Category Archives: health care

On the History of (Jack’s) ColonFiberOscopies

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First, I have to begin with a word of caution. This biographical entry contains some materials of a medical nature that might make some people a bit queasy. Best to skip this article if you don’t like hearing about blood or poop.

I’m writing this after my most recent colonfiberoscopy at UT Medical Center, which stirred the memory of how I became about the 3rd person in the United States to be treated with that instrument.

My earliest recollections of serious medical issues involving my guts go back to when I was 8 years old. That’s when I first noticed that there seemed to blood in the potty when I went to the toilet. Although my parents were not exactly the most medically knowledgeable people in the world (an understatement of considerable proportion) they did understand that this needed attention. Our family doctor recommended that they take me to Mt Sinai Medical Center.

There, and at many other times throughout my childhood, I experienced all the diagnostic tools available multiple times: the barium enema, proctoscope, and sigmoitoscope. None could detect the problem, although the presence of blood was confirmed and indeed obvious. In those days, the only thing that might have worked was exploratory surgery and as it turned out, thank Heaven my parents chose not to put me through that. So I regularly found blood, and every few months, there would be quite a bit of it.

In the Fall of 1969 I headed off to the University of Wisconsin, which had and still has one of the finest medical research hospitals in the world. As a freshman living in the dorms I reported my issue to the Student Health Service and they put me through the same battery of tests with the same results. Yes, there is blood, no, we can’t figure out where it’s coming from.

In my sophomore year, I was living off-campus with several guys who have become my life-long buddies. As it happened, our landlord stopped by to chat. He had a brand new powder blue Cadillac he was showing off. I felt some pressure and went to the toilet where I expressed approximately half my blood supply. I staggered out of the bathroom and passed out. I woke up in the University Hospital ER. I learned later that my hematocrit was 18 (42 is low-normal for adult men), so they gave me a transfusion of two units of blood. By then, whatever had caused the hemorrhage had ended, so once again, they were stymied about what was causing this. 

The way I got to the hospital was that the aforesaid landlord, who we thought was kind of a joke, grabbed me and threw me into his brand new car and drove me to the ER. You can never tell how kind and gracious a person can be until you see how they react to unusual circumstances. I never joked about Sid Livsey again. But I have to say that the next time I saw him he was driving a different car–he said, “Well they got the stains out, but they couldn’t get the stink out.” So he bought a new car.

I spent a few days in the hospital recovering and on the day I was to be discharged an impeccably dressed man came to visit me. His name was Dr. John F. Morrissey. Dr. Morrissey had formed a strong relationship to a team of Japanese doctors who had invented a new device which was then called a colonfiberscope in 1969. Dr. Morrissey had used it for the first time that very week and he invited me to become the third patient. He explained that this was a flexible tube that could reach far higher into the intestines than a sigmoitoscope. And, depending on what they found, they could actually use the instrument to fix some sorts of problems. I didn’t need much convincing. So that is how I became patient number 3 for this new device in the US. 

When you hear about this procedure these days, mostly what you hear about is how difficult the “prep” is. Basically, the idea is that the physician using the scope has to be able to see the intestinal wall, and that’s hard if it’s covered in poop. So you have to do something to clean it up. In 1971 that meant not just laxatives, but enemas.

On the morning of the procedure, I arrived at the clinic and was strapped into a chair that could be inverted. When I was upside down, they pumped water into my colon until my bowels were bloated. Then they right-sided the chair and the water poured out of me. They did this three times.

Next, I was wheeled into the room with the instrument. In those days the instrument was much thicker than it is today and you can guess what that might mean in terms of comfort. Of course today, Propofol is the drug of choice and you really don’t feel a thing. But in 1971, as Dr. Morrissey explained, they could not use anesthesia because they needed my feedback (so to speak) on whether the instrument might be causing too much stress. But they did use an I.V. to provide me with valium (diazapam) which made me a bit loopy.

The scope was inserted and at intervals of 25, 35 and 45 cm (about 18″) they found large polyps. The deepest and largest of these was big enough to have produced the hemorrhage that nearly killed me. Dr. Morrissey used the scope to extract the polyps and cauterize the areas. A few days later the pathologist reported that while these were very large polyps, they were benign. For the first time since I was 8 years old I could go to the bathroom without seeing blood in the toilet.

