Modern Medical Morass

Medical maze

I had a very interesting discussion with my orthopedic physician a while back (as I age, I seem to collect more and more physicians of different specialties). He was helping me to decide a course of action to take with my balky knees that have deteriorated over the course of my lifetime, and as we discussed the specifics of my knees, we diverged and ended up discussing a wide range of topics concerning the US health care system.

He was of the opinion that the current system we have for health care is incredibly inefficient, and shared an anecdote to illustrate his point. A woman came into his office complaining of leg pain and weakness. She had been to multiple physicians in the past but had found no relief. As his assistants were taking her history, and conducting an initial assessment, they sensed that her problems were not in her legs, but were caused by back problems. They discussed this with the doctor, and he agreed that an x-ray of the back was justified.

The x-ray revealed that the patient had significant arthritis in the back, resulting in bone-on-bone contact for at least one set of vertebra. This had caused impingement on nerves going down the legs, accounting for her symptoms. The normal progression of the diagnostic process would call for a MRI exam to confirm the extent of the back issue.

But. The insurance company response to this type of diagnosis is firm and consistent. No MRI will be authorized until the patient has exhausted all other options. In this case, it means that the patient was referred to physical therapy for a 6-week course of treatment. So the insurance company was willing to spend $3,000 on a course of therapy in order to avoid a MRI expense (I have no idea what an MRI costs), with its potential diagnosis of a need for back surgery at much greater cost.

The doctor had referred the patient to therapy, and the course of therapy had not yet been completed. He said that he fully expected that the patient will have no improvement from this expensive course of treatment, and then he will be able to get the approval for the diagnostic tool he knows is necessary for this patient to finally find relief through treatment. He speculated on the reason why insurance companies would go this route – refusal to fund an expensive diagnostic tool but approve an even more expensive course of treatment. His speculation is that actuarial analysis shows that if even a few patients do receive help from physical therapy, or a few patients die during the course of therapy, or a few patients give up on the process and just keep suffering with their ailment, then the avoided surgeries more than offset the cost of the therapy.

My doctor was very generous with his time with me. We did discuss my options, and my preference for lower levels of intervention. Right now I am receiving periodic injections of cortisone. More intrusive means of treatment are available if I don’t have relief from this level of treatment, up to and including knee joint replacement. I am very grateful that my doctor has allowed me to have enough information to make an informed decision and to be an active participant in my treatment.

We discussed the problems that the current insurance-based systems impose upon doctors being able to provide options to patients. He presented a hypothetical case where a patient with a high-deductible insurance policy, but with a health savings account, would come in with symptoms that indicated a need for further investigation. The two choices would be an MRI (expensive, but comprehensive), or an ultrasound (less-expensive, but not as sensitive and potentially could miss rare issues that an MRI would pick up). The current environment would indicate that the standard of practice is to insist upon an MRI, and if the physician should ever be in the position where he / she went with an ultrasound, and that patient happened to have that obscure condition that only an MRI would detect, he / she would be liable under malpractice litigation for not following the standard of care.

But if the doctor and the patient could enter into an agreement where the patient accepted the risk of a potential for a missed diagnosis for a rare condition, in exchange for a lowered payment for the test, then overall costs for the medical industry would be reduced. That is just not possible right now, but with the huge increase in insurance deductibles, it may be coming back. No, my doctor said that at present, he has the need to reduce his liability risk to zero by over-prescribing diagnostic tests since there exists no mechanism to transfer the risk for a missed diagnosis to the patient. This is where my doctor says that the malpractice industry has raised medical rates, by insisting that all illness can be detected or treated if only the patient is tested for all potential conditions related to their symptoms, regardless of the likelihood of a rare condition. Thus a huge cost results from the excess diagnostic tests required to detect the condition that afflicts a few tenths of a percent of the population.

My doctor expressed hope that a single-payer system would emerge out of the morass of the current health-care system. He acknowledged that any such system could have its own set of problems, but he seemed to be comfortable to accept standards such as Medicare has established for treatment to be extended to the population at large. Insurance companies would still have a role in administering claims, but the ability of doctors and patients to have a say in the treatment protocol would be greatly increased.

