Category Archives: Government

My Life in Guitars (Part 3) – the Desert

I’d been quite happy with my Peavey Predator, so although I looked—and occasionally drooled, I didn’t seriously plan to buy another guitar. I became a geo-bachelor in Oakland, California, and had my Peavey, but no amplifier. In my teeny-tiny one room apartment, I could hear my playing well enough to keep my sanity.

Then I got the word that as a reservist, I was being recalled and would soon be in Southeast Asia. Obviously, the military pretty much dictated what would go on the plane, so the word was—mail yourself the survival gear you’d need in a plastic footlocker, with the fiberglass reinforced packing tape in every direction. Contents included books, electronic games, civilian clothes (sometimes referred to as “mufti”), and, in my case, a small ham radio station. If the footlocker was shattered, the tape would keep everything together.

What? No guitar?

No guitar. I did not want my Peavey damaged, and, besides, the military exchange system was there to take our money and send us whatever we desired. I’d just order a new guitar once I got there.

I did.

The order was cancelled.

I placed a second order with AAFES (Army and Air Force Exchange System)—the store for our men in women in uniform who are deployed.

Cancelled again.

I called the AAFES command—I mean, why be a senior officer if you can’t call the military’s retail headquarters? As a civilian I can call Radio Shack headquarters—never mind.

When military are deployed their mail is routed through a system to an FPO (fleet post office) or an APO (Army post office) so that mail to overseas bases is treated—and costs—like it’s within the continental United States. However, AAFES claimed they didn’t ship to APOs or FPOs.

Huh? Isn’t that why the Military Exchange System exists?

I suspect that items like musical instruments are “drop-shipped” from the manufacturer directly to the customer. If the manufacturer was not located in the USA, then it couldn’t be sent as US mail to a US APO/FPO address. (Damn bean counters!)

Fortunately, I realized that the horse was dead, so I should stop whipping it, and went over its head, straight to . . . . . .

eBay!

Peavey Acoustic

I found a nice used acoustic guitar in the “Buy it now” section. I even talked with the seller (if you could dial back to a US base via the military system, you could then use your prepaid WalMart 5 cents-per-minute account to make a prepaid call elsewhere within the US). The seller was a nice guy who told me that he had changed out the bridge from white to black for a customer who changed his mind. Did I want it changed back?

No—just send it to me.

The vendor was either Music 123 or Musicians’ Friend—it doesn’t matter, they’re all part of the Guitar World now. The neat part was that for deployed military (you know, those with the dreaded APO and FPO addresses), these vendors, replaced the shipping cost with “Thank you for your service.” (To this day, they’re still my primary source for anything and everything musical—thanks, folks!)

For my new guitar, oddly enough I had picked a Peavey acoustic (imagine that). It arrived in short order in perfect condition. When I was “home” I tried to practice regularly and I also played at church. St. Augustine said that “He who sings, prays twice.” If you sing at a service at which I’m playing guitar, your prayers are probably worth a hundred-fold. On the other hand, one could always count dealing with my playing as penance.

After Mass one evening, Rubin, a fellow officer, approached me and asked if I wanted to play in a Beatles band. I laughed and pointed out my general (if not total) lack of talent, but Rubin (and I’m spelling his name the way I THINK he spelled it) said, “No problem, it was just for fun.” I thought about it, and figured that at the very least I’d get free guitar lessons out of the deal, so I agreed.

We didn’t get a lot of USO activity at our location, and what little we did always happened when I was on the road. There was a fair amount of excitement when a women’s volleyball team stopped by (so I hear) and Charlie Daniels performed, after which he autographed the guitar of one of the other Beatle band members. He had a black guitar with a mother-of-pearl Statue of Liberty inlay on the fretboard that had been custom made when he was stationed in Korea. Charlie signed it with a bold silver marker of some kind. The final result couldn’t have been more awesome.

But I digress, although I’m digressing about guitars, so it’s okay.

Just before Christmas, after weeks of rehearsing in a warehouse, WE became the USO show and did about 30 minutes of Beatles music for a crowd of fifty or so (after all, there was not much else to do if you weren’t on duty). However, a good time was had by all, and I had my 30 minutes of fame.

Next—a different guitar for an encore presentation.

Founding Fathers vs Today’s Leaders

In my many years, I have come to a conclusion that one useless man is a shame, two is a law firm, and three or more is a congress.

John Adams

The Founding Fathers, for all their myriad imperfections, did manage to design a workable form of government. The operative word is “work.”

