How it worked, and how it didn’t

This is going to be a personal one, and a long one. I don’t like to write about myself in this way, but the story is so illustrative that I can’t resist.

First, the epic saga of my left eye. (Close friends can now go get a sandwich – you’ve heard this one) About a year ago I was at my optometrist for my regular exam, with complaints of moving spots of light in my left eye. She saw an odd blotch of pigment on the retina of my left eye. She referred me to an ophthalmologist for another look.

He pronounced it a spot of pigment of little significance, but recommended that my optometrist keep it under annual surveillance.

By the middle of this last summer my left eye was getting fuzzy. We all get “floaters” in our vision now and then, but this was like a squadron of jellyfish. More swooping lights as well. I went back to my optometrist, who kicked me up the ladder to a partnership of retinal specialists. One of them examined me, identified the spot as a birthmark, and scheduled me back in three months for another look.

In mid-September the view in my left eye was like looking through a mass of frog’s eggs.  I accidentally noticed that I was losing my peripheral vision in the top of the eye, so I emailed the retinal specialists. The next day I got the call from the doctor’s office. “Come in today” was the command. They thought that my retina might be rolling down like old wallpaper. The doctor fit me in at the end of the day. My eyeball got a visual exam, and ultrasound, and an angiogram. Then the doctor came into the exam room and shut the door.

“I think you have a choroidal melanoma, “he said. “At least, I hope it’s a choroidal melanoma. Yes, I’m pretty sure it’s a melanoma.” That means a malignant tumor – cancer of the retina. Yes, I was terrified.

My doctor got me an appointment at the Wills Eye Institute in Philadelphia for ten days later. I would go in for tests on a Monday, and if it was actually a choroidal melanoma (I didn’t have the balls to ask him what he hoped it wasn’t, but I had an idea) I would go in on that Thursday to get a metal plate loaded with radioactive iodine sewn to the back of my eyeball. Then three days in isolation, plate removal, and probable loss of vision in my eye. My chances of remission were around 98%.

The Librarian and I took the train down and she accompanied me to the Wills. I went through the usual battery of tests and was examined by a doctor from India on a fellowship and then by Dr. Carol Shields. She and her husband Jerry Shields are, as I found out, the world leaders in the treatment of ocular cancers.

The punch line: It wasn’t cancer. It was (and is) a benign hemangioma, a kind of leaky birthmark on the retina. I still had to have it treated to save the eye. Otherwise I would end up with a rakish eye patch, and every day would be Talk Like a Pirate Day.

I returned to Vermont with the Librarian (after a certain amount of celebration) and scheduled an appointment for Photo Dynamic Therapy, or PDT. This is a process where the patient is injected with a light sensitive drug that seals up capillaries. The doctor beams a cold blue laser on the spot to be treated and the drug is activated there and only there.

And so it came to pass. A couple of friends drove me up to the clinic, I was injected with $1200 worth of Visudyne, and the doctor shot me in the eye with the laser for 81 long, bright seconds. Then I reached into my “burkha bag” for a balaclava, a scarf for my face, glacier sunglasses, and gloves. With the Visudyne in me any skin exposed to the sunlight would blister like leprosy. I spent the next two days indoors with the curtains closed.

My eye is improving. The funhouse mirror effect has gone away. The frog’s eggs have diminished. The light show has toned down.

One could say that the system worked. I brought my complaint to my regular doctor at my regular checkup. I got kicked up the ladder as my condition changed. The retinal specialist made a mistake, but made it in the right direction – caution – and I was sent to the specialists who could nail it for what it was. I received state of the art treatment, which seems to be working.

Then again, one could say that the system worked because I am a special case.

Unlike many people, I go to my optometrist regularly. She has a baseline understanding of the condition of my eyes. Having been myopic for most of my life (Lasik changed that) I have an optometric habit. I was talking about my false alarm with a friend at the farmer’s market and he related the story of a friend of his who actually had had a choroidal melanoma, successfully treated with radiation therapy. He noted that in most cases choroidal melanoma is fatal. How was this, I asked, when they have a 98% effective therapy? Most people don’t get to the doctor until it’s far too late. Oh, right. Most people go through their lives with their retinas unscanned. And not just their retinas.

