September 2011
October 1, 2011
Particulars I Ponder… Some incomprehensible facts confound my best attempts at logical explanation. For example: · Why has college tuition increased more than twice the rate of inflation? It quadrupled for the last generation. My experience was decades ago: tuition for my last year, 1953-54, at the University of Pittsburgh cost $450. Is higher education that much higher? · Did the same folks who brought us the mortgage crisis design student debt? The average student graduates with debt that tripled in little more than a decade. Unbelievable that some students end up with loans greater than most mortgages, or more than the actual value of most homes. · When did an extensive “internship” take the place of an interview and real-paying job? Students no longer hit the job market directly. And when they do, they find starting salaries that fell again last year. · How can job prospects and income decrease while education costs increase? · Another area of bewilderment is the outrageous rate of increases in the cost of medical care. Certainly medical technology is expensive, but do the costs ever go down? If an iPad gets cheaper, why not technology in the medical world? · Why aren’t experts trained or rewarded for using the simplest, and often least expensive, treatments? One big problem in healthcare is that we don’t have enough primary care doctors. Those are the doctors who know patients best, who can give patients more options. Patients tend to choose the least invasive option, which is often also least expensive. · Would it be rocket-science to figure formulas to pay doctors for keeping patients healthy and well, keeping them out of the hospitals? · One more item regarding physicians: It seems many have conflated patients and patience. That’s the kindest way to put it. I understand delays due to emergencies or complications. But frequent and unbearably long delays in the waiting room are often followed by an equally long passage of time as the exam room tests patients’ patience. The patient waits behind a closed door, with no clue of whether the doctor is a few steps away or the office has closed for lunch. · Exasperated with debt and budget news? I propose term limits to get Congress to act in a responsible and timely manner. Check my previous posts (November 2010) for more on the continuous campaign cycle. · The quandary is getting a “current” Congress to pass single term limits. Two weeks after election results, eighty percent of their effort focuses on the next campaign season. · Why do we tolerate campaigns that start two days after an election? My prediction: if Republicans win the White House in 2012, two days later they would start campaigning for 2016. President Obama started campaigning for 2012 a few days after his 2008 inauguration. Can anyone want to campaign continuously? I’d wager Presidential and Congressional cabinets and staff drive the campaign schedule because they are so enamored with their own job perks. · Who does the Washington Press Corps think they are convincing when they keep telling us that Congress has a difficult job? Working in a coal-mine or digging ditches is a difficult job. Raising teenagers is a difficult job. Working in Congress is a cakewalk by comparison. · Thinking of Congress working reminds me of the spate of “How many --- to change a light-bulb?” jokes. We’d start with “How long would it take Congress to agree that the current light-bulb is burnt out?” · Does Congress realize we recognize that extensive breaks, recesses, or vacations by any other name are something most people think evoke some feelings of guilt? · Why is it that in contrast to predictable inertia of politics, witnessing Ohio State’s dotting of the “I” seems more thrilling than becoming President could ever be? · Does Baseball realize it was their and their teams’ stupidity that destroyed their historic advantage and made the NFL so much more popular? A current cliché for American metaphors might still include “apple pie” but probably not baseball. · How can the average guy balance “time off” when work is a livelihood and nothing’s worse than unemployment – through layoff or strike. Anxiety isn’t a comforting companion as one gets up each morning with nothing to do all day. · Didn’t the airline industry realize taking the “friendly” out of the skies makes transportation by flying less appealing than having a root canal? · Airlines comprise one reliable industry for showing appreciation for their pawns, I mean, their customers: When Congress failed to reauthorize the Federal Aviation Administration in late July, nobody replaced the FAA as tax collector and the tax expired and airline income was boosted by about $25 million a day. Any chance the savings is to pass on to passengers? · No matter how intriguing the 60 Minutes episode, why does it seems so much less significant without Andy Rooney in the program? · Who does not yearn for the respite provided by the late the Road with the late Charles Kuralt? · Can