Medicine

I’ll Have the Medicare — & Hold the Mayo

Dr Bob

The blogs have been abuzz about the big news from Arizona: The Mayo Clinic in Arizona will no longer be accepting Medicare patients for primary care.

The Mayo Clinic, praised by President Barack Obama as a national model for efficient health care, will stop accepting Medicare patients as of tomorrow at one of its primary-care clinics in Arizona, saying the U.S. government pays too little.

More than 3,000 patients eligible for Medicare, the government \'s largest health-insurance program, will be forced to pay cash if they want to continue seeing their doctors at a Mayo family clinic in Glendale, northwest of Phoenix, said Michael Yardley, a Mayo spokesman. The decision, which Yardley called a two-year pilot project, won \'t affect other Mayo facilities in Arizona, Florida and Minnesota.

Obama in June cited the nonprofit Rochester, Minnesota-based Mayo Clinic and the Cleveland Clinic in Ohio for offering “the highest quality care at costs well below the national norm.” Mayo \'s move to drop Medicare patients may be copied by family doctors, some of whom have stopped accepting new patients from the program, said Lori Heim, president of the American Academy of Family Physicians…

I’m surprised it took this long.

Mayo Clinic has long had a well-earned reputation for providing high-quality care at lower cost than much of the health care economy, due in large part to their successful formula (closed panel, salaried clinic physicians, and the resulting tight peer review) which is difficult or impossible to reproduce throughout the highly-diversified delivery systems in U.S. healthcare.

But Mayo Clinic is now coming to terms with the hard economic realities of seeing Medicare patients: it costs more to see them than you are paid:

The Mayo organization had 3,700 staff physicians and scientists and treated 526,000 patients in 2008. It lost $840 million last year on Medicare, the government \'s health program for the disabled and those 65 and older…

For years, physicians and clinics have simply absorbed this cost, effectively using their cash flow from better-paying private insurers to cover their Medicare losses. And we have reached the point where this calculus is no longer viable — a line crossed some years ago with Medicaid, the federal health program for the poor, whose reimbursements are only 60% or less of what Medicare currently pays.

What we have here is an unsustainable business model.

Typically, the folks at CMS downplay this reality, using the accounting chicanery so prevalent among our government bureaucrats, who love to piss on your leg and tell you it’s raining:

Nationwide, doctors made about 20 percent less for treating Medicare patients than they did caring for privately insured patients in 2007, a payment gap that has remained stable during the last decade, according to a March report by the Medicare Payment Advisory Commission, a panel that advises Congress on Medicare issues. Congress last week postponed for two months a 21.5 percent cut in Medicare reimbursements for doctors.

Yes, the gap may have remained stable — but Medicare payment rates have declined significantly over the past decade. In 1997 the Medicare conversion factor per relative value unit (RVU) was $40.97; in 2007, it was $37.89 — a nearly 10 percent decline, without factoring in inflation — and not including significant reductions in relative value units themselves (which are purportedly a hard measure of the costs and value of the service provided, but in reality are frequently “recalculated” to reduce Medicare expenditures), and a marked increase in bundling (wrapping several services together and paying for only one). What has happened is that private insurers have followed Medicare’s lead and also significantly reduced their fees, which are commonly calculated based on Medicare’s rules and formulas, but at a slightly higher conversion factor.

So while the ratio may appear stable, the reality is that both Medicare and private carriers have been dropping their fees, while medical expenses (salaries, benefits, supplies, malpractice premiums, etc.) have risen significantly faster than inflation. So the income vs. expense curves are now crossing for many, if not most, medical practices, and Medicare patients are beginning to generate significant losses, while private reimbursements can no long cover the difference. The only economically sane decision to remain solvent is to cut back or eliminate Medicare patients. The result? Reduced access to care. Of course the politicians will take credit for reducing health care costs — caring for fewer patients will certainly cost less.

Who needs death panels?

This is simple economics, really — but far too difficult for our politicians and liberal policy wonks to understand:

Robert Berenson, a fellow at the Urban Institute \'s Health Policy Center in Washington, D.C., said physicians’ claims of inadequate reimbursement are overstated. Rather, the program faces a lack of medical providers because not enough new doctors are becoming family doctors, internists and pediatricians who oversee patients’ primary care.

“Some primary care doctors don \'t have to see Medicare patients because there is an unlimited demand for their services,” Berenson said. When patients with private insurance can be treated at 50 percent to 100 percent higher fees, “then Medicare does indeed look like a poor payer,” he said.

No, Medicare doesn’t just look like a poor payer — it is a poor payer, and doesn’t cover the expenses involved in providing the medical care it pays for — even for a highly efficient organization like Mayo Clinic. This idiot’s theory is that simply by increasing the number of primary care providers, competition will be greater, and more MDs will be willing to take less to provide care. Law of supply and demand and all that.

So if you’re selling TVs which cost you $500 to purchase wholesale at a retail price of $350 (and that’s the price the government mandates), opening new dealerships will make this arrangement more economically viable, through competition.

Where do they find these morons?

Not unexpectedly, Mayo Clinic’s jilted Medicare patients are none to happy, as they are being asked to pay cash (gasp!) to keep their physicians:

A Medicare patient who chooses to stay at Mayo \'s Glendale clinic will pay about $1,500 a year for an annual physical and three other doctor visits, according to an October letter from the facility. Each patient also will be assessed a $250 annual administrative fee, according to the letter. Medicare patients at the Glendale clinic won \'t be allowed to switch to a primary care doctor at another Mayo facility.

A few hundred of the clinic \'s Medicare patients have decided to pay cash to continue seeing their primary care doctors, Yardley said. Mayo is helping other patients find new physicians who will accept Medicare.

“We \'ve had many patients call us and express their unhappiness,” he said. “It \'s not been a pleasant experience.”

Mayo \'s decision may herald similar moves by other Phoenix-area doctors who cite inadequate Medicare fees as a reason to curtail treatment of the elderly, said John Rivers, chief executive of the Phoenix-based Arizona Hospital and Healthcare Association.

“We \'ve got doctors who are saying we are not going to deal with Medicare patients in the hospital” because they consider the fees too low, Rivers said. “Or they are saying we are not going to take new ones in our practice.”

So Mayo’s trying to offload their Medicare patients onto other primary care physicians in the community, who no doubt will be more than happy to pick up these new financial albatrosses.

Best of luck with that plan.

