An Ounce of Enthusiasm…

…is worth a pound of skill.

Dear readers, I have discovered a gem.

Back in 1970 a teacher at the Portsmouth School of Art, Gavin Bryars, decided to form a student orchestra. He used an odd selection technique. The players had to be non-musicians, or if musicians, utterly unfamiliar with their chosen instrument. The result was the Portsmouth Sinfonia.

And it was magic. Please enjoy Thus Spoke Zarathustra.

How it worked, and how it didn’t

This is going to be a personal one, and a long one. I don’t like to write about myself in this way, but the story is so illustrative that I can’t resist.

First, the epic saga of my left eye. (Close friends can now go get a sandwich – you’ve heard this one) About a year ago I was at my optometrist for my regular exam, with complaints of moving spots of light in my left eye. She saw an odd blotch of pigment on the retina of my left eye. She referred me to an ophthalmologist for another look.

He pronounced it a spot of pigment of little significance, but recommended that my optometrist keep it under annual surveillance.

By the middle of this last summer my left eye was getting fuzzy. We all get “floaters” in our vision now and then, but this was like a squadron of jellyfish. More swooping lights as well. I went back to my optometrist, who kicked me up the ladder to a partnership of retinal specialists. One of them examined me, identified the spot as a birthmark, and scheduled me back in three months for another look.

In mid-September the view in my left eye was like looking through a mass of frog’s eggs.  I accidentally noticed that I was losing my peripheral vision in the top of the eye, so I emailed the retinal specialists. The next day I got the call from the doctor’s office. “Come in today” was the command. They thought that my retina might be rolling down like old wallpaper. The doctor fit me in at the end of the day. My eyeball got a visual exam, and ultrasound, and an angiogram. Then the doctor came into the exam room and shut the door.

“I think you have a choroidal melanoma, “he said. “At least, I hope it’s a choroidal melanoma. Yes, I’m pretty sure it’s a melanoma.” That means a malignant tumor – cancer of the retina. Yes, I was terrified.

My doctor got me an appointment at the Wills Eye Institute in Philadelphia for ten days later. I would go in for tests on a Monday, and if it was actually a choroidal melanoma (I didn’t have the balls to ask him what he hoped it wasn’t, but I had an idea) I would go in on that Thursday to get a metal plate loaded with radioactive iodine sewn to the back of my eyeball. Then three days in isolation, plate removal, and probable loss of vision in my eye. My chances of remission were around 98%.

The Librarian and I took the train down and she accompanied me to the Wills. I went through the usual battery of tests and was examined by a doctor from India on a fellowship and then by Dr. Carol Shields. She and her husband Jerry Shields are, as I found out, the world leaders in the treatment of ocular cancers.

The punch line: It wasn’t cancer. It was (and is) a benign hemangioma, a kind of leaky birthmark on the retina. I still had to have it treated to save the eye. Otherwise I would end up with a rakish eye patch, and every day would be Talk Like a Pirate Day.

I returned to Vermont with the Librarian (after a certain amount of celebration) and scheduled an appointment for Photo Dynamic Therapy, or PDT. This is a process where the patient is injected with a light sensitive drug that seals up capillaries. The doctor beams a cold blue laser on the spot to be treated and the drug is activated there and only there.

And so it came to pass. A couple of friends drove me up to the clinic, I was injected with $1200 worth of Visudyne, and the doctor shot me in the eye with the laser for 81 long, bright seconds. Then I reached into my “burkha bag” for a balaclava, a scarf for my face, glacier sunglasses, and gloves. With the Visudyne in me any skin exposed to the sunlight would blister like leprosy. I spent the next two days indoors with the curtains closed.

My eye is improving. The funhouse mirror effect has gone away. The frog’s eggs have diminished. The light show has toned down.

One could say that the system worked. I brought my complaint to my regular doctor at my regular checkup. I got kicked up the ladder as my condition changed. The retinal specialist made a mistake, but made it in the right direction – caution – and I was sent to the specialists who could nail it for what it was. I received state of the art treatment, which seems to be working.

