Wednesday, August 19, 2009

Health Care and the Free Market

So, lately there's been a lot of discussion about what kind of health care system we should have in this country. Currently we don't have so much of a system as a patchwork quilt (with some holes in it). We've got all different types of public and private insurance, and I'll discuss these types more later. I think most of us are in agreement that health care as it is now is becoming unsustainable--prices are going up exponentially, many people aren't covered by insurance, and even those who are covered sometimes have trouble paying bills or even have to declare bankruptcy. We do have lots of modern technology, but we aren't doing some things as well as we should (our life expectancy is nowhere near the top; we have really high rates of expensive chronic diseases like diabetes and cancer; etc.).

There are several economic reasons that purely market-based health care systems don't work well. One reason--externalities. Externalities happen when consequences of an economic transaction are externalized--experienced by a third party who wasn't involved in the original transaction. These can be positive or negative. An example of a positive externality might be something like this: I don't want to get my kids vaccinated for the swine flu, but since all the other kids in the class are vaccinated, my kids aren't exposed and don't get sick. I don't pay for the vaccine or expose my kids to any risk, but I'm getting rewards because the kids are protected since everyone else is vaccinated. An example of a negative externality is when the uninvolved party has to pay the costs accrued by someone else. For example, I go to the hospital but I can't pay. I declare bankruptcy, but the hospital never receives any money, so they raise their rates. Everyone following me has to pay my costs. This is something that happens a lot (over half of bankruptcies in the US are related to medical concerns--and most of these people are middle class homeowners with jobs and health insurance). In other words, those people who don't want to pay for other peoples' health care already are, in the form of higher bills (from providers like doctors and hospitals, or insurance premiums). Not paying for anyone else's care means that as a society we have to be willing to accept that people will be turned away from emergency care, and that people will die from preventable illnesses. I'm not okay with this because I don't want it to happen to me, or to anyone else I know.

Another set of issues with health care and the free market comes from having imperfect information. In an ideal market system, the consumer can compare the price and quality of the service or good being received. For example, I purchase a share in a CSA (community-supported agriculture), giving my money to some farmers, and in return I get produce. Although it's probably more expensive than the grocery store, I think it's higher quality and I like the fact that I can go and see how my food is being produced. Of course, lots of decisions are made based on price alone (that's the reason so many airlines now have extra fees for baggage etc.--people often choose whichever ticket is the cheapest, even if it's only by $5). With health care, we do not have information on either price or on quality. When we go to the doctor, we generally have no idea how much we are going to pay, or how much the insurance company is going to pay. I pay my deductible and almost always end up getting an additional bill later. When I had to have surgery, I called and tried to find out the price of the surgery if I had to pay it myself, and they wouldn't tell me. That's because there is not one price! The price depends on what is negotiated between the insurance company, the group plan, the doctors, the hospital, etc. Often, people paying out of pocket with no insurance end up paying much more than those with insurance, because they don't have the negotiating power that the large groups do. Also, it's very hard to compare quality of doctors and hospitals. The Agency for Healthcare Research and Quality has some indicators, but I haven't been able to really find specific ratings of hospitals and doctors, and it doesn't seem very accessible to the general public. Besides, many of our most important health care decisions are made based on what is most convenient! If I get in a car wreck, please don't take the time to check the AHRQ website--just take me to the nearest hospital!

So, without being able to compare price and quality, it's hard to say that we have a truly informed "choice" on any health care issues. These kind of market failures are classic examples where society/government/some larger body needs to step in and create some rules. I can't see any way around these issues for health care. I have heard suggestions that Health Savings Accounts (HSAs) would enable more standard pricing of medical care. Under this scheme, people put aside money toward health costs and pay out of this account rather than having insurance, or supplementing insurance. This way, the theory goes, people would be more conscious of their own medical costs because they'd be paying themselves, not relying on insurance companies, and they would become healthier. Although I'm all for encouraging people to be healthier, the fact is that even low deductibles for preventive services like Pap tests and colonoscopies are enough to stop many people from getting those services. This means that later on, those who didn't get preventive services are at higher risk of expensive diseases and likely don't have the money to pay--thus we run head-on into the externalities. Also, if paying for ones' own medical care resulted in better health, you'd think that uninsured people would be the healthiest--and this is not the case at all.

I guess what I'm saying is that we are already paying for each others' health care, in various ways. This is the basic idea of insurance. We pay in each month and pool our money, and spread our risk. Then when one in the pool gets sick, the money from the pool is used to cover the costs. We're also paying for those who aren't in the insurance system--somebody's got to pay for those unpaid bills, after all. If we did it in a planned way, encouraging healthy behaviors and prevention, it's likely we could help people be healthier AND save money. Other countries have figured out how to do this, so I'm sure we can too.

Sunday, August 16, 2009

Jumping into the fray

While I was dealing with the situation with my hips, I also had a rather stressful situation with health insurance and bills. I didn't blog about it too much, for various reasons. But now, with everyone talking about the health care system in this country, I think it's important to let people know what I went through.

