Pawns

Book Ends

I have written before about my life as bookends.  Before I was commenting about growing up in the 1930s and 1940s, and now seeing some similarities here in the US to those troubled times.  But now, my bookends relate to health care.

We are on Medicare, thankfully, and have been for 15 years. We have also lived in Concord for the same 15 years.  During that time, thanks to our daughter, Erika, who is one of the doctors in a leadership position at Cabarrus Family Medicine, we have gathered around us a supportive network of high quality physicians to care for us as we age into our final life stage.   And we feel very well cared for indeed.

Now, one of the things you discover as you age a bit (I have now entered my 42^nd 39^th year of life—you do the math) is that you require increasing amounts of medical care—both from the docs, and from Big Pharma, as well, occasionally, from the local hospitals. Yes, aging in place is a lot of fun, but as has been noted by others, aging is not for sissies.  And in discovering that one needs a lot of care, one also discovers that the trusty old Medicare doesn't quite pay all the bills. Congress has seen to it that Medicare hasn't quite kept pace with inflation and there are increasing gaps between what our Medicare pays and what the actual bills are. So, guess what, one needs what they call Medigap policies.  The gaps exist in regular Medicare payments for physician visits, tests, and the pharmaceuticals that keep one upright (most of the time).  So, in addition to the regular Medicare insurance, one now needs to purchase some added insurance.  So we do exactly that.

Now, for those folks currently whining about the complexities of Obamacare, or the bad old IRS, it is useful to note that those complexities do not begin to compare with the complexities introduced by the much beloved private insurance companies.  Yes, we understand that republicans do so love private insurance companies. They’re private after all.  They’re not big bad GOVERNMENT.

So, we have been dealing with these beloved private insurance companies for many years now. We have occasionally changed carriers, mainly because the companies keep changing how they cover, what they cover, and how much one has to pay for the various services one needs. They do keep you on your toes.

In a recent open season (what a charming name, huh?) we again switched from one carrier to United Health Care, mainly to gain some pricing advantage.  They were somewhat less expensive than our previous carrier.  We attended an open meeting sponsored by United, listened to their sales pitch. We checked their materials to be certain that our entire panel of both primary care and specialist care physicians were on their list of “in-network” physicians, and that our drug regimen was within their formulary.  All were included, so we decided to change.

That was last November.

What United Health Care neglected to tell us was that they were currently in process of negotiating a new agreement with the vast Carolina's Health System, which includes the hospital we use, and the entire panel of doctors we visit.  Had we known about their “negotiations”, we almost assuredly would have foregone the pleasure of changing to their coverage.  A bit risky.

But we didn’t know and they didn’t bother to tell us.

So, the changeover occurs, and now we are using United Health Care. Lots of changes, but the complexities are all manageable. But then . . . the “negotiations” drag on—December . . . January . . . February.  Then we start getting notices from United that we may have to obtain a different primary care provider, one who is “in-network”, since they seem not to be able to conclude their “negotiations” with CHS yet. The shocking piece of news from United is that Cabarrus Family Medicine—our PC provider network system, will soon be “out-of-network”.  But, ever helpful, United offers to sign us up with a new primary care doc. They suggest a doctor by name.  We check the doctor. Turns out he is a resident in training at, guess where . . . Cabarrus Family Medicine.  So, it seems they don’t have a clue what they are doing.

The “negotiations” drag on. It is now nearing the end of March. Still no progress. The rhetorical war heats up, with the equivalent of name calling.  I begin to think about the Arab-Israeli “negotiations”. The reason they always fail to reach an agreement is that both sides think they will/must “Win”, ergo they never really put anything worthwhile on the table. As a result, no settlement is ever reached. I imagine the same thing occurring with United and CHS.   Neither side wishes to give in, lest they “lose” something of value (money). And then, while checking something on-line, my wife notes something interesting. United has already ‘assigned” us to a new primary care physician.  Note, not only did they not ask our permission to assign us, they did not even have the courtesy to inform us.  Oh, and it turns out the doctor to whom we were assigned is a staff physician on a local indigent care clinic in our town. Wow, that really fills us with enthusiasm.

Well, it’s really all about the money. And, as I noted in my last blog posting, when money becomes the sole criterion, then nothing else matters, including especially the wishes/interests  of the people within the system-the customers/patients. No we really don’t matter at all. Money is all that matters. Oh and forget about that "continuity of care" thing.  Our insurance company either doesn't understand that concept, or it has been lost in the money chase.

