Happy Thanksgiving

From McComb, Missisippi, where the camellia tree in our yard is once again in bloom, we wish you a happy Thanksgiving holiday.

The Blistering: Chapter XV

To read this serial novel from the beginning, go here. 

 

The Principal's Office

A few minutes later the van started rolling, and one of the goons in black fatigues got up from the front seat and blindfolded them both.

"Pretty amateurish," Cardinal said, smartly. "You should have blindfolded us before we left the interrogation room."

The goon whacked him in the side of the head, also smartly. "You shut up," he said.

"Hey! Your boss wants my brains for something. If you don't deliver them to him intact, he's not going to be happy."

He smacked him again. After a while (Cardinal tried to count the seconds; roughly 27 minutes) the van stopped. Cardinal felt a goon hand seize him by the shoulder. Rights-deprived, he stumbled out of the van and up a few steps. The sudden breath of climate control told them he was in an office building. Down a long corridor, then a door closed behind them, then another corridor, then another door. The blindfold came off, and he found himself facing Marsha in an elegantly furnished office.

"Nice carpet," Cardinal said, looking around. "Better than your typical federal issue. I'm guessing this guy is either pretty high up, or not really a fed. Or on the take."

One of the goons raised his hand. "No, Dryfus. Don't hit him. I'll take it from here." A very professional looking man had just entered a side door, and took his place behind a broad mahogany desk. "Name's Rove. Just call me Rove, nothing else. I am the bureau chief here."

"You might offer me a drink. Rove."

"I don't drink. I'm a Quaker. But let's not get into that. I brought you here for a reason. Actually, just you --" he looked at Cardinal "-- but I see you picked up an appendage. Well, we can make use of her. She seems to possess certain abilities, not the least of which is getting you out of awkward situations."

Marsha said, "I suppose I have to come along for the ride, or be killed."

"Don't be silly," Rove said. "We are the U.S. government. We don't kill citizens. On the other hand, if someone in our custody should happen to slip from our grasp into the hands of experienced torturers, well, we can't be held responsible for that."

"I would be more honest to just kill people and be done with it."

"No, no," Rove said, his voice rising casually but emphatically. "That would make for bad press. We have a nation of millions to lead, and we don't need bad press. When it comes to controlling the masses, lies are cheaper than soldiers. The trick is to offend many different groups and force them into the same foxhole where they can tear each other to pieces." He laughed. "You would think people in the same foxhole would join forces against a common enemy, but they never do. Why go for your enemy's supplies when you can eat your own neighbor?"

"Is this one of those moments in the spy novels where the bad guy spills it before he leaves the good guys to die?" Marsha asked.

"No, no. Well, maybe yes. I'll tell you the great secret. 'Rosebud' is a sled! Ha, ha, ha! But seriously folks, I will tell you a few truths. I don't care. Our enemies think we are a secretive group. Actually, most of the time we do our worst in the open, and people forget. Remember Katrina? Me neither. Ha, ha, ha!"

"All right, we get it," Cardinal said. "Can we cut to the chase? Explain what you want with us."

"Yes, John Cardinal, I heard that you disdain frivolities," Rove said. "I also. I have a mission for you. A brief junket to Damascus."

"Damascus? You expect me to go to one of the most dangerous places in the Middle East?"

"Or we can revoke your pardon, get you back on the electric chair, and send your girlfriend to jail for hijacking a commercial airplane."

"You tempt me."

Rove paced out a wide arc around the room, and then returned to his place behind the desk. "Since 9/11 -- "

"Now you sound like every political speech in the last six years," Cardinal broke in. "Cut the crap."

"Yes. Since 9/11, there has been a lot of, oh, how shall I say it, competition among the various federal departments to distinguish themselves in the war against terrorism. Occasionally a department has overreached in its zeal, bringing about absurd situations. Well, some would call them absurd, but in the Bush administration we call it trying hard.

"At any rate, the Department of the Interior -- the department that runs the national park system -- got itself into a situation. From what we can tell, they were trying to bribe their way into a weapons cartel in Damascus. Since federal money is traceable, they decided to use a private resource -- baby seal pelts harvested from federal parks in Alaska. It was going good for awhile, but a reporter got ahold of the story -- not a very credible one, an online muckraker, in fact -- but it is only a matter of time before a reporter with better credentials picks up on it. Paying off reporters to keep a story quiet only works for so long. Since I have explained to you already how dimly we view bad publicity, you may perhaps anticipate where I am going with this. We need someone to bust up the operation. Interior can't extricate itself from the deals without being blackmailed. But if an unrecognized party came in and blew up a seal skin drop off, they could get out of it."

"So that's it? I go to Damascus and shoot the place up, and you let us off? There must be a catch."

"Just a little one. I need you to bring enough seal skins back with you to make a full length coat. Vice President Cheney is holding a fund raiser next month, and I want my wife to finally show up Mrs. Cheney's vaunted leopard skin ensemble."

Next Episode: A Night in Damascus 

The Looming Medicare Problem

The AMA News leads off this week with an update on Medicare reimbursement: Unless Congress acts very quickly, doctors who see Medicare patients will see their fees cut by 10.1% starting January 1^st. The way Congress has been working lately, it is unlikely that there will be any progress on this issue any time soon. As a result, most people involved think likely that the cuts will take effect.

