Dear Madam/Mister Future President

As I am writing this, you don’t yet exist, and I hope you never will. As I am writing this, at least half a dozen people are still standing in the quadrennial jousting tournament we call elections. Elections in America is that brief and fleeting period of time when Washington DC turns its gaze to the rest of the country feigning passionate interest in our lives. This time around America is staring back at you in seething anger. In the olden days, this would be the proper time for tar and feathers, for pitchforks, and for burning you in effigy. Nowadays, this is the time for Twitter trolling and lack of what you call decorum in public discourse. Like all well fed, self-described benevolent aristocrats in the past, you seem surprised at our indifference to your accomplishments, and shocked at our plebian preference for rough and tumble champions of our own choosing.

Try not to worry too much. Time, and the robust voter suppression machine you and your “donors” built over centuries of enlightened democracy, is on your side. You will prevail. There will be no impractical socialist in the White House, and no vulgar businessman will be allowed to touch the intricate web of global domination your donors weaved over decades of hard work and heroic determination. Not peacefully. Not without a violent American Spring. Not in our lifetime. Not while you have a good “ground game” to get votes. Not while you have big data to “profile”, “target” and “persuade” voters. There really is nothing I want to tell you, or ask of you, because I know precisely what you will be doing in the next four years, but let’s continue this farce where you pretend to be a public servant, and I pretend to be an engaged citizen.

You are obviously “electable”, which means you passionately advocate for nothing in particular, in long erudite sentences that rise at the very end (like JFK). You certainly look “presidential”, which means that you’re not too fat or too old or too short, your nails are trimmed and your hair is combed.  You addressed every policy nook and cranny in your issue-oriented debates, in your canned stump speeches and in your ten point policy proposals that will become obsolete once the last polling station closes on November 8th. But there is one thing nobody is talking about. No clever moderator is asking, no candidate is volunteering an opinion, let alone a “plan” to tackle what is perhaps the defining issue of our times.

“It's about the next 20 years. In the '20s and '30s it was the role of government. '50s and '60s it was civil rights. The next two decades are going to be privacy. I'm talking about the Internet. I'm talking about cell phones. I'm talking about health records and who's gay and who's not. And moreover, in a country born on the will to be free, what could be more fundamental than this?” –Sam Seaborn, The West Wing, Episode 9: The Short List (for Supreme Court appointees), 1999

The events of the new millennium do not seem to support Sam Seaborn’s prediction, and your campaign is stark testimony that privacy is to be forfeited without much pushback from any quarters. We could argue that principled liberals of the previous century were ill equipped to appreciate the true benefits of the Faustian deal we are now making with the Lords of the Global Digital Panopticon. One could also argue that since the days of Sam Seaborn, privacy has become all but extinct, and lo and behold the sky of freedom hasn’t fallen. Or has it?

Let’s take a quick look at your campaign operations. Did you avail yourself of a voter database? Are you paying for special software that “appends the richest set of consumer and interest data, allowing the most sophisticated targeting” of voters? Do you employ an army of techies in the basement of your national headquarters, like the landmark Obama digital campaign did? Do you have an app on iTunes that tracks your “supporters”, their friends and their families, everywhere they go? Is your voter segmentation machine spitting out properly scripted “messages” at the most opportune time for the most receptive individuals? Do you think this is what Thomas Jefferson meant by freedom and liberty? Or do you think that’s what your kindergarten teacher meant by lying and cheating? Do you even care?

Politics in an age without individual privacy is as principled as marketing toilet paper. Your brand is softer, stronger, more absorbent, bigger, smaller, whiter, greener, and very much preferred by wild bears in the forest. You stand for nothing and everything. You stand for moderation in the North and you stand for God in the South, and you stand for Nelson Mandela to offset all the white old men who manage your campaign. You stand for America in the abstract, and use personal misfortunes of citizens to illustrate your history book, but even if your poor mom or dad were of the people, you have long ago ceased to be one of us. The reason we are asked to vote for you is the same reason we are asked to choose Charmin instead of Cottonelle, with the same de minimis consequences.

Now let’s take a look at Obamacare, which you are certain to tinker with, one way or another. In your mind, Obamacare is about money. It’s about premiums, deductibles and percent uninsured, but if that’s all Obamacare was about, it wouldn’t have required hundreds of densely typed pages, and it wouldn’t have triggered a tsunami of lesser legislations now percolating through Congress. In reality, Obamacare is how your donors use the latest technology to ensure that future elections are free from glitches that allow old communists and potty mouthed billionaires to come close to disrupting a carefully constructed world order. Obamacare is not about a human right to health care and it’s not about keeping Americans from dying in the streets, as your rogue competitors seem to believe. Obamacare is how Google, Apple, Facebook, Amazon (GAFA), and their Silicon Valley brethren, take control of human life on earth, and get rich beyond the dreams of avarice.

