Archive for September, 2010

How Medicare will pay doctors

Wednesday, September 29th, 2010

UPDATE: Those interested should read this article in the WSJ today about the rapid consolidation of American medicine taking place right now, not in 2014.

Across the country, providers are building giant hospital systems and much tighter doctor alliances like multispecialty groups to get out ahead of a concept known as “accountable care organizations,” or ACOs. To modernize the delivery of medical services, ACOs would encourage doctors to work in teams to use resources more efficiently, streamline treatment and improve quality. The model is the Mayo Clinic and other large integrated systems.

Of course, the Mayo Clinic has concluded that it cannot treat Medicare patients and survive, as many of its Medicare members learned a few months ago.

At the moment ACOs are only a gleam in some bureaucrat’s eye, and no one has a clue how they’ll operate in practice until the government releases a working regulatory definition next year. Yet the percussive effects are already being felt across medicine.

Hospitals are now on a buying spree of private physician practices in the rush to build something that will qualify as an ACO. Some 65% of doctors who changed jobs in 2009 moved into a hospital-owned practice, while 49% of doctors out of residency were hired by hospitals, according to the Medical Group Management Association. In its 2010 census, the American College of Cardiology reports that nearly 40% of private cardiology groups are currently integrating with hospitals or merging with other practices.

Doctors are selling because complying with the ever-growing list of mandates has become more cumbersome; and while staff physicians on salary do gain predictability, they also lose the autonomy of independent practice. The other problem is price controls in Medicare, which are about 20% below private payments for doctors and 30% lower for hospitals. Hospitals are also scooping up practices to lock in referral sources and make up for ObamaCare’s Medicare cuts. As it is, two-thirds of hospitals lose money today on Medicare inpatient services, according to Medicare.

I get these e-mail articles from several industry sources, some of which sell practice management, others supported by ads. This one looks interesting for those who are wondering what Obama will do to Medicare. This is not Obamacare but Medicare will be heavily affected since his plan intends to take $500 billion from Medicare to pay for the Obamacare new enrollees.

Physician Payment Reform: What it Could Mean to Doctors – Part 1: Accountable Care Organizations

Kenneth J. Terry, MA


The fee-for-service method of payment is wearing a bulls-eye target. It’s been blamed as a major factor in high healthcare costs, and as a result, Medicare and private insurers are exploring new ways to provide patient services and to pay doctors for those services. The new models vary, and some will be more appealing — or less unappealing — than others. This series will explore proposed payment models, what they could mean for doctors, and how they may affect physician incomes. We’ll start by looking at accountable care organizations.

Quick Summary: An accountable care organization (ACO) is a contracting group accountable for the quality and cost of care provided to a defined population. It may be led by a hospital or a physician organization, and may be a single business entity or include multiple entities. An ACO must include primary care doctors, must manage care across the continuum of care settings, and must measure and provide data on the quality of care.

This is nothing new in California where they are called IPAs (Independent Practice Associations) and are run by a board of directors. They contract with insurers as a single entity, subtract a healthy management fee and then pay the individual doctors by various formulas. I was involved in this although avoided being a board member pretty much because, as a surgeon, it is easy to alienate the treating doctors and surgeons rely on referrals. The GPs make out fairly well but there are lots of perverse incentives. For example, there are bonuses for meeting goals for keeping cost down. Some of the GPs ended up with 50% of their income from the annual bonus.

How Doctors Get Paid: There are 2 reimbursement models. In risk-taking ACO arrangements, organizations take financial responsibility for all inpatient and outpatient care and can profit by meeting quality goals and by keeping the cost of care under budget. Under the shared-savings model that Medicare will use, physicians get paid fee for service and can split savings with Medicare if they reach benchmarks on quality measures. A single ACO can have both kinds of contracts.

The IPAs were conceived as an alternative to HMOs, first seen in the Competitive Practice Act from its first incarnation in 1974. It was the model of Paul Ellwood, who liked the Kaiser HMO and tried to make that the national model. He had only non-profits in mind and has become disillusioned in recent years. The for-profit HMOs figured out that they did not have to build a large infrastructure like the Kaiser system. They could simply set up their own “HMO without walls” and go around offering terrible contracts to local physicians who were afraid of losing all their patients. The IPA was created as an attempt to control this race to the bottom. The results have been spotty but better thann the alternative.

Pros: As reimbursements decline, ACOs offer an alternative source of revenue for physicians while giving them the infrastructure and the information systems they need to improve the quality of care across the board. Primary care doctors should do especially well financially because they’re key ACO players.

Cons: The ACO model is set up to gradually transfer more financial risk to providers, forcing doctors to become more efficient. They will also have to follow clinical guidelines and have their quality measured continuously. In some markets, a shift to ACOs will accelerate hospitals’ employment of physicians, hastening the demise of private practice in those areas.

I think this is where this will go. Hospitals are employing more and more doctors and, especially in smaller population areas, this will be the only viable model for Medicare. Hospitals will run clinics for Medicare patients run by nurse practitioners.

Where ACOs Stand: Many large medical groups and independent practice associations (IPAs), especially in California, are ready to become ACOs. Some hospital systems with large employed groups could do the same fairly rapidly. This activity will undoubtedly grow before Medicare launches its ACO program on January 1, 2012.

