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Tuesday, May 2, 2017

An American Sickness, continued


Hashtag #anamericansickness.

MAY 6TH UPDATE: I finished this book. EVERY member of Congress (and his/her staff) should have to read it and take a test on its contents. Every taxpayer should also read it closely.
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Continuing on from my prior post. The book's Dedication page:
Dedicated to all the patients, doctors, and other healthcare professionals who so generously shared their stories and experiences to bring this book to life. Waiving privacy concerns, they agreed to have their real names appear in print. In the hope of contributing to change in our healthcare system, they spent hours digging up copies of their bills, insurance statements, correspondence, and other documents to provide verification. I’m deeply grateful for their help, commitment, and courage.

They—and all Americans—deserve better, more affordable healthcare.
Interesting. Candid disclosures of (US) HIPAA-protected "PHI" (Protected Health Information) in the service of larger, socially beneficial goals. I can't help but recall my post citing Gideon Burrows' excellent, courageous (UK) book back when I finished my own cancer tx in November 2015.


My own family revelations began in the late 1990's with my posts recounting my late elder daughter's illness and death. Now, we are struggling to come to terms with her younger sibling's recent shocking dx of Stage IV metastatic pancreatic cancer. We got a 2nd opinion consult at UCSF (she's a Kaiser enrollee), and Danielle signed the Consents for enrollment in a clinical trial now getting underway.

Then some adverse, worryingly elevating labs came in, and she was declared ineligible for the RCT (owing to hepatoxicity risk). Back to Plan A (at Kaiser) -- Folfirinox.

Suffice it to say that my wife and I are reeling. I struggle to find any motivation to do much of anything (beyond yet again my requisite next-of-kin caregiver duties).

PERSONAL DISCLOSURE - STEVE BRILL

CHAPTER 1. LOOKING UP FROM THE GURNEY

I USUALLY KEEP MYSELF OUT OF THE STORIES I WRITE, BUT THE ONLY way to tell this one is to start with the dream I had on the night of April 3, 2014.

Actually, I should start with the three hours before the dream, when I tried to fall asleep but couldn’t because of what I thought was my exploding heart.

THUMP. THUMP. THUMP. If I lay on my stomach it seemed to be pushing down through the mattress. If I turned over, it seemed to want to burst out of my chest.

When I pushed the button for the nurse, she told me there was nothing wrong. She even showed me how to read the screen of the machine monitoring my heart so I could see for myself that all was normal. But she said she understood. A lot of patients in my situation imagined something was going haywire with their hearts when it wasn’t. Everything was fine, she promised, and then gave me a sedative.

All might have looked normal on that monitor, but there was nothing fine about my heart. It had a time bomb appended to it. It could explode at any moment— tonight or three years from tonight— and kill me almost instantly. No heart attack. No stroke. I’d just be gone, having bled to death.

That’s what had brought me to the fourth-floor cardiac surgery unit at New York– Presbyterian Hospital. The next morning I was having open-heart surgery to fix something called an aortic aneurysm.

It’s a condition I had never heard of until a week before, when a routine checkup by my extraordinarily careful doctor had found it.

And that’s when everything changed.

Until then, my family and I had enjoyed great health. I hadn’t missed a day of work for illness in years. Instead, my view of the world of healthcare was pretty much centered on a special issue I had written for Time Magazine a year before about the astronomical cost of care in the United States and the dysfunctions and abuses in our system that generated and protected those high prices.

For me, an MRI had been a symbol of profligate American healthcare— a high-tech profit machine that had become a bonanza for manufacturers such as General Electric and Siemens and for the hospitals and doctors who billed billions to patients for MRIs they might not have needed.

But now the MRI was the miraculous lifesaver that had found and taken a crystal clear picture of the bomb hiding in my chest. Now a surgeon was going to use that MRI blueprint to save my life.