The solution to this imminent disaster in access is not merely an increase in Medicare payment rates — Medicare and Medicaid are hell-bound for bankruptcy, and a few band-aids won’t stem the hemorrhage, but only make it worse. The imminent passage of “health care reform” legislation now bubbling in the witches’ cauldron of Congress will not only worsen Medicare’s situation — half a billion dollars are being cut from Medicare under the new legislation — but will instead bring this access disaster to private insurers as well. As their loss ratios are fixed by law at unsustainable levels, and community ratings forces them to accept high-cost patients without financial compensation for their increase risk and cost exposure, they will be forced to raise premiums to untenable levels — or drastically cut reimbursements to hospitals and physicians.

The system is a disastrous maze, and needs to be completely dismantled, and rebuilt from scratch. And the chances of that happening are zilch, zip, zero.

Welcome to the future of health care in America. Better stay healthy.

The Non-Reform Health Care Bill

Dr Bob

In the dark of night, appropriately, the Senate last night voted to end debate on its health care reform bill, bringing it to a floor vote. From Commentary magazine comes the following assessment of what will be voted on:

The non-reform health-care bill does, to the disgust of liberals, make insurance companies very happy. The government is coercing customers to buy the companies’ products under penalty of prosecution and fine. The non-reform health-care bill does, to the horror of seniors, slash $500B out of Medicare with no conceivable alternative other than rationing to meet its new budget. The non-reform health-care bill does, to the delight of trial lawyers, do nothing to reform the tort system or the problem of defensive medicine. And the non-reform health-care bill does, to the chagrin of deficit hawks, do nothing to bend the cost-curve or cut the deficit. (James Capretta explains: “For starters, as CBO notes, the bill presumes that Medicare fees for physician services will get cut by more than 20 percent in 2011, and then stay at the reduced level indefinitely. There is strong bipartisan opposition to such cuts. Fixing that problem alone will cost more than $200 billion over a decade, pushing the Reid plan from the black and into a deep red.”) Finally, the non-reform health-care bill will, to the embarrassment of good-government types, in all likelihood get passed through a combination of bribery and secrecy, with virtually no time for thoughtful consideration.

On every level it \'s a policy train wreck.

Not to mention that it pushes many of the uninsured into Medicaid, in a massive expansion of a program which is bankrupting the states, and which very few physicians can afford to take due to abysmal reimbursement rates which do not come close to covering expenses. The 22% Medicare fee cuts to physicians — one of the many accounting gimmicks thrown in to make this bill appear to be financially viable — will, if enacted, lead to a mass exodus of physicians from Medicare as well. Universal insurance coverage (which this bill does not even achieve) does not equal universal access, as we are about to discover to our horror and dismay.

I am doing my best to be sanguine about things over which I have no control, but it is difficult to watch the death of a profession and a superb health care system, to advance the partisan agenda of the power-hungry crooks and cronies who make up our current government. Revulsion is not too strong a word.

We will live to rue the day this disaster passes into law.

UPDATE: From the WSJ:

The rushed, secretive way that a bill this destructive and unpopular is being forced on the country shows that “reform” has devolved into the raw exercise of political power for the single purpose of permanently expanding the American entitlement state. An increasing roll of leaders in health care and business are looking on aghast at a bill that is so large and convoluted that no one can truly understand it, as Finance Chairman Max Baucus admitted on the floor last week. The only goal is to ram it into law while the political window is still open, and clean up the mess later.

***

• Health costs. From the outset, the White House’s core claim was that reform would reduce health costs for individuals and businesses, and they’re sticking to that story. “Anyone who says otherwise simply hasn’t read the bills,” Mr. Obama said over the weekend. This is so utterly disingenuous that we doubt the President really believes it.

The best and most rigorous cost analysis was recently released by the insurer WellPoint, which mined its actuarial data in various regional markets to model the Senate bill. WellPoint found that a healthy 25-year-old in Milwaukee buying coverage on the individual market will see his costs rise by 178%. A small business based in Richmond with eight employees in average health will see a 23% increase. Insurance costs for a 40-year-old family with two kids living in Indianapolis will pay 106% more. And on and on.

These increases are solely the result of ObamaCare --above and far beyond the status quo --because its strict restrictions on underwriting and risk-pooling would distort insurance markets. All but a handful of states have rejected regulations like “community rating” because they encourage younger and healthier buyers to wait until they need expensive care, increasing costs for everyone. Benefits and pricing will now be determined by politics.

As for the White House’s line about cutting costs by eliminating supposed “waste,” even Victor Fuchs, an eminent economist generally supportive of ObamaCare, warned last week that these political theories are overly simplistic. “The oft-heard promise ‘we will find out what works and what does not’ scarcely does justice to the complexity of medical practice,” the Stanford professor wrote.

• Steep declines in choice and quality. This is all of a piece with the hubris of an Administration that thinks it can substitute government planning for market forces in determining where the $33 trillion the U.S. will spend on medicine over the next decade should go.

This centralized system means above all fewer choices; what works for the political class must work for everyone. With formerly private insurers converted into public utilities, for instance, they’ll inevitably be banned from selling products like health savings accounts that encourage more cost-conscious decisions.

Unnoticed by the press corps, the Congressional Budget Office argued recently that the Senate bill would so “substantially reduce flexibility in terms of the types, prices, and number of private sellers of health insurance” that companies like WellPoint might need to “be considered part of the federal budget.”

With so large a chunk of the economy and medical practice itself in Washington’s hands, quality will decline. Ultimately, “our capacity to innovate and develop new therapies would suffer most of all,” as Harvard Medical School Dean Jeffrey Flier recently wrote in our pages. Take the $2 billion annual tax --rising to $3 billion in 2018 --that will be leveled against medical device makers, among the most innovative U.S. industries. Democrats believe that more advanced health technologies like MRI machines and drug-coated stents are driving costs too high, though patients and their physicians might disagree.

“The Senate isn’t hearing those of us who are closest to the patient and work in the system every day,” Brent Eastman, the chairman of the American College of Surgeons, said in a statement for his organization and 18 other speciality societies opposing ObamaCare. For no other reason than ideological animus, doctor-owned hospitals will face harsh new limits on their growth and who they’re allowed to treat. Physician Hospitals of America says that ObamaCare will “destroy over 200 of America’s best and safest hospitals.”

• Blowing up the federal fisc. Even though Medicare’s unfunded liabilities are already about 2.6 times larger than the entire U.S. economy in 2008, Democrats are crowing that ObamaCare will cost “only” $871 billion over the next decade while fantastically reducing the deficit by $132 billion, according to CBO.