I have written about this before, at length, and will summarize my point of view. The fee cut is unfair, since physicians face rising prices (wages, taxes, rents, insurance, utilities) just like anyone else. Imagine the bind a gas station owner would be in if the cost of gasoline rose by 4% and he was required by law to charge his customers 10% less. (Federal law prohibits doctors from charging patients more than Medicare will pay.)

One could argue that doctors are rich and can afford a little pay cut. But remember that much of a doctor’s fee goes to overhead, the costs involved in keeping an office staffed and operating. Overhead costs are relatively fixed, and run at about 50% for most offices. (For specialist clinics that use a lot of expensive equipment, such as dermatology or surgery, overhead can be much higher.) If overhead costs are fixed, all of the 10% cut comes out of the doctor’s profit, which is his take home pay. Now we do some simple math:  50% (the doctor’s cut after overhead) – 10% = 40%. If the doctor, who once got 50 cents per dollar now gets 40 cents (with the other 10 going back to the feds), he now gets 40/50, or 80% of his old pay. This is a 20% cut, a significant reduction no matter how rich you are.

This is not simply a short term issue. Unless the Medicare law is completely rewritten there will be the cuts will recur annually, indefinitely. Many people are fond of saying that the U.S. has the “best health care system in the world.” While this observation depends on how one defines “best,” it is nonetheless fair to say that we will not be best for long if reimbursement cuts force doctors to start refusing care to the elderly.

My favorite quote from the AMA News article is this one:

Fee calculations also were affected by the three-year update of geographic adjustment factors in this year's rule. CMS [Centers for Medicaid and Medicare Services] uses the geographic adjustment factor -- an index of work and liability costs -- to benchmark physician operating costs around the country, which influences its overall physician fee calculations. In 2008, rural Maine will receive the highest geographic increase at 5.9%, while Detroit's index will decrease by 4.3% -- the biggest drop.

What does this mean? It means that doctors get reimbursed based on where they live, according to a formula. This would be funny if it weren’t so sad – doctors who treat Medicare patients not only have to take what the government gives them, they also get penalized extra for living in Detroit.

I suppose there is a rationale for this formula, but I don’t see it. In a free market system, people charge what they want for services. If you wanted a raise at work, you could ask for one. You might not get it, but at least your boss won’t say, “No, I’m cutting your salary because you live in Detroit.” I know of no other business where customers get to pay less depending on where the service provider lives. Even with government contracts, the contractor bids for a job, and agrees to a price. With Medicare, you take what they give you, and if you don’t like it, too bad.

The amount of money Medicare pays doctors may be fair, or it may be unfair, but one thing is certain – it has nothing to do with free markets. It is tempting to say that if doctors don’t like the price, they can walk; but this is not a fair argument. It is not easy to throw away a patient you have been treating for 5 years. It is not good medicine, and is unfair to patients. Besides that, most private insurance companies follow Medicare pricing. When Medicare cuts, everybody else follows.

If this continues, there will be major upheavals in medicine. Some doctors will abandon insurance and switch to cash only. Patients who have insurance will have to pay out of pocket and later settle their own accounts with their carriers. Others will stop taking new patients. A few will start charging extra fees, such as an annual subscription fee, to patients, and will drop patients who don’t pay.

What concerns me most of all is that doctors will switch to more profitable services that people will pay cash for, like liposuction, botox treatments, plastic surgery, and other non-essential medical care. Or they will game the system by offering technical services like ultrasounds, scans, and other special procedures that still pay well, while handing off patients that require less profitable care, like the kind that requires actual talking. This process, which is already well underway, is drawing skilled doctors out of mainstream medicine. Why treat pneumonia when you can make twice as much prescribing wrinkle cream and removing tatoos?

As I have said before, the evil part of me hopes the Medicare cuts take effect. When doctors start refusing patients and new Medicare patients cannot find doctors, the pressure for health care reform will rise markedly. For the first time, large numbers of middle class Americans will feel real pain. It is an unfortunate fact of political life today that people only take action when a problem directly effects them and their bank accounts, but that is where we are. Nothing to do but let the ugliness begin.

Thanks, Congress

It is not very often that the U.S. Congress acts on sound principle, but last week it did. Overriding President Bush's veto, Congress passed a $23 billion water bill that included $7 billion for coastal restoration in Louisiana.

The Louisiana money was very important. I know when most people think of a water bill, they think of porkbarrel projects and wasted taxpayer dollars; but the Louisiana share is for a very good cause. It will be used to close the Mississippi River Gulf Outlet (MRGO) and render it hurricane resistant. As I have written before, the MRGO served as a sluiceway for the Hurricane Katrina storm surge; water poured down the outlet and overflowed it. In Louisiana we have long known that MRGO was responsible for most of the worst flooding after Katrina. MRGO was a federally designed project, and the state of Louisiana did not have the power to fill it in. We needed that money, and now that the funds are locked in, St. Bernard, the Lower 9th, and New Orleans East can be made much safer.

 It is a shame that it took over 2 years to get the money to do what should have been done a month after the storm, but it is never too late to do the right thing. The rest of $7 billion will be used to start a massive levee project that should protect New Orleans from the next Katrina. Let's just hope the Army Corps of Engineers can get the job done on time.