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Sunday, November 29, 2009

It Was A Working Holiday

Through a series of flights, drives etc, my immediate family all managed to end up together for Thanksgiving in the Ne. That was the great part. The weather was not great.

The difficult part was that my brother the TechnoBuddha was scheduled (while he was in the area) for a checkup with the doc. That's my doc - SuperDoc. And I had gotten the Chief an appointment with SuperDoc the day after Thanksgiving. (SuperDoc seems afraid to take more than one day off at a time, I suppose because when you are a SuperDoc you don't like abandoning your medical salvage projects to lesser docs.)

I had tested TechnoBuddha's blood sugar in April while he was with me for Easter, and he was close to veering into Type II. So I then gave him a series of instructions and shipped him off to SuperDoc, and this was a followup for that. (TechnoBuddha has lost a TON of weight since then, and is progressing nicely with his exercise program, and his blood sugars have plummeted way out of the iffy range.)

So when TechnoBuddha arrived for his appointment at 7:30 AM (SuperDoc likes to crank them through early, which leaves more time for screaming at insurance companies all afternoon, I suppose), he discovered a very frantic SuperDoc whose network was down. Apparently the guy who normally works on it fled to Europe or went there on vacation or something.. So TechnoBuddha spent most the day on Wednesday getting him at least up, which finally involved buying new cable to connect the server and the router and reprogramming the router (which cable is now duct-taped across the back office). The router was new. The network is totally undocumented - even the cables are unlabeled, and you just can't start pulling cables at random to find out what is connected to what..

SuperDoc asked TechnoBuddha to come back on Friday to fix some other problems with two computers (Vista) that had apparently never been working right since they were put in.

So TechnoBuddha asked me to come with him on Friday to work on the problem, which was pretty dire. If I had been trying to work on those two machines, and if I were not computer literate, their broken and bleeding carcasses would long ago have been found by the side of a country road. I would have considered it justifiable homocide in self-defense. Those two PCs were a crime against humanity, and I am not exaggerating.

And we were at it most of Friday before we traced enough of the network to find where everything was hooking up and what the problem really was. I am sure we looked like a couple of bumbling idiots, but when there is no documentation and no cable labelling it is hard to even find the device locations much less figure out what to change, so I spent considerable time crawling around on the floor looking at connections. Commandments 1 - 10 of dealing with computer problems can be summed up with "Always wear pants and comfortable shoes". Friday night late I downloaded manuals and researched enough to figure out possible fixes for the problem, but Saturday we ended up pinging all possible addresses to find the freakin' IP addresses to get in there to get the information we needed to fix the freakin' problem.

Both Friday and Saturday we had to do all of this while the office was running and treating patients, so it was hardly an ideal situation.

We did finish those two machines on Saturday. I think whoever fled to Europe might not want to come back. SuperDoc had been instructed to buy Windows 7 and put it on the two machines which were so problematic, but that wouldn't have fixed the problem - IMO it was the way that they were hooked up to the network devices that appeared to be causing most of the nightmare. SuperDoc is having Comcast come in to rewire the building in a few weeks, so that may help. However his network has other problems - it needs to be documented and have a bunch of things done to it for safe operation. I am writing up all of what we did and learned, and there is a lot that still needs to be done.

Of course in the middle of this, SuperDoc had looked at the Chief's records from his recent hospitalization (which were not easy to get). The Chief has an emergency appointment at the hospital up here tomorrow, because according to SuperDoc the Chief was treated by "A person with an elementary school education and a cardiologist's degree" in South Georgia. SuperDoc said it was clear that even the hospitalist had doubts, and SuperDoc advised me that it could have been possibly lethal if I had not shooed the Chief in for his SuperDoc grease and oil job. SuperDoc hasn't said much, but he seems quite agitated and he told me to be sure to go in and talk to the doctor at the hospital. So I am nervous.

