Monday, December 12, 2011

J & B - a 2011 Review

John & Barbara
Christmas 2011

Hint - click on any picture to enlarge it 
Rather Sporadic, like our life, but here is a note of the clan happenings lately. It would be easy if we could just say we worked, hung around the home, and read a few books, but fortunately we were able to get around a bit again this year.

In January Barbara left ahead of John for Palm springs, doing a “ricochet” road trip with Joanne, one of her girl friends. We departed the desert early this year for purpose; a March wedding! Karen and Brian were wed in a beautiful ceremony (and rocking reception) in Tucson in late March. It was a formal wedding, but with a notable lack of stress and abundance of fun. After the honeymoon, Karen, now a board-certified psychiatrist, is back in her practice and Brian has taken advantage of an opportunity to expand his law practice. They have all the paperwork in place for adoption and hope to be parents very soon.
June found us on the way to England, Norway, and Denmark with Dale and Ann Roberson to see the fjords and Some of Dale's family. We started in London, where Barbara And John had lunches with English friends, both old and recent. Barbara, as usual, uncovered things off the beaten path, this time a Victorian operating theater (pre-anesthesia and pre-antisepsis) for the Guys Hospital women's wards that had been closed off for construction, forgotten about, and then discovered as a veritable time capsule more than a hundred years later. 

We then embarked for a cruise along Scotland , the Norwegian fjords, Bergen, and Oslo, winding up with a few days in Copenhagen.  Barbara again searched the side streets, leading us to a Leper Hospital in Bergen from the 1700's and an old medical school and hospital in Copenhagen that contained a remarkable collection of the very earliest X-ray equipment.

On the shore day in Flam, the Floyds and Robersons rented a car and spent the day visiting with Dale's family and touring the family farm and homes and the wonderful, old church. To add a bit of excitement, we left the family at the last minute, drove like mad ( including a ferry connection and the longest automobile tunnel in the world), and made it back to the ship just as they were raising the gangplank. Participating in Dale's family connection was the highlight of the trip.

In July, John drove our motorhome as the support vehicle for Matt (John) and two of his friends on RAGBRAI as the boys (and 10 or 20 thousand others) did the annual bike ride across Iowa from the Missouri to the Mississippi. Fun (and air conditioning) for all. While Matt was conditioning for RAGBRAI, Rachael was in Portland training for half-marathons (challenged by her mom, who travels to Portland for the races.) M & R seem to be thriving in Portland (great city!)
Anne is back in School in Phoenix and will soon join her siblings as college graduates. She is on the Dean's List! RC continues to work in what in Phoenix is a very challenging real estate business. They drove to Estes Park in August, joining Matt, Rachael, Karen, and Brian so all could celebrate with us our 40th wedding anniversary . . . the best present we could have.
We were in Estes Park for much of the Fall (with John commuting of course.) It remains a remarkable place. This year we had a mother bobcat park her 3 kittens in a tree next to our deck for the afternoon and evening; pictures ended up in the local paper. We had a visit from Barbara's cousin Steve and wife Janet and a couple of visits with John”s cousin John and wife Donnice who live in Fort Collins. It was a great opportunity to stay in touch with our many friends in Estes Park, many whom are neighbors on our street.

In early November, we combined taking the RV to California with a trip to Green Valley, AZ for
a weekend celebrating Tom and Elaine Ferguson's 50th wedding anniversary – what a party! It was also a chance to see friends from our old gourmet club.
We did a slight twist on our annual visit to Chicago for the big radiology meeting the week after Thanksgiving by not using an hotel, but staying in a condo (owned by a friend of a friend) a block from Water Tower. Chicago has long been our favorite city for downtown living/visiting, though we must say that now we are getting to know Portland, OR, it too has a great downtown.
We will be heading back to Estes Park for Christmas and New Years, and be joined there by Matt/Rachael and Karen/Brian. Ann and RC might or might not be there because of medical issues with his family in Cedar Rapids.
Barbara keeps adding to the family history, with research here and there across the country. In addition to working in the Newberry library in Chicago, she “discovered” one of the best genealogy libraries in the country in Fort Wayne, IN, and combined a visit there with a trip to attend a memorial for Bill Wilson, her aunt's husband, in Princeton, IN. Barbara also continues to hone her jewelry making skills. This year she moved from student to teacher, leading two classes in chain maille at a local shop here in Cedar Rapids.
John still enjoys his practice, and has committed to working through 2012. Next summer he will decide about 2013. He relishes those days without the alarm clock going off, and could learn to live that way all the time.
We wish all of our friends and family the best for the coming year. We cherish each and all of you and we are thankful we have you in our lives.

