Saturday, February 18, 2017

Trump Adopts Terrorism

Many have lamented the tide of decline of liberal democracy throughout the world, me among them. Clearly, the tide has moved into the United States. For a few weeks after the election I was willing to give some breathing room to Trump, to see how much was talk and how much would be action. My wife warned me that this was not a wise stance. But I found myself hoping. Denial is a primitive psychological defense, and I have long employed it. I was using it with Trump. No longer. The cabinet appointments have been horrible. And now the shock and awe of anti-immigrant terrorism has been overwhelming. I'm more than there.

Trump has a large following. Not a majority, and I'm hopeful that I am not in denial in thinking that it won't be such ever, but they sure have taken over. It's scary. I'm hopeful again not to be in denial in observing that Nazi control of Germany arose from weak governmental institutions, as opposed to strong American governmental institutions, and in observing that ours is the economics of prosperity rather than Germany's economics of Depression – although if Trumpism is to continue, the result could well be depression, it's true. I'm hopeful when I look at the world of the caudillos and observing that their traditions were less secure than ours, and that the gulf between rich and poor was wider, although understanding that ours is growing. I am cautious, but I'm hopeful.

But as Peter O'Toole defiantly declared in Lawrence of Arabia, nothing is written. They look like they are making a good try at it, riding the international wave. Executive Orders, the product of decades of executive strengthening, are providing the surfboard to ride the wave. EO's provide a narrow platform; it would take legislation to provide a motor on the board, and at this point we have to bless the tradition of the filibuster, a bulwark against tyranny of the majority. Bless you.

So what do you do if you only have a board and not a motor? Trump and the Republicans in their tolerance/support of him – I was going to say “Right Wing Republicans” but that has become a redundancy – have shown every caudillo inclination, and envy of the capacities of Putin to do what he wants with no troublesome restraints of separation of powers. Torture, victimization of minorities, bullying, suppresion of the press? Not a problem! “Do to them what they do to you,” not “do what is right,” is the mantra.

So, what you do is adopt the tactics of the enemy where you can, and get around Congress as best you can. You pick on those who are most powerless, you go for shock and awe. So, you can't deport all the 11.5 million undocumented immigrants without a lot of money and legislation – and you don't call them “undocumented immigrants,” but “illegals” – but what you can do is to terrorize them. Nothing wrong with terror, is there, if you use the standard of what “they” do to “us?” And within every society are goons who would love to do just that. ICE probably has them, they just are not wearing brown shirts yet, not yet.

Make widely visible raids, arrest random sympathetic people, mothers, saints if you can find them, put them in police vans, have children crying on TV, show the distress. Worldwide opprobrium? Bring it on – it's publicity. Defy, find people to defy. Instill fear, empower bullying. It's even better and cheaper than actual mass deportations. Terror works, it insinuates itself into the society, not just those at current risk, but those who view themselves as the next group.

Which is why I agree with everyone who says, “Resist!” Institutions and traditions are important, but in the end it takes people, specific persons, to act within those institutions and to follow those traditions. Today, even as I write this, I am at a committee meeting of the AAP, where we broke the ice by going around the table and saying what political success we had recently had, each one personally. Most people said they had been to the women's marches. Others said their kids had been there. I thought of my family's resistance, and then I noted our personal efforts to help some undocumented immigrants to get legal. Apparently all it takes in their case is money. We're happy to help. I'm thinking we should just put a sign out on our front lawn: “Resist!”

State-sponsored terrorism is a fearful thing. We're seeing the start. It's time to remember those who helped the Jews in Europe and pay back. It's time to resist. I'm still thinking that this evil wave will be meet by a far bigger counter-wave that strengthens us even more by current knowledge of how strong our democracy is. It's hard, seeing all the hatefuls in office. I just hope I'm not in denial.

Budd Shenkin

Monday, February 6, 2017

Hospitals, Health Care, Buggies, and Automobiles

I've been thinking a lot about the shape of health care, and working on a paper that is so tortured in its development, I'm beginning to think that it's a paper that will never be finished. Which is a shame, because I think the ideas are good, and naturally, because I love to see my name in print. But in a way it's not a shame, because what the paper is doing is forcing me to learn, which is I guess what a paper should actually be about.

The essence of the paper is that the shape of health care is changing, and what I see is that hospitals are trying to centralize care around themselves by buying up medical practices, and buying up skilled nursing homes and other allied facilities. You could call all this vertical integration (VI). At the same time you see lots of horizontal integration, with medical practices merging, hospitals merging, insurance companies becoming fewer and larger, etc. So there it is, lots of agglomeration, all in the service of protection of them that is and them that has. Rationalizing the industry? Somewhat, yes. But also protecting and aggrandizing themselves.