Obamacare is about replacing personal and slow medicine, with high-tech, high-speed, precision medicine administered through metallic algorithms supplied by your donor community. Obamacare is about managing expectations (you should be familiar with that little game), to make the busywork of tracking and scoring citizens seem like medical care. Obamacare is about shifting the locus of medical decision making from individual people and their doctors to the invisible hand of computerized bureaucracy. Obamacare is to health care what high-speed trading is to stock markets. To this end, Obamacare must unleash a biblical flood of personal information for its doomsday machines to consume, and dutifully share with other stakeholders, such as your campaign software vendor. Any remote notions of physical and mental privacy are therefore obstacles to progress.

Perhaps it is logical that your party and the other party as well, have viciously turned on their front runners in an effort to select a nominee with the best ROI record for those who consider themselves owners of a global humanity.  Perhaps it’s not by accident that Obamacare which was first known as HillaryCare, and then as RomneyCare, may eventually be known as BushLeagueCare. Perhaps, as our own, bought and paid for, disruptive innovators love to point out to their less enthusiastic colleagues, this is all inevitable. Perhaps, but somehow, at some point in this long game, the courts will have to weigh in and decide if the framers of our Constitution intended to set up a government whose sole function is to capture and deliver its citizens to global moneyed interests for lifetime exploitation.

This Saturday, Justice Antonin Scalia died. In this election year the usual and customary horse trading to seat an “acceptable”, thus by necessity mediocre, judge on our Supreme Court bench for life, may not be an option. The insurmountable task of nominating the next Supreme Court Justice may land in your lap, pretty much on your first day in office. There is a bold and beautiful solution to this quandary, a grand bargain that rises above your petty party politics, and for that you’d have to turn again to the liberal fantasy called The West Wing (Season 5, Episode 17: The Supremes, 2004). Unless the Obama administration, which over the years exhibited a peculiar interest in reenacting The West Wing, beats you to it, you will get to appoint (unopposed) two Supreme Court Justices and the rare opportunity to stand “in the gaze of history”.

Unfortunately, whether you belong to Clan Clinton or are hailing from the Bushes, I am having difficulty imagining you giving up any perceived party advantages for the sake of judicial excellence on the Court. I can certainly imagine the angry socialist and the mercurial businessman rising above the pettiness, but this wasn’t meant to be. Not this year. The next four years are yours, and you will need to hurry up and bolt the doors and bar the windows. A really big war, preferably in Europe, would help tremendously. Either way though, your days are numbered. We are no longer progressive or conservative. We are either feeding at your trough or we are not, and there are many more of us than there are of you, and one of these days we will have nothing left to lose. Not even our privacy.

The Era of Value Based Care

The Centers for Medicare and Medicaid Services (CMS) is working hard to transition physicians’ payments from volume to value of services. The current Acting Administrator at CMS is a former top executive at United Healthcare, a commercial health insurance corporation. The previous Administrator at CMS is currently the president and CEO of America’s Health Insurance Plans (AHIP), which is the dominant health insurance lobbying group. It may therefore behoove us to rephrase the opening sentence: The corporate-government health care conglomerate is working hard to transition physicians’ payments from volume to value of services.

In response, health care delivery corporations, which are employing large numbers of physicians, are joining their forces through mergers, acquisitions and other arrangements to better manage the transition of physician payments from volume based to value based models. When you ask the architects of this supposedly tectonic shift from volume to value to explain their enterprise, you get back lengthy dissertations about better service at lower cost due to computerization, analytics and standardization of an industry long overdue for modernization. The basic argument is that health care in the U.S. sucks on many levels, and proper management that employs the latest technologies and business methodologies will fix everything that needs fixing.

But what does it mean to pay doctors for value instead of volume? Does it mean that we don’t pay physicians unless we get better? Does it mean we don’t pay for health care unless we are “kept” healthy by our doctors? Does it mean that we don’t pay a red cent for advice or procedures that we judge worthless? How long do we have, post service, to decide if what the physician did was valuable? Thirty days? Five years or 50,000 miles whichever comes first? A lifetime? The answer emerging from opinion pieces published by members of the corporate-government conglomerate, which are intended to soften the ground before official rules and regulations are promulgated, is much simpler and should be much more familiar to any small business owner, or anyone who visited a restaurant or a hotel.

