Hey, Medicare geezers, when was the last time your doctor saw you naked?

 The S.O. and I were chatting the other day, talking about doctor appointments and the annual "wellness" visit with one's primary care physician, and we started wondering just when was the last time either of us had an actual full-blown annual physical. In my case, it was probably in Atlanta. Might be the same for the S.O. In any case, it was before passage of the Affordable Care Act. 

One of the provisions of the ACA is that Medicare will pick up 100 percent of the tab for an annual wellness visit with your primary care physician. No co-pay like there always was (and still is) with an actual physical exam. And, yes, young folk, Medicare has co-pays just like every other insurance plan in the U.S. The stuff it covers (and there's a lot it simply doesn't cover, just like . . .) Medicare reimburses providers 80 percent of what they (Medicare) has decided is a reasonable rate. The patient is on the hook for the other 20 percent, although there are providers who are happy to just get the 80 percent -- they treat it like full payment and never bill the patient for the rest. Those providers are rare.

Anyway, the purpose of the wellness visit is supposedly to just chat with your PCP about your health, raise any concerns you may have, and decide if "further research is needed." This is actually the visit that had right wingers foaming at the mouth because it was originally framed as the moment when your doctor would ask you about care directives, the infamous living will. It got redefined as a time to talk with your doctor without getting naked. An office visit where the doctor and you would talk about your health in general and decisions could be made about what to do next. You know, do you need to actually take your clothes off for a thorough exam? Or maybe get a referral to a specialist? It was quite explicitly not meant to be an actual annual physical exam. 

Except, of course, it gets treated like one. You make an appointment for an 'annual' with your PCP and by default it becomes the wellness visit. Or, as I tend to refer to it, the "yes I'm still breathing" chat. You get your temperature and blood pressure checked, the nurse or technician reviews your record (any new medications? Been to any other doctors since the last time you were in?), and that's about it. Your doctor comes in, asks if you have any concerns, reminds you (if you're a woman) you're overdue for a mammogram, and life moves on. The guy I see will usually get out the stethoscope and listen to me breathe (confirming, I guess, that I'm not a revenant), he'll ask a few ADL-related questions* (e.g., can I still tie my own shoelaces), we'll make small talk about infectious disease (he went to Africa as part of a team responding to one of the Ebola outbreaks a number of years ago, I worked on the journal Emerging Infectious Diseases at the CDC), and we go our respective ways. No feet in the stirrups and an ice cold metal implement being inserted into a very personal space, no quick manual boob exam, no doing a quick scan of exposed skin for odd looking growths. None of the stuff that used to be a routine part of an "annual."

I see this as typical of the Law of Unintended Consequences. The intent of the wellness visit provision was to improve elderly person's health by giving them an opportunity to talk with their doctors. It was meant to be a complement to other routine care, like an actual annual physical. It was not supposed to replace it. But inevitably it did -- a wellness visit takes a lot less time than a full-blown physical, which means more patients can be scheduled in a physician's day, which in turn means more money and reduced expense for the provider. It may seem kind of minor, but when patients keep their clothes on you don't have to worry about providing gowns for them to change into, there's no time being wasted while waiting for patients to undress, there are no supplies like gloves or lube being used, cleaning the exam room between patients is a lot faster and easier. It adds up. 

It also makes perfect sense that in the profit driven model that is the American health care system that the wellness visit would morph into the primary visit. Next step, as we've already seen during the pandemic, is going totally to telemedicine. Health care delivered via telephone and Zoom meetings. We're all really close to being able to list WebMD as our PCP. 

Which, in an odd way, is rather comforting. Back when the annual was truly an annual, I swear every year found me with a new comorbidity. Since it became the 'are you still breathing' visit, no new pre-existing conditions have emerged. I am apparently a heck of a lot healthier now than I was ten years ago. Ignorance can be bliss.

 *ADL - activities of daily life. Questions about ADLs are meant to determine if you're still capable of living independently or do they need to start getting a bed ready for you at the local nursing home.

Obvious unintended consequences: Grandma as a permanent houseguest

One of the things that I've heard coming up as part of the ambitions of the Trump administration is the desire to turn more stuff over to the states, like converting programs such as Medicaid into block grants. Medicaid is the federal program that funds health care for extremely poor people. You know, our fellow Americans who too many of us assume are shiftless, lazy, and unwilling to work. If you ask the typical right-wing conservative what they think of government-funded health insurance for persons living in poverty, the likely response is going to be "they should get jobs and pay for insurance like those of us who are willing to work do." Only one problem with that thinking.

You know where the bulk of Medicaid funding goes? It's not so to some kids or people of working age. It goes to keep old people in nursing homes. Observant readers may have noticed a proliferation of attorneys specializing in "elder law" in recent years. There was a time when only the wealthy worried a whole lot about estate planning or what was going to happen to their assets such as real estate once they hit their golden years. Since life expectancies crept up and more people started living long enough to develop the wide array of chronic morbidities that hit with age (i.e., diabetes, heart disease, hypertension, arthritis, dementia, . . . ) families of the elderly began realizing that it was quite possible that whatever Mom and Dad managed to accumulate during their working lives was going to vanish as the medical bills piled up. Instead of inheriting the old family home or a stack of T-notes, the potential heirs realized they'd have to accumulate their wealth the old-fashioned way: earn it themselves. Unless, of course, they could shelter assets through estate planning. Hence the proliferation of elder law specialists.

