On cutting Medicare Payments to Doctors

Link: http://mailview.custombriefings.com/mailview.aspx?m=2010060901ama&r=4763043-01b4

Many believe doctors should make less money. After all, theirs is just another job, just like everyone else's, so why is it they have to make more? Sure, long hours, being available on nights and weekends, etc. But if that's what they chose, well, suck it up and be modest.

Many doctors (I like to think most) chose this profession for reasons other than being financially attractive (i.e. trying to help the sick, overall helping the society with one of the most important needs: fighting disease). However, the problem is that if you degrade doctors societal and financial rewards, some degree of contra-selection will ensue. In other words, no longer would the best and brightest want to pursue this career, at least some of them wouldn't.

Such contra-selection could compromise the overall intellectual standing of this group. I am afraid that can drive up health care costs (less experienced or smart doctors are, thinking that's their best strategy to fend off lawsuits, more likely to order all sorts of tests and services "to be safe" that industry makes them think are needed, as their lack capacity to have their own research and opinion on these matters).

Cutting Medicare payments to doctors will likely further the process of "elitism" in practice, i.e. popular, "successful" practices will increasingly refuse dealing with Medicare altogether, while the Medicare providers will increasingly be at the lower end of the professional hierarchy. Unless of course states make it mandatory for any physician with a license to accept certain number of MC patients, in which case they pretty much artificially down-regulate all practitioners' income. That obviously will accelerate the contra-selection process, which (as explained above), paradoxically will drive up health care costs, something cutting doctors' fees was hoped to counter in the first place.

How High Can We Go? On the Question of Rising Health Care Costs as a Function of the Health Improvements they Help Achieve

The fact health care costs are rising doesn't surprise anyone. As complex as the reasons for these increases may be, the bottom line nevertheless is that we justify the increases in cost for ourselves by the (correct or incorrect) assumption of improving outcome measures.

The question then becomes how much improvement can you justify by a unit increase in costs. E.g. extending a cancer patient's life by a month may mean the world for them (e.g. being able to live to see the birth of a grandchild, etc), but may be a very minimal improvement if you look at it from the health economics standpoint, for, say a 10% increase in cost.

Unfortunately we don't have infinite means to spend as much money on health care as it takes. As compassionate as we may be, we have to draw the line somewhere. Some would argue that we shouldn't double our health budget in order to achieve a marginal improvement, but at the same time it feels wrong to refuse better care for financial reasons, even when it is the financial reality.

Also, even if we took the stand of erring on the side of human life and health protection and did everything possible to maximize spending on health care in hopes to improve lives of patients even if by ever so minimally, that would clearly mean that we would have to make severe sacrifices elsewhere, which we have already been trying to do and could be detrimental to health and human life in other (indirect) ways.

It brings us to the perennial dilemma of how much human life and health is worth to the society, as opposed to individuals who are currently sick. For the healthy ones maximizing health outcomes at the expense of skyrocketing costs is obviously a much lower priority than to the sick ones, which represents a conflict. We have been struggling to address this conflict and find the right balance.

As our society ages (thanks to medical advances and investments in research and health care...), paradoxically we will have even more people with health needs and thus the balance will have to shift to reflect that, but at the same time, we might have even less resources as sick people may be less productive.

I don't know what the long term answer is to resolve this conundrum. I think once we can truly genetically cure disease and enhance health, as well as be far more efficient and productive, as a society, due to technological advances, we could find a better balance. Or we just roll back on technology and advances and accept we, humans, were born to live a limited life, which disease may be part of, and simply we just can't expect to live 150 years. We need a lot of thinking to figure this out and opinions surely vary widely. Until we can actually figure out, the dilemma of how much extra spending it is worth to produce (relatively/arguably) small health improvements will remain a somewhat scary and unsettled question.

Which is "good": Comcast or Verizon?

Link: http://zneuro.net/blog2.php/2010/03/26/verizonagain

It is hard to say "which is good". I am inclined to say "neither". The issue goes down to the model of customer oriented businesses.

The way they make money is to have "efficient" customer support, which includes saving money on hourly wages (obviously getting sub par semi-idiotic and/or outsourced customer support staff) and making customers' interest the lowest possible priority (i.e. not bothering with the fact you have to hold the line for hours on the phone, not having effective communication and coordination system to protect your time and avoid inconvenience, not putting sufficient resources to have a billing system which avoids over-billing, etc).

At the same time, some of the money saved ignoring customers and having shitty customer care, will go into propaganda where they say in a pleasant loving voice all they care about their customers' satisfaction.

Bullshit! They absolutely DO NOT care about that, more than some bare minimum that allows them to stay at or above "industry standard", which is horribly low. What they care about is to make money, for their shareholders. Obviously these interests are conflicting. If they were all super loving and caring, making sure every customer received 1st class service, the shareholders would boot the management for wasting money, as that kind of customer service most certainly wouldn't pay off.

