Thoughts on Health Economics

I’ve been reading some of the comments coming out AARP’s Medicare Forum, and they got me thinking.

I wrote my thesis on improving an estimated average cost function for acute care, and I learned a couple of things: it probably can’t be done, and never get two economists on a thesis committee.

Here’s one thing: say I buy a state-of-the-art camera and memory card for $100. What’s the cost of a picture? It depends almost entirely on how many pictures I take with that camera and memory card over its lifetime, not to mention the cost of the photographer. If I only take one picture before I drop it into the canyon, that picture cost me $100 (and it’s on the card at the bottom of the canyon).

What if a much, much better camera comes out while the old camera is still functional, and no one wants a picture taken with the old camera anymore? Do I get the new camera? The photographer across the street is getting a new camera.

I won’t get into the need for a building to house the camera or the need to co-locate it with the subjects or disposal of its hazardous waste by-products or its life-saving implications.

Let’s talk about outcome measures. Want to compare mortality rates? A lot of people do.
If that’s important to you then you probably won’t want an emergency department or to partner with a nursing home, because emergency departments bring ambulances and uninsured people who lack preventive services. Can you guess why you don’t want to partner with a nursing home?

I did an internship in the Quality Management Department of a small community hospital where the Director tasked me with developing outcome measures so that the hospital administration could compare the morbidity rates of the medical staff against state, regional, and national outcomes. I actually told her that I was pretty sure that a few people might not want her to have that; and, after I was done, some of the doctors bought the hospital, and terminated my internship and most of her department. Just saying…

Still, we ought to be able to figure out what an average discharge costs a hospital (or doctor or other provider) in terms of resources, yes? Perhaps. I worked for a doctor who was pretty cutting edge in technology and mastered laparoscopic surgery. She certainly saved her patients at least a few days in hospital, and insurance companies the cost of those days; but she was only paid a fraction of what she’d have received if she’s just cut the patient and it took her substantially longer to perform each procedure through a “keyhole.” How does that make sense?

Then there’s the whole insurance thing. I don’t have an axe to grind with insurance companies, but they don’t deliver health care. I get that they take premiums and invest them and make money with them, and that paying for my health care is a tsuris.
They come in with data on what their average payout is to my hospital for a tonsillectomy, and they offer me like 90% of that and stop nit-picking every single detail of every bill and pay me within a month of discharge. Maybe I can make it up in the business office.
The next thing I know all of the insurances companies have made me (coincidentally, I’m sure) the exact same offer. FYI, most hospitals operate with a profit-margin of less than 5%.

We used to kid one another (they probably still do) about “billed charges” and “cash patients;” but the reality was that the people who could pay us were going to pay us what they wanted to, and the people who couldn’t wouldn’t. Hospitals know what their costs-per-discharge are, and aspirin don’t cost $25 apiece, but the object of the exercise is to try to balance expenses with income; i.e. keeping the doors open. I’m not going to say that there are no bad apples in the healthcare delivery system, but I haven’t met very many people who weren’t at least committed to – if not passionate about – quality care.

If the American public wants to entrust their health to corporations with a vested interest in not paying for it, that’s their business. I’m old.

If consumer activists want to nickel and dime their doctors, they can do that. Seems short-sighted to me, but it’s their call. If you want your health care from the lowest bidder, go for it.

I spent twenty years getting (and providing) health care in a federally-operated managed care system, and I haven’t run into too many shipmates who were dissatisfied. Plus, I’m pretty satisfied with Medicare. I don’t see the problem with it.

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Thoughts on Journalism

I’ve had quite a bit of time to reflect this week as the media strove mightily to wring the last possible second of screen time out of the Boston Marathon bombing and its sequelae.
It occurred to me that ours is one of the first generations that has been able to instantly access inputs from across the globe, and we obviously have no idea how to manage that.
I have a couple of thoughts.

Merriam Webster defines journalism as the collection and editing of news for presentation. More specifically, they define it as writing characterized by direct presentation of facts or description of events without interpretation. I also checked for a definition of news and found: a report of recent events. Parenthetically, in order to be newsworthy, something should be “interesting enough to the general public to warrant reporting.”

I know the bombing was a big deal, and I was concerned for friends in the area; but, really, what was the news? Obviously some people must have been glued to their screens because the MSM could not shut up about it. I don’t think we needed the hours and hours of “reporters” in front of cameras sharing tweets, rumors, file footage, and speculation.

The absent parents can’t believe their kids did this; I get that. I worked with a woman whose son murdered a woman, and she had a lot of trouble dealing with that. If either of my angels got into trouble, I’d blame their mother straight out.

Since they stopped the race after the blast, there’s no way we needed more than three or four hours of media coverage from the blast to the capture of the second suspect last night to address the actual news. Everything over that was just the media sucking every iota of interest out of what was, at its root, a tragic event that will forever change the lives of the casualties and all who loved them.