anyone explain the current spate of assaults of women by sports figures? I don’t recall even a few such news items during my days as a university sports information director. The general decline in civility and manners are undeniable, but I suspect the causes include drug use and publicity pressures as athletes now become celebrities. Decades ago, celebrity-status incurred accountability. Now it proxies as a license for recklessness. · Is membership on Corporate Boards really related to ability of ensuring the corporate missions or to scratching each other’s back in these exclusive clubs? The same guys are on multiple Boards. Some perspective and experience may help, but not as much as someone who can represent other faction of society and consumers. · Why is no one surprised that Corporate Board members receive extravagant benefits yet, as some members of the Sports media imply, owners of sports teams should not have a right to profits? · On the topic of exclusive clubs, aren’t graduates of any Law Schools besides Harvard and Yale qualified for Supreme Court nominations? Six of the current Justices are from Harvard, three from Yale. Stanford, Michigan, Georgetown, and many smaller schools have strenuous academics. Aren’t tough academics a better qualification for Judges and Justices than competitive admissions to elite institutions? · If the discussion of U.S. debt reduction includes Medicare (a topic I discuss separately) and public sector pensions (the few pensions left in our country), why aren’t the captains leading the cavalry? I propose having Congress and state legislators start with eliminating their overly-generous lifetime pensions and healthcare. · Why do so many members of the media use “choke” when describing an athlete’s bad day in an important game? I mean, this term is used in reference to even high school athletes. I understand when a professional freezes, but a simple fumble does not mean the athlete cannot stand up to the pressure of performance. · Where will the push for shopping seasons stop? Christmas shopping, years ago, starting the day after Thanksgiving, and now it begins before Halloween. · Does no one consider that the over-concern with today’s kids’ self-esteem might be a dangerous direction? Glad I won’t be around when these tykes grow up to run things. · How did people ever manage to meet, converse, and be social before everyone became continuously “wired”? Amazing that before the electronic age, we had communication through effective and even intrinsically pleasant means. · Who, besides Madison Avenue, wants more “new” phone features? I just got another brochure from a phone company regarding how they can satisfy my “appetite for new.” No thanks, I’m happy I’ve conquered the few current features and usage I need. · How do we rationalize misaligned loyalties? For example, “I’m Italian” or “I’m Irish” or “I’m French” coming from folks down the street, with no accent, no real baggage from any immigration. This allegiance seems to be relative: I think if I ran into the same people in Paris, France or Munich, Germany, they would say, “I’m American.” I intend no bias as my heritage is 50% Irish. · Who decided to call Personnel “Human Resources”? I think it happened as “outsourcing” gained traction. · Why do members of the print media refer to “pre-season” football instead of “exhibition”? OK, it’s an the extra syllable, but they use the more accurate term for baseball and basketball. · When did the cockpit become “the flight deck”? Did the airline PR people watch too many Star Wars episodes? ##### © 2011 Beano Cook
September 1, 2011
Calling Dr. Welby…
Normally I would write nothing pointedly political, but here is a difficult and currently critical topic: Medicare. The issues must be addressed in places more political than I ever enter, but I hope you can grant me this exception. My intent is to honor Sgt. Joe Friday’s oft repeated request for “just the facts.” First, let me state that I was once a Democrat, but now I’m Independent. As the saying goes, I didn’t leave the Democratic Party, the Democratic Party left me. The reason Medicare remains in precipitous danger is that Congress, both Republicans and Democrats, allow problems to exist rather than to face the tough decisions, to resolve real problems.
The volatility of this publicly-funded national health insurance is evidenced in the fact that when Medicare legislation was passed, many citizens were for it, and if legends are true, almost as many against it. However, very few Congressmen were against it when President Johnson signed it into law, making Harry Truman and his wife, Bess, the first and second beneficiaries.
Along with Social Security and the G.I. Bill, Medicare remains one of the most important parts of social legislations in our country. As the G.I. bill and Unions built the middle class, Social Security helps bridge the savings of many elderly to a reasonable living standard of living, and Medicare prevents many from going bankrupt buying prescriptions.