During the uproar with the Affordable Care Act, much was made of the imposition of “death panels” who would represent government imposing life and death decisions upon poor helpless upright citizens of the US. What opponents of the Affordable Care Act have always refused to acknowledge is that the “death panels” they feared have always existed, and they belong to the faceless bureaucracy of the insurance companies, doing their darnedest to increase both the complexity and costs of the medical profession, and actually harming patients in their insistence to adhering to rigid and often obsolete standards of diagnosis and treatment.

But what do I know? I’m only a consumer of the medical industry, with very little input on treatment options and zero input on the cost of the approved treatment. I am very thankful for physicians like my orthopedist, who is treating me as a full partner in my own treatment, and who is willing to share his thoughts on the medical system.

 

Let the Games Begin

 

Let’s get ready to rrrrruuuummmmbbbblllle! The Senate Republicans have now laid down the gantlet, and it is now time for us to have a complete and thorough discussion and debate about government involvement in the health care system. One where open suggestions and ideas may be freely floated, and where hearings will bring forth legions of experts, putting forth the benefits of the case for both parties.

Oh. You mean that’s not going to happen? We’re going to barely have a week to discuss and debate this immense change being proposed to our already dysfunctional health care system, then a vote will be forced through? No other alternatives except for what 13 white male Senators came up with will even be considered?

I am truly disgusted by the spectacle of our legislators working hard to craft a bill aimed at causing the greatest amount of harm to the greatest number of people. The old adage was that the legislative and bill drafting process was akin to making sausage. That may still hold true, but it seems that a new step is added whereby the sausage has to pass through the digestive system before the new legislation is laid, steaming fresh, at the feet of its admiring partisan supporters.

It has come down to this. Both parties repudiate any notion of working across the aisle in order to craft a thoughtful comprehensive approach to dealing with the huge problem we have with excessive costs and maldistribution of health care services. Instead, one party works diligently behind closed doors to create a tax cut that only affects those who have income greater than $200,000 per year ($250,000 for joint filers). True, it also removes $19 billion in taxes imposed on medical insurers, pharmaceutical firms, and medical device manufacturers. The removal of these taxes shows the value of campaign contributions to the Senators who drafted this legislation. I saw today on TV that over the past few years, these Senators received about $0.5 million in campaign contributions from these entities. $19 billion / $0.5 million = $38,000 in tax benefits for each dollar in campaign contributions.

So we have a bill nominally posited as a health care bill, but in reality it’s a tax cut favoring the top 1% of income earners, and favoring those whose businesses greatly benefited by the increased demand attributable to the Affordable Care Act. And in order to frame this as a win for the average person, we will enable states to allow for limited insurance products, much like it was prior to the ACA’s implementation. Can’t wait to see the expression on the face of some poor schmuck who grabbed on to one of the new cheap health care insurance plans only to find out it pays a total of $400 per day for hospitalization expenses when they have to cover a heart attack hospitalization.. But it’s all good, since the health insurance consumer could have chosen a better plan (but couldn’t afford it).

Let’s have a real debate as the outcome of this faux discussion. Let’s make a determination whether we believe the US is an outlier from the rest of the civilized world, and make health care an independent responsibility, or whether we wish to join the rest of the world and enable a single-payer system to provide health care for all citizens.

My confidence that this type of discussion will occur in the hallowed halls of Congress? Less than the square root of negative 1. My reasoning? There is zero incentive for members of Congress to reach across the aisle and actively involve the opposition party in legislative negotiation. As the French have said, La Plus ça Change, la plus c’est la même chose. The more things change, the more they remain the same. It sounds better in French.

Whatever happens with the current health care bill negotiations, I sincerely doubt whether the outcome will improve the situation for the majority in this country who are dependent upon either government policies directly, or dependent upon the structures set up by the ACA.

I call for the creation of a brand new party that is no beholden to the existing power structure. I call for a Macron-like entity to take over US politics from the completely corrupt and compromised party structures that we are burdened with. Part of our problem in the US is that we do not have a parliamentary structure. If we did, then Nancy Pelosi would have been driven from her leadership position in disgrace over the last few election cycles as her position would have been exposed as having a fatal flaw. Meaning, the vast majority of voters in this country do not agree with a San Francisco liberal.

