Saturday, August 23, 2008

A Summer Night in 1958

Dinah Washington: All of Me.

Catch her fooling around with the vibes during the break. She looks like she knows what she’s doing to me.

Fifteen days of blogging for health care reform: Down on the pharm

Guest post by Skylanda...and sorry folks, this is a long one!

A virile sixty-ish male chucks a football through a tire swing, raises a couple of fists in victory, and manhandles his comely wife; the final voiceover lists headache, flushing, dizziness, rash, cognitive dissonance, sudden loss of conscience, and pernicious priapism as possible unintended consequences of the little blue pill that made this moment possible. I might have just made up the side effects, but you’ve seen the ads.

If you’re old enough to remember ten years back or more, you remember a time when pharmaceutical ads did not appear on television. These ads first appeared around 1996, when changes in FDA regulations began allowing direct marketing of pharmaceuticals to consumers, bypassing the expertise of your doctor and asking you as the patient to approach your provider and ask for medication that might benefit you. Pharmaceutical peddlers now go to a lot of trouble to make sure that you know their brand names as you know the brand of your kid’s cereal: they debut ads during Superbowls, they hire ex-presidential candidates to plug drugs for conditions that no one wanted to talk about in public a year earlier (Bob Dole wants you to know that Bob Dole has trouble with his wee wee, says Bob Dole).

Among the most eye-browing raising ads I ever saw for a pharmaceutical product was for Procrit, an extraordinarily expensive injection used to drag red blood cell counts up in anemic chemotherapy patients, those with end-stage renal disease, and those doping for high altitude sports. The former patients are usually managed closely by specialists who keep an eye on issues like this, so unless you are trying to get yourself kicked off the Tour de France, this is probably not something you need to ask your doctor for. Nevertheless, these ads are more or less asking you to call up your doctor and request yourself what roughly amounts to a chemotherapy drug (Patients, ask your doctor if adriamycin is right for you today! …sorry, geek humor…move along…nothing to see here…)

The opening of the advertising for pharmaceuticals was ostensibly done equally in the name of the free market and in the name of full patient education. And indeed, there is some equalizing factor poured into the mix when you as a patient find out that there are six roughly equal allergy medications on the market instead of the one marginally effective one that your doctor has been prescribing you for ten years simply because it is the one that he or she is comfortable with. The concurrent explosion of direct-to-consumer advertising and the arrival of the world wide web have contributed to a double-edged sword for doctors: a generation of patients that is perhaps the best-informed in history, and the enormous headache of trying to sift through the raft of misleading misinformation that is now at every patient’s fingertips.

Aside from direct advertising, pharmaceutical companies have more insidious ways of inserting their buy! buy! buy! message into the public consciousness. Gone are the halcyon days of all-expense-paid golfing trips to the Bahamas to hear a one-hour lecture on the newest heart drug, but pharmaceutical money still pays its way into physicians’ minds in a variety of ways. Drug companies buy their way into trainees’ heads by providing food for required lunchtime lectures in return for a few minutes of air time on their latest product. They sponsor professional conferences, which for small states and less lucrative specialties like mine, could not happen without some commercial support (ironically, in family medicine, these conferences are often the site of ragged ongoing debate about the issues du jour surrounding affordable health care and - always - the role of drug pricing in that affordability). They litter the hallways with cheap pens, clocks, and other products bearing the flashy logo of their expensive wares. You would think that future doctors and practicing doctors wouldn’t sell out quite so cheap, but this is an awful large outlay of funds across the nation for these efforts; something must be working.

Most controversial of all is the provision of free sample drugs to clinics. Ostensibly, this is charity: who can nay-say free drugs? But by providing free drugs as a start-up pack, pharmaceuticals hope to buy patient-doctor loyalty to that brand, and this is often the case - and it is important to note that only patented, on-brand drugs are given out for free (no one runs around in fancy suits with branded pens and clocks pedaling drugs that cost four dollars a month). A patient is started on, for example, a cholesterol medication out of the doctor’s free sample closet, and once the samples run out, the patients transitions to paying for the medication at full price because it works and they are comfortable with it and they know the brand. You can see how this does not work at all as a charity for uninsured patients, it only works as a come-on for insured patients. You’ve probably seen this tactic before; it’s called “First one’s free!” and - not to be too prejudicial or anything - it’s also used by the guy selling heroin a block down the street from your local high school.

It is for all these reasons that some institutions - often at the behest of medical students and residents - have started to boot the pharmaceutical companies out of their clinics, their mailbox, their lunchrooms, and their drug closets. The integrity of education is at stake, they argue, as is the integrity of their ability to treat patients without this ultimately costly interference. The American Medical Student Association’s Pharm Free campaign has successfully spearheaded the movement to drive the pharmaceutical companies out of several major university hospitals, and is gunning for more. (Of note, some community-oriented providers have made interesting compromises with pharmaceuticals to continue providing expensive drugs without compromising patient priorities. Both community clinics I have worked in within New Mexico have had a policy of allowing pharmaceutical companies to hawk their wares and leave samples, but only those with whom the clinic has established means of continuing uninsured patients on those expensive drugs through corporate-sponsored patient assistance programs, which give a certain number of prescriptions out for free each year as a charity write-off for the drug company. Why the pharmaceutical companies even bother with these clinics, I cannot imagine - perhaps the hope that one day these patients will receive paying Medicare benefits? - but nevertheless, there it is.)

So the move is afoot to boot the pharm companies from places they should not be sticking their noses, to reclaim a less biased territory for training new doctors, and to control costs. This is a universal good, yes?

Well, it may be more complicated than that. Drug innovation is a mighty expensive enterprise. It depends who you ask (and what their motivation is for cooking the numbers in any given direction), but from the moment a drug is first thought up to the time the first commercial batch is sold off the assembly line, the total cost of developing a new drug is somewhere between $75 million and $800 million dollars. This can include versions of the drug that are canned early on because of safety or efficacy failures - expenses which biotech companies routinely swallow as a cost of doing business, which is part of why it is so hard to say exactly how much a new drug costs to get to market. And every drug that does reach the market risks being yanked later (amidst a raft of lawsuits) due to unforeseen safety problems…even a blockbuster like Vioxx. With that kind of up-front investment required of pharm companies to keep the conveyor belt of innovation moving, it requires some powerful motivation to keep the pipeline open. That motivation is known as profit. There is a danger to impinging too deeply on pharm profit, and that danger is that we slow the pipeline for innovation into advances that may be life-altering or life-saving down the road. What is the use in inventing drugs that no one can afford?, you might ask, and that is indeed the balance that has to be struck: keeping the pipeline open, but in a means that at least a useful critical mass of people can afford.

It is also useful at this point to widen out the scope of this discussion to a more global scale, to understand the role of the US market in the drug trade (the legal drug trade, that is) around the world. And for that, we have to go back in history a few years, to a very different time and place.

That place is New Hampshire, around 1944, in a town called Bretton Woods. The Allied victory was starting to look like a sure thing, and the representatives of the future victors gathered quietly to start planning for what that victory would look like. Galvanized with the understanding that punitive measures against the loser nations (especially Germany) after World War I largely sparked the disastrous build-up toward World War II in Europe, these planners sought to employ the lessons of the 1920s and 1930s toward building a better world. You’ve probably never heard of Bretton Woods, but you’ve certainly heard of at least one of the global institutions that were born or consolidated that summer in New Hampshire: the International Bank for Reconstruction & Development (later the World Bank), the International Monetary Fund, the General Agreement on Tariffs and Trade (GATT), and the United Nations, which had its roots in the post-WWI League of Nations and was formalized in the spring of the following year. Together these formed the logistical underpinning of the Marshall Plan, perhaps the most ambitious (and arguably the most successful) program ever undertaken to promote peace and prosperity in the world to date; in a couple of decades, western Europe was transformed from a zone of constant conflict and cyclical spasms of poverty into the wealthy and relatively peaceable place we know it as today.

Among these institutions, the one you are least likely to have heard of is GATT. The GATT treaty was designed to create a forum for breaking down trade barriers that had both hindered free movement of goods and people and also encouraged the kind of regional Balkanization that historically sparked wars throughout Europe. When GATT was originated, its founders probably had no idea the sort of contentiousness and riots would one day be fomented in its name wherever its representatives gathered, for what started as GATT eventually morphed into its heir child, the World Trade Organzation.

