Monday, March 24, 2014

My Pen Pal Alla, and My Friend Victor Lvov

From my American Academy of Pediatrics, Section on Administration and Practice Management (SOAPM) listserve:


Don't forget, that there were very few reasons for someone to be kicked out of medical school in my times...

Killing someone, applying for leaving Soviet Union as an "enemy of people" or... failing the very important for all physicians communist ideology class. We had 4 years of internal medicine studies, 4 years of surgical studies, 4 years of military training studies (we all graduated as second lieutenants of the soviet army reserves) but all 6 years of mandatory brainwashing where we had to take detailed notes of all historic publications (Marx, Engels, Lenin) and modern (Brezhnev's "literary" writings along with the party resolutions and other documents). I was able to swing though the dialectic materialism, historic materialism, scientific atheism and communist philosophy courses by doing research on philosophical views of Avicenna, but even the great Maimonides was able to save me from the history of Communist Party in my freshmen year and Political Communism in my senior year. Our 3 mandatory graduation exams were: (a) Medicine, (b) Public Health, (c) Political Communism. And that is on top of all the similar brainwashing through grammar, middle and high school.... To be allowed to present my PhD thesis I had to take another 3 exams:  specialty (i had to do two there - dermatology and medical genetics), foreign language (I can tell you one day how I was GIVEN that exam) and communist philosophy. 

...In 1989 despite of losing everything, uprooting everything and coming to the US with retired parents, 5 yo son, 2 suite cases per person, $90 per person in a pocket, and a dream, I did feel very optimistic. Scared - the lives of 3 people were depending on how I will be able to survive in this new country, on me and me alone - but optimistic. The best description of that feeling was that I had nothing to lose except for my own (socialist) chains, but I could get the whole world (of American dream).

Alla Gordina

And I responded to Alla:

Here is the story of my friend from Russia, Victor Lvov. 

Victor was a dear, warm friend, although we didn't socialize.  He came from St. Petersburg.  I met him when he was our neonatologist at Summit Hospital in Oakland, and I was the Chief of Pediatrics.  We worked together for years, with the warmest relationship ever. 

Victor had been a wunderkind (sorry, German word) and got his doctorate before he was 20, probably.  He was friends with the Saint Petersburg chief of police and they went fishing together.  Victor then published samizdats on the real statistics of public health, not the false ones published by the authorities.  He was told not to do this but persisted.  One day he got a call from his friend the chief of police that was very impersonal, telling him he was an enemy of the state, how could he do this anti-social activity, and that he, his wife, and his young child had to leave the Soviet Union within 24 hours.
Victor hung up the phone and thought, "He is saving me from the Gulag."
Within 24 hours Victor was in Boston with a few suitcases and his family and no money, knowing maybe one person, I think.  He was rescued by the local Jewish agency and was soon working on polishing floors with other Jewish refugees and had a small apartment for his family.  He knew no English.
Within 18 months he had mastered English and passed the medical exam.  He moved to San Francisco and started a neonatology fellowship and in a few years wound up with the Oakland neonatology group.  He was a great doctor, and was soon circulating figures that showed that Summit Hospital had the largest concentration of neonatal syphilis in the country.  We also had outstanding diagnosis and treatment results.  We completely rocked.
By the nineteen-nineties Victor and Barry Phillips, the head of the Children's Neonatology Group, had started the Heart to Heart program linking Children's Oakland to St. Petersburg Children's Hospital Number One as sister hospitals, with neonatology and pediatric cardiology and cardiac surgery.  Then a team from Children's was slated to come to St. Petersburg to consult for a few weeks.  There was a hitch -- the St. Petersburg group said that they could come, but Victor could not receive the Visiting Professor title because of his history.  Barry Phillips stood up and said, if that didn't happen, there would be no exchange at all.
Victor was then appointed as Visiting Professor and returned to St. Petersburg with the highest honors.  Victor was the true victor.  You can imagine!  Many exchanges followed back and forth, and I was lucky enough to be one of the personnel in the exchange.
Several years later I made rounds one morning at Alta Bates Hospital nursery and hadn't seen Victor in a few months.  Gil Duritz, the chief of neonatology at Alta Bates (and father of Adam Duritz, lead singer of Counting Crows) said to me, "Did you hear about Victor?"
I said, "No, what?"
Gil said, "He died last week."
"He wasn't feeling well for about a month and finally checked with a doctor.  He had lymphoma.  He did within one week."
That is the story of my friend Victor Lvov.