Nothing will happen unless enough of us speak out and demand change. Even then, there is no guarantee that we will see significant change. But I do know that if no one speaks out, there will be no change. I am speaking out, here and now.

Ghosting, or Sloth? You Decide

Targets

We are in the midst of a target-rich environment. There are so many manifestations of incompetence and evil in the current administration that it is difficult to single out one as representative of the whole. So let’s bore in on a single area that most reasonable people feel is important. Let’s look at the number of roles in the Department of Defense that require Senate confirmation, where a nominee has been confirmed and is serving. The Department of Defense has 55 such roles. As of April 24 (last date I could find easily through search engine), guess how many people had been confirmed.

Give up? Exactly 1, Secretary of Defense General Jim Mattis.

How many of the 55 roles have had people nominated? Again, as of April 24, exactly 4, and two of those failed confirmation. How many more have been announced, but the nomination has not been transmitted to the Senate? Exactly 7, and one of those nominations for Secretary of the Army (replacing one of the failed nominations) has been withdrawn since April 24.

How many positions remain to be announced, nominated and confirmed? Forty-three positions are in Trump-limbo, awaiting any action to be taken. Now, this is the Department of Defense. Few people would argue that this is one of the governmental functions that should be staffed expeditiously in order to ensure that the department is able to perform its prime directive of keeping the nation safe. And yet here we are, 3 1/2 months after the inauguration and nearly 80% of the roles needing Senate confirmation have not even had an announcement of a candidate for the role.

It appears that one of the guiding principles of this administration is that they consider governmental agencies to be grossly overstaffed, and therefore substantial savings can be made by refusing to fill roles within the government. But to this outside observer, failure to staff essential roles will soon lead to paralysis within governmental agencies, leaving them unable to fulfill their duties. Many small-government champions may view this as a victory in the case of departments like Labor, or Education, or other similar agencies viewed as hotbeds of excess regulatory activity. But the Department of Defense?

If the act of leaving roles requiring Senate confirmation vacant is a deliberate decision being made as part of a strategic process to force administrative shrinkage, then let that be announced and we can debate the merits of the strategy. But if what we have is the Trump administration simply ghosting the agency positions, deliberately ignoring the need to fill them so as to hope that they go away, then we have yet another glaring example of the incompetence of the Trump administration.

There is one other possibility that comes to mind. What if there have been attempts to identify candidates for these roles, but either those candidates refused to be considered, or they were considered and then failed their background and security clearance process? Given the nature of this administration to be an information black hole, we may never know the full story.

So this is one simple example of how this administration has hit the ground and immediately assumed the prone position. An administration led by a caricature of a leader, who only knew how to drive his businesses into bankruptcy. An administration which found an eager legislative partner, looking for ways to implement Randian philosophy and effect a total reversal in government direction. This is where the discussion of evil comes into play. There are undoubtedly sincere conservatives who still believe that the country ran off the rails of Constitutional intent when the New Deal was adopted. That is a valid perspective, and it could be debated through the electoral process.

But this election offered a bait and switch. Campaign promises to drain the swamp of undue influence by banks like Goldman Sachs, only to reverse that pledge and fill the swamp with hordes of Goldman Sachs employees and alumni. Campaign promises to get this great new improved health care system that will cost less and provide better services. These promises were co-opted by the Ayn Rand wing of the Republican party into the AHCA, and once the bill passed the first step in the legislative process, they celebrated with Bud Light as they had designated bus drivers take them down the mall towards the White House. You know, that last bit may be the worst of all of this. To think that Republicans believe Bud Light is actually beer says more about them than all of their pronouncements of the moral inferiority of those who develop pre-existing conditions.

We now have a massive tax cut for the truly wealthy disguised as a revamp of health care legislation. If failure to staff the government is one of the manifestations of incompetence of this administration, then allowing this reversion to the bad old days of insurance company death panels represents the evil side of the administration. And still, the true believers do not realize that they have been trolled by experts as they pledge undying support for their supreme leader. If this legislation actually does pass, then their undying support will likely turn into dying support as states requesting waivers to the mandated treatment standards remove drug abuse treatment from insurance. The waivers will reinstitute lifetime caps on payments. But for those who are fortunate enough to remain healthy, they will save a pittance, and the Republicans will say, “See! We came through for you!”