The Congress was tasked with making laws, the President with either signing or vetoing those laws—although the President’s veto could be overridden with a two-thirds majority of Congress—and the judiciary with interpreting how the laws should be applied.

Congress is made up of two houses; the House of Representatives, with 435 voting members elected for two years, who represent the states and 6 non-voting members, who represent the US territories. The House focuses on the latest legal or social fad.

Each state has two senators, who are elected for six-year terms and are expected to be more deliberative and sophisticated. However, the Senate has spawned members like Joe McCarthy, who are generally dangerous to the country.

Sometime in the last century, Congress decided that certain laws would be unpopular, meaning that a member might not get re-elected and have to get a real job, so many laws were made by virtue of the decisions of the Supreme Court. This gave the members of Congress more time to pontificate and profess their principles without actually doing anything, other than raising campaign funds and running for re-election. Since this gave them more time to talk, even (if you ever watch C-SPAN) if most of their colleagues were not in attendance, they were happy. They rarely had to do anything, except talk, talk, talk. Making sense was optional (and rare).

On those occasions that Congress did pass a law, the law was prepared by lobbyists and most members of Congress were ignorant of most of its content (except for pork barrel amendments inserted to get them re-elected).

Eventually, the President wanted to get in on the action and began to issue Executive Orders. Even though the Constitution stipulates that Congress has the power to declare war, it has not done so since 1941. The Korean War, the Vietnam War, the Gulf War—and the sequel to the Gulf War, and the War in Afghanistan were not wars but “police actions” initiated by various presidents. While it may have been war to those who fought, were wounded, or died, Congress maintained plausible deniability by not declaring them as actual wars.

Executive orders worked so well that presidents began issuing them for whatever issue caught their attention at the moment. Some were good, some were not. The problem with executive orders is that they can be issued by one president and cancelled by the next.

How do we fix it? All we have to do is follow the US Constitution. If you haven’t read it within the last year, please do. It has been amended 27 times to reflect changes in society and its needs. For a copy, go to https://www.gpo.gov/fdsys/pkg/CDOC-110hdoc50/pdf/CDOC-110hdoc50.pdf.

Labor Day

According to the US Department of Labor, Labor Day was first celebrated in New York City in 1882, although there is some disagreement as to whether the machinists’ union or the carpenters’ union can claim credit. It was a municipal holiday, and other cities were invited to follow suit. After 23 states recognized it in 1894, the US Congress passed legislation making it a national holiday.

As one trained in management, it was repeatedly pointed out to us in college that the real job of management is to remove the roadblocks that prevent workers from being productive. Except in very small businesses, managers and owners produce no products nor do they provide services to the customer. Everybody’s paycheck comes from the efforts of the workers.

In many ways, we seem to have forgotten that and tend to believe that the people in the big offices and the expensive suits are the producers. Meetings don’t generate revenue. PowerPoint slides, slickly bound and printed reports, consume a lot of resources, but belong solely to the Expense side of the ledger.

Even as automation takes over many jobs, reports are that the demand for workers is increasing. The workers may perform different functions, but they are still critical to the process, no matter how much the elites may wish to believe otherwise.

Today there are many industries that produce nothing. Instead they move money around, mix it up, and in so doing make a profit. Some of this “profit” is virtual—it exists on paper, but may never translate into cash. Other profits occur when money is moved from one owner to another; this is a transfer—profit means that there is more, not that we’ve moved it around.

We are becoming a banking and finance nation, which is one of the places where a nation moves when it ceases to be great. The great nations of only a few centuries ago—The Netherlands, Spain, Portugal, France, Great Britain, etc. are only a shadow of their former selves.

So, to those of you who build, grow, design, or otherwise create, thank you. It’s your day—enjoy.

It’s Good to Be the Tsar!

putin

Vladimir Putin, according to reports, is wealthier than the next two richest people combined with a net worth of $200 billion. Pretty good for someone who grew up as Communist with enough commitment to work for the KGB.

His career with the KGB was unremarkable (his highest rank was lieutenant colonel), but once he got into politics, he found his niche. Trained as a lawyer, he adopted the Don Corleone business model (“One lawyer with a briefcase can steal more money than 100 men with guns.”–The Godfather). When the Soviet Union fell, various Russians began to acquire wealth. Putin apparently made many of them an offer they couldn’t refuse.

It might be good to keep that in mind before considering doing business with Putin.

Fixing Healthcare – Part Three

Physician’s Assistants (PAs) and Advanced Registered Nurse  (ARNPs) are helping lower costs and increase access. While some nurse practitioners, can operate relatively independently; other nurse practitioners and most physicians’ assistants, cannot. Why?