Then again, one could say that the system worked because I am a special case.

Unlike many people, I go to my optometrist regularly. She has a baseline understanding of the condition of my eyes. Having been myopic for most of my life (Lasik changed that) I have an optometric habit. I was talking about my false alarm with a friend at the farmer’s market and he related the story of a friend of his who actually had had a choroidal melanoma, successfully treated with radiation therapy. He noted that in most cases choroidal melanoma is fatal. How was this, I asked, when they have a 98% effective therapy? Most people don’t get to the doctor until it’s far too late. Oh, right. Most people go through their lives with their retinas unscanned. And not just their retinas.

When I got my first diagnosis the doctor asked me if I had insurance. I did, but with a $10,000 deductible. “That’s gone,” he said. I noted that I had a $23,500 annual out-of-pocket maximum. “That’s gone too,” he said. Luckily I do have insurance, and a retirement account I can raid for this kind of emergency. 40 million Americans lack insurance and most people don’t have that much backup money.

An acquaintance told me the story of one of his golfing buddies, a successful lawyer with a six figure income, gold plated insurance, the works. He had been diagnosed with pancreatic cancer. Three hellish years later he was in remission, but also bankrupt, minus insurance, and foreclosed. Moderate wealth is no guarantee.

I had an interesting discussion with my retinal doctor as I put on my cloaking after the laser treatment.

Not surprisingly the conversation turned to the financing of health care. He was not optimistic. He reported that a number of his colleagues were folding their private practices and running for the cover of medical centers. I asked him why.

“This really needs to get out there,” he said. What follows won’t be news to Vermont doctors or hospital administrators.

He pointed out that if he and an equivalent specialist at the Fletcher Allen Health Care (FAHC) in Burlington do the same procedure, Fletcher Allen gets twice to six times the money from Blue Cross Blue Shield (BCBS). Likewise, BCBS pays him less than a 5% margin on any drug he uses, while FAHC gets a double digit percentage. FAHC gets a “facilities fee” that independent doctors don’t get, as if the independents were operating under a tree somewhere.

Why is this? “FAHC is the 1200 pound gorilla in Vermont.” He pointed to a couple of incidents in the last decade where FAHC had publicly threatened to cut off the insurance company CIGNA due to a dispute over reimbursements. I looked it up and in fact FAHC and CIGNA had gone toe to toe on reimbursement rates in 2003 and 2008. Vermont is a relatively small health care market, but our money is as green and spendy as anyone else’s. FAHC has the biggest revenue stream in our market, by far. It takes in 47% of the net patient revenue in the state, around $925 million. An insurer that loses access to FAHC becomes irrelevant in the Vermont market. Apparently the insurance companies yield to FAHC on reimbursement and make up for that by squeezing the independent practitioners.

I just received a letter from this doctor stating that his practice was ditching Blue Cross because of insufficient reimbursement.

This makes me wonder how efficient it is to have a big medical center like FAHC. Are they still trying to pay for the Renaissance Project? (From the memory hole: The Renaissance Project was a $173 million expansion approved by regulators in 1999, which turned out to be a huge fraud. The FAHC executives were keeping two sets of books on what was actually a $364 million expansion. Five C-level execs eventually pleaded guilty to various felonies and misdemeanors.)

I suppose there is a certain critical mass necessary for having a Level 1 trauma center and a teaching hospital, but do they really need twice the money for a procedure? I wonder how that plays out across various specialties, and whether one is used to subsidize another, or if it is just administrative bloat. My doctor doesn’t have any highly paid executives managing him.

It’s just another little facet of the whole dysfunctional health care mess. It points up the problem of having a monopsony (near monopoly) in a business where the consumer is desperately interested in results rather than price. That monopsony is necessary in certain cases. We can’t afford to have half a dozen Level 1 trauma centers in Vermont all competing on price. We can’t imagine that they would compete on price if there were six. What terrified relative would shop around while their loved one was bleeding from an artery?