Yet some 98% of the total cost comes after 2014 --remind us why there must absolutely be a vote this week --and most of the taxes start in 2010. That includes the payroll tax increase for individuals earning more than $200,000 that rose to 0.9 from 0.5 percentage points in Mr. Reid’s final machinations. Job creation, here we come.

Other deceptions include a new entitlement for long-term care that starts collecting premiums tomorrow but doesn’t start paying benefits until late in the decade. But the worst is not accounting for a formula that automatically slashes Medicare payments to doctors by 21.5% next year and deeper after that. Everyone knows the payment cuts won’t happen but they remain in the bill to make the cost look lower. The American Medical Association’s priority was eliminating this “sustainable growth rate” but all they got in return for their year of ObamaCare cheerleading was a two-month patch snuck into the defense bill that passed over the weekend.

The truth is that no one really knows how much ObamaCare will cost because its assumptions on paper are so unrealistic. To hide the cost increases created by other parts of the bill and transfer them onto the federal balance sheet, the Senate sets up government-run “exchanges” that will subsidize insurance for those earning up to 400% of the poverty level, or $96,000 for a family of four in 2016. Supposedly they would only be offered to those whose employers don’t provide insurance or work for small businesses.

As Eugene Steuerle of the left-leaning Urban Institute points out, this system would treat two workers with the same total compensation --whatever the mix of cash wages and benefits --very differently. Under the Senate bill, someone who earned $42,000 would get $5,749 from the current tax exclusion for employer-sponsored coverage but $12,750 in the exchange. A worker making $60,000 would get $8,310 in the exchanges but only $3,758 in the current system.

For this reason Mr. Steuerle concludes that the Senate bill is not just a new health system but also “a new welfare and tax system” that will warp the labor market. Given the incentives of these two-tier subsidies, employers with large numbers of lower-wage workers like Wal-Mart may well convert them into “contractors” or do more outsourcing. As more and more people flood into “free” health care, taxpayer costs will explode.

• Political intimidation. The experts who have pointed out such complications have been ignored or dismissed as “ideologues” by the White House. Those parts of the health-care industry that couldn’t be bribed outright, like Big Pharma, were coerced into acceding to this agenda. The White House was able to, er, persuade the likes of the AMA and the hospital lobbies because the federal government will control 55% of total U.S. health spending under ObamaCare, according to the Administration’s own Medicare actuaries.

Others got hush money, namely Nebraska’s Ben Nelson. Even liberal Governors have been howling for months about ObamaCare’s unfunded spending mandates: Other budget priorities like education will be crowded out when about 21% of the U.S. population is on Medicaid, the joint state-federal program intended for the poor. Nebraska Governor Dave Heineman calculates that ObamaCare will result in $2.5 billion in new costs for his state that “will be passed on to citizens through direct or indirect taxes and fees,” as he put it in a letter to his state’s junior Senator.

So in addition to abortion restrictions, Mr. Nelson won the concession that Congress will pay for 100% of Nebraska Medicaid expansions into perpetuity. His capitulation ought to cost him his political career, but more to the point, what about the other states that don’t have a Senator who’s the 60th vote for ObamaCare?

UPDATE 2: from Robert Samuelson, WaPo:

These fears are well-grounded. The various health-care proposals represent atrocious legislation. … So Obama’s plan amounts to this: partial coverage of the uninsured; modest improvements (possibly) in their health; sizable budgetary costs worsening a bleak outlook; significant, unpredictable changes in insurance markets; weak spending control. This is a bad bargain. Health benefits are overstated, long-term economic costs understated. The country would be the worse for this legislation’s passage. What it’s become is an exercise in political symbolism: Obama’s self-indulgent crusade to seize the liberal holy grail of “universal coverage.” What it’s not is leadership.

Samuelson argues that the uninsured will receive better care because more of them are covered. Of course, that is only true if they can actually get to see a physician who accepts their Medicaid coverage, which is already an enormous problem, and will certainly grow worse. I suspect they may actually receive better care now, uninsured, than they will covered under Medicaid.

No Death Panels Needed

Dr Bob

Over at Big Government, we get a glimpse of where ObamaCare will take us: Health Care \'s Coming Heart Attack – A Pre-Obama Care Death Panel?

I am writing of the Obama Administration \'s – regulatory decision – to go ahead with a massive cut in Medicare payments to cardiologists. I emphasize that this is a regulatory decision because it was not made by the Congress legislatively (not that that would be ok) but, instead, it was made by the massive Health and Human Services Department of the US Government. Given the limited resources of the Medicare budget, in order to increase payments to general practitioners (in an effort to attract more such doctors – a good idea), bureaucrats needed to gore somebody \'s ox and cardiologists were chosen (a horrible idea).

The decision to do so is astonishing.

Keep in mind that the very purpose of health care is to improve the health and therefore the lives of Americans. The cardiologist community has been wildly successful in that endeavor. Although heart disease remains the #1 killer of Americans, the mortality rate for heart attacks has plummeted. For instance, the post-heart attack, 30-day mortality rate decreased from 18.9 percent in 1995 to 16.1 percent in 2006 and the in-hospital mortality rate decreased from 14.6 percent to 10.1 percent.

Further, between 1994 and 2006, the mortality rate among women 55 and under who suffered a heart attack dropped an incredible 52.9%. For men in that same age group the drop was 33.3%. According to the author of the mortality study that determined those latter figures: “It appears that risk factors, which may be controlled through prevention efforts, are very important in driving these mortality reductions.”

Given those figures, it is hard to argue with the success of cardiologists who sit on the forefront of heart care and heart disease prevention – unless, of course, you are a government bureaucrat.

Rather than pouring more dollars into an obviously successful branch of medicine that is saving lives (the ultimate purpose of health care?), the Obama Administration is going ahead with a plan to cut nearly $1.5 billion from Medicare payment to cardiologists. Obama is doing so by such devices as literally eliminating reimbursement for certain services and/or reducing the amount they will pay for others. Case in point, cardiologists have been able to bill for an extended first visit with Medicare patients to get their history and to recommend a course of treatment. As of January 1, 2009 [2010 – ed.] – no longer.

What is being referred to here is Medicare’s decision to eliminate consultation service codes as of Jan 1 2010. These codes are almost exclusively used by specialists, and pay substantially better than standard visit codes, reflecting the higher complexity of care typically involved in specialty care. It is not just the cardiologists who are affected by this administrative change in Medicare payment — it is all specialists: oncology (cancer treatment), infectious disease, pulmonary, surgical specialties such as orthopedics, urology, ENT, neurosurgery, cardiac surgery, etc. etc. They are betting on a premise already proven false: that preventive medicine through primary care will reduce costs.

