Pump You Up

Hans_FranzFor those of you following the Floyd Landis doping scandal, or who are interested in how testing for anabolic steriods in sports is done, this is an interesting post on the chemistry behind the testing. Since testosterone is, well, kind of a natural guy thing, one might wonder how to differentiate normal human testosterone from administered synthetic testosterone in otherwise studly athletic males (testosterone is the “steroid” referred to which athletes use to enhance performance). Turns out we animals have been grabbing the light carbon isotopes for the past gadzillion years, leaving the poor plants (which are used as the basis of the synthetic testosterone) with the heavy stuff.

Who knew?

A little chemistry background helps understand the article a bit better, but the fellow’s good at ‘splainin it for the non-chemist as well. An interesting read…(HT: Instapundit)

Euthanasia Investigation in New Orleans:
Medical Personel Charged

syringeFor those who may have read my earlier posts (here, here, and here) about the possibility of euthanasia at a hospital in New Orleans in the aftermath of Hurricae Katrina, you may be interested in the following report on the conclusion of an investigation by the Louisiana Attorney General, just reported by CNN:

NEW ORLEANS, Louisiana (CNN) — In the desperate days after hurricane Katrina struck, a doctor and two nurses at a flooded New Orleans hospital allegedly killed four patients by giving them a lethal drug cocktail, Louisiana’s top law enforcement official said Tuesday.

“We’re talking about people that pretended that maybe they were God,” Attorney General Charles C. Foti Jr. said, announcing second-degree murder charges against Dr. Anna Pou, Lori L. Budo and Cheri Landry.

“This is not euthanasia. It’s homicide,” Foti said.

The charges stem from the post-Katrina deaths of some patients at New Orleans Memorial Medical Center.

An affidavit said tests determined that a lethal amount of morphine was administered on September 1 to four patients ages 62, 66, 89 and 90. Hurricane Katrina swamped the city on August 29.

According to the court document, the morphine was paired with midazolam hydrochloride, known by its brand name Versed. Both drugs are central nervous system depressants. Taken together, Foti said, they become “a lethal cocktail that guarantees that you die.”

The doctor and nurses were taken into custody late Monday, following a 10-month investigation that continues. Each was charged with four counts of being a principal to second-degree murder and released on $100,000 bond.

The original reports showed up in a British tabloid not known for its reliability, and this sourcing, as well as some of the details therein, led to widespread scepticism about their reliability. However, interviews with physicians and health care workers at Memorial Hospital raised troubling questions as well, and a formal investigation was launched. The investigation was delayed by the reluctance of the involved hospital personal to testify, as well as the difficulty of obtaining autopsy evidence on the badly decomposed bodies after the fact.

What struck me the most, at the time I first posted it, was the vehemence of some commenters about how ridiculous this report was. One suspects there will be no humble pie eaten by those who sarcastically castigated me for posting on such obviously fictitious urban legends.

But sometimes the truth can be more frightening than fiction.

UPDATE: Here’s some earlier media links filling in some detals of the investigation as it unfolded (I’ll keep this updated as more becomes available):

The Maze at Politics Central


There’s a new site just launched, affiliated with PajamasMedia, called Politics Central, the beta of which is now up and running. In its mission statement, Politics Central “aims to promote a deeper level of discourse, and seeks to introduce a consistent tone of civility in our coverage and discussions [of politics and discourse about public policy].”

It is a highly-polished site already, and promises to be a great resource, with some excellent pundits and writers, which can hopefully restore the substance, depth, and interplay necessary for a healthy democracy–characteristics long gone AWOL in our daily political discourse, much to our detriment as a nation.

And I am honored–and humbled–to have been chosen as one of the contributors for its maiden voyage. The Maze series–a multi-part work detailing the madness of our current medical billing and reimbursement system–will be featured in the Health Issues category. The first of the series (familiar to those who have been regulars here) may be found here.

So hop on over and take a look around–I think you’ll enjoy it.

Posting Frequency


 
I’ve been feeling a little guilty lately about not posting very often. Of course, I could lay out the usual (and usually true) excuses that I’ve been busy, work’s a killer, family commitments, etc, etc. But no one wants to hear that, so I won’t…

So it did my heart good to stumble across this post (HT: QandO) which says posting too often is bad. Whoa!–I’m likin‘ this guy! But now I’m feeling guilty that I’m posting about someone who says not posting too often is good, and maybe that’s just another excuse, so that’s bad … or maybe it’s bad because I’m posting just to not feel too guilty about not posting, by posting a link to a post about not posting–and maybe that’s just what this guy is talking about, posting too much about nothing …

I am sooo unworthy… “Who will save this miserable wretch that I am?” to quote a guy who might have been a blogger if blogging was around 2000 years ago in places like Rome and Corinth and Ephesus.