So, one option is for us to have the equivalent of no insurance, i.e., we would be paying United, but be unable to access any of our regular physicians or hospital.  And that brings me back to the bookends concept. See, when I was little, growing up in New York City, we didn't have regular physician or dentist visits. We simply didn't go, except when an emergency occurred (like me breaking an arm, or requiring a dozen stitches. Dental care? Nope. Regular "well-child” visits?? Nope.  Dental care occurred once in a while, when I needed something done, and then I went to a dental school, where they practiced on me.

So, now, we understand that we—the insured—are the pawns in this chess game being played between United and CHS. They are quite willing to use us in any way they choose, as bargaining chips (remember that old saw about taking your football and going home?). Yep, that’s United Health Care.

So, instead, we are taking our business elsewhere. Turns out, we can switch back to our original plan, if we don’t like our new coverage, anytime within the first year.  So, yeah, that’s what we will do.  And our suggestion to United?? Perhaps they should go into some business they might better understand—like maybe auto insurance. Yeah, they could start a motor maintenance organization (MMO). That way, they might still screw things up, but, hey, it’s only your car, right???

Anyone for a single-payer system???? I'm in.

Money as the Enemy

Dr. Danielle Ofri is a practicing physician, as well as a prolific author. She writes often about medicine and the practice thereof.  She recently penned a thoughtful (they always are thoughtful) article about the increasing role money plays in medicine and the delivery of health care. She begins below:

"In mid-January a patient called me from her pharmacy, frantic. Her asthma inhalers came to $168—a sum that she hadn’t been prepared for. But she can’t live without those inhalers, so she withdrew cash from her meager savings account and skipped her blood pressure pills for that month.

This is such a familiar story by now that it hardly makes news. Yet it is tragic, every single time.  Beyond the fact that it is monstrously cost ineffective, there is something just plain wrong about it.

Money, of course, cannot be ignored in medicine. But just because money is a realistic consideration in medicine, doesn’t mean that we have to blindly accept all the consequences..."

Read her full article here:

http://danielleofri.com/ethics-of-money-in-medicine/

I often respond to Dr. Ofri, because I find her articles both stimulating and thought-provoking. My response is as follows:

You are correct when you assert that earning money is not in itself an evil thing. But it is that same old saw, “guns don’t kill people, people kill people.” And I could add, “Alcohol doesn't kill people, people with too much alcohol kill people.”

Why do these three things all say the same thing? Because excess is itself a bad thing.  Is big bad? Well no, but too big is bad.  When an entity, a bank for example, becomes “too big to fail”, then it must be judged too big to exist and should be broken up.

Money in the medical system is not in and of itself bad, but in the pursuit of more and more money, the chase begins to crowd out the central purpose of the system.  As money begins to dominate any system, the other relevant criteria of “goodness” are moved aside. We understand that corporations exist to earn money, and that means drug companies, insurance companies, medical device manufacturers, hospitals, and, even medical practitioners.  They all wish to make money.  Yet, in this vast system, if the health and well-being of people—patients—in the system becomes lost, a casualty of the financial aspects, then the entire system becomes meaningless. That is when money becomes the central evil—when it drives out the main purpose of any system.  In health care, the central purpose of the system is to maintain a full population at its expected state of health and well-being.  When folks are trading off one element of the system –say drugs to control blood pressure—in order to obtain and use another element—say asthma medication, then that system is by definition operating suboptimally.

But I should add at this point that all of our systems in this country have moved in that direction. We are trading off optimal performance in order to either reduce cost, or increase income/profits. You can observe this phenomenon in system after system. In the broad range of consumer products, by shifting to a single criterion—cost—we have opted for a consumer product system in which we produce garbage in China for sale in America, regardless of the consequences in terms of performance. Quality in this system is no longer a relevant criterion.  Reliability is nearly irrelevant.

In perhaps the most egregious example of this phenomenon, Banking, the pursuit of ever greater profit margins and ever greater CEO salaries and bonuses, we have produced an almost completely useless system that operates at the “out-of-control” stage almost continually.

In Education, we have begun to dismantle a system that has worked reasonably well over a very long time period, and we are shifting to systems that, not only do not work as well, but almost by definition are seriously flawed systems, because they favor money over performance.  In that system, we have begun to rid ourselves of the task of educating our population. Why? Because it costs money, and, not coincidentally, it produces a population capable of thinking and potentially rejecting the politicians who favor money over performance.

And so it goes. Money has become not merely the most important criterion in our systems, but is closing in on becoming the sole criterion, with all other criteria being relegated to nominal performance criteria.

And the saddest part? This has been happening with relatively little outrage on the part of the affected population.  We are all sitting around, sucking our collective thumbs, while distracting ourselves with video games, Facebook, Twitter, and March Madness.   Meanwhile, the 0.1% continue to acquire all the available money in the world, while we sink into a morass of our own making.

