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The health care crowd is abuzz with The New York Times revelation that Medicare billing rates seem to have increased by billions of dollars in parallel with increased adoption of EHR technologies for both hospitals and ambulatory services. The culprit for this unexpected increase is the measly E&M code. Evaluation and Management (E&M) is the portion of a medical visit where the doctor listens to your description of the problem, takes a history of previous medical issues, inquires about relatives that suffered from various ailments, asks about social habits and circumstances, lets you describe your symptoms as they affect your various body parts, examines your persona and proceeds with diagnosing and treating the condition that brought you to his/her office or hospital. The more thorough this evaluation and management activity was, and the more complicated your problem is, and the more diagnostic tests are reviewed, and the more counseling the doctor gives you, the more money Medicare and all other insurers will pay your doctor. Makes perfect sense, doesn’t it?

In 1995 and again in 1997 Medicare has specified exactly how to measure a doctor’s thoroughness by creating 5 levels of visits and defining each level’s complexity in terms of an exact number of questions a doctor asks, and an exact number of organs and body parts that are addressed during a visit. The more sanctioned questions and body parts are addressed, the more money the doctor gets from the payer. During the olden paper days, no physician in his right mind would go to the trouble of actually writing down all these largely irrelevant things, and since Medicare always threatened to audit physician billings, most doctors practiced “defensive billing” and consistently charged less than they should have, because the hand written documentation was rarely indicative of the actual level of service. Enter Electronic Medical Records.

Since before the HITECH act and before the Meaningful Use epidemic, EHR vendors promised doctors an automated way of documenting a visit, so they can spend more time with the patient and not have to constantly write things down. Instead, a click on a couple of boxes would do that for them. Furthermore, physicians won’t have to waste money on expert coders to go through their scribbled notes and figure out a visit level. The software will automatically calculate the appropriate E&M code, based on boxes clicked. Structured data can be very useful for calculations. To make the entire process most efficient, three methods of documentation have been developed to replace hand writing and to efficiently minimize the need for extensive box-clicking.
  • Documentation by Exception – Every EHR has this “feature” allowing the documenter to click on ONE box usually at the top of the page which generates a professional sounding clinical sentence for each organ or body part stating that everything is perfectly normal, or that all your histories are unremarkable in any way. This is a great efficiency to be applied presumably after the interviewer ascertained that all is well with your past and present relatives and body parts. If something is wrong with one or two organs, the clinician can click the Normal button and then edit the exceptional few organs that are affected today, thus obtaining documentation for a complete review or examination of all your systems. Remember that every organ and family member documented is worth a few more dollars according to Medicare’s fee-for-documentation model of reimbursement. No wonder then that this is now a basic feature in every EHR.
  • Pre-filled Templates – These go by different names, but they are a huge time saver for simple and common problems and here is how they work: Let’s say you see a patient with an URI and it is flu season. You document the visit de novo starting from a blank URI template, use all the previously described efficiencies and generate a lovely visit note for this patient. It then dawns on you that you are likely to see hundreds of similar patients in the months to come, and that you always go about these things the same way asking the same questions and getting the same answers. You can save this visit note as a pre-filled template sans patient demographics and histories (really just the HPI, ROS, Exam and for the brave also Assessment and Plan) and when the next URI patient shows up, you can load this pre-filled template and edit exceptions, if any. Since technology is magical, EHRs will also load the patient specific histories and merge them into your brand new note automatically. Two or three clicks will get you enough documentation to allow your EHR to calculate a very nice E&M code and generate enough documentation to keep the payers at bay.
  • Bring Forward – This is really sweet for complex patients with chronic disease that come to see you every few months or so. We all know that not much changes in a few months and most likely everything you will be documenting today is exactly what you documented six months ago. Instead of starting from scratch every time, EHRs have created great efficiency by making it possible for the documenter to bring forward, or load, the previous visit note and allow him/her to edit and make changes based on today’s visit. This beats the old “copy & paste” by a mile, and with a click of a button you have all the organs and relatives and complexity of decision making documented in minute detail. You can now make a few changes here and there as necessary, and the EHR will calculate the appropriate E&M code.
There are other features in most EHRs that are designed to improve reimbursement, but these are the most popular. There are also administrative functions embedded in larger EHRs that allow those who employ physicians to ensure that the docs click on all the necessary things to ensure optimal billing and payment. It is very easy to be critical of clinicians in these scenarios, but let’s remember that if Medicare wouldn’t have defined the value of a doctor visit to be proportional to the amount of text generated during the visit, none of this would have happened.

So the “unintended consequences” of pushing physicians to use EHRs seem to consist of doctors actually using EHRs, as effectively as possible, to document all the little details Medicare wants to see. This can only surprise people who had no clue what EHRs are, how they work, and how they are used in everyday practice, which did not (does not) prevent said people from proclaiming themselves as health care experts, best suited to set the national agenda for EHR design and adoption.

Bonus Tip: Now that everybody has been properly shocked by the E&M coding efficiency introduced by EHRs, I would suggest examining the efficiencies introduced by the variety of “smart” order-sets.