So here is how this is envisioned to work. Physicians will still get paid a base amount per service provided. If the corporate-government conglomerate judges the work of the doctor to be beneficial, they will throw in a 5% gratuity bonus. Moving forward, if physicians can reduce the overall COGS (cost of goods sold) for the corporate-government conglomerate, they will get a moderate percentage of net profit. Finally, if doctors are willing to take full P&L (profit and loss) responsibility for health care services, they can get a slightly bigger piece of the profit to offset the risk of massive loss. Essentially, if you are a physician, and if you agree to do what the corporate-government conglomerate wants you to do, and if you are really good at it, and if you are willing to put your money where your mouth is, you should expect nothing but financial prosperity in the era of value based care.

The things you would have to do to enjoy the value based financial bounty are not very difficult, particularly when compared to the practice of medicine. The goal is to keep the corporate-government conglomerate happy without distinguishing yourself from the generic woodwork of the new system. There is safety in the herd, and you should aim to be somewhere close to the middle of the herd. Stragglers, and those who venture too far out in front, are usually eaten. Below are a few strategies to help you position yourself for long and uneventful survival.

Percentage Medicine

If you dabbled in the game of tennis, whether as a player or an avid spectator, you are probably familiar with the term “percentage tennis”.  Playing percentage tennis means staying away from corners and lines and spectacular shots. It means playing it safe, taking little if any risk, getting the ball over the net without fanfare, and absolutely no aces on serve. Percentage tennis is how middling players, who lack exceptional talent or physique, are advised to play the game. Serena Williams is not playing percentage tennis. Great champions never do.

If you like to think that you are a great doctor, brilliant diagnostician, or anything else preceded by some sort of superlative, tone it down. This is not about excellence. It’s about percentages. Wasting your precious time on the quickly fading Miss Henrietta Wilkins, who spent the Great War welding big chunks of metal in the shipyard, and a variety of other losers, who will never bring their biometric indicators up to corporate-government conglomerate standards, is not considered good percentage medicine. Ideally, you could ship these folks to the nearest community center, but if you can’t, see if you can reassign them to your NP/PA, or some outsourced care management service, and stay away from direct contact. If you want to personally help people, you should consider volunteering in a soup kitchen on Wednesday afternoons.

Generally speaking, seeing patients one-on-one is not a good use of your time. Your initial efforts should be directed to shaping a robust patient panel that can be managed by your care team working at the top of their license. Later on you should switch to maintenance mode and work the analytic dashboards, Excel sheets, pie charts, bar charts, and all the reports and data provided to you by the corporate-government conglomerate. These things are usually marked with red-yellow-green risk indicators, so it’s not that difficult to get started. Watch your reds. If they’re amenable to change, have your staff change them. Otherwise find a way to quickly remove them from your panel. Don’t neglect the yellows either, because if you’re not careful, they have a tendency to turn red without much advance notice.

This is how percentage medicine is played. This is population management and this is also precision medicine because some of those colored risk scores are accurate to the second, or even third, decimal point which is something your over educated human brain could never calculate on its own. As long as your panel looks green, but not too green, because that may be indicative of gaming, you should be safe. If you feel a sudden urge to jump back in and play doctor, maybe with an ominously red marked patient, resist it. Go take a brisk walk around the block or listen to a motivational TED talk. Try making a nifty Power Point presentation for the next leadership meeting (Power Point art can be very relaxing) or book some travel to a health innovation conference.   

Fake it ‘till you make it

When you see patients, and you will have to for a while longer, you will need to present a caring and expert, yet humble, persona that reflects well in satisfaction surveys. You will have to be persuasive, without coming across as overbearing, when you steer clients towards product lines that are most beneficial to the corporate-government conglomerate, which is either your one true customer, or your direct employer. You will have to cultivate an engaging and compassionate image to elicit the trust of your clients. You will need to be friendly, but not too familiar, to maintain a certain aura of non-threatening expertise. You will need to say please and thank you, and you will need to display properly calibrated humility when apologizing for the shortcomings of the new and improved system, without throwing your superiors under the buss.

Since value based health care is a team sport, you will need to cultivate a non-disruptive, non-elitist image to present to the team. The team of course includes representatives of the corporate-government conglomerate, some of whom you will interact with in person, and others who will be watching you through rolled up dashboards and reports. Read a couple of value based policy papers or newspaper articles (they’re about the same as far as depth and substance are concerned), and memorize a few key words and phrases, such as “transformation”, “lifestyle and behavioral modifications”, “less is more”, “consumers want to be kept healthy”, “patient activation”, “triple aim”, “quadruple aim” (there is no quintuple aim yet, but watch for it soon), “our health care system is broken”, “$3 trillion”, “medicine has always been about information processing”, “the single most important thing to have is good data”. Stuff like that. When in doubt, just prepend “patient-centered” to whatever you plan to say next.