Tomorrow morning early I have to go to SuperDoc's to make sure his network comes up properly, and then I rush back and get the Chief and go to the hospital. As soon as I get a clear Chief day, I have to go back to SuperDoc's and work on his computer situation some more.

So you can safely assume that blogging will be light this week. SuperDoc and the Chief come first. More than a decade ago SuperDoc administered medication to me to try to save my failing brain. He opened up his office every day for months to do it - including Sundays. Including Easter Sunday. My situation then was totally dire, and I was one of those salvage projects. I would crawl across broken glass for SuperDoc, and I know darned well he isn't earning much. He has old-fashioned medical principles and does a lot of free medical care. He won't take most Medicaid patients, because it costs him more to treat them than if he were doing it for free, but he will treat people for free, including people like me that current medical protocols consign to the "untreatable" category. There is a divine sort of symmetry involved in applying my salvaged brain to straighten out his computer situation. SuperDoc said quite plaintively that he had had about five people in to work on it, but of course you will not get good results when the thing is undocumented. .

Before I get back to network diagrams, I would like to point out this profoundly stupid op-ed by Nicholas Kristof in the NY Times Are We Going To Let John Die?. I do not believe that even the SuperDoc and the Shrink combined could sort out Kristof's mind - I think this is self-inflicted, willed mental suicide in action. The basic points are:
John's story is very heart rending, and one may feel that Kristof has a point, until you read on and learn that that John is now covered by Oregon's Medicaid program, which fact Kristof includes but does not seem to assimilate:
He hasn’t been able to find a doctor who will accept him as a patient for surgery, apparently because the reimbursements are so low. Doctors tell him that his condition is operable — but that they can’t accept him without conventional insurance.
I am extremely sympathetic to John, considering that I too, know what it is to vomit because the headache is so bad. My last such episode was not that long ago. Last night I only slept about four hours because I was in so much pain. Pain is a feature of my daily life. I do not suffer, but I do feel pain and my body experiences the stress of it. However, what I get (and what John is not getting) is the best possible treatment that gives me the maximum of achievable functionality. I wouldn't be getting that care if I were on Medicaid, which explains some of my hostility to these bills.

But what is Kristof's point? Does Kristof know himself? The facts of this case seem to justify the senators who are asking questions and demurring on the health care bill rather than those who are willing to go ahead with it.

Under any of the current bills I've read (which is why I read them), John's coverage would not change as a result of the bill. He'd still have Medicaid; whatever his current situation, it would continue as is. If anything, some of these bills would make John's situation much, much worse due to the liability problem and the failure to pass tort reform. See NOFP's post on the subject. NOFP quotes Critical Care:
Section 261 (p. 149–150) of Speaker Pelosi's bill puts physicians in an impossible conundrum. Doctors will only be reimbursed that amount for which the health-care commissioner determines is the appropriate treatment for a particular set of symptoms. However, doctors may still be held legally liable for failing to give that care which they could or should have given if additional care is actually more appropriate for the patient's well being.

So doctors are left with a choice between providing care that they know will benefit the patient but for which they may not be reimbursed, or providing limited care for which they will be reimbursed but quite possibly also sued by the patient.
And that is a big part of why John is not getting the surgery he needs, and a big part of why many doctors will do free work, but not Medicaid work, and won't be able to do much for certain patients that they would otherwise treat. If patients won't get the ancillary care because it is not funded by public insurance, it is useless to perform a dangerous operation. And unless a surgeon can get a hospital and other doctors to commit to performing the extra care, it may be very dangerous to operate on the patient and leave him in worse condition. And that would expose the doctor to a lawsuit - word has it John Edwards has some pretty big alimony to pay and that he is looking for just such patients. Medicaid reimbursements are frequently so low that a doctor does not just lose money on the time spent treating them, but if a doctor accepts a lot of Medicaid patients, that doctor may not be able to afford the cost of the malpractice insurance to cover them. (Malpractice premiums vary by specialty and by patient count.) Still, I think there is something wrong with the story as told in this column. I am pretty sure that John can get treatment in Oregon provided his condition seems treatable.