Elder law specialists do more than draft wills to help prevent heirs from squabbling over who gets Great Grandma Clara's Wedgewood china. They help people with assets (real estate, cash, whatever) figure out ways to shelter it so that if the day comes when they've got to go into a nursing home the cost of their care is going to fall on society as a whole, aka taxpayers, and not on the individual elderly and their immediate family. The initial legislation for Medicare and Medicaid was passed in 1965. It took a decade or two, but people eventually realized that if their elderly parent qualified as "poor" that Medicaid would pick up the tab for the nursing home. The trick was making the parent poor enough, which is where the elder law attorneys enter the picture.

It can be a rude awakening for most folks when they discover (a) Medicare does not pay for nursing homes; (b) when the government says you have to be poor to qualify for Medicaid, they mean it. Absolutely bare bones no assets whatsoever worth mentioning. If you own real estate, if you can't sell it before you die, it's going to have a government lien on it when you do go. If you have a whole life insurance policy, you're going to have to cash that sucker in, although you will be allowed to use a chunk of it to pre-pay for a funeral. And, as any good elder law specialist will tell you, the earlier you realize those facts of life, the better. The government can go back several years searching for reimbursement for the cost of your care. It used to be three years; it might be more now. That particular aspect of Medicaid law is, of course, intended to prevent people from trying to milk the system the day after they require nursing home care.

So what happens if the conservative Republicans succeed in their plans to turn Medicare into a voucher system and Medicaid into a grant block program? I can tell you. I've seen it. I remember it. Back when I was young, in those days of yore when dinosaurs roamed the earth, when someone's elderly relative became too fragile or feeble to live independently, they took up residence with a relative. If they had multiple adult children, families would engage in "pass Gramps around." The old person would spend a month here, a month there, until whoever was hosting the old geezer or geezette would decide they'd had enough and pass the aging parent on to the next unlucky sibling. In some cases, PawPaw or MawMaw would become permanent houseguests. Family members would find themselves having to bathe and diaper their now senile and incontinent parent or grandparent. Without having to think about very hard, I can recall at least half a dozen friends who had a grandparent living with their families. For most, it was not a happy situation.

You don't find many elderly chronically ill people living with their descendants these days. They're in nursing homes. How many would be there if not for Medicaid is debatable. Until the reality slaps you in the face, the typical person has no idea just how incredibly expensive caring for the elderly can be. Back in the '90s I served as my aunt Thelma's financial representative. She had to go to a nursing home after she had a stroke following by-pass surgery. She was a frugal woman and did have the cash stashed away to be private pay. At that time, the basic monthly cost was about $3500 a month. It would easily be double that today.

So what happens when the greedy heirs who have pushed their parents into estate planning and signing away their assets discover that the reason for doing it -- Medicaid -- no longer is an option? Are they going to be willing to start liquidating the stuff they'd anticipated inheriting? (I'm guessing probably not.) And what about the elderly who were genuinely poor to begin with, the old folks who maybe have a small life insurance policy and not much else? Families have gotten smaller -- it's no longer possible to play pass the grandpa -- and most don't have the ability to pay for outside help, like an aide to stay with the senile parent while the adult child goes to work. What happens when Medicaid goes away and the nursing home tells you to come pick up your senile parent or grandparent because they're about to close their doors  because without Medicaid payments they can't operate and the old person has to go somewhere? Every so often there'll be a story on the news about an aged relative being abandoned at a highway rest stop or other odd location because the family hadn't been able to get that person into a nursing home but could no longer cope on their own. How much more common will that scenario be if Medicaid vanishes?

We live in interesting times. Here's hoping that enough politicians can be persuaded to look at real world consequences instead of blindly behaving like lemmings and following The Donald and Paul Ryan off a cliff.

I'm in better shape than I thought

I had the odd experience yesterday of suddenly feeling remarkably young and healthy. I decided recently to go looking for a new primary care physician and, as long as I was doctor shopping, to seek out a geriatrician. After all, I'm a geezer now. It made sense to go looking for a physician who specializes in taking care of old people. People can try to put a positive spin on aging, make ridiculous statements like 60 is the new 50, and talk like they're going to live forever, but the reality is that once you hit your 60s you can no longer claim to be "middle-aged." You're old.

And you start feeling old. You wake up some days with assorted aches and pains and you haven't even done anything yet. You get nervous when you have to get up on a step stool to get something off a high shelf because the idea of falling is getting scarier and scarier. You can feel yourself sliding into that broken hip demographic. It's hitting you more and more than you're not just old, you're elderly. And then you walk into the waiting room at the geriatrician's office.

Holy wah, I'm young again. No walker, no cane, no oxygen bottle in tow, no one hovering by my side making sure I don't fall over . . . suddenly I am apparently the healthiest person in the room. It felt . . . odd.

As for why I went seeking a new PCP, among other things the doctor I had been seeing had mentioned that she's not happy with the weather here on the tundra. I got the distinct impression that as soon as her contract with the local clinic is up, she was going to disappear over the horizon to a warmer climate. I was due for an annual check-up so decided it was a good time to make the switch. I've got to drive farther, but I think it's going to be worth it.

The doctor, incidentally, affirmed I am in good shape in general, although (no surprise) I should establish a formal exercise routine. I figure that if I've gotten to the age I am now without incorporating a formal exercise routine into my daily schedule, it's not likely to happen in the future, but you never know.