Anyway, it did bring about a few thoughts on blogging. Now don’t get me wrong: I love sites like Instapundit which steer me to What’s Happening Now–very efficient, and I’m glad they do it frequently. Others like American Digest, mix cool, short, funny, offbeat stuff with deep essays and drop-dead good writing. Others, like the Anchoress, combine current event commentary with personal life and deep faith, dished up daily from the depths–gotta love that approach as well.

But for me, daily blogging’s never gonna happen–nor should it. If I’m going to write, I’m going to try and say something of substance–and for me, that takes time. Serous time. All-too-scarce time, sometimes. Yeah, sometimes there’s a quick post on something that’s funny or crazy or maddening–but the bottom line is that writing a blog is really for me. I don’t like wasting much time on the trivial: life has a purpose, and its time is not unlimited, so I hate spinning my wheels. Writing for me is about reflecting on what’s important in life, inspecting it from every angle, chewing it over, looking at it from perspectives I don’t even think of sometimes until I actually start.

If you’re a blogger–and I assume many of my readers (perhaps 3 out the 5 total who read this blog) are bloggers–here’s a question for you: would you blog if you knew no one was reading? For me, I think the answer is yes–it’s something folks have doing forever, really, called journaling, and it’s a valuable personal and spiritual discipline. But there is also something about blogging, knowing that others are reading–hopefully not just to impress with fancy words or turns of a phrase, but because of the accountabilty it brings. I believe people sense in the better bloggers something genuine, something real, drawn from the depths of a life of substance. Most of us have fairly good B.S. alarms, and can tell when someone is just tootin’ their horn or blowing hot air.

Anyway, I feel better now, having posted something… and it’s late, so off to bed. Night night.

An Other Eye

dragon
 
In one of the more moving and powerful essays I have read in some time, Gerard Van der Leun gives us a glimpse of the heart–not merely the warm, affectionate, tender place we normally associate with that term, but also its dark recesses, the hidden caves and dank caverns where, were we to be honest, far more of our lives are lived then we would ever care to admit. For the heart, we are quick to believe, is a place of genuine goodness, occasionally tainted by weakness or a justifiable self-interest, small dark clouds in an otherwise seamless blue sky. But the truth, were it to be known, is that there lies within our hearts a darkness, an energy both powerful and driving, which rules and dominates our lives, disguised but by a thin veneer of social acceptability and pretentious purity.

We live our lives thinking highly of ourselves and less of others, bestowing upon them our graces and gifts like laurels tossed from the train of a conquering king, each leaf a precious symbol of our goodness and generosity. Yet in the darkest hours of night, were we receptive to truth, we would hear the demons of our souls arise to carry on their conversations, revealing the true motives of our heart and the vacuities of our virtue.

To make a change of which Gerard speaks so eloquently is not a work of the will, nor of the intellect, nor the virtuous fruit of some project of self-improvement: it is in fact a work of grace. It is a grace which begins in that most difficult of visions: the ability to see ourselves honestly, without charade or deceit, to stare unblinking into the dark heart which dwells within.

I have known of the hatred of which he speaks: an energy so forceful as to terrify a sane man–but sanity is not the lens by which our hatred is viewed. For we, so discerning and perceptive about the simple and superficial, lose all ability to distinguish love from hatred, righteousness from brutality. We have lost the capacity–if indeed we ever had it–to discern that which is true from that which is deceit, and transform our very demons into something most desirable.

We look with great condescension upon those poor souls drinking screw-top wine from brown paper bags, or mainlining some medicinal salvation through oft-used needles. Yet we ourselves are addicts, each of us: addicted to the power which hatred gives us over those who have harmed us, whether in reality or in perception. There is in our inner rage a rush, a high, an intoxicating euphoria which provides great pleasure even while it destroys our souls and poisons our spirits. We lust for more, our minds transformed through chemicals no less powerful than those purloined from pushers, feeding our addiction with ever-spiraling fantasies of destruction and revenge upon the object of our wrath.

To change–to find release from these strong chains which bind us to hopelessness and hatred–is one of life’s true miracles. For there is no formula, no therapy, no mood-enhancing medication which can bring about this metamorphosis: we must, by grace, see those whom we hate with another eye. It is an eye which sees the deep wounds inflicted by another upon us, yet which sees as well those wounds we ourselves have inflicted. It is an eye which remembers the treasured things, those good things, which fostered the depth and richness of relationship which, in true irony, became such fertile ground for hatred and harm. For to open the heart to love is to expose it to grave danger, for only in the transparency of the heart can such severe wounds be suffered.