Because of the reporting I had done for the Time article, until a week before, I had been like Dustin Hoffman’s savant character in Rain Man— able and eager to recite all varieties of stats on how screwed up and avaricious the American healthcare system was.

We spend $ 17 billion a year on artificial knees and hips, which is 55 percent more than Hollywood takes in at the box office.

America’s total healthcare bill for 2014 is $ 3 trillion. That’s more than the next ten biggest spenders combined: Japan, Germany, France, China, the United Kingdom, Italy, Canada, Brazil, Spain, and Australia. All that extra money produces no better, and in many cases worse, results.

There are 31.5 MRI machines per million people in the United States but just 5.9 per million in England.

Another favorite: We spend $ 85.9 billion trying to treat back pain, which is as much as we spend on all of the country’s state, city, county, and town police forces. And experts say that as much as half of that is unnecessary.

We’ve created a system with 1.5 million people working in the health insurance industry but with barely half as many doctors providing the actual care. And most do not ride the healthcare gravy train the way hospital administrators, drug company bosses, and imaging equipment salesmen do.

I liked to point out that Medtronic, which makes all varieties of medical devices— from surgical tools to pacemakers— is so able to charge sky-high prices that it enjoys nearly double the gross profit margin of Apple, considered to be the jewel of American high-tech companies.

And all of those high-tech advances— pacemakers, MRIs, 3-D mammograms— have produced an irony that epitomized how upside-down the healthcare marketplace is: This is the only industry where technology advances have increased costs instead of lowering them. When it comes to medical care, cutting-edge products are irresistible; they are used— and priced— accordingly...
Yeah. Goes directly to Elisabeth's book, 'eh?

From An American Sickness:
10. THE AGE OF HEALTHCARE AS PURE BUSINESS

Our healthcare system today treats illness and wellness as just another object of commerce: Revenue generation. Supply chain optimization. Minimization of tax liability. Innovative business modeling. Things sold. Services rendered. Bills to be paid. “As a consumer (formerly ‘patient’ or ‘sick person’) how cool it must be to find oneself on the innovative, enrollment-optimized upper specialty drug tier when sickness strikes and you face 20 to 30 percent coinsurance,” quips Uwe Reinhardt, a Princeton economist who has been challenging the financial underpinnings of the American healthcare system for years.

Helen, a real estate professional in a major eastern city, had a history of ruptured disks in her back that required surgery. So when she developed severe pain in her neck and numbness and tingling in her hand and arm she knew she would likely need another operation. An MRI showed a piece of bone pushing on a nerve.

The first surgeon she consulted said he wouldn’t see her because her Oxford Premium plan paid fees that were too low. The second, a surgeon she’d used twice before, agreed to take her on. His office would negotiate with Oxford to obtain a reasonable rate. “I begged them to get me on the schedule as soon as possible— I was in unbearable pain,” she said. With neurological deficits that merited urgent intervention, he scheduled the surgery for a fortnight later. She drugged herself, canceling all work appointments.

But five days before surgery, the doctor’s office called to inform her that Oxford wouldn’t agree to more than $ 58,000, less than half the $ 130,000 the doctor usually charged. The office biller asked Helen to send in $ 23,000 to help make up the difference, in addition to the $ 12,000 co-payment. If she couldn’t come up with the money, the surgery would be canceled, the biller explained: “We can’t do the surgery for what your insurer’s willing to pay.”

From about 2010 on, new types of medical charges multiplied, just as priority boarding fees and fees for window seats appeared on airline bills. Doctors who considered themselves good diagnosticians began charging longtime patients annual retainers of $ 2,000 to remain in the practice, or $ 150 a month extra for customers who wanted same-day answers to medical questions, or $ 20 just to write each prescription. Some parents of children in New York City public schools began receiving $ 300 explanation of benefits statements generated for a child’s trip to the school nurse’s office (which had been outsourced to a contracted medical provider), even if for a scraped knee on the playground or a stomachache born of test anxiety.