But, is centralization the best model? I think not. I think that decentralization would be better. We need lots of coordination of care, true, but VI is probably not the best way to get there, although coordination does need leadership, and that's hard to find in a decentralized system. But especially with modern IT and communication technology – if the government mandated that Electronic Medical Records (EMR) all be inter-operational, which it has to do, has to do – decentralized systems could work just fine. The decentralized system could be called the Center of Excellence (COE) system, because with all the competition for patients, each unit would have to work to become excellent. By contrast, if a unit is in a system like Kaiser, where all referrals are mandated to be intra-organizational, a mediocre unit is cushioned from competition.

Here are a couple of paragraphs in praise of COE from my paper:

The COE model envisions not VI corporations, but rather individuals and groups networked together by information and communication technology, rather than by ownership and overt direction. In this model, for instance, incorporating the model of the Patient Centered Medical Home (PCMH), the patient and the primary care provider would be choosing referrals among competing centers with varying combinations of cost and quality, be they large or small specialist practices, general or specialty hospitals or procedure centers, etc., rather then being tied into a mandatory network.

The more direct financial and personal connection to the patient may provide increased incentives for patient-centered care. Information in small units can be informal and immediately visible. Staff in smaller units specialize in only one enterprise with the skill that repetition conveys, and can focus on detail with unmatched attention. Hiring can be made appropriate to the specific need without the need to explain the job to HR. Talented and creative professionals and staff can exercise their particular abilities (e.g., computerized innovation) without corporate restraint.

The “caring function” may be easier to convey in decentralized settings, as patients may be more easily known personally by staff and professionals. Small units may have great flexibility to serve individual patient needs, whereas large companies may have relatively general and inflexible guidelines. (On the other hand, classically underserved populations might welcome general policies applicable to all, as they will not be discriminatory.) Staff and professionals can likewise benefit from enhanced non-bureaucratic personal relations.

Modern information and communication technology has given added strength to the decentralization argument. What had been a weakness – coordination and information exchange – is now easily effected by small offices as well as large, so long as the EMRs are inter-operative. If run well, a small practice can be exquisitely efficient with modern technology.

Anyway, I've got a lot more written about the details, so many details that it is probably pretty unpublishable, at least for this non-academic writer. But this is all prologue. As I lay awake this morning thinking about it, I had a thought that I liked. Unlike all the details of my paper that contrast the pros and cons of the integrated system vs. the pros and cons of the COE, this thought is succinct. And so appropriate for a blog post. Which, with no further ado, here follows.

What happens when an obsolescent institution seeks to direct an emerging institution? By this I mean:
the hospital has been the center of medical care for a very long time. It looks as though it has become very expensive, too expensive for the system as a whole. It looks also as if the locus and means of care is changing. It is becoming outpatient, with specialty units such as the outpatient surgicenter, and more and more elements of care can be lodged in outpatient settings. In addition, it seems that more and more “medical care” should really be “health care,” with attention to prevention, social determinants of disease, etc. And as we live longer and acquire more chronic diseases and we just get run down, residential facilities become merged with health care units.

So the system is changing, and the money still resides with hospitals, and they will use that money to perpetuate their predominance. But they are aware of the changes, and so they change their definition of their mission accordingly. They become not purveyors of inpatient medical care, but purveyors of health care in general. This is what organizations do. (Parenthetically, one of the reasons they do this is that the people in those organizations are loathe to give up on the organization, since the organization works, and the organization also confers onto those individuals a means of livelihood, and perks, neither of which is to be abandoned.)

So what are the consequences of this means of succession from one type of organization to another – where the obsolescent institution seeks to direct the birth of the emerging industry? One consequence is that the change is delayed by old habits that are not suitable for the new challenge. Another is that the change is wasteful, since old functions persist and are paid for. A third consequence is that the new organization has trouble being shaped into something that looks new.

What it reminds me of is the original automobiles. What preceded them was buggies, so of course the new autos looked like the old buggies, just with an engine behind instead of a horse ahead. The old stereotypes persisted and it took a couple of decades of persistent change until the Model T didn't look like a buggy at all.

I'd say that's the way we should look at the emerging health care system. It still looks like a buggy.

To really accelerate change, what's needed is a way for inventors to make gobs of money. Right now, everyone is (rightly, I guess) focussed on reducing the cost of health care. But it's hard to make money by reducing costs. When someone figures out how to make money with new institutions, that's when the buggy will come to look new and streamlined. Idealism is great and medicine has probably more of it than any other industry. But Schumpeter's fabled “animal spirits” come out when the scent of money to be made is in the air. That's what we are praying will happen with renewable energy – find a way for the animal spirits to do well by doing good. I'm thinking, same thing with health care.

Right now, the health care animal spirits are still looking around, to the on-line doctor (doomed!), to health monitoring by your smart watch (better chance here.) When the specialty hospitals take over, when money flows into primary care, when teaching is divorced from tertiary and quaternary care, when pharma is rationalized – that's when the reorganization will really take place. But while money is still with the bloated hospitals and academic centers with their gobs of money and administrators and grants and God knows where it all goes – while all that is still predominant, the future will still lie pretty far ahead.

Anyway, that's what I've been thinking.

Budd Shenkin