Physicians are adamant that they maintain a high degree of control over these and other healthcare workers. This is a throwback to the nineteenth century—which is kind of interesting in a weird sort of way. The story, and I cannot vouch for its accuracy, although all my research seems to support it, is that the country was besotted with traveling medicine shows hawking patent medicines (You’ve seen it in the movies—“One for a man, two for a horse”). The physician industry supposedly promised to get things under control if they were put in charge of medical practitioners, i.e., physicians and surgeons (MD). It, at best, minimized, if not blackballed, osteopathic physicians (DO), chiropractors (DC) and chiropodists, now known as podiatrists (DPM).

A physician, at the time, could authorize any hireling under his license to perform any duty under the concept that the doctor was “the captain of the ship” and was responsible for everything. Therefore, he had authority to authorize any employee to do anything—hopefully, but not necessarily, after some training.

Today, many non-physician healthcare workers are licensed in their own right; in most states this includes nurses (of all levels), therapists (of all varieties), and technologists (ditto). These people are trained and possess technical skills that physicians do not. Generally speaking, only television doctors leave their practice in order to operating high technology devices. It’s good theater but bad economics.

Many of the other healthcare careers such as nurse practitioners, physicians’ assistants, etc., have made significant advances Unfortunately, old attitudes die hard, and there are too many physicians who try to maintain an inordinate control over everything, including these other professionals. Nurse anesthetists and physicians’ assistance must be “supervised” by a physician, although such supervision does not require actual observation or even the presence of the supervising physician.

Efforts to keep others under control have led to some bizarre arrangements. In radiology, for example I’m told that the technologists are now required to periodically retake the examination that initially proved their competence even though there has been continuing education requirements for 40 years. If true, I believe this is a unique requirement, but a warning to all others. Of all the physicians’ assistants, only those specializing in radiology are not permitted to interpret x-ray or other diagnostic images.

Why?

Some blame the American Medical Association, a very powerful organization with effective lobbyists. However, it apparently speaks for a self-selected group of physicians. Out of 923,308 practicing physicians, the most recent numbers available indicates that only 228,000 belonged to the AMA. If you don’t round, that’s just less than 25 percent.

Nobel Laureate Milton Friedman and his wife, who wrote the book Free to Choose, asserted that the AMA functions more like a guild with the goal of increasing physicians’ wages and fees by limiting both the supply of physicians and the competition from non-physician groups.

This is yet another issue that must be addressed if we are truly interested in fixing healthcare.

Medical School Rationing

Fixing Healthcare – Part 2 — Doctors

I’ve known many intelligent, talented, committed young people who aspired to become doctors, but couldn’t get into medical school. Some were resigned to their fate and used their degree in biochemistry to become medical technologists; others made arrangements to attend medical school outside the United States—primarily in the Caribbean. In one case, in order to study at a school in the Caribbean, the aspiring medical student’s parents sold virtually everything to finance her education. She’s nearly complete with her rotations back here at US hospitals and plans on serving rural or tribal underserved areas.

While we don’t have enough graduates of United States medical schools, we grant 85,000 special visas to foreign medical graduates every year because it’s a “critical shortage.” Today, roughly one quarter of all practicing physicians are foreign medical graduates. I’ve worked with many, and while their initial desire is to return home, after about six months the sports car and the arm-candy significant other appears. When I ask if their plans have changed, I’ve been told, “If I return home, I will be paid in chickens and melons. If I stay here, I will be paid in dollars. I like dollars better than chickens and melons.”

So, we import thousands of non-American doctors every year even though we have many Americans who want to study medicine but are turned away.

A decade or so ago, when more students wanted to study law, the educational industry had no difficulty in adding seats—even if they had to build new schools. Why won’t (not can’t) we do the same for medical schools?

Some claim there wouldn’t be enough residency opportunities if we graduated more doctors from US schools, yet foreign medical graduates can and do get residency positions at US hospitals. In any other industry, this might be viewed as restraint of trade.

I suggest that the goal of US medical schools should be to increase their capacity so that by 2030 ALL US residency openings can be filled with US citizens who graduated from US medical schools.

