Tuesday, August 18, 2009

Public Enemy

In order to better understand the occasionally dreaded Public Option, I’d first like to recall a story I heard from the founders of Ben & Jerry, who spoke at my undergraduate institution when I was a freshman. They talked about the beginnings of their company, starting small in Vermont and quickly observing that they were successful because their product was good. It was so good, in fact, that they were noticed by the big companies in the ice cream market, specifically Pillsbury (owners of Haagen Dazs), which felt threatened by this tiny outfit in the snowy abyss of Vermont. Ben and Jerry found it funny that a giant multinational company so dominant in the field would worry about a small upstart and try to strong-arm distributors into not selling the upstart’s product, that they hired a plane to fly a banner at a Boston College football game stating “What’s the Doughboy Afraid Of?”, leading to a legendary advertising campaign that turned them into major players in their field. (Of course, the answer to that question is that the Doughboy was probably afraid of the awesomeness that is Coffee Heath Bar Crunch, Strawberry Cheesecake, or Dublin Mudslide.) In healthcare, one could easily imagine that for-profit private insurance companies are the doughboys…but who plays Ben & Jerry?

File that anecdote away for a moment. Now, I want you to close your eyes and imagine something rather fanciful. Wait. Open your eyes again. OK, forget the part about how closing your eyes means you can’t read what I'm writing. Just imagine something along with me. Imagine a healthcare system in a society that is entirely government run. Patients report to government-sanctioned hospitals, see physicians only within the government-approved network, and pay fees mandated entirely by the government. There’s more: the government sets what drugs within each class can be prescribed in this system (and makes it more difficult to obtain so-called “non-formulary” drugs, those that are basically not as cheap as the ones the government gets after negotiating with drug companies), it utilizes its own electronic medical record, and it inserts an oddly musky smell into the hallways of the hospitals it runs.

Is this a nightmare? A dream? A reason to transform into a screaming lunatic, unable to articulate even the most remotely intelligible thought while narrowly avoiding the rupture of every bulging vein in his increasingly sweaty forehead? Well, I got some news for you – what I just described isn’t some sissy Scandinavian healthcare program or a totalitarian Soviet-era monstrosity, it’s the Veteran’s Administration healthcare system that I’ve worked in as a medical student and a resident, and it has been around for a while. And let me tell you something even more earth-shattering, another government-run program that includes parts of what was described above is something called…Medicare. The point of this exercise is to dispel the myth that government has no place in healthcare, or that it is not already heavily involved in our healthcare. I thought people already knew this, but all those “keep the government out of my Medicare” quotes reaffirm how dense many of us are.

With that background, let’s take a look at the next semi-interesting part of the health care bill, Section 221 – Establishment and Administration of a Public Health Insurance Option as an Exchange-Qualified Health Benefits Plan. In this plan, the Secretary of Health and Human Services “shall provide for the offering of an Exchange-participating health benefits plan (in this division referred to as the `public health insurance option') that ensures choice, competition, and stability of affordable, high quality coverage throughout the United States in accordance with this subtitle. In designing the option, the Secretary's primary responsibility is to create a low-cost plan without compromising quality or access to care.” In other words, this plan is intended to serve as a check on the world of for-profit private insurance - our modern day Doughboy - that currently rules the health-o-sphere. On the surface, at least, this sounds like a good thing…unless you are in the health insurance company loving camp, which I suspect is less popular than a Brett Favre jersey at Packers camp. Let’s dig further at what this offers:

  • “Ensuring a Level Playing Field” – In other words, requiring that the public option be held to the same rules that all of the other insurance options. Reasonable.
  • “Provisions of Benefit Levels” – Here it is described that you can choose between “basic, enhanced, and premium plans”, as well as a potential “premium-plus” plan. Wait, I thought the point was that everyone should have access to the same affordable healthcare? This implies that there will be differences in the type of coverage one gets…or does the “enhanced” plan simply refer to the free Enzyte that comes with a subscription (in which case, sign me up!) . Admittedly, this smells fishy, but would not be a significant departure from the way the VA works in terms of service-connection, so I can handle it.

