. But we can’t support it as it is. So it has to get itself in shape, have a plan, diet some, and hit the treadmill.

Atul Gawande, the genius Peter Bent Brigham surgeon who is my hero for his great writing (I bet he’s also a great surgeon, such is my hero-worship), says in a recent New Yorker article that in the experience of virtually all countries, health care systems evolve, and comprehensive change all at once doesn’t happen. I had always naively thought that the British National Health Service had been a comprehensive imposed change by a socialist Labor government. Apparently not true. The change came about after their wartime experience, when people were moved en masse to the countryside and arrangements for medical care had to follow. (He doesn’t say how the new medical care arrangements built on what went before, and I don’t know.) But the new arrangements of medical care worked just fine, so they continued them as the National Health Service.

What he says has implications for the Hillary task force of 1994 and their misbegotten overhaul plans issued by a secret cabal of cognoscenti which was un-negotiable as presented. A permanent black eye for the Clinton Administration, and a temporary but profound delay in health care reform.

But now the Obama Administration is set on a more incremental reform that comes from wide negotiations. (I loved his idea that all negotiating sessions should be on C-Span, but it always seemed impractical – privacy will always find a way.) Reform will have to be change that is familiar. So they say that if you like your present health insurance you won’t have to change. In my experience no one likes his or her present health insurance (except my brother who gets it from the government of Pennsylvania), and no one should like their present health insurance. It all sucks. Most everyone is underinsured. But no one wants anything worse, and the unfamiliar could be worse.

To me, the most attractive near term fix is apparently what is actually being contemplated by the Administration. It would be introducing the present system that government employees have, with a twist. Their present system is to have a menu of health insurance options from which to choose. The government regulations set the basic standards that the plans have to meet – they need to cover pregnancy, etc., and as they accept all applications, they cannot retroactively revoke a policy for “non-disclosure”, a particularly disgusting health insurance company abuse. They in essence regulate away some dirty tricks. So, there is a menu of options. The twist is that, in the new plan, there would be a governmentally sponsored and run option. You could choose Aetna, Cigna, Blue Cross, etc., and Big Government Health Plan.

This option scares the shit out of the health insurance industry. Their overhead pus profit is very high, 20% or more often. They call the money they pay out for actual medical care the “medical loss ratio,” and I think Blue Cross of California boasted about their 78% ratio. The government overhead would be capped at 5%. So, even if the private companies get rid of the cost of underwriting and thus lower their costs, their profits would diminish or probably disappear. Good, I say. Make them into utilities. They are not providing any value to the system anyway – I can’t think of one positive thing they do. But you can see why they are scared.

So scared are they that they have said at the beginning of negotiations that they will accede to taking all comers and giving all the same rates (so-called community rating.) Just please, please don’t let the government program come in! They are now using scare tactics. An article in the WSJ opines that government will have unlimited resources and thus will be able to drive the private companies out of business. The government can lower their premium rates, and shortly thereafter as the private companies wither and die from that unfair competition, the government can use its unparalleled leverage to drive their payments to all providers down and down. This is a familiar tactic that businesses recognize, because it is their own monopolistic tactic that is supposedly illegal, but familiar all the same.

Truth be told, the rates of payment need to be driven down. Hospital charges are so high as to defy adjectives. Fat, as I said, is everywhere. The problem is how to get the industry lean and mean, and not just mean, the way most public entities react to cuts. But I agree with critics that government is unlikely to be a reasoned substitute for a market. But then, so are insurance companies unlikely to be reasoning, public-spirited agencies. It’s a logjam, which needs to be broken.

So I think the next step of letting the government enter the competition would be just fine. It, the government, just needs to be regulated when they enter. The accounting needs to be free and fair. They cannot be allowed to dip into general revenues and run their program at a loss. They need to have some quality regulation, but I don’t know just what that would be.

In other words, let the government into the competition and let every plan, public and private, endure identical regulation. That seems to me to be the next best step.

And now my hobbyhorse. Make sure that for Medicaid, just as for Medicare, that competition among providers is fair. Currently the Federally Qualified Health Plans get 2-3 times as much per visit as a private provider such as yours truly. This is precisely, precisely what the private health insurers are afraid of, and our experience in Medicaid shows that they are right to be afraid.

And hobbyhourse #2. As part of the rules of engagement, I would also ban high deductible health plans. While I understand that some think it is good to give some (healthy) people the right to gamble on their continued good health, and wrong to "tax" them because they are healthy -- especially wrong because a good part of unhealthiness comes from voluntary poor health habits -- nonetheless, when viewed from the public point of view, these plans suck. Why? Because, again from the point of view of the whole community and the whole nation, they don't meet the problem of high and rising health costs. They are like the drunk looking for his keys under the street light not because he lost them there, but because that's where the light is brightest. High deductible health plans attack primary care expenditures. Hospital costs? NOt touched (the deductible expires quickly at this level of care, so no restraint on these costs is exercised.) High priced specialists? Ditto. Health insurance companies? Nada. In other words, they violate Sutton's Law by going exactly where the money isn't. And research has shown that people make bad decisions about their health when it is on the marketplace - they forego early and preventive care, and thus wind up costing the system more.

