Reckonings: a journal of justice, hope and history

Concierge medicine of a different and better sort

I've written elsewhere about "concierge medicine," in which patients pay a stiff (typical $3000-3500) annual fee for "patient-friendly" extra services from their primary care physicians (more time, same-day appointment-making, email contact, customized electronic medical records, form-filling at home, etc.). Apart from the two-tiered medical service model the concierge service entails (one for those who can afford it, another for those who can't), I learned today of a new model, called One Medical Group, a San Francisco Bay startup with practices in the Bay Area, Boston, Washington D.C., Chicago and New York, whose annual fees are much more modest ($150-200) and whose services really do serve patients well. Here is the article I read:

One 

Medical Group: A Concierge Service By Another Name (And Price)

 

 

Routine visits to the doctor’s office have become the definition of inefficiency. Whether patients are stuck filling out mounds of paperwork or counting ceiling tiles in the examiner’s office, time–with or without insurance–is always at a premium on doctor’s visits.

 

 

Doctors are well aware of this, too. Early in his career, physician Tom X. Lee posed a simple question: When was the last time someone enjoyed visiting a doctor?

 

That question became the basis for One Medical Group, a San Francisco-based healthcare startup that focuses on building the physician-patient relationship and improving the average doctor’s office visit. By employing technology upgrades and a mantra of complete and transparent access to doctors, Lee’s company intends to remove the bureaucratic hindrances that have hampered the $125 billion primary care industry.

 

“What I found was that the system was not allowing physicians to spend enough time with their patients and constrained by the arbitrary nature of how it was financed,” he says. The issue is that insurance favors rewards based on visit volume—not efficiency or positive experiences—leading to overcrowded waiting rooms, rushed patients and stressed doctors.

 

“Everyone in healthcare is well-intentioned,” he says. “But the system is so bizarre that you end up doing stuff that is completely not why you went into medicine.”

 

One Medical is looking to reverse that. With about 90 physicians based in the Bay Area, Boston, Washington D.C., Chicago and New York, the practice accepts all types of insurance on top of a $150 to $200 annual fee that covers the cost of what it calls “patient-centered” extras. Services include same-day appointment booking through the company’s online or mobile apps and customized electronic medical records. It’s all aimed at making the doctor-patient relationship more efficient, says the company’s founder and CEO.

 

That focus on efficiency and improved service has made for an interesting business proposition. Last week, the company announced a $30 million round of funding led by Google Ventures, bringing the total outside investment One Medical to $77 million from firms including Benchmark and DAG Ventures. Investors are betting that consumers will pay a little more (though not as much as traditional concierge practices) to make their trips to the doctors more enjoyable, something that Lee believes can only happen if doctors have more contact with their patients.

 

 

At One Medical, patients can fill out forms online to cut down waiting room times and extend the length of patient visits to their physicians. On the other side, doctors are seeing fewer patients than the average practice—only about 15 to 16 a day as opposed to the traditional 25 to 30, says Lee. Another bonus: direct email contact with doctors allows patients to ask about small concerns without having to make that visit to the office.

 

Technology—even something as simple as allowing email—is a main driver for humanizing the physician-patient relationship. And that’s why Lee, who holds a Stanford MBA, sees One Medical as both a medical service provider and a software company. Lee, previously a founder at health application company Epocrates, has overseen the development of a One Medical iPhone app, website and company-specific electronic medical record all for the sake of preserving the most valuable ingredient in primary care: time.

 

“At its highest order we’re trying to make healthcare work again,” says Lee. “We know how broken the system is and I got tired of hearing everyone complaining. I decided to fix that system.”

A letter to some family and friends, a Merwin poem, intimations of memory, and a few photos

I thought you might like to see a little of the native life in this blessed part of the world. I took all but the two photos in which you see me, the first with camera in hand on the shore of Lake Lagunitas, the other a snap of me during the one time I was persuaded to do a talk here about ER and FDR. The railing and courtyard is my small deck, home also to my bikes and bird feeders. 

 

These spring days I am getting mostly finches, sparrows and the omnipresent chubby mourning doves, for whom I have a special affection because they and their distinctive cry have been present without exception in every one of the many places I've lived.

