Concierge Care

I've been seeing a concierge practice doctor for several years now since he and his partner decided after the departure of two of their colleagues to form their own high-priced retainer service to opt for a middle-class one. I pay several hundred dollars a year for unlimited care from my doctor. This has been invaluable to me, although more useful when I was coordinating my cancer care in 1998 than in recent years. Until Ben's first cold several months ago, I had avoided any cold or flu that was more than a passing runny nose for two years. Now I've had several colds via Ben, and I don't blame him a bit.

Concierge medicine involves a doctor assuming only the risk to provide their service to a patient and the services of their office. This has caused Washington State's insurance commissioner to investigate the practice as he believes it might fall under the provision of an insurance company. I don't believe risk is really involved because the doctor is pledging his or her own services. My doctor's practice puts fees in escrow until after each month in which service is provided, thus limiting a patient's actual dollar exposure to $0.00 for any given month.

The New York Times is picking up on this trend quite late. The Wall Street Journal wrote about my and other doctors back in 1998, and I was quoted in the article. I have the same reaction as many of the folks on both sides of the concierge debate in this Times article: I love the access I have and I know my doctor enjoys his practice more. And I know that he is able to better keep up on developments in treatment and have his own life. Nobody said that being a good doctor should involve 80-hour or 100-hour weeks for your entire career.

The "lavish care" in the headline doesn't apply to most retainer-based doctors. Lavish means getting the doctor on the phone when you call, getting in the same or next day for an appointment, and spending 15 to 30 minutes with a doctor when you're there. Lavish. Right.

On the other side is the fact that the more doctors that retreat into retainer-based services, the fewer doctors available for general medicine. Retainer-based doctors have fewer patients in their practices. Because I can afford his fees, it means I get better health care than others who have to see whomever.

Of course, my reaction is that Medicare and other social support systems for healthcare should organize to build networks of retainer-based clinics that would allow patients to avoid expensive emergency room visits and save everyone in the system money. For fairly small fees, people with little or no money could be subsidized into better health care. Right now, hospitals eat huge bills (or pursue people with no money like they're the Erinyes) or people face financial ruin.

There is a lot of evidence that the lower you are on the income totem pole in the US, the worse you sleep and the worse your health. Because you make less money, the less you are able to improve your health through routine care and medication that might cost a fraction of emergency-room visits or late-in-the-process care. There's that telling scene in As Good As It Gets when Helen Hunt's son who has some kind of asthma-like disease is finally seen by a regular private-practice doctor paid for by Jack Nicholson: the doctor says, this is pretty easily treated as long as we're on top of it. This is not Hollywood magic.

US Out of WalMart

Does any small fraction of our population understand that WalMart is a scourge not because it offers low prices, but because it's destroying our healthcare system?

The company has 1.33 million employees. According to a leaked memo in today's NY Times on reducing health-care costs, 46 percent of those employees children are uninsured or on Medicaid. Because WalMart pays essentially poverty wages (legally), when they replace jobs in communities through their predatory practices that first drive out businesses through underpricing, they do the following:

  • Reduce money going into the community. They don't grow jobs, they replace them, typically higher-paid jobs within a town or city with lower-paid jobs often outside the tax boundaries.
  • Reduce tax revenue. Despite selling lots of merchandise, they often replace revenue rather than increasing it. Because people are paid less and the owners aren't local so that profit is spent local, money is sucked to Bentonville instead of spent in the area.
  • Burden the health-care system. Poverty wages and no health insurance guarantees offset health care costs to the local community, sucking more money away. The memo states bluntly, "Specifically, our coverage is expensive for low-income families, and Wal-Mart has a significant percentage of associates and their children on public assistance."
  • Tenure is a problem for them. They note that productivity doesn't increase with seniority and they don't like paying people more over time. This seems like a strange problem: hiring new workers incurs costs, and the longer someone works, the better they should perform on average, if not fired. Thus this "compensation" problem is a management problem.

This is sort of free-market capitalism at its worst: Because we as a country don't require health-care insurance for all employees of large companies, this allows a firm to offload its health-care burden. It's easy to argue that predatory underpricing shouldn't be regulated because the market will take care of it--and it often does--it's very hard to say that a company should force local communities to lose tax revenue and pay for health care.

This is not to say, by the way, that WalMart isn't paying anything for health care: 45 percent of their employees are covered. They spent $4.2 billion last year. Even so, a $17,500 per year job has a limit of $2,500 in out-of-pocket expenses or more, according to the Times article.

But it's another key to the broken health-care system that the increases in costs outpace inflation by a factor of three to five per year, and that this leaves more people behind instead of prompting massive reform by the affected businesses.

The Senate Dismisses Inflation's Power

By denying a Democratic move to raise the federal minimum wage from $5.15 an hour ($10,300 per year for a full-time job) to $6.25 over 18 months, the Senate Republicans have decided that on one hand, wages don't need to increase along with inflation's affect on decreasing buying power and, yet, on the other that business isn't increasing its revenues at least as fast as inflation. The most recent previous proposal by the marvelous and bilious Sen. Ted Kennedy was for a $2.15 increase (to $7.30) over 26 months, and this reduction picked up a vote.

A Republican counterproposal would have kept the $1.10 increase but required a remarkable array of horrible add-ons, such as allowing "flex-time," in which overtime one week could be made up through undertime another. These senators are pretending that people working these kinds of jobs have the easy flexibility that would allow the kind of schedules that employers would impose if no longer subject to week-based overtime rules. Jeesus.