After a while, all of this will become second nature. If you get really good at it, you may want to go for a leadership role within the corporate-government conglomerate. It pays much better, and there are decent opportunities for advancement. Another option is to drop out of whatever is left of patient care and join the entrepreneurial side of the house. You can join a startup, or make your own. You need not be a techie or understand technology in any way. Startups are hungry for MDs, so they can advertise products “built by doctors”. Investors love that type of stuff and potential customers still have some residual respect for physicians. It won’t last long, so do it now or you may miss the boat.

One thing is certain though. A passive-aggressive attitude, or its burned-out martyrdom cousin, won’t do you any good. If you really and truly can’t get on board with the destructive recreation of your profession, you’d better quit. Get out and open a boutique cash-only practice or subcontract with one of those hit and run value based telemedicine services for the healthy or just find something else to do. Write a book, buy a little farm and make organic goat cheese, dabble in politics, start a movement. Have some fun. Life is short.

Iowa is voting on Health Care tonight

In his last State of the Union address, President Obama stated that “anyone claiming that America’s economy is in decline is peddling fiction”. I agree. The American economy has roared back from the Great Recession with 14 million new jobs, a ridiculously low unemployment rate, a booming stock market and 57 brand new American billionaires in 2015 alone.

The American people on the other hand are in a completely different boat. Almost a third of us are not working. Half of us have practically no savings and a record number is surviving on public assistance. Wages are stagnating and the middle class is shrinking. Student debt is skyrocketing and 20% of our kids live in poverty. Whereas in the immediate past the economy and the welfare of the people used to be one and the same, nowadays these terms have little if anything to do with each other.

The President did acknowledge that “the economy has been changing in profound ways” and therefore “a lot of Americans feel anxious”. To allay our collective anxiety, the President announced an unemployment program that will pay up to $10,000 to those who lose jobs to the economy fixing racket, money that can be used to retrain machinists, welders, builders and such, to flip burgers in the booming job market of the fixed economy.  The anxiety reduction program will also ease the transition to a “work-sharing” economy, where lower wages and no benefits, augmented by public assistance, a.k.a. the Walmart and Uber models, are the new normal.

Health Care is about the Economy

After fixing the economy, our government is now full throttle ahead with fixing our health care. My expectations would be that health care will be fixed in very short order, with very similar results. Health care expenditures will plummet, uninsured rates will be near zero, quality measures based on cost and utilization will be stellar, and most people will end up with little if any medical care when they fall sick. To ease our anxiety, or in health care parlance, to provide us with “peace of mind”, everybody will be awarded a Medicaid managed care card, if you’re lucky, or a high deductible insurance exchange plan that kicks in after you go bankrupt.

In the midst of the previous century, when people talked about “the economy”, the term conjured visions of molten iron being forged, of combines sliding gracefully through oceans of golden wheat, of gigantic cranes towering over monumental construction projects, of dusty rugged Americans building and making with pride and determination, of former soldiers poring over text books, of men walking on the Moon. Today, “the economy” brings to mind images of stock tickers, conference rooms with sweeping views of Alcatraz or Central Park, fancy men in fancy suits getting in and out of black limos, and endless streams of brightly colored graphs, percentages and statistical trends. The economy is no longer about us.

Health care is no longer about us. Health care is about waste, fraud and abuse. Health care is about “bending the curve”. Health care is about global competitiveness of corporations. Health care is about carving up a $3 trillion opportunity. Health care is about private equity, mezzanine funding, return on investment, valuations and public offerings. Health care is about the economy, and the economy is no longer about us.

Perhaps this was never about us, but if “time is the fire in which we burn”, America was the one unique experiment where a group of people came together to protect each other’s rights to freely determine how they wish to burn. The idea spread a little bit, but not much, and now it is collapsing under the hubris of an Information Revolution, which looks more like a slow motion coup d'état to transfer control of the burning process from millions of hands to a global “digital assembly line” where physical objects, virtual algorithms and human beings are melded into one efficient production system. This is a kinder and gentler slavery nation.

John C. Calhoun

Historically, the enslavement process was physically harsh and cruel, because back then the work of a slave was physically harsh and cruel, and because the only tools available for recruiting and maintaining slaves were physically harsh and cruel. Today you give a guy an iPhone app and he willingly and painlessly joins the driving plantation. You give a guy a free Internet search tool and he unconsciously and painlessly joins the advertising plantation. This is a major improvement, since as grandma used to say, you catch more flies with honey than with vinegar, and from a respectable distance it looks like you’re generously feeding the dumb little critters.

