Bioethics and Beatitude

I’ll just get out with it: I have a favorite moral theology series. It is this one. The introductory book is the most academic (I’ve only just started the one in the post title). The second two, Sex and Virtue and Church, State, and Society, are more practical books. But don’t confuse practical with prescriptive or think of them as sort of moral manuals harkening back to the days after people forgot about Thomas, but before Veritatis Splendor. This series is part of the revival of virtue ethics, which, as Grabowski points out changes the fundamental moral question from “What is the law and must I obey it?” to “What must I do to be happy?” Of course, happiness is not pleasure or the like, but beatitude and joy. Among my favorite quotations from the series is this excerpt from the Introduction book: “…because human reason is able to discover what suits the in-built entelechies of human nature, the Christian moral theologian can confidently expound on the teleological dimension of the moral life without undue appeal to legal sanctions and punishments.”

That’s why I’m so excited about this book. It will not be a manual listing what are acceptable and unacceptable medical or scientific procedures, but rather explore the manner in which various procedures, etc. are harmonious or discordant with being virtuous in that arena. This is definitely a book that every Catholic physician or scientist should read, but probably all of the non-Catholic ones too. It goes well beyond the med school ethics of “this is what presently won’t get you an ethical inquiry, take notice.”

To discuss virtues, they must first be defined, which is the purpose of this post. The quotation below is the several paragraphs in which each virtue is introduced (I read it into my computer using Dragon Speak, 100% kidding, I used the identically functioning Speech Recognition that is included in Windows…). I thought it quite lucid.

Given the common difficulties that prevent the acting person from acting well, the moral life in general, and moral reasoning in bioethics in particular, requires the virtues – stable dispositions in the human agent that enable him to know, to desire, and to do the good – to help us act well. Classically, the virtues can be divided into three categories: the intellectual, the moral, and the theological virtues.

First, the intellectual virtues allow the human agent to perfect his scientific, artistic, and technical abilities. Particularly important in bioethics, the three virtues of understanding, sure knowledge, and wisdom and perfect the intellect so that the human person can know the truth well.  Understanding or intuitive insight, intellectus in Latin, allows the person to grasp the necessary troops expressed in first principles, such as the whole is greater than its parts.  Sure knowledge, scientia in Latin, perfect the speculative intellectual that the human agent in reason well.  Finally, wisdom, sapientia in Latin, dispose of the human being so that he can understand reality from the divine perspective.  These virtues would allow the bioethicist in the patient to know the truth is that are necessary prerequisites for moral judgment, and what enabled a scientist to excel at his task to understand the world.  Last, the intellectual virtues of art, ars in Latin, and of prudence, prudentia in Latin, perfect the intellect and predispose the human agent to produce works of skill that are gone well – including, for the physician, a healed patient, or for the scientist, an elegant experiment – interact well, and respectively.  As we will see below, prudence is a unique virtue because it is numbered among both the intellectual and the moral virtues, because a parting individual needs not only to know the true good, but also to act in order to attain it.

Next, the moral virtues order our desires so that we retain the desire of the good and enact to attain it.  They can be acquired by human effort and are the fruit of repeated morally good acts.  The ancients emphasize that these virtues that could become like a second major after long conditioning and constant practice.  However, for St Thomas Aquinas, these natural virtues to require God’s grace for them to function well.  Significantly, he also proposed that there are infused virtues that correspond to the acquired moral virtues and that elevate the human being so he can perform supernatural acts that transcend reason and duty in light of the Cross. As Michael Sherwin, O.P., has convincingly argued, the infused cardinal virtues must exist because they explain well the experience of those acting persons, especially former addicts, who struggle with the lingering effects of the required vices.  By definition, these infused virtues are gifts that can be received only from God along with sanctifying grace.  They order the human agent or his ultimate beatitude, which is the life of the Triune God.

The moral virtues are also important because they help the acting person to regulate his emotions, those bodily movements the classical tradition called the passions of the soul.  As Etienne Gilson, the distinguished medievalist, observed: “When the moralist comes to discuss concrete cases, he comes up against the fundamental fact that man is moved by his passions.  The study of the passions, therefore, must precede any discussion of moral problems.” in themselves, these passions – and they can include love, pleasure, hatred, fear, despair, or anger, among others – are neither morally good nor evil.  For example, fear, in one case, fear of cancer, may incline an individual to give up an unhealthy habit like smoking, while fear, in another case, fear of prolonged pain, the incline another patient to ask his physician to kill him.  The former passion would be morally good, while the latter passion be morally evil.  Not surprisingly, therefore, the acting persons called to order his passions so that they are directed toward his authentic good.

A handful of moral virtues, prudence, justice, fortitude, and temperance, are called cardinal virtues because they are those principal virtues upon which the moral life pivots.  Prudence is the virtue that disposes the individual not only to discern the true good in every circumstance, but also to choose the right means of achieving it.  It is the virtue that facilitates good human acts.  It allows the acting person to intended, to deliberate, to decide, and to execute this particular act well, here and now, with his and his community’s authentic good in mind.  Prudence would be the virtue that this poses a patient not only to properly weigh the medical opinions of his doctors, the desires of his loved ones, the financial exigency use of his particular situation, in his own authentic good before making a morally upright decision with regard to his healthcare, but also to carry it out.  It would also be the virtue that disposes the scientist to properly weigh all the scientific, financial, and moral factors that impact every research program before choosing a morally upright experiment to test a hypothesis.

Next, justice is the virtue that dispose of the individual to give God and to neighbor that which is properly due to both of them.  It allows a human being to properly see that his own well being cannot be separated from the well being of others.  As we will see in chapter six, justice is the virtue that would dispose of the individual or a transplantation team to properly allocate transplantable organs to those patients who are most in needed them.

Fortitude is the virtue that this poses the individual to remain firm in the face of difficulty and to remain constant in the pursuit of good.  Also called courage, it moderates the passion of fear, allowing the individual to act in a morally upright manner even when he is frightened.  Fortitude strengthens his resolve to do to good even in the face of temptations or of strong emotions that may dispose him to do otherwise. It is the virtue that disposes the patient to conquer fear, even fear of death, so that he does not seek physician-assisted suicide. It is also the virtue that disposes the scientist to avoid experiments that involve the destruction of human embryos, even in the face of pressure from editorial review boards, tenure committees, or grant-funding agencies to do otherwise.