A year later, I returned for a follow-up procedure. Major improvements had already been made and I don’t recall any pain or problems. The scope showed that my intestines remained in fine condition and no new polyps had grown. I was then 21 years-old.

I didn’t have another colonoscopy until I turned 50 when my family physician advised it as part of my regular checkup. As you can imagine, I was astonished by the difference those decades had made. I know it’s an over-used metaphor, but comparatively speaking, it was a walk in the park. On that occasion, they found 2 “diminutive” polyps and now they applied the more technical term “adenoma” to them which is the more dangerous kind because they can become malignant. Mine were benign, but they recommended 3-year follow-ups. So while we lived in Michigan, I went twice more and both times the results were “clean”–no more polyps.

We moved to Tennessee about 9 years ago and when the time came for a follow-up I had an unpleasant surprise. Our GI folks prescribed a “prep” which in it’s own way was as bad as what I went through in 1971. If you’ve had a recent colonoscopy, you know what I mean–a requirement to drink a full gallon of ghastly stuff. There are more palatable alternatives, but many health plans won’t pay for them. So I did what I knew to be the stupid thing and didn’t go.

This year my health plan, it turned out, had authorized the more palatable solution and so I scheduled my visit for today. The prep was awful, but less awful than drinking a gallon. The test itself was, as I said, a walk in the park. They did find three (again) “diminutive” polyps and my GI doc said there’s no chance that they are malignant. But that doesn’t mean I wasn’t stupid. I should have swallowed my pride and the prep and gotten the test earlier. I could have as easily allowed myself to get cancer for nothing as have this better result.

Don’t do as I did, do as I say: get the test when the docs tell you to.

American Healthcare Cost Drivers: Explaining the Technology Money Pit

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Let’s begin with a simple illustration that probably resembles what you have encountered if you’ve entered a medical office anywhere in the USA in recent years. That is, if you are lucky enough to have health insurance. But then again, if you don’t, you probably haven’t entered any medical offices.

 

The receptionist probably handed you a clipboard asking for your basic information including family health history and of course your insurance details. In recent years, I’ve been handed an electronic tablet instead of a clipboard. Interestingly (to me, at least) on my most recent rounds the tablets have vanished, and the clipboards have returned. Something rotten in the state of technology, perhaps?

 

One way or another, all that information will become part of an electronic record-keeping system. And the financial part will likely be interlinked with the data systems of your health insurer.

 

At my physician’s office, the practice accepts a bewildering variety of health plans. These include several local, state, and federal systems. Medicare, Tenncare (Medicaid), different plans for Knoxville City employees, County employees, University of Tennessee employees, of which I am one. As it turns out, because the University of Tennessee is part of the State government, I actually have the same coverage as the governor and legislators. That’s how I know I have a terrific plan―the Republicans in charge of our Tennessee legislature may do a lousy job governing the State, but you can bet your bottom dollar they’ve taken excellent care of themselves.

 

But wait, there’s more! Many large employers allow their employees to choose among a smorgasbord of different plans. Different deductibles, allowable services, service companies, on and on. But take a step back from all that and ask yourself the question, what does any of it have to do with my own health care requirements? I mean, suppose your appendix bursts, or you have a heart attack, or it turns out you have diabetes. Don’t you just want to go to a doctor or hospital and have the problem addressed? Are you going to say, gee, I have an agonizing pain in my side, so let me figure out whether I need to go to this hospital system over here, or that one over there? That’s the right way to deliver and receive healthcare?

 

Supposedly this is a great free market opportunity for me. Why, I can decide which plan will best serve me. But that turns out to be a con man’s pipe dream. Consider: in my service area we have a few major hospital providers, including Tennova and the University of Tennessee Med Center. Every October, I can decide which of the several providers will best serve my needs. But how exactly do I figure out whether I might need a given medical treatment in May that previous October? Most people can’t predict when they might have a serious accident or come down with a grave illness. Guess wrong, and you get the inferior service, right? That’s the American way!