Physician Payment Reform: What it Could Mean to Doctors – Part 2: Global Payments

Leslie Kane, MA


Quick summary. Doctors in a solo practice, group practice, or large organization would be evaluated on the cost of the resources they use to manage their patient population. The premise is that by paying attention to the total cost of patient care instead of payment for each individual service, physicians can focus on ways to manage the cost and quality of patient care more effectively. Global payment plans would address the financial risk that plagued earlier capitation plans by taking into account the healthcare resource needs of patient populations. Global payment plans also require data reporting and quality measurements.

Ever heard of death panels ? The global payment for a large population will force medical groups to concentrate resources on some of those patients and triage the rest.

How doctors get paid. There are variations, but typically, insurers pay claims as services are rendered. If doctors keep total healthcare costs under the annual target for overall patient care, they get to share in the savings. For large provider organizations, in some proposed global plans, insurers make estimated advance payments to the physician or group; withhold payment for services that the group doesn’t provide; and periodically reconcile with the group.

Pros. Global payments help address the problems of rising healthcare costs. Some proponents believe that physicians will make greater use of email, telephone calls, and care teams involving mid-level practitioners for patient communication and management, which doctors previously rejected because those activities did not get reimbursed. Global payment plans place a strong emphasis on primary care. Insurers say doctors can focus on improving a patient’s health instead of being concerned with how many patient visits or services are involved.

This is the end of seeing the doctor for Medicare patients. They will be seen in clinics as noted above. “Improving a patient’s health” is mostly BS although there is a model that can do that. I once wasted a lot of time trying to get a university hospital to adopt it. It involves very elderly people, often called the frail elderly, who are often living in assisted care homes, not nursing homes. Many are couples. There have been pilot programs in which these 85 year olds going through an intensive evaluation involving an internist, a pharmacist and a psychologist. Many of them are taking medications that interact with each other. They may have other chronic problems. The theory, and it has been tested several times in pilot studies, is that you spend more money the first six months or so and the care of these people costs less money after that. They are also in better shape. The barrier is spending more money that first year and, if you think the Obama people are going to go for a program like that, I have a bridge to sell.

Cons. Most physicians will need to plan more carefully how to proactively manage their patients and will need to retool their practices away from the current focus on patient visits. They will also need to pay more attention to the cost of care that they are delivering or referring. Doctors who don’t pay attention to costs and to the avoidance of admissions and complications are likely to earn less than they did under fee for service. They will have to consciously try to limit costs and, in most cases, aim for specific quality targets. The larger concern is that doctors may find themselves pitted against patients who want care that involves the most costly treatment alternative or that may be unlikely to improve patient outcomes.

Doctors’ incomes from Medicare are already so low, they are dropping out of the program.

Physician Payment Reform: What it Could Mean to Doctors – Part 3: Bundled Payments

Shelly M. Reese


Summary. Unlike the current fee-for-service system in which each provider who cares for a patient is paid for the different services he or she provides, a bundled payment — also known as an “episode of care” or “case rate” payment — is a single payment covering a particular episode of care, such as a myocardial infarction or a hip replacement. Multiple providers in multiple settings may share in the payment for a patient’s episode of care. An episode of care could encompass a period of hospitalization, hospitalization plus post-acute care, or a defined time frame of care for a chronic condition.

This is already the way IPAs work and I have negotiated methods of payment for surgeons. There are some benefits to this system if the global payment is fair. In our IPA, we instituted a system in which surgeons were paid a monthly fee that was shared among all the other surgeons of that specialty in the IPA. The share for each surgeon was determined by the number of new patients he/she saw each month. That made it easy for GPs and internists to get their patients seen quickly. The surgeons were NOT paid by the number of surgeries they did each month. When that system went into effect, back surgery dropped by 40%; General Surgery, my specialty did not change. The implications are pretty clear. Not all of this stuff is bad.

How doctors get paid. A bundled payment is made to a hospital, which divides the payment between the hospital and all of the providers who cared for the patient. If the cost of an episode of care is less than the bundled payment amount, typically the hospital and physicians share the difference; physicians may receive a bonus. If the cost of care exceeds that of the bundled payment, the hospital and doctors bear the financial liability.

This will be another driver of hospitals hiring physicians. Hospital administrators hate physicians because they are disruptive to smooth operation. They keep demanding things for their patients. That will stop when they are employees. There may not be enough jobs in some specialties.

Potential benefits. Proponents of the system hope it will give providers a greater incentive to coordinate care, thus improving outcomes and reducing waste and unnecessary care.

Potential problems. Physicians worry that hospitals will get the lion’s share of payments and that those unaffiliated with hospitals or integrated networks will find it difficult to participate. Some worry it could put patients at risk because providers might shun very sick patients as too expensive to treat. Access to specialists could be limited. Defining an “episode of care” can be difficult for certain illnesses and chronic conditions.

These are obvious concerns, or should be.

