Saturday, August 01, 2009

Is Health Care Reform Going to Fail Again?

I've been watching the debate over health care reform and I'm losing hope that it will happen. People of good will can disagree about the best way to deliver health care to all Americans. But, we're not seeing that. Instead, the debate is about nonsense. Things like:

  • You're going to substitute socialized medicine for my Medicare! (No, Medicare IS socialized medicine and nobody is trying to mess with it.)
  • You're going to make health care elitist, so only the wealthy will have good health care! (No, the way it is now, only the better off can get good health care. Obama wants to make it less elitist.)
  • The government will withhold health care and let old people die! (No, nobody has proposed that and nobody would tolerate that.)
  • An anonymous bureaucrat will control my health care! (What do you think is happening now? With public health care, you can write to your congressman. Under the current system, you get to write to the company that denied you coverage.)
  • It's going to be too expensive! (No, doing nothing is too expensive. Nobody has argued with President Obama's point at his last press conference, that doing nothing will double our health care costs in ten years, while further reducing the number of people covered.)
  • I won't have the freedom to choose my health plan! (You don't have that freedom now. Your employer selects the plans you get to choose from. If you're lucky, the plan you can afford is adequate. If we have a "public option," that plan will be available to everybody, actually increasing choice.)
  • I won't have the freedom to choose my doctor! (The way it is now, you have to choose a doctor who takes your plan. If your employer decides to change your plan, you might have to change doctors. That won't change unless regulations require insurance companies to accept all willing providers. Fat chance.)
  • I won't be able to keep my current plan! (Yes, you will. There is nothing in any of the current proposals to keep you from doing that.)
  • I'll be forced to buy insurance when I don't want it. I should have the right to go without insurance! (No, we're all in this together. You never know when you'll fall down the steps, get bitten by a mosquito carrying Lyme disease, or be diagnosed with cancer. Just like with car insurance, you pay into the system so you can get the benefits when you need them.)
The health insurance companies like the system the way it is. They're making money hand over fist. They don't want any changes and they are throwing money at both parties (1.4 million dollars a day!) to defeat reform.
Worse yet, the Republican Party has decided that defeating Obama is more important than helping US citizens. They have been actively feeding this nonsense through their usual media outlets. They ought to be ashamed of their lies, but I don't think they have the moral fiber.
There is no reason we should be holding to the current system. It's a social and economic mess. People are going bankrupt with medical bills, while others have no coverage at all and only get treatment at an emergency room when they are really sick. Furthermore, we cannot compete internationally if we continue to throw good money after bad for health care.
Every other western nation has managed to provide health care for all its people. Why can't we? There's only one reason we can't: We've got Republicans and they don't.
Blue Dog Democrats are bad enough, but at least they're willing to vote for something. If health care reform fails it will be on the Republicans, and they will happily take the credit. But, while they are celebrating, they should know there will be a lot of us who will remember what they did.
I guarantee you, if health care reform fails, the only time I'm going to vote Republican is for dog catcher. Then I'll get the meanest, nastiest dog I can find and set it loose.
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Tuesday, June 30, 2009

How Health Care Reform can Save Money

Health care reform is near and dear to my heart, both as a provider and as a patient. The national situation, where 40 million Americans either have no health insurance or bad health insurance, is an abomination. Under Obama, it looks like some kind of reform is going to happen now. I've been wondering about some more obscure aspects of the system.

The Senate Health, Education, Labor, Pensions (HELP) committee has released an outline of its latest proposal for for health care reform. I just found the bill on their web site. It's 615 pages, so I don't think I'll be reading it between clients. I skimmed over it, and didn't see what I was looking for.

I was specifically looking for reform of programs that have health insurance components, such as:

  • Worker's (or Workman's) Compensation insurance;
  • Motor vehicle insurance;
  • Medical malpractice insurance;
  • Homeowner's, renter's and business liability insurance; and
  • Product liability insurance.
You could probably come up with some additional examples, but these seem to be the major insurance programs. All of them deal with injuries which are attributed to the fault of another person or entity. Under these plans, medical costs attributable to the accident are not paid through the person's medical insurance. They are paid by the appropriate liability insurance company.

