Tuesday, June 21, 2016

The Warriors Lost

The Warriors lost.

Everyone was nervous, and everyone was watching. At the half I drove quickly down to get my wife a burger. There was no one on the road, just after 6 PM on a Sunday. It usually takes me 25-30 minutes round trip, but on Sunday I was back in 15 minutes. I thought, they're up by 7. Is that really it?  Will there really be a parade?

No, that wasn't it at all. J. R. Smith got rid of that notion with a few 3-pointers and then it was grind and grind, miss too many, throw a couple of passes away, and miss the 3's that were the stock in trade. It was sad, that's what it was, it was sad. It was just so sad. Everyone aching, trying, trying to recall the magic, but coming short, or wide.

So, my friends, John, Bob, and Steven all asked me the same question, how do we understand it? How, indeed. There are times when it helps to be from Philadelphia, like Bob and me. Phillies, 1964, no need to say more. That was slower, drip drip drip, morning after morning coming down to eat breakfast at Vanderbilt Hall at med school, auslanders saying, what happened to Shenkin's Phillies?

When the guys get awards, they say it's humbling, to be MVP, or best something. Nah. This is what's humbling. Losing when you are ahead, that's what's humbling.

It was Cuomo pรจre who said that one campaigns in poetry and governs in prose. That's one way to understand it. All year in their campaign the Warriors practiced poetry. Multiple passes, no-look passes, behind the back, and long rainbow arced 3-pointers in droves. Beauty to behold. Lightness and glee, joy and pleasure and appreciation. Thank you, God.

Enter the grim, the grimacing, the driving with shoulders butting out, with pulling and pushing, with non-called fouls off the ball, with getting beat up for no good reason, only for bad reasons. Enter prose. The Warriors pulled on memory, what was it that got us here? Try that, what we used to do, what was it? Couldn't find it, not at the very end, just couldn't find the ease and the poetry, and the shots wouldn't, couldn't drop.

That's one way to understand it, prose and poetry, probably not too bad. Or think about the gods. Not the Christian God, for all its popularity on the Warriors squad – everyone wants God on their side, everyone wants to be rewarded for following a Godly way, everyone is blessed. But thunder and lightening make more sense in basketball, the realm of the Greek gods; Greece, where sports were king. Some gods backed the Warriors – I like to think Zeus was among them, but maybe not – all the Greek gods were problematic, after all (http://io9.gizmodo.com/the-13-biggest-assholes-in-greek-mythology-1454132475.) It had to be a god guiding Steph's 37 footer in OKC. Even Harrison Barnes won a couple with last minute threes. The gods smiled all season long. Was it Zeus behind Draymond in the first half Sunday night? Athena? I like to think Dionysus honored the Warriors in their mindlessness, in their beauty, but then they got carried away, which is what Dionysus does. Better scholars than I can dope out who was on the other side. Some damn god was. Nemesis tailed Curry, and had his opponents hold onto him, hit him, injure him. A whole season of absorbing punishment, unprotected by the refs in the employ of Hera and her minions. Shumpert falls on Curry and it's Curry's foul? Who blinded the zebra? The gods were fighting, and we couldn't see how they influenced play, but we know they did. Someone got Draymond suspended. Someone cursed Barnes. It had to be the gods.

Or, there's always Zen. Kerr said during the long run to 73 and 9, “...maybe all the talk and all the focus on the record has gotten us away from our process and what makes us who we are, what makes us pretty good.” The process, which is all you control. The end result? Hope that the gods will be kind. When the ball leaves your hand, it's out of your control and it's the physics that tells it where to go, and physics is the realm of the gods. Got to trust the process, let it go, don't point – don't aim and point, HB! Don't will the results, will the process.

In the end, it just wears you down. What did they play, 110 games? And it came down tied to the last minute. Which god was it who had the last breath?

Oakland was quiet today. My physical therapy office was quiet. The gym was quiet. Our usual Monday lunch at the Rockridge Cafe found us only the second customers for lunch at 12:15, when usually there are only one or two tables empty. We were quiet. Beauty had lost, prose had won, our community, home of the Warriors, had lost. We were all quiet.

But isn't it great? It's only a game! It's not really life and death, right? Sure, it's basketball, the game of the gods, but it's only a game.

I guess.