Shocking News – EHRs Work as Designed

In his dissenting opinion on the health care law, my least favorite Justice, Antonin Scalia, argued that Chief Justice Robert’s opinion stating that the “individual mandate” is simultaneously a tax and not a tax “carries verbal wizardry too far, deep into the forbidden land of the sophists”. Perhaps this is unusual for the legal system in general and the Supreme Court in particular, but in everyday health care conversations verbal wizardry is now the preferred method of communications. However, health care is much more complicated than the law (with deepest apologies to my attorney friends and family), and health care lacks a supreme authoritative source of truth, thus our verbal wizardry cannot be carried out by proclamation alone. Persistence, as they say, is the most important requirement for success, so in health care we are resorting to the tried and true method of repeatedly employing our verbal wizardry in conversation and in writing until it is wizardry no more.

But verbal wizardry is not a random act of confusion. In the Supreme Court opinion, it was most likely a deliberate construct to avoid calamity. In everyday health care discourse, the sustained verbal wizardry seems to serve as a tool for resetting our expectations from a profit driven health care system run amok. When it comes to medical care, most folks have very simple expectations. We want to stay as far away as possible from medical establishments when we feel fine, and we want someone to fix what’s broken when we are sick. It seems that this humble desire is untenable in our current system. It seems that we must frequent health care facilities when we are healthy, but should temper our expectations regarding medical care when afflicted with disease.

And it seems that this is all for our own good, because how would we know that we are fat, out of shape and depressed if the clinical team on duty didn’t educate us about these things. Armed with electronic prescriptions for generic statins and anti-depressants, an armful of personalized education materials and our damn data, we should finally understand what our 48 size jeans and our skinny bank accounts have been trying to tell us all along. Properly medicated and educated we should now take charge of our health. And if we fail somehow and get sick anyway, we should make allowances for this cost-effective and well-meaning new health care system and stop insisting that the doctor fix everything that’s wrong, because health care is about being healthy not about sick care.

Overriding grandma’s advice to eat an apple a day, in favor of regular visits to a job-creator sponsored clinic to assess your current and future productivity, and maybe even check your teeth, is easier said than done. And it is practically impossible to convince folks that demanding sick care beyond certain limitations is unfair, ungrateful and downright immoral. Here is where well-coordinated verbal wizardry comes in handy. There are many linguistic acrobatics in what seems like a perpetual marketing campaign from government officials, semi-officials and all sorts of stakeholders deriving direct and indirect incomes from health services, but the following three terms seem to be at the cold hearted center of it all.

Patient Centered

Everybody seems hell bent to put the patient at the center of something they sell, but the term “patient-centered”, coined some thirty years ago (thank you for the reference, Rick) was really limited to describing a preferred style for the doctor-patient interview, where doctors actively solicit patient opinions and input. The study showed that patients were more satisfied and were more likely to take their meds after a patient-centered interview with their family doctor. Twenty-five years later, Dr. Berwick imported the term to the US, giving it a more expansive definition to include “choice in all matters, without exception” for each patient. Since then, the term patient-centered has been prepended to whatever is on the agenda du jour. We have patient-centered legislation from the left, patient-centered market-based health reform from the right and our path to prosperity seems to depend on patient-centered reform. You want your bill to look good? Name it ‘‘Patient Centered Healthcare Savings Act of 2011’’. You want to be elected to public office? Start by promising that “I won’t stop working on patient-centered solutions to our health care crisis”. Seeking funding from the brand new Patient Centered Outcomes Research Institute? All you need to do is “adapt recommender systems frameworks that are widely used by innovative businesses outside of healthcare” to “an adaptive computer system that will assess a patient's individual perspective, understand the patient's preferences for health messages, and provide personalized, persuasive health communication relevant to the individual patient” [emphasis added]. Basically as long as you can “identify patient-centered factors” and come up with something that “measures patient-centered constructs”, the funding is yours. To round things up, we now have “patient-centered health insurance”, “patient-centered clinical trials” and everything from health care consumerism to health IT is proudly “patient-centered”.
Like a colorful hefty piñata, the patient finds itself now surrounded by well-wishing guests speaking softly and carrying big sticks. The only end in sight is when the last dime finally drops to the floor and there is nothing left to extract from the patient hanging at the center.

Fee for Service

Unless it’s something your mom does for you, the expectation is and always has been that a fee should be paid for work other people do for you. Sometimes you buy services in bulk, such as subscriptions or yearly contracts, but in all cases the fee is calculated, and discounted for volume, based on a preset number of services. Another way to obtain services is to purchase warranties and insurance. In this model there is no preset number of services owed to you and you are paying for the seller to assume your risk, and as you probably know, those contracts are full of caveats and small print, because nobody wants to provide you services worth more than your payment.

