Killer Copays

Most of us seem to enjoy complaining about our so-called health care so-called system, but not a lot of clear paths for improvement have been put forth. I have come to think that above all, we have a failure of imagination. We cannot envision another way of doing things, or at least a way out of the present situation, and so we continue to put up with a reality that is increasingly insupportable. We tinker around the edges, but nothing more. As Dr. Dean Ornish put it, “We spend so much time in medicine mopping up the floor around the sink that’s overflowing without ever turning off the faucet.”

Much of what I’m writing today will focus on a small aspect of the system, copays, and will not offer grand visions for the future, but I would like to drop this idea into your head so you can let it grow in the background: We created the present situation. We can create something else. What we have now is not ordained by God or nature. It hasn’t even existed for a very long time, only a few decades.

After you’ve read this post, please look up the 2012 film Escape Fire, which outlines just how completely screwed we are and what we can do about it. You can find it here:  http://www.escapefiremovie.com/  It’s also available through Netflix.

Escape Fire is based on a book by Donald Berwick, MD, the former head of Medicare and Medicaid. He wrote it early in the 2000s, and you’d think that a decade later we would have figured a few of these matters out, but as far as I know we haven’t made a single one of the changes he recommended. The idea of an “escape fire” is that if one is about to be overtaken by a forest fire, one can burn an area on purpose to provide a path to escape. The film recounts the story of a group of firefighters who were in this type of situation. Their leader dropped a match on the ground and burned a circle around their position, using up the fuels that would have fed the fire. He told the others to stay in the circle with him, but they took off, insisting that they could get out safely. Guess who survived. Dr. Berwick’s point is that we have obvious paths to escape right in front of us, but we refuse to take them, or even to see them.

Dr. Berwick pointed out that people within the health care industry do exactly what makes sense to them where they find themselves. It’s just that the system contains such incredibly perverse incentives that they often do things that have ill effects for the country as a whole.

Recently one of my elderly patients canceled her appointment for the next day. The reason was that she had to see her eye doctor, and the copay for that is $45, meaning that she wouldn’t have the money to pay even the extremely reduced price I would have charged her as a low-income senior who doesn’t have insurance that covers my services. This lady lives in a subsidized retirement apartment complex. Some of the people who live there have income of less than $1000 per month, and few have much more than that. A copay of $45 is huge for them, possibly even requiring saving up over a couple of months. These folks have Medicare and often other coverage, but strangely, it’s still quite possible to face daunting copay amounts.

A few weeks ago, an insurance company representative told me that high copays do not prevent access to care. Clearly, they do. Copays and deductibles* are both going through the roof. I wrote to her company, one of the major insurers in our area, one which pays only 2/3 of usual and customary fees for acupuncture, as follows:

“Copays keep increasing in general. I understand that at least in part this is caused by attempts to limit increases in premiums. What is troubling is that in many cases copays are equal to or greater than the amount insurers actually reimburse for a given service. As copays continue to go up, this situation is likely to keep getting worse.

“Within the ____ system, the most extreme case I’ve seen involves City of Albuquerque employees. They have a $55 copay for acupuncture, but ___ only pays $43.73 for acupuncture. [Your representative] said that she thought in this case the member would only be expected to pay the $43.73, but that is not how it works. EOBs show clearly that the full $55 copay is expected. And providers are not allowed to discount copays and can get into trouble for doing so.

“It is more typical these days to see a $40 copay for ____ members, and has been for a couple of years now. That means that much of the time ____ is paying a princely $3.73 for acupuncture, and the patient is paying nearly the entire charge. When you include the fact that ____ limits members to 20 treatments per year, the total paid for the year can be as little as $74.60, less than the price of a single appointment for most medical services.

“In both of these types of cases, the member and the employer (often through the taxes we all pay) are paying for coverage for acupuncture, but they don’t get anything that can really be called coverage, and in the case of the highest copays, they have a kind of negative coverage. It’s an advantage to me as a provider to have the patient pay a larger copay, but it’s still painful to see them treated so unfairly.

“I imagine that when the HR department or whoever set up these copays were in discussions about how their plans would work, the amounts sounded quite reasonable to them. Perhaps someone said, ‘I don’t know, what does acupuncture usually cost?’ and someone replied, ‘Well, my acupuncturist charges $70.’ It might not have occurred to them that $55 would be higher than the reimbursement amount.

“(After all, usual and customary insurance payments for acupuncture alone are in the range of $62-65, not counting any amounts for E & M codes or other services. ____ is unusual in paying only about 2/3 of that— an amount that has not changed for a number of years even as patients pay more and more. This exacerbates the issues with copays.)

“I don’t know about how other types of providers are affected. I do know that chiropractors have some similar issues.