Budd Shenkin

Wednesday, April 1, 2009

Community Health Centers & County Clinics

I have posted before about Community Health Clinics, and my serious reservations about them. Yesterday I interviewed an applicant for our currently-vacant Administrator post and was sardonically amused to hear what he had to say.

This very nice man had been CEO of two clinics that were Federally Qualified Health Centers. He told me about their financing. I was especially interested to hear about one of them, a network of seven clinics located around Fresno, with headquarters in Parlier. I asked him if one of the clinics was in Orange Cove. He said yes, as a matter of fact, that was the original clinic, set up in 1970. I said yes, I know about that - because I was the one who started it!

Actually, at that time I was a Medical Officer in the US Public Health Service, and was acting as head of the Migrant Health Program nationwide. We had received surprise extra funding from the Nixon Adminstration - no one precisely knew why, but we guessed it was some sort of idea to woo the Hispanic population, but that was just a guess. So with just a few months to go we had to program the extra money quickly. We had determined that instead of using the old style of grants, we would program the new money in the style of the then-new Neighborhood Health Centers, but in rural areas. These were the forerunners of the current CHC's.

Anyway, we had to act fast to program the money, so we identified people to go to known areas of migrant concentration that had the possibility of administering a freestanding clinic. And we demanded that the governing board of the clinic be composed o a majority of users of the clinic - maximum feasible participation of the population to be served. We didn't know who to go to in the Central Valley, so I made one trip there with a consultant, Wendy Brooks, and determined that Orange Cove had possibilities. Then I took a week and wrote the grant with Wendy, consulting with a community organizer there named Bobby Russell. Then I took the grant back to headquarters and I approved the grant I had written. Voila! Money flowed to Orange Cove.

Part of the reasoning about doing a clinic this way was that on top of providing services, it would promote community organization, leaders would emerge, and the whole community would be lifted up. That was the theory. Some of it probably worked.

Now at this interview I was hearing about what had happened in a snapshot taken 39 years later. My interviewee observed that what we have observed about CHC's locally in Oakland holds true both down in Fresno, and in his second CHC in Half Moon Bay. He said that the government funding resulted in his clinics receiving about $140 per visit (exclusive of vaccines, etc.) He said that the FQHC's in a neighboring county were getting over $400 per visit. He said that money was really plentiful - construction, etc., was no problem. We get about $50 per visit in private practice.

The problems the clinics faced? One, the requirement that the clinics have community/recipient majority on the Board. This former CEO said that after a while his clinics became essentially ungovernable. I was not surprised but very saddened to hear this, since years ago I was an enthusiastic proponent of this sort of governance. As I say, there might well have been many positive results of community involvement; many leaders may have been produced, etc. But from a strictly medical point of view, it is discouraging. I know about these dysfunctional boards where everyone is out for himself, looking to move up, etc. Representing the good of the people - that's what made Cesar Chavez great. And unusual, unfortunately.

Another problem - the doctors. By another coincidence, the Half Moon Bay clinic happened to employ a family practitioner who had to leave our group because he couldn't relate to patients, and wound up seeing only patients of other clinicians who wanted urgent visits and so got him for that visit. But they were not attracted and thus never came back to him as their regular doctor. At least not much. The ex-CEO said that this doctor appeared competent (he is), punctual, and his records were good. The fact that he has great difficulties relating to patients had escaped notice. Not a big issue at the clinics. What a shame.

Another problem doctor was a surfer. When the surf was up, he would simply cancel his patients for that day and go surfing. He has since resurfaced (!) as an urgent care physician.

Unfortunately, the Half Moon Bay CHC has just gone bankrupt. The ex-CEO warned them, even consulting a bankruptcy attorney in November. But now here in March bankruptcy came as an apparent surprise to the Board. Perhaps another symptom of Other People's Money.

[By the way, I posted previously about OPM. But I forgot to mention that I heard the great economist Milton Friedman on the radio being asked, after a lifetime of work, if he could sum up his economic philosophy simply, what would he say? He responded: People don't treat Other People's Money the way they treat their own. Talk about pregnant observations!]

And here's more of the story. The Half Moon Bay clinic, before bankruptcy, became part of the county health clinic network o San Mateo County. So in the process of joining the two sides compared productivity. The CHC's goal was to have its docs see 20-22 patients per day. The county was horrified. How many patients per day did its docs see? About 8 patients per day. And these docs were well paid, more than competitive with the starting salaries of private docs in the area.

Let's now tie this to the national situation. I support Obama and I support the stimulus package as necessary. I agree with Keynes - in tough times when each individual acts rationally to save money, the government must provide demand. And in our current situation, much of the stimulus money will go to state and local governments. We hear that the effect will be that teachers and police will not have to be laid off. But what about the clinics? Think there is a chance that the county will look at the clinics and say, we need to boost productivity? I'd say there is no chance in hell that this will happen. In tough times, companies are supposed to get lean and mean. To stay competitive they need to become more efficient, more productive, produce goods and services for less. In tough times, however, governments get mean but not lean. I remember the passage of Prop 13. Governments, pissed off, said they would have to decrease the number of fire stations, lengthen response times, and do all they could to -- avoid layoffs!

It's enough to make a strong man weep.

Budd Shenkin