A full discussion of the WTO and its controversies is entirely beyond the scope of this post, but the role of pharmaceuticals in that morass serves as both an example and a parable of globalization and its complications. And the best place to go to study the globalization of the pharmaceutical industry is the Indian subcontinent. In 1970, India’s populist government passed a law that no pharmaceutical compound could be patented within its borders (patents, incidentally, are nation-by-nation protection; the WTO tries to enforce world-wide patents, but has no legal authority to do so, and can only attempt to wangle compliance through economic pressure on member nations); a nascent industry was born in generic knock-offs of costly medicines patented in industrial nations, unhindered by any legal ramifications of this sort of intellectual piracy. But in 1995, India joined the WTO and was given 10 years to comply with intellectual property rules (known as TRIPS - “Trade Related Aspects of Intellectual Property Rights” in one of the clumsiest excuses for an acronymn ever invented) and cut out the business of knocking off expensive drugs invented in other countries. The intervening ten years saw some profound advances in the treatment of cancer, AIDS, and other devastating diseases, and the dust is still settling on the nuances of which patents are enforceable in the massive Indian pharmaceutical business (some drugs were patented before 1995 but not marketed til later; others receive exemptions from WTO patent rules for their life-saving public health properties; the gritty details go on and on).

The moral right of Indian generic pharmaceutical producers to knock off patent medicines is a tricky one. On one hand, India has a burgeoning population to take care of, and its pharmaceutical industry has traditionally also been a prime source of drugs for developing nations that do not have infrastructure to produce their own nor the cash to buy them on the global market from legitimate producers. On the other hand, lopping a billion or so of the increasingly wealthy Indian people out of the profit-making market for any given drug is liable to put such a crimp on expected revenues that it may hinder motivation for new drugs to be sent down the pipeline in first world countries, when corporations know that these drugs can be knocked off the moment they start coming down the production line. Patent rights may still to this day be threatened on newly marketed drugs because many compounds are patented years before they are proven to be at all useful; this was the driving logic behind the Gleevec decision (which allowed generic versions of a very expensive cancer drug in India), of which I wrote extensively two years ago in this very forum.

Which brings us back to the role of the US market in global drug development. We all know that Americans pay more for the same drugs, no matter how many variables you adjust, than any other nation in the world. Sometimes on an exponential scale. While pricing out drugs in a number of nations for the masters thesis I wrote on TB pharmaceuticals, I stumbled across a policy paper out of the British National Health Service that unequivocably declared that the antibiotic Avelox - at some two pounds per pill - was far too expensive to consider as a first-line drug for any known condition. In translating that number through the exchange rate, I generously doubled two pounds to four dollars (to account for our ghastly exchange rate at the moment) and looked up the price per pill at Walgreen’s: ten bucks a pill. Two and a half times a number that the British medical authorities had deemed too ridiculously expensive to consider for routine use. Avelox is on formulary at the hospital where I work now; not a day goes that we don’t have someone on the inpatient service taking this drug. The mind does boggle.

We pay for prescription drugs at a rate that would impress your local cocaine pusher. We do it because we can, we do it because we’ve been pushed into it, we do it because we have such an obscured system that the only people who actually know the true retail price of a drug are those who are paying out of pocket without insurance coverage. And when we get fed up with it, we get sneaky and order our prescriptions from Canada or India or Mexico and feel like we’ve just got the deal of the century over it (and on that note, here’s today’s PSA: order drugs from Canada, fine, that’s a developed nation with drug standards similar to our own; but caveat emptor if you order medications from developing nations, including India - serious questions of purity, efficacy, and even content have arisen, especially in batches sent abroad to unsuspecting and well-paying foreign buyers). But if you start to strand out the threads of the story, you’ll find that it is not only the pharmaceutical companies that are parasiting off the American consumer; in a very real way, drug consumers in other nations aren’t just getting a better deal than American patients, they are quite literally freeloading off Americans who pay full price for medication. And here’s why:

When a multinational pharmaceutical corporation looks at a promising compound and calculates the plausible return on investment if they take that compound into trials, part of that profit projection comes from bloated, high-roller drug costs in the good ol’ USofA. A large part. If you removed the American portion of that profit margin (or just tightened its belt by a good notch), you would be looking at a far thinner profile. Investment into patent drugs sits heavily on the American consumer; you may eat your shirt every time you pay a hundred bucks for a month’s worth of one drug, but come on, revel in it: you’re ensuring the next generation of cancer cures, blood pressure controllers, and cholesterol fighters in a way that consumers throughout the rest of the world are not contributing so much.

If only the truth were so clear-cut as that murky road home, eh? But of course there is one more twist. And that twist is that the pharmaceutical pipeline is not necessarily as responsive to consumer needs - even the very American consumer that feeds it money-hungry maw - as we might like it to be. You would like to see a safer, more effective treatment for cancer this year; what you get instead is yet another cholesterol drug, in the same class as a half dozen other cholesterol drugs, that is one atom different and costs ten times more than those that have gone generic for no provable increased benefit. You want to a new class of antiretrovirals - AIDS drugs - to see the market this decade; what you get is a blood pressure drug in the same class as ten other blood pressure drugs…again, for an increased price, with little increased benefit. How on earth do you get anyone to buy this stuff - same product, higher price - you might ask? Well, go back to the beginning of this wordy diatribe…advertising, accessing young doctors at their places of training, building brand loyalty through free sampling, obscuring the true cost by filtering it through the insurance industry. The cycle is vicious indeed.

So where do we go from here? We can’t single-handedly redirect corporate funds to socially worthy drugs over yet another branded me-too blood pressure drug, or reform the WTO stance on patent medications (although throwing rocks at WTO conventions seems popular enough world-wide to make an Olympic sport of it). But remarkably, this is an area where patients as individuals do have a marked bit of control. You buy this stuff, you are a market force. Here’s how you can use your dollars to effect this issue.

First of all, the next time a doctor prescribes you a medication, you have the right (you might get a little annoyance in return - but still, you have the right) to ask these questions: Is this the cheapest effective drug for my condition? Are there generic alternatives that are equally effective? If I am being prescribed an expensive medication in a class where there are cheaper alternatives, why is that? You may get a legitimate answer to this last question: because you had side effects to the cheaper alternatives that we tried, remember?; because your condition is severe enough that we go for broke with the absolute best in the class; because the expensive medication happens to be on your insurance provider’s formulary, while a less expensive one is not; because there is no cheaper effective alternative. But many times, there is no good answer, and the next right answer is: There is no good reason why; let’s try a cheaper alternative instead.

Second, you can understand that pharmacies are a market like any other, and that drug prices vary wildly between them. Call around next time you get a prescription and ask how much it will cost before you fill it, even if your insurance will cover it; the answer may surprise you (when I was between insurance plans once, I paid $18 for prescription eye drops that I later found out I could get for $4 down the street…I‘m not talking about fifty cents, I‘m talking about a four-fold price difference). Part (but not all) of this variation is wrapped up in the four-dollar prescription programs at Walmart, Target, K-Mart, and a few chain groceries like Smiths. Far be it for me to gives props to the vortex of social ills that is Walmart, but credit where credit is due: Walmart initiated the four-dollar pharmaceutical plan a couple years ago to provide a month‘s worth of certain generic prescription drugs at a fixed price (a couple hundred different medications at last count), and the others scrambled to follow suit. Walmart surely crunched some heavy numbers before establishing this policy, some numbers that ensure market share and profitability and competitive edge over the mom-and-pop pharmacies that you would love to support instead of the globe-eating big-box chain, but still: gotta give some credit for affordability, transparency of cost, and ease of accessing their list.

Third, you can refuse (unless there is good reason to do otherwise) to buy expensive, new-generation medications for which there is an older, cheaper equivalent. Market forces allow the continued arrival of me-too drugs, and as consumers, we can just refuse to buy them unless there is some pressing reason to do so. Your single purchase won’t re-shape the market, but if as a whole nation we start refusing to buy me-too drugs at inflated prices, the incentive to continue investing in them (instead of in truly innovative and necessary classes of drugs) will dry up.

But eventually we have to tackle the core idea of the how much we are willing to pay for truly spectacular new drugs - cancer cures, HIV treatments, and the like. These will continue to filter down the pipeline to us if we are willing to pay for them - but the price is steep. The top tag I’ve seen cited on a medication is a whomping $100,000 per year for Avastin, a drug which chokes off the blood supply to breast and colon cancers. These drugs arrive because of market forces, and it is entirely possible that we have other priorities that are more important - such as covering all diabetics with drugs that we already know to save lives. Maybe we don’t need a pipeline of new drugs bad enough to pay what we are being asked to pay for them. Maybe innovation should slow a bit to accommodate a market that cannot handle this kind of expense. Maybe the inflated pharmaceutical market needs to accept a slow-down before it hits the kind of skids the similarly inflated mortgage market just took in the gut.

Or perhaps we can work collectively to cap prices while maintaining incentive, by means like trading government or university funding for caps on prices (the former is already in effect, the latter has not generally been demanded yet), or allowing increased patent times in return for limits on prices or guaranteed supplies to patients who cannot pay.

