wnstn.com

The Philosophical Problems

A previous post pointed out that Americans expect perfection in doctors, and often times if perfection is not achieved, a lawsuit is served. This seems to stem from our modern philosophical idea of healthcare, something that has yet to be addressed in any bills or debates on TV.

The issue of drugs and drug costs discussed in the previous post is illuminating in this regards. It is a natural human desire to find an easy way to solve a problem, that�s the goal of most technology and progress. But modern society doesn�t just look for solutions that make sense, instead we look for solutions that are convenient. Just look at the evolution of most devices we use in our modern life – we�ve gone from a mechanical lawnmower that used human power, to a engine powered mower, to riding mowers that have cupholders. Now mowing the lawn is extremely convenient. This is the way modern life works across the board, from coffee machines to razors to, most alarmingly, healthcare.

Modern society has elevated the cure-all to the level of science, and we�ve convinced ourselves that with science, we can live however we�d like. Part of this means we look to drugs to solve ailments conveniently. Most Americans with high blood pressure could eat a little better, exercise a little more and be fine – but it is much more convenient to take this exciting new drug that reduces blood pressure without the lifestyle changes.

The problem with this thinking is that ailments and illnesses become separated from the way we live – each one is something to be dealt with when it arises (with SCIENCE!) and meanwhile the root issue – an overall unhealthy lifestyle – is never addressed. PSA�s and certain observers have of course been saying this for years, but in the specific context of our healthcare system, there is no overall attempt to defeat this fragmented philosophy of health. When we go to the doctor and they find a problem with us, they are rewarded by running a series of tests, prescribing the necessary drugs, and sending us on our way. The insurance company dutifully covers everything because that�s what we pay them to do. But our health, when viewed from an overall lifestyle perspective, does not improve, and the effects later on might be harrowing.

Is this a problem with the healthcare system? Yes and no. It is, as my riding lawn mower example shows, more a pervasive societal philosophy that our technological and scientific advancements have given us the ability to have convenience above all else. But the healthcare system only reinforces this philosophy, and in doing so increases the costs to consumers and further alienates those who cannot participate in the system (the uninsured).

I mention all this because the built in assumption of the healthcare debate is �because we can, we should.� Healthcare is a very sensitive subject, and any talk of limiting its availability seems horrific (see: fears about �death panels�), but the philosophy of excess and convenience we have today has a very real and very steep cost, and when we discuss its availability and how to fix this system, we either have to crown convenience king, at the sacrifice of the cost-cutting, or as a country we have to be willing to sacrifice on certain things to be able to afford the necessary things (e.g. sacrifice on drugs that replace lifestyle changes, in order to afford life-saving cancer treatments for everyone). So in the next post, we�ll look at some potential solutions that make sense to me.

This is rather fitting with the topics of my posts this week.

How Diets affect Weight around the World

Yay, America’s winning!

These blog posts started months ago, with me questioning why exactly Universal Health Care was innately bad on Facebook and proceeding with me reading various analyses and articles on the issue. So the following blog posts are a summarization of my understanding of the issues at stake and an overview of the solutions that have made the most sense to me in my readings. I�m writing this for my benefit as well as anyone who would like a bigger picture view of the system and it�s flaws. I am organizing the posts so that I explore all the flaws first, and then some potential solutions that make sense to me, and I am trying to keep the posts to bite-sized chunks. I am of course, always open to discussion.

Regarding the Uninsured

Democrats say 30 million. Republicans say more like 6 million. No matter which figure you believe, that’s a lot of people in America who are legitimately uninsured. Even more worrisome is that every year the majority of personal bankruptcies are declared because of medical bills that are too expensive to be paid. Insurance providers have no incentive to compete on the individual market because they make the majority of their money from businesses who provide employer-based insurance as a benefit. Healthcare providers do not compete on an open market and thus set the prices of services based on their own estimates, then negotiate with insurance providers for the price that those insurers will pay. But uninsured individual consumers have to pay full price, meaning that most medical services are overpriced and the uninsured avoid medical services unless they are absolutely necessary.