(Winter Holidays in Estes Park
from our bedroom window. )

John & Barbara

Saturday, December 3, 2011

Rationing Health Care: good or bad it's necessary

Book Cover 
"Pricing Life" by Peter Ubel

The USA is going to have to decide what to do about the rampant acceleration in the cost of health care on a national basis, and I am fearful that, lacking the knowledge and courage to do it correctly, the government will simply continue cutting payments across the board to doctors and hospitals, encourage the use of cheaper but less effective care, and continue to ignore the growing tens of millions of citizens without health care insurance.  
PRICING LIFE is one of the few books to use the "R" word (rationing) even though we are already  rationing care in this country; just doing it irrationally.  My daughter, K put me onto this book almost a decade ago, and it is every bit as valid today as when it was published in 2001.

Ubel reviews the many ways rationing has been attempted (with noteworthy experiments in Oregon that were well conceived but still unsuccessful), including prioritizing with cost-effectiveness analysis (CEA) and cost-benefit analysis (CBA) as means to determine the utility of different medical treatments in adding a quality year of life (QALY.)  He comes to the conclusion that these efforts have failed because they don't reflect all community values and only address the average patient.  He contends that only by primary physicians limiting use of and access to marginally beneficial care can substantial reductions in medical utilization and cost be achieved.  He discusses the way physicians are already rationing care by the use of situational examples.

Ubel also talks about the "Moral Hazard" of insurance, even when individually purchased.  This is a phenomena well known by waiters in high priced restaurants.  When there is no splitting of the check, the overall bill will invariably be higher than if individual checks are given.  When Bill is dining with 5 other friends at an expensive restaurant, he is more likely to order his third expensive scotch after dinner since he will be responsible only for $10 (1/6) of the actual $60 cost of his three drinks, while Mary may have the fancy desert she thinks is overpriced and would not otherwise order, but because she sees Bill having all that expensive Scotch she also wants to get her own "fair share."  

This same process acts with insurance, especially when employer or government provided.  If your doctor says there is a test that cost $500 to detect a rare disease that you have only a 1 in 10,000 chance of having, you will probably decline to have the test if you have to pay the $500 out of your own pocket.  However, if covered by insurance and you only have to pay $10 to have the test, you are far more likely to ask you doctor to go ahead with the test.  Thus the "moral hazard" of medical insurance works just like the expensive dinner with a single check.

I do think there is an important component missing in Ubel's book, and it is perhaps because his experience is as a government-employed VA doctor, and because the "business" of medicine has increased in dominance since the '90s when he wrote the book.  I know of no hospital that does not operate on a profit basis; especially a "non-profit" hospital that is in competition with another non-profit in the same community.  

As I have commented earlier, medical groups are also operating on the profit model.  Urologists buy a complete radiation therapy installation, since there is much more to be made from the technical fee for a course of radiation therapy for prostate cancer than from a surgical fee for a prostatectomy.  Orthopedic surgeons install MR scanners in their office and make more money from sending patients to the MR than they would ever make from consultations and examinations in their clinic.  Ditto for Cardiologist, oncologists, etc. etc.  The financial incentives for over-utilization are tremendous.

I see nothing in the behavior of our government members to suggest that they possess the moral fiber to tackle and solve the health care cost and availability problem anytime in the near future.  Only when a crisis brings a consensus in the citizenry that we must accept some degree of rational rationing, and we make it clear to congress and the President that we are willing to accept a fair and rational national health care policy for all our citizens will there be any chance at all to alter the path we are currently on to a complete implosion of  health care in the USA.