Dear Colorado Physician,
Hi.  It’s Jay, the guy from down the hall.  I am writing to you today to talk to you about how our world is changing, and why I think it is doing so.

First, none of this is going to make any sense until we face up to the fact that what we have viewed as “the normal course of business” in medicine is anything but normal.  In the history of the world, never have so many spent so much of other people’s money with so little accountability for how it was spent.  Never.  It’s been the biggest bonanza of unsupervised money in the history of the planet.  You and I, hospitals, drug companies, insurance companies, and many others have made incredible livings based on this lack of adult supervision of our spending patterns.  While we like to excuse ourselves from that list, as Walt Kelly said in Pogo, “We have met the enemy, and they is us.”  At least, partly us.

How did this happen?  Well, remember that in 1950, the sum total of the data about our practice patterns could fit into a cocktail party conversation.   With loud music on.  In the absence of the ability to judge who was doing better and who was doing worse at our gig, society did a number of things to try to help itself sleep at night.

First, they invented the malpractice suit.  By more or less randomly punishing anecdotally bad behavior, they sent the message, “We can’t tell if you’re doing a good job, but we’ll rely on your fear and guilt to regulate your behavior.  Sorry to resort to that, but it’s the best we can do right now.”  We learned to fear and loath trial attorneys.

To try to regulate our spending, the spending with no natural brake on it, they invented prospective review in insurance companies.  This was to send the message, “We can’t tell if you’re doing a good job, but we’ll rely on you giving in to hassle factor for things you don’t really want all that much, to distinguish what’s medically necessary from what’s not.  Sorry to resort to that, but it’s the best we can do right now.”  We learned to fear and loath insurance companies.

To try to regulate our quality, the quality no one could define with any specificity, they created hospital peer review and credentialing.  Good, we thought, because we control those, and so while we do punish egregious error, for the most part we go through the motions and excuse anything we can imagine having done ourselves on a bad day.  We do no root cause analysis, no systems improvement, and we wait for the same thing to happen again.  We shake our heads when it does, and wonder why so many of our peers are having bad days.

But in 2013, we are learning to tell who does a good job.

In 1965, Gordon Moore working at Fairchild Semiconductor, observed that the number of transistors on a chip was doubling every 18 months, and the cost was halving at the same time.  This meant that computing power, and therefore information, was getting cheaper at an exponential rate.   Today in 2013, Moore’s Law is still true, and information is cheaper than zero.

The cheapness of information fundamentally changes the properties of modern society.   It means that everybody’s performance can be measured, including yours, with increasing precision and accuracy.   It means data will be increasingly available to do systems analysis, and improve the safety, reliability, and efficacy of treatments and procedures.  It means that very complicated things will be modeled predictively, including things that are way more complicated than a hip replacement.  So the chances this computing power isn’t being applied to your performance as a doc?  Zero.  All the major health plans have already invested a lot of money to do exactly that.

So we have a couple of options here.   We could try to ignore this trend, and hope everyone who pays for our stuff will, too.  We can spend our time and effort trying to discredit the data that’s being used, even though similar techniques are being used to send coupons to women who are pregnant before they’ve told anyone, through their buying patterns.  Big Data is here, and it cannot be lobbied or wished away.

Or, we can use the information that health plans and others can provide to get better, and to accelerate our quest for error-free, high value care.  We can humbly accept that the smartest doc alone has no chance to do her best work without the data and analysis enabled by Moore’s Law.  And we can begin to use these data to get better at what we do at a rate unimaginable in the days before powerful computing.

I’m not here to make that choice for you, even if that were possible.  I’m here to tell you that whether you voted for this or not, it’s where we are.  The profession will never be the same, and like all loss, that is sad.  But we should recognize that the old system and its imperfect quid pro quo were driven by society’s inability to judge what it was buying from us; its need to feel safe through fear and guilt-based mechanisms; and comforting delusions about our infallibility that we secretly wanted to believe ourselves.  Today in 2013, I am confident that none of those things produced what is best for us, our patients, and our society at large.

What will you choose?  You won’t have to tell anyone.  They’ll know from the data.

            “How did this happen?” Ed asked Marge.

            “Well, it could be those checks I wrote to charity,” Marge said sheepishly.

            “But did you check to see if we had money in the account?” Ed asked.