Perhaps you all may now better understand why I am so concerned about these bills, and why I may end up leaving this country if they pass in order to go to a country that doesn't have universal care and in which I can pay for my own care. Without tort reform, patients such as John and myself are likely to be in more jeopardy rather than less. With tort reform, we are liable to have expanded access to high-quality health care. See Nixon's column on medical liability and Christus Health's experience. Please note that while Massachusett's health reform attempts have produced patients without doctors and in many cases cuts in services provided specifically for those on public insurance, tort reform in Texas has produced more doctors, expanded access, and more services for people like John.

Obviously I would wish not to have the disease I do have. Unfortunately, some of the results of the disease I have are so similar to John's problem that I found it very painful to read of his situation. But I have been treated, and it is largely because I was wise enough never to fall for the sucker bait that is public insurance. It is a lie.

However, because I have been so ill, I have spent a great deal of time exposed to doctors, and the one thing I can tell you is that most of them are very good. They also like to do it. If you remove the impediments (such as crashed networks), they doc. If you just get out of their way, they doc. If you just promise not to sue them, they doc. Doctoring is what they do. The better they are, the more fanatical they are about it - and the US has some incredibly good doctors and a large mass of exceedingly good doctors. The US has doctors so damned committed to treating their patients that they have stripped themselves of all their assets and continued to treat patients without malpractice insurance. Obviously, the limit there is on how good the doc's marriage is. I do not think we wish to perpetuate a system in which the only doctors who can continue to treat large numbers of high-risk patients are those with extremely good marriages.

When even a profoundly altruistic SuperDoc has to draw the line at taking Medicaid patients that he cannot treat effectively because they will not get ancillary care, and they cost more for him to treat than free patients, one must understand that the FIRST step in health care reform should be to change our medical torts system.

These are health care reforms that will not work:
Payment by diagnosis rather than payment for service. ( This is what just happened to the Chief down in GA. He got the amount of treatment that would be reimbursed, and no more. No use ranting about private insurance companies - he is considerably older than me and is now on Medicare )
Mandated practice standards by some stupid government board. Guidelines are helpful, but in fact medicine is highly individual. All this BS about medical boards is going to be worse than useless - it will be used as a means to deny care to those who need it most (like John).
Paying doctors less if their patients are more expensive. This punishes doctors who are ordinarily the best in their particular specialities. These doctors are known to other doctors, who refer them their difficult cases. SuperDoc is on such a list, and I notice he seems to be treating a lot of other doctors. Needless to say, those cases may require more diagnostics and more treatment than the average person with that particular named condition. However, the rewards and cost-savings of effective treatment (such as I received) are disproportionate as well. Medicaid would have paid for me to die very slowly and expensively, but it will not pay for the rather inexpensive treatment (generally less than 4K a year) that allows me to run around and fix desperate SuperDoc's computers so he can doc. Of course, it is so cheap because the doc trained me in some stuff that is often done by medical personnel, but still, there is something wrong with this.
Allowing insurance or boards to mandate which tests/diagnostics should be used: TechnoBuddha had useless surgery this summer for precisely this reason. Because of a possible problem, SuperDoc wanted to send him for certain tests before letting him ramp up the exercise. One of them the insurance company would not pay for - they wanted him to have another, more expensive test which their guidelines said was better. However, for some SuperDoc reason that I do not understand, SuperDoc knew that test was usually better but was likely to generate a false positive in TechnoBuddha's case. But SuperDoc could not get through to anyone at the insurance company who could understand what he was saying, so TechnoBuddha had the insurance company's test, it rendered a false positive, and TechnoBuddha then had useless surgery to treat the condition that he did not have. At some point, we just need to all give up and realize that if our doctors are that incompetent, insurance companies fiddling are bound to make it worse rather than better. (The GIGO principle rules the world. If the average doctor is incompetent, the information pool used to generate the guidelines will also be skewed. Sometimes doctors use the inexpensive, old-fashioned test FOR A REASON.)
Mandating that unneeded coverage be purchased. We have accepted the reality that we can't provide cheap Cadillac medical treatment to everyone. Thus, should the federal government be requiring that everyone purchase coverage for, say, in vitro fertilization? It strikes me that such coverage is quite useless for persons such as the Chief and I. And mandating certain dollar levels of coverage is stupid too; it makes all medical care cost more. The old major medical policies were far more cost effective. If poorer people cannot afford the initial costs of regular treatment, then the obvious way to deal with that is to directly fund them individually, rather than making the entire population adopt an economically inefficient method of paying for health care. One of the reasons we had to work all weekend to deal with SuperDoc's computers is that a staggering amount of software, manpower and electronic filings are needed just to deal with simple doctor's visits. That is one of the reasons why going to a doctor costs so much more than it used to.
Setting up a vast medical bureacracy. Krauthammer's comments on the Senate health care bill cover this issue well. I found the bill unexpectedly arresting - comic even - and spent some rather happy hours calculating the total cost before the news of the Chief's premature clearance came through. If all those boards and new studies are going to be properly funded, they would cost over a hundred billion dollars. I suspect they won't be, which will produce more medical dogma garbage, but it will still cost a lot. Every dollar you spend on overhead is a dollar not spent treating a person.