There is no one answer, no victorious football-through-the-tireswing to mark a successful remedy to the question of balancing drugs and prices in America and throughout the world. What we have is a big, snarly, expensive problem. What we need are thoughtful, balanced, comprehensive solutions. And those are never easy to come by.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

Friday, August 22, 2008

Bound and gagged (by Suzie)

           From an interview with Jewel Staite, who plays Dr. Keller in the sci-fi TV show Stargate Atlantis: 
So I understand that Dr. Keller gets tied up in the woods in like every other episode of Stargate. What's up with that?
Yeah, I don't know what that's about. In season four, I was kidnapped and bound and gagged. This year, it's happened to me twice so far. And I just read yet another script where I am again bound and gagged… .
Is there a site somewhere where they're charging five dollars a minute? Is it a fetish thing?
Maybe that's what it is. … And it's the same writer every time that writes the episode where I'm being kidnapped. Maybe he likes seeing me dragged through the woods. I don't know what's going on. And you know what? I don't question it. I guess. At least he's writing for me.
          Since he’s not writing for me, here’s a question: If Dr. Keller were a man, would there be as many scenes of him bound and gagged? ETA: Maybe so! Please see the comments. 
          Update: Stargate Atlantis has been canceled.

Fifteen days of blogging for health care reform: End of the road

Guest post by Skylanda.

Several months ago, I was admitting a gentleman to the general medicine floor of the university hospital. Per protocol, I gave him our standard speech about how we don’t expect him to drop over dead during this admission, but in case he did, we needed to know in advance if he would like us to make all attempts at resuscitation or let him to die peacefully. I promise, the speech came out a good deal more gently than that; the first time an intern has to ask this it usually feels awkward, but after a several dozen times, you get down a speech that you feel comfortable with, that patients don’t recoil in horror to, and you make it part of your routine admission. It’s quite far from the weirdest thing we do every day, believe me (rectal exams: now there‘s one of the weirdest things we do every day).

“Well,” this gentleman said thoughtfully, “I guess you can bring me back. Just so long as they don’t keep me alive like a vegetable or something. I just don’t want to be a burden on anyone.

This a guy who was being admitted for the sixth time in as many months for one of those diseases you develop by following a particular lifestyle. He had been abstaining from his vice of choice for some number of weeks, and had been asymptomatic of the disease it had been causing, but that evening something had provoked him to hit up one of the local houses of marginal repute. He sat down at a slot machine, he indulged, he landed on our floor via ambulance an hour later, groaning in pain and wondering if this was the event that was finally going to get him.

His response was not new; you might have thought it - or said it - yourself if you’d been asked the question. But it brings up the question: what does it mean to be a burden? Who is a burden on the system? More aptly, is any one of us not a burden on the system? What do we do with those who cost so much for individual care that we are forced to consider the financial consequences of that care on the larger picture - that is, the health we cannot provide to others because of the gross expenditure we are pouring into one person?

There is much rhetoric around the idea of being a burden, or of not wanting to become one. Most of this comes from healthy able-bodied people who do not actually have to face down the question - now, today - of whether or not they want their own burdensome self taken off the human map. Much of this rhetoric is sanctimonious in nature: “I would never want to live like that,” it says of the disabled body or ill body; “Kill me if I ever need a machine to help me breathe, or a tube to help me eat,” it threatens. This rhetoric makes movies like Million Dollar Baby; it creates Jerry Lewis telethons where the disabled are reified as hapless children incapable of anything but receiving your benevolent charity; it finds tragedy in disability, and redemption in a throw-yourself-on-the-fire-for-the-greater-good stance from the disabled, who usually have zero interest in throwing themselves on fires for the comfort of others. It inspires a hypervigilant but entirely necessary form of activism known as the disability rights movement, spearheaded by people with precisely those conditions who have decided that indeed, they would not like to be invited to die just because they require a tube to eat or a wheelchair to move about the world in.

But let’s back up a second. What does it mean to be a burden? On one hand, you could define a “burden” as someone who requires so much individual care that it profoundly disrupts the lives of the people around them, reorienting entire families around the care of a sick member. Financially, you could call a “burden” anyone who draws more off the health care system than they pay into it. The popular rhetoric on this topic would have you believe that the follow groups are the most frequent offenders in the category of “burdens” on the system: Illegal immigrants. Those who frequently visit the emergency room instead of accessing primary care. Severely disabled people. Uninsured patients who don‘t pay their hospital bills. People who smoke. People who don’t eat right and don’t exercise. Drinkers. Drug addicts. Fat people.

I beg to differ with that rhetoric. I argue that just about every last one of us is a burden on the system. There are many reasons why, and here is the first: because at the current cost of medical services, any of us who use any quantity of medical services in a given year - even those of us paying out the nose to maintain private insurance premiums - are likely using more resources than we are paying in. In one particular year of medical school - when I was grousing about paying cash out of student loan funds (which I will be repaying, with interest, for the next thirty years) for a group health insurance plan, I was treated for two benign conditions: chronic migraines, and an allergic reaction to a skin infection that required a long course of powerful antibiotics overseen by a dermatologist. Nothing profound, nothing terribly out of the ordinary. But unless my insurance company was bargaining far lower prices than were showing up my billing summaries, those alone racked up costs in excess of my total premiums. There I am: a burden on society. Few but the healthiest people won’t suddenly rack up costs in excess of their contribution even with just a couple of routine conditions - this is one reason (among myriad others) why premiums go up every year but never seem to quite catch up.

The second way most people become a burden on the system is by outliving their own health. You can be the most good eatin’, clean livin’, regular exercising’ guy or gal on the block, but eventually something is going to get you. And unless that something kills you dead (say, a full frontal bus wreck or a drop-dead cardiac arrest) before you have any chance to haul your rear end into your local health care provider, it doesn’t matter how old you got to be before that bad stuff caught up with you: you too are now a burden on society.

This is the dirty little secret of the public health world we like to call the “prevention paradox”: that good preventive care saves money now, but it generally does not save money in the long run. Here is why: people who stay healthy live longer and take incrementally more out of the system year by year using those preventive and routine services than someone who dies younger. And eventually, all those healthy people will get old, and they will die of something; in the months just before they do just that, they will - on average - run up some astronomical medical bills that short circuit all the savings they accrued over all those long years of good health.

The irony of course is that we spend ungodly sums of money in America to keep people alive during the time of their lives when they are least likely to benefit. Where we hedge about vaccinations for children and click a mouse to donate one hundredth of a free mammogram to a middle-aged adult, we seem quite happy to hurl sums worthy of the national defense budget into stretching life out another month or two when the writing is so clearly on the wall. Bang per buck, keeping a ninety year-old alive for another three months at the cost of four hospital stays does not make near as much sense as getting the whole population to ninety as healthy and happy as can do. You better enjoy those last six months - hospitalizations, crises, dialysis, adult diapers, and all - because they will cost you (or, that is, cost the collective us) some hundreds of thousands of dollars to drag that end heroically out to the last possible second.

And since we are all playing a part in this all-consuming system suck together, it is time to dispense of the notion of who is a bigger burden than whom else. Your contribution to the insurance pool - assuming you do pay insurance premiums - is a poor marginal quantity compared to what you will in all likelihood one day draw off of it. The leg you stand on when feeling self-righteous about your contribution over the contribution of the illegal alien who picks your grapes, or the guy down the street who is that much fatter than you, or the kid with cerebral palsy who needs monthly health maintenance, or the smoker next door, is an ephemeral and illusory source of self-righteousness indeed. Promoting health for the sake of quality of life, controlling cost along the way, and doing some serious soul searching about our emphasis on end-of-life heroics over end-of-life comfort…these are the things that diverge the pathway of “burden” from the pathway of reasonable cost. Not whether you pay your premiums or not, not whether you were born in the country or not, not whether you use a wheelchair, and not whether your BMI fits between the numbers 20.1 and 24.9. Thusfar, the most of us can wear that scarlet B for “burden” without standing out from any kind of crowd.

As for the gentleman I admitted to the hospital that night, he survived just fine to be a burden for another day. Good for him.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

When Men Not Only Let Their Hangups Show But Hang Them For Display Themselves by Anthony McCarthy

What is this about, anyway?

Maybe you already knew but I gladly acknowledge my spotty education had left me ignorant of “truck nuts” until a friend told me about them yesterday. For those of you who are as behind the times as I am, they are simulated testicles in a scrotum meant to be hung below the trailer hitch of a truck. Self awareness isn’t high among the attributes of the macho mind but this is too obviously weird to miss.