Mortality

“Getting older isn’t easy for a lot of us. Neither is living; neither is dying. We struggle against the inevitable, and we all suffer because of it. We have to find another way to look at the whole process of being born, growing old, changing, and dying, some kind of perspective that might allow us to deal with what we perceive as big obstacles without having to be dragged through the drama.” – Ram Dass, Still Here (©2000)

Back when I was younger, I used to laugh at my aunt Ingrid's reactions to the news that someone had died. If the decedent was older than her, she'd sound relieved. Yep, he's dead, but, heck he was two years, five years, ten years or more older so it was no surprise the old dude had bought the farm. Yeah, he's dead, but he was ancient; I've got lots of time left. On the other hand, if the dead person was younger there'd be a kind of surprised, almost fearful response: but she was so young! This is such a shock! Even if the age difference wasn't great, like if she was 70 at the time and the decedent was only 69, she'd start looking worried. Time was obviously running out. 

Well, now I'm in my 60s reading obits and seeing life spans shorter than mine -- and I'm starting to have a similar reaction. Oh, shit. I'm not going to live forever after all. It's one thing to recognize that fact intellectually when you're in your 30s or 40s, but it feels a little different once you start wondering if you really should buy those green bananas. You start to hope you're one of the lucky bastards who drops dead unexpectedly and inspires bad jokes (hit the ball, drag Harry) and not one of the poor saps tethered to an oxygen bottle at the nursing home. 

Most of the time I don't think about it much, but this was one of those months where I wound up having conversations with my primary care physician about glucose levels, cholesterol, weight, and all the other things health care providers love to fret about. My blood glucose was a number that is now considered too high: they moved the goal posts a few years ago, so what was perfectly okay a decade ago is now Ohmigod-you-need-to-take-metformin. Ditto the cholesterol. The numbers haven't changed in years, they always hover right around just over the line, but every time my PCP sees them it's ohmigod-you-need-to-take-Lipitor. 

Why? Am I going to live longer? Well, no. Lots of studies have been done showing that if you're one of those just over the line people treating a condition that's borderline doesn't do a thing to increase your life span. Will it reduce risk of heart attacks or strokes? Ah. . . no. There isn't a statistically significant difference in outcomes for people whose cholesterol falls in that just over the line area. Well, what about quality of life? Are they going to make me more physically fit, help with aching joints, make it a little less scary scrambling up step ladders or easier to get up if for some reason I've decided to kneel on the floor? Nope, not at all. The only thing that helps with activities of daily life is exercise to retain mobility and flexibility.  

In fact, there are no good answers that justify taking drugs for a borderline condition, at least not for me. You go from knowing your total cholesterol is just over 200 to knowing it's just under while at the same time enjoying all the fun side effects, like gas that practically makes you jet propelled, diarrhea that has you wishing you owned stock in Kimberly-Clark, and giving up foods you like because they can interact in a bad way with the drugs. You haven't actually gained any years; it's just going to feel a lot longer because you're miserable. The line between "you're okay" and OMG is a fairly arbitrary one; it had to drawn somewhere, but that area on either side of it is a fairly fuzzy one. 

I can understand why physicians and other health care providers are reluctant to face the truth and admit that the stuff they're prescribing might not actually do much: they're dedicated to saving lives. It sucks that they can't offer their patients immortality (or even a comfortable old age). Handing a patient a prescription lets them feel like they've done something even if they really haven't. I don't know if I'll bother arguing with my PCP about this or not; I might just let her write the prescriptions and then not get them filled. She's talking about leaving L'Anse anyway (the winters are pushing her away). Odds are that a year from now I'll be dealing with someone new so the current PCP will never know how thoroughly I ignored her advice. 

I figure that at my current age, if all goes well, I've got a 50% chance of making it to 86. If the odds are only 50/50, I think I'd prefer to spend that time enjoying a decent qualify of life instead of shuffling pill bottles and wondering if I should invest in some Butterfly Body Liners. After all, nobody lives forever. 

Book Review: Worried Sick

Getting older?  Starting to hear speeches from your primary care physician about your cholesterol creeping up, your body mass index being too high, or your blood glucose levels putting you on the cusp of prediabetes?  Read this book, and then tell your PCP where to shove her advice. 

In Worried Sick, Nortin M. Hadler, a physician and rheumatologist, makes a strong case for evidence based medicine.  He exposes the very weak base underlying many pharmaceutical interventions and invasive procedures, such as cardiac bypasses and stents, and encourages patients to do two things:  educate themselves and -- this is the tricky one for Americans -- accept their mortality.  As he points out, over time the mortality rate for being human is 100%. 

Dr. Hadler notes that there is a definite biological limit to how long any of us is going to live.  If we're lucky, we'll make it into our 80s, possibly our 90s, but by the time we get there we're going to be carrying a bunch of comorbidities with us, most of which we have no control over.  The big question is whether or not any of the many procedures and drugs that get shoved at us will actually make it more likely that we will get to be a nonagenarian.  For most of us, sadly but realistically, the answer is no.  Also sadly but realistically, almost none of us are willing to admit that.

This point about longevity is a no-brainer:  if average life expectancy for someone alive today is, for example, 78, that means that only half of our birth cohort (all the other people born the same year as ourselves) is going to make it that far.  Granted, there are reasons why that mean may be skewed a little low, but not by much.   

So if all the various procedures physicians, pharmaceutical companies, and surgical device manufacturers push at us don't really prolong life, what about quality?  If I can't live longer, can I at least live better?  That's where it gets tricky.  Is it worth it to go through the pain and prolonged healing of a multiple by-pass?  For people for whom the procedure goes well and healing is rapid, the answer might be yes.  They may not live any longer or have fewer heart attacks than they would without the surgery, but they feel better, so for them getting their chest cracked feels like it was a good choice, even if they do end up filing bankruptcy because they can't pay the medical bills.  But are those people with the good results the rule for the aftermath of the surgery or the exceptions?  Good question.  Personally, and I know that anecdotes don't count as data, having observed several people who survived the surgery but then experienced some very predictable aftereffects from blood clots, if my cardiologist ever suggests slicing me open, he's out of luck.  I might buy into valve replacement, but never bypass -- but that's me, someone else might make a different choice.

