Monthly Archives: July 2009

Health Care; What It Should Be

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I’ve been thinking a lot lately about our health care system in America, and why it works well in some areas, and sucks in others. Because of this, I’ve come up with a new way to look at health care, well at least new to me. Let me tell you how it goes.

Imagine in the future, there’s this middle aged guy. We’ll call him Fred. Fred is married, 46, and has two children. He has a job which he has kept for the past 12 years, even in this recession. He is mid/upper level management, and his prospects for higher management look good. Because his wife is at home with their children (ages 12 and 8), they live off his income alone. They own a house, and a few investments, but they do not have a lot of capital otherwise.

When Fred goes to see his doctor for a routine physical, he gets a surprise: he appears to have heart disease, and looks to need a double-bypass. Fred is shocked, but not worried. Fred has been making regular payments for his health care to the government (as a part of his taxes), and his company also has paid for a supplemental health insurance. Fred didn’t have to pay for either. Just by being a citizen he is automatically granted access to quality medical care. However, his company’s payments to the government are not for nothing. They have given him access to speedier care.

So after calling his wife, and telling her the news, Fred calls his health insurance agent.

What? You are thinking. Why would he call his insurance agent?  Well because his health insurance agent actually works for Fred, and his job is to find Fred the best deal on fixing his heart.

The agent glances at Fred’s payment history, and policy, and sees that he is insured for up to $200k on a one-time procedure, (long-term care is much higher, as this is good insurance). Downloading Fred’s data from Fred’s doctor, the agent sends out a query to the local hospitals. (patient X, with this medical history, and these symptoms, is looking for Y procedure, by Z date. Budget under $200k) Immediately he gets back lots of responses. The agent tosses the ones from India (cheap, but Fred wants to be near his kids of something should happen), and the ones from the hospital two towns over (the price is right, but their staffing levels are in decline), and finally settles with three different proposals, which he emails to Fred with his notes on top. Fred glances at the offers, and looks though his agent’s notes.

The first proposal is from the local hospital, and their ratings are pretty good for second class rooms. For a small co-pay, he can get bumped up to a first class room, and get a surgeon with a slightly higher rating. Fred has played golf with the surgeon before, and was not too impressed, but the price is good. However, the timing isn’t. Their first opening, at this price, is in two weeks. Since it’s near the end of summer, Fred wants his procedure done in time for the family vacation three weeks away. He makes a note to his agent to ask what the additional costs would be to have the surgery done next week.

The next proposal is from a teaching hospital in the nearby big city.  The price is cheaper, and there will be lots of over site. All those eager-to-prove-themselves interns will be looking over his chart for any flaw. The actual procedure will be done by one of the school’s best instructors (who has an excellent rating), as a part of a lecture on heart surgeries. The actual surgery will be in two days, which is quick for the price. The procedure will be perfectly safe, even though it will be observed by hundreds of students, as the school’s surgery has one of the highest ratings possible, especially on infection prevention. However, Fred thinks he would like a bit more privacy when getting cut open.

The last proposal is from a hospital in Southern California with excellent medical procedures, but only average room service. Because this hospital is located by several excellent hospitals, local competition has become fierce, and the hospital has had to partner with other companies to sweeten the deal. The advantage for this proposal is that the package includes round trip airfare for the whole family, and a week long pass at Disneyland. Hotel costs are extra, but almost every thing else is covered. If he can deal with slightly poorer room service, Fred can get his surgery next week, and his kids can get a summer vacation they will never forget.

Some nuts and bolts:

First off, every medical procedure is rated, from cleaning teeth to major surgeries. Ratings are made available by government on the internet, and are sorted by doctor, location, cost. etc. Hospitals, and other places where medical procedures are done, are also rated.

Likewise, every doctor is rated, both by specific procedure, and an overall rating (much like an ebay trader rating). Ancillary data, like surgical infection rate, is also attributed, albeit not directly, to them. In exchange, doctors can no longer be sued for malpractice. They can be sued for other things, like neglect, or malfeasance, but the burden of proof is lies with the plaintiff, and the standard for proof is high.

Patients are free to contract with any doctor, nurse, medical practitioner, or health organization (like a hospital or medical group), as long as they are licensed. The federal government pays a fixed minimum amount for almost every procedure (at a rate with is set locally, and is updated periodically). Doctors (health organizations, etc.) can charge whatever they want over that minimum, but half of the overage must be paid back to the government. Because there are some patients who are too poor to pay over the minimum, doctors who have 50% or more of their patient load as these “government only” patients, receive a healthy tax credit. A doctor who sees 90% or more of “government only” patients may be eligible for a reduction in their student loans.