Specialty care is more expensive because specialists care for the sickest and most complex patients. When you are having your acute MI, you need a cardiologist, not a family practice physician. Specialty care is where the vast number of advances in American medicine have taken place — the advances which give us the best results in the world in cancer treatment, heart disease, and surgical advances such as laparoscopy and other minimally invasive procedures.

The inevitable outcome of these changes are that Medicare patients will have reduced access to specialists, as specialists increasingly are unable to afford taking a loss on every Medicare patient they see due to reimbursements which fall below their costs of providing care. They will by necessity reduce the number of Medicare patients specialists see, or force them to stop seeing Medicare patients altogether, resulting in longer waits to see a specialist and regional shortages of care in these areas. One does not need “death panels” to make policy changes which restrict care to the elderly and disabled; quiet bureaucracy works every bit as well, with the added advantage of plausible deniability.

Welcome to the new millennium in health care. Hope you enjoy your government-run universal health care.

Health Care on Life Support

Dr Bob

From the Wall Street Journal, on the passage this weekend of health care legislation in the House:
 

The bill is instead a breathtaking display of illiberal ambition, intended to make the middle class more dependent on government through the umbilical cord of “universal health care.” It creates a vast new entitlement, financed by European levels of taxation on business and individuals. The 20% corner of Medicare open to private competition is slashed, while fiscally strapped states are saddled with new Medicaid burdens. The insurance industry will have to vet every policy with Washington, which will regulate who it must cover, what it can offer, and how much it can charge.

We have little sympathy for the insurers, or for that matter most of the other medical providers who signed on to this process only to claim now to be appalled by the result. The insurance lobby --led by Aetna CEO Ron Williams --made the Faustian bet that it could trade new regulations for more new subsidized customers who would face a tax penalty if they didn’t buy their insurance. The Pelosi bill includes the regulation but guts the tax penalty because it’s unpopular. Insurers will thus have to cover more sick people with fewer dollars, as healthy folk opt out of coverage until they are sick…

Unless the Senate has an epiphany of common sense, Americans will be paying the bills for this willful exercise for generations to come.

Historic moment: you are witnessing the demolition of America’s health care system, and the crippling of its economy for generations to come. When the public wakes up from their slumber to discover what “universal coverage” looks like in the flesh, it will be far too late to undo the disaster.

Best make an appointment to see your doctor now — you may not have many opportunities left…

Deep Waters

Dr Bob

The following essay was originally posted in June 2005. The story is a true one, although the names have been changed.

 
Lake ClarkThey say that hell is hot. Sometimes, however, it is very, very cold.

Jim loved Alaska — it had been his home since birth. God’s country: wild, unpredictable, spectacular in beauty–there was no place like it on earth. Cities were a necessary evil, with their services and surliness, but out in the wild was where life could be found. Out among the glaciers, the ragged mountains framing the endless blue sky like jagged, broken glass, out where grizzlies snatched salmon from raging rapids, shortening their march to death as they fought wild currents to reach their spawning grounds. Out where eagles graced the sky, soaring above green fir spires and spotless snow fields. Out where God lived, where a man could see His hand, and hear His voice.

Jim lived a simple life of simple faith. He loved his wife as he loved the land, and together they were blessed with six children–three older girls, the twin boys, and a baby son their most recent gift. Each was a treasure greater than the next. Their lives were story book: The lodge they owned nestled near the shores of Lake Clark, a large inland glacial sea, mirroring the snow-peaked mountains surrounding it. Summers were busy–hunting and fishing tours, visitors from afar seeking trophies and photographs, decked in newly-purchased gear from REI in the lower 48. Jim loved to fly–the float planes lifted gracefully from the lake, carrying their awestruck passengers over endless miles of breathtaking beauty to some far-away stream where tied flies touched water and fish broke airborne for their last meal.

Out in the bush, relationships were few in number but rich and deep. Church was more than a Sunday obligation–it was a place where life was shared, joys celebrated, suffering comforted–a place where faith begot works, where love put on snowshoes and helped stack the winter’s wood. Family life was alive, ripe with blueberries picked, hikes to the falls, and quiet nights beside campfires. Summers passed quickly at Bible camp, concentric ripples of cannonballs and giggles of joy rolling across the lake from the old dock. Dates with dad and high tea with mom found no competition from mindless cartoons, and bedtime prayers thanked Jesus for His goodness and God for His gifts.

Winter was time for quiet reflection, as the short days and deep snows kept sportsmen far away, and school and indoor chores made the time pass slowly but with purpose. The plane was their lifeline: what few roads there were became impassible in deep snow, and flights to Anchorage a necessity for supplies and health care. The girls came along often, although the younger boys stayed with friends and relatives for lack of space.

Jim had tens of thousands of hours of flying experience, a skill which paid rich dividends in the harsh, capricious winters of south Alaska–there was little in the way of flying conditions he had not challenged and mastered. So this flight to Anchorage in February was a pleasant surprise: the low gray skies broke open to display the rare winter glory of sunshine on pristine snowfields, the glorious tinted rim of Alaska Range peaks and deep seas of Cook Inlet. The supplies garnered and the girls’ dental care completed, they took off for the return flight to home and hearth.

The storm struck without warning, a white she-devil blown in from the Gulf, the Cessna buffeted by sharp, hard winds as visibility and ceiling dropped precipitously. The instruments held true, and countless hours of difficult flying forged Jim’s nerves steely and his focus intent. Mom held the girls’ hands, distracting them from natural fears with songs and stories and heads held to breast, her own pounding heart betraying her calm demeanor. “Will we be OK, mommy?” “Jesus will bring us home, honey.”

The GPS told Jim they were indeed near home–the lighthouse in space beaconing safety and rest. By reckoning they should be near the lake, just a few miles out from the landing strip. But Nature had not finished yet, her rage reserved for one final blow.

A whiteout in a small plane is dreadful beyond imagining. Suspended between earth and sky, with no point of reference, no sense of up or down, sensory deprivation in a aluminum rocket. Your training trusts your instruments, but instinct and eyes scream for visual confirmation. There! On the right! Through a brief window in the suffocating white blindfold, a dark line: the outline of the lake shore. Jim banked the plane toward this beacon of hope. “Are we home yet, daddy?” “Almost there, honey.”

But wild Nature held one last vengeance: an atypical winter thaw had opened a long dark crack in the ice, normally frozen solid in February. The line Jim saw was not the shore. The plane hit water at airspeed.