At the time I was diagnosed with AVN, I was working on a fellowship at a federal agency. I was not a federal employee, and my fellowship did not come with a health insurance plan. I was able to extend coverage from my previous job through COBRA for a while, I believe it was 18 months. After this expired I purchased my own individual plan, which is the coverage I had when I was diagnosed with avascular necrosis (AVN). After my diagnosis I ended up going to many doctors for various consultations and appointments, and bills started piling up, and the insurance company started paying less and less of them. I also started receiving letters from the insurance company--they wanted me to send them ALL the records from every single doctor I had seen for the past several years. I had already had to go through a similar process when I first purchased insurance from them, but this was way more extensive. It was pretty obvious to me that they were either trying to prove that my AVN was pre-existing, so they wouldn't have to pay for it, or else they were trying to find something that would make me ineligible for coverage altogether. During this time I had one outpatient surgery. I received bills for thousands of dollars. I did not document all of the expenses because with everything else I was dealing with, I just did not have the time or energy, or morale.

Meanwhile, I had been asking around at work and I found a different type of fellowship that came with a group plan for health insurance. I would have to pay my own premium, which would be raised from $167 a month to $333 a month. However, because of the fact that the individual policy was suddenly not covering anything and appeared to be about to take some kind of further action, I felt that the change was well worth it. I switched to the new plan before my hip resurfacing surgery. Although I stayed in the hospital for four days, I only payed $200. Compared to the thousands I had paid for the outpatient surgery, this seemed like a real bargain! A few other bills came up once I got home, for some therapists who had come by the house during my recovery, but overall this extensive surgery ended up being MUCH cheaper than the minor surgery, just because of the insurance plan I was on.

On paper, these two plans appeared to cover similar expenses. The differences really only became evident after I had had the two surgeries, and could compare costs. My situation didn't seem that precarious from the outside, because I was employed and had health coverage the whole time. But, because of the high cost of the bills, I would have been in serious financial trouble had it not been for my parents who were fortunately able to help me out. Thanks to my parents, I was able to go ahead and get the hip replacement surgery. If not for them AND my supportive employer, I would have had to either stay in pain and disability, or have accrued medical bills to a degree which could have sent me into bankruptcy.

This scary situation made me realize how easy it can be to get in a really bad situation because of medical bills. This can happen to anyone, but it's especially risky for people who don't have the coverage of big group plans through large companies. The way insurance companies work, the bigger group you're in, the better, because there are more people paying into the plan, so the risk is spread. On an individual plan, there is no group to spread risk around, so if one person starts accumulating lots of medical bills, they look for ways not to pay. Because our health insurance system was set up through employers, people who are self-employed, in transition between jobs, work for small businesses or are entrepreneurs are especially at risk. Any of us could fall into this category (until we're old enough to qualify for Medicare). The current health care proposals out there are not perfect, but they all aim to improve this situation in some way or another.

So here I am, nearly two years after my major hip replacement surgery, and more than a year after the most recent surgery on my shoulders. My hips and shoulders feel great and normal most of the time. Sometimes the metal hip feels weaker than the other, so if I walk lots or dance I'm more aware of the muscles than in the other side. Sometimes the right (non-metal) hip hurts, as well as the shoulders, especially when the weather changes, but overall I'm functioning normally. And, thanks to a lot of help from my parents, I think I've finally paid all of the bills. I just don't think it's right that I should have had to rely on them; I think people should not have to choose between their physical and financial well-being.

Sunday, June 29, 2008

All good, for now

Last week I had a check up with the orthopedic surgeon here in Atlanta (not the one who performed my surgeries). It has been 7 months since the left hip resurfacing and 10 months since the right hip core decompression. The x-rays looked fine! The right hip hurts from time to time. Because the surgery I had was intended to keep it from getting worse, there is still some damage to that hip which will cause pain sometimes. The pain is completely tolerable, but it was disconcerting to worry that the disease process could be worsening meaning I'd need another surgery sometime soon. I'm relieved to find out that this doesn't seem to be the case. My left hip (the metal one) looked good too. The doctor told me, again, all of the reasons why a resurfacing might not work for me, as I was happily standing there in no pain with my x-ray indicating no issues. I've been walking 2 or 3 miles pretty much daily, and my quality of life is extremely improved over what it was last year, so even if the resurfacing were to fail at some point I have gained much joy and use out of it already. The lingering muscle soreness has faded to a point where it's nearly imperceptible, and even my scar doesn't look that bad considering it's less than a year old.

At work the other day someone said "you look like you're walking comfortably." I didn't know what she was talking about--I looked at my shoes to see if they were particularly comfortable. Then I remembered she must be talking about my hip! Actually I've been walking comfortably for a while now but I guess she just noticed. So, it's hardly even on my mind these days.

