:-) Vidette

With all due reverence and respect to my many friends and colleagues
who put in long hours as editors and reviewers, the tedium of academic
publishing is too great a burden for this poor ursine to 'bear'.

Sadly, most journal editors are unable to distinguish between
something seminal and original and something trivial and redundant.
Fielding dozens of requests for clarification because someone doesn't
quite 'get it', and worse still the inevitable revisions to correct
grammar and put in references where none are necessary except for the
fact that the reviewers have no idea what a "thought experiment" is
and editorial policy is that articles should have references, are just
too tedious to describe and certainly to suffer.

I'd rather take a hot poker in my eye than go through the editorial
review process. :-)

But, I am always willing to partner with co-authors whose tolerance
for the submission and review process is way, way higher than mine.

You can be sure that for the next few months journal editors,
newspapers, and TV news commentators will be recruiting dozens of
experts to explain the market meltdown - but many of these experts
were dying to get listened to years ago when the meltdown was just
beginning and the most severe effects could have been prevented. None
of these same people had any interest in the experts views until they
were hit in the face with a baseball bat.

sadly, what is abundantly obvious to me, and has been for three
decades, will take a disaster similar in depth to the week's events to
become clear for most who haven't already put it together...

:-)

bear

--- In Martha_E_Rogers@yahoogroups.com, "Vidette Todaro-Franceschi,
RN, PhD" <vtodaro@...> wrote:
>
> Bear, I do hope you are writing your thoughts up for pub somewhere;
even short letters to the eds of various economic pubs.
> Peace, Love, & Light,
>
> Vidette Todaro-Franceschi RN, PhD.
> Associate Professor & Specialization Coordinator
> Adult Health Advanced Practice Graduate Program
> Hunter-Bellevue School of Nursing
> Hunter College, City University of New York
> 425 E 25th St
> New York, NY 10010
> vtodaro@...
>
> *********************************
> www.energy-enigma.com
>
> "To see that everybody not merely depends on everybody, but actually
everybody is everybody in a deeper sense."
> Bohm, On Creativity, 1998.
>
>
>
>
> ---- Original message ----
> >Date: Sat, 20 Sep 2008 00:32:54 -0000
> >From: "bear" <tc_spirit@...>
> >Subject: [Martha_E_Rogers] An interesting week on Wall Street and
some ursine reflections...
> >To: Martha_E_Rogers@yahoogroups.com
> >
> > Not for the faint of heart...
> >
> > I think most everybody is now well aware that there
> > has been a severe
> > economic crisis brewing for the last few years.
> >
> > There are still some who would like to imagine that
> > nobody could have
> > ever anticipated the unfolding of the mortgage
> > market and its impact
> > on the nation's and the world's financial markets.
> > These are however
> > the same people who could not imagine planes hitting
> > buildings,
> > hurricanes destroying major cities, and they are,
> > unfortunately, also
> > the people who will be blindsided when the
> > disastrous situation we
> > face with respect to health care finance mechanisms
> > also unravels as
> > it unfortunately will in the years (if not months)
> > to come.
> >
> > The number of people who have really understood what
> > I have been
> > saying about capitation contracts, managed care, and
> > the combining of
> > health care providers and finance entities can, in
> > all honesty, be
> > counted on my fingers and toes. This may be the
> > moment to help people
> > understand what is coming in health care in the next
> > few months/years.
> >
> > The mortgage situation developed because greedy and
> > manipulative
> > mortgage companies and brokers sold foolish people
> > on the idea that
> > with an income of $20,000 per year they could afford
> > to live in a
> > $600,000 house, drive a new car every year, have a
> > second home, and go
> > on vacations - all they needed to do was sign up for
> > a 3 year ARM with
> > no interest or principal payments and then in three
> > years they could
> > get another 3 year ARM based on the obvious future
> > appreciation in the
> > value of their houses.
> >
> > But it wasn't just really dumb people making $20,000
> > who fell for this
> > nonsense. Some of the dupes made very large
> > salaries, had advanced
> > degrees, but simply couldn't understand that the
> > RVs, boats, and
> > second and third homes they were buying with the
> > equity in their
> > overvalued houses simply could not have been
> > sustained any longer than
> > it has been. I won't begin to tell you how many
> > colleagues I have
> > urged not to avail themselves of ARMs in the last 5
> > years. Eventually,
> > when the only thing driving up prices is the next
> > sucker standing in
> > line willing to pay the price, markets inevitably
> > collapse.
> >
> > As I have watched over the last couple of years the