“Copays are charged for us DOMs at the ‘specialist’ rate, but since we are not reimbursed at anything like the amounts cardiologists, etc. get, the copays are a much larger percentage of the price. I understand that PCP visit copays are kept lower because insurers want members to see their PCPs to try to catch problems early, but often the PCP can’t do anything and simply makes a referral anyway, meaning that the PCP visit is a waste. Visits to DOMs, DCs and PTs are relatively discouraged by the higher copays, even though we are saving insurers money by helping patients avoid more expensive interventions such as surgeries— not to mention helping the patients relieve their suffering and improve their overall health, which ultimately reduces costs as well as being worth doing in itself.

“[Your representative] said that members have far wider benefits than just acupuncture, which obviously is true, and a member who has a major health problem may end up with much more value paid in benefits than they pay in premiums in a given year. However, this does not change the fact that members with high copays for acupuncture are being sold a benefit that they don’t truly receive. It’s rather like going into a store to buy a shirt, and being told that although the shirt normally costs $45 and most people pay that or less, you have to pay $55 for it.”

So costs to consumers and the country at large keep going up and up and up. In what aspects of the system are those costs increasing so persistently? Let me tell you, payments to doctors are not the problem. We’ve been seeing flat or even decreasing rates of reimbursement. Medicare and Medicaid in particular squeeze providers, and as shown in a heartrending segment of Escape Fire, often the only way a clinic can stay in business is to pack in more and more patients. Again, providers are doing what appears to make sense from their perspective in their corner of the system. But not only is this compression of appointments terrible for patients, especially those with more complex needs, it can actually raise costs. Primary care doctors who don’t have enough time to figure out what’s going on with a patient are likely to refer that patient to a specialist, costing dramatically more, whereas with more time to think, the PCP might well have solved the problem and come up with a treatment plan without making a referral.* So reducing payments for primary care to absurdly low levels is classically penny-wise and pound-foolish. “There is no more wasteful entity in medicine than a rushed doctor.”
http://www.nytimes.com/2014/07/21/opinion/busy-doctors-wasteful-spending.html?contentCollection=opinion&action=click&module=NextInCollection&region=Footer&pgtype=article&_r=3

I would like to propose a simple rule that copays may not be more than 50% of the amount reimbursed for a given service. Period. I truly believe that there is more than enough wasted money, far more than enough, to make this happen. I would also like to propose that resources be redirected into primary care and especially accessible clinics for the most vulnerable portions of the population, like the ones being seen by the frustrated PCP in Escape Fire. Continuing to cut already-thin payments to practices like that makes no sense.

These of course would only be stopgap measures. Next time, I’ll take up some thoughts about self-care and our responsibilities toward our own health. Meanwhile, I offer you one more pithy post to chew on: 
http://rolwingjames.wordpress.com/2014/04/13/the-intervention-fallacy-part-i-how-it-starts/

*https://elenedom.wordpress.com/2014/02/04/health-care-access-and-why-pcps/

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Health Care Access, and Why PCPs?

A friend posted this picture of a rainbow that appeared two days ago in our area, a most welcome sight since we had had no moisture at all for over 40 days.  The rainbow showed up just after her neighbor died after a long illness, giving its benediction to the family.  Last night we had a fair amount of rain and snow, and it feels like we will not dry up and blow away just yet.

I am trying to keep up some hope for our health care system as the conflicts over so-called “Obamacare” continue and costs keep spiraling upward.  There does seem to be some lucid thinking going on in at least scattered spots among those in the medical field and those making policy, and I want to encourage that.  There’s also a lot of the same old thinking that got us where we are today.  Here is my current take on some aspects of the situation, which I sent to the Albuquerque Journal today:

The Journal has published some useful articles lately on problems with access to health care, and I’d like to add my perspective as a provider out in the field.  There are three main issues with access to care for New Mexicans: distance, cost, and scarcity of providers.

I don’t have to tell you that for many of our residents, most everything is far away.  Even in our smaller cities, there are not a lot of services.  In Grants, where I see patients once a week, medical specialists come in from Albuquerque or elsewhere, as I do.  People who need VA services must go to Albuquerque, no matter how elderly or disabled they are.  It’s bad enough in a small city like Grants, but people who live in more rural areas, as some of my patients do, may be completely out of luck if they lack transportation.

Getting more New Mexicans insured is necessary and commendable.  However, this does not remotely solve all the problems with the direct cost of medical care to consumers.  As those who are shopping on the state exchange have no doubt noticed, many plans have deductibles in the thousands of dollars.  Also, with some plans patients pay as much as 90% of the cost of the service themselves, even after their deductible is met, because their copays are so high; they are paying for coverage that they don’t get. The ACA was intended to bring deductibles and copays into the realm of reason, if I understand correctly, but as it is, cost limits access even for those who are insured.

For those on Medicaid, at least, copays are low or nonexistent.  However, very basic and critically necessary care may not be covered.  For example, one of my elderly patients needs drops for an unusual and painful eye condition caused by her recent case of shingles.  The cost is low compared to most of her care, but Medicaid is not covering this medication, and on her extremely limited Social Security income, this lady can’t afford enough of it to last through the month.  For all the millions we spend as a state, we still can’t get people simple things that they need badly.  And while the myriad costs add up to so many millions, Medicaid and Medicare payments to providers are so unsustainably low as to keep providers out of the programs, exacerbating the access problems all the more.

