A bridge in Brooklyn
I cross the Gowanus Canal regularly, and find it difficult to remember where the crossings are, and frustrating to shlep around to them. It seems like there are too few.
As a partial remedy, inspired by Jane Jacob’s memorable discussion of “border vacuums” in her masterful The Death and Life of Great American Cities —
> The root trouble with borders, as city neighbors, is that they are apt to form dead ends for most users of city streets. They represent, for most people, most of the time, barriers.
— I propose the following pedestrian and cyclist bridge over Degraw Street, placed for maximum impact on permeability:
A bridge here would reduce the time to travel from one side of the canal to the other from points in the surrounding blocks dramatically, and make the canal more pedestrian-and-cyclist friendly. I think it would nicely complement the cleanup efforts and other development plans currently under consideration.
Critique of a Plan
A response (heavily influenced by David Goldhill’s indispensable Catastrophic Care) to the five points in the well-meaning: A Plan to Fix Cancer Care.
the payment system needs to move away from fee-for-service toward a system of bundled payments, in which doctors are paid one fee for all the treatments involved
Certainly it does. But instead of replacing one one-size-fits all payment mechanism with a different (probably better, but who knows?) one-size-fits-all payment mechanism, why not free providers to experiment with 1000 different ways of charging for their services, and let patients reward the ones who come up with the best, cheapest, lowest-administrative-cost ways?
Insurers have to give physicians information about where they are spending money,” the authors write, adding that doctors “don’t have a clear sense” of billing and payments.
Insurers already have an interest* in reducing costs, so if they’re not already doing everything in their power to give physicians this information, why should we think that calling on them to do so more will help anything? The relationship between doctors and insurers is too adversarial for this to ever work. Only by empowering patients to demand this information can we impose this kind of discipline.
* For some surprising insight into the ways in which this is not actually true (making the proposal even more naive) read Goldhill.
Any change in payment methods must be accompanied by rigorous quality monitoring to ensure that there is neither under- nor overutilization of care.
Great! Agreed, regulatory agencies should enforce some level of quality reporting. But what central authority can we rely on to be the exclusive enforcer of this? The only people who can effectively enforce the demand for quality are patients, by choosing which providers to frequent and which to punish, driving them out of business.
We need more ‘high touch’ oncology practices. In these practices, nurses manage common symptoms before they escalate to the point that they require visits to the emergency room, and doctors talk with patients about palliative-care services and end-of-life preferences early on — not in the weeks before death.
It’s a nice idea, but two objections: 1) how do we make that happen? We can build a new regulation to encourage it into CMS reimbursement or impose one on the insurers, and that regulation might kinda “work” in a static sense. But it will surely have unintended consequences, will be out-of-date in a year. And 2) in any case this is just one idea. It may be a good one, but we need 1000 more, and we need patients to vote on which ones they like.
We need better incentives for research,” the authors write. “Many expensive tests and treatments are introduced without evidence that they improve survival or reduce side effects, and with poor information about which patients should receive them,” they continue, referring to robotic surgery, high-tech imaging, radiation therapies, and other matters.
In other industries, when an expensive product that’s not better in any way than the products that are already being sold is introduced, what happens to that product? We (300 million consumers) decide not to buy it, and it fails. In medicine, FDA approval leads inexorably to massive subsidy. As a political entity, CMS will always be subject to political pressure from pharmaceutical companies and device manufacturers and a dozen other corrupting influences. If we’re lucky, our political process may muddle together enough resistance to those forces enough to impose some discipline. But I doubt it.
Phnom Penh fantasy bus map
Living in Phnom Penh for the last couple of months, commuting by motorbike between home in Tonle Bassac and work on 271 near the Russian market, I’ve been struck by how abysmal the traffic is. A trip that takes 15 minutes at 2pm can take 90 at 5:30. It hasn’t always been so bad, I’m told. And is now getting worse and worse as cars proliferate. So I’ve spent a lot of time on the moto thinking about what could be done.
Phnom Penh is unusual for a city of its size in that there’s essentially no public transportation at all. Tuk tuks and motos are the only options. There was a Japanese-led attempt to institute a public bus system a while back. But it fizzled out due to…well, I’m not sure why. But I hear it’s because no one used it. I’ve also heard that Phnom Penhians never would use such a system.
It’s only going to get worse as incomes rise and cars become more and more popular, so I think it’s time this city gives it another try.
So here’s a fantasy Phnom Penh bus system:
It consists of three interlocking loops. I imagine buses on the inner loops would circulate in opposite directions - one clockwise, one counterclockwise. And that buses on the outer loop would move in both directions.
The buses should run in aggressively enforced dedicated lanes. Fares should be no more than half the cost of a typical cross-town tuk tuk (or maybe they should just be free!). The system could be funded by dramatically higher car registration fees and gasoline taxes, so that cars are made to be less appealing at the same the bus becomes more so.
I’ve ridden along many of these roads, but not all of them. I’m also not a Certified City Anything. I just like public transportation. So, Cambodia friends, what do you think? Could it work? Do these routes make sense? If it were fast and affordable, would people use it?
(Map image courtesy of open street map)