Yet when that brokenness takes place, that surrender which hands over the sword of revenge in return for the white flag of forgiveness, there comes a peace, a transformation, a healing which brings the soul one step closer to that ephemeral thing we call wholeness. There is, to be sure, a necessary loss in such surrender: for we have given up the right, the power, the control, the delusion that we may find by revenge a peace which is not in its capacity to give. For when we surrender, we win; when we submit, we are victorious; when we give up, we gain immeasurably more than anything we may have lost.

Read Gerard’s essay–no, more than read, absorb it into the depths of your spirit. And muster up the courage thereby to face down those demons dwelling in the depths of your own heart.

Note: The title of this post is not accidentally misspelled–I was informed that the original title (correctly spelled) was copyrighted by an eye care site by that name, who requested that it be changed.

The Maze – Part 7
Is There an Exit? – I

This is a part of an ongoing series on medical coding, billing, and reimbursement.

Previous posts are here:

MazeWhat started off in concept as a few posts on some of the craziness in the medical billing and reimbursement arena has been turning into something of an opus magnum on the subject–yet surprisingly, even at that has not even touched upon all of the complexity or contradictions inherent in this maze of regulations, bureaucracy, and inefficiency which we call our health care system. Such systems–complex, increasingly unworkable and counter-productive–do not arise by design, but rather by a sort of perverse evolution, growing a brier here and a bramble there, creeping tentacles and spiraling vines sprouting to address difficult problems, but increasingly choking the life out of their intended benefactors, strangling both those in need of help and those committed to providing it.

A regular question in comments throughout this series has been, “What, then, are your solutions?” Fair enough question–it is far too easy to dissect and depreciate the medical system we have at once inherited and created: it is, in soldiers’ parlance, a “target-rich environment.” A house built on sand cannot stand — and the mansion of American medicine, still rich in grand gables and ornate glass, is sagging from a rotting foundation, swaybacked from footings set on unsteady soil. The termites eroding its timbers are many, rooted in men’s souls as much as in Senate halls. We demand the finest care for ourselves, sparing no expense to others. We demand perfection of those capable only of imperfection. We hide behind our terror of death, unspoken yet unrelenting, seeking false hope in technology and technique against that dark looming fortress which stands unbending against our extravagant but ultimately fruitless endeavors. We pass law upon law and regulation upon regulation, engorging a byzantine monster so immense it can no longer ambulate–yet still we feed the beast, hoping against hope it may someday become the chrysalis which will carry us to a better world. It will not, and can not, for it has not the wherewithal to do that which is most needed: its own dismantling.

The complexity of our current system is both the cause and the result of its dysfunctionality. We have created an environment of perverse motivation and punitive legalism. Patients are shielded from the true costs of their decisions by insurance rendered nearly free to them by their employers or the government. Physicians, seeing their medical decisions challenged and checkmated by capricious clerks and aggressive algorithms, work the complex system to outmaneuver its clear intent to squeeze more work from them for less pay, while their patients are denied the care they have recommended. Insurers, pressured by employers to cut spiralling premiums, make cold calculations from afar which infuriate physicians and injure patients. Attorneys play Monday-morning quarterback, second-guessing complex decisions years after the fact, before gullible juries with Jerry Springer ethics, reaping personal windfalls far exceeding the benefits of their wounded plaintiffs. And government, having opened the financial floodgates of health care entitlements, now seeks to stem the rising waters by sandbagging the banks rather than repairing the dam.

Each player in this dysfunctional drama plays their part, driven in no small part by incentives which drive up costs and increase inefficiency and complexity. Health insurance, while necessary to avoid financial disaster in a health crisis, serves also to buffer patients from the cost implications of their health care decisions. Costly and sometimes unnecessary tests, drugs, or treatments are demanded because “insurance pays for them”–and because media and internet hype inflate their usefulness while minimizing their risks and costs. End-of-life care is extraordinarily expensive in part because patients and families refuse to accept the inevitability of death. Physicians play along, fearing lawsuits if they do not–while themselves refusing to recognize their own impotence against death and the futility of their own technological railings against the darkness. Government, desperately trying to reign in rampaging health care costs, responds by increasing regulation and complexity while decreasing reimbursements–greatly escalating pressure on physicians to manipulate the complex rules for their patient’s welfare and their own financial survival–and compounding the risk that by doing so they will run afoul of its legal and ethical clutches.