When I got my first diagnosis the doctor asked me if I had insurance. I did, but with a $10,000 deductible. “That’s gone,” he said. I noted that I had a $23,500 annual out-of-pocket maximum. “That’s gone too,” he said. Luckily I do have insurance, and a retirement account I can raid for this kind of emergency. 40 million Americans lack insurance and most people don’t have that much backup money.

An acquaintance told me the story of one of his golfing buddies, a successful lawyer with a six figure income, gold plated insurance, the works. He had been diagnosed with pancreatic cancer. Three hellish years later he was in remission, but also bankrupt, minus insurance, and foreclosed. Moderate wealth is no guarantee.

I had an interesting discussion with my retinal doctor as I put on my cloaking after the laser treatment.

Not surprisingly the conversation turned to the financing of health care. He was not optimistic. He reported that a number of his colleagues were folding their private practices and running for the cover of medical centers. I asked him why.

“This really needs to get out there,” he said. What follows won’t be news to Vermont doctors or hospital administrators.

He pointed out that if he and an equivalent specialist at the Fletcher Allen Health Care (FAHC) in Burlington do the same procedure, Fletcher Allen gets twice to six times the money from Blue Cross Blue Shield (BCBS). Likewise, BCBS pays him less than a 5% margin on any drug he uses, while FAHC gets a double digit percentage. FAHC gets a “facilities fee” that independent doctors don’t get, as if the independents were operating under a tree somewhere.

Why is this? “FAHC is the 1200 pound gorilla in Vermont.” He pointed to a couple of incidents in the last decade where FAHC had publicly threatened to cut off the insurance company CIGNA due to a dispute over reimbursements. I looked it up and in fact FAHC and CIGNA had gone toe to toe on reimbursement rates in 2003 and 2008. Vermont is a relatively small health care market, but our money is as green and spendy as anyone else’s. FAHC has the biggest revenue stream in our market, by far. It takes in 47% of the net patient revenue in the state, around $925 million. An insurer that loses access to FAHC becomes irrelevant in the Vermont market. Apparently the insurance companies yield to FAHC on reimbursement and make up for that by squeezing the independent practitioners.

I just received a letter from this doctor stating that his practice was ditching Blue Cross because of insufficient reimbursement.

This makes me wonder how efficient it is to have a big medical center like FAHC. Are they still trying to pay for the Renaissance Project? (From the memory hole: The Renaissance Project was a $173 million expansion approved by regulators in 1999, which turned out to be a huge fraud. The FAHC executives were keeping two sets of books on what was actually a $364 million expansion. Five C-level execs eventually pleaded guilty to various felonies and misdemeanors.)

I suppose there is a certain critical mass necessary for having a Level 1 trauma center and a teaching hospital, but do they really need twice the money for a procedure? I wonder how that plays out across various specialties, and whether one is used to subsidize another, or if it is just administrative bloat. My doctor doesn’t have any highly paid executives managing him.

It’s just another little facet of the whole dysfunctional health care mess. It points up the problem of having a monopsony (near monopoly) in a business where the consumer is desperately interested in results rather than price. That monopsony is necessary in certain cases. We can’t afford to have half a dozen Level 1 trauma centers in Vermont all competing on price. We can’t imagine that they would compete on price if there were six. What terrified relative would shop around while their loved one was bleeding from an artery?

I certainly wasn’t shopping around on price when I thought I had eyeball cancer. My two questions were

1)      Where is the best place to get treated?

2)      How fast can I get there?

Any real world experience debunks the concept of informed health care consumers using a “free market” to drive down costs. Sick people tend not to negotiate well. The worse, and therefore more expensive the condition, the more likely there is to be a specialist monopoly and the less likely that the patient will shop around.