The grand objective of slavery has always been the amassment of wealth by the magnificent few on the backs of the faceless many. The only things that changed over the millennia are the means by which this is accomplished, and the rhetorical subtleties used to justify the practice of slavery. Notably, health care has been playing an increasingly prominent role in the intellectual quackery employed by evil people towards their evil ends. As early as 1837, John C. Calhoun was extolling the superiority of health care benefits available to the enslaved, especially the compassionate palliative care at the end of life, when compared to the “forlorn and wretched condition of the pauper in the poorhouse”.

It never occurred to Mr. Calhoun that there ought to be a third option, that his own young country has challenged the world order by simply stating that all men are created equal, and challenged the most powerful King in the world, and his mighty armies, precisely so that those equally created men can be free men. But John C. Calhoun was not speaking about us. His oration was about the economy, and the economy thrives on servitude, pauperization, and wretchedness, mitigated only by the “kind superintending care” of masters. If John C. Calhoun were alive today, he would probably be running a billionaire foundation to help “all people lead healthy, productive lives”.

Alexander Hamilton

It must have never occurred to Dr. David Blumenthal either that 200 years after our Declaration of Independence, for a brief moment in time, we had a third option. After watching a Broadway show and perhaps reading one biography of Alexander Hamilton, Dr. Blumenthal found it necessary to write the strangest article in defense of the Hamiltonian version of Calhoun’s “superintending” care, which Obamacare essentially is, or aspires to become with the help of its equally superintending technology bonanza. The article is a case study in demagoguery and the building of alternate realities from partial truths and innuendos, which is how health care reform was and still is being advertised to the masses.

Perhaps we shouldn’t be surprised by Dr. Blumenthal’s admiration for Alexander Hamilton, because Alexander Hamilton was not about us. Mr. Hamilton had great misgivings about the “imprudence of democracy”. He admired the British aristocracy, and insisted with all his might that the “first class” of “the rich and well born” should be awarded a “distinct, permanent share in the government” to counterbalance the bad judgement of the masses, and to prevent change to the status quo. If Mr. Hamilton, the champion of strong central government run by financiers and corporations, were alive today, he would probably be equally smitten with what Dr. Blumenthal represents.

This Night in Iowa

Tonight in the great State of Iowa, we the people are kicking off the only peaceful process available to us to make health care, the economy, and the entire political process, about us. This year we seem to have a bountiful crop of candidates seeking greatness. Some are “rich and well born” asserting their Hamiltonian right to that “permanent share” in government. Many are lifelong corporate servants looking for the next step in their pitiful enterprise. And two are very different than the rest. Two are challenging the status quo, which is so near and dear to the “first class” and its vast infrastructure of minions and pundits, feeding at the commandeered public trough, and whose entire job now is to convince us that neither one of these two men are fit for office.

One is a career public servant, a man of principle, of lifelong held beliefs that health care should be about us, and the economy should be about us, and that central government should be by, of and for us. The other is rich and well born, a swashbuckling traitor to his “first class”, who realized that he cannot possibly have a great country when the great majority is enslaved. The two couldn’t be more different in personal style and fiery rhetoric, but at the heart of it all they both want to reclaim the “permanent share in the government” that was stolen from us by the “first class”, and unlike their corporate serving competitors, who say one thing and do another, neither man is accepting patronage from those who they aim to disempower on our behalf.

For decades the “first class” owned media and punditry, carefully nurtured the appearance of an “ideological divide” designed to keep us engaged in mortal combat over hyped minutia, while the enslavement process proceeded at a brisk pace in the background. Tonight, the people of Iowa have the opportunity to begin refocusing our sights on the real ball. This election is not about Republicans vs. Democrats, it’s not about Planned Parenthood or ISIS coming to kill us in little Toyota trucks, it’s not about men vs. women, blacks vs. whites, young vs. old, educated vs. uneducated or poor vs. less poor. This election is about all of us, it’s about being a nation of free people vs. a replaceable cog in the global “digital assembly line”, and it’s about our hard fought right to govern ourselves, centrally, locally and individually.

We can’t make health care about us until we make the economy about us, and we can’t make the economy about us until we make government about us, and we can’t make government about us until we make the political process about us. We can’t make the political process about us until we dethrone the “first class” from its permanent power perch, and deny the “rich and well born” the ability to buy every election and serve us with a nauseating mélange of sleek and polished John C. Calhoun disciples, promising “kind superintending care” for the rest of us.

Tonight Iowa will vote for Bernie Sanders, will vote for Donald J. Trump, or will vote for the status quo. These are our only choices in 2016. Choose wisely, America.