When he first told me, I thought my friend was pulling my, uh, leg. Then I looked it up and found out that it, seriously, is going on. And until I read deeply on the subject I hadn’t suspected it was a mature cultural expression complete with artistic evolution, esthetic nuance and moral ramifications.

* There are two major differences between the 1st Generation AND the 2nd Generation of Truck Balls developed by

* The Original 2nd Generation Balls are 2" shorter and have the hole through the side rather than front to back like the 1st Generation Balls. (top hanger type)

* This 2nd Generation Balls * Lock-and-Chain Mounting System was designed primarily for ALL trucks (1/2, 3/4 and 1 tons) with the 2" x 2" hitch receiver tube on the truck. Simply wrap the chain around the hitch receiver tube, snug it up and lock it in place, rotating the brass lock up on top out of sight. (no tools required)

# This slightly shorter length also works well for vehicles OTHER than 1/2, 3/4 and 1 ton trucks, such as suvs, cars, quads & bikes.

# 2nd Generation Balls are shorter and lighter, however they have not lost the hefty, fullness of the O r i g i n a l 1st Generation Bulls Balls and Big Boy Nuts.

# Our 2nd Generation chain balls allow more ways to hang AND they remain swinging even when pulling a trailer, also this design prevents the negative look of flippity flopping of the nuts at higher speeds. They simply float nicely as the air pushes them gently up and back.

# Also with the hanging chain and padlock ( included ) they are much more secure from impromptu theft. At least the bad guys have to bring a pair of " Bolt Cutters."

Yes, that unsightly flippity flopping at higher speeds is just so off putting. No doubt we can all appreciate that the “hefty, fullness of the Original” was retained in the second generation. You appreciate that they’re fairly redolent with quality. Standards to rival those of many Olympic sporting events. It’s nice to see that there’s one part of the Bush economy that isn’t lagging, drooping or cutting back.

A quick google of the them will show they are sold in many colors, including brass and other metallic colors. The message of those is probably self explanatory. If I could make an critical point, the symbolism might be a bit muddled on the blue ones.

Who is supposed to admire these things? Women, either lesbian or straight? I don’t think the right sound to express the idea that a woman would find these alluring can be produced by the human vocal apparatus. Eeeew! doesn’t get to the start of it. One hopes that it isn’t gay men who are supposed to find this attractive, at least this gay man hopes not. If either straight women or gay men could be attracted to intimacy by these, I despair of humanity.

That leaves only one segment of the possible audience and the thought of straight men hanging these for the admiration of other straight men, the implications of which are too twisted to follow. As my friend said, men are buying them and crawling under their trucks to install them, so this isn’t an unconsidered act. What does it mean? It’s not Yosemite Sam on a mud flap. Anyone care to speculate?

Thursday, August 21, 2008

Fifteen days of blogging for health care reform: Health care reimbursement - a (hopefully) not too boring primer on a (usually) dry as dust topic

Guest post by Skylanda.

Ever wondered how your doctor gets paid? It’s not something that most patients put much thought into, beyond a cursory glance at the vehicles parked in the physician parking lot and the realization that you’ll probably never drive a car quite like those. But it’s a rather germane - and always understated - topic when it comes to understand how your doctor treats you, and how satisfied you’re going to be with that care, and how reimbursement fits with the total health care reform package.

In reimbursement for medical services, individual doctors (and other direct service providers such as nurse practitioners and physician assistants) can be divided into roughly two camps. The first camp gets paid for the stuff they do. This is called the “fee for service” model; in retail, they call this “working on commission.” In a metaphorical sense, the fee-for-service doctors are the rough equivalent of the used car salesman: they gotta move volume in order to take home a paycheck, and their paycheck is predicated on how many patients they see in a day or a week or a month. The advantage of this system is that doctors who work under it are motivated toward efficiency - people need to be seen, they have carrot and stick driving them to see people. The disadvantage is one you’ve probably seen: if you need more time with a doctor than that fifteen minute appointment allows, you’re gonna rub someone the wrong way. Every doctor who runs their own business operates more or less under this model, as do a whole lot of others who work as employees of larger corporations. Doctors like it because they usually have some flexibility to balance their financial goals against the style in which they prefer to practice; they dislike it because they are always under the gun to produce, and there is a direct hit to their wallet if they choose to provide more personable, time-consuming care.

On the opposing side you have salaried providers. The opposite of fee-for-service providers, these are paid the same no matter what they produce. The advantage is that they can take as much time with each patient as they darn well please; the disadvantage is that functionally, they have no real motivation to do anything at all. These then are the post office workers of the medical profession: you know, you go into the post office, there’s a line of fourteen people, and only two of the four employees are working, and only at a snail’s pace…because, ya know, they get paid for their eight hours no matter what customer service they crank out in the interim. Doctors like this because they don’t get punished for caring to spend time with their patients; they dislike it because inevitably there’s a couple of freeloaders around the office who make the same amount of money for doing half the work, seeing half the patients, taking half the call.

In reality, aside from small private practices, most employed physicians are paid on some hybrid system - part used car salesman, part postal worker, with more tweaks and turns and nuances than you can imagine. Many employers pay a reasonable base salary with incremental upgrades for increased billable services. Some will start doctors at a guaranteed salary to help build a client base, then switch them to a fee-for-service model after a given number of years. A large body of work has been produced on the topic of how to best squeeze a balance of efficient, caring work out of doctors, and much of it would find a far better home in the psychological rather than the economic literature.

Now let’s widen out the picture a little bit a how an entire organization - a hospital, an insurance company, an HMO - organizes billing structures. Similar to how we pay doctors, organizations too can bill on a per-service basis: your hospital takes out one gallbladder, you bill BlueCross/BlueShield for one gallbladder removal. (Insurers can muck of the scene by cutting deals with third parties too - for example, an insurer can cut a deal with a pharmaceutical company to place a particular product on their preferred formulary: the insurer tells doctors which drug to prescribe or which surgical instruments to buy, and in return, the insurer gets a bulk rate on the drug or the equipment; the functional result of this twist is that an insured patient - if they can sort out the Babel-esque complications of their bills - may end up with a lower bottom line than an uninsured patient who gets stuck with the whole thing themselves.)

From an America-centric perspective, the simplest fee-for-service model had been the norm since, oh, approximately the beginning of time (one leech applied for one gold sheckel, thank you very much) until, oh, approximately the mid-1980s or so. And then along came capitation.

First, back up a little bit. By the 1980s or so, a crisis was starting to brew in medical financing. Everything was becoming more expensive, and no one knew quite how to pay for it. The source of the expense was multifold. Over-capitalization and technological advance was one cause; imaging technologies like like CT scanners and MRIs were just coming online, advanced surgical equipment was being patented, drugs to revolutionize cancer and chronic disease management were headed down the pipeline at breakneck speed and wallet-breaking prices. The lack of any inherent cost-control measures was another - doctors merely did what they wanted, billed for it, and got paid, without any thought to systemic effects of their practice. Burgeoning malpractice also played a role, as defensive medicine is also expensive medicine. As insurers struggled to cover the ever-expanding bills, a new system stepped in that promised to put an end to the overspending and lack of accountability: the HMO.

Though you may not know it, “capitation” is why you hate HMOs; the bad taste around the name lingers even though the concept has largely gone the way of other large, flightless birds. “Capitation” means “per head,” and under this new system, practices were given lump sums to per person (that is, per head) to take care of its enrolled patients. I’m making up the numbers, but here’s an example: Main Street Clinic contracts with Hometown HMO; for every patient insured by Hometown that signs up with the clinic, the clinic receives $5000 per year to cover all expenses, whether that patient shows up once, never, or twice a week for the duration. The pooled funds should cover no-cost patients (eg. healthy young men who almost never visit the doctor) and high-cost patients (older diabetics with multiple hospitalizations annually) alike, and any leftover cash at the end of the year belongs to the clinic to keep as profit. Should the cost of caring for those patients exceed the lump per-head sum, well, that’s the clinic’s problem.

You can see where the problems begin. The clinic is going to prefer young, healthy clients and may turn away high-risk patients before they even sign up. Providers at the clinic are under pressure to cut corners and provide sub-par service to save money - possibly for profit, but maybe just to stay afloat if their patient mix is not optimal. In the early years, this seemed like such a good idea that many practices did sign up (so much cash! up front! we can finally buy that CT scanner we‘ve been wanting!), and many of those failed when they realized how direly they underestimated the cost of caring for patients as doctors still practiced under the devil-may-care-for-what-this-costs habit. Later on, only providers with rather dubious practices still had any interest in capitated plans at all, so patients limited to cheaper capitated HMOs had little choice but go with less-than-ideal providers. (Please note: the word ‘capitation’ simply means “per head,” and has been used within health care finance to mean other things at other times; in this setting, it refers to paying a provider a flat fee per patient to take total care of that person.)