To restore a measure of sanity to this system we must return to core principles and truths, long since lost in the maze of regulations and rules we have allowed our health care system to become. In attempting to arrive at a better way to deliver health care, it may be best to start first with doesn’t work–and why:

 ♦ Managed care: Managed care works–or at least it used to–as long as you defined its success as the reduction of health care costs. Managed care uses several models. Most involve the use of a gatekeeper–a primary care provider who is the übermeister of who, when, and where you as a patient get care. Need a specialist? No go, unless Herr Pförtner approves. Got to see that specialist (finally), who recommends you have an MRI or CT scan? Gotta get a piece of paper from the Gatemeister before you go. And in many arrangements, the primary care gatekeeper has strong financial incentives to Just Say No–or strong disincentives should he break down and say Yes. So for you to see that specialist, your family doctor has to: 1) do extra work, filling out and sending more paperwork and forms, and 2) lose money. Bet he or she finds some way to treat you without that visit or test. Even good, ethical doctors get beaten down by such a system.

Another variation on managed care makes the insurance carrier the gatekeeper, making decisions about what care you may have, under what conditions, by which doctors. If you like having your primary care physician giving a thumbs up or down on your tests and referrals, you’ll just love having this process run by insurance clerks, secret policies, and computer algorithms. Of course, the carriers constantly remind us they don’t practice medicine. They’re right, of course: no one would call making regular decisions about your access to referrals, tests, and medications purely for financial gain practicing medicine, no siree. Malpractice of medicine would be a better description.

Managed care saves money by restricting access to care–and hence it resulted, after its introduction, in a significant drop in health care costs. But patients got wise to the game, and became more demanding–and media stories about kids denied cancer treatment and women with breast cancer denied bone marrow transplants, made the managed care companies pariahs. And so, managed care was forced to become more flexible, allowing more specialty visits and looser restrictions on certain tests and procedures. The result? The savings melted away, and after several years of declining costs, premiums and costs for managed care are on the rise–at about the same rate as health care costs across the board.

 ♦ More regulations and harsher penalties for their violation: So here’s the plan: Medicare costing taxpayers tons of money, having covered all those eligible regardless of ability to afford care and opened the entitlement floodgates? Time to micromanage where all that money goes. Create highly complex rules about what services can be provided, under what circumstances, and then change them constantly based not on medical need or progress but simply to stem high cost areas. Make the rules so complex no one can understand them–then go after the bastards who are “cheating” the system by violating the rules. Well, fear works–up to a point. Most doctors will try to ignore the rules and simply code at lower service levels to minimize their risks and the time needed to master the maze; others will buckle down and try to master them. Then, when even this doesn’t work to stem costs, it’s time to lower reimbursement levels. Eventually, this brilliant plan–increasing the costs of providing care while paying less–will result in payments which fall below the costs of providing the care–and doctors either have to game the system to stay afloat, or stop seeing federally-insured patients. The end result: more “fraud”–and rapidly shrinking health care access for covered patients (the elderly, disabled and the poor). Brilliant theory, Einstein. Got any more like that?

 ♦ Paying for quality: This is one of the latest gimmicks the health care policy wonks have dreamed up, more commonly known as pay for performance. It’s based on the (highly disputable) notion that bad doctors are running up the cost of care by ordering unnecessary tests, recommending unneeded procedures and surgery, practicing costly medicine which lies outside the mainstream–renegades all, ransacking the health care treasury. The good guys in the white hats, on the other hand, walk carefully between the lines, following established standards of care, don’t cost the system nearly as much–and should be rewarded with better reimbursements.

Ten solid seconds of thought by anyone with an IQ over 50 should see problems with this idea. A superbly-trained physician saving the life of a desperately ill patient, on a ventilator in an ICU, will be spending a whole pile of money–whereas ol’ Doctor Feelgood, passing out antibiotics for your sniffles and pain pills like candy may not be spending many health care dollars at all. High quality — while not invariably more expensive–is often so. And what about those guidelines? Well, one problem is, by and large, they don’t exist — except in a few relatively straightforward areas of medicine. The reason, in no small part, is that quality medical care is a complex and constantly moving target: what was excellent care ten years ago may be marginal or even poor care today. Once you ossify guidelines into regulations governing payment, you run a great risk of freezing health care advancement. You will be paid for care meeting the guidelines–but not for better care, based on advances in medical knowledge and technology, which will tend to fall outside the guidelines. And any physician who thinks they’ll get paid more for following the guidelines needs a long session on Dr. Sanity’s couch: they will pay those physicians not meeting the guidelines a lot less, and the “good guys” better than them — but still less.