I hope I have added something to this debate. Perhaps not. However I do know that the time I spent on the SuperDoc's floor fumbling around with cables at least allowed him to continue to treat patients.

Kristof's dingbat column has an accompanying blog post. I found reading the comments to be an exercise in disbelief; almost no one comments on the fact that the man has insurance already or the other discrepancies. Here is one exception:
I am not completely certain but I believe your column distorts the facts. Under EMTALA a hospital cannot mandate insurance coverage as a condition of treatment. Under HIPAA laws the maximum length of time John’s wife can exclude coverage to John is twelve months. Oregon is one of the highest paying States for Medicaid reimbursements.
Here is another comment that seems to bear out my suspicions that John can get treatment if surgeons believe it will help him. There may be details about his case that make success problematic; I note that Kristof did not speak to any doctors. One commented on the blog:
I was a physician who accepted Medicaid. They would pay me $120 for a bunion operation. I would have to pay for all the supplies, sutures, injectables and fixation devices. So if I wanted to use a titanium screw to fix the surgical fracture of bone necessary for the surgery, I would have to pay more for the screw set than the surgery paid. Plus the surgery included a 90 day global period. Meaning that the first 90 days I would receive no more fee than the original $120. And all of this because I chose to do the surgery in my off ice operatory rather than waste time admitting a patient to the hospital for a simple procedure under local. Health care reform needs to start in the doctor’s office and not in the insurance company’s bank account.
This entire debate is being conducted in an atmosphere of indignant evasion of reality. It seems that no one but the persons involved in actually treating patients are taking this seriously. The result is likely to be very bad. See also a neurosurgeon's comment here.

You have a very generous and giving nature to expend so much effort in trying to educate your readership in areas in which you are knowledgeable. I always find everything you write very interesting and I thank you.
Thank you Mom,I wish I could argue against you,but I can not.From what I can tell we will be lucky to get "reform" that is merely a disaster and not a catastrophe.And thank you for the work you did,you may well have saved a life or two,and certainly made the world a better place.I have learned that there are no small acts of kindness.God Bless,Tom.
Thanks for the excellent elaboration of the health care farce.
My best wishes to you, SuperDoc and the Chief too.
The irony inherent in governmental proceedure coming in the way of even generous hearted Doctors like Superdoc is too painful to swallow.
Pathetic really.

...I may end up leaving this country if they pass in order to go to a country that doesn't have universal care and in which I can pay for my own care.