Marcus Welby, MD, in ABC’s TV series of the same name, presented the caricature of a polite, dedicated professional who focused on his patients and their illnesses. No worries about insurance plans, forms, and payments—private or governmental. Just practice medicine. Treat the patient. Maybe fantasy but at best a myth today! What this country needs is more general practitioners. More quarterbacks and fewer lawyers would help, too.
Granted, health care and costs, along with longevity expectations, have changed over the decades. My own health situation illustrates the state of medical care today: I’ve had a triple by-pass, amputated toe, 23 days in a hospital, and eleven weeks in post-hospital medical rehabilitation—and none of it cost me a cent. Without Medicare, longevity in the US would decline tremendously, as would personal savings. There is no doubt that some can and should pay more. I would happily shoulder a larger premium to help keep Medicare solvent. Like Social Security, I’d rather know that it’s there when I need it.
I would address Social Security, first, by not permitting any of the funds to be used for anything but the program itself. Next, Social Security, as with Medicare, becomes need-based. The funds of those beneficiaries with little or no present need, could be held in the person’s account. If the funds are not required in the person’s lifetime, only upon death would that account be released to the surviving spouse or the return to the government’s Social Security budget. Also, the cap on income as a base for Social Security tax is counter-intuitive. Any exempt base must be realistic to serve the mission and sustainability of the program.
Medicare, in contrast to Social Security, has no limit on income basis. Instead, the income basis is scheduled to increase in 2013 in a single increment: the 2.9% tax on earnings rises to 3.8% only on the income in excess of $200,000 for an individual, and $250,000 for a couple filing jointly. Any wonder why healthcare is such a hot issue today?
On the down-side of my recent medical treatments, I learned even the most simple and quick procedure incurs overwhelming paperwork. That paperwork is not just for the patient, but piled on the nurses and the medical practice as well. This is not to criticize the administration of Medicare, which, along with Social Security, are probably the most efficiently-run programs in the public sector. Probably more efficient than most in the private sector, too.
Medicare is more than part of a social insurance program. Medicare was developed to improve access to healthcare. Funding a major portion of hospital residency programs addresses part of that mission. Congress and the American public knew, more than a decade ago, that a serious issue for Medicare remains the coming of eligibility age of baby-boomers. Yet Congress then as now, refuses to act. This aging population is only a contributing or possibly secondary factor. Other factors impacting Medicare include increasingly expensive medical technology and pharmaceuticals.
Health and medical treatment are complex. Most of us like to find our Dr. Welby and rely on his—or her, advice and judgment. We respect the relation of medical professionals and the Hippocratic Oath. Just as with drug side effects, the personal harm of the most expensive or extensive treatment need to be weighed against their benefits. I’m too much of a coward to push for Kervorkian-style solutions. The fact that doctors are taught to find remedies leads many to ignore some realities: when you keep looking at numbers, including measuring length of life, the quality of life falls into the neglected column. Don’t get me wrong. Some of my best friends these days are doctors. But, consider the caricature of a doctor who thinks he is responsible to continue “life” at all costs. Medical training needs to include advocating for the patient as well as against the disease: few doctors know when to quit. Many times, carefully weighed options leads to a decision for caring and dignified route to palliative care. Respecting the important role of hospice care is critical to the patient as a person, and to the health of medical treatment costs. To that end, hospice care should not be difficult to obtain. I’m not advocating “throwing Granny under the bus,” as this sensitive topic has been characterized. But a certain amount of common sense would go a long way toward humane treatment. Consider, for example, a friend’s elderly father, who was dying of multiple disease processes. The nurses, who witnessed the increasing debilitation, insisted that the family talk to the doctor. No doctor, however, would answer difficult questions. Each doctor, looking at a single disease, insisted the situation “will not kill him.” Finally the family realized what the nurses were trying to say. The man went to the hospital for palliative care, expecting to return home for hospice care. Two weeks into the hospital stay, as the patient became more debilitated daily, surgery was recommended. In fact, surgery was “required” for his release. It was performed early in the morning, and declared “successful.” Less than 10 hours later, the family was told to call in the morning, as things were “not looking good.” In the early morning hours, the family was told the man was experiencing multiple organ failure: all life-supporting measures would give him only a few days. Without such measures, he had only a few hours. The man’s living will included no extraordinary means to extend a fatal situation. The family decided upon “comfort only” treatment and rushed in for last good-byes. He died a little after 6 a.m.