Dr. Hadler spends much of the book talking about medicalization -- the process by which we as a culture take something that was normal and turn it into a condition that has to be treated.  Along the way he describes the way the medical community keeps changing the definitions for what's good and bad, making the threshholds for "healthy" ever lower (a process which just coincidentally advantages companies such as Pfizer).  This section really resonated with me.  The normal range for blood glucose in a nondiabetic is 70 to 120; I had a blood glucose test done recently where the result was 103 -- and, lo and behold, I'm now "prediabetic" and I "really should think about taking metformin."  (I'll think about taking metformin the same day I decide I'd like to live with chronic diarrhea; over 50% of metformin patients report that particular side effect.)

This process of adjusting "healthy" down has also happened with cholesterol -- the "normal" range has been moved lower, making it less and less likely the average person will fall into it without pharmaceutical interventions.  It's like they're all forgetting that cholesterol is in the body for a reason -- it's needed for Vitamin D retention, among other things -- and have decided all cholesterol, regardless of whether it's HDL or LDL, is "bad" and has to go.

And weight -- the much hyped explosion of fat in the 1990s occurred not because people suddenly started binging like never before, but because the ranges on the BMI for underweight, normal, overweight, and obese were shifted downward by several points.  People who had been considered in a healthy weight range suddenly found themselves Too Fat, all without gaining a pound.  Result?  Instant Obesity Epidemic.  Does anyone even know what a "healthy" weight is?  We all know what a culturally defined aesthetically pleasing normal weight is, although that shifts over time, too (compare the Gibson girls circa 1900 with the women considered attractive today), but what's actually healthy?  A lot of fat is obviously bad -- no one would argue that those folks having to be removed from their homes with forklifts have embraced health at every size -- but where's the cutoff between no problem and too much?  Overweight old people live longer than thin ones, so where does the argument that losing weight will help you live longer come from?

Dr. Hadler raises these questions, and many others.  He notes the skyrocketing cost of health care in the United States, reminds us that rising numbers of people do not have access to health care at all, and pushes hard for evidence-based medicine.  The U.S. spends more as a percentage of gross domestic product (GDP) than any other industrialized country, but has more uneven outcomes and lower life expectancy. There's obviously a lot of money being wasted when the results are so poor. How many procedures are being done that benefit only Medtronics or Pfizer's bottom line while adding nothing to patient longevity or quality of life?  He recognizes that there are some diagnostic procedures that have become so socially entrenched in our collective conscious that they may be impossible to dislodge -- annual mammograms for all women over 50 regardless of risk factors being the prime example of a procedure that has almost zero benefit but has such a strong constituency you can't get rid of it -- but he encourages readers to not allow themselves to be bullied into spending their money (or their insurance company's) on procedures or drugs that they don't need.

Worried Sick also examines alternative or complementary medicine.  After providing a good overview of the area and the history of practices such as chiropractic medicine, Dr. Hadler's attitude toward chiropractors, herbalists, naturopaths, and others is to advise us, in essence, "If you want to waste your money, go ahead."  He also warns the reader that because the standards for "natural" products do not include much in the way of quality control, you really don't know what you're getting in your ginseng tea or gingko biloba tablets.  The actual herbal content might be very low and it might contaminated (as has been found to be very common in products from China).  Caveat emptor. 

This book covers a wealth of material.  It also includes an extensive bibliography and supplemental readings that further explicate the studies Dr. Hadler cites so the reader knows where to go looking for more information.  It wasn't easy reading, but it was worth it.

Update:  After thinking about it, I feel compelled to add that Dr. Hadler isn't saying that all medical treatment is unwarranted or unproven.  He's saying be an informed patient.  Some procedures are necessary, some drugs do work -- but not all of them, not all the time, and not for everyone.  Do your homework.

What's in a name?

I was watching the Daily Show last night.  The guest was John O'Hara, a young conservative who's written a book about the tea party movement.  Jon Stewart and he were having a discussion about the need to have actual discussions, not shouting matches and namecalling.  The phrase "Obamacare" came up, and Stewart politely told his guest that it struck him as being one of those terms that's being used in a derogatory or denigrating fashion -- wouldn't it be more intellectually honest to say "health care reform"?  After some back and forth, the guest agreed. 

Personally, I thought it would be even more honest to call the bill by its actual name, but then it hit me -- just what is the name of the recently passed health care reform legislation?  I don't think I've ever heard anyone actually use it, at least not enough times for it to register.  No doubt it was mentioned in speeches made by various politicians and at the signing ceremony, but the media seems to have ignored it.  The right wing keeps hammering away, calling it "Obamacare" (which could turn out to be a huge mistake politically if the public decides it's not that bad after all), but no one to the left of them ever corrects that phrase with the actual name of the legislation.  So I went looking.  It's the Patient Protection and Affordable Care Act, aka Pub. L No. 111-148, which is definitely a lot less scary sounding than "Obamacare."

And, as an aside, despite the reputation Congress has for sitting on its collective butt, that number means it's the 148th bill passed by the 111th Congress and signed into law.  Now I'm wondering just what the other 147 were. . . and I'm not sure I really want to know.