Where? I've been trying to figure out where all the cool kids are going to run to if things really get bad. Nothing comes to mind yet....
Tom Stone,

If we get this "reform", I think we have to hope for immediate catastrophe. The worse, the better.

They can't stop us from purchasing health care on the open market, at least I don't think they'll get that one past the Supreme Court. The end result, then, will be a parallel free-market health-care system that has no connection with government-run health insurance. That's what seems to be happening in Canada now. In the end, the government-mandated "insurance" just ends up being a poll tax.

The faster doctors and hospitals leave the system, the better off we are.

The pitfall here is if the government mandates that doctors and hospitals accept the government insurance as a condition of accreditation. That will guarantee that the whole system is sucked into the vortex with no escape.
This entire debate is being conducted in an atmosphere of indignant evasion of reality.

Could not have been said any better.

My sister works as a director at Harvard Med School, all of her students and all of her instructors are physicians. She says the #1 problem she deals with every single day is the sense of entitlement doctors have. Unfortunately, she is noticing that the better doctors are slowly abandoning the profession - cutting practice hours is the main way they do it - because they have simply been outnumbered by bureaucrats and other doctors that simply don't care about anything other than their egos.

Democracy only works when the competent and the caring are the majority. A lot of politicians mean well but that habit simply blinds them to reality and they become (purposely) unaware of the horrible seeds planted by their good intentions.

That was a great post. I never comment but have read everything you post. I followed you here from CR long ago and wanted to thank you for all of your efforts, data, and personal adventures. Highly educational, entertaining and humorous. Reminds me of someone I have been missing of late. Take care!
What a great post!

Thanks to you and your brother for keeping Super Doc's technology up and running. You love what Super Doc does, but you are truly a good Samaritan. Blessed are those who help those who need it.

The healthcare reform is a real mess. The two bills are going to make it cost more, be less efficient, less innovative, and still not get healthcare for everyone. How is that an improvement.

This idea of setting up "standardized protocols of treatment' sounds good on the surface but fails badly in the face if any ailment/disease that doesn't fit the standard. My wife has an underactive thyroid. Has had it for 40 years. When she gets the "standard" amount of thyroid replacement hormone, she can barely get out of bed, her hair falls out and the skin on her hands and feet cracks open and bleeds. We have always had a problem finding doctors who will treat her symptoms and not go "by the book." When she gets enough thyroid hormone she's just fine. Doctors claim she will get osteoporosis from too much supplementary thyroid, but she takes supplementary calcium, does weight bearing exercise and has bone density scans evry six months. At 75, she has good bone density. Her doctor will not take Medicare or Medicaid, so it costs about $1800/year for his care. It is worth it to us.

The idea that doctor's will be in trouble if they don't go by the book scares us. I think it shopuld scare others as well.
The medical stuff is scary. The network stuff is obscene. I'm just getting my own home network together (first time I've wanted to run multiple machines; UNIX, not Windows) and the thought of leaving an office like that gives me violent shudders. It's one thing if you have a staff that does nothing but the network; it's another if you are one person in and out occasionally.

That you, MoM, understand enough about MAC addresses and suchlike speaks very well of you. I'm impressed.
Jimmy J - I just read a book on Iodine by Dr. David Brownstein that you and your wife might find interesting. I have a small goiter in my early 40's which is unusual and have been monitoring my thyroid for 2 years now. However, recently my MIL gave me this book and I now have a call into my Endocrinologist. Has your wife tried taking iodine suppliments or been tested to see if she is deficient? According to the book, iodine is desparately needed by the thyroid and can help underactive ones especially.

All I can say is that after a few days of Celtic Seat Salt, vitamin C and a multivitamin that has magnesium & selenium, I feel postively perky. Now, I want to make sure that someone is watching my iodine level.

-- Army Mom
Army Mom,
Thanks for the tip about iodine. Unfortunately, we heard about it a year ago. We thought it would be the answer, but it wasn't. She was tested for iodine insufficiency and the results were normal. Drat!
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