Fourth and finally, temperance is the virtue that disposes the individual to moderate the attraction of bodily pleasures. it steels his will, allowing him to master his instincts and to keep his elicited desires within the limits of what is reasonable and honorable. An important moral virtue associate with the cardinal virtue of temperance is the virtue of chastity, the virtue that moderates the individual’s desire for sexual pleasure so that it is properly ordered according to right reason and faith. As we will discuss in chapter three, chastity is the chief virtue that disposes a married couple to choose only natural family planning methods rather than contraception when they choose to exercise responsible parenting.

Finally, the theological virtues, faith, hope, and charity, unite the human being to God, making him capable of acting as God acts. In contrast to the moral virtues, these virtues cannot be acquired by human effort because they can only be received as divine gifts. Faith is the virtue by which we believe in God and believe all that He has said and revealed to us. Hope is the virtue by which we desire heaven and eternal life as our happiness, placing our trust in God’s infinite power and mercy and His promises that He will save us. Charity is the virtue by which we love God above all things for His own sake and our neighbor as ourselves for the love of God. These virtues capacitate the human agent to know, to will, and to love, as God knows, wills, and loves. In bioethics, these virtues dispose the individual to choose the authentic good in light of the mystery of the Cross. Faith, hope, and charity are the virtues that allow a terminally ill patient to unite his sufferings with the sufferings of Jesus Christ for the redemption of the world. They would also enable him to reject any temptation he may have to take his life by reassuring him of the reality of the resurrection. These virtues would also dispose the nurse to care for his patients in a heroic and self-sacrificial manner, moving him in certain cases to visit them even when he is not on call.

Ante-ante-examen St. Louis

First year is almost over. If the lack of blogging lately wasn’t clue enough, it’s been a busy finish. I’ll have a recap of the year after my final on Friday. For now, I’ll give a brief thought on healthcare economics and then detail my summer plans.

Over the last decade or so, the number of stand alone physician practices has been shrinking. Not necessarily solo practice, but something like a group of cardiologists who used to own their practice and equipment no longer do. In some situations, this might be beneficial by reducing certain incentives to self-refer, but that is not applicable to every type of physician. The primary reason for the disappearance is economic. It’s too expensive to manage a practice (e.g. billing, advertising, etc.) and the equipment it too costly to buy and maintain (e.g. cardiac catheter lab). So these groups sell themselves and associate with a hospital. This follows in the footsteps of places like the Mayo and Cleveland Clinics where physician pay is not procedure based, but rather salaried. The argument goes that pay-per-procedure incentivizes unnecessary procedures and adds costs to healthcare. This is practically indisputable. The nuance in the new paradigm of physicians associating is that while they are salaried and no longer paid on a procedure basis, the associated hospitals and clinics do still bill that way. So, a certain incentive has been reduced, but the system remains. Why is this still problematic? Because while there should be cost savings associated with a probably lower physician salary, those savings are enjoyed by the hospital, not the patient, who still get billed per procedure. Unfortunately, this is just another paradigm shift whose end result is shifting the cost burden to physicians personally while ignoring the numerous other huger players in the healthcare market.

My summer plans: I have a job at the cross-town rival working on a new machine. By new, I mean first in the world. It is an real-time MRI guided IMRT machine that uses Cobalt-60. That probably means nothing to you. But it is something of a chimera of physics tools, old and new. Cobalt is how therapy used to be done. It’s just radioactive stuff in a can. You open the can and radiation comes out. IMRT is how modern machines shape the radiation beam. MRI is not really associated with radiation oncology because the magnets normally affect the electrons that create the radiation (usually the radiation itself is used for imaging). But with the Cobalt, there are no such electrons so they can play nicely together. I’ll be working with the physicists and vendor and they install it and get it up and running. I’ll probably also do some QA for the department, which might buy me two beers at the end of the week.

I have my fingers in several research projects right now. I’m part of a submission from grad school that is working through the referees. I have another project left over from grad school that could be written up in a week or so. I have two projects with a surgeon at my school that are very preliminary right now, but have potential for summer progress. The work on this new machine is worth at least one publication for probably everyone who even looks at it. And, lastly, I have been working with a physician at the cross-town rival on a project that is only slightly beyond preliminary stages. I think this is probably a good start that should take me at least through the end of next year, giving me a competitive application (and maybe 5 publications) for a research heavy field.

Oh, and the FMP and I are making official. (In lieu of a post about the FMP’s feelings, I’ll soon be posting on the next best thing: Pinterest! (and how they can fix their product to make it not go the way of most social networks)).

On a cloud

On Friday, I got a call that the FMP’s wedding band was ready for pick up. She was excited. Here’s a preview:

But this post isn’t about that at all, it was a trick. But now that you’re here, read about the healthcare cloud!

This summer I will probably be working with the cross-town rival in the radiation oncology department. Yesterday, I went to the local chapter meeting for some radiation oncology folk (all but 1 presentation by the my probable summer employers). My interviews at the school and attendance at the meeting showed me I was not alone in my love of the cloud. There are others like me: they’re called physicists.

The physicists in the radiation oncology department are responsible for ensuring that everything is working. This includes the computer system with the images, the planning systems, etc. that the machines are operating within normal parameters (and either making minor fixes or knowing when to call the service folk), and QA. Lots of QA. When the computer says this, does the machine do that? When the machine says this, is it really doing that? Did the machine do this the same way for these two patients? And so on. This can involve a lot of paper work and record keeping. These are not things that physicists like. The department I’ll be working with has developed a lot of in-house software to automate nearly all of this. First off, there’s no paper. Everything is done with a web form. So they can go to any computer by any machine or office and load up the form. They select the machine and what type of QA they are doing and then complete the form with the new data. The report is automated and the comparisons and evaluations are also automated, creating a .pdf saved to the archive folder. Done. You may say: so it’s doing they’re job for them? Not exactly. The physicists job is to do the QA, not to push papers. And while they can still recognize erroneous measurements whether or not the software identifies them, spotting them isn’t the “physicisty” part, knowing why they occurred and how to fix them is. This arrangement lets the physicists (and other members of the department) focus on their actual jobs and not use extra time doing non-essential things.

