Running Again

I started running today, after a relatively long hiatus. I didn't give up on exercise, instead deciding last year to focus on weightlifting. But I missed running, the steady, concentrated effort exerted over time, as opposed to the intense, short-burst effort of weight training. So I stepped out on the track tonight, for the first time in a long time.

Made it 1 and 1/2 miles, which is quite poor by my standards. I really thought the weight training would maintain my aerobic capacity at least a little, but I was very wrong. Not that I was ever a great runner, but there were times in my life when I regularly ran 4 to 5 miles, and long periods when I covered at least 3 miles a day.

For me, starting to run is like quitting cigarettes. I've done it a thousand times. Each time I go for several months, build up my endurance, then move on to something else. When I return to the track, I am back to the beginning, rewriting the oft-written running plan, this week 1.5 miles, next 1.75, 2.5 by the end of the summer, and on and on. When I limped off the track, I was reconstructing dreams of running a 10 k, maybe by the fall.

So here I am, at the beginning, again, wondering if I am too old for beginnings, but I don't have time to think about that. Gotta start figuring out a schedule. 

Why American Health Care Stinks

Recently I saw a patient in my office for a workplace accident. I had seen him 3 weeks prior to that, and at that last visit I ordered an MRI scan.  The scan had to be pre-approved by insurance, but it was, and we scheduled the scan. On this most recent visit, I reviewed his chart, only to find that we had never received the MRI report. We contacted the facility that did the MRI and asked to have the report sent by fax, but by the time the exam was over there was still no report. I had to send the patient home with medication and a promise that we would call him when the MRI report came in and I had made a decision about what to do next.

An MRI costs about $1500. Now, I consider this price scandalous, considering that in most developed countries MRIs cost a fraction of that, but no matter. The main point is that a hospital charged an insurance company $1500 for a test and never bothered to send the results to the doctor who ordered it. For $1500 the test report should be printed in gold leaf and hand-delivered to my desk by a Persian eunich.

This kind of thing happens all the time. I doubt 50% of the tests I order with a dollar value above $500 appear on the patient's chart in 2 weeks. 

I don't have a degree in business, but I have worked long enough to see that every business has a Top Priority, something that they value more than anything else. Top Priority may be making good hamburgers, or picking up the garbage on time, or having every order fulfilled by close of business. In the case of medicine, Top Priority too often is getting paid. In this case, we had to make phone calls in advance to get this MRI pre-approved. No money, no test. The MRI center made certain the check was in the mail before the patient was in the machine, but as for delivering the report to the right person on time, well, they'll get to that later.

Lest anyone think I am scapegoating the MRI people entirely for this situation, I will say that I have been on the other end of it. I have provided services to a patient, expecting to be reimbursed, only to be later denied. It's not a good feeling, and it is the kind of thing you don't forget the next time you are in the same situation. No one likes being cheated.

So many medical organizations put "Pay Me First" at the top of their priority lists. The problem is that when you make something #1, it tends to take the shine off whatever is at #2. I see it often: Medical organizations that worry so much about getting paid  that quality of care starts to slip. It's not greed -- well, not greed entirely -- that drives this. Most medical practices consider themselves lucky if 70% of the services they bill for are eventually paid. When 30% of your bills go into the uncollectible file for one reason or another, you tend to focus on getting your money whenever you can.

That being said, I alight again on "there's no exuse." The object of medical treatment is good health, not getting paid, and it is distressing that many organizations in medicine don't see it that way. If there is any urgent reason for health reform in this country it is this: Everybody worries about money all the time, and it puts us all in bad humor, and bad habits, and bad medicine. 

Right Story, Wrong Angle

Recently, WWL-TV, the CBS afffilate in New Orleans, ran a story about Carol Raines, a New Orleans resident who has been unable to obtain a surgery that would allow her to eat. According to the story, Ms. Raines and her husband were robbed at gunpoint in 1980. One of the robbers murdered her husband, and the other attempted to murder Raines with a gunshot to the jaw. She survived, but has suffered from medical problems ever since.