Historically doctors were paid a fee (or a chicken) each time they did something for you. They were paid directly by you and later you could buy insurance to pay you back a portion of medical expenses. The latter model is still very much alive in European countries with strict price controls and better and cheaper health care systems. In the US, we decided to leave the fees to insurers and doctors to figure out on their own. For a while, when most hospitals were run by selfless nuns and most insurers were mission driven non-profit organizations, this worked well and we were relieved of all that tedious paperwork. As medical care became more advanced, the increasingly large flow of money between all parties attracted the interest of corporate America. Doctors became “providers” and patients became “consumers”, prices started climbing towards what the market can bear and insurers began looking for ways to minimize what they have to pay out in medical loss. Since there is a limitation on how much risk can be returned to the consumer before insurance becomes meaningless, the next best thing was to discharge some risk to the new “providers”. For that to happen, the small doctor shops that are not financially capable of taking risks, had to go away and the remaining “providers” needed to start selling insurers warranties on their “populations”. Where the doctor was once mostly aligned with patient interests, the “provider” is now mostly aligned with the insurance plan with which it shares the risk. I wonder at what point “providers” will begin referring to their operating costs as “medical loss”.

To achieve this wonderful outcome, insurers (public and private) needed to convince the populations involved that fee-for-service is the source of all evil and that their trusted doctors are not to be trusted anymore. Thus we must stop paying for volume and instead pay for outcomes. It makes perfect sense because all of us know that paying the hair stylist on a fee-for-service basis, for example, leads to an explosion in the number of haircuts and we only pay the salon if most patrons like their haircuts. The fact that fee-for-service is the most common model of health care payment in developed countries, and the fact that small practice is both more efficient and much preferred by patients, and also widely used in countries with better and more cost-effective systems, is largely irrelevant to the business model of America’s health care industry, which is now salivating at the prospect of shared “savings”, i.e. splitting what they manage to accountably squeeze from patients through value-based and patient-centered cuts to quality and utilization.

Finite Resources

The final piece in this shell game is to impress upon common folks that in spite of the best patient-centered warranties for our health, there simply isn’t enough money to honor these contracts, and warranties will have to be severely limited. To that end, every self-respecting health economist is somberly announcing that our “resources” are “finite” and sooner or later we will have to responsibly ration medical care (for the poor, of course). Unfortunately, the term "finite" is a mathematically defined term. Only the universe, time itself and God’s wisdom are infinite. All resources on this flying rock are finite. The rock itself is finite and so is the life sustaining energy from its sun. The number of grains of sand on a beach is also finite. The number of cucumbers in your fridge is finite, but that doesn’t mean you don’t have enough cucumbers for a large salad, unless of course your potbelly pig pet is helping himself to a heap of fresh veggies as we speak.

Providing for all medical needs of a finite number of people, with a finite number of organs, who live a finite number of years does not require infinite resources. It does require adequate resources. It may be that almost $3 trillion in “resources” is not adequate to meet the needs of all US residents, although it is a bit unlikely considering that this is double of what other rich and pampered countries spend on their medical care. The explanation to this puzzle is that only a portion of those seemingly lavish resources is going to actual medical care in the US. The rest is going elsewhere, and when our potbelly buddies are done taking their unearned share off the top, we are left with insufficient amounts of cucumbers to make a decent health care salad. 

The Verbal Wizardry Dictionary and Thesaurus – Health Care Edition will be available soon at www.verbalwizardry.org

Verbal Wizardry

A couple of weeks ago I wrote a post about the clueless, but endearing, enthusiasm of technology people as applied to solving the health care problem. A few days ago Dr. Davis Liu published a post on The Health Care Blog describing the vision of Vinod Khosla, the famed venture capital maven, of replacing doctors with machines. It turns out that Mr. Khosla wrote a series of three articles at the beginning of the year in a technology publication describing how his pioneering vision will replace people in industries where either he or his wife are investing capital. Venture capitalists (VCs), although I’m sure they wouldn’t agree with this assessment, are a combination of professional gamblers and loan sharks. The secret to success is pure luck and ruthlessness, and when the combination works and the ball lands on the exact number on the spinning roulette, venture capitalists make lots of money. This is very different than running a business ala Warren Buffet or even Mitt Romney, let alone inventing a business like Apple or Microsoft. In return for risking funds, venture capital gets its juiciest pound of flesh when the funded business sells itself to the public, hopefully for more than it is really worth, and hopefully for a lot more than the venture capitalist risked. For that to happen, you have to create demand for whatever your fund is investing in at the moment. This is why you find VCs shedding tears at the mere thought of global warming, or telling us that the future is all about “I Robot”, or miraculous genetic “I am Legend” drugs , or “gamification” or whatever happens to make up their current investment portfolio. The problem with letting venture capital dictate humanity’s agenda is that the globe is getting warmer; people are getting poorer, sicker and dumber while a few VCs are getting richer.