Our state’s lack of health care providers has multiple causes, but it also has the potential for multiple solutions.  Making better use of mid-level practitioners, as many have suggested, is certainly necessary, and any efforts which will attract more health care workers are worth trying.  However, there are other available health care forces which are only partly being tapped.  One of your editorials did refer to “traditional community health workers,” by which I assume you mean people like curanderas/os and Native healers.  Encouraging greater use of their abilities would be a definite help– but how is that going to be funded?  For the most part our insurance system has ignored the existence of these valuable resources, as it has ignored herbalists, homeopaths, and those who do energy healing such as Reiki.  Most federal dollars will also bypass all those practitioners and the people who rely on them.

New Mexico has a formidable and growing health workforce in the members of my profession, Doctors of Oriental Medicine.  We too are being used far less efficiently than we could be, even though most commercial insurance in the state does cover our services.  Decision makers don’t seem to realize how much primary care we do– and we have not yet managed to get the word out to them sufficiently.  We are lumped in with “rehabilitative medicine” by insurers, but that is only one aspect of our medicine.  Patients walk in to acupuncturists’ offices with everything from flu to IBS to sciatica, and we treat them effectively.  We are well placed to help take the strain off of primary care MDs, and we are ready and willing to serve.  However, provider groups organizing “patient-centered medical homes” have generally not included us in their planning.

Medicare does not cover acupuncture, and under most circumstances Medicaid also does not, largely because the federal dollars are not available to make that happen.  Attempts to fix this in the state and federal legislatures have failed thus far.  So immediately a huge proportion of our population is left out of a major form of effective and cost-effective medicine.  And while our NM-based insurers do offer coverage, as I mentioned before, in many cases reimbursement is slim and patients are left to pay as much as 90% of the charges, so that this “coverage” is not very meaningful.  (Fortunately, there are also many plans with much better coverage, I must add.)  Yet, many patients do use us as their front-line care providers, and that could be expanded.

There are still other possible providers as well.  In some situations a chiropractor may be the best choice to see first, and access can be a bit easier than that for DOMs, with so many chiropractors available and a good number of them accepting Medicare.  For at least some conditions these practitioners could also help to ease the burden on primary care MDs.  Physical therapy is usually given limited coverage, and patients tend to be referred to PT only after they have failed to get better for a long period of time.  That is inefficient and leads to unnecessary suffering.  We could use PTs more as the first choice, go-to practitioners for injuries, back pain, and the like.

There is one access problem that would be very easy to solve, IF those who are in charge were willing.  That is the system of HMO and PPO networks.  It was unconscionable when Lovelace ended its relationship with ABQ Health Partners and tore hundreds of thousands of New Mexicans (including my family) away from the doctors they knew and trusted.  Now Presbyterian has stopped coverage to the UNM providers, again leaving patients in the lurch.  We could stop this kind of abuse, I expect, legislatively or perhaps through actions of the state insurance department.  I am not holding my breath, but as the provider crunch gets more and more serious, I hope access will be broadened across insurance networks.  There is no good reason for things to be this way; we all pay and we all deserve to have the best providers for our needs.  HMOs were supposed to reduce costs and improve health outcomes.  Neither has happened.  Time for a different approach.

And we do have a different approach waiting in the wings: the home-grown, NM-specific Health Security Act is still here and has been gathering more and more support over the years, though so far it hasn’t made it past all the Powers That Be.  In the next few years we will have the opportunity to improve upon the current health insurance exchange and enact this more efficient plan.  We can choose to do it– it’s just a matter of willingness.

 

OK, that’s what I sent off to the newspaper a moment ago.  Continuing:

Let’s say that a patient has jumped through all the hoops of distance and cost and gotten the coveted access to care, and is now sitting in the doctor’s office.  Now the main barrier is time.  The patient may have waited months for this appointment, but she is going to be very lucky to get more than 10 minutes of the doctor’s time.  And maybe even that pittance may soon be a luxury.  An editorial written by two local executives with Presbyterian Health care and published a few days ago stated that because of the pressures on PCPs, we have to find some alternative to the standard 15-minute appointment with the physician, such as group appointments for people with common conditions like diabetes.  Wait just a MRSA-contaminated minute here!  We pay more and more and more for our supposed health care every year, we are totally breaking the bank, we are stressing the whole country out trying to fix all this, and we can’t even get a measly 15 minutes with the Minor Deity?  Seriously?  (Meanwhile, the Deity is struggling to stay afloat in a world of shrinking reimbursements and greater pressures on his or her business.)

I must say that on the fairly rare occasions when I’ve gone to an MD, as for my yearly OB-GYN checkup, I’ve had more like a 25-minute appointment.  I hear that this is not usual, but it has been the norm for me thus far, perhaps precisely because I’m not there all the time– I’m having more than just brief followup appointments.  So I have a little bit of hope, but again, as the provider crunch gets worse, that hope is likely to evaporate.