This means that an individual or family who does not have access to employer-provided healthcare insurance is stuck between a rock and a hard place. Their first option is to pay full price on insurance premiums out of pocket or face the other option – avoid healthcare until they are faced with an emergency, and then face medical bills that are debilitatingly expensive. This is a real problem in America – the human side of the healthcare debate. That is why it has seen the most amount of attention in the debates.

But it�s not just the uninsured who have these problems – even people with insurance are often faced with incredibly high medical bills because they reached the limit of their coverage or their insurance was revoked due to whatever medical problem they have. It is a documented issue that many people nationwide face what is called rescission – the revocation of their policy when a major medical issue arises. Insurance companies have been known to pore through medical histories to find problems which they can claim were preexisting issues, or even to find typos on the original forms which they claim as a lie and therefore reason enough to revoke the policy. These are the extreme cases, but they are documented and the insurance company CEO�s are on record in front of congress saying these practices will continue because they are currently legal.

A sidenote about Drug Companies

All of this information regarding our Healthcare system boils it down to two major players; Insurance Providers and Healthcare Providers. But there is a third party that does a great deal to increase confusion and costs in the medical system. The drug companies, or �Big Pharma� as they are often called, have a really large hand in the pot stirring things around, attempting to profit off our misfortunes as a society. That would seem a dramatic statement, but the Government and journalists have documented the nefarious activities that drug companies practice to increase their market share and profits.

Big Pharma is profitable. The number three most profitable industry in the US in fact, with 20% profits last year alone, which translates into billions and billions of dollars. But Big Pharma has a lot on the line as well – each year they spend billions on research and development of new drugs, and often times drugs can get well into testing (after billions have been invested) before failing out of clinical trials. So Pharmaceutical companies have a lot of risk, and work hard to offset that for their investors by increasing their profits yearly. The problem is, normal ailments just aren�t that profitable.

The laws right now are very strict on how a new drug can come to market – it must be proven through clinical trials and multiple studies against placebos. Once a drug is approved by the FDA for sale, it can only be marketed by its manufacturer for the specific purpose the drug was approved for. This is usually a very specific ailment or problem. However there are no laws restricting doctors on their prescriptions – so drug companies have discovered that an easy way to increase the profitability of a drug is to recommend to doctors that it be prescribed for �off-label� uses. This is a common practice now – and there is very little science that goes into these prescriptions. Drug companies merely tout (to doctors) the great uses of their drug for a certain use, and doctors proceed to prescribe it for that use – whether or not there are any studies to back� what is being touted.

Insurance companies meanwhile are constantly fighting drug companies to keep down costs. A generic version of a popular drug might have the same efficacy and side effect risks, but can cost hundreds of dollars less each month. It is thus very desirable to insurance companies to promote generic drugs to their consumers. Drug companies don�t like this because they need the revenue from their drugs to keep making new ones, so each time the insurance company attempts to encourage generic usage by putting up obstacles to getting brand-name drugs (such as more costly co-pays for the brand name drugs), the drug companies fight back (by offering coupons that remove the copay for the consumer). The consumer loves this, but the insurance company is left paying hundreds more for the drug.

This issue of drugs and their prices might not be so powerful were it not for the philosophical problems in our healthcare system today, which is the topic of tomorrows post.

These blog posts started months ago, with me questioning why exactly Universal Health Care was innately bad on Facebook and proceeding with me reading various analyses and articles on the issue. So the following blog posts are a summarization of my understanding of the issues at stake and an overview of the solutions that have made the most sense to me in my readings. I�m writing this for my benefit as well as anyone who would like a bigger picture view of the system and it�s flaws. I am organizing the posts so that I explore all the flaws first, and then some potential solutions that make sense to me, and I am trying to keep the posts to bite-sized chunks. I am of course, always open to discussion.