The bills totaled over $30,000 for this fundamentally fatal surgery. Months later, Medicare statements still pour in. One statement included physician’s charges of $100 each for daily visits. This doctor charged for a visit every day, from the man’s admission, to, and including, the day of death. Recall that the patient died around 6 a.m. This must be a very dedicated doctor. Did he really get up by 4 a.m. to visit the dying patient? Once no further treatment was possible, what was the purpose of his visit? In fact, what was the purpose of the surgery?
The family called the supplemental insurance to inquire about some bills, including these daily visits. We’re all familiar with hospital visits producing bills from multitudes of doctors, none of whom anyone can recall meeting. “Talk to Medicare: if they approve it, we pay,” the family was told. They called Medicare. “We can only talk to the patient, not to you.” Power of attorney ends at death. This was probably not fraud in the legal sense, but certainly in the ethical sense. But nobody cares to stop it. And now, Medicare statements come in for bills from over one and a half years ago. Who is going to determine if these bills were processed and when? How can a doctor or hospital balance their books if they have accounts outstanding that long?
As for Medicare accountability: the Government Accountability Office identifies Medicare as a high-risk program in need of reform, particularly due to its vulnerability to fraud. Fewer than 5% of claims are audited. Fraud needs to be investigated. More important, perpetrators need to be punished severely, where it hurts: in the wallet. For every dollar lost, the penalty should be a minimum of three dollars. That’s light for stealing the health and welfare of American citizens. Look at it this way: if you steal from The Mob, you swim with the fishes.
Another side of inefficiency is reflected through Medicare practices. This example is from a friend whose husband was not well. In fact, he was fatally ill, and had nutritional issues. Medicare wanted to send a case of 24 cans of a certain food to the man’s house. His wife requested a few samples, knowing her husband’s intolerances. She figured by two or three cans, they would know whether the product would be useful. She argued with the policy that only full cases could be shipped. Finally she got a few cans, but anyone with less persistence is stuck with the full case of 24 cans. Her husband died soon afterwards, having consumed none of the product. This is a small example of waste, but multiply it by thousands of products and millions of people across the US. It adds up quickly.
The New Yorker magazine had an insightful article addressing the inquiry of what Medicine, that is, doctors, should do when nothing can be done. The article stated that typical medical treatment costs can be graphed, with an initial peak—as expected from diagnostics, tapering with treatment, but peaking again at the end. It is almost standard procedure to pursue intense and heart-wrenching treatment regardless of a terminally-ill patient’s desires. Doctors are not trained to admit when they are powerless, when treatment should stop, in the sake of the patient. In my town, a local hospital admitted its “need” of expensive procedures to stay afloat financially. Where to direct mercy? To the patient or to the hospital’s bottom line? The patient goes bankrupt on his way to the grave.
If you can afford it, you need a supplemental insurance and Plan B. Otherwise, one day in a hospital takes all your savings. One can’t imagine how much a hospital charges for an aspirin. My doctors tell me an item that cost $100 in 1965 cost $200 just two years later; I’d hate to think what it cost today. The insurance premiums set you back similar to the cost of a nice family outing. That’s nothing compared to the 20% co-pay for a chemotherapy drug, which buys a large house in a good location.
President Obama and Congress must address the issue of Medicare funding. No politician changes anything for those over 55 years old, or else he loses votes. That’s a given. No denying re-election takes precedence over any other issue. Medicare saved me and surely many others, from living month-to-month. In more than one way, Medicare is “Life or Death.”Thanks for indulging my views on this serious topic. I enjoy keeping the tone of my blogs less somber than this entry, and gladly return to lighter issues next month.
### © Beano Cook 2011 ###