One of the big price points is immediate access. The sooner something is accomplished, relative the to time of asking, the more one pays. Getting an appointment with your doctor for a routine check-up may cost nothing two months out, but cost an additional $100 co-pay if done tomorrow. Some patients may opt to collect a re-booking fee from their doctors if a rich patient wishes to buy their time slot.

Health insurance companies can no longer can tell you what procedures you are eligible for. Instead, they determine what you have invested with them, and what they think they can expect to get out of you. Patients may pay for $10k policies or $10 million policies, depending upon their need. What insurance companies can do is put together package deals, and broker your medical needs, much like a travel agent. They will have a vested interest in keeping the overage costs lower because then they will pay less. This will help to keep overall costs lower.

The government minimum is available for every citizen, and for most medical procedures. Some procedures, like cosmetic plastic surgery, will not be paid for unless it is part of a medical emergency. Illegal immigrants can also use the health care system, but they have to make a small co-pay with every visit, and always receive the lowest priority on appointments.

Money for this program comes in part from overage fees, in part from licensing fees, but the majority of costs are paid by taxes.

Terry and Carol

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Today I met two very different ladies while riding home from work.

Terry approached me while I was waiting for the bus, just after I got off work.  She asked me if I had any spare change as she needed to ride the bus. Terry is tall, thin, in her mid 40s, and Indian (from the sub-continent of India, not an American aborigine). I asked her how much she needed, and she told me $5. Only it wasn’t just $5, it was “$5 because I need to ride the bus to some place” (I couldn’t understand everything she said over the traffic noise, and her accent). She repeated the need to ride the bus as a litany, very much like a person with a mental illness. I don’t know if she had one or not. I could not tell, which doesn’t mean a lot. The mentally ill are often surprisingly good at masking their handicaps.

So I reached into my wallet and gave her a $5 bill. She was kind of shocked. She thanked me several times, shook my hand, and asked me my name. That’s when I learned her name, and asked her how to spell it.  (A curiosity of mine, since I’m married to a Teri, and there seems to be 20 different ways to spell that name)

Later, when I reached the Red Line (the only subway in LA) I ran across a lady I’ve seen several times before. She has lovely gray hair, in very long dreadlocks, and I’ve always appreciated the way her hair looks. Tonight she was also wearing a shalwar kamiz, which is the traditional dress for Pakistan, and parts of India (from what I understand). I just had to compliment her. One thing led to another, and we ended up talking until I got off the next bus.

Carol teaches music at the Musician Institute, in Hollywood, and is quite well known as a singer. With so much in common, we had a fun time talking. Well at least I did, and she made the motions as if she did (which is all that counts, right?). I’m looking forward to seeing her again, and talking shop. Musicians are so interesting to me anyway, and the smart artistic ones are even better. Carol was all that and more. I’ll bet she a great teacher too. She’s got that mother earth goddess thing down pat. Walks with real gravity, she does.

Fruit

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I was buying fruit for my breakfast. I do it almost everyday. Same place, same basket size. It’s a quart of sliced fresh fruit. The type of fruit varies with the seasons. It’s a healthy way to start the day, and seems to keep me awake better than another coffee.

I had just handed my basket to the lady behind the counter, when I noticed an elderly gentleman walk up. He had gray hair, longish cut for most men his age, and was wearing gray slacks, and a red polo shirt. He paused in the narrow aisles near the man in a wheelchair. The man in the chair (Frank to his friends) asked if he was in the gentleman’s way.

“No”, he replied in a kind voice. And then, as an after thought, “not yet.” The last was delivered with a bit of a twinkle to show he wasn’t serious. Nice guy. Comfortable around others and funny.

The lady behind the counter asked how he was. Apparently he was another regular. Then she asked how his wife was doing. I could just picture him and his wife coming to the fruit stand every Thursday or something, and having a polite conversation while picking up some extra kumquats, or navel oranges, or the small red currants, bitter and still on the vine.

“Not too good, Elsie.” He even knew the name of the lady behind the counter. That was impressive.

Then, as if he didn’t realize what he was doing, he continued, “she fell down last week again. She wasn’t hurt much, but she suddenly stopped eating.”

These are not the words one expects in a friendly conversation. I saw Elsie’s lips compress just slightly, and her eyes seemed to fog slightly. Elsie is a busy lady, and she doesn’t always have the time to chat. We all know that. Apparently, the gentleman forgot that while friendly, she was also an employee. She was trapped by employee politeness, that somewhat difficult position in which showing polite interest while working is taken as showing personal interest.

The man was oblivious to all this. He continued, “she doesn’t want to see a doctor. I tried taking her to Dr. Kellar, but she wouldn’t get off the couch. She will let me get her things at the pharmacy, but nothing else.” He stopped for a second, as if to catch his breath, “I was hoping some fruit would bring back her appetite.”