(Appointments with me as the doctor, in contrast, are still normally scheduled for an hour or more.  My patients who have gone to community acupuncture or to other colleagues who see multiple patients in an hour tell me that they appreciate the difference.  I find trying to treat more than one person at a time very stressful, in addition to feeling that I can’t be as effective, and I have no intention of doing that on a regular basis, but the squeeze on insurance reimbursement may force me to change my ways eventually.  I hope not.)

Now let’s think about what actually happens during that 10, 15, or possibly 25 minutes.  What are primary care physicians for, and do they fulfill that purpose?  One of the main things they do is to prescribe and authorize refills of medications.  In the case of chronic illnesses, they should be able to help the patient maintain well and deal with any changes in their condition that come up.  Well, last week one of my patients, who has been taking Synthroid for decades since she had thyroid surgery, went to see her new PCP, who had been forced upon her by the issue I mentioned above, Presbyterian ending its relationship with the UNM system.  Her last PCP had reduced her dosage, and she had done extremely poorly until she figured out the problem– herself– and started taking the higher dose again.  She explained all this to the new guy, but he flat-out refused to consider prescribing the dose she needs.  Total failure both at paying attention to the patient and at delivering the treatment.  Especially at paying attention!  I wish I could say this was unusual, but it’s what I hear from patients over and over and over, and it seems most common with regard to thyroid issues.*  In this case, there was an out– I sent the patient to a colleague of mine who specializes in endocrinology and can prescribe natural thyroid extract.  Not everyone has such an alternative, and many patients go without effective treatment.

The other main thing a PCP is “for” is to be on the lookout for problems and do something about them before they get worse.  Often they really shine in that role.  A few weeks ago we got my mother’s PCP appointment moved up because she was getting markedly weaker and often short of breath.  The PCP (Ann Jones, MD, about whom I have few complaints) didn’t like the way my mom looked either, and sent her for extensive testing at the ER space across the parking lot.  They didn’t find much, but my mom came home– after an exhausting 9 hours– with a clear diagnosis and a prescription that has been noticeably helpful.  That’s more or less how things should work.**

On the other hand, a patient who has recently entered the Medicare age group went for her first ACA-mandated Medicare yearly wellness checkup around the same time.  This lady has had a chronic cough and severe fatigue for months, following a period of extreme stress, and although she’s improving, no clear cause has been found and the problem has been hard to treat.  The idea of these yearly exams for Medicare is supposed to be to give the patient a thorough going-over so that any problems will be found and dealt with appropriately, keeping them from getting worse and causing more cost and suffering.  My patient reported that the appointment lasted less than 10 minutes, she barely had the opportunity to ask any questions, her main complaint was not really addressed, and no treatment was suggested.  And this is a very assertive and articulate patient.  So it didn’t seem like the purpose of the exercise was fulfilled at all.

The PCP is often the most accessible and cost-effective person for performing minor, in-office surgeries.  And of course the PCP can order tests, which will either show that there’s no problem or perhaps guide the path to more specialized care.  When I had that health scare back in August, I ended up with Bob’s PCP, Oswaldo Pereira, MD, who had no more idea what was going on than I did, but could send me for further testing.  We ruled out a number of possibilities, and that was helpful and quite necessary; I needed to know that I didn’t have a cardiac issue, for example.  However, Dr. Pereira never came up with either a diagnosis or a treatment.  Since we couldn’t find anything dire, and since I was gradually getting better, we both dropped the matter.

I had the most significant improvement with a structural approach, under the care of my friend Christine Dombroski, PT.  Dr. Pereira, thoughtful and knowledgeable as he is, would never have thought to send me there, and didn’t really understand why this helped.  It’s just not part of the way MDs are usually trained.

I love the PCPs of the world and feel sympathetic toward them, but the more I consider all this, the more I think our typical use of them is a bit misguided.  I’d like to end with some fairly obvious statements about when to head for your PCP’s office, and how to use that system appropriately.  First, please do not see the PCP when you have a cold!  You will accomplish nothing except to waste time and money, tire yourself out when you need to rest, and spread viruses around the office.  Even a run-of-the mill case of flu is not a good reason to go to the PCP, unless you have an underlying condition that makes it more dangerous; all they can do is give you Tamiflu, which works poorly if at all, and tell you to rest and drink fluids, which you already know.  (Do feel free to see me or my colleagues, as we can actually treat you!)

Do head for urgent care or the ER if you have severe unexplained pain, trouble breathing, or other scary symptoms that are not resolving in a reasonable way at home.  And of course if you are having any signs of a possible heart attack or stroke (I should write another post on those), you should call 911 as soon as you can reach the phone.

 

*It doesn’t have to be that way.  Both my last PCP and my OB-GYN tend to dose thyroid replacement on the basis of symptoms rather than strictly by blood test results.  They are not unique, fortunately, just not the rule. 

