Saturday, January 30, 2010

Stories We Tell

Every culture has stories. So does every age. The Ancient Greeks, who I suspect did not think of themselves as ancient, had stories about an age ancient to them, of battle in and then voyage from Turkey, which they kept adumbrating with new meanings, and illuminating with focus on minor characters – Ajax comes from the wings of Homer’s stage to the center of Euripides’. Kids tell great stories that we pediatricians will ascertain as “age appropriate,” and as adults we keep telling them, maybe or maybe not age appropriate.

My friend Fred Gardner recounted the course of a love affair years ago, saying “And then I was telling her the story of my life. You do that, right?” Yeah, I had never thought about that, that’s what we do. Sometimes it's accepted and sometimes not. In my own case, I get correctives from my wife who puts her own interpretations on things - all stories are interpretations - and makes me think. Often I think, hmmm, I look at things the way my parents did, and sometimes I adjust, and sometimes not, or sometimes I change and then change back.

I thought of Fred’s story, from Horace Mann in New York, or before that, his mother comparing little Fred to Lenin – now there’s a recipe for psychological disaster. Somebody should tell Fred’s story – not Fred. So much ability, so much there, and so much water under the bridge. Anyway, Fred was right, we tell our life stories to those closest to us, differently to different people, trimming to fit. How much bravado, how much triumph, how much Rodney Dangerfield – the art of the story. I catch myself doing it. If it’s bravado, we have to look and see how much we can get away with. Or sometimes if I'm self critical, someone will say, why do you do that to yourself?

I like it when guys trade stories. It’s simpler. John King is my physical therapist – I tried five others until I found John – and we trade stories of the past and present as he pushes and stretches me. Yesterday I told him the story of my Harvard junior year JV basketball team that went 23-0 – 23-0!! What a year! And the first game, before our coach appreciated how good I was, and it was tied with about 2 minutes to go, and he had to put me in, finally, and I scored five points and had an assist and we won by five. The whole team came out to meet me as we walked off the court. I especially remember John Raezer, my high school classmate and four year Harvard roommate, smiling as he came, so pleased and proud, even though he had been the high school hero and me not. A basically generous and nurturing guy. Then last year at my 50 year high school reunion, John said to me, remember that game? John King said, so you said, “What game? I think so. How did that go?” We just laughed. Guys together. I said, if I were talking to Ann I’d have to say the highlight of my life was the day we got married – and John King added, or the day the kids were born – but we know, guys know, that that game was really the highlight of my life.

Which prompted John to talk about the high school football game where he was a free safety and stepped in front of a receiver, intercepted and took off for a touchdown. Then, at the end of the half his team took over with two minutes to go and the coach signaled for time out, and John as quarterback ignored the coach, told the team that taking time out would only give time for the defense to get set and “we knew what we wanted to run,” and they scored. That’s 14 points for John, and they won by two. John and I just smiled at each other. Guy stories, nothing like it.

So, I’m reading “A Traitor to His Class,” a biography of Franklin Roosevelt by H. W. Brands. Brands is a good biographer, not as great as Walter Isaacson, but more than serviceable. I know the story of FDR, Doris Kearns Goodwin’s “No Ordinary Time” is one of the best books I’ve read. There was a great PBS biography a few years ago – just great. The PBS story showed the centrality of FDR’s polio, how in those days you took a cripple and put him in a back room to hide the shame, but FDR tried and tried to walk, then took himself to Warm Springs Georgia where he met the local people, ordinary people whom he wouldn’t know in Hyde Part or Washington or New York, how he made his hotel into a haven for the afflicted, like him. From encouraging himself he went to encouraging others. He was a true hero then, really. That’s when he knew that we all have a common maker. And from this book I learned that he almost exhausted himself financially to do it, until he was rescued by a rich friend who wanted him in politics.

So then he went back to politics and greatness. Without polio he still probably would have been terrific, but no polio, no hero, probably. Maybe. Washington, Lincoln, Roosevelt, our panoply.

I came across this speech extract on page 512:

“Storms from abroad directly challenge three institutions indispensable to Americans, now as always. The first is religion. It is the source of the other two – democracy and international good faith. Religion, by teaching man his relationship to God, gives the individual a sense of his own dignity and teaches him to respect himself by respecting his neighbors. Democracy, the practice of self-government, is a covenant among free men to respect the rights and liberties of their fellows. International good faith, a sister of democracy, springs from the will of civilized nations of men to respect the rights and liberties of other nations of men. In a modern civilization, all three – religion, democracy and international good faith – complement and support each other.”