            “No, I assumed we did—because we still had checks,” she replied.  “Ed, you should have seen those people—they needed coats, and groceries.”

            The reason I bring this up is that I think our country’s finances currently work a lot like this.  We continue to write checks, because there are checks left in the checkbook, not because there are sufficient funds to pay them. 

And, we are doing it for the best of reasons: because we are trying to assure our neighbors get things we feel are human rights, namely health care for the elderly, the disabled, and the poor.  We are scrimping on repainting the house, fixing the water heater, and funding the kids’ college accounts, all to write checks for more health care.  It is borne out of compassion, and many of us feel pretty noble about that.  We’re not going into debt for ourselves, but for the benefit of the sick and the needy.

But compassion or not, there is a day of reckoning when we realize that we can’t continue to spend what we don’t have and aren’t likely to earn in the future.  Many of us think that day is today.  Or maybe yesterday.  In any event, with the debt we’ve incurred, the interest payments alone would be enough to worry Ed and Marge that they’d never catch up.  They’d know that they just didn’t have that many raises left in their working lives. 

The sequester, taking effect at midnight absent a miracle, is an attempt to deal with something like Ed and Marge’s predicament.  While we as a nation made pledges to charity (and bought a big house) based on the thought that we would have ever increasing incomes, the reality is not so rosy in a tough world economy.  Generous people that we Americans are, we’ve taken no raises in the aggregate for ourselves in this last decade; all of our raises have gone to paying interest on our past generosity and increasing that generosity through more health care spending.  The president’s Council of Economic Advisers projects that on our current trajectory, that trend will continue through at least 2040.  As a result, our standard of living has stagnated and will continue to do so in the next quarter century.

Ironically, the sequester makes cuts to almost everything but the main thing that is putting us deeper in debt: Medicare and Medicaid.  If we are ever to stabilize our debt, we’re going to have sit down at the kitchen table, and figure out what proportion of our income will go to health care to reflect the compassion we feel for our neighbors.  But what’s left must still allow us to fix the water heater, paint the house, and start putting money into the college fund again.  We can figure out that number, just like Ed and Marge did.

And so while it is not being framed this way, what we are watching is de facto a question of how much we are willing to give up now in order to preserve the illusion that Medicare is an unlimited entitlement, for another year or two.  In Bowles-Simpson, discipline is imposed, provider fees are cut, higher efficiency is demanded.  None of this would be popular with doctors, hospitals, or other providers in the industry, and their lobbies I’m sure would work hard to defeat this proposal, should we ever give it serious consideration.  In the sequester, we cut virtually everything else, but Medicare in all its inefficient, fee-for-serviceness remains a happily overgrazing sacred cow. 

The process of making that choice would be hard enough in a calm, rational environment.  In that hypothetical world, we’d understand the consequences of each choice, we’d listen to those who would be affected thoughtfully, and we’d make tradeoffs and compromises so that every constituency would be mildly unsettled but not threatened with nonexistence. 

But we don’t live in a calm, rational environment.  We live in a world where poorly informed votes are prized (since they count the same as well-informed ones), emotion sells air time, rationality is often defeated by fear, and the short-term arbitrage almost always trumps long-term investment.  In this environment, my sad suspicion is that the fear of a catastrophic future loses to the prospect of a painful present most of the time.  Through our continued inability to address Medicare decisively, we are increasing the odds of both, year by year. 

What the press is saying is that the first two acquisitions have come now because some stability has been restored to the markets, and people feel freer to put capital on the sidelines to work.  Throughout the Great Recession, companies have been stockpiling cash because it increased their flexibility and therefore survivability in an uncertain environment.  The public did the same, paying down debt, holding cash, getting out of stocks and bonds and into safer investments like money markets.  Now, with volatility down, some sense that Europe will not go to hell in a handcart in the short run, companies are buying future capacity.

But why do companies merge in the first place?  There are good reasons not to: the clash of cultures in the airline mergers is legendary, and some mergers fail because of that.  Companies merge because they cannot compete at the level at which they are currently organized.  American Airlines is a good case in point, where even at their size, they are still in receivership in the tough competitive environment that is the airline industry.  They needed economies of scale, and synergies in their route structure to hit the price points of their competitors. 