 

Medical profiteers have even introduced all sorts of complexity into Medicare. Do you have parts A, B, C, D or F–I give the whole system an F. Do you have standard Medicare or Medicare Advantage? Getting back to all those plans, it turns out that the necessity for dealing with it all has pretty much driven single-physician offices and smaller practices out of business. You might recall that that was the impetus for many a healthcare slogan: “You like your doctor? You can keep your doctor!” Except that most people can’t any longer. The doctors have thrown in the towel and surrendered their businesses to larger and larger aggregates of providers who can afford the technology required to process these multitudes of insurance forms and claims. It’s gotten to the point where my physician’s group office doesn’t even try to tell me what my bill is when I come in for service. They take my information, send it off for processing, and a few weeks later I get a bill. I’m supposed to be able to figure out whether the bill is correct, but I gave up on that years ago.

 

The insurance companies employ thousands of clerks, claims adjusters, and the like whose primary purpose has nothing to do with getting you healthcare. They are there to see if they can save the company money by figuring out a way to force you to pay more or outright deny your coverage. I’ve written elsewhere about the multi-year struggle we had with our insurer to get them to cover an injury and surgery for our son who sustained that injury while away for the summer. But that’s peanuts compared to what happens daily to others in this fair land of ours.

 

I introduced this topic because of technology, and here is how that fits in. Because a patient who enters a practice might have insurance provided by a dozen different providers each with their own bureaucratic requirements, physicians have to buy into expensive systems to determine who gets billed for what. Hospitals require those same systems, as well as their own for amping up their bills. This is how a one-cent aspirin gets charged at $10 or more on your hospital bill. The aspirin is only worth that one cent, but the hospital figures in a charge for their pharmacist to dispense the aspirin, someone to cart the aspirin up to your room, the orderly or nurse who serves it up to you, and the labor it takes to track that aspirin through each stage of the process. And all of that is tracked by huge, costly billing systems which are completely unnecessary in most other countries of the world.

 

All this is a major part of the cost drivers of American healthcare, and none of it exists in most other places. If you’re Canadian and come down with appendicitis, you go to the local hospital, they accept the exactly one form of health insurance they have, and they attend to your issue. Live in Alberta but have the problem in Montreal? No problem, it’s all covered! The same is true in Finland, Switzerland, Norway, Scotland, Luxembourg, France, Germany, Japan, Korea, Australia, New Zealand. Those are just a few of the countries who spend far less than we do and show better outcomes.

 

Now this is a very important point: as you read the back-and-forth of the political games that are unfolding and will continue to unfold through the next election (and beyond), you will hear the frequent and persistent claim that the forms of socialized medicine being proposed will somehow increase costs. This claim is predicated on the false premise that there are no cost savings to be obtained from simplifying the process. Therefore you must keep in mind that what I am describing here—enormous costs associated with tracking and billing the stages of healthcare—can be eliminated under many of those proposals. I’m not claiming that we can save all the funds currently being invested in healthcare tracking. Some of that is necessary for the actual needs of providing healthcare. But the billing component is unnecessary, and all the costs associated with billing can be eliminated under most of the proposals we are discussing. Don’t get me wrong—technology is great. Medical technology can save lives—I know because I was the third person in the world to have a colonoscopy back in 1971. But you know what? I don’t think I ever met anyone whose life was saved by a billing system.

 

 

 

Christian Science and Mandatory Healthcare

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An article in today’s Knoxville News caused me to reflect yet again about the state of healthcare in our country, these United States. The essence of the article was the focus that Christian Scientists do not believe in modern medical practice, but rather in the power of prayer, so should they not be allowed to opt out of paying for the Affordable Care Act?

The Christian Scientists interviewed for the article were by no means stupid or foolish. One stated clearly that they wanted healthcare to be available to all. Well, yes, but then you do have to pay for it.

The reasons why Christian Scientists, and indeed everyone else, needs to help pay for healthcare for all are manifold. Lets start with the simple: even the most dogmatic of practitioners must admit that there are circumstances where they would want to rely on modern medicine. If they are in an accident, or a fire breaks out, or if someone targets them in a drive-by shooting, surely they don’t think prayer alone will repair broken limbs, soothe burns or remove bullets.