I certainly wasn’t shopping around on price when I thought I had eyeball cancer. My two questions were

1)      Where is the best place to get treated?

2)      How fast can I get there?

Any real world experience debunks the concept of informed health care consumers using a “free market” to drive down costs. Sick people tend not to negotiate well. The worse, and therefore more expensive the condition, the more likely there is to be a specialist monopoly and the less likely that the patient will shop around.

I was also lucky that I had access to a retinal specialist less than an hour’s drive away. I am sure that is not universal. In some places people can’t even find a dentist.

And then, of course, I work for myself, so the boss gives me flex time. He won’t fire me for taking days off to get treated.

So, yes, if you see your doctor regularly, and have insurance, and have money in the bank to cover your deductible, and have a flexible work schedule, and have reasonably local access to the right doctor, and, and, and… the system works. That is too many conditionals for most people.

So what do we do?

 (All these answers are post campaign finance reform. The business of health care just wants to churn money through the system in the most extravagant way possible. Investing in the political campaigns of Social Darwinists provides a good return on investment.)

Pick one of the health financing systems of the 36 countries ahead of us in the World Health Organization’s rankings. That includes all of Europe, Canada, and even tiny Costa Rica. (But we just barely beat Morocco) Let’s be picky and choose one from the top ten. Copy it. They all provide universal coverage and obtain better health outcomes for far less money per capita. We are spending 17% of GDP on health care, when the average among OECD nations is around 9%. If we could duplicate France’s system we would save almost as much money as we now pay in personal income taxes. Let me restate that: Adopting a European style health care system would save us almost as much money as the government now collects in personal income taxes. We are simply idiots about this.

Start paying for outcomes rather than procedures. This goes hand in hand with separating doctors from particular technologies. When a doctor owns a special million dollar hammer (a dialysis clinic, a (insert acronym) scanner, an arthroscopic surgery setup) everything looks like, well, you know.

Institute regionally adjusted reimbursements to encourage doctors to move to underserved areas. Adjust the reimbursement levels regularly as the talent moves around.

Institute specialty adjusted reimbursements to encourage under populated specialties. Primary care physicians come to mind. In a recent article in the NY Times, a professor of economics advocates lower tax rates for primary care physicians, and points to a student loan repayment program offered to physicians who work in underserved areas.

Flip the organizational pyramid of hospitals upside down. Doctors, nurses, and technicians should hire and fire administrators. A hospital is about providing health care, not shuffling paper. Administrators should be organizers, fundraisers, traffic controllers, and bookkeepers, assistants to the people who are doing the primary work. Among other things, this would reduce the probability of grandiose, money sucking building projects.

Change direct cash subsidies to corn growers back to price supports. Say what? Before the mid-1970s, the government supported corn farmers as a buyer of last resort. If there was a bumper crop and corn prices fell below the cost of production, the feds would buy the corn at a sustainable price and store it. When the inevitable bad harvest came and prices went up, the feds would sell the corn at a reasonable price to keep it affordable to consumers. No net cost to taxpayers and corn prices stayed steady. Then President Nixon’s Secretary of Agriculture, Earl Butz, promoted ultra-cheap corn and soybeans with direct cash subsidies instead of price supports. The result of this policy is ultra-cheap sugar and fat, in the form of high-fructose corn syrup, soybean oil, and grain fattened meat. While the inflation adjusted price of corn has stayed flat over the past40 years, the price of produce has gone up 40%. Call it subsidized illness.

I’m ok. I’m lucky. I’m not looking forward to paying the bills – probably the price of a used car. But I am lucky; lucky in where I live, in how I work, and in my modest prosperity. However, we’re running a civilized society here, not a jungle. Luck is not the proper basis for a health care policy.

