Eyeworld

EW NEWS & OPINION 18 December 2016 Insights by J.C. Noreika, MD, MBA part-time employment means no health insurance, retirement plan, sick and maternity leave, and other perks of full-time employment. More than a century of organized labor's accomplishment is expunged. But is this not the toll of ownership? The platform economic model holds risk and benefit for ophthal- mologists. If access to surgical care becomes too scarce or expensive, politicians may approve new models employing physician-extenders as alternatives for service. On the other hand, concierge medical practices demonstrate that some patients are willing to pay a premium for perceived quality, convenience, and responsiveness. I am reminded of an instance of collaborative health care that is more proximate to Marx than MACRA and MIPS. A patient, the late Dr. Roland Mansell who prac- ticed during the Great Depression in rural Ohio, told me of his mak- ing house calls and being paid in fresh eggs. Both patient and doctor thought this an equitable exchange. They—not Marx and Engels—solved the price/value conundrum. EW Editors' note: Dr. Noreika has practiced ophthalmology since 1981. He has been a member of ASCRS for more than 35 years. Dr. Noreika would like to thank Ryan Chowdhury for inspiring this essay with their conversation. Contact information Noreika: JCNMD@aol.com destruction." Some consequences are unfair and inequitable. Munic- ipalities, states, and countries are deciding whether they are legal. The hospitality industry is crying foul as entrepreneurs buy houses in neighborhoods for the purpose of using them as Airbnb rentals. Hoteliers rue the lack of regulation. Stable neighborhoods are disrupted as social activists decry rising rents that force working class and fixed income families out of homes. New York City and San Francisco, desir- able destinations where hotel prices are steep, are examples. New York's Governor Andrew Cuomo recently signed a bill that imposes fines on Airbnb hosts who violate housing codes and dodge taxes. Dubbed by media as the "Kill Airbnb Bill," the digital facilitator predictably sued New York state within hours of its signing. Uber faces significant reg- ulatory headwinds worldwide. Des- ignated an unregulated taxi service, Germany, India, Spain, and Thailand have curtailed or banned it. In this country, courts must decide whether Uber drivers are independent con- tractors or employees. Can innovation and regulation co-exist? I like the convenience of Uber, its iPhone interface displaying the price of my trip, its entrepre- neurial culture. As a driver, I would enjoy being my own boss, flexible working hours and using my own means of production, my car. Uber's evolving fee structure charges its drivers 25 to 28% of a ride's fee. But the privilege of independent, would embolden ever-larger cartels at the expense of Main Street impels immediacy to health care's consol- idation by government, insurance companies, pharmaceutical vendors, and hospitals. Once a noble pro- fession, medicine is doomed to be the most important too-big-to-fail business. This brings me to the "sharing economy." At its minimus, it is a provocative trend. At its utmost, it is a revolution that addresses capital- ism's inequities by allocating surplus value to those who produce it. Few Americans have not heard of Uber or Airbnb. They are direct descendants of peer-to-peer businesses like eBay and online retailers like Amazon. Collaborative economies encompass three drivers: social, such as sustain- ability and independent lifestyle; economic, such as idle inventory and economic disparity; and, tech- nologic, such as social networks and mobile payment systems. To suc- ceed, all depend upon the ubiquity and instant gratification of the inter- net. The world wide web may be the nearest thing to a classless society that humans have yet invented. I am fascinated by this eco- nomic megatrend. And left terribly conflicted. The sharing economy is based on two parties freely ex- changing value by renting unused or underused assets at a price each agree as fair. These assets may be bedrooms and houses (Airbnb), cars (RelayRides), chauffeurs (Uber), dog sitting (DogVacay), personal assistance and labor (TaskRabbit), clothing (Poshmark), cash (Lending Club), and mortgages (SoFi). Economists criticized Marx and Engels' failure to solve the value/ price riddle; it was a major blow to their theory's legitimacy. Collabo- rative consumption helps level the value/price playing field. Lessor and lessee must negotiate both before a transaction is consummated. This contrasts sharply with the dollars ophthalmologists attending the American Academy of Ophthalmol- ogy's recent annual meeting paid to hotels for a night's berth. Airbnb, a digital asset platform, fosters com- petition alien to government and other monopolies. It's not all good. The sharing economy has fomented a great deal of dislocation, what Joseph Schumpeter coined "creative As platform economic enterprises multiply, workplace dislocation is inevitable. Medicine is not immune to their risks and benefits K arl Marx was an interest- ing guy. Not that you'd want to have lunch with him. He was said to be obstreperous, intolerant of opinions other than his own, and less than attentive to personal hygiene. He was penurious, wore out his welcome in much of Europe, and was little known during his lifetime. Thanks to the financial sustenance, philosophical collaboration, and posthumous promotion by Friedrich Engels, he became an inspiration to Vladimir Lenin, Mao Zedong, and most of the world's anti-imperialists. A delicious historical irony, Horace Greeley, founder of the New-York Daily Tribune, hired Marx as the paper's London-based European cor- respondent. With his earnings at the Tribune, Marx was able to write his masterpiece, Das Kapital. Contem- poraneously, Greeley was helping create the Republican party while supporting Abraham Lincoln. Marx proved wrong about many things. Anti-capitalistic, he raged against abuses of the working class—the proletariat—yet offered few solutions. He reaped benefit from bourgeoisie capitalism while impugning its excesses. He cham- pioned a "classless society" but accomplished little to ameliorate the lot of the masses. But, as Sean McElwee wrote in Rolling Stone, he did get some things presciently right. Workplace robot- ics and driverless vehicles? Marx foresaw these as a logical extension of the relentless quest for profit by suppressing the price of labor. Globalization? Capitalism's appetite to find new consumer markets and environmental resources was not intuitive to mid-19th century econo- mists. His prediction that capitalism Karl Marx, Airbnb, and ophthalmology J.C. Noreika, MD, MBA

• Cover