Physician Payment Reform: What it Could Mean to Doctors – Part 4: Prometheus Payment

Kenneth J. Terry, MA


Quick summary. One of the current experiments in payment bundling, Prometheus Payment rewards physicians for practicing efficiently and avoiding complications. Prometheus care teams negotiate all-inclusive case rates according to evidence-based guidelines for episodes of acute and long-term care.

How doctors get paid. Physicians are paid fee for service, which is a debit against the case rate. They can share a withhold if their team prevents avoidable complications.

I don’t know if this is bad or good. Some doctors have high complication rates and there is little that can be done unless they are egregious.

Pros. Physicians stand to receive bonuses for high-quality, efficient care without being at financial risk.

Cons. Physicians need the infrastructure of a large organization to make this model work.

Where it stands. The private organization behind Prometheus is conducting four pilot projects across the country, and more are on the way.

Whether Prometheus will catch on, however, depends on whether its incentives to follow evidence-based guidelines will eliminate enough waste to fund quality-based bonuses for physicians.

Conceived by a health policy experts and healthcare, insurance, and employer leaders, Prometheus Payment received a $6 million, 3-year grant from the Robert Wood Johnson Foundation in 2007. The Healthcare Incentives Improvement Institute, Inc, a Newtown, Connecticut, think tank housed at Bridges to Excellence (a national, employer-sponsored pay for performance program), is working with the pilot organizations to develop a variety of approaches to the Prometheus concept.

There could be some benefit to this concept but the temptations inherent in Obamacare are the source of much moral hazard.

There They Go Again . . .

Sunday, September 26th, 2010

By Bradley J. Fikes

Where have we seen this before?

Tired of ‘tea party’ sniping, moderates organize

In Washington, a new advocacy group decries ‘the tyranny of hyperpartisanship.’ And powerful New York Mayor Michael Bloomberg throws his support behind candidates willing to reach across the aisle.

By James Oliphant
September 26, 2010
Reporting from Washington —

Galvanized by the lightning-in-a-bottle success of conservative tea party” candidates, moderate Republicans and others in the political center are looking for ways to push back against what they see as an advancing tide of ideological extremism.

The efforts are loosely organized and embryonic, but politicians, advocacy groups and others are piecing together a framework to promote moderate candidates and advance positions they say have been eclipsed by partisan sniping on the right and left.

“Middle America is being ignored by Washington and the media. Centrists are desperate for a voice today; they feel entirely unrepresented,” said Mark McKinnon, a political strategist and former advisor to President George W. Bush . . .

Underscoring those efforts is a newfound drive by advocacy groups to give moderate voters a louder voice. In Washington, a nonprofit group called No Labels is forming with the goal of bringing Republicans and Democrats together; echoing tea party rhetoric, it terms itself a “citizens movement” and decries “the tyranny of hyperpartisanship.” . . .

You can click on the link to read all of Oliphant’s ponderous puff piece for yet another attempt to match the Tea Party.

Remember the Coffee Party? Remember One Nation, an avowedly liberal group. They both flopped.

The Coffee Party had the same theme as the new group of reducing partisanship and giving a voice to “moderates.” That sounds attractive. But it flopped for two big reasons: One,  it is a top-down movement by Democratic political operatives with no grassroots support. The Coffee Party was created by Democratic operative Annabel Park to take the pressure of Obama and the congressional Democrats.

The same appears to be the case with this new movement, fixated on stopping Tea Party “sniping” as the LA Times puts it. We get the message: The lefty LA Times doesn’t like the Tea Party, so it’s promoting an opposing movement.

The Washington Post did the same thing with its puff piece on the Coffee Party, using this lede:

Furious at the tempest over the Tea Party — the scattershot citizen uprising against big government and wild spending — Annabel Park did what any American does when she feels her voice has been drowned out: She squeezed her anger into a Facebook status update.

Of course, Park isn’t just “any American.” She’s campaigned for Virginia senator Jim Webb and for Obama, her Democratic record airbrushed out of the WaPo story. The other alternative is that the WaPo reporter was just lazy and naive, and took Park’s claim of non-partisanship at face value.

Coffee Party activists go through preposterous contortions to avoid being known as left-leaning Democrats. Alan Alborn, mentioned in the WaPo Coffee Party article, said this in February on his blog (emphasis mine):

Let me add a new dimension to the health care discussion. I consider our nations health a National Security Problem. We maintain a standing Army to defend our citizens from foreign invasion; however, we let them succumb to disease because they can’t afford health insurance. We spend billions for a world class defense establishment; however, our health system is 37th (according to the WHO ) right below Costa Rica and trailing all of the industrialized countries. I am a small Government Libertarian; however, as I age I find it more difficult to rationalize why the richest Country in the world fails to provide a the best health care in the world to its citizens… and trails the Industrial world (including Countries with Socialized medicine). What greater responsibility may a Government have than ensuring the health of its citizens?

A “small Government Libertarian” who approves of socialized health care! That’s an Oxymoron with a capital O. And Alborn uses the “richest country in the world” argument, a common socialist trope. As a real capital-L Libertarian, I smell something very fishy about this claim. I’d say it’s more likely that Alborn has dressed up a socialist idea in flimsy Libertarian drag in the hopes of fooling critics. A more generous interpretation is that Alborn doesn’t understand enough about Libertarianism to know why his muddled support of “Socialized medicine” is incompatible with Libertarian beliefs.