I hadn’t put it together just this way, certainly not the religion part, but boy, does it make sense. Hitler was a huge bully, and didn’t have any of the three characteristics of what we see as a better-than-natural order. Of course there is huge culture boundedness in what FDR saw as good and desirable. But what of it? The underlying sense is, let’s get along, let’s respect each other, and let’s try to make things good for everyone. It’s not cynical, it’s very English, just expanding it to the heathen.

If you read what he had to do with Congress, and the isolationists, and the Wall Street crowd, you see how he came to understood how one has to deal with people as their minds and situations evolve. He was just ahead of events more than they were, and had a high-mindedness that probably was very Episcopalian, but I’ll take it.

Now today, we are again (or still) faced with a new challenge abroad, testing whether this nation, or any other nation so conceived and so dedicated can long endure. The non-Western nations are certainly not so conceived and so dedicated. Maybe they will be like Hitler – it always surprises me, after my Jewish upbringing, to think that Hitler wasn’t Catholic, but was non-religious – and conceive themselves not with a common creator, a good father, and not with a directive to get along and help each other. Maybe they will nurse grievances and dare us to stop them from spoiling our common Earth, while they don't desist. The nature of man is not pacific. But even with as low as Congress has sunk, the Congress of the 30’s can’t have been much better. It seems like a similar struggle.

But what a leader we had! FDR! My mother really loved him.

Budd Shenkin

Sunday, January 10, 2010

Education of a Negotiator

I have been a little thorn in the side of the American Academy of Pediatrics lately, not an uncommon spot for me, over the issue of how they view themselves and their mission, and their conception of what their stances mean.

Here is the essence. There is a division of opinion within the AAP. Historically, they have tended to view themselves as advocates for children rather than looking out for their membership. Other professional societies may have a similar division, but probably none to the extent that the AAP does. Most are more like the surgical societies, that think what's good for them is good for the nation and the patients.

Within our section, the Section on Administration and Practice Management (SOAPM), many voices have been raised on our Listserve and in private counsels - how about standing up for us? If we don't get our margin, there will be no mission. Etc.

Earlier in this decade the AAP had a proposal called Medikids. This was a proposal for universal health insurance for children, and part of the proposal was for pediatricians to be paid at Medicare rates - which suck. In other words, the AAP's proposal would screw its own members - and that was the opening position! I and others excoriated their naivete and indeed, inadvertent malevolence in their self-conception as medical missionaries within our own country.

We just couldn't get rid of this proposal - we would protest, they would say they would change it, and then it would reappear. I'll leave out the AAP internal bureaucratic politics, but that was the result.

Then, last month, a set of articles came out as a supplement to our journal, Pediatrics, evaluating costs of giving vaccines to our patients. The pay rates of insurance companies in paying us for vaccines has been problematic. These articles were commissioned by the AAP to try to give pediatricians some backing in getting paid better. But, just as I had feared when I heard these articles were coming, the articles did a classic pediatrician, AAP preemptive surrender. Instead of viewing these articles as an opportunity to establish a negotiating position, they relied on trying to find an unassailable, reasonable, conservative position. They underestimated the costs - and this is going to be our opening position. Just like Medikids, I thought. They just haven't learned.

Anyway, so I protested on the Listserve, and then I wrote this reminiscence on how I learned to negotiate. Kinda.

Really, I’m just a nice Jewish boy from Philadelphia, sheltered in the suburbs, and put into the college and medical school pipeline. I was brought up to be truthful, fair, and idealistic. I went to medical school, not business school, not law school. How could I be a negotiator?

And in fact, I don’t think I am such a good negotiator. Maybe I’m OK, I don’t know. But my objective is generally just not to be taken advantage of, and not to take too much risk, and not to be stupid. Pretty minimal objectives. Or maybe I’m better than I think. Dunno.

But there I was, right out of internship, a so-called “Two Year Officer” in the US Public Health Service. “Two years,” because that’s what it took to count our time in a uniformed service as service time and avoid Vietnam. (Although I didn’t really have a uniform, although I was issued an instruction booklet on how to dress in one, and how to call on senior officers and leave “my card” with them.) I had always had an interest in administration and politics, and here I had an opportunity, stepping off the clinical treadmill, to participate. I was stationed in Washington, D.C., with a unit that underwent numerous name changes, but the most descriptive might be the Community Health Service. It was deep in the bowels of HEW, under the Health Services and Mental Health Administration, then HHS, etc.