We're safe

Health care reform will not be repealed.  How do I know this, given that the airwaves are full of bloviating Republicans and teabaggers vowing to roll it back ASAP to ensure that cripples, kids, and the chronically ill can still be jacked around by the insurance companies?  Bill Kristol has weighed in on the subject. 

Kristol is, in fact, predicting a fast repeal.  Kristol, the pundit who has never been right on anything (other than his political orientation) in his entire career. 

I have a lot of reservations about the reform as passed.  It is, among other things, a massive gift to the insurance industry, although from the gnashing of teething and tearing at hair on the right you'd never know that.  On the other hand, it is, as even Dennis Kucinich has admitted, a start. 

As for efforts to repeal it?  Lots of luck with that one, teabaggers, when the items that kick in first are the ones that are most popular with the public, like being able to keep your college student kids as dependents on your insurance plan until they're 26 or being able to get health insurance in the first place for your asthmatic child.  It's going to be rather tricky campaigning in November on a promise to do bad stuff to sick kids -- although I'm sure a fair number of Republicans will try.

Bring on the tinfoil hats

Sunday morning. C-SPAN.  Lunatics crawling through the phone lines.  Good times. 

And it's equal opportunity tinfoil this morning -- people calling in on the Republican line to foam about impending socialism, Democrats calling in to rant about the lack of a public option and Obama selling out to corporate interests, and various oddballs calling in on both lines to spin their 9/11 conspiracy theories.  Occasionally Teh Stupid manages to achieve new depths.  One of the highlights this morning was someone calling in to point out that "the government has never made a profit at anything."  Well, duh.  Government is by definition a nonprofit.  It's not supposed to make money.  That's why it's the government. 

There was also a call or two from folks teetering on the edge of senile dementia with their fears about socialized medicine ruining their Medicare or VA benefits, proving that some veins of stupid never stop flowing. 

The most bizarre part is seeing Rick Scott sitting there pontificating about reforming health care.  This guy is the sleazeball who was CEO of a company that got nailed bigtime for Medicare fraud a few years ago.  He's talking up the private sector, of course, and criticizing the proposed healthcare reforms.  It's so weird -- the man should be sitting in a prison cell somewhere, not sitting there in a suit being treated as a respected expert.  Fortunately, several callers have actually pointed that out.

I wonder occasionally just how thoroughly discredited a person has to be before he or she can no longer market him or herself as an expert on anything.  When someone gets called out on lie after lie, and also ends up being wrong over and over again, why does anyone bother listening to anything that person has to say?  And wouldn't it be nice if these various talking heads who serve as fronts for astroturf organizations had to wear coveralls with company logos on them like Nascar drivers so we'd all know immediately just where their vested interests lay?

Tin foil hat time

This has been another week devoted to the health care debate.  It was all over the news channels, both before and after Thursday's political theater. And it is, of course, the first topic up on C-SPAN this morning.

Well, technically they're talking about bipartisanship, but it's all revolving around the health care as an issue and whether or not the Democrats should forge ahead on their own or continue to try to work with the Republicans.

The thing that continues to floor me are the numbers of theoretically ordinary people, folks claiming to be just your average American, who call in to C-SPAN to insist either that our current system is just fine or that we should just let the private sector work it all out, because government is sure to screw things up.  Well, our current system is, for most of us, a totally private system -- and it's not working particularly well.  The private sector has had quite a few decades to get thing right, and failed abysmally.  Premiums keep climbing, what policies actually cover keeps shrinking, people are paying more and getting less. . . so why would anyone with more than two brain cells to rub together think that the government could possibly do worse?  

Controversy du jour

Breast cancer screening. 

It's been interesting watching the uproar.  Once again the American populace is demonstrating its inability to understand simple English -- a recommendation is not the same thing as a requirement -- and its capacity to contradict itself.  Last week the airwaves were still full of bloviation about rationing if the government gets involved in health care so we must trust the private sector; this week the airwaves are full of bloviation about the evil, evil insurance companies and how they'll use the new guidelines as a reason to deny services.  (Of course, a few people are ranting about this being an example of what we can expect under Obama-care, irrationality in action.)

The airwaves are also full of people rattling off their personal anecdotes, some of which actually serve to confirm that the new recommendations might be spot on.  Women, for example, who argued for sticking with the annual mammogram while simultaneously describing how they found their cancer accidentally, i.e., noticed a lump, and then had a mammogram -- so the mammogram saved their lives.  Which is probably true, but it wasn't an annual screening mammogram; it was one they asked for after noticing something that for them was abnormal.  (The most prominent example of that particular experience is probably Congresswoman Debbie Wasserman Schultz.)  Good Morning America just gave air time to a woman in her 20s who's arguing for annual screening because a mammogram found her cancer, totally ignoring the fact that young woman was not yet in the age group affected by the recommendations. Obviously, routine screening was not what found her cancer. 

I'm not a big fan of using anecdotal evidence myself -- the plural of anecdote is most definitely not data -- but if I were, I'd trot out the handful of breast cancer sufferers I've known and point out that not a single one of them had her cancer detected by early screening, either mammogram or routine breast self exam.  In several cases, a sexual partner noticed something odd, in others, the woman herself spotted something while showering or putting on deodorant.  Oddly enough, none of the cancer survivors the MSM have trotted out so far have named routine screening either. . . they all went for a mammogram after noticing something didn't seem right, not before. 