The next point will be more controversial, but it needs to be said. When there are minor children involved, there is a genuine and important conflict between parental rights and the health and welfare of the child–and I think the child’s welfare overrules parental rights. It is one thing to deny a child a medical professional for the common cold, but quite another to prevent that child from receiving care for life threatening illnesses or immunizations intended to protect not only one’s own child, but everyone else in the community. I come down in this issue on the side of the power of the state to intervene and require that competent medical professionals be empowered to care for seriously ill children, and to require immunizations for all children.

One issue which often arises is that of compulsory payment. As far as I know, Christian Scientists have never claimed the right to be exempt from the Medicare Tax which is shared among all employees. We do not allow Quakers or other pacifists to opt out of the income taxes required to fund our military. People are allowed to change their religious affiliations whenever they please–just how would we be able to deal with folks who opt in and opt out of one religion or another over their lifespans?

This past year saw the infamous “Hobby Lobby” decision by the U.S. Supreme Court which I believe may go down as the among the worst decisions ever made by that body, on a par with the Dred Scott decision which helped lead to the Civil War. The Court held that Hobby Lobby could not be compelled to pay for health insurance which included abortion options. But what if a company owned by Jehovah’s Witnesses objected to paying for insurance that covers blood transfusions?

Of course I’m not suggesting that Christian Scientists should not have the right to decline medical attention. And perhaps their healthful lifestyles and meditative practices will lead to better lives and lower medical costs. Hopefully that is its own reward and they will not begrudge the lower costs and better protections that will result for everyone else.

 

Designing a Health Plan, Or How to Deal With Obstructionists…

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All the talk about healthcare plans has stirred up some Memory Lane incidents from my past life.

The first real job I had was one that I remember with great affection. As a student I had received much life-affirming support from the Hillel Foundations of Madison, Wisconsin and Berkeley, California. At Berkeley I began my career of teaching Hebrew which I am still doing, now as a lecturer at the University of Tennessee, some forty years later. Berkeley Hillel and Lehrhaus Judaica (the school associated with Hillel) combined to hire me full-time. For Hillel I was the Associate Director, and for Lehrhaus I was the Director of Hebrew Language Programming. My Hillel job included all the administrivia–managing the financial systems, employee benefits, that sort of thing.

Both Hillel and Lehrhaus were, in those days, under the general umbrella of the national Jewish social organization, B’nai B’rith. The relationship was usually positive, but here and there conflict arose as it so often does between parents and children.

B’nai B’rith had a mediocre health plan which we could buy into, but even that didn’t allow family add-ons or provisions for part-time employees. I began to look at possible plans of our own. I met with insurance company representatives, and a small HMO. The HMO was willing to allow us–and anyone associated with us–to become group members.

I next discussed with our Board  whether we could offer this as an employee benefit, and defray some of the cost via payroll deduction. Not only did they agree, but a couple of those Board members would eventually sign up as well.

When I notified national Hillel (in Washington D.C.) that we would no longer need their health plan, they sent me a rather nasty letter “explaining” to me that I couldn’t do this because we were part of their corporation. Luckily, I had been on the job for enough time that I knew something they didn’t know. Berkeley Hillel had its own corporation! When the money was raised to build the building in the 1950s, the donors were not willing to give the money to national B’nai B’rith. Instead, they incorporated separately. I had to file various reports with the State of California each year, so I knew about this. And pretty soon our local corporation had its very own health plan.

One of our employees was man of color in his 50s who had never in his life had a health plan. He had serious problems with one of his legs. But thanks to our new health plan, he received treatment and was able to work until his retirement.

Oh, and my wife was a post-Doc at UC-Berkeley which provided a plan almost as lousy as the one offered by national B’nai B’rith. But I could cover her through our new local healthcare plan. That meant that when my precious, lovely daughter had to be brought into this world via C-section, all of that cost was paid by our local insurance plan rather than bankrupting us.

Health Care in Post Revolutionary America

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We’re coming up on the first anniversary of my encounter with the American system of health care, so I think it’s worth doing a little recap and asking a few questions. I’ll keep this as short as I can, but health care is a complicated topic, so I hope you can spare a few minutes to read it in full.