At the conference, I learned of a software suite for radiation oncology that automates a lot of image processing and records keeping. For each patient, there are several sets of images (CT, MRI, PET). These images have to be registered to each other so when you tell the computer something about one part of the CT, it knows you’re also talking about the same part of the MRI. This can be challenging because the patient is not always in identical positions when getting all the imaging done. This software is designed for deformable registration. So it can figure out how to match up a CT of someone lying flat with an MRI of someone with his head tilted up. Equally important, is that it can register an image from the beginning of treatment with one from later on when the patient might have lost a lot of weight. This is important for tracking radiation dose. On each plan, many organs are identified on the CT images. The computer then knows how much radiation is delivered to those identified organs for the designed treatment plan. So when the patient loses weight and things change, the original plan might not be reflective of the new anatomical reality. Also, if someone got treatment a few years ago at a different facility, it is usually possible to track down the images, and the treatment plan information, but it is unlikely that the information can be ported into the current plan to count all of the dose. The usual solution is to recreate the entire treatment plan and have your software recompute everything. This software will look at the old planning data, register the images to current ones and map all the doses and structures. The is a reduction of 4-8 hours of work to, no joke, a couple minutes. The secrete (other than the beastly algorithms) is the cloud! The software functions as the de facto image server for the department. Instead of retrieving images from the hospital server and loading them in to the repositories of each treatment planning system, they are all stored in this software and accessed from there by the planning systems. There’s no copying and pushing files to the other places, it’s just the same files.

Big picture: http://www.zdnet.com/blog/health/a-banner-day-for-health-records-management/485?tag=mantle_skin;content

That article says 17 facilities have achieved final stage Electronic Medical Records.

In order to obtain the final stage in the EMR adoption, hospitals must be paperless and be able to share clinical information with other health care facilities, networks, clinics, employers, payers and patients. At this stage, health care organizations also can store and analyze data to use to improve clinical outcomes and patient experience.

You might recall from my Single Payer posts that the physicians pushing that plan claim no benefit from EMRs and consider then a unnecessary expense. If the endpoint of an EMR is just to get rid of paper, it’s a matter of convenience, but probably not going to dramatically improve outcomes. So yeah, maybe not worth it depending on the scope of your clinic. But if we look at the definition above, we can see it goes far beyond that. Sharing is hugely important. Not just faxing forms or e-mails scans of forms. But when two systems can send the data and have it appear in a useful manner in the patient record at both places, it’s almost like there’s no sharing at all, jus the same piece of information! (yay cloud).

The last part of their definition is also really important. I’m sort of involved in an amorphous research project with ambiguous goals related to patient safety. So I’ve been reading a bunch of articles discussing what some committee thinks are important areas to improve patient safety (things like pneumonia when on ventilators, infections during surgery, etc.) All of these things require tracking of certain measures by the hospitals and clinics. Each paper gives 5-10 things to be measured and how to compute numerator and the denominator so when any institution says only so many of their patients have something happen to them, they all mean the same thing. The simple act of tracking and tallying these procedures and outcomes for the purpose of this calculation would probably require a full time employee doing really really boring work. When the EMR is comprehensive, the system just does it. All the time. So when the EMR recognizes that some antibiotic was prescribed for a patient 2 days after his surgery, it will tally that in the appropriate way for the infection statistics. This helps get the numbers right, but it also makes them readily available. The manager can simply look up some statistics without having to call down to surgery, find the guy who keeps track of it, give him time to re-compute with the latest data, blah blah blah.

If you clicked that link, you’ll notice that all 17 of those facilities are part of the same healthcare delivery company. That is an essential aspect of their success given the EMR marketplace right now. There are more than a few EMRs all with their own databases and storage structures. When one facility wants to send something to another one that uses a different system, the relevant data is spit out in to some massive text file with silly delimiters and then everyone crosses their fingers hoping the other system will make sense of it in a way that conveys the useful information. This is because there is no standard for data storage (contrast to the images in radiation oncology. All medical images are stored in a standard file format. The organ structure data and dosing information is attached to these in a standardized way, so any program reads it just like any other program). A future post will discuss the need for standardized health records formats, and how this can occur in a marketplace of many vendors and disparate record keeping needs. Stay tuned.

An admittedly strange idea for Windows 8

I recently created a virtual hard drive and installed the consumer preview on a proper PC. The new interface has grown on me and using a mouse I think it can be very effective, in lieu of touch. I’m still very hesitant to suggest it will be easy to use on a laptop with a track pad. The distance the cursor needs to be moved are just to far for it to be practical. It’s probably that laptops will have touch displays, which would make it easier, but the angle of the laptop screen would make touching it awkward for more than the occasional tap.

There was some news report about Microsoft applying for a patent of a two screen phone or some such thing. This is not so different from my idea:

Instead of a track pad, a mini display, not so different from a phone screen would be there. When in the Metro UI, it would mirror the screen so you could control and touch the pad by the keyboard. When switching to desktop mode, it would function like a regular track pad (and perhaps go blank). Some other gestures and multi touch things would make it more useful (e.g. two finger touch in metro to move cursor).

What exactly is Healthcare Insurance

I’m off to a marriage preparation retreat with the FMP this weekend and just got done with two days of exams, so here’s a post I had waiting in the wings:

The vast majority of people have some kind of insurance, be it car, home, life, or health. In general, an insurance policy provides monetary protection against the loss or damage of some asset, the conditions of a reimbursement are settled in the policy. Compared to most types of insurance, health insurance is rather different. Auto insurance usually pays out if your car is damaged because of something beyond your control, e.g. weather or another driver; homeowners insurance pays out based of the type of damage you’ve purchased coverage for, e.g. theft, fire, flood, etc.; and life insurance usually pays out if you didn’t commit suicide. Attempts to game the system by being the cause of such a claim is insurance fraud, e.g. lit your own house on fire, drove your car off a bridge, or killing yourself. Health insurance, on the other hand, is generally expected to pay out regardless of the nature or cause of your lack of health: Whether your finger got bitten off by a dog or you intentionally cut it off, whether a car accident left you in a coma, or an intentional drug overdose did, etc. For the most part, people are not the cause of their ill health. They get sick from people at work, they break bones in accidents, they are born with some condition, or just develop one later in life. So health insurance fraud is more likely to be committed by a provider, rather than a policy holder, by asking for payment for a service or procedure they didn’t perform. It would be like you telling your auto insurance company that you got in an accident, and then your mechanic billing them for a new engine when you just needed a dent straightened out.

Rather than try to show how health insurance actually is, it would be better to describe what other types of insurance would be like if they worked like heath insurance.