Budd Shenkin

Saturday, June 11, 2016

Centralizing and decentralizing health care

I have been working on an article in which I want to say that there are basically two models of health care organization at the poles: the integrated health care delivery model (e.g., Kaiser) and the decentralized system that used to be called derogatorily “the cottage-industry model,” or as I prefer to call it, the Centers of Excellence model. It will be a great article, but great is in the future. Years ago I coined Shenkin's Maxim and shared it with the kids: “A passing paper in the present is better than a great paper in the future.”
That maxim might have limited applicability, as you will recognize, since I have actually worked hard and long to produce some great papers (in my estimation anyway.)  Although, I have to say, I have other papers that haven't seen the light of day that died on the drawing board, maybe because of standards that have been set too high.
So, that's my “reader beware” statement. I'm not giving up working on the paper; I'm currently doing some basic reading on vertical integration of industries. But in the meantime, here is a little work in progress. First a response I wrote to an article, then the author's response, and then my response to his response. I'm hoping that you, the blog reader, enjoy this brief foray into health care organization theory.  Or skip it until my next post on consumer transportation ripoffs.
My response to his article:
You are of course correct that American costs are high.  Much of this comes from high prices rather than high utilization, although the latter happens, too.  We physicians make more than physicians in other countries, by a lot, especially specialists.  But more importantly, hospitals cost a lot more, and procedures cost a lot more.  And pharma is completely out of hand.  The recent trend to increase prices of established drugs is simply terrible.  Pharma companies have absolutely no sense of the general welfare, decorum, or what is "right."  As long as it is legal or almost legal, they will do it, and government stands by.  It would be really nice if there were honest competition in all of health care, which there isn't, especially since government has allowed lots of oligopolies to arise.
He wrote back:
The fear I have is that because of the high costs of healthcare, the reaction may be to limit access to care.  The far better solution would be to introduce price transparency, patient choice and honest competition.  It seems that for elective healthcare, you could have an Amazon type site that would show a variety of providers and prices.  It seems crazy that when a patient goes to the doctor’s office or hospital, the prices are not displayed on the wall like they are at McDonalds.  When a patient asks about prices, the prices have a huge range based on who is paying.  The answer to “how much will this cost” is rarely clear.
A small example is an ambulance ride.  An ambulance ride can often cost  $2,500.  Rather than calling ambulance in a non-critical situation, why not have Uber offer a “medical” ride for $500.  For that matter, my neighbor may be willing to give me a lift for $200.  The ambulance ride has no price transparency or competition.  It is a one size fits all at the highest possible price.  The ambulance ride is typical of how we deliver medical services in this country.

Thankfully doctor pay is sufficiently high to attract high quality individuals to the profession.
And I wrote to him:
I'm with you on competition, and I'm with you on good compensation for doctors to attract the best possible people, and I'm with you on ambulance rides.  (On the other hand, high remuneration doesn't always work -- the administrations of hospitals and insurance companies are bloated beyond belief, and the high compensations has not noticeably resulted in superior performance, at all.  Medicine and higher education share the affliction of administrative bloat.)
In medicine, the bloat is everywhere, but the cost of care would best be ameliorated if we looked to where the really high costs are, which is in big procedures and studies, in hospital care, and in pharma.  How to introduce competition here is very problematic. 
I think there are two basic models of health care organization, the integrated group and a decentralized model I call the "centers of excellence" model.

For the integrated group, as early as the 1960's, Kerr White of Johns Hopkins wrote that corporate health entities should compete the way airlines compete (this was before deregulation).  Alain Enthoven's "managed competition" of the 1970's and 80's was similar.  There are problems with these proposals, corporate as they are, but they have some really good elements.  Kaiser likes this model a lot, and hospitals are energized behind it, as you probably see locally.  I've got a lot of problems with corporatization, but it seemed to make sense at the time.

When these proposals were offered, they deprecated the old decentralized system of doctor's offices and independent hospitals as a superannuated "cottage industry.” They had a point, although much that is valuable in medicine would be lost by corporatization.  With the advent of modern technology for information and communication, however, I think that intelligent decentralization is now possible. 

