More of Obama's slippery slope.

[Bill Glasheen]

Glenn

This is a typical bull$hit case of a liberal writer slamming the insurance company, and yet not knowing what (s)he is talking about. (I'll bet you a cup of coffee that it's the LA Times.)

Let's start here.

In late April, Shelly Andrews-Buta was scheduled to undergo treatment for breast cancer that had spread to her brain, threatening her life.

The experience has been emotionally devastating. "I have two beautiful children, you know, I'm a single mom, they need me to be around," Andrews-Buta told CBS 5 Investigates.

But instead of having doctors working to remove her brain tumors on the day the surgery was scheduled, she sat in a San Francisco hotel room. Why? Because at the last minute, her insurance company, Blue Shield, decided it wasn't going to pay for the treatment her doctors at UCSF Medical Center had recommended.

Andrews-Buta was stunned. "I mean this is my life, this is my life, this isn't, gee, if we don't do it you're just going to have a cut that doesn't heal, this is you're going to die," she said.

Oh the bad, bad insurance company. Poor Mrs. Andrews is going to die and leave her children w/o a mother because insurance won't pay for her treatment.

But hold on a bit. There's more.

tumors had invaded 15 separate areas in her brain.

WTF??? And they want to gamma-knife 15 separate areas of her brain?

Are they insane?

But then this is oncology. As the joke goes... the reason they put nails on coffins is to keep oncologists from treating dead patients.

Dr. Sneed, who is co-director of UCSF's Gamma Knife Radiosurgery Program, described it as an amazing machine and the most appropriate treatment for Andrews-Buta.

Of course she'll say that. Surgeons cut; that's what they're trained to do. But they often aren't the best MDs to judge whether cutting (by low or high tech means) is the best way to go.

Blue Shield's *** policy lays out that a patient who has more than three brain tumors, what doctors call lesions, would not be covered for the gamma knife procedure. *** Blue Shield said it would pay instead for a less expensive treatment called whole-brain radiation, in which doctors try to kill tumors by exposing the entire brain to radiation.

Ohhh... So Blue Shield WILL pay to treat her. Meanwhile...

Just two weeks prior to the scheduled date for surgery, Andrews-Buta could still walk. Now she's almost paralyzed and unable to walk without assistance.

Why, because if you don't get your way, you take your ball and go home? Cut off your nose to spite your face, eh? What-ever...

And why are we to believe that a patient with Stage IV breast cancer with fifteen (15) mets in the brain isn't going to die anyway? And why did it take THIS LONG for her negligent doctor to detect the breast cancer? They might have caught it before it advanced to Stage IV if they had practiced evidence-based screening. Or maybe they would have caught it before there were 3 or fewer lesions in the brain. Even if they never got it all, they could keep playing whack-a-mole with the brain mets as they showed up. Happens all the time.

Here's the good part...

In Obamacare where there will be a competing government-run health plan, what makes you think THAT plan will pay for this treatment?

If this lady wants to die by gamma knife rather than by some other means, well power to her. Open up your checkbook and pay for it. But don't expect Blue Shield to bankrupt their reserves paying for stuff like this and then not be able to pay for evidence-based care at mega orders of magnitude less cost per unit of service.

This is exactly why we have a healthcare financing crisis today. Everybody wants what they want when they want it, and on their terms - even when/if it isn't evidence-based.

- Bill

[Jason Rees]

Why a lot of people favor health-care reform is because they figure anything has to be better than the current system.

This is a big problem with alot of liberals as I see it. Change is not always better, and starting from the mindset of 'anything' is better leaves alot of room to end up in a worse place than where you're standing. But hey, rushing ahead always gets the better result, right?

Disclaimer: If this doesn't apply to you, and you consider yourself a liberal, either you misplaced the shoe I found for you, or you shouldn't claim it.

[IJ]

I'm with Bill on the gamma knife stuff. When you have more than a dozen scattered tumors, what you need is to zap the whole brain. There are expensive treatments for cancer that cost upwards of 800k per year of life gained (they only extend life a month or two) that DO work (work only means, shows a "statistically" significant benefit, the way a sleeping pill can be approved at $100 a month if recipients fall asleep 5 minutes faster). As we all know, there are cheaper ways to buy a year of life, and I plan to turn down such therapies when time comes for me. Hey, why am I that important? Put it to better use.