Inflation increased 25 percent from 1997, the last increase in the federal minimum wage, to last month. Thus $6.25 would still be slightly short of inflation across that period. I live in Washington State, which requires a minimum wage of $7.35. This is still a ridiculously low wage: $15,700 per year. There are few communities in Washington in which a single person earning that wage and paying no tax on it would spend much less than one-third of their take-home on rent; in Seattle, you'd pay 75 to 100 percent of your take-home pay on rent.

Here's How Ethical I Believe I Am

RealNetworks and Microsoft just settled for $761 million--that's Microsoft to RealNetworks--which covers resolving lawsuits and partnering for services. This is fantastic news for Real, which gets the payoff for years of fighting, and Microsoft, which has now settled all of the major domestic lawsuits and government actions against it. This has distracted them, to be sure, and given Google an opening. Microsoft is now the underdog...with tens of billions of dollars in the bank.

Why does this make me ethical? A reporter called to ask me my opinion on this, and I had to decline to comment. About eight years ago, Real bought the assets of, a company I had helped incubate, and I received a small but very nice chunk of stock for my participation in that. During the Internet heydey, I sold about 2/3rds of that stock paying, among other things, for a new roof for my house.

The remaining stock is Section 144 insider stock which means I have to file about 1 inch of paperwork for it. I've sat on the small number of shares that remain because there was only a little upside versus what I thought might happen if Real resolved its Microsoft difficulties. When Real retained money in the bank turning profits, I had to think Microsoft now knows it can't simply outlast the company which is making money in spite of what it's spending on lawyers. (A commenter pointed out that Real has had little GAAP profit; nonetheless, they have increased shareholder equity while only very slowly tapping cash reserves over the last three years.)

It would be wrong of me holding insider stocks with a material benefit of literally hundreds of dollars--no typo--to comment on it even though I never worked for Real.

Amazon's Review Rules

A rule I set many moons again is apparently still in place at When I was catalog manager briefly (a six-month stint at the company in late 96 to early 97), I had to deal with the burgeoning number of user-submitted reviews which were posted live instantly on the site when I got there. I fought a battle over several months, culminating before I left, in which reviews were reviewed by a staffer before going live. I won this battle partly because more and more reviews were both unpleasant, offtopic, and not noticed until we got complaints. There were turds in the punchbowl, in other words.

One of the rules I set for my staff in reading over reviews was that reviews that attacked the author and that otherwise didn't address the substance of the book were off-limits. This is the "attack ideas, not authors" notion which is a specific case of a general forum policy on most forums prohibiting ad hominem attacks.

An Amazon spokesperson said in a New York Times piece (in Monday's paper), "the posts violated guidelines, which require reviews to focus on the content of the book, not the character of its author." The article covers a tax-denier's book that had reviews that said things like follow this book's tips and go to jail.

Baching It

44582772 0Fc8A8E99E MLynn and Ben are off to visit her parents for 10 days starting tomorrow. Let the waterworks begin on both ends. I may slip out on a frequent flyer ticket to see them, but my list of house repairs while they're gone is quite long. We'll see if I (and they) can hold out. Ten days in the life of a nearly 14 month old is a long, long time. He went from standing to walking well within 10 days. I'll miss them.

Kenwood's Latest HD Offering

Kenwood-1Kenwood just announced last week its EZ900HDS, which is a tour de force of integration: it has AM/FM, HD, and Sirius built in. No external modules as far as I can tell. It's $799 list or about $600 street, which is a tidy price for something with that much integration. The CD player handles MP3 and WMA, of course. The street price drops by $250 for a similar unit without HD Radio.

August Wilson Dies

I have a tiny bit of personal history to add to the knowledge that August Wilson has died in Seattle today at 60 of liver cancer. When I was an undergraduate at Yale, I quickly joined the new weekly newspaper, The Yale Herald, and just as quickly became the regular theater reviewer, handling the Yale Repertory Theatre, then run by Lloyd Richards. Richards was the definitive and premiering director of Wilson's history of black experience in America by decades.

I had the opportunity to interview Wilson through the good offices of the Rep's press department, which treated at least our paper like a real news source, and gave us access to folks. I spent more than an hour with Wilson in 1987 after reading his earlier plays and before seeing The Piano Lesson. He was gruff but willing to talk, and I asked not entirely stupid questions.

But he stressed an interesting point several times that was new to me, white boy that I was having grown up in a white suburb in California and then in Eugene, Oregon, before going to school in New Haven. He said that blacks would have been better off if they hadn't made the great migration out of the Deep South into inner city neighborhoods for blue-collar jobs. He said that if blacks had stayed, they would have changed the destiny of the South by eventually owning a lot of it. He used the phrase, and I have this on tape still, separate but equal, but meant it that the blacks would have created their own nation.

Now having followed his career since, I'm not sure he continued to subscribe to that notion. It wasn't revolutionary, I found out, but it was very interesting. It's hard to say what would have kept blacks in the south--and not like there isn't a large African-American population there now--but as far as my history lessons teach me, the movement north was for jobs and a change from overt, deadly racism to implicit, hostile racism.

Hard to evaluate what would have happened if the folks who had the resources and skills to leave had stayed, but it's hard to imagine a South that isn't deeply divided by economics and in which race and poverty often go hand in hand. Poverty still seems to be the overriding problem, but race continues to compound.