I think the coverage has been a disservice to those folks and bad journalism.

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Thoughts on Difference

Among the things I enjoy about working with the animals at Brother Wolf Animal Rescue is their apparent lack of awareness of their differences. The biggest thing is their lack of any guile, but this is pretty high up there.

When I first met Max, my little Boston, he was in a pasture playing with a Rottweiler and a horse, seemingly indifferent – if not oblivious – to their differences. Max is not what I’d call a smart dog, but I’ve observed many interactions on hikes or in play areas when dogs would just all pile up – sometimes with a cat, although cats seem much more aware of their being cats and not dogs. To be sure, there are spats between dogs, generally when it comes to food or water or attention from humans, and they often behave differently on-lead than they do off-lead. Some of the coon hounds have learned to regard smaller mammals as prey, but that’s almost always  been more of an issue with cats than with dogs; and a bark and a sniff usually straightens it out.

I can’t say that I’ve encountered an aggressive dog. When I first moved to Asheville we went to an established Boston Terrier Meet-Up group, and apparently the dogs there felt that their pack was okay as it was. They collectively marginalized not only Max but other new dogs, but they weren’t ugly about it.

Some dogs are more timid, some more boisterous… They may have their individual hopes, dreams, and agendas. I know Max much prefers being with women to being with me, all other things being equal. A lady recently moved in next door, and since Max met her he’s been going to her door instead of ours whenever we get back from an outing.  Not the first time he’s done this.

This week, within hours of the anniversaries of the Texas City Disaster, and the Branch Davidian Fire and Oklahoma City Bombing, and the shootings at Columbine, it looks like a couple of kids blew up the finish line of the Boston Marathon and West, Texas, got blown up by fertilizer. I hear these discussions of whether or not these kids were inserted back in 2001 as a pre-pubescent sleeper cell. I don’t even want to get started on the Senate’s failure to do anything about controlling access to guns, and the hate legislation coming out of Raleigh. I’m trying to develop mindfulness and compassion and equanimity and I keep coming back to a perception that people suck.

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Happy Birthday, Kay!

There are folks who are so articulate in their comments that you just know they should be bloggers. Kay (of Kay’s Thinking Cap) was like that; plus, she’s passionate and a committed activist for issues she cares about. She makes me feel a little guilty sometimes.

Happy Birthday, Kay! Best wishes for many, many more!

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Happy Birthday to Ronni

Sending out especially good thoughts this morning for Ronni Bennett at Time Goes By.
It turns out that blogging is another thing at which I’m not very good or reliable, but she is no less a blogging hero and role model than she was when she inspired me more than eight years ago.

Happy Birthday, Ronni, and best wishes for many more enjoyed in good health and great happiness.

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Thoughts on Life

I’ve been following a conversation regarding whether or not it’s time it’s time for someone to kill their aging and infirm cat and it struck me that the whole thing feels wrong. Nelson Mandela is 94 years old and people all over the world are anxious that he may not make it to 95, but when a good dog or cat starts showing their age and infirmity people start thinking of killing it. (I’m aware that it is politically correct to term this “euthanasia,” but if we were talking about Nelson Mandela it would just be murder.)

I accept that many religious folk view human life as a distinct variety of life, but I’m pretty sure that life is life. I’ve heard of human cultures that cast their elders adrift on ice floes or whatever, but we have kind of gotten away from that in any obvious sense. What is our rationale for doing that to non-humans? My sense, which I believe is corroborated by our pets concealing their infirmities from us, is that they’d prefer we didn’t.

I don’t mean to present a moral or ethical argument; I’ve told my dog dozens of times that if I get hungry enough, and he’s pissed me off enough, I’m eating him. The thing is that as he gets older (over 10 now) he’s actually safer from that. If I killed him off because who would want to live like that, at some point I think I’d be very uncomfortable calling the doctor or allowing myself to be seen in public because I could be next. If it makes sense then it makes sense, right?

Posted in Life, Morality/Ethics, Rationality | 2 Comments

Observations on Organized Religions

I’ve got way too much to do to be blogging right now, but three things came to my attention this morning and if I don’t write them down in the moment I forget later (which is as it should be).

Among the international celebrities about whom I care less than I do about the British Royal Family is the Pope; and guess who’s all over the news this week? The world really needs an alternative to the corporate mainstream news/entertainment media. Just my opinion.

Then I saw two pieces in the news: one dealing with the inability of the U.N. Commission on the Status of Women to reach a consensual agreement on a communiqué opposing government sanctioned violence against women, and another about the Iranian clerics ragging on Pres. Ahmadinejad for hugging Hugo Chavez’ mother at her son’s funeral; and, although I wasn’t surprised, I was moved to comment.