 

For those of you who don't listen to (or read) Garrison Keillor's daily "Writer's Almanac," his poem of the day and reminder of whose birthdays occur this day (John Muir's among them), I also include from that source a favorite poem of a favorite poet, W.S. Merwin. 

 

On the theme of the Merwin poem — the allusiveness and elusiveness of memory — I used to think that I could imagine what "I had a mind to do / and what I could imagine / going back to and finding it / as I had found it the first time," but like Merwin "I do not know / what I thought when I thought back then." Memories have always, even when young, been oblique and elusive, partial to wish and aversion, the song both new and old. That's part of what makes history, personal and social, so fascinating and so challenging.

 

The New Song

 

by W. S. Merwin

 

For some time I thought there was time

and that there would always be time

for what I had a mind to do

and what I could imagine

going back to and finding it

as I had found it the first time

but by this time I do not know

what I thought when I thought back then

 

there is no time yet it grows less

there is the sound of rain at night

arriving unknown in the leaves

once without before or after

then I hear the thrush waking

at daybreak singing the new song

 

"The New Song" by W.S. Merwin, from The Moon Before Morning. © Copper Canyon Press, 2014.

 

Much love,

 

Dad / John

 

 

Increasing inequality and plutocracy: Thomas Piketty's "Capital in the 21st Century"

Bill Moyers described this week a central conclusion of an essential new book, Capital in the Twenty-First Century, by the French economist Thomas Piketty. "[We] are heading into a future dominated by inherited wealth as capital concentrates in fewer and fewer hands, giving the very rich ever greater power over politics, government, and society. 'Patrimonial capitalism' is the name for it [plutocracy is another], and it has potentially terrifying consequences for democracy. For those who work for a living, the level of inequality in the US, writes Piketty, is 'probably higher than in any other society, at any time in the past, anywhere in the world.' Over three decades, between 1977 and 2007, 60 percent of our national income went to the richest 1 percent of Americans. No wonder this is the one book the 1 percent doesn't want the other 99 percent to read."

Paul Krugman, who is interviewed by Moyers, adds in his reading of Piketty: "We're rapidly moving towards a state where inherited wealth dominates. I didn't know that. I really was — I should've known it. I should've thought about it, but I didn't. And so then here comes this book with — I mean, it's beautiful — absolutely analytically beautiful, if that makes any sense at all.... You're talking about a situation in which dynasties come increasingly to dominate the top of the economic spectrum and a tiny fraction of the population ends up very dominant... Teddy Roosevelt could’ve told you and did: —  when you have a few people who are so wealthy that they can effectively buy the political system, the political system is going to tend to serve their interests. And that is going to reinforce this shift of income and wealth towards the top.... "

Bill Moyers concludes:

"The evidence keeps mounting. Just this past Tuesday, the 15th of April, Tax Day, the AFL-CIO reported that last year the chief executive officers of 350 top American corporations were paid 331 times more money than the average US worker. Those executives made an average of $11.7 million compared to the average worker who earned $35,239.

"As that analysis circulated on Tax Day, the economist Robert Reich reminded us that in addition to getting the largest percent of total national income in nearly a century, many in the one percent are paying a lower federal tax rate than a lot of people in the middle-class. You will, no doubt, remember that an obliging Congress, of both parties, allows high rollers of finance the privilege of carried interest, a tax rate below that of their secretaries and clerks. And at state and local levels, while the poorest 20 percent of Americans pay an average tax rate of over 11 percent, the richest one percent of the country pays half that rate. Now, neither nature nor nature’s God drew up our tax codes. That’s the work of legislators, politicians, and it’s one way they have, as Chief Justice John Roberts might put it, of expressing gratitude to their donors. Oh, Mr. Adelson, we so appreciate your generosity that we cut your estate taxes so you can give $8 billion as a tax-free payment to your heirs, even though down the road the public will have to put up $2.8 billion to compensate for the loss in tax revenues.

"All of which makes truly repugnant the argument, heard so often from courtiers of the rich, that inequality doesn’t matter. Of course it matters. Inequality is what has turned Washington into a protection racket for the one percent. It buys all those goodies from government: tax breaks, tax havens, allowing corporations and the rich to park their money in a no-tax zone, loopholes, favors like carried interest, and on, and on, and on.