I Didn’t Watch

I didn’t watch the presidential debate last night. There is only so much my psyche can take. I have read a few of the after action reports, and it sounds as if I didn’t miss much.

Apparently Mitt Romney “won” on style, which is mostly what these things are about. He wore out his teeth from behind by lying through them continuously. Obama was professorial and languid. Yawn.

One commentator pointed out that the debates are aimed at the undecided, which means the low-information, low motivation voters who haven’t been paying attention in class, ever. I guess this means the people who are more concerned with the latest celebrity breakup than the future of the nation. It sounds as if the proceeding delivered for them. The outcome of the election may hinge on their casual judgment.

The contest of personalities between Romney and Obama interests me not at all. Their political differences are akin to the differences between a medieval surgeon who wants to bleed you before cutting your leg off and a 19^th century surgeon who knows better than to bleed you but wipes his saw on his pants by way of sanitary practice. Obama is a few centuries more advanced than Romney, but neither offering us a sure path to survival. Neither is operating on the basis of state of the art medicine or offering to save the leg.

This makes sense. Both men were chosen through the accumulation of large campaign donations from multi-millionaires. These wealthy donors, in turn, are remoras sucked on to the inhuman corporate sharks that run our society. These corporate sharks have all the foresight and compassion of…sharks. It should not shock us that the candidates have no policies that truly address the realities we face.

In a recent interview, writer and political activist Noam Chomsky was asked how progressives should view the present electoral contest.

Chomsky said “I think they should spend five or ten minutes on it. Seeing if there’s a point in taking part in the carefully orchestrated electoral extravaganza.  And my own judgment, for what it’s worth, is, yes, there’s a point to taking a part.”  The long and short: Vote against Romney/Ryan (for Obama) in a swing state. Vote third party in a non-swing state. Then get on with more important things.

What are those more important things? Primarily, fixing the machine. We don’t like the products, but most people are caught up with hating the present malfunctioning unit. They hope, against all rationality, that the same machine will suddenly produce a perfect model after an endless string of defectives. It’s a factory, not a slot machine. It’s not designed to produce what we need. Quite deliberately the opposite.

The first step in fixing the machine is doing what I am doing right now: Pointing directly at the machine and noting that it is what needs fixing. Education is the starting point. Most of America is caught up in its tribal hatreds.

A suggestion: The next time someone starts talking to you about how much they like candidate A or dislike candidate B, don’t get caught up in that discussion. Talk about the machine. The money filter. The Saving American Democracy Amendment. Anything other than personality driven horse race politics. The first step towards an answer is getting people to start asking the right questions.

Smooth Roads

"Frightful roads. Perpendicular descents. Way not banked; the route is but a passage made through the forest. The trunks of badly cut trees form as it were so many guard-stones against which one is always bumping. Only ten leagues a day.” Gustave de Beaumont, travelling companion of Alexis de Tocqueville in America, 1831

A friend of mine is retiring this week. For the last three decades he has worked for the Vermont Agency of Transportation, most recently as a project manager. It would embarrass him if I named him, but I’d like to acknowledge him.

There is a saying that sex is like air. You only think about it if you aren’t getting enough. Another thing in that category is transportation infrastructure. Most of us only think about roads if they are rough or potholed. We only think about sidewalks if they are cracked and heaved. We only think about bridges if they are closed or restricted. Of course, we also think about all these things when they are being repaired, in which case we are generally annoyed by the delay.

I’d like you to think about these things differently. Please consider:

Roads, sidewalks, bridges, and anything else we walk on or roll across, are all in a constant state of decay. Every foot and wheel brings a surface closer to failure. A road is less of an object than a process, in a constant cycle of destruction and renewal. Nature may abhor a vacuum, but what it really despises is a smooth, impermeable surface. There is a cliché about the Golden Gate Bridge – by the time they finish painting it from one end to the other, the place where they started is ready to be painted again. This applies to road maintenance in any state. It is forever unfinished business.