The prop and windshield exploded. The cabin filled instantly with icy water, as Jim craned his neck to reach the fast-retreating air, still restrained by his harness. Years of wilderness training sprung to life, as without a thought he grabbed his Bowie and cut free the webbing. He struggled with the girls’ restraints, hopelessly locked between seats crumpled by the impact. His wife was nowhere to be seen. Time was up–the air was gone. He broke from the cabin, gasping for air at the surface, hoping to dive and try again to free his treasures. It was not to be: the plane sank like a millstone, 600 feet to the bottom of the frozen fjord, entombing the family he worshiped.

In shock, he looked around. His wife, by some miracle, thrown from the plane at impact, had struggled to the surface and clung to a floating berg. Spared from a frigid tomb, they stood on a fragile shelf of thin and breaking ice. Over two miles from the shore, clothing soaked through in sub-zero temperatures, their survival was still a loser’s bet. Slowly they worked their way shoreward, breaking through the ice at times, body temperatures dropping despite their exhausting physical efforts. Guided by some hand unseen, they finally fell exhausted on shore, finding shelter in an empty lodge. Blinded by cold and head trauma sustained in the crash, Jim was led into the cabin by his wife, who cut off his frozen clothes and started a fire.

Friends awaiting their arrival grew anxious, and the Air National Guard was called. A Pavehawk helicopter–battling the same merciless weather–located the crash site, and ultimately reached them at the cabin. Even then, they could not be evacuated, as conditions grounded the rescue helicopter until morning. A friend flew a Piper cub–braving the same horrendous storm–to bring arctic sleeping bags and warm food. Bravery, love, and duty had spared their lives.

Months passed. Physical healing came quickly, but the rawness of heart wept like an open sore, gently salved by friends and faith, prayers and potlucks, tears and thankfulness. The boys were precious as never before, but the emptiness of heart left by a lost child cannot be filled. The rage at God passes–slowly–as strength flows from trust born of countless old decisions to set aside self and act in faith. But the memories remain–the laughter lost, the peace of a sleeping child, the love of a flower picked, the unexpected hug. There is no answer to “why?“–only time, and trust, and talk, and the tender whispering of a gentle Spirit. Yet one haunting regret refused to die: the vasectomy Jim had undergone after their last son–expeditious at the time, financially prudent–was now a self-imposed prison in a home filled with people, yet achingly empty.

And so they sat in my office, seeking my skills to restore what no man should be asked to provide–hope and happiness. And they told their story, my heart aching with each small detail disclosed. Jim was a man of enormous character and strength, his wife still bearing the unspeakable pain on her face–yet there was no shame in the tears that welled up in their eyes. As I gently probed deeper with almost unseemly curiosity, I was drawn in by the most remarkable revelation: these two would stand. Theirs was a strength not merely of hardiness, or training, or steely denial hiding a dying heart, but of power beyond the means of any mortal. They had faced the hell that men fear even to consider, and conquered it. There was glory in their weeping, victory in their agony. They would never be alone, and never be defeated. I, the proud expert, felt strangely insignificant in their presence.

The surgery went well, and early recovery smoothly. As I spoke with Jim before he left for home, he talked about the girls who had loved their daddy and whom he still loved so deeply. “You know, if I could fly to heaven and bring them back, they would not want to come. Their happiness is complete, ours still unfulfilled. Jesus has indeed brought them home.”

H.R. 3200

Dr Bob


 
If you have a serious case of insomnia, have far too much time on your hands — or have a vested interest in not seeing government take over your health care — then you will want to spend quality time reading the legislation which will change your life, irrevocably and disastrously, forever: HR 3200, “America’s Affordable Health Choices Act of 2009”. Various summaries and commentaries are floating about the web, and while helpful, they are tainted by too much histrionic commentary, often SHOUTED TO MAKE A POINT! which may or may not be be a valid inference from the legislation.

Here’s the HTML version with links.

So now you can go straight to the source, and judge for yourselves. Even though your elected representatives will try to pass this without reading it, that doesn’t mean you can’t do the responsible thing and get informed.

Here’s a good summary of HR 3200’s key aspects, from AAPS:

New bureaucracies: These include State Health Help Agencies (HHAs), with a federal fallback plan should states refuse to create them; an advisory committee to report annually on modifications of benefits, etc.; some mechanism to “adjust” the Medicare Part B premium based on whether or not each individual “participates in certain healthy behaviors”; other agencies to calculate payments, monitor individual behavior, set standards as for chronic disease management, check compliance with standards, monitor loss ratios and outcomes of chronic-care management, etc.

Individual mandate. All adults must buy a government-approved Healthy Americans Private Insurance Plan (HAPI) [love the abbreviation!] and constantly report on compliance, at every interaction with federal, state, and local government, including at voter registration, motor vehicle departments, or other checkpoints, as well as when filing tax forms. This applies to all legal residents, including non-citizens, although not to illegal aliens.

Penalties. The penalty includes the average monthly premium, plus 15%, for all “uncovered” months. Penalties are not subject to discharge by bankruptcy. This means that the HHA, which receives the penalties, takes precedence over other creditors.

Insurance mandates. Guaranteed issue, community rating, coverage of “wellness” without copayments, annual physicals, a required “health home” (gatekeeper), mental health parity, and reconstructive surgery post mastectomy are all mandatory. Each HAPI plan “shall” make available supplemental coverage for abortion, unless affiliated with a religious institution.

Progressive taxation equivalent. Premium subsidies are phased out incrementally up to 400% of poverty. This means that working harder and earning more is punished by higher mandated health insurance “premiums” (which are the functional equivalent of taxes). People will constantly be reporting on their income status.

School-based clinics. Care must be provided at no cost, or on a reimbursable basis, by school-based clinics, which must provide, “at a minimum,” mental health services, and use electronic medical records by 2012.

Job killer. Every employer “shall pay an employer shared responsibility payment,” which increases for each additional employee in excess of 50. Employers must deduct the individual shared responsibility payment from wages “as and when paid.” This amount is not allowed as a deduction from the employer \'s taxable income.

Savings. To offset the costs, Medicare and 90% of Medicaid disproportionate share (DSH) payments are to be “recaptured.” Tax exclusions for health benefits will be limited (sections 661-666). According to section 801, “private insurance companies will be forced to hold down costs and will slow the rate of growth because they are required to offer standardized Healthy Americans Private Insurance plans.”

These cool cats in Congress are, of course, only interested in your welfare, and always have the interest of their constituents first and foremost in their minds:

So give them a piece of your mind, here.