The Problems with Doctors

There have been a lot of words thrown around about the “fee for service” structure that we have in place – where a doctor’s income is based not on a salary but on each specific service they provide. A patient may be diagnosable with reasonable confidence based on one test, and multiple tests may not increase the confidence of the diagnosis at all, but the system is set up so that the doctor gets paid more for ordering more tests, the patient sees no extra cost (because insurance covers it all), and furthermore the doctor is seen as going above and beyond due diligence which protects him from malpractice lawsuits. A great number of analysts point out these three reasons as the main drivers behind the unneeded medical services provided each year (the 30% figure previously mentioned).

Fee-for-service is the immediate incentive that lawmakers hope to address. Doctors swear, of course, to only do what is best for the patient, and no doubt most intend to do only that. But the system has a built-in incentive to provide more services – which also has the side-effects of giving a doctor incentives to see more patients and spend less time with each to maximize the “effectiveness” of their time (and their income).

Patients have no problem with more taking more tests – from a non-medical point of view, more information can only be a good thing. And the cost of the tests is never known due to the insurance blinder, so it’s a win-win in that your doctor is better able to diagnose your problems while you don’t have to pay anything else. Except that tests – like MRI’s or CAT Scans – can cost thousands of dollars, and the more people who get them the more insurance premiums go up. Consumers aren’t able to link the two – the system does not provide any connectivity between more tests and higher premiums.

This is even worse in markets that are heavily saturated with healthcare providers. Certain analysts have surmised that in over-saturated markets there is a built-in market incentive for excess; because if one doctor won’t order the extra tests, surely another will. So a doctor is compelled to go above and beyond to keep his patients and thus is able to make a living in an otherwise very competitive market. It has been estimated that this can double overall medical costs for markets with this problem.

The hardest aspect of this issue to rectify is that more information does not increase a doctor’s ability to diagnose you – the extra information can many times be unnecessary to a diagnosis. But consumers don’t know this, and because they also see no connection between extra tests and rising premiums, they do not understand that excess is a bad thing. In reality, we want excess because it gives us peace of mind, assures us that doctors are solving all possible issues with our health.

This is where malpractice comes in – the issue of tort reform is another one thrown around in the political debates. America is a very litigious society and medical malpractice lawsuits abound – they are so troublesome that for healthcare providers often the biggest operating cost for providers is malpractice insurance. In these suits it must be shown that due diligence has been performed by a doctor, and if it has not been performed then settlements in the millions of dollars are not out of the ordinary. But what is due diligence? It’s a very nebulous idea, specifically in the realm of a specialized field like medicine. If a doctor does what he knows will give him the best diagnosis and reaches a confidence of 99% that someone does not have cancer but it turns out he was wrong, has he performed due diligence? To a trained medical person, the answer may be yes, but to a lay person this answer is often no – whatever could have been done should have been done, no matter the cost or unlikelihood of helping. And there is no real incentive to the doctor to not order the extra tests and do the extra procedures – he makes more money that way.

Once again, the system incentivizes excess: the doctor cannot do what would be necessary to reach a confident diagnosis, instead he must do every possible thing he can to ensure that there is no doubt left in his mind. We expect perfection from doctors, and if they fall short we sue them.

These blog posts started months ago, with me questioning why exactly Universal Health Care was innately bad on Facebook and proceeding with me reading various analyses and articles on the issue. So the following blog posts are a summarization of my understanding of the issues at stake and an overview of the solutions that have made the most sense to me in my readings. I�m writing this for my benefit as well as anyone who would like a bigger picture view of the system and it�s flaws. I am organizing the posts so that I explore all the flaws first, and then some potential solutions that make sense to me, and I am trying to keep the posts to bite-sized chunks. I am of course, always open to discussion.