We demand incredibly high standards of our surfaces. A half inch bump on a highway is jarring. Think of it; Two twelve foot wide lanes going for hundreds of miles, and along all the hills and curves it is supposed to be smooth within one part in a thousand. That doesn’t occur without a great deal of care, skill, and organization. Nor does it remain that way.

This brings me to my friend and neighbor. For all these years, in the heat and the rain and the cold, and in the hair tearing frustration of offices and administrators, he has been managing this unfinished business. He is one of those everyday unsung heroes who bring us what we expect. If he and his colleagues do their jobs, we don’t notice a thing. We walk, we drive, we ride our bicycles, and we think about something else.

I’d like you to do something for my friend as a little tribute. The next time you are driving or biking on a newly paved road, or walking on a clean new sidewalk, just notice it. Appreciate it. Think about Beaumont’s words. Marvel a little.

Have a good retirement, neighbor.

A Software Problem

The Librarian is a fan of British TV. Not all of it, of course, but series such as Sherlock (with Martin Freeman as the definitive Dr. Watson and that nerd-throb Benedict Cumberbatch) and Downton Abbey. A source of frustration for her is that these programs are released by the BBC months before they show up on this side of the Atlantic. The BBC actually blocks people with U.S. IP (Internet Provider) addresses from streaming the programs. American viewers don't get to see them until PBS broadcasts them stateside, months later.

Enter IP spoofing. There is software available that fools the BBC servers (or any servers, for that matter) with a false UK address. Now we can watch television with actual plot and character development at the same time as Londoners.

There’s a similar problem with UK musical artists. The UK release of these performers generally predates the U.S. release by a month. The answer for a faithful U.S. fan is paradoxical: Download the music from a pirate site for free when the music is released, and then buy it a month or so later when it is legally available here.

The recording companies don’t seem to get the fact that once a piece of music or video is in digital format it is inevitably going to be released into the electronic wild. It’s not a plastic disc in a box anymore.

Some artists have realized this. Radiohead was first in line among major bands, self-releasing their 2007 album In Rainbows online, allowing people to pay whatever price they wanted. After a few months they released an actual boxed set CD, which sold well enough to hit #1 on the U.S. and UK charts. Estimates for their take from the online offer vary between $2.4 million and $10 million, none of which went towards the salaries of recording company executives.

Other artists have followed suit. Amanda Palmer used the online project funding site Kickstarter to raise money for her new album Theatre Is Evil. She broke Kickstarter’s fundraising record with a $1.2 million take. Donors get various perks, including special preview releases. Palmer gets to do the album she really wants, and delivers her art to her fans without the recording company producers as intermediaries.

In the U.S., mobile phones are connected to particular carriers. If Verizon coverage is the best in your area you might buy a Verizon-compatible iPhone or one of the Verizon-compatible Android-based phones, or a simple feature phone, again, compatible with Verizon. Same goes for AT&T, Sprint, or T-Mobile. Some of these carriers use a system called CDMA and some use a system called GSM, but even within those systems you can’t switch a phone to a different carrier.

This is not the case in Europe. A mobile phone is just a mobile phone. If you want to sign up with a carrier you buy their SIM card (a little plastic chip that sticks into your phone) and start paying them. If you want to switch to a different carrier you buy a different SIM card and sign up with some other company. This lack of a phone lock in results in more competition and, therefore, lower prices.

An example from the Verizon website: 900 minutes, 2 GB of data and unlimited text messaging costs $110 per month. Checking in on the Vodafone UK website, the exact same plan costs 46 Pounds, or $73 per month. A similar plan on T-Mobile UK (900 min., 5000 texts, 1.5 GB) is 35 Pounds or $56 per month. The best price I could find was with a carrier called O2: Unlimited calling, unlimited texts, 1 GB of data, and a free 16GB iPhone for 30 Pounds or $48 per month. A customer can fold in the price of a new phone into the plan or buy a cheaper SIM-only plan for an existing phone.