Auto: your auto insurance policy would pay for all your regular maintenance, any new wiper blades or light bulbs, if you had something if your exhaust pipe, the insurance would pay to have it cleaned, it would also pay for new engines, new oil filters, new tires, oil changes, if all your oil leaked out and that damaged something, it would all be paid for, if you put diesel in your unleaded tank and really screwed things up, the insurance would pay for that too, your premium might go down if you regularly fill the tank with gas, or something.

House: your insurance company would pay for someone to change all your light bulb, fix any holes in the walls that your kids made, replace your roof every once in a while, or every year, they’d pay to have someone clean out your dryer vents, they’d pay to heat your house in the winter, but probably not cool it in the summer, you could probably get your groceries paid for, and the insurance company would even send someone to clean things up. Since you also insured your things, they’ll replace your mattress every so often, and you could probably demand they replace it very frequently if your recreation demands it, in fact, the government will force them to.

That probably sounds a little silly, and possibly hyperbolic. The obvious difference is that people are people with rights and life and so on, houses and cars are not. But it still begs the question: is health insurance really insurance, or is it something else entirely?

One thing that distinguishes health insurance from other types of insurance is the coverage of preventative care. Spend a little now, save a lot later. But auto insurance doesn’t cover oil changes, and if you don’t change your oil for a long time, it will be expensive, though the insurance company isn’t going to pay for the maintenance then either (it’s not uncommon for auto insurance to pay for new windshield because they apparently make it less likely that you’ll collide).

Now, you say, “but you’re insuring your health, you’re not insuring your car’s ability to drive, you’re insuring it against collisions and liability.” This quite right. When your health fails, you should apparently be able to make a claim, just like when your car collides. Which leads to the next question: does it make sense to do this under the auspices of insurance?

The answer is a qualified yes and no, so not really an answer at all. This is because the U.S. has a hybrid payment system: some people have insurance to pay for their care, some people have Medicare or Medicaid, some people pay out of pocket, some people don’t pay for their care, and some people forego care altogether for lack of ability to pay. Each of these system would affect the market in very different ways were they to be the only situation. If no one paid for their care, it would be nearly impossible for someone to cover the costs of training to become a physician, so we’d have none at all. If everyone were on Medicare or Medicaid, payment would be entirely at the whim of the Congress and very likely directed towards specific interventions due to budgetary constraints (and political favoritism either towards a specialty of physicians or a specific patient population or the equipment associated with a particular intervention); this would shape the physician landscape in term of the distribution of fields/specialties in rather unpredictable ways. If everyone paid out of pocket, very few people could afford major procedures. If everyone were on insurance, supply and demand would have a greater impact on the healthcare marketplace, but the quality and quantity of care would vary vastly between patients. The most important question is which is the most efficient means of delivering care, and I won’t try to answer that here. The hybrid system creates uncertainty and causes sectors under the influence of one payment scheme to either be at the mercy of another sector (e.g. low reimbursement rates for Medicare primary care force physicians to restrict the number of Medicare patients) or to exploit the circumstances of another sector (e.g. Medicare pays full cost for the most expensive prostate cancer radiation therapy, regardless of whether the patient needs it, so unless private insurance will do the same, those patients may have restricted access); additionally the uncertainty of payment in general causes providers to have a 100% markup for most services. It is worth noting that this hybrid system was reinforced with the healthcare reform bill by mandating participation in one group, and if not that one, then another, etc. Also important to the comparisons is what kind of good healthcare is, viz. is it a right and if so what kind of right; also for another post.

Back to insurance: how does an underwriter accomplish this? Actuarial science is the statistical assessment of risk. The insurance company takes a group of people, and based on whatever data points about them, determines the likelihood of having to payout for any given intervention, e.g. 0.0004% chance of having to pay out $25,000 for some surgery in one year. This cost is then passed on to the policy holder in the form of a premium, so for this particular surgery, the patient would pay ten cents (there is also the non-care revenue of the insurance company, perhaps two cents in this case). For this to make any economic sense, the group of people (i.e. people buying the same policy), would have to be 250,000 people. This is rarely the case, so patients have deductibles and co-pays. You might have to pay $5,000 for this surgery on top of the ten cent premium, now the pool only has to be 200,000 people. The co-pays and deductibles can also serve as a fudge factor to normalize the percentages to the size of the group. Add up all these ten cent premiums and you get the total cost of buying that insurance policy. Since it’s all statistics, any anomalous events are factored in for the future, e.g. a severe flu outbreak. It is important to note that for accounting purposes the premiums and payout for a group are isolated. Since many policies are sold by the one company, if one group claims twice their premiums, that loss would have to be covered by the company drawing from surpluses from another group. But it is not right to say that all the premiums from every group are in the same pot paying out for everyone who brought any policy. If that were the case, your premiums would be entirely based on your individual health and personal characteristics or those of the entire population, not on those of the specific group with whom you bought a policy. This serves to prevent you from being charged excessively for someone else’s propensity to need care (e.g. a smoker) and presumably permits you to buy a policy more cheaply, and prevents insurance from being a form of wealth transfer between patients (of course, it is still wealth transfer to the company to the tune of about 6% of all healthcare costs in the U.S). The most important part about the technical side of insurance is that the company will make sure that it makes sense for them to sell the policies.

So, does it make sense for a patient to buy an insurance policy? If we consider that $25,000 surgery, of course it does, you’re coming out at least $19,999.90 ahead, were you to need it. If you didn’t need it, you’d only be out $0.10. What about an intervention needed by 90% of the group? If this costs $100, the premium is going to be $90, plus maybe $10 for the insurance company’s overhead and profit. Now, you’re seeing almost no benefit to buying the insurance if you use it, and you’re out $90 if you don’t. If everyone who decided they didn’t want coverage for this intervention, perhaps it was reimbursement for gym membership fees and they didn’t belong to gyms, opted not to get it, the payout rate becomes 100%, the premiums are adjusted, and those suckers still buying this part of the policy are paying the insurance company to pass along their membership dues. So, while it always make sense for the insurance company to sell you a policy, it doesn’t always make sense for you to buy it. It would be an advancement if someone figured out how to apply actuarial science to the buying side of insurance. A coarse version of this exists in the form of high deductible catastrophic insurance.