Alborn even trots out the argument that the “general welfare” part of the preamble justifies national health care. So much for his knowledge of the Constitution and its enumerated powers. The preamble is a list of reasons why the Constitution was established, not an enumeration of the government’s powers. Not surprisingly, that distortion was used by congressional Democrats to justify ObamaCare.

Astroturf and a phony message turned the Coffee Party into rancid grounds. The newest faux-grassroots attempt to match the Tea Party is headed for the same dismal fate, because they still don’t get it.


As with all published here, this article represents my opinion, and not necessarily that of my employer, the North County Times.


Sunday, September 26th, 2010

We may be entering an era when cyberwar is a real threat, at least to some. I was a computer programmer in 1958-59 but that is the stone age of computing. The machine I programmed was An IBM 650 which was so primitive that it did not use hexadecimal code. This was even before FORTRAN was written so I claim no current expertise. Later, after medical school, I took some computer science courses and learned to program in Pascal and C. Still later, I learned Visual Basic but never got very far in C++ so I am pretty much a neophyte in Object Oriented Programming. The term, often abbreviated to OOP, is a way of creating small pieces of code that can be reused over and over without rewriting it and the attendant risk of error. It is also faster. This also applies to modular programming and the differences are explained in the wiki entry.

It now appears that a new “worm” has been created by someone that is capable of attacking the Iranian nuclear program. Roger Simon is the only one I have seen so far discussing it and its implications. This involves small devices called PLCs, or “Programmable Logic Controllers” some of which run your washing machine. They are the heart of computer controlled machinery, such as the 30,000 Iranian centrifuges that are purifying Uranium 235. What if all those 30,000 centrifuges went crazy, spinning so fast that they self destructed ?

This brings up the subject of Stuxnet, a computer “worm.” It attacks one specific system, the Siemens company’s SCADA systems. It happens that Siemens designed and built the SCADA systems that run its nuclear program. What a coincidence !

Has the war with Iran already begun ? Maybe.

But just as television news was transformed by technology before the Iranian Revolution in 1979, and politics was transformed by social networking before it appeared that Twitter would bring about a second Iranian Revolution, process and progress need crystallizing events, where the political and cultural significance of technological innovation becomes indisputable.

Such a moment came in July with the discovery of a worm known as Stuxnet, which sought out a particular version of the Siemens’ SCADA (supervisory control and data acquisition) systems that control power grids and industrial plants. According to Ralph Langner, an expert in industrial control systems who published a study of the worm last week, Stuxnet was capable of taking over SCADA controls in order to deliver a kinetic attack by causing critical systems to physically malfunction. The systems infected weren’t randomly targeted: a majority are in Iran.

It’s an interesting idea. A lot of Windows 7 code was written by Israeli engineers. Maybe their target is more than the nuclear program.

Stuxnet is an even more dramatic transformational event: warfare is never going to be the same, at least while the underlying protocols governing the Internet create these kinds of systemic vulnerabilities. But even if there was agreement to rewrite these protocols starting tomorrow, such a project would take a decade. So, let the damage assessment begin. Who knows? By demonstrating how Iran could so very easily experience a Chernobyl-like catastrophe, or the entire destruction of its conventional energy grid, the first round of the “war” may have already been won.

Unfortunately, the Chinese have been working very hard at the same sort of thing and we had a determined cyberattack on the Pentagon e-mail system two years ago. This may be what war looks like in the future.

UPDATE: Some body is noticing.

The White House Insider Series

Tuesday, September 21st, 2010

Roger Simon has links to a series running on another blog that is alleged to be interviews of a White House insider in the Obama administration who has become disenchanted. The interviewee is, of course, anonymous and there are doubts about the authenticity but it rings true to me. I will make comments about some of the statements.

The first installment is here.

White House Insider on Obama: “the President is Losing It.”

Quite a title.

When I asked this insider if the media gave candidate Obama an assist throughout his campaign, it elicits a sly smile. Sure – we definitely had people in the media on our side. Absolutely. We went so far as to give them specific ideas for coverage. The ones who took that advice from the campaign were granted better access, and Obama was the biggest story in 2008, so yeah, that gave us a lot of leverage.

Could Obama have succeeded without the media’s help? Yeah, I think so. As I said, on the campaign trail he is very-very good. The opposition didn’t have near the energy, or the celebrity attraction that Obama brings. Plus, the country was burned out after eight years of Bush. We knew that going in. We knew that if we won the Democrat nomination, we were likely going to cruise our way to the White House – and that is exactly what we did.”

This sounds authentic to me. I’m not sure Obama could have won without both the press and the flow of anonymous money that has yet to be explained but he was good with a teleprompter and Bush was unpopular.

But after Obama was sworn in, things began to change? Almost immediately. Obama loved to campaign. He clearly didn’t like the work of being President though, and that attitude was felt by the entire White House staff within weeks after the inauguration. Obama the tireless, hard working candidate became a very tepid personality to us. And the few news stories that did come out against him were the only things he seemed to care about. He absolutely obsesses over Fox News. For being so successful, Barack Obama is incredibly thin-skinned. He takes everything very personally.