**Update, later in the day:  This morning my mother saw Dr. Jones again, and she is leaving most medication issues up to the specialists.  So I ask again, what is the PCP for?  It’s not easy for 89-year-olds to get to appointment after appointment, nor for their families to get them there.

 

As I was writing this, I came across a great Medscape article by a doctor who has a vision of what a true health care system could be like.  You may have to sign up with Medscape to read it, but if you have any interest in medical matters, it’s well worth it.
http://www.medscape.com/viewarticle/819947?nlid=46863_1521&src=wnl_edit_medp_wir&uac=167278MR&spon=17

Here the author imagines an idealized school health teacher:
‘”She sat down with all of the physical-education, biology, and health-education teachers in her system, and together they outlined a plan to change the curriculum such that health education starts in kindergarten. In their system, by the time children reach the 12th grade, they know which side hurts when their appendix is about to rupture. They know the warning signs of a heart attack. They know when to start screening for colon cancer, and they know when it’s appropriate to access the doctor’s office, the urgent-care clinic, or the ER. They understand the basic dangers and positives of over-the-counter medications. In other words, by the time someone puts a high school diploma in their hands, they are as well equipped to take care of their bodies as they are to find their favorite iPhone app.

“They understand the difference between a carbohydrate and a fat and which foods fuel their systems to fight cancer, heart attack, and stroke. They are not going to be obese because they know to exercise at least 150 minutes per week. Mrs J’s students are going to cost us less and live longer. They will live better with more money in their pockets, because they won’t have to buy a laundry list of prescription medications every year until they die prematurely from a preventable illness.’

And here’s her imaginary doctor who figured out a fix for electronic health records:  ‘Then, there’s Dr P [for practical]. Although we acknowledge the necessity of electronic health records [EHR], our earliest efforts have failed the patient. A doctor’s daily work has ground down to a snail’s pace. Patients complain about the basic lack of eye contact during an office visit because the doctor is focused on a screen. Dr P revolted against that practice. He designed a system where there are shorter updates at each visit and there is a symptom-limited entry into each subsequent visit. You don’t have to go through 900 reviews of systems that have nothing to do with why this particular patient has come to see you. He does only a positive review of systems. He took the time away from his EHR and gave it back to his patients, and his patients are more satisfied and better taken care of because of it.’

All this could happen.  There’s no reason why it couldn’t.

It’s Mainly Medical, Not Moral

I’m told that this was a real sign, no longer in use, at a hospital in Buckinghamshire, England. I couldn’t resist adding it here– it’s so painfully appropriate to our current situation in the US.

You’re probably sick of hearing about the war over insurance coverage for contraception under the Affordable Care Act, but I think I have a few useful points to make that haven’t been brought up elsewhere.

For those of you who live elsewhere, let me catch you up on this only-in-America craziness.  The Affordable Care Act, otherwise known as the health care reform law, mandates that contraception must be covered by insurers without co-pays (direct costs at the time of service) to the patient, and that employee health plans must provide this coverage.  While there is an exception for employees of churches and other places of worship, hospitals, universities, and other institutions owned by religious sects are included in this mandate.  A number of right-wing forces have complained that this tramples upon religious freedom.  After being thoroughly raked over the coals, the President and his advisors worked out a compromise: the religious groups would not have to pay for the coverage, and it would be provided directly by the insurance companies, so that those who object could keep their sense of purity.  Insurers have agreed to this because providing contraception saves them money (and is expected to save money for the entire health-care system as well as for individual families).  The war is still raging as I write this, with the self-styled guardians of freedom insisting that the government is still overstepping its bounds.

On the front lines of this trumped-up battle, we find none other than the Conference of Catholic Bishops, the same fine folks who protected us from the evil, dangerous practice of Reiki by banning it in all Catholic hospitals and other institutions.  (See my post “Attack of the Bishops.”)  Need I state the obvious?  These ideas are being promulgated largely by partnerless elderly men.  These are not people who have any need to prevent pregnancy or any understanding of what that issue is like for those who do, including the 98% of Catholic women who use birth control at some point in their lives.  This outrage is compounded by the fact that Viagra is covered and the bishops have no problem with that.

A letter I wrote about this recently was published in the Albuquerque Journal on Sunday 2/12/12, before the President backpedaled, and before Rep. Darrell Issa convened a panel of ALL MALE religious leaders, Catholic and otherwise, to testify before Congress.  Issa and his Religious Right cohorts have managed to make it crystal clear that their agenda has little or nothing to do with religious freedom, and is really about a) attacking the president and killing the Affordable Care Act any way they can, and b) controlling women.  They’ve abundantly shown that they want to get rid of not only abortion but all forms of contraception.  And while wailing about the government infringing upon their freedom, they’ve shown that they have no problem with curtailing the freedom of others– especially if those others happen to have pairs of X chromosomes.