Doctors and medical centers, who two decades ago might have worked hard to figure out an affordable payment, now rapidly turned over patient accounts to billing services and collection and credit rating agencies. By 2014, 52 percent of overdue debt on credit reports was due to medical bills and one in five Americans had medical debt on their credit record, impacting their ability to get a mortgage or buy a car.

There was money, money everywhere . . .

In my own years of medical school and practice, I never saw a single patient with hemophilia, whose victims lack an essential clotting factor (most commonly factor VIII) and so suffer from repeated internal bleeding. Treating this rare condition certainly didn’t seem like a profitable proposition. So I was surprised to hear a medical marketing consultant I interviewed refer to hemophilia not as a devastating, debilitating illness if left untreated, but instead as a “high value disease state.”...
"There was money, money, money everywhere."

A couple of observations recur, circa the time of my birth. First, an interesting quote from one of the patron saints of "libertarianism," followed by the opinion proffered by the WWII era British Prime Minister:
"Nor is there any reason why the state should not assist individuals in providing for those common hazards of life against which, because of their uncertainty, few individuals can make adequate provision. Where, as in the case of sickness and accident, neither the desire to avoid such calamities nor the efforts to overcome their consequences are as a rule weakened by the provision of assistance, where, in short, we deal with genuinely insurable risks, the case for the state helping to organise a comprehensive system of social insurance is very strong. There are many points of detail where those wishing to preserve the competitive system and those wishing to supersede it by something different will disagree on the details of such schemes; and it is possible under the name of social insurance to introduce measures which tend to make competition more or less ineffective. But there is no incompatibility in principle between the state providing greater security in this way and the preservation of individual freedom."

- Friedrich Hayek, The Road to Serfdom, 1944

“The discoveries of healing science must be the inheritance of all. That is clear: Disease must be attacked,  whether it occurs in the poorest or the richest man or woman simply on the ground that it is the enemy; and it must be attacked just in the sane way as the fire brigade will give its  full assistance to the humblest cottage as readily as to the  most important mansion… Our policy is to create a national health service in order to ensure that everybody in the country, irrespective of means, age, sex, or occupation, shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available.”

- British Prime Minister Winston Churchill, 1948
“You’re going to have such great health care, at a tiny fraction of the cost—and it’s going to be so easy.” -- Donald Trump, October 2016 Florida campaign rally


Then there are people like the smugly arrogant and ignorant Alabama GOP congressman Mo Brooks:
Rep. Mo Brooks (R-Ala.) told CNN’s Jake Tapper that sick people should pay more for health insurance ― an opinion reflected in the newest proposed version of a Republican health care bill.

Brooks, who is one of the more than 30 congresspeople who make up the so-called Freedom Caucus, a far-right contingent within the House of Representatives, made his comments in response to a claim by President Donald Trump. Trump stated Monday that he wanted to carry over Obamacare policies that protect people with pre-existing conditions.

But the newest version of the bill wouldn’t do that, a fact Brooks emphasized.

“My understanding is that it will allow insurance companies to require people who have higher health care costs to contribute more to the insurance pool,” he said, “thereby reducing the cost to those people who lead good lives.”

Of these people who live “good lives,” he then added, “They’re healthy, they have done the things to keep their bodies healthy, and right now those are the people who have done things the right way and are seeing their costs skyrocket.”
 I guess Jimmy Kimmel's newborn's then-brief life wasn't a "good" one.

And, I have no doubt that Congressman Mo Brooks will continue to take his 70% taxpayer-subsidized FEHB health plan benefits.
"Pricing sick people out of insurance coverage is abuse. It will make them go to the doctor less often, meaning less early detection and more early death.

And discrimination against sick people is as morally wrong as discrimination against people because of the color of their skin. High-risk pools are American Sowetos in a system of medical apartheid."
ERRATUM

We're at the Kaiser facility in Vallejo. And so it begins...


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More to come...

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