"Listen, there’s a big study coming out in the fall from Martin Gilens at Princeton and Benjamin Page at Northwestern, based on data collected between 1981 and 2002. Their conclusion, quote, “… America’s claims to being a democratic society are seriously threatened … the preferences of the average American appear to have only a minuscule, near-zero, statistically non-significant impact upon public policy.”

"Sad, that it’s come to this. The drift toward oligarchy that Thomas Piketty describes in his formidable book has become a mad dash, and it will overrun us, and overwhelm us, unless we stop it."

The weakness of Moyers' program is that he doesn't take time with Krugman to ask "How?" How do we stop the drift toward oligarchy, or plutocracy, before it overwhelms us?

Potpourri of images and stories

I mentioned a few days ago that Garrison Keillor, in his "Writer's Almanac," keeps me in daily touch with some of the notable birthdays, today including those of two artists whose works have nourished me for a whole lifetime, Henry James and Leonardo da Vinci.

Other than his more famous depiction of Vitruvian Man, and his image of an old man that many have imagined as a self-portrait, I've been most drawn over the years to Leonardo's sketch of St. Anne.

Also, reading and reflecting on Andrew Revkin's essay in The New York Times yesterday on the plight of monarch butterflies, I remembered my first — 16-year-old — driving adventure from Los Angeles up the coast to Monterey, which I imagined primarily as a home of monarch butterflies and of Doc and the other characters of Cannery Row, one of my favorite books by John Steinbeck. Monarchs and canneries there were, but alas no Doc. 

Monarch butterflies are indeed endangered, and serious efforts are getting underway to restore the habitats along their long north-south migratory paths. As Michael Wines wrote in the Times late last autumn, 

"The number of monarchs that completed the largest and most arduous migration this fall, from the northern United States and Canada to a mountainside forest in Mexico, dropped precipitously, apparently to the lowest level yet recorded. In 2010 at the University of Northern Iowa, a summertime count in some 100 acres of prairie grasses and flowers turned up 176 monarchs; this year, there were 11."

A report by the Xerces Society adds, "Monarch butterfly numbers have declined by 90% over the last two decades, and the loss of milkweed—the necessary host plant for monarch caterpillars—is one of the key factors responsible for the decline." Richard Conniff wrote a recent article in Yale Environment 360 about what farmers and gardeners can do to restore the habitat of monarchs and other pollinators (notably including honeybees, whose numbers are diminishing with comparable seriousness).

 

 

Remembering Seamus Heaney

Garrison Keillor reminds me this morning that it's the birthday of Irish poet Seamus Heaney, born in Castledawson, Ireland, in the same year (1939) that I was born in Seattle, Washington. Since the subtitle and theme of Reckonings are drawn from Heaney's The Cure at Troy, a version of Sophocles' play Philoctetes, and since I have admired Heaney's poems and prose for so many years, I'm glad to be reminded.

As Keillor writes, "He was the oldest of nine siblings. His father was a cattle dealer, and Heaney grew up in a three-room thatched farm. He said, '[It was] an intimate, physical, creaturely existence in which the night sounds of the horse in the stable beyond one bedroom wall mingled with the sounds of adult conversation from the kitchen beyond the other.'"

Being a follower of family history, one of Heaney's poems I have returned to most often is "Digging."

 

Between my finger and my thumb   

The squat pen rests; snug as a gun.

 

Under my window, a clean rasping sound   

When the spade sinks into gravelly ground:   

My father, digging. I look down

 

Till his straining rump among the flowerbeds   

Bends low, comes up twenty years away   

Stooping in rhythm through potato drills   

Where he was digging.

 

The coarse boot nestled on the lug, the shaft   

Against the inside knee was levered firmly.

He rooted out tall tops, buried the bright edge deep

To scatter new potatoes that we picked,

Loving their cool hardness in our hands.

 

By God, the old man could handle a spade.   

Just like his old man.

 

My grandfather cut more turf in a day

Than any other man on Toner’s bog.