The man who shot her, Dwight Powell, is now in state prison. (His accomplice is still free, because Powell refused to give police his  name.)

Raines has, since the shooting, suffered from degenerative disease of the temporal mandibular joint, or TMJ, and over time the joint has deteriorated to the point where Raines can no longer open her mouth. Today she weighs 89 pounds and gets all her nourishment by drinking liquids through a straw. She needs joint replacements of both TMJs, but the artificial joints will cost $14,000, and her insurance will not pay for them.

The angle WWL chose for the story is that Powell, as an inmate of the prison system, would be eligible for the TMJ implants if he needed them, but Raines, the woman he tried to murder, cannot afford them. Although this angle adds to the sense of injustice of the story, I think WWL missed the more important point: Raines has health insurance. In fact, she has two plans, not one -- Medicare and United Healthcare -- and between the two neither will pick up the tab.

This is the real problem with health care in America. You may think you have health insurance, but you really only have the coverage your insurance company decides you can have. Few Americans, after all, really choose their health coverage. Most people take what their employers give them, or what Medicaid or Medicare offers. Very few people gets a choice -- in fact, the average auto insurance company allows buyers more coverage options than employers do. Carol Raines does not remember ever signing a document excluding TMJ replacements from coverage. But I promise you United and Medicare had no trouble finding the clause that allows them to do it.

The reason we don't have a decent health care system in this country is because about 70% of all Americans have either private insurance or Medicare, and sit fat and happy thinking they are covered. Certainly their insurance companies lead them to believe this is the case. The reality is that insurance serves most people well as long as the problems remain mundane, problems such as allergies, hypertension, or diabetes. When problems get complicated and expensive, the helping hands folks in the insurance business often do little more than help to hand their customers the bill.

A 2005 study by Harvard University showed that the average American who filed for bankruptcy that year had $12,000 in medical bills. Worse, 68% of these people had health insurance, and 50% of all filers cited health expenses as an important reason for their bankruptcy. The one thing insurance is supposed to do more than any other thing -- protect the client from the financial consequences of catastrophe -- is the one thing health insurance repeatedly fails to do.

 I have patients like Carol Raines, patients who have suffered severe financial setbacks from medical bills despite having all the coverage they could possibly get. You could be the next victim. It could be only a single blood test, or trip to the ER, or as in Raines's case, a terrible misfortune not of your own making, away.

That is the story the WWL news story missed. Until we, as a nation, realize that even those among us with "good" health insurance are terribly exposed, there will not be meaningful health care reform.

The Myanmar Cyclone

The Myanmar cyclone that struck a few days ago looks worse and worse every day. Currently it is estimated that 100,000 may have died, and this is only the beginning. There is no clean running water or functioning sewerage in the disaster area, which means dysentery and cholera will arrive in about a week, killing tens of thousands more. Starvation looms. And who knows how many children were orphaned by the storm, or are separated from family, and at risk of death?

The junta that has controlled Myanmar (formerly Burma) since the 1980s is resistant to allowing foreign aid to come in. The President and the First Lady are urging the junta to allow U.S. assistance, which is fine, as far as it goes. The French are calling for the U.N. to invade Myanmar and forcefully deliver aid, which is much more like it. There are only a few days left before this disaster becomes a secondary disaster of infectious disease and starvation. There is no time to wait for a corrupt government to come around.

Unfortunately, in U.S. politics everything comes back to Iraq. Our army is pinned down over there, meaning the U.S. really doesn't have the personnel to spare for a military-led rescue. Which is what critics of the war have always pointed out: As long as we remain in Iraq, our hands are tied everywhere else in the world. So we get to wait while the U.N. gins up to molassas speed in an attempt to step in.

 It's a very sad day for the people in the West who want to step up and help. But not nearly as sad as it is for the people of Myanmar.