The airline merger is an example of horizontal integration, the merger of companies in the same business.  But increasingly in health care, we are watching vertical integration, the merger of companies in related businesses, but who do not do exactly the same thing.  Hospitals are acquiring physician practices at an increasing rate.  They are also entering related businesses.  There was a recent announcement here in Denver that the University Hospital system is contemplating building its own health plan.  Rumor is other systems are thinking the same thing.  Now running hospitals is hard enough, as anyone who has tried can tell you.  Why would they want to acquire practices and health plans?

I think it’s because of the same reasons other companies in other industries do: because they can’t compete at the level of their current organization.  If your competitor has an integrated enterprise of hospitals, docs, and health plan functions, you might need the same in order to compete in the marketplace, say, a health benefit exchange. 

This brings me back the beginning of this post, and Joe Swedish taking the wheel at Anthem.  Mr. Swedish is a long-time hospital executive; but Anthem may have recognized that its future disproportionately depends on the integration and efficiency of its provider networks.  And Joe Swedish knows all about those.  

Now that everyone is feeling safer, the cash that has been stockpiled in health care companies will likely be mobilized in the same way it is in other industries.  I will be watching for more integration of assets, both vertically and horizontally.

What I think we are watching is the end of an illusion, so well maintained, that there are no limits in time, money, or resources that we can devote to the pursuit of the medically-based fix.  We have created and maintained this illusion so very well that we have two generations of medical professionals who claim as birthright this illusion and defend it with passion and fervor.  We medical professionals make outstanding incomes from this illusion, and so in the words of Upton Sinclair, “It is difficult to get a man to understand something when his salary depends upon his not understanding it.”  And nonetheless, we are out of money in this richest of all societies to continue to believe what isn’t true.

The mechanisms by which we have preserved this illusion are instructive.  The third party payer system allows us to feel emotionally that the cost of an intervention is just the copay or deductible, even though intellectually we know that to be untrue.  The separation of payment of premiums and delivery of services uncouples them emotionally, and so we don’t feel them as causal.  Indeed, if you have employer based insurance, you don’t even see about 70% of the cost as a payroll deduction, as it’s coming out of your company’s profitability.  In essence, we don’t notice the true cost of medical stuff because we are using pooled dollars, metaphorically grazing our sheep on the village green, in our time of need.  Haven’t we done that for others in their time of need, and so aren’t we entitled to the same?  Of course we are, we think, and the “best” (read: most expensive) intervention possible because of a vague and fervent hope that the additional dollars buy some benefit that we can neither directly sense nor articulate.

The grand challenge of payment reform is to restore some sense of limits to those who allocate finite resources that are fungible into medical interventions.  In essence, we are trying to undo the spending behaviors that have arisen from the lack of accountability that insurance offers us.  While neither I nor anyone I know would want to do without the peace of mind that insurance offers, it also creates moral hazard, the decreased sensitivity to the true costs of goods that comes with not paying the tab out of pocket and at the time of service.

I do some work in payment reform around the country, and I am starting to note a trend: those places with the least are often the first to understand this, and are beginning to behave in ways that reflect health care as a limited and shared community asset.  They are doing it before communities and regions that have more wealth, and therefore the luxury of preserving the aforementioned illusion.  The late Elinor Ostrom’s theory of common pool resource management, for which she won the 2009 Nobel Prize in Economics, is a reasonable first approximation of those mechanisms and structures that create sustainable use of shared resources: http://en.wikipedia.org/wiki/Common-pool_resource.  While its pretty dense, and requires an economist to explain it to us all, it does outline those things that successful communities build to prevent the depletion of stuff all might need at some time but can’t have simultaneously.

So in the best of worlds, when a shiny new medical intervention appears in your community, someone in your community would evaluate this intervention, its cost, and the health it creates, against the aggregated resources your community has to spend on health in general.  They would understand that spending on that intervention necessarily means other interventions would likely not be funded, and it would have to stand up to that test of value.  As all of us know, this evaluating someone doesn’t exist in American communities, and we have a primal cultural dread of that someone that goes back to the reason many of our ancestors migrated here.  Despite this, as I like to say, being out of money has an amazing clarifying effect on people’s thinking, and we are figuring it out with a speed inversely proportional to the amount of disposable income we have to spend on preserving the illusion.