Back in 2010 I retired from the University of Michigan a few years earlier than most people can consider such a thing. The largest obstacle many of you will face in taking early retirement if you are US citizens living in the US is the question of how you are going to obtain health care. And let me explain that I didn’t take early retirement so that I could play golf or sit on my butt, my object was (and is) to see if i can do something with my life more in line with what I set out to do after college. For my first year out I spent time trying to help folks living with a mental illness and now I am engaged in teaching Biblical languages and literature at the University level. With a little help from the Almighty and my friends I might see the day when I complete the Ph.D. I started to write in 1979.

Back to health care. Shortly after I agreed to the terms of the early retirement, the University of Michigan informed me that I could continue to receive their health care plan, but the cost would be $1,400 per month. As generous as the retirement offer was, there would have been no way that I could have afforded to pay that out of pocket. The reason I could consider taking the University of Michigan up on an offer to retire early was that I have a supportive spouse who agreed to carry me on her health plan. And so, with health care presumably under control, I took the offer.

A year after I retired, my wife received an attractive offer from the University of Tennessee Knoxville (UTK). Since I was retired, it was easy to give the offer serious consideration and we ultimately decided to take it. I arrived in Knoxville slightly before Terri just after Thanksgiving 2011. And just after I arrived, I suffered a pretty severe injury to my left knee brought on by all the moving activity. I wound up in the ER of UT where they spent some time making sure that I wasn’t going to bleed to death or need an amputation, and then they sent me home with a referral and advice to follow up with x-rays, etc. That’s when the “fun” began.

At that time (late November 2011) I was fully covered by the health plan of the University of Michigan. Beginning on January 1, 2012 I was fully covered under the health care plan of the University of Tennessee. At no time, not one day, was I lacking health care insurance. Nevertheless, I found myself effectively deprived of health care for about six weeks. This is how that happened.

As soon as I returned from the ER, I did what I was supposed to do under the terms of my Michigan insurance. I called the plan to inform them of the injury and to request that they authorize the recommended care. They cheerfully informed me that less the deductible, my ER visit was fully covered. They also said I was welcome to obtain all the follow-up care recommended by the ER with my “primary physician.” I pointed out that I was living in Knoxville and the primary physician was in Dexter, Michigan. They recommended that I fly or take the bus so I could receive my health care. When I pointed out that the health care was supposed to be covered when I was living outside Michigan, they replied, yes, that’s true, but you have to prove that you have lived outside the state for three years before that kicks in.

I wasn’t going to leave my spouse to deal with all the moving issues as she settled into her new position in Knoxville, so I just “toughed it out” reasoning that I would soon be covered by health care via the University of Tennessee. On January 2, now legally covered by UTK, I called a physician who had been recommended to me here in Knoxville. His appointments secretary looked me up “in the system” and informed me that since I wasn’t listed (yet) she could not offer me an appointment. I was flabbergasted. Really? She went on to explain that the UTK policy was that claims have to be filed within two weeks of the appointment or they would be automatically denied. It can take two or three weeks for the coverage to show up, and so in the past they have lost the ability to collect their fee for service because of this policy. As a result, they adopted their own policy which is not to see anyone who doesn’t appear on the claims list.

I did not have to wait the month or so this would have meant. I had made a physician friend in the community and he called to ask me how things were going. When I explained all this to him, he called the physician directly and the following day, the appointments secretary was back on the phone to me offering me an appointment. Altogether, I was unable to see a follow-up physician after my accident for six weeks.

This is how it was for a person with some of the best health care insurance in America. And all of the barriers to care that I experienced can be chalked up to insurance companies. Had I lived in Canada, England, New Zealand or tiny Israel I would have received prompt, good attention to my medical needs without fuss or muss. But in America, with our vaunted health care as available to those lucky enough to have insurance, I was treated like a pauper begging for care. Actually worse, because a pauper might have been eligible for indigent care.

The political silly season is now upon us. I am unconvinced that the problems I have experienced will be ameliorated by Obamacare because I don’t think Obamacare does much to reign in insurance abuse. What I would like to know is what precisely Romney/Ryan will do to improve this situation. I understand they oppose Obamacare (as I do). But that’s not good enough. While I dislike Obamacare, I think it is better than the nothing we had before Obamacare. Getting rid of Obamacare only puts us back to an even worse situation. What is the solution to this insanity we have in our country? Under what clause of what Romney/Ryan plan would I have been able to receive medical attention in less than the six weeks it took?