So, for example, a worker injured on the job is compensated by the employer for his or her injury through Worker's Compensation. Injuries from slipping on a wet floor at the supermarket are paid by the supermarket's liability insurance. An injury caused by a defective product is paid for by product liability insurance. Here's the critical thing: While the person's initial claim may be covered quickly by the insurance company, escalating costs are fought vigorously. The only thing an injured person can do is hire a lawyer.

Universal health care can reduce some of these costs, but my reading of the bill says it won't. This is a shame, because one of the goals of insurance reform is to reduce costs to businesses. Let me show how it can do this. First, as an example, consider worker's compensation:

An employee is hurt on the job. He goes to the emergency room as instructed by his employer and gets initial treatment. Then, he goes to other physicians or therapists as appropriate and takes some time off to recover. Ideally, Worker's Compensation would cover the medical costs and the lost wages.

"Ideally" is the operative word. Worker's Compensation insurance will cover the employee's claim only if they are convinced that the injury is genuine and a direct result of the employee's accident. They fight the claim if there is any ambiguity in the diagnosis or if there is any reason to suspect a preexisting condition. There is always ambiguity and there are frequently preexisting conditions, so a large number of Worker's Compensation claims end up in litigation.

The whole thing can take years to resolve. During this period, the employee is subjected to extensive harassment and intimidation. I have heard all of the horror stories, and I've heard them repeatedly. The first time you hear them, you think the person is paranoid. But then you hear the same stories again and again, and it no longer seems delusional.

For example, a person receiving Worker's Compensation benefits finds that, with no good reason:
  • The person goes to a pharmacy to refill prescriptions. The prescriptions, which were covered a month ago, suddenly aren't being covered. There's a $500.00 bill to be paid before they get their pills.
  • The monthly check covering lost wages stops coming without warning.
Frantic phone calls go unanswered until the person retains an attorney, and then magically the benefits start up again for some period of time. Then, other things start happening:
  • The person is followed and videotaped by private investigators to find evidence they're not disabled. Investigators are allowed to videotape through the person's windows and show the tape in court.
  • The person is sent to a physician, sometimes far away from their home, whose sole job is to review the claim, perform an examination, and proclaim they are ready to go back to work.
  • Hearings over eligibility for Worker's Compensation are scheduled far in the future and then continued for no good reason, often leaving the person without a check or without medical care.
  • Needed treatment is denied after a long decision-making process. Often this means that more extensive and expensive treatment, with poorer results, has to follow after the claim has been resolved.
I would rather find out that a nuclear cruise missile has been launched directly at my rectum, than to go through this. Of course, that's the point.

For Worker's Compensation companies, there is no downside to this level of harassment. The more they harass you, the more you get worn down, and the quicker you are to settle. It's expensive, but the costs are just passed on to the employer, who is reassured that they are really saving money because none of their employees are (God forbid!) getting over on them.

My experience has been that Worker's Compensation has been the worst of these systems, but this can happen anywhere when liability for medical care is involved. I've seen it with motor vehicle accidents, and have heard about it with medical malpractice and product liability cases.

We all pay for this crazy system. We don't pay it up front, and the costs are hidden, but they are there. When you buy a car, a refrigerator, or a can of soup, part of that cost covers workers compensation and product liability insurance. Similarly, when you pay your car insurance premium, part of that premium pays for health care costs for injuries others have sustained in an accident. The price you pay for food or for a swing set partly covers these costs. Your health insurance premium partly pays for medical malpractice and workers compensation for health care workers.

So here's my question: If health care is a right, not just a perk provided by your employer, why not just include the treatment of all injuries under it, regardless of origin? That way treatment is administered in a timely manner and without difficulty. There will still be litigation over lost wages, pain and suffering, and lost capabilities, but at least health care will be out of the picture.

I can hear the demagogues bellowing, "I don't want my health insurance to pay for someone else's mistakes!" Well, as I just indicated, you pay for it anyway. You just pay for it with a different check. And you pay more for it because you have legal fees attached to it. We can streamline the process and reduce costs by eliminating the adversarial system as it covers health treatment.

Will people try to run up health costs to appear more disabled than they really are? Of course they will. But however health care reform works, there will be cost controls in place to handle unnecessary treatment. Those cost controls are much less expensive than litigation.

How much less expensive is an open question. I haven't been able to find statistics on how claims break down into medical vs. non-medical payments. One site I found wanted $500 for access, so I'll leave that issue to others who have better library access than I do. I would love to hear from you if you do have that data.