> > thought that has
> > constantly run through my mind has been the
> > ebullience that
> > characterized the country just before The Great
> > Depression.
> >
> > If the only people hurting were foolish people who
> > signed such
> > mortgages and the foolish people who bought
> > supposedly high return
> > mortgage derivatives, i could easily live with their
> > pain. But the
> > greed knew no limits, and in the end, it isn't these
> > most foolish
> > people who will shoulder the bulk of the burden of
> > the bailouts, it is
> > the ordinary, everyday people who live within their
> > means and who
> > avoided taking such risks who will ultimately pay
> > the tens of
> > thousands of dollars per person in deferred taxes
> > that it will take
> > us, our children, grandchildren, and
> > great-grandchildren to pay off
> > the massive debts being assumed by the federal
> > government for its
> > failures to stop the mortgage meltdown years ago.
> >
> > How does this relate to nursing and my work on
> > Professional Caregiver
> > Insurance Risk? Just as foolish people took the risk
> > that they would
> > not be able to secure refinancing on their
> > overvalued properties,
> > despite the fact that this risk was palpable to
> > anyone paying
> > attention, the sheep kept walking willingly to their
> > future slaughter.
> >
> > But of concern to me is all the similar risks, in
> > this case health
> > insurance risks, that doctors, hospitals, nursing
> > homes, and clinics
> > have willingly accepted as they have signed on for
> > managed care
> > agreements, capitation contracts, and the worldwide
> > use of Diagnosis
> > Related Groups financial reimbursement formulae.
> >
> > Just as mortgage brokers preyed on the ignorance of
> > borrowers,
> > organizations that purport to be health insurers
> > have effectively
> > transferred the actual insurance risks involved in
> > the legitimate
> > practice of running an insurance company and
> > transferred these risks
> > to health care providers. Over the short run this
> > worked out pretty
> > well for a small number of greedy and predatory
> > companies, executives,
> > investors, and sales people. Individuals made
> > hundreds of millions of
> > dollars by limiting patient's choices and delaying
> > diagnosis and
> > treatment â€" the most fundamental cornerstones of
> > "caring". After all,
> > if you haven't figured out what sort of care your
> > patient needs, how
> > can you possibly provide that care?
> >
> > Who this massive transfer of insurance risks hasn't
> > worked out too
> > well for are the tens of millions of people who lost
> > the benefit of
> > separation between their health care provider's
> > personal financial
> > gain/loss and clinical and professional duties and
> > responsibilities.
> >
> > If you walk into virtually any managed care or
> > capitated group
> > practice, you won't need a PhD and a research
> > background to note that
> > the offices are overcrowded, the staff are
> > overworked, the waiting
> > time is absurdly long, and the amount of time each
> > patient spends with
> > their physician or nurse practitioner is too short
> > to provide
> > comprehensive diagnosis, treatment, and "care".
> > These providers are
> > really good at giving low cost, immediate care, but
> > they really
> > perform badly when it comes to delivering care to
> > people with complex
> > needs â€" our best friends, the unitary human beings
> > who have complex
> > needs, require longer visits not shorter visits, and
> > whose needs are
> > not well addressed by a prescription pad and a pep
> > talk...
> >
> > The consequence of this, of course, is that hundreds
> > of millions of
> > patients spend far too long waiting to be seen and
> > even when they are
> > seen, the "focused visit" supersedes clinical
> > efficacy. If there was
> > no financial gain or loss in this situation for
> > providers we might
> > just all rail about the declining quality of care
> > and how overburdened
> > practitioners are. But there is a financial benefit
> > to providers in
> > this situation.
> >
> > Providers (and obviously not all providers) who
> > overbook themselves,
> > their offices, and their staff in order to add more
> > managed care
> > patients to the office roster are doing so to
> > maximize their revenues
> > without regard to the declining quality of the care
> > they provide. They
> > chose to accept health insurance risks but they have
> > not, by and
> > large, stood up and accepted the inevitable costs,
> > their needs for
> > bigger offices, more equipment, and more staff. That
> > is one side of
> > the financial gain/loss picture, the other is
> > nowhere near so pretty.
> >
> > The other way providers (Hospitals, nursing homes,
> > group practices,
> > integrated health care delivery systems) optimize
> > their financial
> > performance is by ignoring, even denying, the
> > clinical needs of their
> > patients. Over the last few decades more and more
> > patients have not