Budd Shenkin

Tuesday, March 18, 2014

The Ukraine

Dear readers, please allow me a somewhat disjointed post, perhaps, in the interest of topicality:

I have had a vigorous conversation with members of my family on the Ukraine.  My brother-in-law Jim is very conservative, tends strongly toward the ideological and even the pontifical, but for all that is a very nice man, and one with whom I seek reasoned agreement.  Sometimes it’s possible.  There’s something to be said for conversations within family where you can maintain an emotional equilibrium and appreciation for seriousness of purpose.
Jim thinks the West has been weak, Obama terribly so, and that the Soviets – I mean the Russians – have been more or less invited to be aggressive.  I read The Obamians by James Mann two weeks ago, and I see that Obama has wanted to be fresh and non-postVietnamian, and to lead to an era where everyone understands win-win.  I also have read others who say, lots of luck with that!  See my friend Michael Nacht’s oped on that point of view:  Michael negotiated with the Russians on nuclear disarmament in the Clinton Administration and he just shakes his head with the memory.
On the third hand, I’m reading cold-warrior Bob Gates thoroughly engrossing and so-far inadequately reviewed (they just look for dirt to dish) new book “Duty,” and he says that in recent decades the United States has treated Russia with disrespect, insensitivity, and arrogance.  Wow, coming from Gates.  The “Ugly American” is an image that will not die.  (“Ugly American” as popularly conceived; actually, as drawn by Eugene Burdick, the Ugly American was actually a positive person who happened to be physically unattractive, I think, but his aggressive colleagues in the CIA and American business have garnered the stereotype.  I mention this only to show a modicum of erudition.)  In that sense we have goaded Putin to assert himself when the opportunity and perhaps necessity has arisen.
That all being said, what I said to Jim was, I still think we'll just have to see.  It's not all over in a fortnight.  The Crimea is historically Russian, and it is unrealistic to ask Russia to give up their warm water port.  Perhaps they have been paranoid and worried that it would go away when it wouldn't, but this move of theirs ensures that they will keep it, and Putin shows strength domestically in the way he is doing it.  But at the same time he will be losing abroad and be more isolated, but perhaps there is some splendor in that.

I actually doubt anything more will happen.  Over the longer and more important term, the major job will be to get a functioning democracy going in Ukraine, a formidable task given the Ukrainian kleptocracy that has put other kleptocracies to shame.  Yanukovich seems to have had palaces, for God’s sake; Yulia Tymoshenko was a thief, too, who probably actually did belong in jail, I figure.  Here’s the question: can the technocrats produce a government that allows the country to move forward?  That's the real challenge.
You remember the intercepted phone call of Victoria Nuland's when she said, "Fuck the EU."  A noble sentiment, that.  Attention focused on the expletive and her attitude toward an ally, but titillating as that was, the key was that she was talking about helping to get a real government going.  That's what Putin objected to, all the meddling of the US.  Her seeking good government was interpreted by Putin as meddling to achieve a Western ally.  Both were correct.  What Putin misses is that the US would have liked to have Russia as an ally as well – that’s the win-win perspective that has gone missing in the KGB perspective.

The biggest problem really is Putin's Russian economy.  It grows but doesn't reach modernity.  It remains a resource state, a petrostate, and typical of these states, doesn’t sufficiently develop human capital.  What is to be gained by grabbing more territory, if that territory is simply some glory and some rustbelt?  If people in the new territory continue to be impoverished compared to the people across the border, Putin will lose.  That's what has motivated the Ukrainians - they see the Poles across their border with good lives, and they themselves are stuck in the muck.  That's why a good government is essential.  (For an over-rated exposition of the centrality of good government in economic progress, see: Why Nations Fail: The Origins of Power, Prosperity, and Poverty, by Acemoglu and Robinson.)