High deductible catastrophic insurance functions more like auto or house insurance. It doesn’t cover the small stuff (pay for a physical exam just like you pay for light bulbs), but will cover the unexpected huge cost (payout for knee surgery from a ski injury just like payout for water damage). Now, if you don’t make claims, you’re only out those bundles of ten cents. Should you need one of those frequently accessed services, the extra cost is not very much, and foregoing just one can cover the extra cost of several. Why don’t more people use these? I would guess that with the risk being closer to the patient, there is some aversion, also a general ignorance of the costs of various frequently accessed services precludes comparisons. Furthermore, that pesky hybridness comes back. If you do need one of those other services for which you don’t have coverage, why not use one of the vehicles that give free access (e.g. not paying)? A more subtle, but more impactful, consequence of the hybridness, is that procedures and services can cost wildly different amounts based on who’s paying. If you’re on insurance policy A, an office might bill $500 for an MRI, they might bill policy B $650, and they might bill someone with no insurance $1,500. This is, in part, risk management by the office. They know they will get that $500, but they have no idea if they’ll see your $1,500, or two other peoples’, so they try to get enough from every third person. Regardless of the tricky finances, the single most important reason these policies will become less popular is that they will soon be illegal, courtesy of healthcare reform. The argument is that people with these policies will freeload on those cheaper services, but also that they are not paying sufficiently into the general healthcare payment pool (presumably to subsidize someone else’s care). This stance attempts to reconcile one aspect of the hybrid system, albeit the smallest one, while making the error of lumping all payments into the same pool.

To really see the impact of health insurance in the healthcare industry, you have to look at subsidies. Another post.

Medical Malpractice

I went to a lunch presentation by a medical malpractice lawyer the other day. It was sponsored by the Christian Medical Association, which no doubt contributed to their finding a truly charitable lawyer. He struck me as profoundly honest, and even though he currently works on the patient side of law suits (he had previously worked on the physician side), he seemed genuinely interested in teaching us how to approach the very real possibility of being sued in our professional careers.
Here are the tid bits:
1. Physicians currently win about 75% of cases. This is good and bad. It means that physicians probably aren’t losing cases based on bad outcomes (rather than bad medicine), but it’s bad because lots of cases are being brought to trial that shouldn’t be. This only costs the plaintiffs more money and contributes to medical costs.
2. He said there’s literature to suggest that litigation only adds about 5% to medical costs. This isn’t large, but it’s still billions of dollars. This figure probably doesn’t include the costs of unnecessary defensive medicine. In states like TX and CA with malpractice reform, the overall costs of litigation and insurance have not dropped all that much, leaving just the malpractice insurance firms to make boat loads. Though, I think I’ve read that TX has significantly lower insurance premiums than many other states.
3. As I fortuitously remarked at the end of my last posts, there is a lack of disciplining of bad doctors. The state boards of healing arts are the folks that dole out the medical licenses, they also take them away. Currently, the only real offenses that will jeopardize your ability to practice medicine are drug diversion or having sex with a patient. The side effect of this is that this lawyer sees the same doctors being sued over and over, and losing.
4. He gave us some pointers. Things like always ask to see an article before you agree or disagree with its findings during a deposition. But he also had a list of the big four ways to avoid a lawsuit:
a. Proper documentation in the chart. Charting sucks because everyone is so busy, but even adding “etc.” is enough to show you had a linger conversation with the patient than you care to rewrite.
b. Bedside manner is the most important thing. People don’t sue people that they believe are genuinely trying to help them.
c. Good communication keeps the patient in the loop and aware of outcomes etc.
d. Concern for the patient goes with b.
5. One of the massive cost contributors to lawsuits is the expert witness. These are physicians hired by either side to evaluate the care given. They costs $1000/hr. Because they can. It’s absurd and pretty much everyone thinks so except for the few physicians that sell their services. Of course the first thing they are asked on the stand is how much they’re being paid, so the juries don’t like it either.
Lastly, since it was the CMA he offered this:
Gal 6: Do not become wary of doing good.

Les Misérables and a word on the hidden side of the physician shortage

Some time ago, the FMP told me her favorite book was Les Mis, so I felt some small obligation to read it. If you’re not aware, it’s 1463 pages. I couldn’t tell you when I started, but it was circa 2010. I made steady progress for a while, then around page 1066 (Battle of Hastings), I had to put it down because I had to move and start med school. Over the last few weeks, I knocked out the remaining 397 pages. I have had the same two favorite books for some time now (The Right Stuff for non-fiction and The Name of the Rose for fiction). I may have to reconsider. I suspect if I had read Les Mis in one go, I would definitely name it my favorite book. It’s been reviewed a bazillion times and I’m not going to offer anything new on the text, but I’ll just write a few words about why I liked it so much.

Back when I was getting a liberal arts education, one thing that was drilled into me during English class was Human Nature. How did the text represent human nature, did the text present human nature in a way that conforms to reality, and so forth. Dostoyevsky was once accused of being a psychologist after having written Crime and Punishment, he retorted that no, he was just a student of human nature. For most people, the only aspects of human nature about which they could convincingly write are those they have personally experienced. Good authors are able to capture the natures of people unlike themselves. Hugo has captured nearly the entirety of human nature in his book. So much so that you might presume he had experience being a mayor, a fugitive, a factory owner, a teenage girl in love, a revolutionary, a relentless police inspector, etc.

In brief, it is the story of Jean Valjean’s redemption. He was a convict given parole who then stole from a bishop, when the authorities brought him back to the bishop’s to return the silver, the bishop said it was a gift and implored Valjean to use the gift to make himself right before God. He takes on a new identity and become a successful businessman and mayor of a town. He is then confronted with the choice of keeping his secret and enjoying his success, or revealing himself and saving a man condemned as Valjean. He is given every legitimate opportunity to escape his moral duty but he is bound to do right and shows up at the courthouse. He is now a fugitive. The rules of his business had necessitated the firing of a woman who had a child out of wedlock. She then did every horrible thing just to earn money to send to a family that was caring for her child. Valjean’s promise to her on her deathbed was that he would care for her child. So he rescues her from the wretched caregivers and the two of them are fugitives, but Valjean’s life has purpose again: to care for little Cosette and ensure her happiness. The rest of the book tells this story juxtaposed against their being fugitives. Even briefer: it is the story of a man seeking redemption through good works juxtaposed against a man seeking adherence to the law, juxtaposed against several love stories.