The Healthcare System

There are two main critiques of the healthcare system that we are supposed to be solving with whatever bill emerges. The first is that there are millions of uninsured people in America who either can’t obtain care because of “pre-existing conditions” or are unable to afford healthcare but don’t qualify for the existing government programs. Secondly, there is the issue of excess, fraud, and inflation in healthcare – estimates are that about 30% of all medical services provided are unneeded, but are still covered by insurance thus contributing to the rising costs. Because of these unneeded services, healthcare costs are rising faster than the GDP or the average American�s income.

It would seem that the two problems are directly linked – as healthcare costs rise yearly, insurers must be more careful about who they cover and what issues they cover, leaving millions of people uninsured with no hope for coverage that is reasonably priced.

This is the simple version though – and as I’ve read what I’ve had time to read and parsed the sometimes overwhelming amount of information, my frustration has risen at the amount of people who take this simplification at face value and assume that this is the totality of our problem and that’s why a simple solution is needed. This is the American way though – we boil something down so simple that it’s seemingly a straw man, and then we just fix the straw man. But the devil is in the details, and healthcare is all about the details so that is why I�m writing these posts.

The Complications

The Healthcare system as it stands now is not a free market system. Politically minded people want us to believe that the choice is between our free market status quo and Obama’s socialistic plan. This is not the case, and it is confusing a lot of people. Right now as a consumer of insurance, my best bet for obtaining coverage is through an employer based group plan. That plan is provided by a Insurer that can only operate in the state I live in, meaning that in every state in the US insurance works differently and has different main players. To provide coverage in each market, each insurer must negotiate with each Healthcare provider to decide on rates and coverage for each service provided – and the rates that the Healthcare provider and Insurer decide on in no way change the rates that another insurer might get with the same healthcare provider.

Because of these problems, we work in a very monopolistic market, where each state is dominated by two or three major insurers. Those insurers are the only choices employers have for providing insurance, and anyone who cannot join group coverage is faced with the exorbitant costs of premiums that come with individual coverage. They have no real choices because there are only two or three major providers and these insurers have any incentive to compete with each other on individual plans because their main consumers are businesses who obtain group coverage.

I should note – the laws right now do not allow insurers to provide coverage across state lines, this is a legal hindrance and not a choice on the part of insurers. Because of this, each state is a unique market in healthcare and prices fluctuate from state to state (and often city to city within states) because there is no actual open market that guides pricing.

Pricing in the healthcare industry is yet another confusing, non-free-market system. Every hospital sets the prices for what it thinks the services it offers are worth. This is probably not completely arbitrary, but it can vary a great deal within a city. No hospital is required to publish a price list and there is no free market pressure to reduce prices as each hospital usually is only competing for business from a few major players (the main insurers in that market). Consumers have no knowledge up front of the cost of their medical procedures and thus are unable to make economically-minded decisions about healthcare. That point will be revisited.

For an insurer to provide coverage at any specific healthcare provider, the insurance company has to actually go to that healthcare provider and negotiate rates for all the services they provide. If a hospital says that a certain test costs $1000, the insurance provider will negotiate how much they have to pay for all the people they cover if those people receive the test, and it will typically be a drastically reduced rate (like say, $300-400). But EVERY insurance provider has to do this negotiation, and all of them will get different rates. It used to be (until a decade or so ago) that hospitals were the losers in this battle, because they were the small dog at the negotiating table.

A decade or so ago, coinciding with the rise of the HMO’s, hospitals began banding together into networks, increasing their negotiating power with insurance providers. Because the insurers goal is to have as many choices for the people they cover, when hospitals banded together, insurers had more incentive to come to an agreeable deal with the hospital networks so that their insurees had more options. Before the hospitals banded together, the insurer always had the option of saying due to unreasonable rates, we will not provide coverage at your hospital to the thousands of people in your market. The hospitals banding together into large networks removed this threat because an insurer couldn’t risk not providing coverage for so many hospitals in a certain market.