You may recall the wacky Moore "documentary" Sick, where they interviewed bunches of people with similar sad stories. My husband was dying of renal cancer, and the insurance company blocked the bone marrow transplant, and now he's dead. Left out of the film: FRIGGIN BMT ISN'T A RENAL CARCINOMA TREATMENT.

Anyhoo, I inherited another patient today who was "full code" despite the problem list including: dementia and delirum at 90 years old. Kidney failure. Heart failure. Massive colon infection. Arrhythmia. Chronic lung disease. Bone marrow failure. More to the point: unable to speak and moaning in pain, progressive decline over months to years, accelerating, was home only 12 hours from last 30 day hospitalization when readmitted. Now they want "everything" because "none of us are God, she might get better." Again, everything is not on the table. Luckily the 4 other doctors involved agreed and told the family so, and as it happens, I don't cave to all demands. Now we're still trying all "noninvasive care," but some progress has been made. It'd be interesting to see what would happen to these requests if the family finances were being drained--as we saw above, there are elaborate collection efforts sometimes, but they simply wouldn't work if everyone tried them.

[Glenn]

This is a typical bull$hit case of a liberal writer slamming the insurance company, and yet not knowing what (s)he is talking about.

That may be Bill, but my point is we do not have to look to other countries to see complaints about someone other than the doctors making healthcare decisions. The complaint I posted is no different in then those made against decisions by governmental agencies in the UK, in both cases someone other than the doctor is making the decision. I was just pointing out that this condition already exists in the U.S.

[Glenn]

This is a big problem with alot of liberals as I see it. Change is not always better

That's not just a liberal philosophy, in a mandatory online training course I had to take a little over a week before I was laid off from my job, the company's employees were told specifically that we needed to accept a new practice because "change is progress" (and no, that is not out of context, that is truly all it said). And this from a corporation run by conservatives. I saved a screen shot of that one for posterity.

[Jason Rees]

http://www.docstoc.com/docs/10582301/Pr ... ber-8-2009

Dear Leader goes straight to the children...

[Bill Glasheen]

That may be Bill, but my point is we do not have to look to other countries to see complaints about someone other than the doctors making healthcare decisions.

I'm not picking on you, Glenn. But this anecdote was too good to pass up.

Your example gives a textbook case of

• MD conflict of interest. The head of the gamma knife facility wants to use gamma knife where she shouldn't. Furthermore... the more you have MDs investing in said ancillary facilities, the greater the regional costs and the greater the number of examples of bad medicine. The company I work for did a study of a rural Texas town where costs were skyrocketing because... It made it as an article in The New Yorker.
• MDs not practicing evidence-based medicine - at the expense of the individual patient's well-being and at the expense of society as a whole.
• Patients blindly asking for expensive high-tech therapies that they don't need.
• Poor screening practices leading to "too late" therapies.
• A reporter using the "Poor Mrs. Jones" anecdote against the bad, bad insurance company, not realizing that she makes a case FOR the insurance company making the tough decision.
• In general, society not wanting to make tough choices when it comes to spending someone else's money.

- Bill

[mhosea]

But then this is oncology. As the joke goes... the reason they put nails on coffins is to keep oncologists from treating dead patients.

I hadn't heard that, but it is painfully amusing. My father-in-law was diagnosed with stage IV esophageal cancer. He wasn't going to make it. The gastroenterologist who diagnosed him knew he wasn't going to make it. His oncologist knew he wasn't going to make it. So they opted for radiation and chemotherapy. The chemo made him completely miserable, and the radiation sapped his vitality and ultimately killed him (via COPD). The whole affair cost him little in money, but it shortened his life and decimated the quality of it. He had probably some good months to live if he'd chosen hospice. Instead he died in weeks.

My own father died (also at the age of 68 ), from carcinoid syndrome detected well after it had metasticized to the liver. Removing the carcinoid tumor would therefore have solved nothing. He was entitled to one long-acting Sandostatin shot per month under Medicare. This is a very expensive injection. He probably could have used two shots a month, but Medicare wouldn't pay for that. However, they would pay for the liver embolization that nearly killed him immediately. He never fully regained his strength after the procedure and died a few weeks later. I think we do have to get smarter about these things. I don't know whether another dose of Sandostatin would have prolonged his life, but I do know that the right choice for him was not an expensive surgery, and I believe (based on a lecture from the leading expert on the disease) the extra dose of Sandostatin was worth trying. Note the man never retired--he worked and paid taxes up until the few weeks before his death.