Here’s my letter:

“In all the indignation-filled rants I’ve heard about the Obama administration requiring religious institutions to include contraception in employees’ health insurance coverage, there has been one glaring omission:  No one has mentioned the fact that quite often, hormonal contraceptives (the Pill, patches, or implants) are used for medical reasons that have nothing to do with birth control.    Many women take the Pill, etc. for conditions like polycystic ovary syndrome or severely painful periods.  Many of those women are not even sexually active, or not sexually active with men.  I’ve seen this quite a bit with my own patients.  Whatever one thinks about contraception, it’s hard to imagine even the staunchest Catholic objecting to legitimate medical treatment for such conditions.

“I’d just as soon see women use natural alternatives, but in many cases hormonal birth control really changes their lives for the better.  The costs of these medications can be quite substantial, however, and that can put them out of reach for students and low-paid workers.  The costs of the conditions they treat can be substantial, too, as when a woman must miss work because of debilitating pain.  We would not ask an employee to forgo painkillers for arthritis or inhalers for asthma.  How is this different?

“The President may have lost some votes with this decision, but there are quite a few of us who are relieved to see him standing up for women and for what makes medical sense.  Try as I might, I can’t see this as primarily an issue of religious freedom or of morality.  Women who object to contraceptives are still free not to use them.  Morality means doing the best we can for everyone in our society, and that includes medical care, which includes birth control.”

I didn’t want to get all confessional in the newspaper, and I wanted to focus on a single point for impact, without bringing in other aspects of the situation, but I have a personal story that I think sheds particular light on the complexity of this issue and the reasons a total ban by religious “authorities” is not only ludicrous but cruel.

When I was about 25, I developed severe cervical dysplasia, well on the way toward cancer.  This was treated with cryosurgery to remove the diseased cells, which was a standard treatment back then; no one realized at the time that cryosurgery would only mask the problem, which would resurface later on.  My primary care doctor told me I should have a hysterectomy, which showed a remarkable ignorance on his part, it seemed to me, as the precancerous cells were not invasive and might never be.  I had not yet had a child, and was determined to be able to do so.  After I healed from the cryosurgery, I did get pregnant, and my daughter was born when I was 27.  Over the next couple of years I became allergic to or unable to tolerate most forms of birth control, and so, with my husband and my very small daughter in agreement (Lenore’s opinion was “We have enough babies around”), I had a tubal ligation.  Which was covered by insurance, by the way, because my husband is one of those awful, greedy public employees, a teacher that is, and he gets all those totally undeserved benefits.

That was not the end of the medical story.  I had a number of years of clear Pap smears, then skipped a year, because it didn’t seem critical to have one at that point.  The next Pap showed carcinoma in situ.  The tissue underneath the layer affected by the cryosurgery had been stealthily developing toward cancer the whole time, and it had simply taken that long to show up on the surface.  By that time, most of my cervix consisted of abnormal cells, and I was noticeably ill.  To deal with this, my OB-GYN did a cone biopsy to remove all that– they use the word “biopsy,” since it does have a diagnostic aspect, but it’s a far larger matter than the word suggests.

The hospital personnel wanted to do a pregnancy test.  I explained that I’d had my tubes tied.  They impressed on me repeatedly that after this procedure my cervix could not support a pregnancy, and that I needed to be OK with that.  I reassured them again, and the surgery was done.  The pathologist found that there were still diseased cells around the edges of the cone, so a few months later I went through the whole thing again, nearly bleeding to death afterward, and ending up with even less of a cervix.  I emerged from the process weakened but cancer-free.

I often thought about what would happen if a woman in this condition did get pregnant.  Surely it has happened many times.  An embryo would start to grow, everything going fine, and at some point it would lose its moorings in its mother’s womb and essentially fall to its death.  I wondered how far developed the poor creature would be when that happened.  It seems horribly sad, doesn’t it?  The child would be doomed from the start.  The mother would suffer both mentally and physically for nothing.  And all of that could be prevented with the use of reliable contraception, or with my chosen option, sterilization.  If it could not be prevented for some reason, it seems very clear to me that abortion would be a far kinder choice than allowing the baby to keep growing until its inevitable demise, possibly till it could begin to feel something, and certainly exposing the mother to greater risks and discomforts.

I have always wondered how very observant Catholics would find their way through this dilemma, since there would be no way to avoid pain and tragedy, only to minimize it.*  The Church’s official stance, I suppose, would be simply “Don’t have sex.”  Ever again, or at least not until menopause, so that such a tragic pregnancy could never get started.

And of course there are also medical situations where pregnancy would be life-threatening or seriously health-threatening for the mother.  These women need their contraception to be as effective as possible, and depriving them of it verges on criminality, I would say.  Birth control advocates tend to mean hormonal drugs when they speak of “effective” contraception, and that has been the focus of much of the fighting.  I certainly think women should have access to these medications, but I don’t want to come across as a wholehearted fan of the Pill and its cousins.  The Pill, patch, and implant can be problematic for many women, and they can have dangerous side effects, especially as women age.