That is exactly the epitome of this question, the "industry standard" of customer service and satisfaction. Because it is so low, you can't solve the problem. You are stuck. So answering your question, neither is good. Same thing with the banks or other "competing" customer oriented businesses. If you switch to the competitor, it is just a question of time and luck when you will be in for the same exact type of shit you decided to leave the other company in the first place.

There is nothing you can really do to make it better than it is, this is still the best system, because at least there IS a bare minimum industry standard. In other words, the shareholders and management do get incentivised to NOT allow customer satisfaction into a free fall, i.e. going well below industry standard, because then the competitor would start picking up business. At the same time nobody (except for customers who just hope for a miraculously good deal by improved support) are much interested in improving customer support above the industry standard minimum, as for every dollar invested above that level you get declining returns.

The only way the model perhaps could accommodate people like me, who could afford (and without thinking would pay for) "premium" services, in other words a tiered support system. It exists, there are many examples, but most mainstream big volume providers (banks, internet, phone companies, etc) did not quite bite on it yet. The ones that are working, are not working very well (I tried for example CompanionLink, a software to sync Outlook and Google), where I purchased the premium customer support level, only to realize it is not exactly working too well...).

Verizon: Almost One Year Later

Link: http://zneuro.net/blog2.php/2009/07/01/1st-followup-to-verizon-saga

Just a another Verizon followup (or rather, a brand new post) from today, 3/26/10, nearly a year after my first similar posts...

Last night I went home and found that my internet wasn't working. I called tech support and after the usual hold (or perhaps a bit longer than usual) I got somebody to tell me that the account was suspended. Without being able to confirm it, the person told me that seemingly this was due to "non-paying" (I have always paid all my bills in full, on time). I was also told that nothing could be done to this (to activate my internet connection) at that time (it was 11 PM), and that the issue needed to be addressed during normal business hours.

I took the time and called today. I was on the phone for an hour and a half (!). Let me summarize (below) what happened during that 90 minutes...

Somehow I was connected to FiOS support first (navigating through the tricky menus I selected the option that I wanted a new service, hoping that would give me quick access to a live person, assuming their incentive to sell you "new" services), but then when asked about the type of service I just dialed zero.

Interesting that I still had to hold 20 minutes despite the hope of a quick sales line. Nonetheless after 20 minutes I did get a live person, albeit a FiOS one.

Anyhow, I did get a live person. After some 5 minutes on the line with her (asking all my account information etc), she determined I needed to be transferred to the DSL people. BTW, she offered, so that next time I don't get connected to the wrong area, a "direct" line to DSL (800-567-6789). Very nice, I said, that actually was the number I called in the first place for how I managed to get to her...

After another 10 minutes of music (which wasn't too bad, at least for the selections, the quality was sub par), I now got the usual outsourced accented gentleman. We started chatting in a friendly tone and after a little while I learned from him that he is actually sitting in the dial-up department. He courteously offered, however, to transfer me to the DSL department. Not only that, but he even helped me further than that. He actually went ahead and offered to disclose the DIRECT number to DSL (800-567-6789).

Unfortunately, at this point, my friendly attitude waning, I declined, citing the fact that was the very number I called in the first place (and the only number I always call), yet managing to get to all sorts of departments around Verizon, with the only common denominator being they can't help me. The outsourced gentleman, with apparent modest to moderate communication challenges related to the use of the English language, unfortunately did not understand exactly why I would decline his help offering this secret, direct number, so he said it anyway.

As calm as I was earlier, this was getting a worthwhile experience. My cognitive self-therapeutic efforts focusing on not becoming frustrated, showed some wear and tear at this point.

Now, as you probably guessed, came more transfers... I finally got to the DSL folks, which, on the surface, you would think is a good thing. Right? Wrong. After another almost 10 minute hold and getting to another outsourced gentleman (who sounded exactly like the previous one), I had to painfully realize that no real progress was being made.

Anyhow, I share the account info, answer all security questions, describe the problem, to this new gentleman, my new friend. My account is suspended, I am told, therefore the billing department should be working with me. Great. Yes, that means TRANSFER!

So I weather another transfer with some mix of apathy and frustration, and this time sounds a non-outsourced voice on the other end, hurray. Of course the hold time adds on again. After share my convoluted story, which includes the fact I moved my voice part of the account to VoIP (Vonage) recently and I suspect this had caused the issue in the first place (and all I want is internet only, restored right away, something I previously had been told was possible).

Unfortunately, the billing person is confused, challenged, frequently puts me on hold to look into things. As the situation is getting more and more hopeless for him, he even (cautiously) tries the "t" word (transfer), which, by that time, had become my rage trigger.

Increasingly seeing no way out between his intellectual limits and the complexity of the situation at hand, as a punchline at the height of tension, the line gets dropped. After 90 minutes total.