The hour is late, and the corrupt political class wants to radically transform the health care system — not for your benefit, but for theirs.

Get to work before its too late.

The Preventive Medicine Con

Dr Bob

Well, the first details of the long awaited health care plan are now coming out, and the Internet is abuzz with shock and awe about many of its aspects, particularly its high cost, the undermining of private health insurance policies, and the complexity of its administration, manifested in a host of new bureaucratic agencies to bring the joys of government health care into every nook and cranny of your pitiful and meaningless life.

One big-picture aspect of this huge transformation in American health care which seems to be receiving little or no attention is its heavy emphasis on preventive medicine. We have been hearing for some time about how preventive medicine will save substantial sums of money and thereby make the overall health care system far less costly. Of course, such rhetoric has an enormous appeal at a surface level — after all, if you can prevent diseases, you certainly don’t need to spend money to cure them.

Who could argue with this?

But this innocent-sounding, simplistic Trojan horse will prove deadly for American health care, and end up empowering the bureaucrats and politicians who will, in fact, gain the most from this change in direction.

When we talk about preventive medicine, we are generally speaking of two general areas: the screening and early detection of diseases, and lifestyle changes and therapy to reduce long-term medical risk. Screening and early detection of diseases is appealing concept, but devilishly difficult in practice. The idea sounds wonderful: do a simple, inexpensive test; detect the disease earlier, when it is simpler and less expensive to treat; and you will be healthier in the future, requiring far fewer health resources. The problem lies, as I have discussed elsewhere, in the malignant mathematics and sickening statistics of applying medical screening to large populations. Simply put, no screening test is perfect, and all such tests generate both false positives — telling you that you have a disease, when you do not — and false negatives — telling you you’re fine when you really have the disease. Even with an extraordinarily accurate test the problem lies in applying it to large populations. If you have a cancer screening test with a 1% false positive rate (an extraordinarily low number in the screening business), and have a disease which occurs in one patient out of every 10,000, applying the test to 10,000 patients will generate 100 false alarms (false positives) for every patient with the disease. These false positives all require additional testing or procedures to determine whether in fact the abnormal test really means you have the disease. And herein lies the economic trap: you will in fact spend an extraordinary amount of money on patients without the disease for every patient detected who does have the disease. This phenomenon has been well demonstrated in almost every study of screening — to wit: screening actually increases rather than reduces medical costs.

Of course many simple screening tests and procedures are used every day in medicine. When you go to the doctor, your blood pressure is checked, your cholesterol is measured, you stand on the scale and are weighed, and asked whether or not you smoke. If your blood pressure is high, you will likely be started on medication, and it is also likely that you will need to stay on this medication indefinitely. If your cholesterol is elevated, will be encouraged to exercise, make dietary changes, and lose weight (most of which you won’t do), but will also likely will be started on cholesterol-reducing medication, likely for the long-term. Of course, we recognize that this is appropriate for the reduction of risk from high blood pressure or high cholesterol. What may not be recognized, is that many people with high blood pressure or high cholesterol, unrecognized and untreated, may not have significant problems from these disorders for many years, if ever.

Suppose that 100 people with high cholesterol levels take statins, a common treatment for high cholesterol. Of them, about 93 wouldn’t have had heart attacks even if they had not taking the medication. Five people, on the other hand, will have heart attacks despite taking the statin. Only the remaining two out of the original 100 avoided a heart attack by taking the daily pills. In the end, 100 people needed to be treated to avoid two heart attacks during the study period --so, the number of people who must get the treatment for a single person to benefit is 50. This is known as the “number needed to treat” — and is a common way in which health researchers determine the cost and effectiveness of preventive therapy. Ideally, we will get better at selecting those patients at the front end who actually will benefit from taking the drug, and therefore avoid administering it in those who ultimately will not need it. But such health forecasting is far, far from perfect, and there will always be a need to treat patients perceived to be at risk even though time will ultimately find them not to be at risk at all. The human organism in health and disease is far too complex to eliminate this reality.

Problems such as these arise in every aspect of preventive medicine. It also goes without saying that implementing lifestyle changes, such as weight reduction, regular exercise, smoking cessation, and dietary modifications, is largely a fool’s pursuit. We humans love our addictions, and rarely overcome them even when they threaten our health and well-being.

The myth of the economic benefits of preventive medicine dies hard, however, and the pending changes in the health care system are placing a very large bet on this loser’s hand. The systemic manifestation of this crap shoot is the glorification and indemnification of primary care as the solution to all of our health care woes, economic or otherwise. Although the final details of the pending reforms of health care are still far from complete, it is clear that there will be a heavy emphasis on steering patients toward primary care physicians and away from specialists.

Health care bean counters have long known that care delivered by specialists is more expensive then that delivered by primary care physicians. It is the specialist who performs the expensive surgeries, procedures, and diagnostic studies which cost the government and health insurers a substantial percentage of their total outlays. When viewed from an economist’s standpoint, it makes perfect sense to reduce the utilization of more expensive specialty care, and increase the utilization of less costly primary care. Although the details remain to be fleshed out, it appears that there will be a substantial increase in reimbursement to primary care physicians, and reduction in reimbursement to specialists by eliminating higher payments for consultations, procedures, and surgeries. These changes are already beginning to be implemented in Medicare, even prior to passage of any large healthcare reform legislation. There are plans to bundle payments for chronic disease management, paying the primary care physicians who manage them higher rates, most likely on a fixed payment schedule designed to motivate physicians to reduce costs and improve outcomes.

Like most great ideas arising from the government, this is a day late and a dollar short.

The insurance industry came up with this idea over a decade ago, and implemented it in systems extensively, using the tools of capitation (bulk payments to physicians upfront for future care) and the gatekeeper model (having the primary care physician who receives such bulk payments control referrals to specialists, with a strong financial incentive not to send them there).

Many of you may recall how popular these programs were. What you may not have noticed is that virtually all insurers have dropped them.

There were a host of difficulties with this approach to medicine. First of all, it put the physician in a position of conflict of interest, by giving him or her a financial incentive not to order additional tests or make referrals to expensive specialists. While this incentive would obviously reduce unnecessary tests and referrals, it also gave the physician an economic incentive to defer or eliminate such tests and referrals, when in fact they were in the patient’s best interest. Simply put, your doctor made more money if he did not order your CAT scan, even if a CAT scan had a strong medical indication.