And you state he despises Joe Biden? Oh yeah. That is very well known in the White House. Obama chose Biden for one reason – to have an older white guy with some international policy credentials. Period. If Biden has all of this international experience that Obama found so valuable, why has he buried him under the pile of crap that became the stimulus bill? What does Joe Biden know about budgets and economics? Not much – but Obama didn’t care. Give Joe a job and get him the hell out of my hair – that pretty much sums up the president’s feelings toward Joe Biden.

Read the rest. This is only the first segment.

What about Hillary Clinton? Obama is scared to death of Hillary. He doesn’t trust her – obsesses over her almost as much as he does Fox News. He respects her though, which might be why he fears her so much as well. He talks the game, but when it comes down to it, she has played the game on a far tougher level than he has, and Obama knows that.

I include this only because I think the anonymous interviewee is a Hillary staffer. Watch his comments on the Clintons. For example:

How about Bill Clinton? I never heard Obama say anything about Bill Clinton personally, though I was told he has cracked a few jokes about the former president since getting into the White House. I have heard that Bill Clinton does not like Barack Obama. That really started when Obama played the race card against him during the primary campaign. Apparently Clinton was apoplectic over that and still hasn’t gotten over it. If there is one thing I have learned in this town – don’t make an enemy of Bill Clinton.

So if Obama doesn’t appear interested in the job of president, what does he do day after day? Well, he takes his meetings just like any other president would, though even then, he seems to lack a certain focus and on a few occasions, actually leaves with the directive that be given a summary of the meeting at a later date. I hear he plays a lot of golf, and watches a lot of television – ESPN mainly. I’ll tell you this – if you want to see President Obama get excited about a conversation, turn it to sports. That gets him interested. You start talking about Congress, or some policy, and he just kinda turns off. It’s really very strange. I mean, we were all led to believe that this guy was some kind of intellectual giant, right? Ivy League and all that. Well, that is not what I saw. Barack Obama doesn’t have a whole lot of intellectual curiosity. When he is off script, he is what I call a real “slow talker”. Lots of ummms, and lots of time in between answers where you can almost see the little wheel in his head turning very slowly. I am not going to say the president is a dumb man, because he is not, but yeah, there was a definite letdown when you actually hear him talking without the script.

That sounds like you are calling Obama stupid to me. No – I am not going to call him stupid. He just doesn’t strike me as particularly smart. Bill Clinton is a smart guy – he would run intellectual circles around Barack Obama. And Bill Clinton loved the politics of being president. Obama seems to think he shouldn’t have to be bothered, which has created a considerable amount of conflict among his staff.

The second installment is here and just as interesting.

So you still wish to keep your name hidden from the public? Why? I intend to remain working in this town for a bit longer. A public disclosure might complicate that just a bit given who is in power right now. But I won’t be the last one from the current administration coming forward. After the midterms, there will be a number of us speaking about what is really going on in the Democrat Party, if for nothing else because it’s such a damn mess right now.

What do you mean “it’s a damn mess”? I mean just what I said. The Democrat Party is the most chaotic I have ever seen it – and that goes back almost 30 years.

So who is to blame? We all are. By we I mean those of us who were working within the party power structure the last ten years or so. We got so caught up in the hate Bush mentality, we let the party get hijacked by our own far left. That was disaster the moment it happened. The disaster that will be the midterm election in 2010 started in November of 2006 when Pelosi and Reid took over the Democrat Party. Those two have only brought trouble to the Democrat Party since day one of that time.

This again rings true to me. And this is a revelation to me.

What scares you more as president – Sarah Palin or Barack Obama? (Hands to head) Oh boy. What a choice! People would kill me for saying this – actually you know what, there are more and more of us Democrats saying what I am going to say in one form or another… Sarah Palin understands America more than Barack Obama. Yes, she has a minority of our far left who hates her, and some in our media are part of that group, but overall, she seems to get America. Americans aren’t a complicated people, and neither is Sarah Palin, so that probably works in her favor. But President Obama is just out of touch. He really doesn’t understand what America is. What it’s about. Or who it is. And that is a real problem for him – and the Democrat Party at this moment in its history.

Are you saying you would vote for Sarah Palin over Barack Obama? No, I don’t think I could do that. As much as I admire Palin’s ability to connect with the American people, I just can’t stand her politics. I am a pro-choice Democrat. I support unions. I support welfare programs. Sarah Palin understands America, but that doesn’t mean she understands the best parts of America. That being said, I think President Obama understands hardly any of America. That is probably a big reason he appears so lost these days.

That is quite an interesting admission if the interview is legitimate. The third segment is here.

Why is he doing this ?

I am doing it for me, for my party, and for my country. In my own small way – maybe it’s insignificant, maybe not, I want to see Democrats move ahead of this mess that we are in right now. It is a mess of our own making, so we need to be the ones to clean it up. If we don’t, this country is going to continue hurting, and too many people out there are really hurting these days.