(I just did the math. 5000 texts per month is one every six minutes for 16 hours per day. Does anyone actually do that? What else could they possibly accomplish?)

Mobile phone companies in the UK also have a wider variety of plans with more combinations of features than their U.S. counterparts. Such are the benefits of unlocked phones. You’d think that a Federal Communications Commission or a Congress concerned with the financial well-being of the citizenry would outlaw the locking of mobile phones. Oh, right, “concerned with the financial well-being of the citizenry.” Never mind.

Those of you who are technically savvy have been waving your hands and bouncing up and down in your chairs like that smart kid in math class. Of course, the million code monkeys out there pounding away on a million keyboards have come up with an answer. There are software packages out there that you can use to unlock your phone. There are businesses where you can send your phone to be professionally unlocked. Even the CDMA/GSM divide is being bridged by new quad-band phones that can run on all the U.S. and European systems. It’s cheaper for the phone manufacturers to make, distribute, and support one model with all the capabilities built into the chip instead of a different model for each system.

Right now the process is kind of an edgy thing and the buyer must beware. A phone can end up “bricked” instead of unlocked, and the warranty is voided by such shenanigans. Things keep developing, however. With the advent of the quad band phone it became a software problem, and software only requires brains and time. My prediction is that unlocking will become more mainstream and reliable. Just as the record companies got caught flat footed by online digital music distribution, I foresee the mobile phone monopsony being flummoxed by the unlocking issue. I can imagine them throwing huge resources into security software in a hopeless attempt to stop the million code monkeys.

The common thread between music and mobile phones is that once information is reduced to electronic bits the ability of authorities to control that information becomes compromised.

This brings me to electronic voting machines. Most of those machines are manufactured by one of three companies: Sequoia, ES&S, and Premier Election Solutions (formerly Diebold). There are two basic types. Card readers do exactly that – the voter fills out a specially formatted ballot and feeds it into a machine that reads it and records the vote. DRE (Direct Recording Electronic) machines have a touch screen with a virtual ballot on it. Votes are recorded electronically and sometimes a paper record of the vote is produced. About 25% of voters in this election will be using DRE machines with no paper record of their vote. Without a paper trail the integrity of those votes relies entirely on the security of the voting system computers. The software that runs these systems is considered proprietary by the manufacturers, so the voting machines essentially become impenetrable black boxes. Except, of course, to hackers.

Electronic voting systems have been plagued by failures. Voters have watched as their vote selection flipped form one party to another. In some districts thousands of electronic ballots have disappeared. In other districts vote counts have exceeded the actual population. In New Mexico the number of spoiled ballots in majority Hispanic (read: Democratic) districts rose dramatically when touch screen machines were introduced and then dropped again when paper ballots returned. In both 2004 and 2008 there were statistically significant discrepancies between exit polling and the official results. And those are just the problems we know about.

 I guess that is the real problem with electronic voting – it is almost impossible to know if we’ve been cheated. Two-thirds of Americans are now voting with paper ballots, or at least paper records. However, in the tight races we have been witnessing even a couple of percentage points in a swing state can make the difference. One doesn’t have to steal the entire vote, just the important bits.

The problem with hand counted paper ballots is that they are time consuming and bulky. The beauty of hand counted paper ballots is the same as their faults. Yes, they are time consuming and bulky. If some group wants to steal an election they literally have to steal physical objects. Stuffing the ballot boxes requires that physical copies of ballots have to be produced, filled out, transported, and placed into many breached physical boxes. Faking a vote count requires suborning a number of people, all of whom have to keep their mouths shut. It has been done many times in American history, but it takes real effort and is generally detected.

A number of European countries have experimented with electronic voting. Both Ireland and the Netherlands tried it and went back to paper. Other countries, such as Germany, simply banned electronic voting.

There are many reforms needed in U.S. politics. One vital reform is keeping our ballots physical and our ballot counters human.

Then, perhaps, we could get a consumer friendly FCC and cheap mobile phone service.