There are various other smaller details in this plan that are not all that interesting (unless you find “data collection” interesting, in which case I have a used life-size Britney Spears blow-up doll for you). I’d like to go back to the imagery put forward earlier in this piece, because it represents not only a government-run system, but also the health care plan we give to our troops we entrust to defend our freedom. I know first-hand that it is not a perfect system, and that there are many ways it could be improved (nurses who give a shit would be a good start). That said, it is at worst comparable to the private insurance plans out there and often much better. Better in terms of access to basic care and specialist services, to evidence-based therapies, and to integrated systems that move with the patient. Since private insurance companies (who have no access to this small market of veterans seeking health care) currently have no competitive interest to provide these services to the much larger population that they supposedly serve, perhaps a bit of competition might actually be a good thing - it appears that in the realm of healthcare, the government is the only party willing to and big enough to play the role of Ben & Jerry. We already have many public universities competing with successful private ones and public mail systems competing with private mail services, all leading to better options for you, the consumer.

After all, what is the doughboy afraid of?

Tuesday, August 11, 2009

Health Choices Commissioner: A Case Study In Ambiguity…and Michael Chiklis

After meandering through a tedious few sections on other consumer protections that are definitely important (non-discrimination rules, parity in mental health, and other vaguely defined things that sound really good on paper but are going to be pretty painful in person – that means you, “Ensuring Adequacy of Provider Networks”) but definitely not that interesting, one laboriously comes upon something called “Subtitle E – Governance”. Somewhere around here, this bill takes a fascinating turn into the definition of a new government position. Wait, sorry, it’s still really boring. But it does provide a lot of fodder for the “Big Brother Is Taking Over Our Lives!!!” freak-out camp that is wholly against this health care bill. It does so by defining a new commissioner intended to oversee the American health care system. Oh, that sounds so scary! Is the commissioner a good guy or a bad guy. Superhero or villain. Batman or The Joker. Anyone else or Rush Limbaugh. Yankees fan or a Red Sox fan (well, in that case, the Commissioner is a douche no matter what). But then even a superhero in charge can have its perils (look no further than to The Terminator’s fiscal policy). So what am I actually referring to? Something called the Health Choices Commissioner.

OK, take a deep breath.

Done? Good, because before you get your panties up in a bunch (Glenn Beck, I’m looking at you) about the “Health Choices” part of that title, let’s actually look at what this person will be doing before wondering when the Commissioner to decide whether you can get that hemorrhoid clipped. In Sec. 142 the duties and authority of the Commissioner are outlined:

(1) Qualified Plan Standards - establishing qualified health benefits plan standards. This includes leading something called a Health Insurance Exchange, which I am pretty sure has nothing to do with anything interesting, but it sounds a lot like the stock market exchanges we, as strident capitalists, strive for, so it can’t be that bad. Right? Individual affordability credits are also mentioned and sound ominous, but seeing as both of these topics appear later in this bill they’re probably worth tackling at a future time.

(2) Promoting Accountability – This includes complying with audits, ensuring that only qualified health benefits plans are available, and making sure the insurance companies pay for the studies done to determine whether they are kosher or not. While there is probably plenty of legal gobbeldy-gook to prevent the following scenario, it warrants mentioning because it seems so easy given the corruptible nature of our political-lobbyist-insurance company complex:

INSURANCE COMPANY PRICK: How much will it cost us to have you guys audit our insurance performance? And by audit I mean turn the other way while we do business as usual and deny little Billy that new kidney.
COMMISSIONER: Umm…well…my wife’s breasts are sagging, so a couple of implants…oh and I need a pre-auth to cover Viagra for…umm…my friend. You scratch my back and I’ll scratch yours.
INSURANCE COMPANY PRICK: Sorry, your wife’s saggy breasts are a pre-existing condition, you should have known they were going to be scraping the floor when you were younger and they were already swinging at the knees. We won’t cover that.
COMMISSIONER: Wait but you aren’t allowed to invoke pre-existing conditions anymore. That’s why I am auditing you.
INSURANCE COMPANY PRICK: Damn, you’re right. OK deal. So the audit is done, right?
COMMISSIONER: Yep, you passed!
INSURANCE COMPANY PRICK: Great! Thanks! By the way, your wife’s sagging breasts are considered elective surgery and we cannot cover their repair, have a nice day! [click]