Capitation is not commonly used anymore - anything that predatory eventually eats its own flesh - but its arrival occasioned some of the worst excesses of the for-profit health care market and set the scene for the ongoing crisis in health coverage today. Concepts like “pre-existing condition” and low lifetime caps on benefits were born during those years and have not quite lived out their life expectancy just yet. Moreover, this was the era when Americans truly - and rightly - came to believe that health care security was a largely ephemeral notion.

So then, what does this all have to do with you? For one, the manner in which a health system reimburses its providers (both individual doctors and institutions) is a salient factor in how satisfied its customers are. If you got the big brush-off the last time you went to see your doctor, it may be that you happened on one jerky guy or gal with an MD (or DO), or it may be that you’re seeing the under-the-gun results of an individual who would love to sit for an hour and chat about your diet and your health maintenance and your life stressors, but can’t because of the circumstance of his or her employment.

Second, the parenthetical manner in which insurers bargain with providers means that it is very difficult to ascertain what sort of cash actually gets paid for what; this is not a surprise if you have ever been hospitalized and actually tried to read the bill afterwards. Moreover, there is an inherent issue of justice at stake here: when insurers can bargain down their payments because of their status as a bulk customer, but uninsured individuals cannot, the poorest and most vulnerable actually end up paying more for the exact same health care services than the wealthier and better insured - giving a sinister new meaning to the concept of the regressive tax.

Third, the lack of transparency in what you (or your insurer, should you be so lucky) is actually paying for contributes to an atmosphere of inevitable mystery and unpleasant surprises, where the provider is in total control of the cost and the patient is obligated to pay whatever is asked of them or billed to them at a later date. Have you ever asked the awkward question of what an appointment is going to cost? Or seen a charge list posted in a medical office like a menu at the deli counter? Or been able to calculate a side-by-side comparison of your costs at this medical office versus that, as you would do before you bought a washing machine or car?

In medical economics, there is a phenomenon called the “moral hazard”: this is what happens when a patient buys more health care goods (medicines, visits to the doctors, what have you) on the recommendation of the provider than the patient would buy on their own if they had all the information the expert had before them. Say you have marginally high cholesterol; your doctor recommends a fancy new drug which works great for your condition, but if you were as expert as he, you might also know that a six-month trial of diet and exercise modification, followed by a cheaper older drug if necessary, would be just as good. But you don’t know that because you didn’t go to medical school: moral hazard.

The “moral hazard” phenomenon is supposed to refer to the quantity of goods purchased (did you take that fancy new cholesterol medication or just go with the diet and exercise), but I believe it also applies to the cost of those goods: when the cost of health care is hidden from the patient until the bill arrives two months later, that patient does not have full rights to accept or refuse a given cost of care, or go elsewhere for care, or exercise their right to a free market approach.

Some innovative strategies have been proposed to increase the transparency of a deliberately opaque system, and interestingly, a return to the two-gold-sheckels-for-one-leech approach has turned out to be popular: cash-only clinics. This doesn’t work for expensive hospital stays, of course, but doctors and patients alike give high marks to clinics where you pay your bill, at the front desk, based on a deli-counter menu of fees for services, and then you’re done with the matter. It’s cheaper (no $30k/year staff in the back to bill insurers), it’s simpler, and it creates an aura of open-ness and honesty between the provider and the patient. Cash-for-service clinics plus catastrophic coverage for unexpected disasters could go a long way toward satisfying some currently unhappy customers. It is limited by the ability of patients to pay up front, but then, every system has it’s limitations.

But this does nothing to address that thorny question of the relative injustice of charging uninsured patients more than insured patients at the hospital or clinic door. This is going to be an unpopular stance with many interested parties, but I’ll just say it: this has got to stop. Period. Legally, at some point, someone has to grow the cojones to step up to the insurers and the hospitals and legislate an end to a dual system in which poorer patients are charged more than wealthier patients for the same services. It’s not that complicated, really: institute a legal mandate that an institution cannot charge an uninsured patient for any admission, drug, procedure, etc more than they are charging for the lowest bargained bulk rate.

So this is my over-simplified, understated, over-generalized prescription for improving health care billing and reimbursement schemes:

1. Design reimbursement systems that combine efficiency with effective patient care. No one is sure of the best way to go about this, but history has definitely given us a few good lessons on how not to. Heed those lessons.

2. End the unfair skew in billing of health services toward uninsured patients.

3. Increase the transparency of medical costs and billing, so that people know - upfront, before they accept services - how much they will be charged and what they will be receiving for their cash. This is a key crossroads where justice and the free market share a common seat at the table; it’s time to give a nod to both.

A few places to start, before the real work of health care reform begins.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

There is No Right To Deceive The People. By Anthony McCarthy

2. The media.

Watching the string of horrible presidents from Reagan to Bush II, criminals in all three branches of the Federal and many state governments, illegal military actions, invasions and massive theft, the casual and systematic corruption in local governments and school districts, a decision became unavoidable. I could continue to pretend the protections insuring the health of democracy, assumed to exist in American law and society, were effective for their purpose. Or I could believe the evidence all around that those have failed catastrophically.

There was no choice. The traditionally cited protections of democracy, the Constitution, the judiciary, representative government and the media have produced the results we see now. The greatest of those failures, corrupting the very base of democracy, has been the media. It can honestly be called the “free press” now only if sarcasm is the intent.

In a period during which the media have enjoyed just about complete lack of restriction on their content, freedom from any obligation to serve the public or to provide accurate information fairly, and have also enjoyed a level of saturation into our lives to an extent never before possible, the ignorance of the American People about the most basic and essential aspects of life, is conclusive evidence of negligence and malfeasance. The media has abnegated their part in assuring our freedom.

They gleefully and smugly celebrate the ignorance of the American People in short news features about polling which shows a majority more informed of the personal lives of the short-lived celebrities they present ad nauseam, but can’t name their own representative to Congress or identify the Bill of Rights when it is read to them. They didn’t ask what part the media played in this ignorance, though they take up many times more hours of our lives than compulsory schooling does. With the opportunity to inform The People, their choice has been to optimize their own profits and propagandize in favor of corrupt politicians who will ensure their further profit. Facts or lies, it doesn’t matter as long as The People are bamboozled to their benefit and our eyes delivered to their advertisers.

This situation calls into question the theoretical reason for the freedom of the press. Why provide them with it if an ignorant army of voters and discouraged non-voters, ensuring bad government, is the predictable result? Freedom of the press has to be given a thorough look. The various things unwisely bundled under that umbrella need to be separated and inspected for usefulness to the emergency of a democracy at risk of dying through negligence.

Rights held by individual people are possessed by the fact of their birth. Those rights are inherent to every person and are inalienable. The only justifiable reason to abridge the exercise of those rights is if the individual uses them to deprive other people of the exercise of their rights.

Corporations and associations aren’t born, they are created by agreements and contracts. These corporations exist to magnify the power of the individuals who form them. Their purpose is generally to supercede the state of being an individual, to gain the individuals forming them more power to do something than they would be able to without the corporation. Corporations don’t possess natural rights, they were given what rights they are alleged to hold by some of the worst Supreme Court rulings, unenumerated innovations never protested by the “original intent” con game. Without stipulating the legitimacy of that fiction, I will ask if the rights held by corporations don’t, at the very least, carry the same limitations as those held by individuals who use them to deny others their rights? I will also ask if differences in the power of those granted those artifical rights doesn’t require equally powerful restrictions of their exercise, as a matter of regulating the dangers resulting from inequality of effectiveness and motivation. Doesn’t the very fact that a corporation is formed to concentrate and magnify power to acquire and influence require equally strong regulation of their tendency to use that for ends that serve their private gain, as opposed to the public’s benefit?

Why should the press, as a corporate entity, be granted those rights mentioned in the constitution? The traditional answer is that a free people must be informed to keep their freedom. They have to have a sufficient grasp of real life to make good decisions both in their personal lives and as citizens participating in democracy. Those choices aren’t interchangeable preferences like what brand of hand soap you buy. It makes a real difference if The People get it right or wrong. The press is granted the right to serve that non-optional requirement, to provide accurate information for The People so we can protect our freedom and ourselves.

What if the press doesn’t keep its part of the bargain? Which ours has not. What if the press becomes the enemy of democracy and equality, if it subverts the existence of an informed populace? As ours does. Can that press remain free? Can it truly be free.

If our history continues, I believe that one of its lessons will be that when the press freely gives up its responsibility to inform The People, their choice is actually to give up their ability to publish freely what doesn’t serve the despots that eventually result from The Peoples’ uninformed decisions. We The People won’t have to abridge the freedom of the press, the press will provide those who will do it as a matter of course.

