The Insanity of Third-party Payment for Medical Services

I recently got billed from a local lab for a PSA test for $90+. I had the test done in August since I was getting blood drawn for other blood work. Medicare disapproved it because it was a month early (usually get it around my birthday in September). My wife said I should have known better. So I forgot to say "Mother, may I" and got my hand slapped.
The Medicare reimbursment for this test (i,e, what the lab would ha...ve gotten if I had done it in September) is ~ $25. Having run a little office lab for a few years when we had a 4 doctor group, I can assure everyone that one can make a profit with Medicare reimbursement, even with a little office lab running very part time.
Let me say that I don't consider the lab to be the culprit here. Like every other medical provider their fees are set by insurance reimbursement rather than their cost of doing business and their competition. (This particular lab provides a substantial screening lab package for uninsured patients for a very reasonable price and we send our free clinic patients there to take advantage of it.)
The fee is set to capture the highest insurer reimbursement. The overwhelming majority of their customers are insured and are concerned only about their co-pays and deductables, so the only ones who are discomfited are the uninsured or the bumblers like myself.
There's tremendous more to say about the insanity of our third party payment system in medical care but I'd like to keep it short. Let me just make the point that, if the standard way to pay for this test was directly out of pocket, the price to the consumer would be much, much lower than the Medicare reimbursement and in fact most likely much lower than many present-day insurance co-pays. Furthermore we could have the test done at our convenience without having to say "Mother, may I."
I'd love to have a discussion about this general subject. The public needs to be informed about why medical costs are high and increasing and at the same time why responsiveness to public demand is so limited.

Italy and the Terramoto

The "terramoto" is an old and devastating problem in central and southern Italy. From what I read a fault between Europe and Africa runs right down the Italian spine and is responsible for the formation of the Appenines.

A book I'm reading now, "The Italian Emigration of our Times" by Robert Foerster from the Harvard sociology department and published in 1919 (so 13 years after my dad came over), states:

"To indicate (by way of example) the recent earthquakes of Calabria alone: those of 1854, 1870, 1894, 1905, 1907 and, worst of all, 1908, accomplished a disheartening round of destruction of life and property. Today, ten years after the demolition of Messina, the city, its little wooden suburb notwithstanding, still is a pile of ruins"

I was actually in Italy at the time of the earthquake in 1997 and saw the ruins of the Basilica of Santo Francesco in Assisi. It was very discouraging for my family.

Dr Foerster adds:

"The general destruction of capital is pervasive. Of all consequences however the most serious is probably psychological, the creation of a mood of helplessness, or even worse, of apathy, restraining at once the. impulse to progress and the energies needed for accomplishment."

He counted it as one of the many reasons responsible for the diaspora of the Italian peasants or the late 19th and early 20th centuries.

The destruction is particularly frightful in buildings which are very old and constructed of stone. As I learned when I lived in San Francisco (named of course after the same wonderful man as was the Basilica) most of destruction of the 1906 earthquake was caused by fire. It was only the few brick structures in the downtown that collapsed, whereas the great majority of wooden buildings were flexible and stood through the shake only to be destroyed in the great fire that followed.

Here is a photo of the house where my father was born in 1904, in Palazzo d'Assisi, Italy. Most of the damage to La Casa Vecchia as we refer to it was caused by earthquake.

Trending in Retail Sales

I ordered something on Amazon which was by an outside provider which gave free shipping. It got sent by DHL which is apparently a German company which picks up packages locally and delivers them to USPS. It cuts the price of shipping down.

The retail market looks to me to be moving rapidly toward internet purchase with home delivery. My order was for tape that I use to prevent blisters when I golf. I was getting it at KMart but I got it online cheaper with home delivery. I just had to wait 3 or 4 days but that wasn't a problem.

So we went from everyone living on farms and buying what they needed at the general store, to mail order delivered by Sears and Montgomery Ward, to people herding from farms into cities and going to A&P's and Woolworths, and then as we got more mobile moving to suburbs and going to malls, and then going to Wal-Mart superstores with everything under one roof and now shopping on-line with delivery. It's fascinating. The big winners are those who can anticipate how society is going to move. I wonder where we're going next. Anyone know?

 

Unfortunate present state of Chicago

Recently we spent a few days in Chicago visiting my son and his great family. Here's a photo with Luke, one of their 3 kids. He has a few disabilities but thankfully great parents and siblings who are helping him reach his maximum potential. He is truly lovable and making steady progress.

The photo was taken at the Chicago Conservatory, a spectacular botanical collection housed in a gargantuan greenhouse. Well worth seeing when visiting Chicago.
Unfortunately this great city is having it problems. While we were there the major media focus was on a black teenager killed by the police. What wasn't being mentioned, but what all the residents know about, is the deteriorating financial situation and the horrific violent crime going on in the south and west sides. My kids tell me that no one would intentionally drive on any side street in any of these neighborhoods, even in the daytime with the doors and windows locked.
Deterioration is what seems to be happening in most of the big cities in the Northeast and Midwest. A few years back we tried to travel down memory lane when we were in Philly, where I went to med school. We tried to go to the student apartment building where we lived, which was in the ghetto, but not very dangerous. Emily walked the streets, in the daytime at least, without fear. The neighborhood was now so obviously hazardous that we did not dare to go to our destination.
President Johnson's war on poverty, started over 50 years ago, does not seem to have succeeded very well.

Direct Patient Care - then New-Old type of Medical Practice

I saw an interesting new website, jointhewedge.com. It's trying to develop a listing of doctors accross the country who are joining the growing movement of direct patient care - essentially a cash based practice. Although still small in number increasingly doctors are considering this difficult step as the only way of getting out from under the oppressive thumb of the so called health care planners who are destroying medical practice and patient care in the face of all common sense.

This is medical care on the old model which existed when I started, infinitely better than what we've got today. I'm not talking about all the new technological development which has been amazing, but the essence of the doctor-patient relationship.

These days more patients with high deductables and health savings accounts are looking for doctors whose fees are more affordable and comprehensable, and at the same time who will provide more time and personal attention to their concerns. This is the point of the website.

I hope I get some pushback on this comment since it's an important subject which is likely to be increasingly common as the government introduces even more new drastic regulations and changes to medical practice.

Who's interfering in our politics?

It's a tempest in a teapot, but I'm struck by the irony of commentators decrying the idea of Russia interfering in our political process by releasing the DNC's embarrassing emails. Well somehow Hillary's Russian reset didn't work and President Obama's whispered reassurance to Vladimir never really clicked. So we can't really control what the Russian's do. But isn't the real issue that one of our major parties was the one egregiously interfering in our political process by secretly working against one of its candidates?

Ron Blustein's Well Tempered Clavier Synthesizer

An old friend of mine just surfaced, Ron Blustein. We were friends from residency days in the late 60's at SF General. In those days a bunch of us collected most nights at our house in the Mission District to listen to and make music.
Ron is a musical prodigy. He could pick up almost any instrument and play it with proficiency. Back then Indian music was all the rage. Ron got a sitar from somewhere and played it like Ravi Shankar. He could do anything.
We lost contact for t...he most part but Ron through the years has turned composer. He's done all sorts of stuff which can be played on a synthesizer, but most notably he has done a collection of 24 preludes and fugues in every key that are astounding to me. Of course famously Bach started this with the Well Tempered Clavier, but Chopin and Shostakovich also did it and now Blustein! Of course Bach did it twice.
For anyone interested I added a link to a sample.

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