Other Commissioner roles include data collection for the promotion of “quality and value, protecting consumers, and addressing disparities in health and health care”. Again, this all sounds reasonable and nice, but I suspect the details will get far more hairy. For example, some would likely key on the “addressing disparities” phrase and immediately sound alarm that about what that means. The government, at the hand of the Health Choices Commissioner, putting its hand into the healthcare system to make sure that Botox injections in Indiana end up as beautiful as those in Beverly Hills? Or, even worse, the Commissioner encouraging studies to address outcomes for different drugs and procedures to figure out which ones actually work? The horror.

Looking globally, the Commissioner has broad authority to enact many rules and regulations aimed at reigning in the powerful insurance companies, promote accountability, jump-start quality and cost-effectiveness research, and solve health care disparities. This brings up a few interesting points. First, who is responsible for this stuff now? I fear that no one is, and if so, that is really rather depressing but not that surprising, as this explains why insurance companies can do whatever the hell they want without any fear for real punitive damages. It is just depressing that our society long ago decided the government should institute mechanisms to make sure my Tiger Beat arrives in my mailbox on time, but no one gave a shit about making sure your health care was being followed.

That said, where does the Commissioner’s power end? Frankly, after reading this section, I have absolutely no idea. The Commissioner could model other kinds of commissioners in the feeble, pathetic mold (Bud Selig), the gentle-hearted, retarded-son-having mold (Michael Chiklis circa The Commish), or the psychotic, power-hungry, lawless mold (Michael Chiklis circa The Shield). In other words, I don’t think the bill makes this clear, so depending on who’s in charge, it could vastly change the health care landscape for better…or worse. I guess it just depends on whether you trust the government to govern or not. I, for one, am a bit skeptical…but on the other hand, Tiger Beat comes on time every month like clockwork.

Wednesday, August 5, 2009

Pre-existing Conditions: The Prostitute Paradox

(Pages 8-14 of the health care bill list definitions of terms that will be used throughout the remainder of this section, such as “dependent”, “family”, and “State Medicaid Agency”. Oddly absent are terms I keep hearing in the media or my mind when discussing this bill, such as “rationing”, “socialism”, and “Improving Resident Salary”. Not very interesting.)

The next section discusses minimum standards that any reform (or any American healthcare system) should meet, implying that our current system lacks such standards:
  • Affordable Coverage
  • Essential Benefits
  • Consumer Protection
Within each one of these topics they delve into further details, rules, and regulations. One such standard under the “Affordable Coverage” mantra is this (page 19 in the PDF version):

“A qualified health benefits plan may not impose any pre-existing condition exclusion (as defined in section 2701(b)(1)(A) of the Public Health Service Act) or otherwise impose any limit or condition on the coverage under the plan with respect to an individual or dependent based on any health status-related factors (as defined in section 2791(d)(9) of the Public Health Service Act) in relation to the individual or dependent.”