Thus, as usual, Don Berwick is right: cost is the quality dimension of our time, as continuing to delude ourselves increases the odds that some in our society will receive nothing, as we decide that the way to make sure there is enough in the common pool is to exclude some of us, to make the pool of recipients smaller, to decide that really we were only meant to share with those who look, think, and behave like us. And therein lies the great moral dilemma of our time: who are we talking about when we use the term “we”?

Who indeed.

Jane and I met during this trial, and have been friends ever since.  I chaired the steering committee for Northwest Denver, one of the 14 communities Jane studied.  The stories were remarkable.  Hospitals that are ostensible competitors came together with lots of community agencies to design uniform protocols and tools to make transitions of care more effective, efficient, and safe.  Jane tells stories about another part of Denver that was the alpha test site.  The hospital and nursing home staffs in that project had never met each other prior, even though they had shared hundreds of patients.  When they realized how poor and dangerous their communication had been, people teared up, and apologized to one another.  ”I had no idea what I was doing to you.  I am so sorry.”

There is much road to travel before we have safe, reliable, and effective transitions for everyone moving from one site of care to another.  But Jane’s effort began and continues the right way.  It recognized that the experience of care should be continuous, not segmented; that people visit caregivers, but they live in communities; and that few things are as powerful as knowing the people you work with in the common service of your neighbors.  My deepest appreciation goes out to Jane and her team for their vision and hard work to tell the rest of us how much better care can be.

At the other extreme are those who believe that America’s success is the amalgamation of only individual successes, and that pretty much any aggregation of power is an attempt by those with lesser talents to overwhelm those with greater talents, and in fact appropriate the fruits of those greater talents. Luck exists, but is largely irrelevant for the talented because they can overcome any obstacle. They make their own luck. Random catastrophe is simply the outward manifestation of an individual’s inability to cope successfully, and not the responsibility of your neighbor. You may hope for your neighbor’s charity, but you may not feel entitled to it.

Who is right?

I am always suspicious of these kinds of black and white arguments, because I view them as a desire for simple theories to explain a complex world. It is understandable that we seek those in the age of information overload. Somebody somewhere has probably studied this, but my guess is that we are exposed to a couple of orders of magnitude more information daily than people a hundred years ago. Whether we want to or not, because we process emotionally, we have a feeling about everything that crosses our field of view. So the search for easy ways to categorize those things as friend or foe quickly gives rise to snap judgment, emotional processing on the fly, and gets codified as prejudgment. Why? Because when you are flooded with information, it’s all you have time for. Prejudging saves time. You are obligated by survival instinct to evaluate events and information to make sure they don’t cause your demise, and that’s done in areas of the brain completely below the level of rational thought. Ironically, I am afraid abundant information has made us less rational on average, not more.

Instead Brooks’ article lays out a more nuanced view of productive American society, one where infrastructure and community enable individual success. Both the infrastructure, which includes government and community resources, and the individual’s talent, effort, and perseverance are necessary but not sufficient. Infrastructure cannot compensate for lack of talent and effort, and we should not attempt that substitution. Talent and effort cannot replace adequate infrastructure, and neither should we rely on those things as the sole driving force for a healthy society. Without convenient prejudgment, every success is the product of the synergy between the two.

I agree with David Brooks.  I would imagine his article in August 2012 was decried by lots of people.  Some I’m sure dissented because it did not celebrate the individual as the only true American hero.  Others dissented because it did not give communities enough credit, or responsibility.  I choose to believe with David Brooks that the truth isn’t simple, and that in matters as important as our public life, we should spend some time and thought to find the answers that are harder to explain in thirty seconds.

By now I hope it is obvious why this is appearing in a health care blog.  Random catastrophes are legion in health care, but so are the successes related to individual effort and perseverance.  Good health is the product of many factors, some related to our efforts and some related to our circumstances.  Marc Lalonde, a Canadian Minister of Health in the 1970s had a lot to say about that.  He estimated that about 40% of health outcomes are related to behaviors, about half related to genes and environment, and only about 10% of health outcomes related to our attempts to fix the effects of the other factors on our bodies and minds (this last factor is of course health care, and we spend $2.7 trillion annually on it).  The policies we adopt as a nation and in our communities can be ineffective if we fail to recognize the portions of our health that are related to individual responsibility, as well as those related to our underlying circumstances, in more or less equal proportion.

But lately I have noticed some of the conversations are different.  I have been in a couple of meetings recently where audience physicians were answering the doubts and objections of other audience physicians. 