Next, I would change the entry criteria to include the following:

  1. Accepting students with a commitment to actually practice medicine; better yet a commitment to practice whatever type of medicine is in short supply, wherever needed, for at least three years. After that, every accommodation should be made to place that individual in a residency or fellowship of their choosing for which they have the talent, without a decrease in salary.
  2. While academic achievement is important, the ability to work as a team is critical. History is full of brilliant people who didn’t succeed because they could not work with others, and medicine is now a team sport—whether the person with MD or DO after their name likes it or not, they are teammates with the nurses, technologists, therapists, etc. No one is a superstar.
  3. Children of doctors or other elites should have to prove themselves more—not less—than other medical school candidates. They’ve grown up exposed to the field, often in an environment of privilege, so they should demonstrate their desire to serve, not their pedigree.

In short, we need more doctors, but our current method of selecting them is less than optimal.

Fixing Healthcare in America

First in a series

To correct healthcare and get costs under control, we must first acknowledge, then change the healthcare industry’s unique and outrageously dysfunctional business model.

  1. Physicians and other practitioners who decide which resources will be used in a hospital are often neither the direct provider, the one who pays, nor the beneficiary of the service. Basic economic rules, therefore do not apply. Medical tests, which are intended to provide information that will in some way impact the patient’s course of treatment, don’t. Many test and other procedures are ordered even when the outcome of the test will in no way affect the treatment of the patient or its results.
  2. Medical products and services are priced without any rationale. Often, prices are set artificially high in order to allow large discounts to insurance companies. This means that patients without insurance can be charged list price; eighty dollars for an aspirin or $100 for a BandAid®. Hospitals, which were once a ministry, stewardship, or public service have changed their priority to the bottom line. Some hospitals now own and operate their own collection agencies augmented by a small army of lawyers to guarantee that they collect what they have billed. This is why it is not uncommon for a small-town hospital to have millions of dollars in the bank—and still retain their not-for-profit status.
  3. And the insurance companies that get those big discounts? The hospital needs a staff of trained bureaucrats to generate the paperwork that is sent to the insurance company in order to receive payment. Payments may not be received for several months (for the MBAs out there—remember the first rule of finance—a bird [dollar] in the hand is worth two in the bush [accounts receivable]). When payment does arrive, administrative staff must reconcile the payments and file additional paperwork as necessary. All this adds to the hospital’s costs without adding any value. The insurance companies, on the other hand, are usually quite profitable, even after spending a lot of money on lobbyists. But just like Don Corleone said, “It’s nothing personal, it’s strictly business.”

So, what do we do?

First, it would be valuable to have the physicians evaluate how tests really affect the outcome for their patients and develop appropriate protocols. Malcolm Gladwell relates an excellent example in his book, Blink. The cardiology staff at Cook County Hospital was able to reduce tests while simultaneously improving patient outcomes.

[Gladwell, Malcolm (2005). Blink: The Power of Thinking Without Thinking. New York: Little, Brown.  ISBN 0-316-17232-4 (Especially the chapter on Cook County Hospital Cardiologists)]

Second, revise medical pricing so that it reflects reality—and that must include adequate margin to offset costs for necessary but expensive services. Emergency rooms are expensive to operate while an intensive care unit for patients suffering from burns is actually cost prohibitive. However, hospitals have an obligation to the community to provide necessary services—either directly or by affiliation—to the community. The community, in turn, must ensure the hospital is resourced to provide a wide range of services. If hospital prices reflected cost plus a reasonable margin to offset other costs, and everyone paid the same price—patient or insurance company, it might lead to more rational decisions—outcomes first, but economics as a consideration. If Grandpa—God love him—is a 96-year-old heavy smoker with high cholesterol and other morbidity factors who was hospitalized because of a stroke, a battery of tests that will not affect his quality of life or his longevity are not appropriate, and the insurer should not be expected to provide carte blanche payments. However, if the prices are realistic, the family may decide that they would be willing to pay for those additional procedures on their own.

Third, emphasize cooperation over competition. Is there any other business, other than hospitals, that would allow someone to work in their facility AND directly compete with it? Radiologists have their competing imaging centers, surgeons may have their private surgery centers, etc. Should specialty practitioners be entitled to benefit from the hospital’s patients and compete with the hospital for those same patients? It should be the practitioners’ choice—one or the other, but not both.

Two excellent resources for these issues are:

Brill, Steven (2015), America’s Bitter Pill: Money, Politics, Back-Room Deals, and the Fight to Fix Our Broken Healthcare System. New York. Random House. ISBN 978-0812996951

Rosenthal, Dr. Elisabeth (2017). An American Sickness, New York: Penguin Press. ISBN 9781594206757

If you want to fix American healthcare, pass this along to your friends, neighbors, doctor, etc. I’ll get a lot of hate mail, but we need to have the discussion.

More to follow.