I call back. This time I use a different approach. How about if I pick the "cancel" account option from the main menu instead of trying the sales lines. In fact I did not have to fake it. At that point I was determined to do it too (i.e. cancel the entire Verizon account for once and all).

Surprise! I get somebody on the line in less than 5 minutes! So I share my story for the 6th time in 90 minutes. Another surprise: the person speaks English well (understands almost everything I say), plus, as an added bonus, actually he is almost semi-competent. Huge contrast with all the earlier imbecile folks. Makes me wonder if they pay higher for the "cancel my account" reps as that is of even greater relevance than the new sales and definitely greater than customer support. If I can give you one advice here, if you have a problem and want to get somebody on the line quickly, go for the account cancellation option...

The guy relatively efficiently reviews notes, maps out the situation, and it becomes clear to both of us what had happened. My act of moving the voice away from Verizon did not automatically activate a "dry loop" (I wonder why they call it that way) DSL only subscription under the same account, but somehow caused suspending my account. The reason for that is that when you change your subscription that way you have to pay, up front, using a credit card, before anything else happens (I thought I would just be billed as I do normally).

OK, now that the investigation of history is done, let's look into the future and figure out what can be done. Again, my intention at this point is still to try to just simply reactivate the account.

There is some complexity regarding how the still technically open DSL subscription from a discontinued DSL+voice subscription, in the context of moving the voice to another provider, plays out, so I won't further complicate this technologically heavy post. Enough to say that my internet service was in "limbo" (that's the exact word the guy used), so we needed to make some decision regarding how to proceed.

Turns out, my internet service, after all this, could not simply be re-activated. If I wanted Verizon DSL internet back (in a "dry loop" manner), I would have to do the entire setup from scratch.

Why is that relevant? DSL tends to be a bit more complex than cable, including setup. My situation is even more complex, because I opt to not use the Verizon DSL modem as a router (which would be the routine setup), because I use my own (gigabit) router and use the DSL modem solely as a bridge, which requires some special account setup, which is a nightmare.

When the guy revealed that all my account settings were now erased and if I wanted to have my internet reactivated (without voice; i.e. "dry loop"), I would have to do the setup from scratch.

OK. At this point my decision matured to the point of no return. Cancel my account. I felt bad, because all day this was the only time I spoke to the most competent, and nice sounding gentleman, who was actually helpful and was on top of the situation. He was classy. Once I told him I just wanted to cancel, he acted accordingly.

Of course, I am writing this post before I see any further development, letters, bills, etc, so I'm pretty sure it is appropriate for me to say now (about this blog): "to be continued"...

The end of Palm

Link: http://www.businessweek.com/technology/content/feb2010/tc20100225_755804.htm

Palm is now irrelevant. Caput. A sad story of internal turf battles compromising mission.

Jeff Hawkins, Donna Dubinsky, and Ed Colligan, the original inventors of the Palm Pilot and founders of Palm Computing, founded Handspring, after 3Com was taking the Palm division to a direction they didn't like. 3Com folks were... pleased to seemingly win the turf battle by letting these innovative folks be pushed out.

Then these turf winners were pissed seeing the success of Handspring at the same time they were doing OK at best. Handspring's Treo was a tremendous success and the model 600 (which I owned in its heyday) was the 1st truly smart mainstream smartphone.

As pissed as the Palm/3Com folks were, they struggled to convince their shareholders to acquire Handspring, which eventually happened. Their agenda, however, was perversely (and obviously against their shareholders' best interest) to suffocate the immensely popular Treo line, to make a point about who's boss.

In fact not only did they suppress Treo R & D and marketing budgets, but they funneled funds to develop their own children projects, directly competing with Treo (Tungsten W, Centro). Now how screwed up is it to develop competition internally for your own products?

I guess in their ideal world, the Centro and other Palm (non-Treo) smartphones would have reached greatness and glory, to contrast with the "failed" Treo line acquired from Handspring.

Well, it did not work that way. While the Treo got a serious hole and began to sink, the other Palm products never caught on, RIM and Apple moved in and claimed rapidly increasing market share in the smartphone world, that Palm and Treo helped create/pioneer.

After shareholders got alarmed they demanded change. The Treo line received some renewed support and then last year Palm orchestrated a respectable comeback with the Pre and Pixi, running WebOS. Great reviews, decent products. But nothing to change anything in a cut-throat competitive smartphone market, where the faith of Palm had already been determined at the time years prior, when they suppressed (rather than aggressively riding on its success) the Treo line.

This is an educational story about greed and turf, minds obscured by power and immature human conflict, driven by insecurity, where a "turf battle" can compromise the entire mission.

As a result, Palm is now dead and will soon be looking for a buyer and likely at a discount. I hope we can all (intelligence community, paying attention?) learn from this sad story and make sure we always keep the mission on the top and not let it be compromised by conflict of interest, such as turfs.