Where Hugo shines, apart from the brilliance of the story and his telling of it (we’ll forgive the Waterloo and Sewer interludes), is in portraying the inner struggles of every character when confronted with choices that weigh against their final destiny. This is exemplified in Marius’s intergenerational political struggle with his grandfather, Marius’s falling for Cosette, Marius’s ignorant devotion to Thenardier, Valjean’s willingness to do anything for the sake of Cossette, and his despair when this is achieved, Valjean’s unfailing devotion to doing right when constantly given opportunities to do otherwise, Eponine’s love of Marius that is so great that she’s willing to die so that he can find happiness with another, Javert’s struggle with life outside the law, and the list goes on.

I guess if you’re not familiar with the story and not ready to take the plunge, I wouldn’t argue against the tempered introduction that I had. The film adaptation with Liam Neeson is not bad (Geoffrey Rush is brilliant as Javert). This will give you the plot points while not spoiling any of the text. I would advise against seeing the musical before seeing a film or reading the book. While it’s brilliant on it’s own, it leaves out hugely important plot points that tie it together, while also stripping most of the non-literal and spiritual aspects of the story that make it so timeless. But after that, listen away. There’s a film adaptation of the musical adaptation of the book coming out this December.

And now for something completely different:

One of the worst parts of the physician shortage is that it is nearly impossible for horrible and unethical physicians to permanently lose their licenses. Suspensions are the order of the day.

How did Eric and I meet, as told by the FMP

Against my better judgment, I agreed to post this, not without editing, of course.

How did Eric and I meet? It’s a perfectly reasonable question for people to ask. Polite and expected, even, when you’re planning to marry someone. But there is just no quick and dirty answer to explain it, and definitely no honest answer that makes us sound anything but ridiculous. I usually go with, “We met through a friend,” or “We met at a wedding.” Both true, but not TMI.

But if I had to sum it up in a sentence, the embarrassing truth is that we met through Facebook. Now I am a big fan of Facebook, and I’m not ashamed to admit it. But that doesn’t make it any less embarrassing to meet someone through Facebook, so I usually leave that part out of casual conversation.

During my third year of med school, we were forced to move to the Middle-of-Nowhere, Texas to train at the hospital there. That’s when I really started spending time with John R. I *love* John R. Ask anyone.

So I spent hours upon days at Johnny’s using his kitchen to cook him delicious things (except for that grilled soy-cheese sandwich…). At some point I got really into agave syrup (Eric has since convinced me of its nutritional lies), and around Thanksgiving 2008 I posted on Johnny’s wall about a pumpkin pie I wanted to make with it. This is neither the time nor place for John & Eric’s pumpkin pie story (Absolute nonsense, here it is: back at UD, there was a pumpkin carving contest. John and I got a pumpkin and carved a π into it and then tried to make a pie. We followed all the directions to the letter, made two crusts from scratch and started to pour the filling in. But after filling the crusts, there was still a lot of filling left over. A lot. We then blitzed to make more crusts and filled more pies. Six pies. These pies were served later than evening with made from scratch whipped cream and the leftovers were distributed amongst the student apartments. But not one person who ate it believed we had made it. Absurd.), but let’s just say, pumpkin pie making is a little bit sacred to them. And by a little bit, I mean freakishly so. So within mere minutes of my post, Eric responded on J’s wall: “Johnny, I’m reading your wall. Are you pumpkin-pie-making cheating on me? Tell this Andrea Jackson that she needs to find someone else to bake with.” If you’re thinking they’re uncomfortably close, you’re not wrong.

And thus started our Facebook banter on J’s wall arguing about who could bake better. I found Eric to be a minor source of amusement in my small-town life, so being the tremendous fan of Facebook stalking that I was, I friended him. And he *refused* my friendship. That’s right, what is may have never been because this kid was *rude*. Fortunately for all involved, J then Facebook-blocked Eric until he agreed to be my Facebook friend. Are you beginning to see why the real story is never told?

The banter continued intermittently for a few months, then in February Eric posted the most ridiculous thing I had ever seen in cyberspace, the “Application to be the Future Mrs. P.” I couldn’t make this up. But at J’s recommendation, I submitted my application.

Then began the email chatting, followed a few weeks later by the GMail chatting. I finally learned about what this “Art of Manliness” business was, and one article that Eric specifically pointed out to me was about love letters. To prove his point, in April, he sent me a love letter. More specifically, not having my address, he sent the letter to Johnny. Johnny was so excited about the letter, he ripped it open without seeing the addressee, and he thought Eric was getting a little sentimental. Then he thought Eric was getting a little weird. Then he saw it was addressed to me. Up until that point, I don’t think Johnny had known we were in contact, but he figured us out…

I sent my response love letter, and Eric was so smitten, he extolled it in an email to me. At the end of the email he wrote, “perhaps if in addition to emailing, GMailing, and YouTubing, your BlackBerry quadruples as a telephone… (I’ve heard rumors)”. I assumed this was his awkward way of asking for my number, and thus began the phone chatting. Our first talk lasted almost 2 awkward hours (sure was…). We continued talking almost daily in some form or fashion, and when I called him one night in June while driving home from my sister’s birthday, he said something along the lines of, “So Andrea… ███ ████ ███ █████ ███ █ ██ ███ █████ ██ ███ ████ ██ █████ █ ███ ██ ███ █ ██ █ ██ █ █ ██” I probably should have seen this coming, but I didn’t. But I wasn’t exactly disappointed to hear it. I was a little confused about if he was asking me to long-distance date, but apparently he was just letting me know. So we didn’t start dating.

Many chats later, once we had more or less recovered from that awkwardness, Eric suggested that we meet at a wedding he was attending in Houston. I was hesitant, not really knowing how I’d crash this wedding four hours away for people I’d never met, so Eric called J to bring me as his date. And we finally met in person. I wore some lovely dresses and was only moderately clumsy (meaning that her first act upon seeing me was to run into a door the wrong way so it didn’t open), so I think overall I made a pretty good impression (on the door…). Eric likes to talk about how the heavens shined down on me the moment he first saw me. That or how I had trouble opening a door and then ran into the glass (ah, here it is). He was very sweet though, so I was able to get over how very red his hair was in person. All in all a pretty successful meeting. But we still didn’t start dating.

