October 2013

Surgery, Robots, Bills

This summer I had part of a kidney removed, and I have now joined the ranks of the Cancer Survivors. I will not be wearing the ribbon that seems mandatory for those who have, to use John Wayne’s expression, “whipped the Big C,” because I don’t see renal cancer as an achievement that merits a decoration, because I doubt the fruit-salad of pink and teal and white on people’s lapels has done anything except enrich the ribbon manufacturers, and because my malady is championed by two competing foundations, so I would have to choose between green and orange. Either color would be problematic: green also stands for support of the family farm, a fine cause but not what’s closest to the heart of this city boy, and, as a graduate of Princeton University, I wear too much orange as it is. My doctoral gown makes me look like the Great Pumpkin, and it was probably a mercy that my Irish father had gone to his reward before I first donned the livery colors of the oppressors of our people. And if tried for a more thoroughly Irish look by adding a white ribbon between the Green and Orange, it would not suggest peace between the warring kidney factions, but someone half as interested in breast cancer as in kidney disease.

The surgery showed everything that is best in American medicine. An operation that in my mother’s time—kidney cancer seems to be one of the Abel family curses—would have involved a large incision in the back and a lengthy hospital stay, kept me in the hospital for only two nights—and I might have gone home after one. The laparoscopic technique and robot-assisted procedure left me with only a few small “bullet holes” in the belly and no stitches that needed to be removed. The gas that expanded my abdomen into a working surgical theater did cause some pain and made me look like the Michelin Man when I returned home, but once it dissipated, I was fine. In less than a month I was traveling overseas.

So all praise to the doctors, nurses, techs, and other healers and carers. But while I am sure that those who treated me used the best practices to be found anywhere and applied them both rationally and humanely, I can’t say that about the rest of the system.

I am lucky enough to be able to afford health insurance. Since I had a “previous condition” when I left my last place of employment, I had to obtain it through the State of Missouri’s “Risk Pool.” (That is a system that forces insurance companies to cover their share of the bad risks: the term is best known from automobile insurance, where the worst drivers end up in the Risk Pool.) For the option with a reasonably low deductible, I have been paying around $700 a month—or $8000 a year. Thankfully, I can afford that.

With this coverage, my two days in the hospital has cost me about $5000, so far. I can afford to pay that amount, too—and much, much more was spent on my care. What someone in my medical and insurance situation with the median American
household income of $51,000 a year would do when faced with medical expenses that reached $13,000 just for basic insurance and one brief stay in the hospital is a question that leaves me both thankful and appalled.

But it is not just a question of the money to be paid. It is how the money is collected. The hospital whose staff cared for me so well has already had a functionary threaten to sic the collection agencies on me if I don’t pay up pronto. As I pride myself on paying my bills as I receive them, that is the sort of threat I rarely have to hear. But it is hard to keep track of all the different bills that are presented—hard not just for me, but for the hospital itself. I spent part of this morning on the phone trying to discover what payments they had received, which they hadn’t, and what they would do to make sure my credit card wasn’t charged twice if the payment I had submitted previously turned up after I had allowed them to charge my card again. That was a more difficult task than I thought. They could not simply check my account to see what payments had been posted. That was impossible, because they create a new account for each patient for each day he is in the hospital, each with a different number. I cannot think of any other business that works that way. It seems to be a system designed to create confusion.

And that is only the
hospital billing. The billing for the physicians is separate—and not always the same for all of them. I am now on two online networks that collect my medical information and allow me to pay my bills. That there are two of them undermines the purpose of the operation, because the information from different sets of doctors is not pooled. And some of my physicians are not in either system. My primary care physician, the specialist who discovered my cancer, the surgeon who treated it, and the hospital at which he operates are “owned” by different insurance companies or health care companies. The docs work together just fine. The organizations don’t.