This move on the hospital’s part, and the increased power on their part at the negotiation table meant that rates started rising – insurance providers could no longer lowball. But the combination of state line limits on insurance providers with the new hospital networks means that in each state the size of the insurance provider dictates the rates they receive – the hospital networks didn’t just even the scales, in many cases they tipped the scales in the hospital’s favor. If an insurer in a specific state doesn’t have a lot of clout (meaning a large amount of people that they cover in a given hospital network’s area), they cannot negotiate lower rates. This only increases the monopolistic market of insurance, as only the biggest insurers can negotiate lower rates with more healthcare providers so that their premiums don’t rise as fast. The smaller providers are stuck with higher rates that they must pass on to the consumer.

Tomorrow: “The Issues with Doctors”

In view of this control and the conflicts of interest that permeate the enterprise, it is not surprising that industry-sponsored trials published in medical journals consistently favor sponsors’ drugs�largely because negative results are not published, positive results are repeatedly published in slightly different forms, and a positive spin is put on even negative results. A review of seventy-four clinical trials of antidepressants, for example, found that thirty-seven of thirty-eight positive studies were published.^[8]But of the thirty-six negative studies, thirty-three were either not published or published in a form that conveyed a positive outcome. It is not unusual for a published paper to shift the focus from the drug’s intended effect to a secondary effect that seems more favorable.

This article from the New York Review of Books about how the doctors who lead medical tests on new drugs from big Pharma companies is particularly damning. I’m especially worried about how the medical doctors don’t seem to recognize that these are conflicts of interest – the fact that they receive thousands if not millions each year from the companies that produce the drugs they are supposed to be scientifically (read: without bias) testing. Yet another hole in our current medical system.

For anyone who might read this blog regularly I am preparing a series of posts on the information I’ve gained in the past few months about the US healthcare system. Nothing groundbreaking or revolutionary, but just trying to compile and sort out all the information in my head. I hope to start posting them over the weekend, once I get the drafts for every post completed.

�Here�s to the crazy ones. The misfits. The rebels. The trouble-makers. The round heads in the square holes. The ones who see things differently. They�re not fond of rules, and they have no respect for the status-quo. You can quote them, disagree with them, glorify, or vilify them. But the only thing you can�t do is ignore them. Because they change things. They push the human race forward. And while some may see them as the crazy ones, we see genius. Because the people who are crazy enough to think they can change the world, are the ones who do.�

-Jack Kerouac

This has always been, and most likely will always be my favorite ad campaign ever. There are lots of reasons why it works as excellent advertising, but I love the way it works as inspiration. Seeing these great faces and hearing Kerouac’s quote is inspiring. This commercial (and the posters that were part of the campaign as well) reminds that mankind is capable of truly awesome inventions and art, and it is not necessarily the smartest of us who create them, it is the bravest. Those who step out and do think different.

I need to watch this video on a regular basis.

I’m in no mood to write a review, so this is a scattershot meditation on Spike Jonze’ film that came out today. Freya and I couldn’t wait any more to see it, so we braved the midnight showing here in Nashville.

This film is a child-view examination of the life that we live in constant tension. The wild things are ferocious and more than capable of crushing or eating Max, but they also want him to lead them and all have their own problems that they think he solve.

There is no attempt to simplify life or hollywoodize a moral out of a wandering story, rather the film is simply concerned with what does it mean to be a child, what does it mean to have emotions that are stronger than we care to admit, what can imagination and escape do for us, and yet to simplify the film to these questions offends the power and beauty of it. Spike, and co-writer Dave Eggers have attempted to remove the wisdom we get as adults and simply capture the volatility and wonder of being nine years old, of trying to understand why good things happen and why bad things happen.

The film is beautiful. That’s really all I have to say about it right now. I can’t wait to see it again, to enter back into the world where the wild things are, to see the reign of King Max, who will be a good king. This movie is devoid of nostalgia about childhood, and in stripping that away, we remember the world as it was before we built up our defenses and coping mechanisms. And that world, as scary and volatile as it was, is worth revisiting.