So what is Mr. Khosla selling us now? It seems that his machines, outfitted with “bionic” software are set to replace the 80% of “middling” doctors and also 80% of equally “middling” teachers. Only physicians like Dr. House will remain standing (for a short time) so they can be “leveraged” to create even more “bionic” software, and may I suggest that Albus Dumbledore could be used to illustrate the surviving human teachers of the bionic era. If you are a little bit familiar with the startup world, then you probably know that a business based on services provided by people is not an appealing investment gamble, because it doesn’t scale well, i.e. revenues and EBIDTA cannot go simultaneously through the roof at the same incendiary rate, because people need to be paid for labor. The trick is to find a business model where no labor is required or to find laborers who don’t require payment. A couple of centuries ago we “imported” such laborers from Africa. Today we are “exporting” labor to where those laborers naturally reside. For tomorrow, we are proposing to make machines that work for free. And this in a nutshell is Mr. Khosla’s vision.

Let’s pause for a moment and address the technorati among us. This is not about medical technology for Dr. Leonard McCoy and Dr. Beverly Crusher or about the holographic doctor in Star Trek Voyager, all very awesome and super cool. This is not about stardate 43632.8 or a galaxy far far away. This is about a time frame of “five or ten years” for “bionic” software and “a decade or two” for an army of “Dr. Algorithm” practicing independently. It should be obvious even to the most ardent believers that, in such a short period of time, neither the science of medicine nor technology will be anywhere near the creation of the medical droid that administered to Padme in childbirth. However, these time frames are short enough to appear on corporate financial projections and startup pro-forma budgets. This is about real money and about some flimsy machinery deployed to play doctor to the poor (China and India are mentioned by Mr. Khosla, but the Mississippi Delta can’t be far behind), and if folks are harmed in the process, oh well…. (See below).

Now, how about this “bionic” software that Mr. Khosla envisions to be a temporary bridge between human cognitive endeavor and full machine control in “a decade or two”? Turns out that the term was introduced by a serial entrepreneur in the social media/marketing, hotter than molten lava, sector.  Later adopted by the O'Reilly AlphaTech Ventures folks who invest in clicks and links and data as well, “bionic” software has something to do with “programmable people” and “it has the potential to unlock a massive amount of unrealized human potential”, presumably as programmed and networked by VC funded programmers. According to Dennis K. Berman, a WSJ journalist writing about technology and “corporate scandals”, also cited by Mr. Khosla, we should accept the “rise of the machines” just like we accept earthquakes and hurricanes because it is simply inevitable. And if we still have any doubts regarding the superior intelligence of Jeopardy winning machines, we are reminded that “systems are now of such scale that they can analyze the value of tens of thousands of mortgage-backed securities by picking apart the ongoing, dynamic creditworthiness of tens of millions of individual homeowners. Just such a system has already been built for Wall Street traders”. I am so totally convinced now, but if you need more real life examples, you should read about the $108 million in venture funds going to “bionic” software helping pharmaceutical companies track social media activity to identify doctors more likely to influence their peers, or the $84 million venture investment in “bionic” software to spy on customers and make them buy more fatty food stuff.

According to Mr. Khosla, soon we will advance beyond simplistic “bionic assistance” to “lazy” doctors, and we will no longer be “free to be stupid or political” and “reject” the “cost optimization” served by “Doctor Algorithm” in its medical practice and none of us will need those multitudes of “average” doctors stuck in the “18th century tradition of “first do no harm””. Since VCs are only interested in engineering, as opposed to social engineering, their off the cuff suggestions for the “middling” 80% in any profession or occupation, where wages are proposed to be eliminated from the expenses column, is usually something vapid like “empathy, advice and caring”. Of course “empathy, advice and caring” doesn’t pay anything like actual doctoring, and it is precisely those large wages that need to be eliminated. Highly educated professional workers are also much harder to transform into “programmable people”, like say, the young girls working in one of those infernal laptop assembly lines in China. So once the new troves of captive cheaper-than-machine labor pools have been secured, all that is left in the quest for zero COGS, within the short cash horizons of venture capital, is to eliminate those expensive and volatile knowledge workers from the balance sheet. And since Mr. Khosla’s educated estimate is that “medical diagnosis or 90% of it is an easier task than Jeopardy”, and since he urges us “not to extrapolate the past and what has or has not worked”, it should be easy as pie to imagine a future almost completely free of professional physicians, classroom teachers and non-programmable people in general.

Thus, in Mr. Khosla’s hospital of the future, medicine will be practiced by thinking machines, while floor scrubbing, sheets changing and bed-pan emptying will be left to humans. Eventually, the medical machines, or the few human lords remaining, will probably take on the last yard of efficiency and create menial machines for janitorial purposes, at which point the only human beings in a hospital will be the patients in the beds, and venture capital’s ROI will be inching towards infinity. Unfortunately for Mr. Khosla, or future generations thereof, the transactional volume will be trending to absolute zero, since the “middling” 80%, after advancing to the mindless 80%, are now mostly extinct or have reverted to gathering wild berries where vegetation still remains. I hope being the Supreme Ruler of nothing at all proves to be a very satisfying experience for Khosla Ventures.