> > been diagnosed early and correctly. Even when their
> > physicians and
> > nurse practitioners have finally acknowledged their
> > needs, they have
> > often been denied the very treatments they so
> > desperately needed as
> > their providers tried to escape their obligations to
> > cover these costs
> > â€" precisely what they agreed to do when they
> > signed up to assume
> > health insurance risks. In the end, the very
> > providers that patients
> > need to be able to rely on unquestionably, have
> > violated the trust of
> > their patients, just as the people selling no
> > interest/principal
> > mortgages and mortgage based derivatives to unwary
> > borrowers and
> > investors, many health care providers have benefited
> > financially in
> > their actions by delaying and denying diagnosis and
> > care â€" passing the
> > risks on to their unknowing patients.
> >
> > That individuals, even very large aggregations of
> > health care
> > providers cannot effectively manage health insurance
> > risks is sort of
> > a no-brainer for anyone familiar with elementary
> > sampling theory, the
> > core of my work on professional caregiver insurance
> > risk. Large
> > insurers manage risk by knowing their business,
> > aggregating millions,
> > even tens of millions, of policyholders, thereby
> > reducing the
> > variation in their insurance operating costs.
> >
> > But when companies that act like, talk like, and
> > walk like health
> > insurers transfer their health insurance risks to
> > various health care
> > providers, the risk aggregation is undone. Mortgage
> > companies evaded
> > the small amount of risks of non-payment due to poor
> > underwriting, by
> > transferring the risks of future non-payment to home
> > buyers by selling
> > them mortgages they couldn't afford and for short
> > terms that virtually
> > guaranteed defaults. What the mortgage companies
> > failed to recognize
> > is that eventually the houses they would be
> > repossessing wouldn't be
> > worth anything.
> >
> > Similarly, year after year of mismanaged care has
> > led to a situation
> > where millions of patients needs have been ignored,
> > tens of millions
> > are completely uninsured (Though i would argue that
> > we can probably
> > count the number of Americans with real health
> > insurance with a very
> > small number of beads).
> >
> > When large "health insurers" transfer insurance
> > risks to health care
> > providers, they KNOW that the health care providers
> > cannot manage
> > these insurance risks as efficiently as insurers
> > can. The consequence
> > of this is that health care providers do the only
> > thing they really
> > can to cut costs â€" remember, if health care
> > providers were making
> > their operations more efficient we would already
> > have electronic
> > medical records, and your waiting time for an
> > appointment would be
> > moments not hours.
> >
> > Capitated providers clearly cannot operate their
> > practices efficiently
> > and this is the area of their presumed expertise.
> > Insurance
> > operations, a field considerably older and far more
> > developed than
> > modern medicine and nursing, is way out of the
> > domain of expertise of
> > health care providers. So what do health care
> > providers do to manage
> > the financial risks they face? They reduce the level
> > of services they
> > provide.
> >
> > It takes longer to get appointments. Even when you
> > get to the
> > office/hospital, they don't want to take care of all
> > your needs, they
> > want to take care of the easiest needs you have and
> > have you come back
> > some time in the future when you can wait too long
> > for too little care
> > again. Delaying costs is a common insurer practice.
> > Obviously delaying
> > costs for one policyholder doesn't mean much. But
> > delaying payments to
> > millions of policyholders, precisely what happened
> > after Katrina and
> > which will happen with Gustav and Ike, dramatically
> > affects the bottom
> > line, for a while anyway.
> >
> > It is, in my humble opinion, long past time for
> > nursing to champion a
> > restructuring of our failing health care finance
> > system and way past
> > the time when nurses should be talking about working
> > with managed care
> > systems. The consequence? If you own stock in a
> > managed care company â€"
> > bail out while you can!
> >
> > I know it is one of my long rants, but I would feel
> > remiss if I didn't
> > point out that one of the next big ripples in our
> > financial services
> > sector is our 'about to collapse' system of health
> > care finance and,
> > by extension, our wildly dysfunctional health care
> > system.
> >
> > Health care providers, like mortgage derivative
> > investors, signed up
> > for risks that are simply unmanageable. It is time
> > to stop a system
> > that hasn't worked for providers or consumers.
> >
> > Selfishly, I don't want anyone on this listserver to
> > ever say that
> > nobody could have possibly anticipated what is so
> > clearly coming...
> >
> > Bear
> >
> >
>