Leadership was at a premium, and somehow in these days of expansion of health services, despite my youth and inexperience, I was given leadership and responsibility for first Neighborhood Health Centers, and then the Migrant Health Program.

(Side note. The NHC’s were started by the Office of Economic Opportunity, and copied by the so-called 314 (e) program of HEW. David Blumenthal, currently HIT czar in the Obama Administration, wrote a summa [I think] Harvard political science thesis on the 314(e) program. He was following the example of his brother, Richard, currently slated to succeed Chris Dodd as Connecticut senator, who wrote his Harvard summa thesis on OEO, which was the primary document for Senator Pat Moynihan’s famous book, Maximum Feasible Misunderstanding. End of side note.)

Anyway, to the point. There I was at a meeting on Migrant Health, which I was taking charge of, and across from me was the lady who had had lobbied for this program to get started, and then had been in charge of it for years and years. The only background I had was college, medical school, and being a nice boy, taught to be reasonable, and not to get caught out by an attending on rounds making stuff up. I forget the exact points that were being made, but I know that I started to make a proposal that sounded reasonable and acceptable to me.

I had just started and someone else was talking, when I felt a tap on my shoulder. The owner of the finger was Tom Uridel, 6’3” 225 lbs., then and now a hero of mine. Tom was a genius. He came from Medford, Oregon, heard jazz on the radio station and was entranced, went to Mexico to have experience and now spoke great Spanish, came back and settled for a while in Alviso, California, down by San Jose, a poor Mexican community. Tom had no health background but he saw the need for community health services, and built one of the first ones in the United States, from scratch. And when I say built, that includes building the building himself with other community people, literally. Plus recruiting doctors and a dentist, and getting some funding, and running it. Building and running it from scratch, with no models to guide him. The man was a genius.

After Alviso was up and running, Tom was recruited as a consultant for our unit by higher-ups who wanted us to at least to have someone around who knew something. So there he was, sitting just behind me, tapping on my shoulder.

Tom said to me, “Budd, is that what you want, what you are saying?” I nodded yes. Then he said, “Then you had better get out on the wing, so you can compromise to that.” So I made a proposal that an attending physician on rounds would tell me was self-centered and ludicrous, and we compromised to the center, where I had figured it from the start it would be fair to be.

The next year, we had a similar situation, except I was in Tom’s chair, and I was the person tapping on the shoulder of my new Deputy, telling him not to make his “reasonable” proposal, but to get out on the wing, if that is where he wanted to wind up. Many of you probably know my then-Deputy, who was Jim Perrin, now Chief of Pediatrics at Mass General in Boston.

See one, do one, teach one. Except in this case, do one, teach one.

Now let’s leap forward to that misbegotten proposal known as MediKids. Remember that, sports fans? Proposing what – universal childhood health insurance coverage, paying 100% of Medicare? And remember our SOAPM outrage at this proposal that wouldn’t go away? Was it “reasonable?” I would say not, others would say it was marginally so. But it was a proposal that no attending physician would attack as self-centered and outrageous. It was certainly “good for the children.”

And where are we now? The current health reform proposal gives close to universal coverage of children, all the programs considered, in a total program of Medicaid, CHIP, etc. And what is our payment from this? They have compromised down to the “middle,” which is far below what we think is acceptable, which was where we seem to have started from. We will, in short, be screwed.

To be fair, I really doubt that pediatricians had any input at all in health reform; if we did, then it certainly wasn’t to our advantage. If we did, I doubt there was a Tom Uridel, tapping on someone’s shoulder, trying to get to the wing so we could have an acceptable compromise. But if we had any influence, I would say it came from MediKids to start with, where the framers of the legislation noted that pediatricians would be happy with 100% of Medicare, put it in the original House legislation, and whittled it down from that starting point. Where was Tom when we needed him?

So let’s finish up with vaccines. We have a couple of articles that are supposed to support our claims to “fair” payment for vaccines. Like the good little boys and girls we are, not wanting to be called out by our attending physicians for being self-centered or outrageous or God forbid, giving ourselves benefit of any doubt, we go for valid “scientific” data. If there are assumptions to be made, we make them in favor of our opponents in the negotiations – no wastage assumed! Fully efficient practices, such that we can in reality only aspire to! Medical Assistants that only God could really deliver to us, uniformly! Marginal instead of average costs, not asking vaccine payments to bear any of our basic costs of doing business, or to assume pediatricians get more than minimum wage. (OK, I exaggerate – don’t call me out on this, attending sir!)