Ok…but how does giving me some apparent insider information going to help the country, or help your political party? Simple – it lets others know it’s time to start talking. It’s time to get the word out. It’s time to challenge the inept status quo that is currently running things. People are scared – hell, I’m a bit scared myself. But enough is enough – this political train has got to get back on its tracks. And I’ll tell you this, my talking to you, and your little blog stories, is already helping. More people are ready to talk. It’s already happening. And more is coming. The media won’t be able to ignore it anymore. This administration, the leadership in Congress, they need to account for how they have totally mishandled the responsibilities given to them. That accounting is coming soon enough in November – we are going to get what we deserve. But I am still hopeful it is not too late to save 2012.

He is talking about Congress and I agree that somebody has to.

We are literally killing our political futures out of some need to keep supporting an administration that has in no way, shape, or form shown itself to be worthy of that support.

Those are strong words – but what exactly to do you mean by that? What do I mean!? (Voice rising) What I mean is exactly this – we got Congressmen and Senators running for re-election right now whose political careers are about to be ended because they supported a president and a Democratic Party leadership that told them to do so. They trusted they would be politically protected, that the American people would agree with the agenda. Well guess what? That hasn’t happened. Good people, good Democrats, are being tossed aside like so much trash – and this White House DOES NOT GIVE A DAMN. In my eyes that is absolutely unforgivable. You just don’t do that to your own people. And some of these politicians are talking. They are – but for the most part the media is ignoring them because they don’t want to hurt the administration. To that I say enough! Do your damn job. Report what is going on within the Democratic Party. We need to clean up this mess, and it starts by getting the truth out there. That is my motivation.

The shift of independents to the Republicans is evidence that he is correct. Hell, I don’t even trust the Republican party after the past ten years. The 1994 revolution petered out in politics as usual. Tea party people are cringing in anticipation of the new “Contract” that the Republican leadership is preparing to release tomorrow.

This White House doesn’t give a damn for the concept of loyalty, dedication, sincerity. This White House is the most self-centered, arrogant, and ignorant…they just don’t care to know what they are doing. And when they do it – consequences mean nothing to them. NOTHING. And that is not to say it’s all bad at the White House. There are some very bright people working there. But you know what, those people have been marginalized, pushed aside, and are now leaving. You watch – the exodus from this White House will prove to be of historical proportions.

The exodus is already starting. It will be interesting to see how large it gets. Even the interviewee is frightened of what Obama could do to the country.

For most of the last year, you want to know what question keeps playing in my head?
What question was that? WHAT THE HELL HAVE WE DONE? Now that may come off terribly disrespectful to the president, but so be it. What have we done? We were led to believe this man was one thing, but everything I have seen, heard, and understand, points to the indisputable fact he is not what we hoped for. Not what we were promised. Maybe he might have been. Maybe a full term or two in the Senate and he would have had the experience and maturity to handle the job of President of the United States. But right now – the man is simply not up to the task, and yet it is loyal Democrats who are paying the price for his incompetence and incoherence. The health care bill? Do you know I was told he has never read the bill? Not one part of it? NOT ONE. Sounds like something you would hear on one of the talk radio shows, right? And I wouldn’t normally consider such a possibility, but this came directly from one of those good Democrats who might now see their political careers ended because they supported that bill and now its being used against them like some political sledgehammer. How is that supposed to make someone who put their career on the line feel? Betrayed. A whole lot of us are feeling betrayed these days and it just pisses me off.

As for all the accusations that the Congress hadn’t read the health care bill ?

they pushed it a bit further – suggested the president could do some town meetings and answer questions about the bill, alleviate all the concerns and fight back against the conservative chatter that was being put out there. Guess what they were told regarding that? They were asked one question – did they read the bill? This Congressperson admitted they hadn’t. Like a lot of them, they had voted for it, but hadn’t read it. That was a mistake, sure, but the thing is over 2000 pages, right? Well, after admitting they didn’t read the bill they are told in a laughing way mind you, “That’s ok – neither has the president, so you can’t expect him to take on a bunch of town meetings on it, right?” So that was it. Nice, huh? Bye-bye, thanks for playing, and good luck with the -explitive- storm coming your way this summer.

Anybody who has been around legislatures knows that bills are written by staff and lobbyists but you could at least expect them to read it before voting. Why healthcare ?

Was everyone on his staff on board with the president pushing so hard for healthcare? Absolutely not. There were some who voiced concerns. Some who pushed for a more clear economic agenda. Apparently Obama wanted none of it – he was obsessed, absolutely obsessed with getting some kind of healthcare legislation. And the ones who did voice concerns…they are, or will be, among the first to go. And it’s coming sooner rather than later.

And now, what may be the motive for this interview.

Any ideas as to an acceptable alternative? Hillary Clinton perhaps? (Smiles) The Clinton angle was not missed in your last two articles, was it? I make no attempt to hide my admiration for President Clinton. Unfortunately, Bill Clinton cannot run for another term as this country’s president. As for Hillary, I do not know her as well, but I do admire her – a lot, and now regret not having been a part of her own run for president. My ties to the2008 Obama campaign feel more and more these days like a dishonorable victory.
But would you like to see her run in 2012 if President Obama, as you put it, fails to improve? Yes. I would support Hillary Clinton over Obama in 2012 if the need was still there to help ensure President Obama was given only one term. But Hillary Clinton is not the only possibility for the Democrats. We are a party with many fine leaders – many, many potential candidates for president who I would gladly support.

