Sunday, November 29, 2009

ObamaNeeds to Move on the Financial World

Politically, the Obama Administration is in trouble, although they probably think they’re not. People are getting impatient; I’m getting impatient. Yes, there is change, and this isn’t the Bush Administration – that is what has given the Administration so much slack, we still remember the WAH (Worst Administration in History). We now have some people who have some brains and some basic humanity.

But we’re not really going to see too much positive for quite a while, the way we’re going. Let me count the deficiencies.

Guantanamo – maybe not as grim as it was, we don’t really know. It’s just taking a while to wrap it up.

Torture. He did well at first saying we won’t torture, but we’re still going to do special renditions.

Justice Department. Still incompetent, and still double-dealing with Spiegleman. Still taking some Bush positions.

Greg Craig. All pundits agree, a good man wronged by bureaucratic infighting and failure of Obama himself to stand up.

Health care. Not going to go so well. Some things will be better, but not clear how soon, and not really clear if it will be a lot better in the end. Meanwhile, the perhaps necessary strategy of letting the Congress lead has not been pretty.

Afganistan. Will not a pull out, will readjust objectives and management, it will look competent, but it will take time.

Pakistan. A very most improvement, but the area itself is so difficult, who can expect much? If it doesn’t blow up, we will be well served.

Iraq. Certainly much better, but Obama can’t take credit for this; most people think that by our staying in there, it finally will be somewhat better, although it was done in the least effective way imaginable.

Middle East. No particular competence shown here.

All the public appearances. Regular guy, OK, but too many appearances. Watching basketball games, the turkey, enough, give me a break. It would be different if things were going well.

Which leaves the big boy, the economy, joblessness, low growth, the specter of more and more loss of homes, more financial upsets. The stimulus package was necessary, of course, but it’s controversial and since it’s just cushioning a fall, there is no one there to shout “whoopee!”

Which leads us to Wall Street. If there is one leaking sore, this is it. The other items above may not be solved, but many are somewhat better, and none demonstrably worse. Wall Street, the major miscreant in the most major problem we have, is awash in money and notably devoid of contrition. Quite the opposite. And their facilitators, their enablers, Geithner and Summers, are insiders.

So, here’s what I have been thinking for the past month or so. Get health care out of the way, one way or another. Just get it done, call it a victory, and move on. Say the results will take some time to see, although there will be a special near-term fund from the government for the uninsurable to buy insurance.

Get Afganistan set, say it will take time, we are not bugging out, but our strategy will be intelligent, and hope it recedes some in prominence.

Then, attack the financial problem head on. First, say that the system has been rescued. We had to prop it up so there wouldn’t be a liquidity crisis and there wouldn’t be a meltdown. Unfortunately, in the process of doing this, we have found out that the denizens of the Street are profoundly unconscious people. They have revealed themselves as who they are, and it’s not a pretty picture. It’s time for the extortion to end.

So, here’s what we’re going to do. We’re going to push for really big regulations on the Street. We’re going to reintroduce Glass-Steagall, which never should have been repealed – thanks, Clintons and thanks, Phil Gramm et al. We’re going to take measures to break up the big banks so that nothing will be too big to fail.

And we’re going to take the money from the banks and make them start lending to small business. We will start with gentle persuasion. If that doesn’t work, we’re going to take them over one by one. And we’re going to make the mortgages go back to the original interest rates of the ARM and not let them vary upward. Too bad, lenders; you’ll survive.

Now, a lot of what I suggest is untutored – I don’t know 5% as much about this as I know about health care. I’ll follow this up in a while with something more accurate. But I’m trying to indicate what I think is the tone they need to strike -- we’re kicking ass and taking names.

OK, it’s populist. But politically, this is what they have to do. Let the Republicans start to defend Wall Street. Isn’t that what the Administration needs?

Budd Shenkin

Saturday, November 28, 2009

Health Reform (for a change)

OK, this is very repetitive, but I'm now restating my position on health care reform, as I wrote to my old mentor, Phil Lee:

Hi, Phil:

Hope you're having a good Thanksgiving and are hale and hearty.

A couple of decades ago you said to me that it seemed to you that there is so much money in the game that it's hard to change. I didn't have the wisdom to reply at the time. But it is just so obvious you were right then, and would be even more right now if you made the statement again.

It's pretty clear to me that should health care reform pass in its current state, and for Obama's and the Democrats' sake it had better do so, who would be sitting pretty? The same ones who are sitting pretty now. Pharma, no problem. Hospitals? All those newly insured patients and minor inconveniences of making their services non-infective, no new prohibitions on local and regional monopolies, no problem. Insurance companies? No more underwriting, continue to write up policies with big premiums, few if any assurances of breaking their oligopolies (I assume the retraction of insurance company immunity from antitrust will not go through), no problem. Training programs, with more money for nurses and more places for trainees? No problem. Nurses, now able to head medical home installations without physician direction or participation? No problem. FQHC's, with $1B growing to $4B increased funding over 5 years? No problem. Everyone with a strong lobby, no problem.