The Bionic Medicine of Programmable People

High Tech people are very enthusiastic people. We are optimistic, confident and creative and if I may be allowed to say so, really, really smart. We start out by saying “Hello World!” not “Hi, I’m Jack or Jane”. We hail the entire Universe and assume it knows who we are, or that it will soon find out, because the sky is not the limit and we are going to change the world, all at once. We don’t wear pocket protectors or duct tape on our spectacles. We wear defiantly baggy clothes; have tattoos and piercings in all the right places, ride motorcycles and listen to the latest music. Actually many of us are former or part-time musicians, or at least dabble in painting, spiritual philosophy and sometimes even a little writing. We don’t make telephones or missiles or coffee makers, but we make your phone smart, your missile guided and your brew master programmable. We solve problems and sometimes we get carried away.

Back during the heyday of the Certification Commission for Health Information Technology (CCHIT), a grumbling sound began to emerge from the medical community moaning and groaning about the Big Boy EMRs certified to meet CCHIT’s standards. Those who underwent the onerous CCHIT certification process which began in earnest in 2006 were said to be nothing more than “bloatware”, expensive, cumbersome and useless software developed by programmers who know nothing about the practice of medicine and forced on physicians by an emerging semi-governmental effort and greedy, unscrupulous EMR vendors. This of course gave birth to the most ridiculous slogan in EMR advertising: built by doctors for doctors. Every fledgling new entrant to the EMR market and every retrofitted DOS program with less functionality than Microsoft Office seemed to have been built by doctors, presumably by the one MD usually introduced at the beginning of the “About Us” inspirational story. Obviously there were some true stories too, and some MDs ended up specializing in C++. The CCHIT wars have ended and even the great CCHIT era crusader, Dr. Al Borges, seems to have gone silent somewhere around 2010, but the notion that EMRs, or EHRs now, are falling short of expectations because they were built by programmers has become a widely accepted “fact”.

Very few products successfully sold for mass consumption are ever built by end users, software included. A retrospective look at the EHR market would indicate that regulations and certifications and now also incentives and penalties were applied too soon in a normal market cycle. EMRs were never allowed to evolve, just like any other product, based on user preferences as manifested in buy/no buy decisions. Try to imagine what would have happened to the cell phone market if during the first years of its existence someone would have mandated, for quality and consistency reasons, that the antenna should always be on the left side and it should be between 1” and 2.4” in length and no less than 0.25” in diameter. And then the Department of Motor Vehicles in collaboration with the Department of Homeland Security and Motorola would have provided everybody with a hefty tax deduction for buying a certified cell phone. It wouldn’t have mattered much who actually built those cell phones. Since High Tech people are more enthusiastic than most, we are now not only fixing in amber the size and shape of our software product, but also endeavoring to prescribe how it should be changed and how it should be used. To use the early cell phone analogy, we are standardizing the button sizes, adding a 911 auto dial button and mandating users to push that button after an accident if they want Progressive to honor their claims.

ONC is short for the Office of the National Coordinator for Health Information Technology. It is the highest office in the land for High Tech people working in health care, and enthusiasm should probably be its middle name, rainbows, stars and all. ONC is not really writing EHR software, but from its high perch it is guiding programmers on what to build, in what order to build things and recently began dabbling in advising on how to build EHRs. Many veteran EMR programmers weary of the built-by-programmer vs. built-by-doctor fight are probably breathing a sigh of relief right about now, because customers, who don’t like what they see in the product, can now be redirected to log their complaints with the powers to be at ONC. Fortunately, for every veteran EMR programmer laying down his arms, there are dozens of brand new and experienced High Tech people enthusiastically answering the call to arms for solving the national crisis posed by our health care system.

Old EMR programmers assumed that they know nothing about medicine, and although believing that doctors are equally ill-equipped to architect software, programmers recognized that doctors are their customers and mighty tough customers at that. EMRs were a tool & die business, something one sells and another buys, if needed. The new and very enthusiastic High Tech people in health care, unburdened by any previous EMR scars and bruises, have a different mindset (or so they say), most likely brought about by ONC’s very successful public relations efforts. EHRs and Health IT in general are now a cause, something you advocate for, something you believe in, something you write about, something to be fostered, promoted, or adopted. Health IT is an ideology. Health IT is a political issue that should support governments. Health IT is a social issue that should reduce disparities. Health IT should change medicine as we know it. Well, not that we actually know medicine in the classic meaning of the term, but we just know better in general.

After all, we changed the world already. Just look at the Internet. We have no money to buy books, but we have Facebook. We have no food to speak of, but we have democracy in Egypt. We can’t afford tuition, but we have Khan. We have no jobs, but we have passionate blogs and tweets that reach billions in an instant. We make no saleable products, but we can market with laser accuracy. We have no money for doctors, but we have Google. We have no friends, but we have Siri to keep us company in big old empty houses. We have no worldly possessions, but we own the world of Zynga. We have no clue, but we have data. We can do the same for medicine. We can make it virtual, free, fun, engaging, personalized, simple, participatory, democratic, pain-free and expertise-free. We don’t know what DNA stands for, but sequencing the genome sounds like something we can write software for. We don’t care if observations are prospective or retrospective, as long as we have plenty of data points. We feel strongly that double blinding something is cruelly medieval, in an age of transparency and visibility. We have created a world where babies can manage hedge funds, lizards can sell insurance, everybody can run an agribusiness and every barefoot, malnourished child in Rwanda has a fair shot at the Nobel Prize. We can fix health care once and for all, and we know exactly how to do it.