I was also lucky that I had access to a retinal specialist less than an hour’s drive away. I am sure that is not universal. In some places people can’t even find a dentist.

And then, of course, I work for myself, so the boss gives me flex time. He won’t fire me for taking days off to get treated.

So, yes, if you see your doctor regularly, and have insurance, and have money in the bank to cover your deductible, and have a flexible work schedule, and have reasonably local access to the right doctor, and, and, and… the system works. That is too many conditionals for most people.

So what do we do?

 (All these answers are post campaign finance reform. The business of health care just wants to churn money through the system in the most extravagant way possible. Investing in the political campaigns of Social Darwinists provides a good return on investment.)

Pick one of the health financing systems of the 36 countries ahead of us in the World Health Organization’s rankings. That includes all of Europe, Canada, and even tiny Costa Rica. (But we just barely beat Morocco) Let’s be picky and choose one from the top ten. Copy it. They all provide universal coverage and obtain better health outcomes for far less money per capita. We are spending 17% of GDP on health care, when the average among OECD nations is around 9%. If we could duplicate France’s system we would save almost as much money as we now pay in personal income taxes. Let me restate that: Adopting a European style health care system would save us almost as much money as the government now collects in personal income taxes. We are simply idiots about this.

Start paying for outcomes rather than procedures. This goes hand in hand with separating doctors from particular technologies. When a doctor owns a special million dollar hammer (a dialysis clinic, a (insert acronym) scanner, an arthroscopic surgery setup) everything looks like, well, you know.

Institute regionally adjusted reimbursements to encourage doctors to move to underserved areas. Adjust the reimbursement levels regularly as the talent moves around.

Institute specialty adjusted reimbursements to encourage under populated specialties. Primary care physicians come to mind. In a recent article in the NY Times, a professor of economics advocates lower tax rates for primary care physicians, and points to a student loan repayment program offered to physicians who work in underserved areas.

Flip the organizational pyramid of hospitals upside down. Doctors, nurses, and technicians should hire and fire administrators. A hospital is about providing health care, not shuffling paper. Administrators should be organizers, fundraisers, traffic controllers, and bookkeepers, assistants to the people who are doing the primary work. Among other things, this would reduce the probability of grandiose, money sucking building projects.

Change direct cash subsidies to corn growers back to price supports. Say what? Before the mid-1970s, the government supported corn farmers as a buyer of last resort. If there was a bumper crop and corn prices fell below the cost of production, the feds would buy the corn at a sustainable price and store it. When the inevitable bad harvest came and prices went up, the feds would sell the corn at a reasonable price to keep it affordable to consumers. No net cost to taxpayers and corn prices stayed steady. Then President Nixon’s Secretary of Agriculture, Earl Butz, promoted ultra-cheap corn and soybeans with direct cash subsidies instead of price supports. The result of this policy is ultra-cheap sugar and fat, in the form of high-fructose corn syrup, soybean oil, and grain fattened meat. While the inflation adjusted price of corn has stayed flat over the past40 years, the price of produce has gone up 40%. Call it subsidized illness.

I’m ok. I’m lucky. I’m not looking forward to paying the bills – probably the price of a used car. But I am lucky; lucky in where I live, in how I work, and in my modest prosperity. However, we’re running a civilized society here, not a jungle. Luck is not the proper basis for a health care policy.

Medical Loss Ratio

The other day I received a letter from my insurance company telling me that I wasn’t going to get a refund. I was reasonably happy about that, actually. The reason has to do with the Affordable Care Act (ACA) and the Medical Loss Ratio (MLR).

The MLR is the ratio of how much money a health insurance company pays out to cover medical expenses versus the amount of money it collects in premiums. An MLR of 75 means that for every $100 the company takes in it pays out $75 in coverage.

An MLR of 75 isn’t good enough anymore. In an amazing denial of insurance company wishes the ACA contains a provision requiring a minimum MLR of 80 for small group policies and 85 for large group policies (over 100 people). Companies that don’t meet this standard have to refund money to their policyholders to the point where they are at an MLR of 80 or 85%.