It is a natural right for an individual to publish their words and ideas, such as we writers for this blog are engaged in. It is an extension of free speech and if the words do not deprive others of their rights the exercise of those rights cannot be limited justly . But even the biggest blog, unamplified by the commercial media in the way that Matt Drudge regularly is, has a limited effect on the political life of the country. Amplification makes all the difference in the political effect of any part of the press.

There is an absurd presumption that the amplification of words by money and the media it buys doesn’t fundamentally change the nature of the press. This is a pretense we can’t afford after witnessing the selling of the Iraq invasion, the stolen election of 2000 and myriad other betrayals of democracy by the press. Corporate media isn’t a guarantee of democracy and freedom, their use has proven that they are the harbingers of despotism in service to wealth. “More speech” is a snappy slogan when it’s a difference between five hundred more words posted on an obscure blog or two hundred words fed to millions through the TV and radio. The medium matters. The Founders had no idea that the kind of mass media around today could exist, they had no idea of a “press” dominated by corporations that can swamp their tiny competitors at will, effectively blacklisting any ideas they choose through ignoring or distorting them in an effort to negate their effect.

With the experience of the modern, mass media, and corporate concentration of the most effective parts of the media, it is clear that “the press” is able to be as much a danger to democracy and civil liberties as it is a guarantor of liberty when it is diverse and diversely held.

Taken in aggregate, the media in the United States is a device to disable the ability of The People to cast an informed vote. Through lies, bias, distortion, propaganda, distraction and demoralization, the media is guilty of corruption of voters and potential voters in the United States. The exceptions, mostly in print, are, at best, of scanty importance to the issue of self-governance. The rest, commercial and allegedly public and non-profit, are guilty of a list of crimes against democracy.

You cannot also serve both democracy and Mammon. You will always serve one and hate the other. The corporate media serves Mammon.

Wednesday, August 20, 2008

The People Are the Ultimate Place to File an Appeal and Make Our Case. by Anthony McCarthy

1. Religion

The questions of maintaining a secular government in an overwhelmingly religious country aren’t going to be finally settled to anyone’s liking. The best that can be attained are temporary, shifting and variable lines separating the state from various groups which attempt to use it’s power to establish their domination. On our side of those lines are people and groups trying to prevent the others from using the state to run everyone else over. It has been the situation for the entire period during which the secular Constitution has been in effect. The results have been regional variations and local ones. The attempts of the mid-20th century to enforce non-establishment across the country had some success during a period of Democratic control of the federal government, during the period of Republican control it has been in retreat. Republicans have blatantly used the issue of religion and it has worked for them. It worked very well for them.

There is simply no way to enforce the non-establishment provisions of the Constitution on voters. Arguing whether or not that should be true is entirely futile. Voters, themselves, decide if their part in the most basic level of government will or will not be on the basis of a religious test. Voters are not bound in their decision by any of the provisions of the non-establishment clause and the no-test clause anymore than they are the several Civil Rights amendments. Those voters who want to will use their vote to put people into power who are willing to breach the wall of separation in direct violation of their oaths of office*. Those unscrupulous office holders will then have the power to appoint equally unscrupulous members of various courts, including the Supreme Court. The Republican Party has based a good part of its success on the cynical and highly selective use of “christians” of a kind unwedded to an egalitarian democracy and individual freedom. Would that Democrats of the past had been wiser in forming a coalition among various groups to thwart their success instead of insisting that the question had been settled.**

Today we are in the situation where the federal courts we unwisely depended on to protect our liberties, not only don’t do that, they are in the forefront of tearing down the Wall of Separation. It should be no surprise that a court which is increasingly destroying the most fundamental feature of democracy, the ability of people to cast a vote, would have no trouble destroying other aspects of an egalitarian, democratic government. We must give up the myth that the Constitution, which exists only within the interpretation the present day courts impose on it, is any substitute for direct, continuing political involvement. Direct political involvement always ends in trying to convince a winning margin of the voters to your point of view.

In the appeal to the voters it has to be remembered that we only need the margin of victory in any election, we don’t need to convince the entire population of the wisdom of our position. But you must also remember that the people we do need to convert to the cause will be religious believers, most of them self-defined as Christians. That has been a fact for the entire history of the United States, it is a fact that we operate under today. Antagonizing them will not get us anywhere anymore than depending on the present day Supreme Court will. Considering the history of the Supreme Court, the Warren Court, which you can still just catch in your rear view mirror, as it rapidly vanishes into the horizon, should be considered a fluke. We are living in a different world than that one.

I am an absolutist in the question of the Separation of Church and State but I am an absolutist-realist. In our politics, down here where we really live, to insist that it has ever been a settled matter is to ignore most of our history. If we want to defend The Wall of Separation our only secure tool is not the courts, it is The People, in all their diversity and at times their perversity. It has to always be remembered that The People, the final and most basic part of a democratic government, are the only secure guarantee of any part of our liberty and freedom. And you can’t force them to vote any particular way by Supreme Court order or through legal doctrine. You have to do it by appealing to their sense of justice and fairness and by pointing out the benefits of keeping the government out of religion. One way to do that is to point out it also protects them from unwelcome meddling in their religious beliefs, by competing religious groups.

Christianity, if that is the attempt to follow the teachings attributed to Jesus, never lost more than when it became an established religion, of Rome and then various other countries and nations. The earliest Jesus tradition, as described in Acts, was radically egalitarian for its time and it was overwhelmingly concerned with the welfare of the poor. That tradition never died out, though it was never dominant within the sphere within which Christianity existed. With establishment came a religious establishment and establishments tend towards their maintenance and enrichment. With establishment also came an ossification of the spirit into creedal statements as a means of enforcing uniformity. It isn’t any accident that some of the earliest ones were as a result of imperial command. Some of what was come up with would certainly have come as a complete surprise to the earliest members of the Jesus tradition, those who actually knew him.

The charade that goes by the name “christianity” in the American media has more to do with the imperial religion of a totalitarian monarchy than it does the teachings of the destitute Jewish peasant they claim is the son of God. I hold that today’s liberal Christianity is far better at following the teachings of Jesus than fundamentalists have any intention of attempting. I don’t think those teachings as understood within liberal Christianity are inconsistent with a real democracy or with the agenda of the left in general. One of the most basic tenets of religious liberalism is that people get to decide for themselves what they believe and do, so long as they don’t abridge the rights of others to do the same. As a non-Christian, I would have no concern for my freedom under a government dominated by liberals of any Christian churches and traditions. I believe they would most likely appoint judges who would protect personal freedom. Though with judges, the part of the federal government most remote from The People, it’s always something of a gamble.

Arguing these civic religious issues is a more effective means of fighting a corporate-state empire than insisting on what clearly has been a losing political, and so, ultimately, a losing legal position. Contending with “christian” fundamentalism on the basis of their complete non-observance of the justice teachings of the man they pretend is their Messiah, that’s messy, it’s hard. Many will turn up their noses at the prospect of the fight. And it’s fraught with problems. But so is democracy. Appealing to people on the margin of the groups wanting to destroy the Wall of Separation, those who might be convinced to join us, will be more successful than insisting on absolutist positions. You won’t be able to convince them in any language but the one they speak. If you aren’t willing to do that on the basis of some abstract principle, the fundamentalists don’t share that scruple.

Our politicians make some of the most careful observations of the political reality in which they either win elections or get out of politics. They have no choice but to work with the country as it really is.

* Is there a better example of the wisdom of Jesus teaching against the taking of oaths than Republican politicians promising to uphold the secular Constitution?

** The reliance on the courts instead of relying on convincing The People is at the heart of the problem. That reliance made the left lazy and over secure. You would think that watching the post Warren court systematically destroying our liberties for most of the last four decades would cure us from that complaisance. The first step in overcoming it is remembering how those courts are appointed and remembering that when the Supreme Court makes a decision against freedom and democracy, The People are the ultimate place to file an appeal and make our case. That is a fact Democrats ignored and Republicans remembered, to our loss.

Fifteen days of blogging for health care reform: Overuse, underuse, barriers, and compliance

Guest post by Skylanda.

There are a few folks out there who overuse the medical system. Every emergency department has its “frequent fliers,” and every clinic has its quota of personality disorders on the rolls that require an individualized level of energy that could otherwise fulfill the needs of ten patients in the same time span. These people are often the bane of primary care and emergent care facilities alike, they are a vortex of resource suckage (and if they were stable enough to stay enrolled in a billable insurance plan, they wouldn’t be causing your practice so much grief). But in all honesty, they are usually people with very large problems. Those problems may be occurring entirely above the brainstem, but nevertheless: large problems. Thus need lots of help.