The doc took shoulder x-rays too, but he's not a shoulder specialist. He didn't see anything to worry about but I'll mail them to Baltimore so they can interpret them. The left shoulder hurts intermittently, but less than before the surgery. So, all's well for now!

Tuesday, May 13, 2008

Back to Baltimore

I haven't posted for several months... just to give you all the hip update, my hips are doing well! My left resurfaced hip is good--the muscles are sometimes sore, but it gets better and better. If I sit for a long time and then get up it can be stiff. All in all, I'd say I'm a whole lot better than before surgery and about 90-95% of normal. As for the right hip that had the core decompression, it seems pretty good too. I've been walking a lot lately and it only seems to hurt every once in a while, usually when rain is coming. The core decompression ideally stops the progression of the bone loss but there is still damage to the bone and cartilage, so it's not surprising that it aches a little sometimes.

I found out a couple of months ago that I also have ON of the shoulders. The doctors here in Atlanta didn't really have any suggestions and thought I should do nothing. Replacements and resurfacings for shoulders do not seem to be as common or successful as for hips, and I'm not a fan of the idea of doing nothing while my bone dies. Dr. Mont in Baltimore thinks that we can slow or stop the progression with CD's of both shoulders, so we are leaving tomorrow to go for more surgery. Thank goodness I don't walk on my hands, so the shoulders aren't weigh-bearing! That means the recovery, although it might be painful, shouldn't affect my life as much as with the hips (although I might not be able to drive for a little while).

I'll update and let y'all know about the shoulder surgery.

Sunday, December 23, 2007

5 week check-up

I can't believe how long it's been since I posted... I've been busy! Last week I was back at work full-time and it went pretty well. I need to get up and walk around pretty often, or else my hip gets stiff and sore. Wednesday I had my five-week check-up here in Atlanta with Dr. Steven Smith. The x-ray of the resurfacing looked good and the doctor told me I could transition to walking without a cane. The right hip looks good too, so far. Of course I started immediately walking around the office without a cane to show off--and after I sat down and did some work, then got back up, *ouch* the muscles were sore!

I've still got a bit of a limp, which is worse when I've been sitting and first get up and am stiff and sore. Once I get going I don't think it's very noticeable, although I haven't made another video yet. Yesterday Danielle and I did all kinds of shopping and I was on my feet for hours--way longer than I've spent doing that kind of thing for a while! I was definitely sore but this morning I'm fine. Before the surgery, I couldn't have spent that much time on my feet, and would hardly be able to get up out of bed the next day. The muscles still get quite sore, but I'm looking forward to physical therapy which should help me with that.

Thursday, December 13, 2007

4 weeks out!

I'm four weeks out from my hip resurfacing surgery today. No film today; I don't have Boppa around for the commentary anyway. I'm back at home in my condo (on the third floor, no stairs). Getting up the stairs is okay; I just plan my trips and have help so I'm not constantly running up and down.

I started back to work some this week. I've been going into the office for several hours each day and also doing some work from home. Last night I took of my stockings (the lovely anti-embolism T.E.D.s) and my left (operated) foot was swollen. I've heard of this happening after surgery, but the fact that it hadn't been noticeably swollen up until then (even after surgery) worried me a little. I was pretty active, working and then straightening up at home, so I decided to work from home today and keep my feet up. I think it worked--it doesn't look swollen at all anymore. Of course I'm bored to tears and missing a backyard bonfire as I write, but it's too hot for a bonfire anyway. Right??

Oh--one other hip-related thing happened. As I've said before, I'm not supposed to bend the hip over 90 degrees. In other words, I can sit up straight but can't lean forward. When lying down, I can bend the knee but can't pull the knee forward to my chest. Etc. Anyway, I was sound asleep and my beloved cat Poe was snuggling up to me (something he hasn't done much since I've been back--he's still a little mad at me for leaving him). I awoke to hear, at close range, the gagging sound he makes right before he coughs up a hairball or pukes. This cat weighs 17 pounds and is very stubborn, so pushing doesn't work--you have to pick him up. I sat up and threw him off the bed just in time! As soon as I did so I felt pain in the hip and thought, uh-oh, I forgot to be careful about the 90 degrees... I was still mostly asleep so I'm not sure how much I bent but IF it was more than I was supposed to, it wasn't by much--I don't think I could do much more even if I tried. In any case it feels fine, thank goodness. I was a little worried how I was going to explain to the doctor "um, I dislocated my resurfacing trying to avoid getting puked on by the cat..."

Sunday, December 9, 2007

Rae-Rae gets a cane!

At first my niece Rachel seemed to be afraid of me with crutches or a cane but more recently has taken to holding onto them while I'm walking. Last night she came over and turned over a basket of Christmas cards that also had one of those candy canes filled with Hershey kisses in it. She immediately picked up the cane and started walking with it, just like me with my cane! I wish these pictures had been better but my camera is clearly not made for high-action photos...