My health insurance provider has been paying out more than 80% of premiums, so no refund was forthcoming. Other people around the country are getting refunds, however. In Florida, one company is going to be refunding $15.7 million to 67,000 people. That company is called Golden Rule (*cough, hack*). Pardon, a little bile caught in my throat.

The Minor Heretic was once a customer of Golden Rule, back when Lake Champlain was salt water. I was on a budget, and they offered a cheap, high deductible plan. It was a good thing that I was healthy, because they provided an empty parachute pack. Look up “Golden Rule Insurance review” online and you will find a string of stories from people who were denied coverage, dropped when they got sick, or had their rates doubled or tripled without warning. Behavior like this did wonderful things for GR’s MLR. I found out while I was throwing my money down their gold plated toilet that their MLR was 52. They pocketed 48% of every premium dollar. More recently, in 2010, their MLR in Florida was 65.

No more. Thanks to that goddamned socialist ObamaCare that is going to enslave us all, health insurance companies can no longer gouge us. At least, not much.

Speaking of socialism, the MLR for Medicare, run by those bloated, inefficient, wasteful bureaucrats, is 97. No private insurance company comes near that, of course. That’s why they bribed, er, lobbied so hard against the public option provision when the ACA was being written. They simply couldn’t imagine competing with a program with only 3% overhead.

It would be a huge fight, but adding a Medicare-like option to the ACA would legitimize the “Affordable” part of the name. It would drop insurance costs by 15% or more, and might very well kill off a major part of the quasi-criminal health insurance industry.

For the moment I’ll appreciate not being screwed so badly by my insurance company. Down the road I look forward to Vermont becoming the first state with public single payer health coverage. Perhaps, eventually, all of America will realize that getting health insurance doesn’t have to mean wasting money.

Health Careless

“I don’t know what alarms me more, the state of our health care system or the fact that we accept it the way it is.” Thus spoke a friend of mine as we discussed the health problems of those dear to us. What follows is less of an essay and more of a series of vignettes that raised my blood pressure recently.

I was in the lobby of our local hospital recently, on my way to visit a friend who had broken his ankle rather badly. There was a large sign in the emergency room that said that the hospital is legally required to treat you even if you don’t have any money. There was another like it in the main lobby. This goes under the second clause of the initial quotation above. The fact that this isn’t simply understood by everyone tells a story about how hoodwinked people are about our basic human rights.

The friend who uttered the opening quotation also told me about an interview she heard on a British radio show. The guest was an American woman who had been diagnosed with cancer the day after her insurance had lapsed due to a clerical error by her employer. The woman spent a tense few weeks trying to rectify the situation, literally a life or death effort. Apparently the British interviewer had to keep reminding her to define her terms. “What is a co-payment? Our listeners wouldn’t know.”

Then there is the story of another friend who spends time in two different states, one in the east and one in the southwest. Her health insurance only works when she is in the eastern state. If she were to get sick in the southwest she would be on her own.

Getting back to the friend with the broken ankle, I was recently looking into bone growth stimulators. There is a class of devices that emit low intensity ultrasound directly into the affected place and stimulate bone growth. These are especially useful in cases where bones fail to heal rapidly.

I found one made by a company called Smith and Nephew. The Exogen 4000 appears to be a standard electronics box about 3” by 4” with an LCD screen and a cord leading to the small cylinder that emits the ultrasound. Apparently it retails for something between hundreds and thousands of dollars, depending on the source. This price spread is weird in itself. The real outrage, though, is how they power the thing. It has a non-rechargable, non-replaceable battery. The purchaser gets about 350-400 uses out of it and then it is junk. Used devices show up on eBay, with the sellers noting how many times it has been used and how many cycles should be left. It’s akin to buying a disposable laptop computer. It’s obvious that the device could be rechargeable or have a replaceable battery, or could even be plugged into the wall. However, Smith and Nephew, in its corporate greed, decided that profits should win out over affordability, effectively denying the use of their device to a class of uninsured. No way are these things going to be passed on from patient to patient indefinitely. It makes perfect sense financially, and it is a perfect crime against society.