I could continue, but enough of bad ideas. More of the same is not the answer to our health care system. In my next post I hope to lay out a few ideas which are based, I believe, more solidly on reducing complexity and aligning our health care more solidly along the lines of simplicity, accountability, and transparency. Stay tuned, back soon.

The Maze – Pt 6
The Nigerian Health Care Plan

This is a continuation of a series on medical coding, billing, and reimbursement.

Previous posts are here:

See no evil
 
OK, I have a business deal to offer you:

STRICTLY CONFIDENTIAL

PROPOSAL FOR URGENT BUSINESS ASSISTANCE.

With due regards, I take the liberty to contact you for an urgent business transaction which will be of immense benefit to all parties concerned. I am Mr Kingsley Chiugo, the Chairman of the contract Tenders Board of Nigeria National Petroleum Corporation, (NNPC).

My committee has the responsibility for the recommendation and award of contracts and supplies for the NNPC. In the course of our assignment, we did over-inflate the contracts for some supplies to the NNPC as a result of which the sum of USD $25.8m (Twenty five million, Eight Hundred Thousand United States Dollars only) is now outstanding. The original contractors who executed the jobs have since been fully paid off, leaving this outstanding sum. Unfortunately, we as civil servants are not allowed to own or operate a foreign account and it is also not possible for us to withdraw the money here locally.

We therefore need your kind assistance to transfer this outstanding sum of USD $25.8m to your account anywhere very safe. We shall compensate you with 25% of the funds for your assistance after the transfer. We the officials here shall have 65% while 10% will be set aside for any incidental expenses.

Oh, wait–you know about that one, and you’re not interested… OK, so here’s another–and this one’s for real:
Continue reading “The Maze – Pt 6
The Nigerian Health Care Plan”

Another Birthday

Lucy
 
Another birthday this month–not mine, you silly (that was last month, 56 long trips about the sun, and the treads are definitely showing the wear…), but this blog: two years old. For a project started on something of a lark–writing for a non-existent audience, with nearly non-existent time to pursue yet another Bob Obsession–it has proven to be quite a journey in many ways. The odyssey has been one from within and without, both reflective and relational. Putting thoughts to paper, as it were, seems to plumb some inner space, revealing dark recesses and flashes of light in often surprising ways, as the discipline of writing seems to free the spirit in some mysterious way. Writing for this blog, and elsewhere, has released thoughts, insights, and words which are, more often than not, as startling to me as they seem to be pleasing, and at times helpful, to others. And the surprise of new relationships and friendships, many virtual and virtually anonymous, yet friends nevertheless, rich with oneness of spirit and mind, is a real treasure–and frankly as surprising as the words I sometimes find myself writing.

I don’t write with any desire to be famous, or have the most hits, to get links on Instapundit or interviews in the media or a book deal. And I am pleased to inform you that my lowly objectives have been achieved beyond my wildest dreams: no fame, no fortune, no Instalanche, no book deals–and that’s perfectly alright, thank you very much. My goal–my hope, really–is to touch others in some small way, to perhaps give them a glimpse inside a remarkable profession–or even more so, a glimmer of God through the cracks in my own broken vessel. If I have accomplished this, even for a few, the effort will have proven more than worthwhile.

I write about bridges, and cooking turkeys, and the joys, frustrations, and insanity of a noble profession, and things I find humorous, or tragic, or touching, or life-changing, because changing life is what life is about: mine, my family, my patients, my friends, my readers. We of all creatures are aware of our own mortality; we get, to a greater or lesser degree, much choice in life’s summation: in many ways, we get to write our own novels. To come to the end of life with great wealth, or fame, or success, is perhaps understandable–even desireable in some small way–but invariably bequeaths a hollowness of spirit, a pathos of lost opportunity–for such things endure but briefly, if at all, after we ourselves return to the minerals of which we are made. To have touched those those with whom we have walked; to have drawn them in some way toward the light; to have left a legacy of goodness and mercy and grace behind: these are the things which will endure, things at once quite small yet vast and eternal.

I have watched, in this short time, many bloggers–bright, energetic, insightful, often excellent writers–post their swan song and fade to black, burned out on the relentless demands of daily delivery of content and commentary. I have at times wondered when, and by what manner, my own minor nova might flare, posting some sad goodbye to a few polite claps as my words fade like falling embers of a party sparkler. But hopefully–when that time comes–those words will linger with at least a few retinal ghosts, varicolored streaks of light against a dark background, that a few lives will thereby have been touched and changed.

I am grateful above all for those of you who visit here regularly, or rarely; who read, and visit, and think, and comment–or perhaps just wonder who this self-important fool might be. Thank you for listening, for spending those precious minutes of our too-brief lives–and especially for being friends.