Primary care? Only a possible promise of a MedPac in the executive that might or might not dodge the specialty interests and help redress the RBRVS inequities. A policy to lure people in with debt forgiveness and more training slots, not to make the ultimate destination more palatable. No strong lobby, no place at the table.

And have you seen the plans for the Primary Care Extension Program? Pure public health, no involvement of the professional primary care givers at all! The Feds through AHRQ will dish out grants to states who will set up "Hubs" of the state health departments who will send out who, RN's and MPH's, to tell us in practice how to practice medicine in a medical home, with no money promised to fund it all, just another unfunded mandate? That'll sure be well received!

And patients, what kind of health insurance are they getting? The terrible kind of insurance that the insurance companies have come up with over the years, high deductible and high out of pocket costs up front, with no restraints on insurance payments at the back end, where the consults and the hospitals sock it to them, and will be fully funded. Reminds me of Goldmine Sachs and AIG - 100% on the dollar, while Main Street (Primary Care Street), takes it on the chin. I didn't know Larry Summers and Tim Geithner designed health insurance also.

There is so little about cost control, really. I don't know about funding the ACO's, but I would hope it could help. The biggest fights will be political -- who controls these babies, I guess. It would be great if they worked, just a muscled up version of the old DRG's.

Why is all this happening? Why is the government so weak? One, Senate representation of two Senators per state, no matter what the population. Two, election finances, with so much money necessary and corporate interests thus foremost except for the Obama national campaign. Three, the difficulty of fixing election finances, because of the First Amendment, and because of the long-standing confusion of treating corporations as persons with the same First Amendment rights as real persons. We can pin it on individuals, and on the weaknesses of the political class, but it's really structural.

What forces can be mustered for real reform? It's got to be the profession itself. Professional ethics really do exist, goodwill toward man really does exist in so many ways throughout the profession, if the professional societies and organizations could be mobilized. To me, that's our best hope.

I'm still for health reform on the basis that ethically, Americans need to be able to insured, and on the basis that at least the logjam will be broken. Breaking the logjam will be only the first step, but a necessary one.

Anyway, that's my hit on things.

Again, Phil, I hope this Thanksgiving greeting finds you well, and I would love to come down to Palo Alto and take you out to lunch.

Best as always,


Budd Shenkin

Wednesday, November 25, 2009

The Reid bill in the Senate

It's true, dear Blog, I have been neglecting you. I think of it as a fallow period. After all, before just signing in and blogging away, it's good to think first. So I guess I have been.

I have read most of the Reid bill in the Senate, and earlier this year I read the two house bills, especially HR 3962. All I can say is, deficient as I think the bills are, and I think they are grossly deficient, at least they will break the logjam in health and get change moving. I'm trying to be optimistic. My essential pessimism comes from realizing that the powers that be, are the powers that will be. It's not only the rules of the Senate, it's the makeup of the Senate with over-representation of the West, the South, and the rural, and the lack of electoral reform that makes money talk. None of this is going to be fixed in my lifetime, and perhaps in yours. And this situation conditions events strongly.

But, given that, here are some observations on the Reid bill.

The problem of primary care, that there are a diminishing number of primary care physicians and the field is economically uninviting, remains unaddressed. The House bill had a 5% primary care bonus, and it had more people on Medicaid (150% of the poverty line), but increases of Medicaid payments over 3 years to 100% of Medicare. That's all gone in the Reid bill. What remains is nothing to make primary care a more attractive destination, but to make entry more attractive by loan forgiveness and more residency places - not an ideal solution to my mind. In fact, pretty poor.

There is a chance that the changes envisioned for MEDPAC, the body that recommends payment levels in Medicare, would change that. I do think that separating MEDPAC from the special interests, which is what insulation from Congress means, is very good. But I still doubt that they will go ahead and pull compensation for primary care up. So, I think the primary care issue, grounding the system in primary care, is very poorly addressed.

I think the hospitals are going to make out like bandits, because their uncompensated care will now be compensated and they will have given up nothing. The quality measures under Medicare (not getting paid for patients who are readmitted, not paying for hospitalizations for infections acquired in the hospital, etc.) is something they should do anyway, and can do, and in the end it will cost little. Most of them, for all their complaining, do very well with local monopolies, pay SEIU very well (for all their complaining), pay nurses far too much (for all their complaining), pay the administrators phenomenally well, and don't do basic management well (clearing OR's so the next case can follow, etc.) Instead of being efficient and kicking some butt they just raise their rates. Can't see that changing. Hospital rates are so unbelievable, it is surprising there is not more focus on that. This is such a core problem, and it is very poorly addressed.

Pharma will do just fine, thank you, as has been well documented. They will sell more than ever and not much competition will ensue. This issue, festering since the Kefauver investigations, remains poorly addressed.