Personally, I think Hillary is no more competent than Obama to be president and I think she is just as far left but it is interesting to see the developing split between the progressives and what is left of the Democratic Party.

Read all three installments. I have only posted the sections that most interested me. There is a lot more, including some about Michelle that is interesting.

Getting into medical school.

Tuesday, September 14th, 2010

This has been moved to a page.

9/11 nine years later

Saturday, September 11th, 2010

On Tuesday, 9/11/01, I was having breakfast and preparing to catch the train to Los Angeles for a day of teaching first year medical students. I was watching a special edition of Good Morning America which was on early because of a mysterious fire in the World Trade Center. Normally, that program did not come on in California until 7 AM and it was just after 6, nine o’clock in New York. As Diane Sawyer and Charlie Gibson talked about the fire, a huge explosion occurred in the second, heretofore undamaged WTC tower. Diane Sawyer flinched visibly and I went into the other room to awaken my significant other suggesting she turn on the TV. This was not just a fire.

We hadn’t yet seen the video of the planes flying into them so there was still some mystery about what was going on. I still was scheduled to teach, although I doubted much would be accomplished that day, but I changed and caught the train. Much of the talk about the medical campus was vague and of the sort one would hear at any disaster occasion. Nobody yet was talking about the fact that we had been attacked.

What does all this mean for us nine years later ? First, radical Islam has been at war with us since 1979. We have been attacked repeatedly with major loss of life. I once attended a session at the American College of Surgeons meeting by the surgeons who had been on the ships offshore of Lebanon when the Iranians blew up the marine Barracks in Beirut. That was 1983.

In one of Ronald Reagan’s worst foreign policy decisions, he had placed those Marines in the middle of the Lebanese civil war and left them unarmed. The guards at the entrance to the underground garage saw the truck with the bomb coming. They saw the driver grinning as he saw success for his mission and his 72 virgins waiting. But their M 16s were not loaded. I have heard arguments that this is not true but the fact remains they did not fire.

The surgeons said the worst part of the whole disaster was that there were no patients. They received no wounded to treat. The Marines were all dead. 241 Americans died, including some CIA personnel who were at work early. The bombing was a sophisticated operation by Iran. We bombed Libya for a less serious incident. Why did Reagan not retaliate for the Marine barracks bombing ?

There is an interesting book, called Rogue Warrior by a former SEAL who retired as a full commander. He was in Beirut before the bombing and has a number of harsh criticisms of our security. Among other things, he writes that the US knew that truck bombs, which had been used before, had remote detonation devices activated by radio in case the driver had second thoughts. Since we knew the frequencies used, why not send out random signals to set off any bombs that might be under assembly or in transit. He was turned down because of the risk of civilian casualties. Better the bombs reach their target intact, I guess.

Bush attacked Afghanistan after the Taliban refused to give up bin Laden and his fighters, once they had been identified as the perpetrators. At first there was hand wringing from the usual suspects that we would be involved in a “quagmire” in Afghanistan. Initial reports of less that unqualified success were seized upon by the political left. There were actually peace marches conducted against any invasion of that country. Those marches have been conveniently forgotten by the Democrats.

We threw out the Taliban and made a good faith effort at stabilizing Afghanistan but now I think it is time to quit that fight. Our enemy over there is Pakistan, or at least the radical elements of the Pakistan Army and the ISI. I stated my reasons nearly a year ago and have not changed my mind. Our primary enemy remains Iran. That seems to be forgotten. The NY Post seems to get it.

More Stream of Consciousness

Tuesday, September 7th, 2010

Politics is in a bit of a lull right now and the house is slowly coming together so I thought I would continue my last post. However, it has been changed to a page and can be viewed there with the rest of the series.

The Education Bubble.

Monday, September 6th, 2010

There has been quite a bit of discussion on various blogs about the rising cost and declining utility of a college education, especially outside the “hard sciences.” Even the left is beginning to notice some of the problems.

And if colleges are ever going to bend the cost curve, to borrow jargon from the health care debate, it might well be time to think about vetoing Olympic-quality athletic facilities and trimming the ranks of administrators. At Williams, a small liberal arts college renowned for teaching, 70 percent of employees do something other than teach.

Complaints about athletics are old news in leftist publications but that number for non-teaching employees is an eye opener.

Tuition is part of the problem.

No one can look at that curve and miss the magnitude of the problem. Roger Kimball has a nice summary of the problem and the comments are almost as interesting as his post.

I went through college and medical school mostly on scholarship. I did lose my scholarship one year through the effects of too much extracurricular activity. I was taking a calculus course from this little Indian professor. He was difficult to understand but I thought we had an agreement. If I got an A on the final, I would get a B in the course. I had been delinquent in turning in homework assignments but had finally seen the light. The final exam came and, since I had finally begun to study systematically, I got the A. All my life, I had gotten by with minimal study. I was finally motivated enough to do the work necessary instead of just enough to “get by.”

