August 2009 Archives

This comes from an internist. He has had a primary care practice in the New York metropolitan area for more than 20 years. For obvious reasons, he asks to remain anonymous. I've met him and can vouch for his identity.

Right now, I have dropped my participation in every insurance plan except Medicare. I can tell you from first-hand experience that the private managed care plans are out of control with their denials, pre-authorization requirements, and drug formulary restrictions. Plain old Medicare is the last bastion of health care insurance that actually allows the doctor to make a decision on what a patient needs without having to fill out reams of paperwork or spend endless amounts of time on hold, waiting for insurance company representatives who barely have a high school education to tell me if I can provide needed procedures or specialist referrals for patients they've never laid a hand on.

Has anyone looked at the expenses of a primary care physician's practice vs. the ridiculous insurance company reimbursement schedules for E&M (evaluation and management) services? That is, for actually talking to and caring for patients instead of cutting and irradiating them? My average reimbursement for a 15-minute office visit by a patient covered by a private managed care plan is about $50 vs. Medicare's $70. Too bad it currently costs me $92 to provide that same service. And can anyone explain to me why I have to pay $50,000 in salary and benefits for someone in my office to sit on a phone all day long fighting for my patients' health care needs? Especially when I'm attempting to authorize procedures I believe necessary that I will not earn a penny on? At the same time, radiologists and other overpaid subspecialists get to bill hundreds of thousands of dollars a year on the procedures I have to fight to authorize for them?

Or maybe someone would like to explain the insurance companies' wonderful new managed care formulary departments, which approve medication requests -- or don't. Three times in the last two months they have rejected my requests for more "expensive" diabetic medications, invoking the requirements that all diabetics be given generic Metformin as a first-line agent. Unfortunately, these patients all happen to have weakened kidneys (common for diabetics) and would get lactic acidosis if I prescribed Metformin. It would likely kill them! But I guess dead patients cost the insurance companies less money than living ones.

Watch President Obama reiterate his belief in the health care public option just a couple of months ago.

"Those ain't lies. Those are campaign promises." -- William Demarest, in Hail the Conquering Hero.

Postscript: Obama's Trust Problem

$80 billion of WHAT?

Oughta put the cost of U.S. healthcare reform into perspective.
Reform would cost $900 billion to $1 trillion over the next 10 years.
Which does the American majority prefer -- taking lives or saving lives?

Consider this trade-off: Taxpayers in New York City, where I live, will pay $30.6 billion for total war spending in Iraq and Afghanistan since 2001. That amount of money could have paid for an entire year's worth of health care for 5,637,896 people, more than half the city's population.

Or how about Elkhart, Indiana? "Hammered by the recession," it became Barack Obama's "symbol of the need for his stimulus plan." Taxpayers in Elkhart will pay $99.7 million for spending on both wars since 2001. That could have provided 29,533 people with health care for an entire year.

Have a look your own community's trade-off.

I know, because I live in one, and I'm doing fine. I haven't been arrested for jaywalking, littering, loitering, begging, or sleeping under a bridge. I haven't been arrested for sleeping in a homeless shelter when there's an outstanding warrant against me for sleeping on a suburban sidewalk. I haven't been arrested for being someone who looks to a reasonable person like I belong on public assistance. I haven't been arrested for eating food someone gave me in a park. I haven't been arrested for not being white, wearing a wrong-color T-shirt in a wrong-color neighborhood, or looking overly anxious in an airport. I haven't been arrested for being late for school or without ID in public housing. And those are just some of the things I haven't been arrested for. The reason I haven't been arrested is not because I'm white and haven't committed any of these crimes -- let's face it, I've jaywalked, littered, and loitered, which makes me a triple threat -- it's because I'm not poor. If I were, living in my police state would not be OK, as Barbara Ehrenreich points out today in her must-read NY Times op-ed on "the viciousness of the official animus toward the indigent."

(Crossposted at HuffPo)

Postscript: Talk about a police state ... a friend writes from Germany: "Did you know that the German govt is now authorized (by a Parliament fulla worthless flakes) to invade everybody's pc or laptop with a spy program -- called, don't laugh, 'Trojan horse' -- and make a record of every key touched, and store the information for six months, etc. Of course, Hitler waived the idea of opening everybody's mail and used a shortcut: Dangle a few krauts from the nearest tree with a cardboard sign around their necks that says: I am the evilest pig in town / With Jews I have been screwing around. Selah. In other words, we have accomplished the unthinkable -- we have sunk below herr Hitler ... and M'sieu Napoleon, and Henry VIII ... and Nero."

So I'm reading a Christian Science Monitor article recommended by a friend as "wonderful writing" -- A day of reckoning for Bush's 'torture' lawyers, by Ronald Sokol -- and I think, Yup, clean, clear, an excellent summary of all that's been said before many times in many places. But when he writes, "To regain its moral legitimacy, America must formally recognize that some of its official post-9/11 practices were unlawful," I have to ask what moral legitimacy is he talking about? America doan haf no moral legitimacy.

Seems to me el Senor Sokol subscribes to a notion of America the beautiful that went away long, long ago, if it ever was anything more than a myth, and it ain't comin' back. Uh ... Vietnam, anyone? Iran-Contra? Remember the Maine? Westward ho!? The belief that America has moral legitimacy was buried next to the WMDs we never found. Drowned in the claim that water boarding wasn't torture.

We live in a world of delusions. I'm no historian, and certainly not an authority on the subject, but long story short: one of those delusions began with the defeat of Shay's Rebellion in 1786. The U.S. Constitution, its virtues aside, was then written to serve the interests of a slave-owning financial elite.

Now click to David Bromwich's HuffPo article on America's addiction to "serial war," a useful term. He reminds us that the national security state as we know it requires "an enemy at all times that exceeds the citable evidence of danger at any given time." And Obama ain't gonna change that.

It is not only the vast extent and power of our standing army that stares down every motion toward reform. Nor is the cause entirely traceable to our pursuit of refined weapons and lethal technology, or the military bases with which the U.S. has encircled the globe, or the financial interests, the Halliburtons and Raytheons, the DynCorps and Blackwaters that combine against peace with demands in excess of the British East India Company at the height of its influence. There is a deeper puzzle in the relationship of the military itself to the rest of American society. For the American military now encompasses an officer class with the character and privileges of a native aristocracy, and a rank-and-file for whom the best possibilities of socialism have been realized.

The worst, too: See Kathryn Bigelow's prize-winning indie flick The Hurt Locker, which has just gone wide, and read today's New York Times frontpage feature on soldier suicides. Oh, and let's not forget all those dead Iraqis.

Remember in December, 2005, when we were talking about potential genocide in Iraq? How it could well be a part of U.S. strategy, or as one Pentagon proposal put it, the Salvador option? Here's Juan Cole writing of the death toll about a year later, in October 2006: "A careful Johns Hopkins study has estimated that between 420,000 and 790,000 Iraqis have died as a result of war and political violence since the beginning of the US invasion in March, 2003." He warned that due to conditions we created the number could reach a million "à la Cambodia or Afghanistan." Is anyone still counting?

PS: A reader writes:

Moral legitimacy... Sounds like a Bush invention along the lines of Office of Homeland Security... Office of Moral Legitimacy. "Here to keep America on the right track..." Sarah Palin would be its first secretary. "I don't want my physically disabled child to grow up in a morally disabled America," she proclaims to an audience of white people (travel expenses sponsored by Wal-Mart).... After her first big success -- the suppression of free speech ("If it's free, you get what you pay for") -- she renames her branch the National Office of Religion, Morality, and Legitimacy -- NORMAL...