So my perspective may be somewhat skewed here, but these experiences have had an effect on me, and as a result, I'm not in favor of desperate measures to extend life when they offer little hope for recovery. I do think we've got to get smarter about this as a culture, with or without government run healthcare, and one of the complications is that people aren't objectively rational when a loved one is dying. They're going to need some help making the right choices.

[cxt]

Glenn

Not a bad point on the insurence corps being the people that get to decide.......problem is that I have not heard anything that would suggest that making the Fed the "decider" would be any better and plenty to suggest that it could be much worse.

Kinda a catch 22.

I'm sure that there are plenty of bad outcomes from greedy insurence corps we could tell........but I'm also fairly sure that things could well be worse under other schemes.

I'm all for improvement---just want to make sure that what were going to be spending 1 trillion dollars on is going to be "better."

What is the current polling running at? 80% or more of people in the USA are at least "satisfied" with their health care......last time I checked.
It would be nothing short of a disaster to tank a system that 8 out of every 10 people finds workable unless your going to get something that pans out better----and there is little evidence that we can expect that of the current plans.

Not saying we shouldn't be looking and not saying we should not be trying....just we need to be very careful and IMO start small...baby steps.

[cxt]

Bill

Good points!

Could we bring the cost of care down if we re-vamped malpractice costs? Tort reform....etc?

I have a buddy that went into Peds........and has nearly been driven out of it due to costs of malpractice insurence etc.

[Bill Glasheen]

Could we bring the cost of care down if we re-vamped malpractice costs? Tort reform....etc?

I have a buddy that went into Peds........and has nearly been driven out of it due to costs of malpractice insurence etc.

First... This would help, but it wouldn't completely cure the problem of health care financing. And it would help the most in obstetrics where the malpractice insurance premiums now can be as much as $200K per MD per year - or more. That's insane. In some states where trial lawyers have undue influence, women can no longer get obstetrical care in certain areas of the state (for instance Pennsylvania and West Virginia).

First thing we do is keep the lawyers out of politics. Unfortunately the horses have fled that barn. When you put lawyers in charge, they pass laws to protect their self interest.

The most important things I think would help are the following:

1) Require all to get at least a bare-boned health insurance policy the way your require people to get auto insurance if they want to drive.

2) Pool risk so that the very sick cannot get priced out of a policy. This has been discussed before by Enthoven and others. All risk pools should be sufficiently large so that you don't get a "death spiral" of higher-risk groups.

3) Pay doctors by the health risk of their patients and their patient outcomes, and not by the number of services they perform. There are working models of this from HMOs to "Medical Homes."

4) As much as possible, make sure patients have "skin" in the game. If they don't pay a share, then they won't care about cost or what it takes to avoid getting care in the first place (like stop eating cr@p and get off your @ss). I don't believe that medical care is a "right." It's something we should have access to, but at the same time something we should pay for in some way.

- Bill

[Glenn]

As much as possible, make sure patients have "skin" in the game. If they don't pay a share, then they won't care about cost or what it takes to avoid getting care in the first place (like stop eating cr@p and get off your @ss). I don't believe that medical care is a "right." It's something we should have access to, but at the same time something we should pay for in some way.

Given what all we have to pay for insurance, I don't see that we have this problem. Just the opposite in fact, because insurance has become such a necessity the insurance companies have all the power to stick us with high premiums and deductables and then turn us down when we need coverage. So much for capitalism, which only works when there is a balance of power between producers and consumers. Insurance companies take full advantage of this lop-sided situation and no longer see themselves as offering a service to customers, but rather taking what is "rightfully" theirs.

Maybe insurance is not a right, but life liberty and the pursuit of happiness is, and insurance is meant to give the majority a fairer shot at better health care so that we can exercise that right. Unfortunately we have returned to the point where your level of health care is based on your income, the wealthy can afford the better health care while most Americans can not. Insurance was meant to level that playing field, but currently is not, hence the need for reform. And while private insurance can never be a right, state-run health care could be in theory.

What is truly annoying is that Republicans were in control of the White House for 20 of the last 28 years and yet made no attempt at fixing the problem. Now a president they don't like introduces a plan and suddenly they have all these ideas for "better" plans. They already had their chance, and missed the boat.

[Bill Glasheen]

Given what all we have to pay for insurance, I don't see that we have this problem. Just the opposite in fact, because insurance has become such a necessity the insurance companies have all the power to stick us with high premiums and deductables and then turn us down when we need coverage.