Not to be too Marxist, but the economy will tell the tale.  I think my brother-in-law Jim on the Right will join me in that assessment.  Right meets Left?

Budd Shenkin

Saturday, March 1, 2014

The Problem is Price, not Utilization

OK, stop me if you’ve heard this before, but I understand we have some new readers, so here are the latest horror stories from my AAP Section on Administration and Practice Management colleagues on the Listserve:

From Sue:

OK...this goes deep into You are $#%^ kidding me, right?

So, I slipped getting of our hot tub a few weeks ago (yes, one extra glass of champagne) while we were at our beach house in NJ. It was 11:30 at night, laceration on my forehead below my hairline. If I had dermabond at home, probably would have glued it, but I didn't. Wouldn't stop bleeding, no "urgent care" open, so I decided to head to the local ER in Cape May Courthouse for a few stitches. I hate over-utilizing healthcare resources, but really had no choice.


The ER billed Aetna 
99283 (level 3 emergency service) say, Yep, you need a few stitches $725.00.
I had a $200 copay, and Aetna paid $503.24
they also charged a 12013 (repair superficial wound) an additional $725.00 of which Aetna paid $703.24
along with some supplies for nominal charges paid about $50.

ALL total: Aetna paid $1,256.12 for my FIVE stitches and I paid $200. 
Total paid:  $1,456.12

NOW, I get a bill for the ER physician services who are NOT participating with Aetna, asking me for an additional $254.80 for the amount Aetna wrote off and didn't pay them.

No WONDER we are having so much trouble with the insurance companies trying to send everyone to the Urgent care centers. 


But not to be outdone, Michael:

Ah, c'mon Sue.  Your E.R. billing department must be staffed by amateurs if that's all they charged - I'd say that only deserves a "$#"  kidding me :)

When our son got a nice scalp laceration at night and we took him to the E.R. for staples, how's this for a "$#^!@&*^#)(&" kidding me:

E.R. "Emergency Service" charge - $1,906
E.R. "Surgery-Skin" charge - $1,235
E.R. "Supplies-Sterile" - $557 (I'm guessing this is for the stapler and two staples applied)
E.R. "Supplies-Non Sterile" - $160 (this must have been for the H20 flush to clean the wound prior to the staples)
Doctor "Emergency Service" - $284 (the only reasonable charge of the bunch)
Doctor "Surgery-Skin" - $533

So a grand total of almost $5,000 charged for ten minutes of history, exam, and anticipatory guidance,  some water flushed by a nurse (actually I think it might have been a nursing tech), and the doctor putting the staple gun against his scalp for 10 seconds to pop in two staples.   Since I knew this doctor and I hadn't seen him in awhile we probably spent more time catching up then was spent on medical care.

Obviously the insurance PPO discount got it down significantly.    I need to call the billing office on my day off and have some fun seeing how they justify such ludicrous charges.

The policy implications:

While these true stories are amazing on their face, I believe that they are emblematic of what the real problem is with high costs of health care in the US.  The problem is not overutilization, it is high prices, and creative billing by hospitals, and also some doctors.
When reforms to lower health care costs are proposed, a prime question needs to be: would the proposed reform attack those high prices?  Or is the proposed reform something that would diminish utilization more, make utilization “more efficient” (e.g., reduce duplicated tests), or put more burden for paying onto the patient?  If a reform doesn’t attack prices, it is slashing at a peripheral issue only.

Note also from Sue’s post the complicity of the insurance company.  Some say they should be our agents to keep costs down.  But high prices in one sector leads to high prices in another.  If the insurance company has a set margin and it pays out more for care, it raises its premiums so it can collect more, and its profit will be a percentage of that higher number.   As a result, the insurance company and its executives make more money.  This phenomenon, then it collects more in premiums, and the companies and the executives make more.
This is precisely what happened in the auto industry, as UAW and management scratched each other’s back.  Only competition from abroad brought changed that situation.  Bring on more Indian radiologists on call at night!
budd shenkin