At the U.N. Commission, Iran, Russia, and the Vatican – in particular – are holding out for “conservatives” who are apparently “iffy” on the idea that “violence against women must be seen as a human rights issue, and that has nothing to do with culture of religion.” Well, of course, with Iran and the Vatican it’s all about religion. Putin’s Russia is just corrupt.

As for Ahmadinejad, it occurs to me that it takes some extraordinarily twisted dickheads to make Ahmadinejad look like the sanest guy in a roomful of senior Iranians today, but I think the Imams have pulled it off. When all of your friends are invisible and magical, you can come up with some weird shit.

 

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Thoughts on the death of Hugo Chávez

I was reading up a little on Hugo Chávez on his passing. I never paid much attention to him in his lifetime, but I knew he was identified as an adversary in Washington and he regarded Dubya as the devil; so I figured he couldn’t be all bad. As I see it so far, his biggest sin was withholding oil revenues from the 1% to keep it in Venezuela and Latin America.

That set me to thinking about how the USA identifies its friends. Castro’s greatest sin against us was booting Batista and his American business partners from Cuba but then declaring himself as a communist. At that point, he stopped being Robin Hood and became a minion of the Red Menace.

Then I started looking for patterns – real or imagined – and hit on Hawaii and Native Americans. We were apparently fine with the Kingdom of Hawaii until it looked like Queen Liliuokalani was going to tussle with the haole for a better deal for Hawaiians, and then we – technically the planters – staged a coup d’etat. (Not entirely unlike our takeaway of Texas from Mexico.) As for Native Americans, our first official notice of them was when the Bureau of Indian Affairs was established in 1824… in the War Department.

Yesterday’s editorial in the NY Times reminds me that Chávez wasn’t a saint, but there was a taint of bias. Embracing “malevolent foreign leaders like” Assad and Ahmadinejad would sound worse if we hadn’t embraced a whole slew of malevolent foreign leaders such as the Shah, Marcos, Noriega, etc., when it suited us. What I got from that was that he pissed off the 1% and the politicians paid to support them.

Our national policy regarding peoples of color seems to have been that, if they were or became unfavorable for American business to deal with, they were enemy combatants. We still seem to do that.

Rest up, Mr. Chávez; you have some explaining to do. On the other hand, if Dubya gets to Heaven, you could be alright.

 

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Note to Myself

Today I opened Daily Zen to see this:

In the autumn of my sixty-sixth year,
I’ve already lived a long time.
The intense moonlight
Is bright upon my face.
There’s no need to discuss
The principles of koan study;
Just listen carefully to the wind
Outside the pines and cedars.

 - Ryonen Genso (1646-1711)

This started me thinking again about how I might best use whatever time is left to me. I am 106 days from the end of my sixty-sixth year, and am reminded that for several generations the men in my father’s line haven’t lived to see the end of their seventieth.

My mortality isn’t something I obsess or even worry over, but I am conscious of it. I try to set a goal every morning, and to take a few minutes to reflect on the day at its end, but I really don’t have the discipline to do that consistently yet. My goal would be to use the bulk of each day productively. For now it’s enough for me that, when I become conscious that I’m vegetating, I do something.

Today will be for apartment cleaning. Then we’ll see what’s next.

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How to Trust

I have a problem when it comes to trusting others. It has been an issue from time to time, and I suspect it has a lot to do with my inability to sustain a relationship. I was reminded of this again today when I came across a quote from Thich Nhat Hanh: “I am determined to cultivate only thoughts that increase trust and love.” I have no idea how to do that. I guess it could be like practicing prayer, but I’m agnostic so what’s the point of that. I feel a little like Cdr. Data trying to learn humanity.

I think it would have been better if I’d learned to trust as a child, but I didn’t; I learned that I was expendable. I, with my younger sister, spent seven years in foster care while my mother went to college. If my baby sister had been put into foster care there would have been trouble from her father’s family; and if my oldest sister had been left in foster care there would have been trouble from our grandmother. When Mom graduated from college on my fourteenth birthday, we went back to live with her but I continued to work (I’d had a paper route since I was twelve) and paid a little rent and most of my own expenses.

Actually, my time in foster care was where I saw life in a stable loving family environment, and was probably pretty far up toward the higher end of foster care experiences. Being the only two foster kids in a rural town of 1200 was really a little isolating; people were nice, but we didn’t get invited to birthday parties. Anyway, I think most kids pick up that there’s someone they can trust by the time they’re in their teens, and I didn’t get that.

Going forward then, I expected relationships to end. Finally I caught myself hastening the end if it got too drawn out. I did call a woman I was seeing back in 1997 when my car broke down, and she told me to call AAA and a cab. Now I plan moves so that I can get everything on and off the truck by myself.

So, there it is. My task is to “cultivate only thoughts that increase trust and love.” I make every effort to be trustworthy; but to develop, much less increase, trust in others… not a clue. I guess they call it “practice” for a reason. If I don’t get it in this lifetime I’ll just have to do it later.

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