In November, while I was on the interview trail for residency, I realized that one of my interviews would only be a couple of hours from where he was living. Even though we were getting closer, I still couldn’t bring myself to apply for residency in Indiana without him requesting it. Instead I invited myself to visit for a few days between interviews. He of course accepted. We went out for sushi when I arrived, and before we got out of the car, he started telling me ███ ██ ██ ███ ███. I nearly fell over myself with laughter, because that’s what I do when I feel uncomfortable, and I’m sure he was flattered. Later I practically asphyxiated on entirely too large pieces of sushi that I tried to take in one bite. Then we headed to a Christopher West conference on marriage. *Foreshadowing!*

We had talked vaguely about him driving back to Texas with me and then flying back to Indiana, because my family hates when I drive long distances alone. But neither of us was keen on a long-distance relationship, so after a wonderful week together, I headed to Kentucky alone. We both moped around a bit the night of my interview, and when he tried to distract me with a link to something amusing, he accidently sent me a link to flights he was looking at from Texas back to Indiana. Cat was outta the bag. I went back to Indy the next day, we drove to Texas together, and after a very brief stay with Johnny, he flew back to Indy again. Not having much time alone once we arrived in Texas, we still didn’t start dating.

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Yadda yadda yadda, we started dating, and then this.

Nooooooooo Smoking

If you’re my reader from MN, you’ll recognize this guy:

Bob Casey was the PA announcer for the Twins for quite some time and one of his signature phrases was that there was “Nooooooooooooooooooooooooo smoking in the Metrodome, or anywhere else in Minnesota for that matter.”

I’ve participated in the program called Tar Wars, mostly because I was tricked. We go to mostly public grade schools in St. Louis and try to convince the kids to not smoke. The two big take aways from doing this are 1) managing a room full of 9 year old is hard, especially if you’re the guest and they all want to tell you something and 2) kids still think everyone smokes, which means every older person that they know is a smoker, and regardless of what I say to them, there’s a good chance they will be too.

Everyone knows that smoking is bad for you and causes things like this:

The other things smoking does to you.

The CDC gives this breakdown:

The good news is that smoking rates are on the downslope, but still 1 in 5 American of at least high school age smoke:

Compared to non-smokers, smokers put themselves at greater risks for potentially catastrophic health outcomes:

• coronary heart disease by 2 to 4 times
• stroke by 2 to 4 times
• men developing lung cancer by 23 times
• women developing lung cancer by 13 times
• dying from chronic obstructive lung diseases (such as chronic bronchitis and emphysema) by 12 to 13 times.

1 in 5 deaths in the U.S. are attributable to the effects of smoking, and on average, smoking reduces life expectancy by 14 years. And today, just like 40 years ago, lung cancer is every bit as much of a death sentence.

I like economics, so here’s some dollar figures:

Almost $10 billion spent on advertising in 2008, which is more than a million dollars an hour. The societal costs of smoking are nearly $200 billion (not including the $90 billion spent on tobacco, because well…the jobs!!?).

And in case you’re not upset yet: states collect tobacco taxes and legal settlements form tobacco companies totaling more than $25 billion, but only spend $500 million on tobacco control programs (about 2%, to fund all of the programs recommended by the CDC, this would need to be 15%). This is very telling because it places the state governments on the same level as the tobacco companies. The states take their taxes and legal winnings and just dump them in the general fund to make partial payments on their bonds or whatever other nonsense they’re doing on behalf of special interests. Should tobacco control programs actually succeed, these states would be out the nearly $25 billion they spend on general operating and would have to collect that from the regular folk.

Back in MN the former governor had made a no-tax pledge, and to stick to it, but close a budget gap, he instituted a cigarette fee, not a tax. He termed it a fee because it was meant to disincentivize the buying of cigarettes. So-called sin taxes are quite popular because most people think smoking is bad etc. but also because they’re very robust. Smokers will still buy cigarettes. This is exactly why everyone says the tobacco companies are so bad: they’re making money off of some poor schleps addiction. And yet the states are doing the exact. same. thing.

The real reason for this post is because I’m in pharmacology right now and the professor just threw a bunch of stuff about nicotine at us the other day. I will attempt to explain the actual things that smoking does to your body.

Nicotine is a drug and the way drugs act on the body is by binding to receptors. After the smoke being in your mouth for just 2 seconds, 2/3 of the nicotine is absorbed, with inhalation, this goes up to 98%. So there’s plenty to act on the receptors. The nicotinic receptor is found in three places: on your skeletal muscle (the muscles you control), between the two-nerve chain that controls bodily functions (sweating, toileting, pupils, etc.), and in your adrenal glands (to stimulate the release of noradrenaline).

The binding of nicotine causes the following in some degree or another based on the dose:

• Increases blood pressure and heart rate because of the release of noradrenaline and adrenaline
• Increases gastric motility
• Increases saliva and mucous production
• Stimulates respiration
• Releases dopamine (pleasure!!) and vasopressin (higher blood pressure) in the brain

Aside from being addicted, people are prompted to smoke because the nicotine can

• increase psychomotor activity
• increase cognitive function
• increase attention
• increase memory consolidation

The actual act of inhaling smoke over a prolonged period also has a considerable impact on health. Your airway leading in to your lungs in lined by cells that are columnar in shape and have little hairs on them. There are also cells that secrete mucous. This mucous traps particulates and then the little hair sweep it up the airway until your either hawk a loogie or just swallow it. With the smoking, these columnar cells eventually become flat and lose their little hairs. So the mucous is still there, but it can’t be swept out so it just builds up and you have to cough a lot to get it up. This cellular transformation is a first step on the way to cancer and the inability to clear the mucous and the chemicals it traps is also a contributor. When you inhale air, it goes to tiny sacs in your lung and in crosses into your blood. Chemicals from smoke stay in these sacs and irritate them, and eventually they rupture. Other things happen and yadda yadda you have emphysema.

The recap:

1. Smoking destroys your lungs
2. Smoking destroys your airway
3. Smoking raises your blood pressure through several mechanisms
4. Smoking increases your heart rate

But there’s hope:

TMQ on Healthcare

I’m a big fan of the Tuesday Morning Quarterback over at ESPN.com’s Page 2. Gregg Easterbrook writes an approximately 20 page column each Tuesday of the NFL season in which he discusses Football and current events, while lampooning pop culture. Lest you think he can’t write capably on healthcare, he is also a senior editor of The New Republic magazine.