So should we stick with annual screening and pushing BSE anyway?  I don't know.  I'm enough of a nerd that I did the research for myself years ago (family history, various risk factors, comparisons with survival rates here and in Europe where the screening schedule is different), and decided no way in hell was I putting my tits in a vise as often as my doctors were recommending.  Two years apart?  Heck no, I've decided three sounds good.  But that's me.  My body, my life, and my choice to avoid a test I view as (for me) an uncomfortable waste of time.  Someone with a different family tree and risk factors might look at the available evidence and make a different decision.  But whatever decision anyone makes, it would be nice if it could be made dispassionately and not colored by MSM-generated hysteria.

Update:  Science Based Medicine has a good post up now on the topic.

Tunnel vision

Maybe I should have subtitled this post, "It's not all about you." 

We Americans really seem to be lacking the ability to do big picture thinking.  I was listening to C-SPAN this morning and once again was struck by the incredible tunnel vision way too many people display.  Over and over I heard the complaint that health care reform is going to drive up the costs for small businesses so they won't be able to compete.  Several callers, in fact, claimed to be business owners who said having to pay for health insurance would drive up their labor costs and thus they'd lose their competitive edge.

Edge against who?  Who is the competition?  I can understand complaints about labor costs going up if you're manufacturing widgets to sell to Walmart, because then the competition is child labor in a third world sweatshop working for pennies a day, but if you're a construction contractor?  A hotel owner?  Someone who runs a local grocery store or tire shop?  News flash for those folks:  everyone else's costs are going to go up, too.  The playing field will actually be more level than before -- because the employers who had been trying to offer health benefits, i.e., the small business owners with some compassion and/or sense of decency, willl no longer be competing with businesses whose idea of health benefits had been keeping a box of band-aids in a desk drawer. 

The complaints about health care costs, the mandatory insurance payments, remind me a great deal of the same complaints small businesses engage in every time there's a discussion about raising the minimum wage.  They all howl as though their individual business is the only one that is being forced to raise pay rates -- they behave as though their roofing company or restaurant or local supermarket is going to so screwed because everyone else will still be paying the old wages.  It never seems to occur to them that if they're being forced to do something, so is everyone else.  Nothing's changed in terms of competitive edge.  If there is an added cost, it's industry-wide.

It's a good thing I'm not a C-SPAN moderator.  I would never be able to resist the urge to tell people to STFU and stop sounding like whining teenage prima donnas. 

Can we get a giant tinfoil hat for the whole country?

Saturday morning.  C-SPAN.  Health care reform debate. And caller after caller saying, yes, we need reform -- but no way in hell should an illegal alien ever get any health care on the taxpayer's dime.

Bizarre.  Truly bizarre. 

Personally, when I'm buying food (grapes picked in California, meat packed in Nebraska, whatever) where the odds are most of the workers handling it until it landed in the supermarket cart were 'illegals,' I'd prefer that those workers were able to see a doctor when they sneeze, have a chronic cough, or run a fever.  Ditto when I'm eating at a restaurant -- go behind those swinging doors into the kitchen in almost any restaurant in an urban area and you're going to find undocumented workers.  When they spit on my salad, I'd rather not have that spit laced with mycobacterium tuberculosis.  To me it makes no sense to actively campaign for putting roadblocks to health care in the way of the people who work most intimately with our food supply.  But apparently I'm in the minority. 

And, yes, it's also the humane, decent thing to do to ensure that everyone in a society, no matter what their position (social, economic, ethnic, citizen or not) has access to health care -- but if we're not willing as a society to behave like civilized people for moral reasons, how about simple pragmatism and some enlightened self-interest? 

Summer's over and my head hurts

Although the two aren't related.  I was just thinking that it was official, Autumn is definitely here because I felt the urge to turn the furnace on this morning (it was 64 in the living room when I came stumbling down the stairs heading for the coffee pot), and then I heard Nebraska Congress critter Lee Terry in the background.  And he was saying something that had my jaw dropping. 

I never agree with Lee Terry.  He's one of the Congress critters that comes across (at least to me) as smarmy beyond belief, another one of the vacuous Herb Tarlek-types who slither the halls of the Capitol while spouting platitudes about the sanctitude of life and family values. 

So what shocked the bejesus out of me?  Terry is introducing an amendment to the healthcare legislation that would make the same type of cafeteria insurance plan (the Federal Employees Health Benefits Plan) senators and congress persons enjoy available to everyone in the country.  He stood there agreeing with ABC's Dr. Tim Johnson that the complaints about Congress not wanting ordinary folks to enjoy the same sort of health care they did were totally valid, and the FEHBP should be available to anyone who wants to opt into it.

Of course, Terry being a Republican I'm sure there's a catch somewhere, probably in the financing details, but, still, I'm stunned.  Lee Terry said something that superficially sounds good.  I'm also totally suspicious, of course.  Because it is Lee Terry.  And it's Nebraska, the heart of the heartland, a state so red it bleeds.

[I will concede that much as I dislike Terry, he's smarter than he looks.  He went on the Colbert Report very early in the history of that show, before politicians had had much of a chance to size it up and figure out exactly what Colbert was up to, and actually displayed more wit than I thought he possessed.  He may exude used car salesman vibes, but he's definitely not stupid and does have a sense of humor.]

Tin foil hat time

I love Saturday mornings and C-SPAN. The absolute certainty that in any 10-minute period there will inevitably be a phone call from someone with a Southern accent ranting about Obama mind control, the evils of socialism, and the Democrats wanting to control every aspect of our lives is oddly comforting.

This morning, of course, they're talking about health care reform. And once again callers are focusing on "choice" and preventing bureaucrats from coming between them and their doctors. What choice? Unless you're one of the extremely fortunate few, i.e., independently wealthy and paying cash for everything, you're either dependent on what your insurance company tells you to do or or, if you're uninsured, keeping your fingers crossed you stay healthy. Anyone who thinks the insurers don't control what treatments you receive and when is living in a fantasy world.