In a COE system, you and your primary care doctor could together find the best place for this and for that.  Doing the best job for you will always rely primarily on the doctor's professionalism and fiduciary responsibility, but there have to be financial considerations as well.  It's important to have you and your doctor on the same side of the ball, so you can harness his or her expertise and continuing involvement.  Technology should make this possible, with very transparent information on price and quality and with electronic medical records if they were freely inter-operable (which they are not and which both EMR firms and hospital buyers of EMRs don't want them to be), and there will need to be inventive financial arrangements so that both doctors and patients benefit from some frugality, and not just the insurance companies, but at the same time not overburdening patients financially.

One good step toward that goal is what is called "reference pricing."  I don't know if you are familiar with this, but it's where the insurance company will pay a standard rate for a procedure that is set to the second lowest price extant in the area, and if a patient wants a higher priced provider then he or she has to pay for it out of pocket.  Part of the problem there, however, is identifying standard procedures, and equivalent quality.  And the biggest pot of money is in chronic care, probably, rather than standard procedures, and I don't think reference pricing will work there.

So there is much more to be done. Note, however, that the first steps taken by insurance companies has been "narrow networks," which is a heavy-handed and quality-killing approach designed to introduce multiple levels of quality of care to patients according to their ability to pay.

The biggest problem, however, is really political, where the biggest players have immense war chests, and while all are for improvement and rationalization in the system, it's the other parts of the system that need change, not mine.  Pharma - 'nuff said.  Academic medical centers?  Hospitals?  Radiologists?  The constituency for meaningful change is not great.
This calls for government intervention to make the playing field work for the public, but our government is fairly weak and ineffective, and the path is far from clear.  Every good business does what it can to establish a monopoly or oligopoly, and the government has let that happen so much that one despairs.

And I added: “As Kurt Vonnegut observed, 'And so it goes.'”
Budd Shenkin

Thursday, June 9, 2016

Dollar Rent-A-Car Sucks


Regular readers will recall our train adventure last year in Scotland where Scotrail did their best to charge for first class and deliver economy and not refund the difference. It took an intervention by the BBC to get us our money back, and to get Scotrail to change their reimbursement policies. Happy ending, which is unusual in any transportation saga.

This year's episode of transportation ripoffs comes from our trip last week to Los Angeles from Oakland, which we accomplished by Southwest Airlines and Dollar Rent-A-Car, and for the time we spent traveling and waiting and standing in lines, we could have done as well by driving the 385 miles, and I will give that serious consideration when the time arises. Seriously, it's probably a 5 ½ hour car trip, and it took us longer than that door to door going down there, and not much shorter coming back.

Why did it take so long? It wasn't TSA's fault – we got pre-checked and the lines were miniscule, although one does have to leave early to play it safe. The biggest fault was at Dollar, where despite having made the reservation on line and having filled out all the requisite documentation, we still had to stand in a line at LAX for 40 minutes while the groups of young people diddled around with the staff in making their rentals, and the staff had to take a break in the back room after each transaction, and where the technology was so slow that it took about 15 minutes when we finally got to the counter. Dollar really sucks. Next time we'll go Hertz or Alamo, where you arrive at the agency and move straight to the lot to pick up your car. My brother did that with Alamo and it was cheaper, too. We will adjust; there are alternatives.

But here's my consumer complaint that is more like the Scotrail trap of last year. Look at the receipt at the top of this article. You see that the rental rate was $29.73 per day for a total of $59.46. Fine, that's what we contracted for, I think, somewhere near that figure, anyway. And you see that we declined all extra coverage, and that we filled the gas tank before returning the car so we weren't charged for gas – I had to show the receipt for the gas to the Dollar attendant. OK. But what's all that other crap underneath? “Concession fee recovery” for $6.84? What the hell is that? “FF surcharge” for $2.08? “CUST FAC CHG” for $10? What the hell is that? Two taxes, well, OK, they do tax everything for tourists everywhere. But what are all those extras?

Who knows or cares what the extras are? What we care about is the final score. Which is, unbelievably, $89.12!

In other words, the total for renting this car from Dollar is 50% higher than what you get from the basic per day charge.

How is this not fraudulent, I ask you? Why does the web site say only $29.73 a day, and not $29.73 + 50%? How is that not false advertising? How is that not like the small print in a credit card contract or a cell phone contract? Is this truly the “American Way?”

I'm hoping Elizabeth Warren addresses this soon in one of her speeches and refers it to the Consumer Financial Protection Agency, and asks Trump what he would do. Don't you think? I mean, 50%? What do they think this is, a payday loan?

Budd Shenkin