Several problems here.

First... Very few people now appreciate the true cost of health care. We have some of the best health care AVAILABLE because it is both labor and technology intensive. If you take all the insurance company profit out of the system as it exists today, you still have "high premiums." Now take the 800-pound gorilla insurance companies out of the system and we're back to the days where

• doctors could charge "UCR" (usual, customary, and reasonable) rates rather than RBRVS (resource-based relative value scale)
• We pay hospital charges rather than DRG-based case rates
• We pay AWP (average wholesale price, a.k.a. ain't what's paid) for drugs rather than negotiated rates.

Fine... Profit gone and the big bad insurance company gone. Good luck going out there in the wild jungle of healthcare and getting evidence-based care at any kind of affordable rate.

Unfortunately we have returned to the point where your level of health care is based on your income, the wealthy can afford the better health care while most Americans can not.

This is the land of opportunity, and not the land of entitlement. Disparities serve to motivate the individual to produce. Without disparities, you have unmotivated single moms staying at home making babies without working, and having the system pay for their healthcare and education. But wait, there's more! When the adolescent males of these single moms discover there isn't a dad at home to show them the right way to live, a good portion of them end up in prison where they have yet another source of free healthcare and 3 free meals a day.

Even in this wacky system we have today, you can get primary care in the ER. That's not a way to run a system, but it's a way for even an illegal immigrant to get healthcare.

Insurance was meant to level that playing field, but currently is not, hence the need for reform.

Insurance was meant to pool risk. And you purchase as much benefit as you can afford. And if you live a lifestyle that makes you higher risk, you must pay a higher premium.

Insurance was never meant to "level the playing field." Socialism and communism was meant to do that.

And while private insurance can never be a right, state-run health care could be in theory.

It is in socialist countries. But be careful what you wish for. Quality, evidence-based healthcare is expensive. If you want to level the playing field and you are given a fixed budget, you may not like what is affordable.

And whenever you have a state-run healthcare entity, it becomes something which the state will not allow to fail. As such, there is no motivation to run in an efficient manner.

Private health insurance companies fail all the time. Back in the 1990s, myriad entities (e.g. academic institutions) were convinced that they could do it better than health insurance companies, and make a good profit while they were at it. So a whole bunch of them started their own health plans. And you know what? Virtually all of them failed (including one in this state), and got bought up by private insurance companies.

Meanwhile, healthcare kept getting more expensive. So... where is all the money going?

What is truly annoying is that Republicans were in control of the White House for 20 of the last 28 years and yet made no attempt at fixing the problem. Now a president they don't like introduces a plan and suddenly they have all these ideas for "better" plans. They already had their chance, and missed the boat.

I agree up to a point.

As soon as you let a government-run entity enter the equation, then it will become something that's "too big to fail." We've seen the blueprint for what Democrats will do by watching the bank and car company rescues. Meanwhile, nobody needed to rescue Honda and Toyota, and those cars are actually made in this country.

If a government-run health plan enters the picture, you will be guaranteed the following:

• Since the government-run plan will always be "too big to fail", it will bully its way into the market and be propped up by our tax dollars whenever it can't compete. That isn't true competition, and it won't foster either efficiency or good customer service.
• Taxes will go up. A LOT. Check in any country that has government run healthcare.
• We all will end up being reduced to a lower average standard of healthcare.
• Rationing will happen. The government will decide what is covered and what won't be.
• There will be long queues for elective procedures.

The government plan is what most free market people abhor. Once you let that baby out of the bag, you won't be able to kill it - no matter how ugly it becomes.

Be careful what you wish for.

- Bill

[CANDANeh]

* Since the government-run plan will always be "too big to fail", it will bully its way into the market and be propped up by our tax dollars whenever it can't compete. That isn't true competition, and it won't foster either efficiency or good customer service.

* Taxes will go up. A LOT. Check in any country that has government run healthcare.

* We all will end up being reduced to a lower average standard of healthcare.

* Rationing will happen. The government will decide what is covered and what won't be.

* There will be long queues for elective procedures.

Welcome to Canada. My former employer on a case to case bases paid to send injured (work related) employees to the USA to avoid waiting often years...yes YEARS for treatment such as ACL surgery.

[Bill Glasheen]

Whenever the state makes benefits a right, there are unintended consequences. Check this out.

'Viagra effect' undermining Brazil's pension system: study

Sounds good to me!

- Bill