There is another type of overuser, one that no one takes to task for their affect on the total medical system: the user of boutique clinics, unnecessary specialty services, and excessive cosmetic commodities. These people pay - usually straight out of pocket - for the privilege, so we usually don’t get huffy with them for altering the landscape of medical economics in such a way that the limited number of doctors in the nation get pulled to doing things other than providing general care for actual medical problems. This is a mutual harm for sure - doctors who choose lucrative Botox practices over low-income community clinics certainly have their own free will in sustaining this market - but nevertheless: very easy to blame the mentally ill self-medicating narcotic addict for overusing the ED. Very rare to blame the wrinkle-free six-time Botox patient for their role in the dearth of primary care providers, even though on a market-level scale the relationship is hard to miss.

From an economics perspective, you could say that an “overuser” is someone who draws more on the system than is necessary to accrue the most maximal level of benefits per dollar spent. Put that in yer calculator and smoke it. Something is very inefficient, for example, when a person - any person - hits up the emergency department more than once a month, unless that is one clumsy person. Something is also very maladjusted when a cadre of providers is yanked out of the low-pay business of providing primary care and into the high-pay business of catering to people with an excess of time and money on their hands.

But if there are over-users, does that mean there are people on the other side: under-users? You can ask ten providers and get ten thoughtful answers to this question, but from a social justice perspective, the answer is - without a doubt - yes. From an economics perspective, I would argue that the answer is also an unequivocal yes.

For the sake of simplicity, let’s define an under-user in this manner: an under-user is a person who costs the system more when they fail to utilize health care. This is the homeless person who does not make it to a local clinic to get simple treatment for a foot ulcer from sleeping upright on the street, and thus ends up getting scraped unconscious off the park sidewalk a week later and dumped on the emergency room with a bloodstream infection - at an exorbitant, avoidable cost. This is the poorly controlled diabetic who skimps on insulin to pay the electrical bill, only to end up on dialysis because of the consequences of their years of high blood sugar. This is the uninsured construction worker who ignores that shooting pain because he can’t afford not to work, only to end up on long-term disability from continually re-injuring a wrist that could have been fixed permanently if addressed right away. This is the heroin-addicted street person who was hacking up blood in a shelter for a month before anyone noticed that every cough brought up aerosolized whiffs of tuberculosis bacteria. No matter who ends up footing those bills, the whole lot of us would be better off if the care were done earlier, on the cheap, and to the benefit of the individual in question.

There are a myriad of reasons why people underuse medical resources, but the big ones are obvious: Can’t afford it. Don’t have insurance. Could qualify for public coverage, but don’t have the wherewithal to navigate the system. Don’t speak the language. Don’t have transportation. Don’t feel welcome. Aren’t welcome. Have been turned away before. Can’t take time off work. Have a violent partner that won’t allow it. You have your own imagine - feel free to add your own to that list.

The system as we currently know is designed to throw up as many barriers as possible to the class of folks who we could call “under-users.” We have clinics that are only open during business hours; we make sure that if you don’t fill out this piece of paperwork by that date, you fall off the Medicaid rolls for at least such and said number of months; we place facilities where it convenient for developers and physicians, not where it is most inconvenient for people who need it most (the medical school in Oregon, for example, is so far removed from town - perched on a height aptly known as Pill Hill - that a common reason I saw cited for patients no-showing to appointments was simply that they could afford the bus fare from poorer parts of town).

Several years ago, in another state, I watched a debate rage over five dollars. Five dollars per month: the amount that the state suggested asking of every enrolled Medicaid member to maintain their status with the program. Its intent was to force the Medicaid enrollees to buck up and contribute to their care. Indeed, there is a fair amount of evidence that having patients pay for part of their care - even a nominal sum like five dollars - contributes positively to how seriously they take the advice they get, how likely they are to comply with physician recommendations. After all, if you paid for it, you’re more likely to pursue your money’s worth. But the behavior of rational, middle-class consumers in regards to a nominal fee has no bearing on the effect of attaching fees to people who simply cannot pay those fees or do not have the wherewithal to locate the local bureaucracy to whom they must be paid, monthly and on time.

When the policy passed and a five-dollar monthly “premium” was attached to Medicaid enrollees, the net immediate effect was to boot the poorest and most vulnerable patients - those already most likely to be under-users - right off the rolls. In the short term, it cut costs by cutting coverage to a whole sector of the population; in the long term, those cut off the Medicaid rolls will cost the state (and the local hospitals that swallow the cost of charity care) eons more in time, money, and human health by putting up one more barrier between the most vulnerable people and the one source of coverage they qualify for. All for five bucks a month.

The right wing, wouldn’t you know it, likes to put a morality spin on this issue. The rhetoric at the time was all bootstrap and welfare queen: If these people can’t even bother to come up with five bucks a month - and who can’t come up with that - why should we bother to keep giving them free healthcare handouts? An ounce of imagination and a droplet of empathy should put that question to rest, but in case that is lacking, let’s go back to good, sound finances: because it costs us more in the long-term to deny coverage over five bucks a month, that’s why. Medical problems do not go away unless the person who has them ups and dies on you; they merely get worse - and more expensive - until they are treated or debilitating or fatal. And if those medical problems happen to be contagious? All the more reason to get on them now rather than wait until they spin out of the margins of society and into the core of people that actually seem to matter.

It is for these reasons that any comprehensive health care reform must have built into the system a means of reducing barriers to care for the people most prone to getting locked out of the system. First and foremost, this means nixing this morality rhetoric out of the debate; whether or not you believe in bootstrapping has zero regard on whether a homeless man with TB should have to come up with five bucks before someone figures out what he’s got and makes damn well sure he doesn’t pass it on. Whether or not you believe in scapegoating welfare queens has nothing to do with the financial difference between treating a simmering case of diabetes and letting that case go until the body it is developing in loses its kidney function and ends up on the public dollar for dialysis three times a week.

Second, this means that the characteristics and demographics of people most likely to get locked out of the system need to be identified, and those people need to be exempted from the sorts of petty penny-grabbing fees and bureaucratic hoop-jumping that form barriers to care. These barriers include but are not limited to: nominal monthly premiums to stay on the Medicaid rolls; copays at the point of service; inflexible paperwork and deadlines that cause people to be booted off Medicaid if they turn in a signature a couple days late or can’t provide proof of address when indeed have no address. These demographics include but are not limited to: homeless individuals and families, unemployed heads of household and their children, people undergoing treatment for chemical addiction (or heck, throw in those who merely should be undergoing treatment but aren’t yet), the disabled and chronically ill who have trouble accessing the bureaucratic arm of the health care infrastructure due to transportation issues, the developmentally disabled, those with profound mental illness, women and children living in shelters to escape violent partners, and other groups with similar impairments to full access. These are people who you do not want falling off the Medicaid rolls and losing their only access to care, who are prone to becoming the expensive sorts of under-users that eventually cost the system dollars on pennies further down the line. Sanctimonious rhetoric about bootstrapping and personal responsibility aside, regular unfettered access to care is a necessary (though not adequate) safeguard against pointless and costly delays and medical care for these demographic groups.

Paul Farmer - the demi-god of international medicine - has said some inflammatory things in his time, and this may be one of the more calmly understated of those quotes:

"Throughout the world," he writes, "those least likely to comply are those least able to comply."

If we want to demand compliance from the people that we like to label as social problems - that addicts attend treatment, that the mentally ill take their antipsychotics, that the homeless quit with that annoying habit of slumping over on the street and dying while we with homes and shoes and places to be are trying to walk where they lie across the sidewalk - the absolute minimal obligation from those in power is to remove all unnecessary barriers to accessing care.

The five-dollar Medicaid premium? Piece of cake, swipe of the bureaucratic pen and it‘s gone - cheaper in fact to eradicate it than to pay a cadre of bureaucrats to push the paperwork required to collect it. Now then, establishing trust between these individuals and a system that has routinely failed them such that they actually access that care when necessary and appropriate? That, my friends, is what is known as a challenge.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

Tuesday, August 19, 2008

Goodbye To All That

Somebody buy Barack Obama this book. I have a feeling that he needs it.

“Question with boldness even the existence of a god.”--Thomas Jefferson.

“Religious bondage shackles and debilitates the mind.”--James Madison

“I doubt of Revelation itself.”--Benjamin Franklin

“My own mind is my church.”--Thomas Paine

The religious right is gaining enormous power in the United States, thanks to a well-organized, media-savvy movement with powerful friends in high places. Yet many Americans—both observant and secular—are alarmed by this trend, especially by efforts to erase the boundary between church and state, re-making the United States into a theocracy.

But most Americans lack the tools for arguing with the religious right, especially when fundamentalist conservatives claim their positions originated with the Framers of the Constitution. Until now. . . .