“Hello Health Care!”

Curb Your Enthusiasm…

“There were two men in one city: the one rich, and the other poor….. “
(II Samuel 12:1-12)

Thus begins the story of King David’s punishment for robbing a simple man of his life and of his one beloved wife. I have had the incredible fortune of being taught the Bible in the City of David, probably a stone throw away from where he perpetrated a sin that haunts his people to this very day. I was taught the Bible not as a divine text, but as a political, historical and philosophical manuscript written by ancient sages, and David’s story was not about the perils of philandering. It was about the disastrous results of social injustice. The story is not a Socialist manifesto. The Bible in its entirety accepts the fact that there are rich men and poor men and David was not admonished for not redistributing his riches equally amongst the poor. The line of decency is crossed when the rich and powerful wantonly decide to take away the poor man’s “one little ewe lamb”, not to love and cherish as the poor man and his family did, but to carelessly slaughter and serve at some casual meal. The predicted future for such rich men and for their people is that “the sword shall never depart from thy house”. Of course, this is just a story, but over the thousands of years since Nathan the Prophet delivered his indictment, many nations and great kingdoms came to experience gruesome violence and ultimately collapsed due to excesses of the rich and powerful, and careless disregard for basic social justice.

Today, America is taking the first step towards joining the pantheon of cruel nations doomed by history to crash and burn. The Grand Old Party of Abraham Lincoln, who went to war with itself to rectify social injustice, is asking the American people to elect the Romney/Ryan pair to the highest offices in the land, based on their solemn promise to hunt down all remaining little ewe lambs of the poor and serve them up butchered and dressed as an afternoon snack for the rich men they represent, because the only way for poor people to survive and avert the wrath of the rich is to make the sacrifices necessary for feeding the rich men’s insatiable appetite for tender shish-kebab.

I am not an economist or a financial expert of any sort, and I have no appreciation for the fine differences between long term and short term capital gains, or the multitude of tangled terms used to obscure intended and unintended realities from common folks who have not experienced any type of gains in half a century. I am perfectly willing to accept the obvious fact that the US is spending more than it’s making and that we must make more and that, at least temporarily, we must tighten our collective belts. The Romney/Ryan notion of fiscal responsibility is placing the rich folks, each with his own private belt, at the soft center of the beltless masses of poor people, all surrounded by one national belt, which is to be tightened at the same time as the epicenter of wealthy individuals loosen their belts by a few notches. The incredibly well calculated idea is that the circumference of all of us can be reduced while the wealthy center is actually increasing its girth. Millions of faceless and nameless poor people will of course suffocate to death during this geometric wizardry if allowed to proceed, but the captains and titans in our midst will thrive, and promise to eventually share a bit of their good fortunes with the surviving cannon fodder in their immediate vicinity.

If you are one of the fewer and fewer citizens who are not poor, and if you think that when the Great Republican belt tightening exercise commences, you could wrestle yourself a cozy place close enough to the center to allow you to keep your belt where it is today, or if you’re lucky maybe even relax it a notch or two, while shielding your eyes and ears from your neighbors getting crushed at the periphery, remember that this great nation was created as “one nation under God, indivisible, with liberty and justice for all”, and God has spoken on this matter over five thousand years ago, and regardless of your beliefs, history is teaching us that nothing that was built on social injustice and “that which is evil” can stand for very long, and no matter how many fortunes were bestowed on a man or a nation in the past, once “the poor man’s lamb” is not safe from the selfish greed of the rich and powerful, sooner or later calamity always follows.

The 2012 Presidential election is not about different fiscal approaches to the national deficit. It’s not about efficiency of private markets as opposed to incompetence of public solutions. It’s not about health care or Obamacare. It’s not even about gay marriage or abortions. This upcoming election is unfortunately about politics as usual versus sheer evil. And it is your decision to make on November 6th. Please vote.

One Little Ewe Lamb

Like most home buyers, I toured the house with my family, checking closet space and bathtubs and finally descended into the basement to see if it has any potential. It was a very large and dark basement mostly unfinished, but the scene in front of us was breathtaking. Thousands of glass jars and bottles of every conceivable shape and color, sparkling clean and neatly stacked in groups by size and shape, some in small pyramids, on a myriad of shelves, small tables and wooden crates. There were no labels on any of them and there were no tops. The ex-Marine Sergeant who built the house in the fifties and lived there ever since, must have spent a lot of time cleaning, processing, sorting and arranging glass containers for what seemed like an awful lot of years. Why did he do that? What did he see in those glass mazes he built in his basement? I never found out. We bought the house almost eight years ago, and had a “guy” come by and remove everything that was not nailed to the walls before the painters and floor refinishers showed up. Sgt. C.’s big collection of empty glass shells ended up as Big Trash, because although empty containers may hold certain fascination, particularly for those who lived through the Great Depression, there is absolutely nothing useful you can do with a basement full of glass.