Once I carried him milk in a bottle

Corked sloppily with paper. He straightened up

To drink it, then fell to right away

Nicking and slicing neatly, heaving sods

Over his shoulder, going down and down

For the good turf. Digging.

 

The cold smell of potato mould, the squelch and slap

Of soggy peat, the curt cuts of an edge

Through living roots awaken in my head.

But I’ve no spade to follow men like them.

 

Between my finger and my thumb

The squat pen rests.

I’ll dig with it.

 

 

Jane Goodall's 80th Birthday (April 3, 2014)

 

 

 

 

 

 

 

 

 

 

 

 

 

From Maria Popova's excellent blog, "Brain Pickings" (www.brainpickings.org).

A few days before, Popova offered and celebrated Goodall's interview with Bill Moyers. Goodall reads her lovely poem, "The Old Wisdom."

Jane Goodall on Science and Spirit: The Iconic Primatologist Talks to Bill Moyers and Reads Her Poem “The Old Wisdom” 

“As human beings, we can encompass a vague feeling of what the universe is, and all in this funny little brain here — so there has to be something more than just brain, it has to be something to do with spirit as well.”

 

Happy 80th Birthday, Jane Goodall: The Beloved Primatologist on Science, Religion, and Our Human Responsibilities

Legendary British primatologist Jane Goodall (b. April 3, 1934) is celebrated not only as humanity's greatest expert on chimpanzees but also as a remarkable mind that bridges the rigor of science with the sensitivity of spirituality. In a passage from her altogether fantastic 1999 exploration of science and spirituality, Reason for Hope: A Spiritual Journey(public library), which also gave us her gorgeous poem "The Old Wisdom", Goodall reflects on a trying time in her life – her divorce in 1974, coupled with her quest to reconcile the faith in a higher power that she had harbored her whole life with the new understanding of and awe at evolution after her transformational experience of studying the chimpanzees at Gombe Stream National Park.

She writes:

Even if there was no God, even if human beings had no soul, it would still be true that evolution had created a remarkable animal – the human animal – during its millions of years of labor. So very like our closest biological relatives, the chimpanzees, yet so different. For our study of the chimpanzees had helped to pinpoint not only the similarities between them and us, but also those ways in which we are most different. Admittedly, we are not the only beings with personalities, reasoning powers, altruism, and emotions like joy and sorrow; nor are we the only beings capable of mental as well as physical suffering. But our intellect has grown mighty in complexity since the first true men branched off from the ape-man stock some two million years ago. And we, and only we, have developed a sophisticated spoken language. For the first time in evolution, a species evolved that was able to teach its young about objects and events not present, to pass on wisdom gleaned from the successes – and the mistakes – of the past, to make plans for the distant future, to discuss ideas so that they could grow, sometimes out of all recognition, through the combined wisdom of the group.

Echoing Mark Twain's lament that we often use religion as a mask for human egotism, Goodall considers how these human capacities unfold beyond the intellectual and the spiritual to affect the very behaviors that shape our future and the responsibilities we have to our species, all species, and our precious shared planet:

With language we can ask, as can no other living beings, those questions about who we are and why we are here. And this highly developed intellect means, surely, that we have a responsibility toward the other life-forms of our planet whose continued existence is threatened by the thoughtless behavior of our own human species – quite regardless of whether or not we believe in God. Indeed, those who acknowledge no God, but are convinced that we are in this world as an evolutionary accident, may be more active in environmental responsibility – for if there is no God, then, obviously, it is entirely up to us to put things right. On the other hand, I have encountered a number of people with a strong faith in God who shrug off their own human responsibilities, believing that everything is safely "in God's hands." I was brought up to believe that "God helps those who help themselves." We should all take responsibility, all play our part in helping to clean up and heal the planet that, in so many ways, we have desecrated.

 

"The Old Wisdom"

When the night wind makes the pine trees creak

And the pale clouds glide across the dark sky,
Go out, my child, go out and seek
Your soul: the eternal I.

For all the grasses rustling at your feet
And every flaming star that glitters high
Above you, close up and meet
In you: the Eternal I.

Yes, my child, go out into the world; walk slow
And silent, comprehending all, and by and by
Your soul, the Universe, will know
Itself: the Eternal I.