“Aren’t all these quality measures arbitrary, and unhelpful in real patient care?” one might pose. 

“No, in my organization, knowing our real performance has helped us improve things for patients.  We’re thankful for this information, and we’re proud of doing better,” another would answer.

“Isn’t this just a race to the lowest price?  Isn’t this just a way to penalize me for investing more in the care I give?”

“No, in fact quality and value rankings have helped weed out the bad performers in my procedure.  The guys looking to make a quick buck are gone, and should be gone.  And, my designation as a center of excellence has brought me new business.”

Say what?  Where did this second group of docs come from?

I’m not sure of the answer, but here are some guesses:

• From integrated delivery systems.  Many of the docs in this new category come from places that have been able to generate their own internal quality and value reports.  Because these systems often have advanced IT shops and analytics, they are able to generate useful information based on both financial and clinical data.  This definitely is an advantage in the era of Big Data, and is one reason why we have seen and will see more provider consolidation.
• From specialties that are competing for business nationally.  If your particular niche is a rare and expensive one, you’ve already experienced something many of your peers have not—buyers shopping actively and aggressively for value, holding up your services to the light.  They don’t come to you because you’re down the street, or even in the same state.  They come to you because you are able to offer something predictable, affordable, and professionally excellent.  And what buyers are shopping for is expanding.  They are looking at more services and conditions every day, and shopping for them regionally and nationally.
• From those who have grieved the loss of unaccountability, and moved on.  If no one can measure whether you’re doing a better or worse job than the next person, it’s hard to penalize anyone for bad performance.  (It’s also hard to reward anyone for good performance.)  This is a real loss for us docs, as we took the lack of shopping by buyers as a tacit endorsement of our judgment and competence.  But truthfully, it probably represented as much an inability to judge quality by any meaningful criteria.  That’s hard to swallow, but those who are succeeding in quality-driven markets have gotten over that loss.

This second group of docs is by no means a majority.  But a decade ago, they were almost nonexistent.  I think we are following the typical innovation diffusion curve: experimenters, followed by early majority, followed by late majority.  I think what I have been seeing recently is the move from experimenters to early majority.  And that, as those familiar with that S-shaped curve know, is the steepest part of the curve.  Here’s hoping.

In the January 7 issue of the New Yorker, Eric Klinenberg has a fascinating article about the resilience of communities to disaster.  This was especially timely in the wake of Hurricane Sandy, and in fact part of his article visits people trying to recover from its damage on Long Island.  Dr. Klinenberg has been studying community responses to disaster for a couple of decades, most notably the heat wave during the summer of 1995 in Chicago.  During that disaster, 739 people died.  Analysis of the patterns by neighborhood found things you might expect.  The poor died disproportionately to the better off.  But there were some poor neighborhoods that had death rates that were lower than in the more affluent neighborhoods on Chicago’s North Side.  Two neighborhoods on the poor and predominantly African-American South Side had mortality rates an order of magnitude different from each other.  What does he make of this latter finding?

In response to disaster, communities have at least two categories of response: physical infrastructure and social infrastructure, he explains.  Many communities around the world have gotten good at dealing with the kind of flooding we saw from storm surge during Sandy.  They have installed dikes and seawalls, waterproofed utility lines, etc.  A mass effort to install air conditioning in every apartment in Chicago would have been such a response.  (Having air conditioning apparently reduced one’s odds of dying by 80%.)

Instead because Chicago now knows about neighborhood specific mortalities under these conditions, in hot periods they escalate welfare checks to the people they know are vulnerable there.  Klinenberg thinks these high mortality rates are reflective of low social cohesion, and that the low mortality neighborhoods (the ones that don’t differ much in geography, income, or race from the higher mortality ones) have high social cohesion.  There, people know who their vulnerable neighbors are on their block, and in their apartment building.  They know this because they have lived there for years, and know when their neighbors usually shop for groceries, or visit the hair salon.  The differences are not related to physical infrastructure; they are related to social infrastructure.

Put simply, lack of social cohesion kills.

So what if disaster response (or lack thereof) isn’t the only way poor social cohesion kills?  What if the same factors also predict medical mortality?  Re-admission rates to the hospital?  Medication adherence? 