These policies led to no small amount of disgruntlement among patients covered under such plans. It became clear that patients could not get to see specialists when they needed them, because their physician or their insurance company refused to allow them. Even when the system worked as ideally designed — preventing referrals for unproven experimental or unnecessary treatments — patients nevertheless demanded these treatments, and often resorted to heart-rending media exposés on how the evil insurance companies had refused to pay for their experimental treatment for cancer. In one sense, this approach did work as intended: by restricting access to care, particularly specialist referrals and expensive diagnostic testing, HMOs and other similar insurance schemes did in fact reduce substantially the rise in medical costs. But they did so by rationing — and thereby sealed their own fate when this became enormously unpopular among patients, and (of course) exploited by politicians. Although some remnants of this system remain intact, particularly preauthorization for specialist referrals, certain procedures, and diagnostic imaging studies, the coercive restrictions in place during the height of this trend have greatly mitigated. Those restrictions which remain are still the most common source of discontent among patients and physicians, as insurance companies continue to refuse payment for medical services recommended by their physicians, or require onerous paperwork for their authorization.

As you can imagine, primary care physicians, who have been lobbying for higher reimbursement rates for many years (and not unreasonably so) find many aspects of a new financial emphasis on primary care to be attractive.

They should be careful what they wish for.

One of the deadliest traps of bundled payments such as capitation was the problem of medical outliers. Getting a payment every month for your entire patient population, to manage all their care, is a great deal if all your patients are healthy, as they cost you very little, and you get to keep the difference. The problem arises when your practice involves a large number of patients whose care is very expensive. Your lump sum payment begins to look very small when a large number of your patients require costly hospitalization, surgery, expensive medical therapy or drugs — the payment for which is coming out of your own pocket. This reality created an entire consulting industry to analyze patient populations versus capitation rates, with the goal of reducing the physicians exposure to such potentially disastrous financial consequences. Physicians and their consultants got very good at selecting populations of healthier patients — which often excluded those patients who needed medical care the most. Physicians who got burned on this difficult calculus often ended up terminating their relationship with specific insurance carriers, resulting in large numbers of patients abruptly losing their physicians, and forced to hunt around for new physicians who would accept their insurance.

For these and a host of other reasons such insurance models have largely died an ignominious and well-deserved death. but their rotting corpses are being raised to life again. The Undead will walk the earth, this time with even greater powers granted them the federal government.

With private insurers, physicians and physician groups at least have the option of terminating their contracts with insurance carriers whose reimbursements or capitation rates were insufficient to cover the risks of the patient populations they covered. With universal health care, especially one predominantly or exclusively provided by the government, this escape route will no longer be available. The primary care physician who finds his reimbursement improved for managing chronic diseases will also find himself burdened by a blizzard of additional paperwork to document that the “quality” of his care meets government standards — whether such standards are realistic, or even in the patient’s best interest. Furthermore, if such reimbursements do not cover the inevitable increase in management overhead, there will simply be no place else to turn. One cannot fire the federal government when they are the only source of payment for the medical services you provide. The only option available to physicians will be to opt out of medicine altogether — and you may anticipate the increasing numbers of physicians will do exactly this. Universal health insurance is not the same as universal health access — a lesson we are about to learn painfully if we continue down this path. A seat at the Captain’s table on the Titanic seems propitious until the chairs start sliding toward the bow of the sinking ship.

But there is another aspect to this heavy emphasis on primary care which has received virtually no attention. Although certainly not without problems and potential abuses, the simple fact remains that America’s specialist-intensive health care system is in fact the driving force behind its technologically advanced benefits. Simply put, we are not living longer, healthier lives because we have beloved family doctors who hold our hands and listen to our complaints. The huge advances in medicine in the past 50 years have occurred in large part because of the specialization of medicine. The extraordinary complexity of contemporary medicine has made its mastery by any one type of physician utterly impossible. Even the brightest internist or family practice physician cannot be master of all of the complex aspects of cardiology, surgery, oncology, or the management of increasingly-challenging infectious diseases. Certainly good physicians in primary care are well-versed in many of these areas, at some level, but it has long since been unrealistic to expect primary care providers to be masters of such vast and ever increasing knowledge and complexity in the different realms of specialty medicine. This is not to denigrate in any way the importance of primary care physicians, most of whom are highly accomplished at the health maintenance of large numbers of patients — a skill which has contributed greatly to our improved quality of life and longer lifespans. But our system provides the enormous benefits in high quality and longer, healthier lives because the primary care physician has a very deep bench of specialists at his beck and call.

At some point even the most skilled and capable primary care physician will encounter complex, difficult, or intractable problems which he or she simply is not trained or skilled to manage. Specialty care is indeed expensive — and it is expensive in no small part because the patients who need such care have more difficult or complex medical problems, which simply cannot be best treated without the expertise of specialists.

As our system increasingly steers patients away from such specialty care for economic reasons, it will do so at significant cost in a variety of realms. Much of the advanced medical innovation, which has given us longer and better lives, has arisen out of specialty care, and it is inevitable that significant restrictions on such care will blunt and slow such medical advances. But there are costs hidden in such an approach which will also become apparent with such an unbalanced emphasis. When we, through financial coercion, force primary care physicians to assume the care of increasingly complex patients for which they have neither the training nor depth of experience to manage, such care will inevitably end up being inferior in quality — and likely will end up in the long run, being far more costly. Without access to specialty support, primary care physicians tend to fall back on using more expensive medications, diagnostic studies, and therapies, sometimes inappropriately. The unusual skin condition, which can be promptly diagnosed and appropriately treated in a few visits to the dermatologist, may instead be treated with an increasing array of expensive and ineffective therapies or drugs by primary care providers who are unwilling or unable to avail themselves of specialty consultation and treatment. The insurance companies learned this long ago, and it was one of the factors motivating them to dismantle the gatekeeper model.

The enormous push toward primary care and preventive medicine embodied in the currently-envisioned transformation of the health care system being pushed through by Congress will be doomed to fail, brought down by the flawed premises upon which it is based. But it will, in one important regard, prove successful to those who are currently pushing its implementation. The system as currently designed, with its emphasis on primary care and preventive medicine, will not improve quality or reduce costs, but will give government a far greater degree of control over physicians and the nature of the care they provide. Increasingly it will be the government, and not the physician, who dictates what care you will receive, which specialists you will see (if any), and whether the medically appropriate care which you need will meet its financial standards for return on investment. As Obama has promised us, we will all be asked to “take the pain pill” rather than undergo the surgery we need and which will improve our lives.

It likely is too late to stop the perfect storm of health care reform, given the current makeup of our Congress and Administration. Be prepared for a brave new world in medicine.