Meanwhile, on the Vermont end of things, we put the call out through the neighborhood for various necessities for someone with a bum ankle, including a walker. Emails and calls came in and we found a couple who runs a free medical appliance exchange out of their garage. These good people spend their spare time maintaining and distributing walkers, wheelchairs, crutches, and the like. We all pitch in around here.

It’s a bright spot in the gloom, but not a solution. It looks as if the nation’s bought and sold “representatives” in Washington will do the bidding of the insurance and drug industries. Vermont will have to navigate its own path to a rational health care system and let the rest of the country follow along.

In the meantime, try not to get too sick, ok?

Update: Just when my blood pressure was returning to normal, I read about another symptom of the recession. Some companies are cancelling their employee's health insurance plans without telling them. The first that people know about it is when they present their insurance card to the nurse and it gets handed right back.

What Obama Should Have Said

President Obama held yet another one of those pointless town hall meetings in Montana recently. It did allow him to respond to some of the absolute mythology that the health insurance industry has been promoting, but the format itself is the folksy equivalent of a show trial. There is only the illusion of discussion and thought. Television viewers get the vicarious satisfaction of seeing their views expressed, pro or con, and the president gets to make his case to the .02% of the population as yet undecided.

Here’s one exchange:

Q My name is Mark Montgomery. I'm from Helena, Montana.

THE PRESIDENT: Great to see you, Mark.

Q I appreciate you coming here. It's great to be able to do this.

THE PRESIDENT: Thank you.

Q Mr. President, I make a living selling individual health insurance. (Laughter.) Obviously I've paid very close attention to this insurance debate. As you know, the health insurance companies are in favor of health care reform and have a number of very good proposals before Congress to work with government to provide insurance for the uninsured and cover individuals with preexisting conditions. Why is it that you've changed your strategy from talking about health care reform to health insurance reform and decided to vilify the insurance companies? (Applause.)

THE PRESIDENT: Okay, that's a fair question, that's a fair question. First of all, you are absolutely right that the insurance companies, in some cases, have been constructive. So I'll give you a particular example. Aetna has been trying to work with us in dealing with some of this preexisting conditions stuff. And that's absolutely true. And there are other companies who have done the same.

Now, I want to just be honest with you, and I think Max will testify, that in some cases what we've seen is also funding in opposition by some other insurance companies to any kind of reform proposals. So my intent is not to vilify insurance companies. If I was vilifying them, what we would be doing would be to say that private insurance has no place in the health care market, and some people believe that.

I don't believe that. (Applause.) What I've said is let's work with the existing system. We've got private insurers out there. But what we do have to make sure of is that certain practices that are very tough on people, that those practices change.

Now, one point I want to make about insurance: Some of the reforms that we want for the insurance market are very hard to achieve, unless we've got everybody covered. This is the reason the insurance companies are willing to support reform, because their attitude is if we can't exclude people for preexisting conditions, for example, if we can't cherry pick the healthy folks from the not-so-healthy folks, well, that means that we're taking on more people with more expensive care. What's in it for us? The answer is if they've got more customers, then they're willing to make sure that they are eliminating some of these practices. If they've got fewer customers, they're less willing to do it.

So it's important for people -- when people ask me sometimes, why don't you just do the insurance reform stuff and not expand coverage for more people, my answer is I can't do the insurance reform stuff by itself. The only way that we can change some of the insurance practices that are hurting people now is to make sure that everybody is covered and everybody has got a stake in it, and then the insurance companies are able and willing to make some of these changes that will help people who have insurance right now. But thank you for the question. I appreciate it. (Applause.)

Sorry, Mr. President, but that was anemic. Here’s a preferable response.