A friend of mine who cannot use these drugs was put in a ludicrous position by our local Presbyterian Health Plan, on purely ideological rather than medical grounds.  Having been unable to tolerate the type of IUD that releases hormones into the body, she and her doctor decided that she should try the old-fashioned, non-hormonal IUD.  Presbyterian refused to cover that, saying that it’s an abortifacient rather than a contraceptive, and therefore not morally acceptable.**  They were happy to cover the hormonal IUD, which they insisted my friend should use despite the fact that it was already proven to be unsuitable and harmful for her.  The patient’s medical needs meant absolutely nothing.  Let me repeat that, because this is how our system works, and we need to be clear about it:  The patient’s medical needs meant absolutely nothing.  Her own beliefs and moral convictions also meant absolutely nothing.  Fortunately, although she was a college student doing low-paid restaurant work, this young woman was able to get the money together to pay for the IUD herself.

And that is what we face when religion, and only some people’s religion at that, is allowed to determine our medical care.  If the bills currently being proposed by certain members of Congress were to become law, any employer could refuse to cover any type of treatment for any reason.  I don’t think that will come to pass, but stranger things have happened, and we need to stay on top of this situation.  I can only hope that American women will continue to get more and more engaged and will work to hold the ground we’ve gained– and that men have gained along with us– over the past few decades.

I promise to get back to more spiritual matters in my next post.

*Despite 12 years of Catholic school and being good friends with a nun, I still can’t answer this.  Odd situations like this never came up in the typical anti-abortion rhetoric.  And by the way, I don’t remember Catholics railing against birth control back in the ’70s the way it’s happening now.  Maybe I just didn’t notice.

**The common scientific view is that pregnancy begins with implantation, not with conception.  The IUD prevents implantation.

For some other current perspectives:

http://msmagazine.com/blog/blog/2012/02/13/hervotes-americas-supposed-war-on-religion-and-the-actual-war-on-birth-control/

http://msmagazine.com/blog/blog/2012/02/14/conservative-war-on-contraception-is-nothing-new/

 

 

What If Police Service Were Privatized?

Hey, don’t laugh.  Firefighting used to be provided by private companies.  If you had a fire and you hadn’t paid up, it was too bad for you.  If certain forces in Congress and elsewhere had their way, everything in the world might be privatized.

But health care is already being controlled by private, for-profit corporations.  Here, James Fieseher, MD gives us a look at what things would be like if police protection were administered the same way.  He asks, “What if police services were privatized and to receive them we had to be covered through a private police services insurance policy?”

Thanks to Mary Feldblum of the Health Security for New Mexicans Campaign for passing on this almost too-true-to-be-funny script:

“9-1-1”

“Yes, I need help. Someone’s downstairs breaking into my house trying to rob me. Please send somebody right away.”

“Can I have your insurance number, sir?”

“My WHAT?”

“Your police insurance number. If you want us to send a policeman over, we’ll have to have your insurance number.”

“But there’s someone in my house now.”

“I’m sorry sir, but without your insurance number I am unable to authorize a patrolman.”

“Okay, let me see if I can find it. I have the lights out and the robber doesn’t know we’re up here.”

“I can wait a short time sir, but I do have other calls.”

“I think I found it. The number is YGG73552W.”

“I’m sorry, sir, but that was last year’s number. You would have been issued a new card for this year. You should have a new card with the last letter Q.”

“Oh here it is. The number is YGG73511Q.”

“Very good, sir. Let me check your number through our system. Please hold just a moment.”

“Please hurry. I think I hear him moving up the stairs.”

“I see from our records sir that your policy doesn’t cover robberies.”

“WHAT?”

“Your policy doesn’t cover robberies, sir. I’m sorry. I won’t be able to send anyone out right now.”

“Look, I’m being robbed. This is the only police policy my employer signed up for. I didn’t even have an option for robbery coverage.”

“I’m sorry sir. You know, you could have purchased an individual coverage policy outside of your employer’s insurance.”

“I can’t afford that. That policy costs over $600 a month!”

“I’m sorry sir. Is there anything else I can help you with this evening?”

“You mean that’s it? That’s all you can do for me?”

“Yes sir.”

“Look, lady. This guy has just broken into my home, he’s now up the stairs and I think he’s about to attack my wife.”

“Oh, that’s good, sir. Your policy covers assault.”

“It does?”

“Of course, sir. That’s part of our personnel protection policy. I also see that you also paid for family coverage, which means that not only are you covered for assault, but your wife and children are covered as well.”

“Thank God! Now, please, send someone over right away!”

“Yes, sir. Would you like us to send a criminal law student, a rookie policeman or a veteran police officer?”

“What kind of ridiculous question is that? Of course I want a veteran police officer. My wife is being attacked!”

“It’s just a matter of co-pay, sir. The generic criminal law student is a $10 co-pay. The rookie will cost you $25 and the veteran police officer is $75.”

“Why so much?”

“That’s what you pay when you want a brand name — our finest.”