I've gotten to witness that (again) this past year. In April 2007 I went for the annual physical, the one that included a full range of blood work (lipid levels, white and red cell counts, etc) and a chest x-ray. The radiologist spotted a possible aortic ectasia on the x-ray, so my primary care physician decided to do a cardiology consult, complete with echocardiogram. She had to give a reason for the echo, but said she could not use the aortic ectasia as the reason -- Blue Cross would not pay for it. She had to use either elevated cholesterol or high blood pressure. Or both. She went with the lipids.

Personally, I would have thought the aortic ectasia would be a damn good reason for further testing in and of itself, but my gold-plated insurance bean counters disagreed. And because my PCP put high cholesterol (for the record, mine usually runs right around 2o5, which is just barely over the line -- and I have a really good ratio of "good" to "bad") in the request, it colored the interactions with the cardiologist. He's busy worrying about clotting and blockages while I'm trying to get him to think about the semilunar valve and possible aortic regurgitation. In short, I've spent the last 18 months being treated for one thing while the other thing that does have the potential to kill me is being ignored. Thank you, Blue Cross.

Garbage in my In Box

There are days when it doesn't pay to check the In Box for my Hotmail account. Or, for that matter, my work e-mail. For some reason, several different friends and relatives of the right-wing Faux News indoctrinated persuasion decided to forward a piece of crap about the "gold plated" free coverage that politicians enjoy. Apparently it reallys chaps their collective ass that President Obama, members of the Senate and House of Representatives, and various others who collect federal paychecks actually have employer-provided health insurance.

In fact, those politicians have the same employer-provided coverage that I do: they also fall under the Federal Employees Health Benefits Plan. And you know what? It's not free. It's not gold-plated. And it's not a single "government run" health plan. It's a smorgasbord of private insurance and HMO plans, including Kaiser, Blue Cross Blue Shield, and a bunch of others. Like every other private plan functioning in the U.S. today, the plans in the FEHBP have premiums, co-pays, exclusions, deductibles -- all the same stuff every other private plan entails.

Is it better than what a person can get if a person is working in the private sector? Maybe, maybe not. From a purely personal perspective, the best health insurance we ever had was while the S.O. was working as an aircraft mechanic in the 1980s -- since then it's been steadily downhill in how much insurance costs and what all it will cover.

I do know, however, that it is truly bizarre that I am getting these e-mails from (and there's no polite way to put this) dumbfuck cousins who don't see just how incredibly stupid it is for them to fear a theoretical government-run health plan when the family tree is full of relatives who have struggled with medical bills for many years. My idiot cousin Wayne, for example, got to watch his sister totally stress out over her inability to pay her bills while she was dying of breast cancer. On what planet is it more acceptable for a dying woman to have to beg friends to put on spaghetti feeds and hold bake sales to raise money to pay her bills than it would be for her to have access to a system that would eliminate the bills to begin with? And this was a woman who had a decent job (school teacher) and the health insurance that came with it. So much for the private sector always doing a better job than the government.

One of the other people who sent me the anti-government health plan propaganda is a woman who's also dealing with cancer -- and she's past 70 now so her bills are all being paid by Medicare.

The stupid, it burns.

More health care musings

I've been reading the article about health care costs in the New Yorker that's been referenced a number of times in various discussions, both in the MSM and in the blogosphere, and it's pretty interesting. The author, a surgeon, went to McAllen, Texas, an area with the highest per capita medical expenses in the country. He wanted to find out what was going on there that made it different from a place like Rochester, Minnesota, home of the world-famous Mayo Clinic. Per capita costs in Rochester average about 60% what they do in McAllen.

It's an intriguing article. The first thing the author discovers is that the clinicians and health care administrators in the area had no idea they ranked first in the country for patient costs. As far as they all could tell, no one was going out of his or her way to push treatments that weren't needed. So they posit that perhaps the problem is that McAllen just has a higher than average percentage of unhealthy people. It is, after all, a poor area with an extremely low average household income, which in turn suggests lousy diets, obesity, and clogged arteries.

Well, that theory gets blown out of the water pretty quickly. Turns out that the while the local populace looks like they'd be key candidates for things like heart disease and its attendant high dollar procedures (echocardiograms, angioplasties, by-passes, etc.) the average number of procedures done in McAllen isn't noticeably higher than any some parts of the country and is actually lower than cardiac procedure rates in regions that have lower overall costs.

What it comes down in the end turns out to be pretty predictable: physicians, hospitals, and other providers who have come to see patients as a revenue stream. No one thought that he or she individually was pushing unnecessary procedures, but it turned out the overall culture with its emphasis on profits and revenue streams encouraged doctors to do just that. McAllen has high medical costs per capita because the system, both private insurance and public programs like Medicare, incentivize high dollar procedures. The more procedures that get done, the more patients that cycle in and out of waiting rooms, the more money the doctors make. (In contrast, the Mayo Clinic in Rochester removes the financial incentive by putting physicians on straight salary; there's no linkage between number of patients seen and the size of their paychecks.) In McAllen no one is seeing the system as a whole -- they're just viewing each patient, each procedure, as a unique cash transaction in itself. Ironically, despite having all this high dollar medicine available, the overall morbidity and mortality rates for McAllen aren't so hot. Turns out that as clinicians focus on revenue streams, they lose sight of prevention. So the elderly in McAllen get a lot of colonoscopies (over $3000 a pop) and echocardiograms ($1400) and not enough flu shots ($20 at the local Walgreen's?).