We as a species are now collecting data. We’re not sure exactly why or how we’re going to use it, but we are convinced that we cannot, should not, discard any electronically recorded piece of information. You may clear your browsing history on your own computer, but somewhere, somehow, someone retains that information. You may delete all your text messages from your own phone, but they may still exist in some database somewhere in some cloud. You may delete your old emails, but somewhere there will still be a record for them. Your tweets, your Facebook messages, all other social media participation, every syllable you ever typed and every tag or image you touched, all these things are being neatly catalogued and stored in some data basement somewhere. And now we have apps that most of what they do, other than show you that cheesecake has more calories than turnips, is to collect even more bits and pieces of information and add them to that big basement in the sky.

Previous generations of human beings created as much data as we do. They shopped and traveled and engaged in conversations. They kept diaries and every single one ate, slept, walked, breathed in and out, had a heartbeat, loved and hated things, experienced profound happiness and despair, and when all was said and done, discarded the containers of life without a second thought. We are the generation of the Great Information age, and just like Sgt. C. we feel compelled to keep everything that was scarce and hard to come by only a few years ago. We talk about treasure troves and are so very certain that all those mountains of carefully scrubbed and meticulously arranged pieces of information will yield some miraculous result any day now. And if it’s not clear what miracle exactly, that’s because we need more data and we need to arrange it in other ways. I wonder if Sgt. C. was consciously shopping for foods packaged in glass containers, just so he can add another shiny piece of the puzzle to his collection.

I’d like to imagine that when Mrs. Sgt. C. whipped up a batch of her famous tomato sauce, she would stroll down to the basement and pick a nice jar to store the sauce in, or when Sgt. C. brought her flowers for her birthday, she would pick the nicest blue glass container to put the fresh daisies in. She probably never had to buy those ugly plastic Tupperware things either. There was some utility in Sgt. C.’s glass collection, but did it really warrant giving up an entire basement and countless hours of maintenance work? There is some utility in our big data collection too. When we need to sell tomato sauce or flowers to people, we can dig through our data basement and find just the right message and the right people to send that message to. Today’s Mad Men need not be as “creative” as Don Draper had to be in order to increase sales and profits for clients.

If Sgt. C. could have collected all the glass jars in the world and if he could have shared them with all people in this world, nobody would have needed to worry about storage for their secret recipe potato salad ever again. If we could listen to, collect and analyze every heartbeat in the world, we could instantly identify impeding disaster, and correct the problem. We could be saving lives judged worth saving. If we could know in real-time when people are sad, we could make them happy in real-time. If we could know in advance which people would become ill and exactly when, we could tell them and maybe treat them if it made economic sense. Eventually, we could ensure that all our babies are born healthy and with proper monitoring live long, productive and happy lives.

Mrs. Sgt. C. died at the turn of the new millennium, and Sgt. C. died a few short years after that. He never knew what eventually befell his glass containers collection. I am grateful for that. Perhaps if someone other than us would have bought his old house, those beautiful glass jars would still be there today and perhaps more would have been added. Perhaps a pattern would have emerged and something great would have happened. But it did not because I trashed his life’s work. We will most likely all die before our collection of digital shells of life will yield any benefits or alter the definition of humanity in any significant manner, and we will never know if our data basements will be preserved or relegated to the Big Trash pile. I am grateful for that too.

Big Trash

Dr. Gawande has a new article in the New Yorker suggesting that hospital chains may very well be the solution to our health care problems. Dr. Gawande has a very engaging writing style and in addition to writing for the New Yorker, he writes books and delivers memorable speeches and he is also a surgeon at Brigham and Women’s hospital in Boston. In recent years, Dr. Gawande’s writings have become the cornerstone of health care policy and none more so than his 2009 New Yorker article explaining the inexplicable health care cost explosion and the variability of medical expenditures across the nation. As the New Yorker itself proudly noted, President Obama himself had a most fortuitous epiphany after reading the New Yorker article, and summarily decided that “This is what we’ve got to fix.”

In “The Cost Conundrum” Gawande explored the differences in expenditures for Medicare beneficiaries in two Texas towns whose names became synonymous with our health care issues, the expensive McAllen and the rather cheap El Paso, concluding that “across-the-board overuse of medicine” induced by “a culture of money” was the root cause for the “extreme” expenditures in McAllen. The article, accompanied by an illustration of a patient dressed like an ATM machine, quickly became the foundational axiom at the base of health care reform efforts, and Peter Orszag (the then OMB Director) immediately adopted this axiom and translated it into hard dollar amounts: “The result is an estimated $700 billion a year spent on health care that does nothing to improve patient health, but subjects you and me to tests and procedures that aren’t necessary and are potentially harmful – not to mention wasteful.”