By removing medical coverage from worker's compensation and various liability insurances, we reduce costs to employers and manufacturers. We have heard about tort reform for years and it is usually a code for "let's screw the little guy." This is a simple tort reform that has the potential to significantly reduce costs and will benefit the little guy at the same time. It makes our products more competitive on the world stage and that cannot be a bad thing.
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Sunday, April 26, 2009

Grieving for our Parents

This week's New York Times Magazine has a fascinating article by Christopher Buckley about the deaths of his parents, Pat ("Mum") and William F. Buckley ("Pup"). The article, excerpted from his upcoming book, is about his ambivalent relationship with them. Christopher is a wonderful and compelling writer. He tends to write in a style we clinicians call, "rambling, but goal-directed." He often digresses, but there is always a purpose to it, and returns to his main point quickly. He is an apple that didn't fall far from his parents' tree.

Christopher's mother died 11 months before his father. He relates seeing her in the ICU. At a point when she may have already been dead, he found himself saying, "I forgive you." Like so many essential things we say, his words surprised him. Then, a few months later, with his father facing death, they had this interaction:

I had planned to leave mid-July on a trip to the West Coast. One night as we watched the first of three — or was it four? — movies, he said apprehensively, “When are you leaving for California?”

“I’m not, Pup. I’m going to stay here with you.”

He began to cry. I went over and patted him on the back. He recovered his composure and said, somewhat matter-of-factly, “Well, I’d do the same for you.”

I smiled and thought, Oh, no, you wouldn’t. A year or two earlier, I might have said it out loud, initiating one of our antler-clashes. But watching him suffer had made my lingering resentments seem trivial and beside the point.

I wondered, while keeping this vigil with him, whether to bring up certain things and talk them out so that, when the end came, nothing would be left unsaid between us. But each time I hovered on the brink, I found myself shrugging and saying, Let it go. Perhaps it was another way of saying “I forgive you” — as I had to Mum that night in the hospital — on the installment plan. I felt no need for what is called, in other contexts, the “exit interview.” I was able to love him now all the more, and actually laugh (inwardly, anyway) at that “I’d do the same for you.” Oh, yeah? Ho, ho, ho.
We come to terms with a loved one's death by accepting them as they are. It is at best unnecessary, and sometimes counterproductive, to try to leave everything said, or to "talk things out." Instead, we need to understand that in the face of death, "my lingering resentments seem trivial and beside the point."

When we grieve for our parents, we grieve for them as they were, and we grieve for what we have wished they were. As we come to terms with that discrepancy, we come to terms also with our own lives. We do not have to be perfect to be valuable human beings. Our past mistakes and our current faults do not make us despicable; they make us unique and human. In some ways, Buckley is telling us, our faults are just as precious as our our assets.

Saturday, April 18, 2009

The Psychology of Jealousy: Guest Post

I recently had a request from Sarah Scrafford, to post on JND. As I haven't been posting lately, I welcomed her offer. Below are her thoughts on the psychology of jealousy.

The Psychology of Jealousy

Relationships are complicated, even when things are going smoothly. You never know when you’re going to be overcome by emotions like anger, sadness, and the worst of them all, jealousy. It’s an evil, green-eyed monster that makes your life miserable; it eats away at every shred of happiness you have until you’re a bundle of nerves and an emotional mess; and it makes you do things you would never do when you’re in your right senses. We only have to look at the female astronaut who put on a diaper and drove all through the night to attack a rival for her beau’s affections to see the truth of this statement.

A close friend and I were discussing a couple whose relationship had hit the doldrums. He wanted in, she wanted out; and the more she wanted out, the more he wanted in. My friend was of the opinion that that’s the way human beings are – when we know that we cannot have something, we somehow seem to want it even more. So when someone close to us withdraws and retreats into a shell, we seem to crave their company and affection in the worst possible way. It’s worse when there’s a third person involved, when you know that someone else is getting what you think you deserve. Jealousy comes rushing in and takes over your life, making you incapable of rational thought or reasoning.

While I’m no psychologist, here’s what I know about the psychology of human relationships – the best way to attract someone’s attention is to pretend to be totally unaware of them. This works really well when they know you’re interested in them and when they’ve rebuffed your advances at least once. The moment you stop hanging around them or trying to get them to show an interest in you, they’re going to wonder why you changed your mind, why you’re not as into them as you seemed to be before. And this hits their ego, the one that you helped inflate with your undivided attention.