Pre-existing conditions. This is a bane for insurance companies and would be a boon for the consumer if it were stricken from our vocabulary. Since this is a complicated topic and can get tedious in the usual setting, let me try to break it down by applying this principle to a problem we are all much more familiar with: Say you are an enterprising young woman (or man) and you just moved to Anytown, USA, eager to resume your career as an escort or gigolo. You approach a casually dressed pimp on the street and suggest a business partnership – he (or she) provides you protection, tight clothes, and cocaine and you perform sexual acts for money. The potential pimp asks you about your preferences and you are quick to mention that, as a result of a catastrophic gerbil-meets-rectum celebrity party you participated in many years ago, you sustained permanent anal damage and are exclusively an ‘exit-only’ kind of escort. The pimp quickly denies covering for your street protection, citing this pre-existing defect in your skillset. You plead with him, explaining that you had no choice, it was completely out of your control, and you have been struggling with the consequences ever since and only wish you could have this problem be addressed. He threatens to choke you and you leave, approaching another pimp and receiving a similar response. And another, and another. And before you know it, you’re alone on the streets, bleeding out your butt and crouched in a naked ball begging for some breathmints, all because of an incident – that was no fault of your own - that happened to you years earlier that remains a chronic problem. Ladies and gentlemen, pre-existing conditions!

I have heard from many new clinic patients who have waited months to see a new primary care doctor (once they lost one insurance plan and then scrambled forever to find another insurance company that would actually cover them). Naturally, these tended to be middle-aged people who already had accumulated a medical problem or two, and thus kept getting denied coverage for having these problems, leaving them in a position where they could not be taken care of for the medical issues they have because of the issues they have*. In other words, barring hordes of cash that no one has anymore, the only way you can get real health care coverage is if you are already healthy and don’t need it as urgently in the first place. Meanwhile, the rest of us are subjected to lesser or no care, and pretty soon everyone is terrified of the gerbil that will seal their doom.

Interestingly, a way around this is to simply lie, as physicians have attempted to do, by hiding a patient’s health problems on the chart until the whole pre-existing conditions exclusion period is over and the patient magically develops hypertension, diabetes, and heart disease overnight. Unfortunately, insurance companies figured this out (presumably as a result of disappointing profit margins) – my health insurance company, Blue Cross PPO, even threatened doctors on this problem last year in a memo of remarkable douche-itude.

Given this, I thought I’d attempt an experiment and confront a random insurance company with my pre-existing condition to see if I would still be eligible for coverage. I constructed a heartfelt letter explaining my condition, hoping that it would not bar me from getting access to medical care. However, I have not yet received a reply. My problem? I have a superfluous third nipple. I bet you thought I was going to say something about my butt.

*For any computer science geeks out there (don’t be shy, everyone already knows you are a loser), it’s sort of like a logic error in your code leading to an infinite loop, but instead of the loop just screwing up your crappy attempt at an iPhone app, it slowly makes you blind, shuts down your kidneys, and kills you. I should add that I might be totally wrong on that. I should also add that I first dabbled in computer programming in 6th grade, making an Apple IIC to print “Fuck you!” forever (I almost got suspended for that one). Look at me now, Temple Emanuel Day School!

Monday, August 3, 2009

A First Look

This bill is long. War and Peace long. Ron Jeremy long. Longer than the last two minutes of any close NBA game. So long that I wonder whether congressmen are paid by the word so they fill these bills with random fun facts from Us Weekly just to pay off their hookers and their families (Congressmen have hookers who visit them in secret society fundamentalist clubs, then get their parents to pay the hookers hush money - they’re just like us!). But not long enough that, in little chunks, it can’t be tackled. Yet, I suspect that some of the motive for making this bill so long is that it will discourage all but the most stubborn, bored, and/or totally lacking in all matters of social outlets to really read the damn thing in an effort to understand it. Fortunately for you, I have no life and would much rather delve into this word salad so that I can toss aside all the nonsense.

The byline on this bill reads, “To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes.” So basically we get more stuff that is better than the old stuff and pay less for it? There can't possibly be a catch. Only 1,017.75 pages to go.