Darnielle, of the Mountain Goats, reviewed some of his favorite Christian and religious albums for emusic, on the occasion of the release of his new album, on which every song is inspired in some part by a scripture verse. Here, he recommends “The World as Best I Remember It, Vol. 1″ as the album to check out from Rich Mullins:

It’s hard not to go with�Songs, the first greatest hits collection � it’s more solid end-to-end. But the title of this one comes from “Jacob & Two Women”, which is one of the best Christian songs of the past thirty or forty years by anybody and an incredible song by any measure. (My favorite version of it is Carolyn Arends’s graceful reading on�Awesome God: A Tribute to Rich Mullins.) It’s a song that shows Mullins at his best: witty; clever; open; doubting; playful; faithful; wistful; in touch with the sorrow & the loss & the hope & the wonder that lies underneath all spiritual seeking, and all housed in one flesh-and-blood, wholly unpretentious person. There’s also “Step by Step” and “Calling Out Your Name” here � both clear evidence of how truly great a songwriter Mullins was and how much the music world lost when he died.

Amen. Amen. �See the full list here.

Over on Tiny Mix Tapes, Darnielle is given the full interview treatment, and this question is illuminating, heartbreaking, and worth swallowing any immediate reaction you have to consider what he says for awhile.

Let�s turn to the album. Religion always seemed hinted at in your music, but it�s never been so blatant as it is on�The Life of the World to Come, even without the song titles. Is there any reason for this explicitness? Religion is treated here in a similar way as subjects like love or family on past albums.

For sure: religion�s explicitly personal for me, for a bunch of reasons. My early school experiences were in Catholic school, and some of the early Sisters who taught me were real heroes to me: they nurtured me, treated me with love and respect; they meant so much to me. Experiences like those, at a parochial school, can really cement one�s ideas about God and bind them with one�s ideas about self-worth and feeling welcomed and at-home.

And then my parents divorced, and church became something we only did when we (my sister and I) would go to stay with my dad, and he wasn�t Catholic any more at that point, so I�d get exposed to the weird world of protestant services, which had their own warmth for me. And then I renounced God and raged against religion for years, as I still will, often, given all the damage that Christians (not fake Christians, that�s a cop out: real ones do all kinds of harm) will do. But down in my gut, I want to believe so badly. I can�t stand the idea that Christian virtues are mainly humans celebrating their indwelling natural goodness; it�s probably true, but I want transcendence. That�s personal. And some of my friends are dead, but I feel that what they left in this world persists: and that�s spiritual. So, yes. Spiritual stuff, way personal for me.

Thursday afternoon Freya and I are our skidaddling out of Nashville towards the similar sounding city of Asheville for our one year anniversary trip. We’re a week early so technically it’s a 51 week anniversary but we’ll take it.

The cabin has a hot tub on a deck and a skylight-lit loft area and acres of woods surrounding it, followed by mountains and forests surrounding those.

I’m taking my typewriter with a fresh ribbon, a stack of blank pages, a notebook or four, 5 New Yorkers, 1 Wired Magazine, 3 books of poetry, one book of non-fiction and possibly a novel.

I think Freya’s list of items to bring is similar in length but decidedly more visual arts themed.

We’ll be taking two cameras, one digital SLR, one polaroid.

At the Greenlife grocery in Asheville we’ll be buying ingredients for homemade chicken salad and homemade butternut squash bisque and any other recipes we find that strike our fancy.

We are making no plans except for maybe a picnic drive up the Blue Ridge Parkway, and on Monday we’ll be visiting the Biltmore.

Otherwise we will spend our days creating and reading and enjoying the hot tub and the complimentary bottle of champagne and most of all the company of each other.

And Thursday cannot, absolutely cannot come soon enough.