If they’re the mature kind, they realize this hurt ego for what it is and let things go; after all, they’re really not interested in a romantic relationship with you. If not, they’re definitely going to hang around you more, check if you’re looking at them from afar, tease you a little with a text message or a mildly flirtatious email, or invite you out for a cup of coffee. But before you jump for joy at this new attention, let me warn you that this interest, the one that’s riding solely on a hurt ego, will disappear the moment you begin to reciprocate, unless your beau is really into you by this time.

Yes, as Shakespeare rightly said; it’s a tangled web we weave, when we first practice to deceive. The psychology of relationships is complicated, more so when we have to play games to win over the people we really want.

This article is contributed by Sarah Scrafford, who regularly writes on the topic of online radiography schools. She invites your questions, comments and freelancing job inquiries at her email address:

Wednesday, January 28, 2009

Traumatic Brain Injury and Football

Almost exactly two years ago, I posted a sports rant focusing on the effects of repeated concussions on football players. Here it is Superbowl time again, and another story has surfaced on the topic. (Also see here.) I assume these stories are released at Superbowl time to get more play.

The study of the brains of former NFL players is being conducted by the Center for the Study of Traumatic Encephalopathy at Boston University School of Medicine. Credits are as follows. I added the parenthetical clarification of the acronyms:
CSTE (Center for the Study of Traumatic Encephalopathy) is a collaboration between SLI (Sports Legacy Institute) and USM (Boston University School of Medicine). SLI was founded by former Harvard football player and WWE pro wrestler Chris Nowinski, and neurosurgeon and concussion expert Robert Cantu, MD, chief of Neurosurgery and director of Sports Medicine at Emerson Hospital in Concord, Mass, and clinical professor Neurosurgery at BUSM. The work at BUSM is being led by McKee, an associate professor of Neurology and Pathology, director of the Neuropathology Core of the BU Alzheimer's
Disease Center, and the director of the brain banks of the Framingham Heart Study and the Bedford VA Medical Center, and Robert Stern, PhD, associate professor of Neurology and co-director of the BUSM Alzheimer's Disease Clinical and Research Program. The CSTE received initial funding for their research from BUSM and subsequently received a $100,000 grant from the National Institute on Aging to support their work. This past week, the group of researchers learned that they received a $250,000 grant from the National Operating Committee on Standards for Athletic Equipment (NOCSAE).
According to the story, players have been asked to donate their brains for study under the "88 Plan," named for John Mackey who wore jersey 88 for the Colts and now has severe dementia. So far, 7 NFL players have been evaluated, an 6 have been diagnosed with chronic traumatic encephalopathy. Trauma refers to damage. Encephalopathy refers to brain pathology. Hence, traumatic encephalopathy is a technical term for brain damage caused by head injury.

One can diagnose encephalopathy through brain imaging, psychological tests, and by clinical signs and symptoms. However, in this case, the diagnosis was made the most reliable way, by autopsy, so there is no mistaking the severity of the problem. Interestingly, the players' brains had some similarities to Alzheimer's patients. Most of the players showed signs of memory loss, impaired thinking, depression, and impulsive behavior. They also may have abused substances. Two died of suicide and a third died of a self-inflicted gunshot wound ruled accidental.

This is pretty scary data, but I want to add two cautions to interpreting the data. First, these are people who have died early, between 25 and 50, so they had severe and repeated injuries. If we examined players who lived a full life, we would certainly see a different picture. This is why the authors have carefully avoided claiming that most NFL athletes have brain injury.

Second, the players with traumatic encephalopathy played at a time when concussions weren't taken seriously. The NFL has developed procedures for managing concussions and when to allow a concussed athlete back onto the field. The NCAA has supported studies of concussions. The American Academy of Family Physicians has a nice summary of how to manage concussions in high school athletes. As mentioned above, the quality of the equipment is also being evaluated. So, now that concussions are being taken more seriously, the pervasiveness of traumatic encephalopathy should be declining. But we don't know that for sure.

As someone who spends most of his time in his head and others', I question why we accept this risk at all. Remember the old commercial, "A mind is a terrible thing to waste"? When a child or a young adult athlete is concussed, the rest of their life is at risk. And for what?