The next notable part of this bill is the listing of contributors:
Wait a second – Mr. Waxman? The Henry Waxman?! True story: Henry Waxman is my hometown congressman and he visited my high school when I was in 10th grade. He gave a special talk to the occupational immersion program I was in, a program created for fat awkward kids so that we could sign up for internships in the community rather than do P.E. (For the record, the production company I worked on for that program put this puppy on TNT during my tenure...you're welcome.) I remember that talk vividly because a) his physical appearance is so shockingly comical that I can only hope that he gets a paycheck every time they play that Chipmunks Christmas song on the radio and b) he spent 30 minutes talking about his crowning achievement that took him more than 20 years to accomplish – the creation of those Nutrition Facts labels on all food. At the time I remember thinking, “In 20 years the best he could accomplish was a nutrition label that no one reads and is probably wrong a majority of the time?”, but now I find that reminder of how awful everything I eat actually is for me strangely reassuring. Well played, Waxmunk, well played.

The next four pages represent a comprehensive outline of what will be discussed, and we finally start with some meat on page 4. “Division A – Affordable Health Care Choices".

Wait, I thought that was the purupose of the whole bill, not just a “Division”? I wonder whether some other random stuff is going to make its way here on page 746. Anyways, the bill states that it will build on what works and repair aspects that are broken. Funny, that doesn’t make it sound like we become socialist commie pigs if this bill gets enacted. Further reading outlines insurance reforms, including creating something called the Health Insurance Exchange, and “shared responsibility among workers, employers, and the government…so that all Americans have coverage of essential health benefits.” I still don’t feel like a communist traitor, but I know that this raises an interesting point of contention – some could argue that there is nothing “essential” about health benefits in the first place, that it is a commodity like anything else and should be treated as such (rather than being something special that requires a 1,018 page bill). (In fact, this came up in the presidential debates last year; Obama thought health care was a “right”, whereas McCain thought it was a “responsibility”.)

This is a tempting thought, as it builds on the notion of personal responsibility that this country was presumably founded on, traced back to our Founding Fathers (less clear is whether this can be expanded to include the personal responsibility to eradicate native Americans and exploit slaves from Africa, but hey, thanks for playing). However, these same people don’t have their panties in quite the same bunch about that less-popularized but far more obnoxious requirement that we all have car insurance. So basically, their argument goes that no one should care that you couldn’t afford to insure all those bones you broke in a nasty car accident (caused, no doubt, by your poor vision that could not be corrected since you lack insurance to get glasses), but if you didn’t insure your piece of crap 1994 Ford Taurus that not only will never get you laid but now needs thousands of dollars of repairs, you’re in a veritable legal shitstorm.

In other words, health care is “essential”, it is a “right” AND a “responsibility”, and anyone who says otherwise clearly hasn’t been sick before. Your thoughts, please.

Alright, five pages down and I’m feeling great. Tune in next time to figure out why they need to spend six pages defining words like “State”, “Family”, and “QHBP Offering Entity”. Also, why “Essential Benefits Package” sadly has absolutely nothing to do with sex. I think.

Background and Biases

The background for why various members of our government are attempting to overhaul our healthcare system are hopefully well-known by now, but just in case you don’t already know, I invite you to read a few background articles (one, two, three), as well as my old nonsensical ramblings that also touch on the subject. But the basic reason for why healthcare has gone to shit can be summed up in this horrible run-on sentence (grammarians, my apologies): Not enough people have access to even marginally adequate care and end up presenting to suboptimal settings (i.e. emergency rooms) on death’s door at much higher cost to society and are assigned to overworked doctors and nurses operating on shoestring hospital budgets who can’t afford to actually take care of these people, while other people with money show up for the same problems and get every obscure test under the sun at massive expense that the insurance company occasionally reimburses after denying coverage seven or twenty times, all while we all get totally fucked over by a pharmaceutical-insurance cabal aimed at capitalizing monetarily from our suffering and lack of access to quality care. Or something like that. Oh, and everyone is way too fat. Yes, I mean you, 400+ lbs woman I saw at Souplantation two days ago mowing down two plates full of pizza, pasta, soup, and cornbread (with a few lettuce leaves on the side) successfully before going back for TWO MORE PLATES. Jesus.

Because of all this, despite spending (by far) the most money on healthcare, our system ranks a pathetic 37th in the world, behind such medically-enlightened luminaries such as Colombia, Morocco, and Luxemborg. While some may doubt the methods behind this particular metric, enough similar studies using different methods have come to similar conclusions to certify that yes, we suck.