We assume that our modest figures, already giving the insurance payers all they should fairly want, will simply be accepted. And where will we settle? Where is the middle? We’ll find out.

As I say, I don’t hold myself out as a great negotiator. I would much rather be fair and reasonable. I’m just a nice Jewish boy from Philadelphia. But I would wager that the health insurance companies will not be represented by nice boys or girls. I would wager that they will be real negotiators. I would wager that given our articles, they will try to negotiate us down to a fraction of what we have honestly underestimated as our basic costs. I would wager, in short, that we will be screwed.

Where was Tom when we needed him?

Budd Shenkin

Sunday, January 3, 2010

Enthoven Destroys Gawande

I have always kind of resented Alain Enthoven, although I'm not sure why. I think it's the air of infallibility he carries, not unlike the McNamara boys at DOD, which I think he was a part of, before he turned his attention to health care. Maybe it's because of his corporatism, and his sense that he uses the Palo Alto Medical Clinic and it's fine for him, so why shouldn't it be for everyone? I can give him several reasons why not - he is an insider, for one, so he's going to get care that's different, and just because he likes it.... Anyway, he is a cold fish. He doesn't have a humanitarian background. I'm such an independent guy that I just bridle at the thought of having to be contained in a corporation and to answer to corporate politicians. And he's at Stanford with their red shirts. Who knows?

But that doesn't obscure the fact that he is quite smart and often right. He is clearly one of the 5 top health care economists/policy experts. If we had adopted his Managed Competition proposals decades ago, American medicine would be in infinitely better shape than it is now.

And now I agree with him completely in his commentary on the insufficiency of the current health reform bills and their really pitiful proposals for pilot projects. Yucch!

Here is his commentary in the cloak of a response to the New Yorker article by Atul Gawande that assets the pilot projects might work in the way that the agricultural extensions worked a century ago in our rural areas. I love Gawande, but smart as he is, he's not a policy guy. Enthoven takes him apart.

Budd Shenkin

Saturday, January 2, 2010

United Health Care and Telehealth (2)

Well, I'm having trouble posting a comment to my own blog. Pretty amazing.

So, here's my response to Donna Cusano, who posted a comment:

Thanks for the comment, Donna. Interesting to see the other side of innovation. We know that innovations come from invention of the technology first, and use second. The inventors of telephones, phonographs, and radios had no idea of the wide usages that would come.

Seems to me that telehealth will be the same. Invent, and then see who can come up with the perfect usages. I’d say that the most obvious use would be in the Third World, and the rural parts of first world. The problem would be money – the same reason there are no doctors in the Third World is why the prospect of profit would be difficult. But there are donors, there is some money somewhere, and maybe that would work.

I think the problem of adult acute but probably not serious care is a problem of organization. Pediatrics isn’t so much of a problem, usually, although more could be done. I think most pediatric practices are like ours – acute illness will be seen on the same day, even on weekends. The main problem is with adults – why adult practices are not set up to see same day sick patients escapes me! Also, why hospitals can’t set up urgent care better is not clear. Hospitals are generally just poorly run, as we all know. Also, they can charge so much for an ER visit and get it – so why settle for an urgent care visit? So, I guess the Retail Based Clinics really do rely on just low cost.

But if that’s the case, would telehealth be low cost and thus competitive? I can’t see how that would be the case.

I agree 100% that the UHC demos of telehealth were based on PR for impressionable Reps and Senators. I agree it was part of their strategy as they won the Health Reform fight. So, I wonder why you think that UHC will be toast with health non-reform? Seems to me the insurance companies are going to get lots and lots of new subscribers with no significant limits on profit. Their problem will be what to do with all the money.

If I owned the UHC zoo, I think I would identify areas that could potentially be like Intermountain, and the Grand Junction Colorado system. I would partner with some, buy some, and then try to spread like ink spots. If I got a great team together, pretty soon I would be predominant in health care in a large part of the country. It would not be easy, it would take real investment and team building, it would take creativity – all of this would be alien to UHC as presently constituted. But that’s what I would do.

Budd Shenkin