One could identify here the beginnings of the currently undisputed rhetoric about a 30% waste in health care, the associated slogans of “more care is not better care”, “pay doctors for value not volume”, and the need to rein in greedy doctors who are knowingly harming patients to enrich themselves through the unfortunate fee-for service payment model. It didn’t matter much that respected researchers like Drs. Robert Berenson and Jack Hadley from the Urban Institute repeatedly disputed the findings of the Dartmouth Atlas on which the Gawande axiom was based. It didn’t even matter that Medicare itself came up with different numbers which show that McAllen is not really that expensive after all. Once the President decided that “this” is what we’ve got to fix, by golly “this” is what we are going to fix, whether it needs fixing or not.

Next Dr. Gawande turned his attention to learning from other industries and applying lessons learned to the troubled health care system. The first such industry was Agriculture, which has come a long way from “strangling the country” at the turn of the 20th century to today’s seemingly bottomless pit of cheap, genetically altered, antibiotics, pesticides, preservatives and other carcinogens laden foods, produced by sub-minimum wages illegal immigrants, and pushed by vertically integrated agribusinesses to every supermarket and every 7-11 across the land. Dr. Gawande is crediting this major development to Government intervention in the form of local extension services to diffuse experimental technology innovations to uneducated and initially resistant farmers, and to various assistive regulations. He sees a similar experimental approach being taken by the Affordable Care Act (ACA) and is hopeful that current health care initiatives will have the same beneficial effects as observed in agriculture.

Aviation with its almost perfect safety track record was the next industry to attract Dr. Gawande’s attention. The checklists used by pilots in commercial aviation seem to have some applicability to medicine. Although checklists were used by others with great success in health care, Dr. Gawande published an entire book on the subject and called it a Manifesto. Next came the race car industry, and in a commencement address at the Harvard Medical School, Dr. Gawande informed the class of 2011 that medicine needs them to be “pit crews” instead of traditional “cowboys”. I don’t know if Dr. Gawande watches too many John Wayne movies or too few car racing events, but old-time cowboys, although versatile and capable of performing many tasks, always worked in coordinated groups of various sizes and compositions, depending on the size of the outfit that employed them. By contrast in a pit crew, one member’s responsibility, which is strictly defined by regulations, starts and ends with the left rear lug nut even if the entire car is on fire. Despite the poor choice of words, the message is the same: standardized, repeatable protocols of care delivered by “medical systems” are superior.

In this month’s issue of the New Yorker, Dr. Gawande takes the systems approach to its logical conclusion. We need Big Medicine. We need chains of hospitals and clinics. Big chains, like the Cheesecake Factory. It seems that health care can also learn from the restaurant industry or retail in general, since CVS and Walmart are also fondly mentioned in the article. According to the story, Dr. Gawande and his children had a lovely dining experience at the local Cheesecake Factory establishment, ergo chain restaurants when managed well, can deliver a fantastic culinary experience for a rather affordable price. Of course, we all know that there are hundreds of other chain restaurants that cannot, and Dr. Gawande himself seemed very protective of his reservations at Per Se, but maybe the reason the Cheesecake Factory is so successful is the automation and team approach to food preparation. No Iron Chefs here. A well-oiled (no pun intended) machine of  managers and sub-managers and workers at various stations of cooking, cleaning and learning on the job, eerily similar to pit-crews, each responsible for a prescribed piece of work, manage to create in aggregate a consistently repeatable faux upscale dining experience for people who have no idea what Per Se is.

Exploring the excellence of chain establishments is not unique to Dr. Gawande, although he may have just turned it into official policy. Similar arguments were made recently by Dr. Peter Pronovost, comparing health care to the exclusive Capella hotel chain, an offshoot of the Ritz-Carlton glitzy chain, and reached similar conclusions. One could wonder how these learned essays would address what most people recognize as hospitality chains, such as Applebee’s, Chili’s, Holiday Inn or Motel 6. One could also observe that anybody with no particular credentials could open a restaurant or a Bed-and-Breakfast, or work at such “one-of-a-kind” place, just like there are no particular education and licensing requirements for working on a farm or for becoming a cowboy. A very interesting experiment would be to require that each mom-and-pop restaurant should have a Parisian Cordon Bleu graduate in order to open its doors, or that every Bed-and-Breakfast would need a Glion graduate on staff. I wonder if in that case, anecdotal evidence from hand-picked hospitality chains would still compare favorably to the one-off little establishments. I suspect not.

Dr. Gawande is proposing that medicine should become Big Medicine and doctors become broiler “chefs” with a computer monitor controlled by “headquarters” hanging above their “station”, or perhaps we don’t even need those super educated doctors and scullery maids can work their way up to “management”, just like his protagonist in the New Yorker story did, because he knew of no other place where he “could go in, know nothing, and learn top to bottom how to run a business”. They used to teach medicine that way before we had medical schools too.
So based on one dining experience at one chain restaurant, “liberals will have to accept the growth of Big Medicine, and conservatives will have to accept the growth of strong public oversight”. Just like we had to accept the growth of Big Farms, Big Banks, Big Automotive, Big Retail and Big Corporate everywhere, all with strong lobbying oversight and strong public subsidies and bailouts as necessary, and a slowly evolving definition of quality to mean cheap enough to keep the nouveau poor from jumping out of the experimental pot of boiling water.

Dr. Gawande’s New Shiny Thing

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