As such, a group of Democratic lawmakers in Congress, under the directive of President Obama, have crafted a bill that they hope will alleviate the aforementioned problems. The problem is that depending on who you ask, this will either solve all our problems with ease or lead to the coming of the Antichrist and the destruction of Earth (being a Jew and, therefore, a potential Antichrist, I can only shudder at the possibility of initiating my own ironic destruction). The only way to know for sure (and to drink heavily in case of the latter) is to look at the damn thing and decide for ourselves, which is what we will be doing.

Before we dive in, a little about me and my biases as I write this. I voted for Obama in this most recent presidential election, I think all elected officials (including Obama) take every opportunity to be as crooked and awful as possible, and I have absolutely no qualifications that make me more likely to understand this bill than the average college-educated ridiculously handsome Jewish male. In fact, the last government-oriented class I took was AP Government in 12th grade ten years ago (although I did get a 5 on that test…as well as on 13 other AP tests. Suck on that, Nancy Chang!), and as anyone from my high school could attest, that civics class was not exactly known for being particularly rigorous (we watched Primary Colors over the course of an entire week to teach us about political campaigns and old people sex). Not to belabor the point, but I haven’t even seen the real version of School House Rock’s “How A Bill Becomes A Law”. Basically, I am already completely over my head and we haven't even started yet.

Yet, I am also a physician struggling within the confines of our current health care system and, by virtue of my residency program, I have had the opportunity to see how different health care management systems in three different hospitals (public-county, private, VA) can fuck everything up. On the flip side, I suspect that I have a lot to lose financially if health care reform passes, and will have to forgo my dreams of paying off my medical school loans before I turn 65.

The only position I cannot accept is the one that states our current system is perfectly fine as it is - any system that leaves 50 million people without access to healthcare and millions more with limited or fragmented care at the mercy of profit motives by insurance companies is simply broken. End of story.

So now that I have proven I am completely unqualified to understand this bill or successfully draw any conclusions, let’s dive into the morass and figure out ways to make jokes about it…and maybe learn something.


Hello, my name is The Fake Doctor. OK, that’s not actually my name, but let’s just say it’s a lot more popular than my real, ethnically hilarious Jewish name. Starting in 2003 I wrote a blog to describe my experiences as a medical student, where, as expected, I encountered so many freaks I didn’t know what to do with myself. From there I somehow managed to obtain my medical degree and proceed to residency, where I encountered less freaks (but am still pleasantly surprised from time to time). Realizing that I was getting a little bored repeatedly delving into the comic misery that is my life, I thought I’d turn my attention to something more exciting and more relevant. No, not the minute-by-minute happenings of Michael Jackson’s half-brain, but close. By “exciting and relevant” I mean a gloriously worded, home-brewed, 1,018 page blockbuster known as HR 3200. It is also known as “America’s Affordable Health Choices Act of 2009”, “Better Than Sex”, or “The End Of Mankind As We Know It”.

Because of its many names, I thought it would be interesting to actually look at this monstrosity in some amount of detail since, unlike just about every other piece of legislation that has been passed in first 28 years of my life, this one might actually affect me as a current and future practicing physician (take that Farm Security and Rural Investment Act of 2002). I though it would be great to actually initiate a dialogue about this bill, since it is all really confusing and, as I learned when my dad challenged me on my thoughts on the matter yesterday, I have absolutely no idea what I am talking about and should probably learn something about how this would shape my career. Also, I thought that deep down, if I could actually find something funny about this, then maybe someone will actually offer me a book deal so I can make a buck or two million.

With that, I plan to analyze this bill over the next month (or when I have time). Since I think it deserves its own post, I will comment on potential biases and background shortly. I invite any and all comments (try to keep it civil and/or ripe with naked pictures of yourself), and I hope you find this at least somewhat useful. And if not, you can’t arrest me for trying…unless I happen to be trying in my own home.