At this point I am sure that some readers are beginning to suspect that I only came down with cancer so that I could use my own experience to denigrate the greatest healthcare system in the world. They may even suspect that I am a proponent of Obamacare and bent on bringing socialism to God’s Country. That is only half-true. I have not liked the Affordable Care Act since it was passed, and only support it at all because it is the only plan to expand medical coverage on the table just now. I would like a plan that was easy to understand, that would more completely ensure health care coverage for all, and that would remove the burden of providing healthcare from employers. (And, most of all, that would not further abortion in any way or trample on the consciences of some people—but I set the most important issue aside for now.)

Like anyone who has had an involuntary encounter with the American health care system, I cannot help seeing the disparity between our technical mastery and our organizational incompetence. Our physicians can do wonders to reduce human suffering. Our medical providers and insurance companies make our lives—and, by all reports, our physicians’ lives—a series of pointless battles fought for no good reason. When I think of a person living on the median household income, especially one in a household of more than one, I also think it is a system that is not only annoying, but genuinely cruel.

The Catechism of the Catholic Church, which I tend to take seriously, has this to say about the role of government in society:

The political community has a duty to honor the family, to assist it, and to ensure especially:
. . . . . . . . . . . . . . .
- in keeping with the country’s institutions, the right to medical care, assistance for the aged, and family benefits;
- the protection of security and health . . . (2211)
We have failed on these measures—and I hope that no one will be pharisaical enough to claim that we’ve got an “out” because our neglect of our duty is “in keeping with [our] institutions.” If ensuring that health care is available to all is socialism, the Catechism is socialist, its promulgator, The Blessed Pope John Paul, was a socialist, and I am, indeed, a socialist as well.

What the Catechism describes is the moral minimum we should set ourselves. And I don’t see how it can be achieved without universal health care.

The practical minimum we should set is that we provide universal care with as much efficiency as possible. Physicians should not spend their days arguing with insurance companies. Patients should not spend their convalescence figuring out “explanations of benefits” and dealing with dunning robo-calls from providers.

The system called Obamacare may do something to provide the minimum level of coverage for all. I do not see how it will address most of the practical problems. It has adopted the current unwieldy structure and added a new level of complexity to it. As the problems with the website show, we have just expanded a Rube Goldberg contraption with a few more shoots and pulleys instead of figuring out the simplest way of putting the ball in the bucket.

No one has ever given me a satisfactory answer to the question, “What value do insurance companies add to the health care system? “They do not make it more efficient. They do not make it easier for the physician to formulate and carry out his treatment plan. They do not make it simple for the patient to keep track of either his medical records or his medical bills. They do, however, put a lot of money that might pay for medical care and place it in the pockets of the executives and shareholders of insurance companies.

I would never want a state-run health care system, such as the British NHS was at its height. I would like a single payer system, where one entity negotiates with private health-care providers and pays the bills. They have that system in Canada, and it works quite well. We, in fact, have it here in America, and it works, too. We call it Medicare.

Medicare, however, generally only covers those of retirement age. Why can’t we simply expand it to all? I cannot help noticing that those groups who oppose “Obamacare” most vociferously are made up disproportionately of people eligible for Medicare, but they do not clamor for that “socialist” system’s abolition.

What do I want? I want a single card for all my health coverage. I want a single website for all my medical records, appointments, and communications with providers. I want the providers to be able to share information efficiently so that I don’t get the same test in three offices. I want to pay for my share of the total cost of medical care through my taxes. I am happy to be charged reasonable co-pays, especially for missed appointments, since people do not value what they do not pay for and investment in the process encourages patient compliance. And I want the people now working in the health insurance companies and medical billing offices to find new careers in fields that might actually increase the stock of human happiness.

That does not seem to me to be a radical plan. I could go on to describe how it would be better for business if they were freed from the burden of supplying health care for their employees—or the stigma of denying it to them. But I have another form to fill out in order to get the supplemental coverage that will pay more of my hospital bill because my kidney problem was cancer and not hepatitis. But if there is a reason you can insure yourself against cancer but not against infection, I have yet to figure out what it could be.