The GOP as Enemy of the Nation

So the GOP has now added “anti-American” as one of its defining traits.  Prior to this stage, they had added the KKK, the NRA, the anarchist, the secessionists, and the ever present Christian Taliban elements to define the core belief system of the GOP. The Tea Party has always been helpful in this regard, bringing the KKK wing into the party. 

But what is one to make of this new GOP? Clearly, they are not a party seeking to govern. Instead, they appear to be a party seeking to divide, even break up this country many of us still hold dear.  It has been amusing at the least to observe the GOP, and its PR wing (aka the Faux News network) chatter on about how supportive the GOP has always been of the civil rights movement, when in fact they are the main opponents of civil rights. It is a fact that, from the end of the Civil War, when southern republicans all switched to the democratic Party (cuz Lincoln won the war) until the 1960s, when Johnson lost the South by introducing civil rights legislation, that the (southern) democrats were opposed to civil rights, But those “democrats” were never serious democrats anyway. Once Johnson made his moves, they all flipped back into the party of Lincoln, only this time on the side opposing civil rights.

But something even more profound seems to be happening to the GOP. It’s like they have become unhinged by the election of President Obama.  They have turned rather completely into the party of No.  It seems to matter not what our President wants to do. They will say No.  And they go beyond merely opposing him. They actively seek to discredit, even dishonor the President and, now even the Office of the Presidency. Their letter to the leaders in Iran went so far beyond mere opposition that it moves in the direction of treason. The letter does not of course quite reach that stage, but it was clearly intended to damage the United States in its attempt to negotiate with Iran. It diminishes the Executive branch really in an obvious attempt to disable it.

And I have begun to wonder whether this nation is at the brink of something far more serious than mere political divisions.  What most gives me pause is that the GOP managed to convince enough voters to place them in charge of both houses of Congress, and many state houses, from governors to state legislatures.  If the nation wants this kind of dysfunctional government, then perhaps we are witnessing the beginning of the end of the great American experiment.  We have been exceptional in many regards, having created one of the world’s great democracies. Perhaps the cornerstone of that democracy is the premise that we are all in this game of life together. Despite our many internal cultural differences, we agree to respect one another and to act as a community. This agreement is in fact the source of our great strength. Without that commitment, we become simply groups of tribal folk who happen to live within the same geographic region. And that is what defines many of the world’s troubled regions—certainly the Middle East, and many regions in Africa. 

But that basic agreement—that comity—is what seems to be breaking down.  People no longer simply disagree politically. No, our disagreements now always seem to contain bitter vitriol, poisonous utterings.

I wish I could say that I saw the light at the end of this tunnel of hate. But I don’t. With Fox News cheering us on, we are on a runaway train plunging down a steep slope with an engineer at the helm, but an engineer being beaten on the head by some of the passengers. And the passengers seem not to care that the train may soon head off its track and plunge wildly down the nearby ravine. They do not care. And that is what troubles me greatly. All reason has left the party of No. And we cannot continue this course they have now set without eventual disaster. So, cheer on, Fox News. Will you still applaud as our train comes apart and leaves its track, flinging us all hither and yon? But then where will you go Fox? And where will you go Republicans?

“At what point then is the approach of danger to be expected? I answer. If it ever reach us it must spring up amongst us; it cannot come from abroad. If destruction be our lot we must ourselves be its author and finisher.” (Abraham Lincoln's Lyceum Address)

Bibi as Chicken Little

The Boy Who Cried Wolf

Bibi as Chicken Little . . . Bibi as the boy who cried wolf . . . Bibi as the mad bomber. Well, at least he’s consistent. Bibi has been predicting the end of his world for 20+ years now, waiting, apparently, for us to bomb Iran for him.  When we don’t he whines a lot and then goes back to predicting the end of his world.

Note please that Bibi never offers any new, potentially productive ideas/strategies to advance the cause of a non-nuclear Iran and world peace. Bibi is not overly concerned with world peace, or any peace for that matter. He’s fine tossing his bombs at the Palestinians, knowing that his Arab neighbors are now incapable of destroying Israel.  So peace is not in his agenda. He’s so . . . republican that way.  That’s why they (his republican allies) love him so much. He’s like one of the head GOPers preaching to his choirboys.  I’ll bet Bibi gets on well with the Cocks of the world. And of course, his speech to the American Knesset (GOP-Congress) had nothing to do with his politics. Heaven Forfend! He is shocked, shocked that anyone would even think that.

So, now what’s next? Well, I guess Bibi goes back home and continues his campaigning to be the Supreme Commander of Israel, the GOPers go back to decrying our President, and Tony and the Supremes return to shredding what’s left of our democracy.

Happy Days are here again folks.