Did you know that:

• The Constitution contains not one reference to a deity--on purpose?

• Jefferson’s original draft of the Declaration of Independence did not mention “endowed by the Creator”?

• “In God We Trust” was not on our currency, and “Under God” was not the U.S. motto, until the McCarthy-ite 1950s?

• The 15th-century Roman Catholic Church considered abortion moral?

• The Treaty of Tripoli--initiated by George Washington and signed into law by John Adams--declares: “The United States of America is not in any sense founded on the Christian Religion”?

• James Madison, “father of the Constitution,” denounced the presence of chaplains in Congress--and in the armed forces--as unconstitutional?

• Lincoln’s first drafts of The Emancipation Proclamation and Gettysburg Address made no mention of any deity?

In Fighting Words, Robin Morgan has assembled a toolkit for arguing, a verbal karate guide: a lively, accessible, eye-opening collection revealing what the framers (and other leading Americans) really believed—in their own words. She resurrects the Founders as the revolutionaries they were: “A hodgepodge of freethinkers, Deists, agnostics, Christians, atheists, Freemasons—and radicals.

The hurricane that wasn't (by Suzie)

       You should never go shopping on an empty stomach -- or the day before a hurricane hits. 
       I braved the grocery store Monday, after taking stock of my cupboard, only to find one can of mushroom soup and another of cranberries, left over from Thanksgiving.
      Later, as I filled containers with water, I sang to my Chihuahua: "Wasn't that a mighty storm? Wasn't that a mighty storm in the morning, well? Wasn't that a mighty storm that blew all the Chihuahuas away?"* I like to personalize songs for her.
      Staff at my apartment complex posted notices on all the doors that read: "REMAIN CALM," along with other helpful tips, such as: Get out. 
      Tropical Storm Fay made landfall in Florida again today, without ever reaching hurricane status. I'm glad I didn't have to huddle in the bathroom (no exterior walls), surrounded by canned goods.
*Folk song about the Galveston storm in 1900.

Fifteen days of blogging for health care reform: The opt-out crisis

Guest post by Skylanda.

I was a sophomore in college, abroad, studying marine biology on a beach in Mexico, when my parents called me up to tell me my father was retiring. He wasn’t entirely too young for it, but neither was he quite old enough to qualify for Medicare. But he had worked long years of hard hours, and they chose together to enjoy the next couple of decades at a reduced income rather than merely endure through them with plenty of money. They were very lucky, and planned extraordinarily well; they will live out retirement with a level of wealth few Americans past the boomer generation will be able to expect.

And so, at age nineteen, like middle-class post-teens all over the nation, I got booted off my parents’ cozy medical insurance plan and out into the nebulous world of the marginally insured. They did their best by me for a year or two; they qualified for COBRA, and since I was in college, I qualified too. They quietly paid premiums that - had I had any idea what they cost - I would have refused their generosity for: some three hundred dollars or so a month for a perfectly healthy, low-risk teenager - at the time, I was paying less than that in rent. The only contribution they asked of me was that my father - ever the academic at heart - routinely quizzed me on the expanded meaning of the acronymn COBRA; to this day, I can still reel it off the top of my head: Consolidated Omnibus Budget Reconciliation Act. Of 1986, by the way. But eventually their COBRA coverage ran out too, and they could no longer afford me anyhow, and so I became uninsured.

This did not make me comfortable. I was never an unhealthy kid, but when I did get sick, it was always the weird stuff. I used go nearly anaphylactic to poison oak, and had been on steroids twice for it. In my first year of college half of my face froze up for a month, and I was diagnosed with Bell’s palsy - a sometimes reversible neurological condition that usually affects septugenarian diabetics. I had migraines and a persistent winter cough that turned out to be undiagnosed asthma. We all have a medical oddity or two brewing somewhere in our corporeal selves.

I searched for insurance, in earnest at first. I tried to find organizations to join to gain the advantage of group rates, looked into catastrophic coverage only, considered the university-sponsored insurance until I realized that I would pay through the nose for a plan that would cover about a quarter to a third of the daily cost if I ever did have to be hospitalized. I identified half a dozen sources of free care in the city (by then I had moved to San Francisco), including the clinic I volunteered at to provide free care to other uninsured patients. Every six months or so I would get on a kick about it, make a few dozen phone calls, search the then-burgeoning internet, give it a good try. After a week or so without success I’d give up again, buried in possibilities and paperwork but no actual insurance on the table. Eventually, when I went to work offshore, I signed up for a dirt-cheap maiming insurance policy (I kid you not, that’s what it was called): one million dollars cash if I was physically injured so badly I couldn’t work anymore. That’s the best it got until I started medical school and was forced to pay for health insurance out of my student loan funds. Three years passed during which I had no medical coverage at all.

For the generations known as “X” and “Y”, this is not an unfamiliar story. Most of my friends went uninsured for some period of time, some by choice and some because they could not find or afford coverage. For the most part, it’s a gamble, but a fairly safe one. I was young, healthy, strong, in excellent shape for the most part (putting my thirty-ish self to shame now), and unless I was struck down by a bus or a pernicious cancer, I wouldn’t be drawing as much off an insurance policy every year as I would be paying into it. If I had tried harder, I probably could have found something.

But I didn’t. Like many healthy young people, I faced some barriers, I gave it a good but not Olympic try, and then I opted out.

It worked for me. The worst upshot I faced was a foot fungus that raged out of control - gross, but far from dire in consequence. For the vast majority of the young, healthy, middle-class opt-outs, the outcome is similar: you skimp on insurance for a couple of years, you save yourself some money. Your career picks up, you get a job with benefits, by your mid-twenties you leave those uninsured years behind relatively unscathed.

Let’s set aside for a moment the disastrous consequence for the unlucky few opt-outs who get sick enough to go to the emergency department - even once - without insurance (mostly because the reverberating effect of a single ER bill on credit, savings, and ability to access future care for years down the line is topic for an entire other post). This is about the effect of opt-outs who successfully navigate the uninsured years without incident.

Let’s consider who they are: the opt-outs are the young and healthy. They pay into the system and draw very little out - particularly young men, who aren’t obligated to yearly visits by the need for prescription contraception and generally don‘t like visiting doctors. They form the low-risk end of total risk pool - in general, their premiums support the care of people other than themselves. No wonder so many maintain a certain disinterest in paying ever-increase premiums on services they rarely use: in an individualistic, every-person-for-themselves system, opting out is both feasible and reasonable.

In a sustainable, collective health care system, opting out is neither feasible nor reasonable. Everyone who lives long enough will eventually reach the age where they draw more benefits than they contribute in cash, and as long as the general pool of funds is maintained by a flow of people from all demographics, it’s a relatively stable system. But everyone has to contribute at any given point in time to maintain the system - young, old, sick, healthy, in the relative proportions that they are able - in precisely the manner that Social Security has historically functioned. If only the people that need health services are asked to pay into the pool, premiums become exorbitant; if you pay your own insurance premiums these days, you don’t need me to tell you this.

In America today, we’re watching the collision of two inexorable forces: the aging of the baby boomers out of their working years, and the normalization of the opt-out phenomenon among the young and healthy. The astronomical rise in premiums - twice the rate of inflation in recent years - can be attributed to a multitude of phenomenon, but this is one of them: at a time when a large proportion of the population is drawing heavier and heavier services, the young and healthy are contributing less and less to the risk pool. Not necessarily because they don’t want to (because really, who wants be to uninsured?), but because barriers are so high to entry into the pool. There is nowhere good this path can go.

The solution is thorny but obvious: we need to start treating health coverage like the public good that it is. Even private insurance works on a pooled risk basis, so that illness in the general population directly affects my premiums, even though I’m (still) a (relatively) healthy young person. Every person needs to contribute in the proportion that they are able, such that when the day comes, they will be able to draw what the need from the system. You cannot force people to buy health insurance (really, ask the couple of states that have tried), but you can use the good old IRS - from which no American can simply opt out - to collect, funnel, and redistribute funds through a single-payer system. Through taxes, everyone can be asked to contribute - in the proportion to which they are able, with the right to draw out the goods that they come to need - the same way that we way do for every other public good: education, roads, the national defense. We don’t question that it works - with all the requisite bumps in the road - for those collective efforts.

And if the thought of higher taxes makes you cringe just to hear the words, remember this: you’re either already paying those exorbitant premiums, or someday you will be, or someday you’re going to get one whomping medical bill that will make you wish you were only paying those premiums...eventually, one of these (or both, or all) will happen to virtually every one of us. Whether we choose to pay that into a sustainable collective system or a crashing individualist system…ah, that is the crux of the issue. And that is a topic for another post entirely.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.