Plus, of course, the fact that a procedure can be done doesn't necessarily mean it should be done. Every invasive procedure introduces the risk of infection or other complications, every "routine" surgery carries with it the possibility of an allergic reaction to anesthesia, wounds that refuse to heal, blood clots, you name it. So between the de-emphasis on preventive health and the excessive ordering of various procedures, the folks in McAllens end up dying sooner than the American average.

I must say that conclusion floored me. At the very least, one would expect that if clinicians are ordering all sorts of tests and things there'd be a pay-off of some sort for the patient: better quality of life, increased longevity, whatever. Nope. No such luck.

The author basically comes to the conclusion that what the American health care system needs isn't a change in who's paying for what because switching who signs the checks isn't going to address many of the fundamental problems in the system now. What the system needs is to go back to being patient-centered. Unfortunately, in a culture that prizes profits above all else, that isn't likely to happen any time soon.

I did learn one interesting thing. In addition to the Rochester, Minnesota, area, there are some other parts of the country that stand out for putting patients first in the health care equation. One is Grand Junction, Colorado. It ranks really high in terms of both quality of care and patient satisfaction. That's were my mom lives. No wonder she never has anything bad to say about her doctors or Medicare.

Still brooding about health care

It's a good thing the S.O. isn't here. He might have had heart failure this morning. The idiots on C-SPAN and the morning news shows had me feeling so frustrated and pissed off that I resorted to doing actual housework in order to burn it off. You know I'm feeling frustrated when I'm on my hands and knees mopping the kitchen floor the old-fashioned way, with a scrub brush and a rag.

I think the one thing that had me wanting to reach right through the screen and strangle someone was the repetition of a flatout lie, over and over, that the problem with Medicare and Medicaid is the horrendous paperwork, just how incredibly inefficient the government is at processing claims. The Medicare program spends less than 5% of its budget on administrative costs, i.e., the paper shuffling, while the private insurance companies are spending well over 30% on administration.

Of course, there is one huge difference between Medicare and Aetna et al: the person running the Medicare program works for us. No multi-million dollar CEO salaries driving up administrative costs. Medicare is part of Health and Human Services. People may bitch about bloated government bureaucracies, but you can get an awful of lot of GS-5 clerks for the price of one private sector executive. Yes, the chief administrator for Medicare is making 6 figures, but not dramatically so. The senior executive service tops out at under $200,000 annually, although there would be locality pay adjustments on top of the base salary. Compare that with the over $15 million that the CEO for Travelers carried home in 2006.

Nonetheless, Medicare is derided for being expensive, cumbersome, and poorly managed. No wonder I felt like scrubbing floors -- the alternative was brain bleach, and that's hard to come by.

(The other thing that drives me right up a wall, of course, is hearing over and over that we don't want government bureaucrats making decisions about which medical procedures are necessary. Given that the first words out of my doctor's mouth every time he's contemplating ordering a lab test or prescribing a different drug are "I'm not sure your insurance covers this, let me check first," that argument doesn't have much traction with me.)

What kind of fuckery is this?

I'm seeing news reports that one way Obama is proposing tackling runaway health care costs is by reducing the amounts Medicare and Medicaid currently pay out to doctors and hospitals. WTF?! There are doctors now who refuse to treat patients covered by those plans because the reimbursement rates are set so low. I need to do more reading, but for sure this does not sound like a particularly bright idea.

Here's a different idea -- how about going after the insurance companies and basically getting rid of them?

Right now over 1/3 of the health care costs racked up in this country go to pay for the papershuffling done by Blue Cross, Aetna, Travelers, et al. Maybe if we went to single payer and simplified the administrative processes by doing so, we wouldn't need to punish actual clinicians and the patients they're trying to serve.

Health care

Why I support a universal single payer system, a case comparison based on personal experiences:

Patient A: 30-something woman with a husband and young daughter is diagnosed with breast cancer. Despite receiving first class care, the cancer metastasizes and becomes systemic. After approximately five years, she dies.

Patient B: slightly older woman, single mother with a teenage daughter, is diagnosed with breast cancer. Her cancer progresses in much the same manner as Patient A, and approximately 5 years after the initial diagnosis, she dies.

So what's the difference? First, Patient A never had to argue with her doctors about whether or not her insurance would pay for a particular treatment, never had to worry about her own co-pays and deductibles, and did not leave her family holding a stack of medical bills several feet high. She and her family went through hell, but the one thing they never had to deal with was the possibility of her not being treated because she couldn't afford it.

Patient B, despite being a public school teacher with a supposedly comprehensive health insurance plan through her employer, wound up relying on loans from relatives, spaghetti dinners, bake sales, and other fund raisers, worried constantly about money, exhausted her sick leave so found herself with no income, and died many thousands of dollars in debt. Given the debilitating effects of stress on the human body, a person can't help but wonder what impact worrying about money had on her disease.

And why the different financial scenarios? Patient A lived in Sweden; Patient B lived in Michigan. When we live in a country where people who are employed full-time at what are supposedly decent, middle-class jobs and have what are supposedly good health insurance benefits find themselves relying on charity to pay for their prescriptions, something is seriously wrong.

My friend Tracy frets occasionally about end of life issues, like being maintained on life support when she really wouldn't want to be. I always tell her, hey, you want to make sure no one tries any heroic measures? Just show up at the Emergency Room of most hospitals without insurance.

On a related note, in terms of how a universal system might actually work, Utah Savage had a good post on the realities of living with Medicare a day or two ago. It's worth looking at.