I could just see him in a dusty brown living room, tan light coming in from the window, standing over the couch, and holding out a plate and saying, “but they’re your favorite plums dear. Elsie packed them special just for you.”

The man was still smiling, still polite. Too lost in the horror of watching a lifetime of shared courtesies, pinching pennies, buying a first car, and sharing late night TV next to each other on the sofa, to realize he had crossed that thin line from friendly to rude. After feet, yards, and even miles of things done together, his wife was dying by inches. And there was nothing he could do.

Elsie handed me my receipt. She had finished charging my card. I placed the slip in my wallet, and slipped the wallet into my backpack. Skateboard in hand, I quickly left the fruit stand, clutching my plastic bag with my quart of fruit, and my plastic fork. I passed the other fruit stands, and the leather repair guy, and was soon in the clear blue sunlight of the parking lot where no one was dying or talked casually about their life falling apart in a cheerful voice. I dropped my board, and made good time pushing my way to work. I was extra careful to watch for cars, especially at the crosswalk in the middle of the parking lot. The cars can’t see you coming, and they never expect someone to be moving as fast as I roll in a pedestrian space.

Finding work on my desk was a relief. Soon I was immersed; fruit container open, headphones thumping, and my mind not thinking. Not thinking at all.

Luz

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I met Luz waiting at the bus stop. She normally didn’t work this late (it was around 7:20) and was curious about the bus schedule. It turned out she is practically a neighbor, living within a couple blocks of our house, so I was able to tell her of the many different routs to get home.

Luz had worked late because her boss, an actress, was in the hospital giving birth to her second child. The nanny for her first child needed to leave early, and so Luz stayed until the grandmother could make it over.

Then Luz started telling me about the household in which she worked.

Luz is one of millions of middle aged Hispanic women one finds in this town. They all speak English to one degree or another, with a Spanish accent, and they all seem to wear a taciturn face in public, and yet are cheerful if spoken to politely. She had gray hair pushing out about an inch into her short red died curls. As I’ve learned from an older neighbor, hair dye is not cheep, and so one often meets 60 somethings who carefully cover up their roots until the next time they can dye their own hair.

Luz told me of the many presents sent to the household to herald the coming of a new baby. She was careful to unwrap them, and place them in the baby’s room to be eventually gone over by her mother. The mother, worried and tired from giving birth had other ideas. “Take the extra gifts, Luz, and place them in a couple of hefty green trash bags. The nanny will take them to the charity tomorrow.”

Luz could simply not understand such extravagance; giving away these gifts, unseen, and unappreciated, was simply more than her frugal upbringing could bare.  She must have told me this story 8 times in the 30 minutes we traveled together. Each time telling me more and more about the household in which she worked, about the money poured out the door each day. “She never shops,” she said. “They bring the groceries to the house each day.” She told me of fresh fruit by the pound being thrown away because it was old, of fresh bagels delivered each morning only to go untouched, of fancy diners, expensive hair cuts (two stylists show up at the house, each is paid over $300, and they are also fed well). She was simply shocked at the huge disparity of wealth between herself and her employer.

Luz was also very careful to say she was thankful she had work, and was also careful to not mentioned whom she worked for. She was not angry at her employer, she simply came from a different world in which one never gave away expensive and unused treadmills, let alone pounds of fresh fruit.

And right there in the midst of her angst is the crux of the issue.  It is almost impossible to understand wealth over a certain amount above what one is used to. Just like it is almost impossible to understand that everyone else is not at your level of wealth.

Since I’ve been freelancing, our income as slowly increased. Each additional chunk of money was incrementally larger, but never arrived in one piece, instead it was slipped into the midst of our regular financial chaos. It was like the water level in a fish tank slowly rising, and we fish are almost completely oblivious to its change. That is until we come face to face with a fish from a MUCH larger tank. Then we are dumbfounded at the disparity in size. We know how a 12 gallon tank with three fish works when filled to the top, but are ignorant to the point of naivety when suddenly confronted with a 60 gallon tank.

The last week we were out visiting the in-laws, we got into a discussion about money. It was surprising because Teri or I casually mentioned how much money I make on most days I work. The amount was so different than what her mother or her brother are used to that they were actually shocked.  Neither Teri or I think of ourselves as wealthy. Sure we make money, but we spent it in proportion to its arrival (don’t we all?) and we don’t think of ourselves as “big spenders”. In fact, we are rather thrifty. And yet there was still a financial wall that separated our household from her parent’s or her brother’s. I think this disturbed us as much as it shocked them. We were raised to be egalitarian by nature, and like to view ourselves that way, so being shown that we are actually wealthy is rather hard to fathom. Much like a fish from a 12 gallon tank suddenly confronted with living in a 60 gallon tank. The water is similar enough to seem natural, but the space, well that’s another thing all together.