Insurance companies still will have little oligopolies and no ceiling on rates. Yes, they will get rid of exclusion and rescissions, but they will reduce their underwriting expenses, have many more people enrolled, government money, and yes they will have to report their medical loss ratio, but what games will they play? They will still torture us, the doctors with their contracted rates and quibbling over bills we send in, etc. This problem is better addressed than hospitals and pharma, but where will the competition come from? The Public Option has withered on the legislative vine. They will all still probably retain their monopolies.

So, where will the savings occur? Can't really see it, despite the optimism of the economists. Some will come from us (physicians, especially primary care), where we don't need it. There are the beginnings of ACO's (Accountable Care Organizations), of course, but they will take a while to work if they do. Of course care has to be organized and coordinated, it's a scandal that it isn't. But the major story with ACO's will be political control. Will this further the corporatization of medicine? Almost inevitably. Who will be in control, hospitals? Dunno. This will be the story to follow, I guess.

Some tidbits from the bill: nurses do well, as they will now be empowered to run medical home practices with them in charge, no doctors, just a back up institution like a medical center or FQHC. Nurses are getting their autonomy! Plus the academics get more training money. What they should do is resurrect the hospital nurse schools, get more LVN's, and break the RN strangle hold on the hospitals. Not going to happen.

I think there is further movement to separate and unequal health systems, as the FQHC's get billions, from $1B to $4B over 5 years, I think, while their colleagues in private practice get squeezed instead, and FQHC's already get 2-3 times as much payment per visit. An inevitably high cost and low customer service solution.

There's also $50 million for school health centers - great jobs! No nights, no weekends, just hang out around the school without anyone checking your productivity - a county job! Sorry I can't be enthusiastic, because on paper it's a good idea. In practice? Not so much. Without productivity measures, people just don't work so hard, they just don't.

Then there's this: "The Primary Care Extension Program shall provide support and assistance to primary care providers to educate providers about pre-ventive medicine, health promotion, chronic disease management, mental and behavioral health services including substance abuse prevention and treatment services), and evidence-based and evidence-informed therapies and techniques, in order to enable providers to incorporate such matters into their practice and to improve community health by working with community-based health connectors (referred to in this section as ‘Health Extension Agents’)."

I can't wait until I meet the little MPH graduate who comes around to my office telling me how to practice medicine!! On the positive side, maybe we could capture this program and become the "hub" and the "agents," but I've been around long enough to be able to spot a disaster in the making. "What are you doing now, Barbara?" "I'm a Health Extension Agent. I get to tell stupid doctors what they should be doing." "Oh, that must be fun! Are any of them cute?"

Well, take away my misogyny, and you get the picture.

Budd Shenkin

Friday, November 13, 2009

The Joy of Sex

Readers of a certain age will remember Alex Comfort's classic, the Joy of Sex. Appearing in the 1970's, Comfort presented a humanistic rendering of what was approached as a very natural process that should be viewed as a pleasure for humankind. The commentary was vivid and loving, the illustrations illustrative.

It turns out that Comfort produced this book with the help of his long time mistress, and that the embarrassment caused to his wife led to divorce, which is a sad story. But the book lives on. I understand it has been updated for a new generation and reissued.

This is a good thing. But what of the old generation that started with his book? We have progressed in age and we have our own new perspective. Can the publishers refocus their concerns on this loyal, now older generation?

I would suggest that new book be prepared. The title would be, The Joy of Regularity. I'm still struggling with the illustrations.

Budd Shenkin

Wednesday, November 11, 2009

Health Reform Endgame? or Foreplay?

Crunch time in health care reform. Public option or not, we'll just have to see. The Catholics, with the same wonderful sense of timing that started the Inquisition, try to retard abortion by extortion - waddya want, health care reform or not? Terrific.

Pharma does great selling more brand named drugs and patents on biotech go up to 12 years, hospitals get all those paying patients and hardly any nonpayers, and health insurance? Some costs go down, actually, because they don't have to underwrite, they keep administering the big time ERISA accounts, and look at all those new policies! With no limits on prices. Wow.

The nurses get a lot! They don't need to be beholden to doctors (their dream!) to head a Medical Home project, and they have some other kind of project they can head that I forget right now. Plus educational money for the academic nurses. The Public Health people get billions, and Community Health centers get $1 billion now and up to $4 billion in four years. Not a bad haul.

The academics always get something - money for training in primary care, a pursuit that they continue not to make more attractive by simply raising the take.

OK - that's the facts, pending the Senate. But we just have to look at it this way -- the logjam is being broken. Health care has been so impacted that nothing has moved for years as the pressure has built up from behind. So, this is the beginning. Who knows how it will come out? But the clear need for reform just from the standpoint of cost, forget quality, will make sure that stuff happens. What is happening now will be enough to set the forces free. I'll try to figure out where a little later.

Figured I had to write something. Been too long.

Budd Shenkin

Health costs? Nothing right now, something maybe