And don’t be surprised if it is not to your liking.

UPDATE: Massachusetts, in deep do-do from their universal coverage, is treading this same hoary path: Massachussetts Health Plan Pushes for Capitation Megan McArdle spells out the problems nicely. Take-away quote: “This is why ‘paying for health rather than procedures’ never pans out.”

A Life Not Long

Dr Bob

Last week, President Obama removed virtually all restrictions on fetal stem cell research, claiming a triumph of science over “ideology.” The hope, of course, is that science may find new ways to prolong and improve our lives, now that the shackles of moral restraint, humility, and ethics have been removed. It seemed fitting, therefore, to repost this older essay, pondering whether the “victories” which science now has in store for us will be indeed Pyrrhic.

 
sunset

A link from Glenn Reynolds hooked into something I’ve been ruminating on in recent days: the endless pursuit of longer life.

Here’s the question I’ve been pondering: is it an absolute good to be continually striving for a longer life span? Such a question may seem a bit odd coming from a physician, whose mission it is to restore and maintain health and prolong life. But the article which Glenn linked to, describing the striking changes in health and longevity of our present age, seemingly presents this achievement as an absolute good, and thereby left me a tad uneasy — perhaps because I find myself increasingly ambivalent about this unceasing pursuit of longer life.

Of course, long life and good health have always been considered blessings, as indeed they are. But long life in particular seems to have become a goal unto itself — and from where I stand is most decidedly a mixed blessing.

Many of the most difficult health problems with which we battle, which drain our resources struggling to overcome, are largely a function of our longer life spans. Pick a problem: cancer, heart disease, dementia, crippling arthritis, stroke — all of these increase significantly with age, and can result in profound physical and mental disability. In many cases, we are living longer, but doing so restricted by physical or mental limitations which make such a longer life burdensome both to ourselves and to others. Is it a positive good to live to age 90, spending the last 10 or more years with dementia, not knowing who you are nor recognizing your own friends or family? Is it a positive good to be kept alive by aggressive medical therapy for heart failure or emphysema, yet barely able to function physically? Is it worthwhile undergoing highly toxic chemotherapy or disfiguring surgery to cure cancer, thereby sparing a life then severely impaired by the treatment which saved that life?

These questions, in some way, cut to the very heart of what it means to be human. Is our humanity enriched simply by living longer? Does longer life automatically imply more happiness–or are we simply adding years of pain, disability, unhappiness, burden? The breathlessness with which authors often speak of greater longevity, or the cure or solution to these intractable health problems, seems to imply a naive optimism, both from the standpoint of likely outcomes, and from the assumption that a vastly longer life will be a vastly better life. Ignored in such rosy projections are key elements of the human condition — those of moral fiber and spiritual health, those of character and spirit. For we who live longer in such an idyllic world may not live better: we may indeed live far worse. Should we somehow master these illnesses which cripple us in our old age, and thereby live beyond our years, will we then encounter new, even more frightening illnesses and disabilities? And what of the spirit? Will a man who lives longer thereby have a longer opportunity to do good, or rather to do evil? Will longevity increase our wisdom, or augment our depravity? Will we, like Dorian Gray, awake to find our ageless beauty but a shell for our monstrous souls?

Such ruminations bring to mind a friend, a good man who died young. Matt was a physician, a tall, lanky lad with sharp bony features and deep, intense eyes. He was possessed of a brilliant mind, a superb physician, but left his mark on life not solely through medicine nor merely by intellect. A convert to Christianity as a young adult, Matt embraced his new faith with a passion and province rarely seen. His medical practice became a mission field. His flame burned so brightly it was uncomfortable to draw near: he was as likely to diagnose your festering spiritual condition as your daunting medical illness — and had no compunction about drilling to the core of what he perceived to be the root of the problem. Such men make you uneasy, for they sweep away the veneer of polite correction and diplomatic encouragement which we physicians are trained to deliver. Like some gifted surgeon of the soul, he cast sharp shadows rather than soft blurs, brandishing his brilliant insight on your now-naked condition. The polished conventions of medicine were never his strength — a characteristic which endeared him not at all to many in his profession. But his patients — those who could endure his honesty and strength of character — were passionate in their devotion to him, personally and professionally. For he was a man of extraordinary compassion and generosity, seeing countless patients at no charge, giving generously of his time and finances far beyond the modest means earned from his always-struggling practice.

The call I received from another friend, a general surgeon, requesting an assist at his surgery, was an unsettling one: Matt had developed a growth in his left adrenal gland. His surgery went deftly, with much confidence that the lesion had been fully excised. The pathology proved otherwise: Matt had an extremely rare, highly aggressive form of adrenal cancer. Fewer than 100 cases had been reported worldwide, and there was no known successful treatment. Nevertheless, as much for his wife and two boys as for himself, he underwent highly toxic chemotherapy, which sapped his strength and left him enfeebled. In spite of this, the tumor grew rapidly, causing extreme pain and rapid deterioration, bulging like some loathsome demon seeking to burst forth from his frail body. I saw him regularly, although in retrospect not nearly often enough, and never heard him complain; his waning energies were spent with his family, and he never lost the intense flame of faith. Indeed, as his weakened body increasingly became no more than life support for his cancer, wasting him physically and leaving him pale and sallow, there grew in him a spirit so remarkable that one was drawn to him despite the natural repulsion of watching death’s demonic march.

Matt died at age 38, alert and joyful to the end. His funeral was a most remarkable event: at an age in life where most would be happy to have sufficient friends to bear one’s casket, his funeral service at a large church was filled to overflowing — thousands of friends, patients, and professional peers paying their respects in a ceremony far more celebration than mourning. There was an open time for testimony — and such a time it was, as one after another took to the lectern to speak through tears of how Matt had touched their lives; of services rendered, small and large, unknown before that day; of funny anecdotes and sad remembrances which left not one soul of that large crowd untouched or unmoved.

A journey such as his casts critical light on our mindless pursuit of life lived only to live long. In Matt’s short life he brought more good into the world, touched more people, changed more lives, than I could ever hope to do were I to live a century more. It boils down to purpose: mere years are no substitute for a life lived with passion, striving for some goal greater than self, with transcendent purpose multiplying and compounding each waking moment. This is a life well-lived, whether long or short, whether weakened or well.

Like all, I trust, I hope to live life long, and seek a journey lived in good health and sound mind. But even more — far more indeed — do I desire that those days yet remaining — be they long or short — be rich in purpose, wise in time spent, and graced by love.