“Forget it. I’ve got a handgun somewhere around here. I’m just going to shoot the bastard myself.”

“I wouldn’t do that if I were you, sir.”

“Why not, he’s assaulting my wife!”

“Yes, but shooting him would be an unauthorized, out-of-network referral not to mention our non-compete agreement you signed. We would have to arrest you for that.”

Preventive Care, Personal Responsibility, and $$

Originally posted August 18, 2009

Last week the president made some comments about the fact that the American health care system pays for treatments that may be unnecessary, such as certain surgeries, while it fails to pay doctors to educate patients and perhaps avoid these procedures.  Many MDs were upset by these words, which may not have been chosen in the most politic matter.  Their feelings were hurt, and they protested hotly.  However, this point needed to be made, and as a society we need to discuss it.

Mr. Obama mentioned tonsillectomies as a potentially unnecessary surgery, and your article appropriately pointed out that in some areas of the country far more of the kids have them than in other areas.  It’s obvious that medical necessity is not the only factor controlling this.  A doctor’s medical judgment might be influenced heavily not only by economic factors but by what habits and traditions are common in that time and place.  When I went to acupuncture school, I was the only student who still had tonsils, out of a group of 20 adults ranging from their 20s to their 50s.  Tonsillectomies used to be more common, as far as I know, and that was because doctors and parents believed that they were a good idea, not because they were always necessary.  Similarly, when I took cadaver lab, the instructor was overjoyed to find that our cadaver had a uterus.  He almost never saw one that did.  Hysterectomies were done far, far too often, sometimes by doctors who were known to be “knife-happy,” as my mother’s generation put it.

Thankfully, both doctors and patients seem to be a bit more cautious with these surgeries nowadays.  However, it is absolutely true that doctors generally get paid for doing something, not for helping a patient avoid procedures or medications.  We are famously told that in ancient China, doctors were expected to keep people well; the lowest form of physician was the one who treated illnesses, and the highest was the kind who taught people to live in a way that kept them healthy.  If too many people got sick, the local doctor might be in big trouble!  That is the tradition in which I was trained, yet I too am paid for the treatments I provide, not for teaching a patient skills which may allow them to stop needing treatment.

We give a great deal of lip service to preventive medicine, yet we hardly practice it at all.  HMO, you may remember, means “health maintenance organization,” and the HMOs were originally supposed to save us money by emphasizing preventive care.  Well, we know how that turned out.  HMOs do pay for a certain amount of screening, but they also typically disallow care that is considered “maintenance.”  That is, if you have acute back pain, you are covered, but if you’ve gotten better and you want to see your chiropractor or acupuncturist or physical therapist to keep you from becoming disabled again, your insurer isn’t going to be interested in paying.  Programs that have shown success in improving the health of diabetics by providing people they can talk with about diet and other issues of daily management of their condition have often had their funding cut.

Charles Krauthammer, in a column printed last Saturday, argued that preventive medicine is not the “magic bullet” to reduce health care costs.  “The idea that prevention is somehow intrinsically different from treatment– that treatment increases costs and prevention lowers them– is simply nonsense.”  Yes, this is true if you accept Dr. Krauthammer’s definition of prevention.  “Preventing a heart attack with statins or breast cancer with mammograms is costly,” he writes.  Excuse me? Statins, which do not address most of the mechanisms behind heart attacks at all, and which deplete the body’s stores of CoQ10, thereby contributing to heart failure (not to mention the other side effects), are indeed expensive, but they aren’t nearly as useful as their manufacturers would like us to think.  And no one expects mammograms to prevent breast cancer.  Mammograms can only detect cancers that have already occurred.  This is still a good thing, but it is not prevention.  Prevention is more complicated, and requires more responsibility, than just showing up for a test.

Most real preventive care comes from the patient, from us as individuals, and costs little or nothing.  Improving our diets, for example, is perhaps the single most important thing we could do to improve the health of the entire country, and it would reduce the costs associated with obesity, diabetes, cancer, and heart disease.  For example, if Americans were simply to stop guzzling the incredible amounts of high-fructose-corn-syrup-filled sodas that we consume, we’d make big inroads on diabetes and osteoporosis even without making any other changes.  Most of our chronic and degenerative diseases are caused by our own behavior, and only we as individuals can control that.

There is so much more that could be said here about the ways in which we make ourselves sick by pouring toxins into our bodies and our environment.  Then there is all the illness caused by well-meaning but wrong-headed medical treatment, including the thousands of people who die because of prescription drugs each year, and the harm done by incompetence and poor procedures, like hospital-caused infections.  Much of the care we pay through the nose for is to fix problems caused by the carelessness and stupidity of human beings as a group.  Humans are probably not going to get a lot smarter or more sensible anytime soon, but we can certainly tighten up things like infection control.

What’s being proposed to reform health insurance is hard enough, but real reform of the health care system will require changing our habits and our attitudes– a feat which people usually try their best to avoid.  It’s not easy to feel optimistic about that.  Yet, we must.