What if building more hospitals, ambulances, and emergency rooms amounts to a physical infrastructure response to problems that are much more amenable to social infrastructure improvement?  As hospital beds continue to proliferate while demand is falling, are we just building more seawalls behind seawalls because we only know how to finance building seawalls, and have no clue how to finance building sustainable neighborhood associations?             

These questions I believe will become more and more prominent in our dialogue on progressing our American system for health optimization.  The health care delivery system seems to be mostly a physical infrastructure solution, and an unsustainably expensive one.  Developing a health optimization system seems to me to lead inevitably to a social infrastructure development system.  No matter how good they are, it seems unlikely that professional repairmen will ever substitute for a neighbor knowing the signs you’re not well, and being willing to do something about it. 

Part of this lack of blogging is related to the fact that I don’t entirely get its use and benefits, at least not yet.  Fortunately, I have experience with not getting it, and persevering despite that.  When I headed a company, I did networking the conventional way, meeting people in person, going to lunch, etc., for a full three years before I understood why.  So I have some faith that some time down the line, this will get clearer for me.

Right now, here’s why I think we do this, in person or on the Internet.  I don’t think one blogs purely to supply others with information.  Most of what I could tell anyone about anything they care about has already been posted by Reuters or CNN an hour before I found out about it.  We live in the information age, and about the last thing anyone needs is more information.  People take long vacations on desert islands to escape that sort of thing.

Instead, if we are lucky, blogging give others insight into the way we think, and how that might be helpful in their own situation.  I think I have shied away from posting partly because it seems odd to assume that the random firings of my neurons might be interesting/entertaining/thought-provoking for others.   And, in the vast majority of cases, I think that will be right; people will read and think, “Not helpful”.  But the beauty of the blogosphere is that those people can move on to someone else’s blog that they do find helpful.  To all that remain, welcome.  Both of you.

We live in an extraordinary time in so many ways, but germane to this blog, we live in the age of American health care reform.  Some of you may have heard me speak about this, but there are a few core reasons why this is:

• We as a nation are out of money.
• We as private enterprises are out of money.
• We as individuals and families are out of money.
• I have slides to prove all of the above are related to the cost of health care.
• Other than that, it’s going very well.

Okay, there are other things at play here, which we will go into over time, but suffice it to say for now, being out of money has an amazing clarifying effect on one’s thinking.  All the other things we will talk about here have been true for many years, even decades.  But the one thing that compels us to have this conversation now, this topic that ranks just below having root canal for most of us, is that we are out of money to buy off the pain of real reform.  I don’t know if anyone’s noticed, but the debate over entitlement reform is largely about one really big entitlement, the one we call Medicare.  Yes, there is Social Security, but simply by changing the cost of living adjustment and raising the eligibility age some, we can take care of most of that problem.

But Medicare, there’s a problem that goes beyond actuarial analysis of the stability of an insurance pool.  While it is technically an insurance program, it is so much more to so many people.  In the simplest terms, it is hope.  It is an amorphous institution in most of our minds, that attempts to buy miracles with pooled resources created by a collective agreement to pay into the pot, without know which miracles we will need for ourselves, of even if we will need them at all.  Unfortunately, the price of this hope is going up at roughly two to three times the rate of general inflation, and it is crowding out other things that also create hope.  But these latter things are for those closer to the beginning of their lives rather than those closer to the end.  These are things like bridges, roads, schools, and other things that create future prosperity, for individuals and the American community as a whole.  There is a commercial on TV right now that decries the tyranny of the “or”, the necessity of choice.  Why can’t we have it all, it asks while the spokesperson does a funny dance?

We can’t have it all, because we never could, and we are having trouble believing that our perception of limitless resources was an illusion.  We make popular movies in which against impossible odds, the hero/heroine saves the day, no matter what any stinking authority figure tells them.  In the movies, the one in a million shot always comes through.

In a way that makes me a little sad, we are having to give up the illusions of childhood, and become adults.  We are being asked by our posterity to recognize limits, that we will not be forever young, that we must choose the nuanced discussion over the sound bite, choose the understanding of others as being as complex as we feel ourselves to be, and just as sympathetically flawed.  We have met the authority figures, and indeed they are us, only with wrinkles and lines that we do not recognize as our own in the mirror.  These things all fall to us: the necessity for mercy, for difficult choices, and for prayers for wisdom in an imperfect world.  None of these can be delegated or outsourced anymore.