Well, I went over to the Math office (In those days a small bungalow painted a dreary sunshine yellow as all the temporary university buildings were.) and the posted grades were up. I had gotten a C. I needed that B to keep a B average and my scholarship. I was doomed. I made an appointment to talk to the professor. He didn’t show up. I made another with the same result. A couple of days later, I was walking down University Avenue when I saw him across the street. I called to him and started to cross. He saw me, his eyes bulged and he started to run the other direction. I didn’t think I would improve my grade by chasing him so that was it.

In those days, there were no student loans except some private funds that I knew nothing about. My father had left high school at the age of 15 to join the Navy in World War I. I have a picture of him in his uniform. When the war ended, he wanted out of the Navy so he told them he was only 15. He never went back to school, which is a shame because he was a very bright man and could have been a very good engineer. As it was, he did pretty well in the middle years of his life and disdained education. I never saw him open a book.

My mother had graduated from high school (In 1915) and from “Business College,” which taught her to type fast enough to be a legal secretary. She could type my high school papers as I dictated them at normal speaking speed. She encouraged me to study and to think about college but nobody knew how you went about it. I knew I wanted to be an engineer and I knew I wanted to go to Cal Tech, to me the pinnacle of engineering (I still think so).

I can’t believe how naive I was about getting funding but I just didn’t know anything. My father declared himself early. He took me down to his basement bar and recreation area and had a serious talk with me. “Son, I want you to get this idea of going to college out of your head.” He wanted me to be a golf pro. One of his standard greetings to me was “Get your nose out of that book !” so this was no surprise. I had never counted on him, anyway. I didn’t know at the time that he would have one more blow to administer to my hopes.

That year, 1956, was the first year a new national scholarship program was in effect. It was called The National Merit Scholarship Program and that became my chief goal. Of course, I didn’t realize there were only 100 scholarships that year. It began with the SAT. There were no SAT prep courses then. We were lined up one day and marched into the study hall, a classroom that was unique in that it had theater style seating. We took the exam and about a month later, I was notified that I was a finalist for the National Merit Scholarship.

What I didn’t know was that a packet was sent to the parents of finalists. One item in the packet was a statement of income, although the scholarship was not based on need, apparently that was one criterion. My father refused to fill it out. It was no one’s business how much money he made, which wasn’t very much by that time. His prosperous career was pretty much behind him. A few months later, I got a letter congratulating me, and informing me that, since I did not need financial aid, I was getting a certificate of achievement. In the meantime, I had been interviewed by a Cal Tech professor who traveled to Chicago, my dorm room had been assigned and I was ready to go except for the lack of ability to pay the tuition. I look back in wonder at my own naivete in not contacting the school after my mother told me about the uncompleted financial statement. Maybe they would have helped. I just didn’t know enough.

A month or so later, I was contacted by the Chicago group of USC alumni. I was vaguely familiar with the University of Southern California and, since my prospects were otherwise dim, I accepted. I was interviewed by Robert Brooker, then a vice-president of Sears, and was awarded a full scholarship plus a $500 stipend for living expenses. My high school’s unfamiliarity with my new university was exhibited by the fact that they sent my records to UC, Berkley. I got a letter from Berkley accepting me for admission and asking me to submit an application. We finally got that straightened out and I arrived in Los Angeles about two weeks before classes began to find a place to live.

I eventually, settled in a fraternity house, Phi Gamma Delta, because, in those days at least, fraternity houses were the cheapest place to live and, of course, the fact that they asked me. I had been staying there at the request of my local sponsor, a UCLA Phi Gam alum, while I looked for an apartment. USC in those days had almost no dorms for men, unless they were football players. When I was asked to pledge, I accepted. It was a good decision in many ways (I needed socialization) but it didn’t help studying. I often wonder how I would have turned out if I had made it to Cal Tech.

Engineering at USC was a weak department but I did not take sufficient advantage of what was there. When I lost the scholarship, I was somewhat at sea. What was I to do ? The tuition was $17 a unit, about $272 a semester. I didn’t have it but, at that time, it wasn’t out of reach like it is now. I got a job. I went to work for Douglas Aircraft at what was called a Mathematician I. This was a junior engineer. I had a couple of fraternity brothers who were working there, working their way through the last year of engineering school. In those days, and the point of this stream of consciousness, is that you could work your way through school in those days, even a private university.

My job was in the wind tunnel facility. I spent most of the day with a Marchant desk calculator and the rest programming an IBM 650 computer. This was about the era when the term “bug” was first used for computer malfunctions. We were told that it derived from the fact that one of the COBOL programmers had spent weeks trying to solve a programming error only to find that a moth had gotten into the machine and was contacting random connections.

After six months at this job, I decided to go back to school at night. I was lying on the beach at Playa Del Rey (now under the take-off zone of LAX) in January talking with my roommates about my future. They were both pre-med majors. I had begun thinking about it several years before, even before dropping out of school. John Paxton, whose father was a surgeon, suggested I take a basic biology course (My high school had zero biology) and another advanced course called “Comparative Anatomy.” The latter was a junior level course and maybe too tough for me but, he said, it would be the closest thing to medical school I would find in undergraduate.

I signed up for both courses, paying the $119 tuition myself. It was a good decision. That was January 1960. A year later, I had been accepted to medical school.

Now, there is no way I could do that and the alternative would be thousands of dollars in debt.