Are You Calling Me A Socialist?

Disgruntled Republican Voter: I’m sure glad that I’m not one of those takers who expect the government to subsidize their health care. Everyone who takes a subsidy from the government is lazy and needs to get a better job that covers them.

Disembodied omniscient voice from above (think James Earl Jones): I’m glad you don’t want your health care subsidized by the government. So you will be in favor of having your health care from your employer being declared as income, and then you can pay taxes on it, right?

Disgruntled: I say – what are you talking about?

Disembodied: Health care benefits have never been considered as taxable income. This is a historical artifact from the time that health care was first provided to employees in WWII as a way to skirt wage controls.

Disgruntled: So what difference does it make who pays for it?

Disembodied: If businesses had to declare the value of health care as income for their employees, then the employees would be liable for taxes on this income. You just said you’d be happy to pay the taxes, right? Just so you wouldn’t be taking a subsidy from the government.

Disgruntled: I’m not sure … how much are we talking about here?

Disembodied: Let’s just use average figures here. You have family coverage, right?

Disgruntled: Yeah.

Disembodied: Average employer cost for a family policy last year was $12,600 per year. Now you are pretty successful, you make between $19,000 and $75,000 per year, right?

Disgruntled: Yeah.

Disembodied: Then you are in the 15% tax bracket. So if you had to declare $12,600 more in income, that means that the federal government is giving you about $1900 in tax subsidy for your policy from your employer. The one that distinguishes you from the moochers who get a government handout, right?  But then there’s more.

Disgruntled: More?

Disembodied: You live in a state with an income tax, right? Say the tax bracket for your state is 5% for your income. Then the state is giving you a tax subsidy of over $600.  That brings your total tax subsidy to about $2500 per year. But then, there’s the FICA tax to consider.

Disgruntled: What?

Disembodied: Since your taxable income just went up, you owe social security and medicare tax on this new income. So for $12,600, your tax that you don’t have to pay at all is almost another $1000 per year.  And your employer also avoids another $1000 per year that they’d have to pay to match your contribution.

Disgruntled: Ouch!

Disembodied: I calculate that due to the way that health care is accounted for in the tax code, your avoided tax is just about $3500 per year, and your employer avoids paying an extra $1000. So I’m glad that you’ve decided not to be a taker of government money, because your government could sure use the extra $4500 that you said you’d be willing to pay.

Disgruntled: Now wait a minute, I never said …

Disembodied: Oh yes you did. You said that you’d never want to be one of the takers who takes a subsidy from the government. That means you want to correct this problem in the tax system. Of course, if you were in a higher tax bracket, like 25%, you’d be getting even more free money from the government.

Disgruntled: You’re using fake facts. You’re probably part of the lying media. I’ve never seen anything about this on Facebook.

Disembodied: Believe what you will. Reality does not change based upon your beliefs. The facts are that you get money from the government to subsidize your health care benefit that you earn. Of course, you still pay all of the out-of-pocket and shared premium as well.

Disgruntled: And they keep going up and up. It’s all due to Obamacare.

Disembodied: Health care costs have been going up faster than inflation for decades before the ACA came into being. One reason is due to the screwy way health care gets paid for. We spend over 25% just on the administration. Funny thing is, when you have a single payer system like Medicare, that administrative burden goes down to about 5%.

Disgruntled: You mean single-payer would cost less? Why don’t we consider it?

Disembodied: Because the 1% class you put into the government believes that only moral reprobates who have immoral habits get diseases or have accidents, and they are the ones who drive up costs for the superior class of folks who have employer-paid health care. Besides, the 1% gets a hell of a lot of tax cuts when the taxes that supported the ACA are backed out.

Disgruntled: Yeah, but isn’t single payer socialism?

Disembodied: You mean the current system that gives free money to taxpayers and employers to have employer-based coverage isn’t socialism? Isn’t that government picking winners and losers? You’re a loser if you work three part time jobs and 60 hours a week but none of your employers provide health care and you don’t deserve any government subsidy? You’re a winner if you work for someone who provides health care as a benefit?

Disgruntled: Nobody knew health care could be so complicated.