This column of his appeared in September of 2009, three months before the Senate passed their healthcare reform bill, and 6 months before the House. Since I know no one clicks the links in my blog, here’s the relevant portion:

Why Not Standard Pricing? I don’t really understand what’s in the congressional health care plan at the moment — and since it changes daily, I bet most members of the House and Senate don’t really understand either. Health care is only the single largest segment of the U.S. economy, so surely there is no risk in passing a 1,000-page health care bill no one understands! Universal access to health insurance is a moral imperative. But huge cost increases are likely to be triggered: Extending coverage will create more demand for services, and rising demand means rising price.

 

 If reform eliminates the dreaded “pre-existing condition” basis for denial of coverage — which makes sense for individual insurers and is nonsensical for society as a whole — that will be significant. Denying coverage to people with medical conditions is not only unjust, it causes insurers to waste money engaging in wars with their own customers. If health insurers must sell to anyone who wishes to buy, then their resources can be better invested in providing care. There needs to be a standard-price rule imposed, too, so insurers can’t effectively bar pre-existing conditions by saying, “Sure we will insure you, the price is $100,000 per year.” My impression is that so much lobbying attention has focused on the handouts, giveaways and interest-group demands for a gigantic new civil-service bureaucracy that not enough attention has gone to a simple change that would remove much of the injustice from health insurance — standard rates with no denials for existing conditions. This is the key to the successful health care system of the Netherlands.

 

So far as I know, health care proposals now in the Senate are so utterly fixated on handouts and giveaways that they don’t even address a core problem — the inability of individuals to buy at insurer’s prices. This is the PPO problem, and is serious. Most health insurance now operates through some variation on the Preferred Provider Organization. Physicians and clinics sign up with some insurers but not others; they agree to discount their list prices; if the patient goes to someone within the PPO, the provider gets business while the patient and insurer pay less. Sensible? The system is full of crazy disincentives.

 

Recently, a family member needed an MRI. The clinic had a list price of $1,500 for the scan but was in the insurer’s PPO, and so discounted (“adjusted”) the price to $690, of which we paid 10 percent and the insurer paid the rest. Clearly, that $690 price allows the MRI clinic to do business, pay its technicians and radiologists, etc., or else the clinic would not participate in the PPO. Yet if I’d walked in off the street and said, “I will buy this MRI myself,” the price would have been $1,500. Meanwhile, if the clinic had not been a member of my PPO, the insurer would have paid the same $621 it pays within the PPO, and I would have been on the hook for the rest, $879. The benefits sections of insurance manuals make it appear that if you use a PPO you pay 10 percent and if you go outside the PPO you pay 20 or 30 percent. Not mentioned, or stated in legalese, is that outside the PPO, the insurer only pays its “adjusted” amount — you pay 20 or 30 percent plus the balance of the list price.

 

The distinction between list prices and “adjusted” prices prevents health care services from functioning as a rational marketplace. It’s not just that many physicians refuse to speak about dollar figures. (“We don’t discuss prices over the phone,” a doctor’s office told me a few months ago when I had the gall to ask what something would cost, adding, “after the doctor has seen you, then we will tell you what the visit cost.”) It’s not just that many physicians’ offices and clinics do not have anyone authorized to discuss prices: They have minimum-wage receptionists and Mercedes-driving docs who expect the max under all conditions, but no one who will talk price with patients. The larger issue is that the system prevents the consumer from seeking the best price. If an MRI makes money for the clinic at $690, any customer should be able to buy at that price. The theory of the PPO from the provider’s prospective is that the provider grants a discount in order to get business: The self-pay customer represents business, just like the PPO customer. But the self-pay customer can’t get the PPO price, and the PPO price is the true price of the service. This prevents the bargaining-for-a-good-deal seen in the parts of the free-market system that function smoothly and hold down prices.

 

That the typical person cannot get the best price for health services is the big obstacle to transitioning away from the pass-along mentality that dominates health care. Right now Americans gripe about health insurance costs, but as this fascinating article by Ron Haskins shows, don’t directly pay most of the cost — most is paid by employers or government (which, in the latter case, means billed to the young via deficit spending). If you’re not directly paying most of the costs, you have little incentive to make smart consumer decisions. And if you can’t buy at the best price, you can’t make smart consumer decisions.

 

 Think about a radically different way to attain health care — in which most people carry only catastrophic-cost insurance, then pay other health costs themselves. No one can budget for a severe illness or injury; every family will always need insurance against catastrophic medical expense. Suppose insurance covered only catastrophes, and you paid the rest. You might think, “No way I am paying some doctor hundreds of dollars to set a broken arm.” But today a typical family’s health care policy that appears to cost the family $5,000 a year actually costs $15,000, it’s just that much of the money is hidden as employer’s costs — and thus, as higher wages the employer can’t pay. If you spent $5,000 a year for catastrophic coverage but earned an additional $10,000 a year, you could cover those strep-throat and broken-arm bills yourself, and probably come out ahead. Plus you’d have a keen incentive to comparison shop. Doctors could no longer loftily say, “We don’t discuss prices.”

 

Homeowner’s insurance is catastrophe insurance. It pays if the house burns down — the kind of thing no one can budget for. It doesn’t cover all costs of maintaining a home; you pay most ownership costs and you comparison shop. If homeowner’s insurance worked like American health insurance, it would not only pay for fires but also cover utility bills, replacing broken appliances, baseballs hit into the window and all the food, drink and paper towels that pass through the kitchen. Certainly, a company could offer an insurance product that covered absolutely every expense of living in a home. But such insurance would be phenomenally expensive and full of ultra-complex rules; the insurer would also acquire an incentive to dream up excuses to deny payment. Just like American health care insurance!

 

Gradually transitioning to a system in which most people carry catastrophic-cost medical insurance but pay the rest themselves could rationalize health care economics while restraining costs, because the wasteful paperwork aspect of the system would decline. The first step would be a standard-price rule — specifying that providers must offer the same price to all comers, whether insured patients, self-pay or Medicare. And the standard price must be published to allow comparison shopping. Good physicians and hospitals could still distinguish themselves through quality of care; in most of the free market, prices are similar, and quality is the basis of sales appeal. Stipulating that health care providers offer standard, published prices would lay the groundwork for an informed free market in health care delivery — and free markets control costs. They do it on their own, without layers of agencies and regulations. We’ve got to control health care costs or the future doesn’t work. Yet the current health-care reform plan is to add more agencies and regulations.