THE PRESIDENT: Okay, that's a fair question, that's a fair question. First of all, I am vilifying insurance companies because they richly deserve vilifying. In fact, when you look at their behavior over the past few decades, you’ll see that they deserve prosecution for fraud. In some cases they probably deserve prosecution for murder, when denial of coverage could easily have been predicted to cause the death of the insured person. Where’s the Tarpeian rock when you need it? Whoops, any classics scholars out there? (Laughter) In ancient Rome they pitched murderers off a rocky cliff, and at least figuratively that’s what we need to do to the health insurance industry. (Applause)

They are playing at cooperation with reform efforts right now. I guess that with the Blue Dog Democrats in their pockets they expect to write in some more subsidies for themselves. They certainly aren’t acting out of the goodness of their hearts, because, well, there’s no goodness in there. Just raw profit motive.

There is ample evidence that they have groups of employees whose sole purpose is to exploit any tiny loophole in their complex contracts to deny people the coverage they paid for and that they deserve. The whole industry is based on suckering people into signing flawed contracts and then breaking those contracts when they think they can get away with it. That’s fraud. It’s also downright immoral. The executives and upper management should consider themselves lucky if they don’t end up behind bars. Once they are in prison I’d make them pay out of pocket for their medical care. (Laughter, Applause)

So, Mr. Montgomery, I consider you the equivalent of a minor errand runner for an organized crime family. Perhaps you do your job with the best of intentions, but thousands of Americans die every year thanks to the efforts of your employers, and millions more suffer pain and hardship. Tens of thousands go bankrupt. If I have my way you will be looking for a new job soon, one that doesn’t involve contractual fraud and sucking the lifeblood from the American people. I hope you enjoy your new anus. I enjoyed tearing it for you. Okay, time for one more question – back there…

In my dreams. Now it seems that the White House is backing off from the public health insurance option. The insurance companies will continue their dominance in the sole industrialized nation without a public health care program. We’ll keep forking over the money and fighting for our benefits. It’s the money, folks, the campaign money.

Outcomes

If you are at all interested in the health care debate, read the New Yorker article by Atul Gawande on health care costs. He examines McAllen, Texas, a community that has Medicare costs per person that average $15,000. This is twice the national average and three times some of the lowest cost areas. His core finding is that these costs don’t relate to the relative health of the community or quality of care, or even bad administration, fraud, or waste. It is all about how doctors are reimbursed and the culture of medical practice in that area.

In our system doctors generally are reimbursed by procedure. Do an MRI and the cash register rings. Blood test, ka-ching. Colonoscopy, ka-ching. Sit down with a patient for extra time and discuss their medical history in depth, no ka-ching. Get advice from a colleague without referring the patient for a procedure, no ka-ching.

Gawande found that the hospitals with the lowest cost per patient were ones that set up cooperative structures for the payment of their doctors, encouraging communication and mutual assistance and discouraging excessive procedures. Patient health outcomes were just as good or better than high spending institutions.

Well, here’s a thought: reimburse doctors according to patient outcomes. That’s what we actually want, right? Not a number of tests, but an actual improvement in the functionality of our bodies.

Modern medicine is a numbers game, after all. When we enter the medical system we get interviewed, tested, and our condition quantified. Depending on the affliction, medical personnel might establish dissolved oxygen in our blood, range of motion in a limb, our heart rate response to exercise, or the concentration of any number of chemicals in any number of tissues. This is then compared to what is considered normal for someone of the patient’s age, gender, and general condition. There are also more subjective tests of comfort and range of abilities.

When reimbursing a doctor we should consider the condition of the patient at intake and compare that to the condition of the patient over a time period relevant to the common recovery period for the particular injury or disease. Add a difficulty factor, as in Olympic diving. During a transitional period we should slowly reduce reimbursements for procedures and increase an outcome bonus. We should distribute that bonus among a group of doctors that work with the same hospital or in a limited geographic area. That would encourage doctors to collaborate and also to police their underperforming colleagues.

The exact formula for this kind of reimbursement is beyond the scope of this essay and, frankly, beyond the knowledge base of your Minor Heretic. But doesn’t it make sense to reward our health providers for making us healthy, rather than making us endure yet another procedure?