Trials of techno-medicine

Provision of medical services has become more and more sliced and diced to provide maximum profit for corporate providers, or so it appears to me.

Last week I accompanied an older friend to an appointment for a prescribed blood draw. The office was in a nondescript strip mall building. The entrance issued on a waiting room with rows of chairs -- and no human attendant. Just chairs and a large wall screen that flashed a series of messages.

A printed sign pointed to another small screen on a podium at waist level and called upon patients to "check in here." This screen asked for an appointment number -- a number which appeared nowhere on the paper notice provided by my friend's doctor. Dauntlessly, my friend ventured down a hall way and around a partition to find a human. That worker offered, resignedly, "just enter your phone number." Seemed she might have been interrupted by this question before.

After a bit of poking around on several confusingly designed screens, we found a place to enter that number and my friend managed to call up a notice of her appointment, offer her ID to be scanned, and also enter some of her insurance information. She never quite finished that part of the process, but eventually her name appeared in the left hand white column on the big wall screen, indicating that the office understood she was there for her appointment.

So we sat in one of the rows of chairs, all of which faced the big wall screen. And there was nothing to fix on except that screen, which flashed a series of messages promoting this for-profit facility. We especially appreciated the one above. So helpful to patients ...

Meanwhile, bloodcurdling screams issued from the back offices -- we'd seen a mother lead a reluctant child down the hall. This was not so much pain, we hoped, but terror. But it was completely unsettling. When they exited, the mother -- in the midst of reassuring the child -- looked around the waiting room shamefacedly. I tried to offer her some comfort.

Finally a human appeared to call my friend to come behind for her needle stick. She was taken to the same room from which the child-patient had been leaving. She reported she still felt the swirl of psychic fear in this antiseptic place. The tech was business-like; her blood draw was quickly accomplished. And then he pushed on to the next waiting patient.

There's no health in a setting like this; we're just profit points for someone. Would hiring a receptionist really hurt the bottom line so much?

From the pest house ...

First off, I should say that Covid is not being very miserable. Some fevers, a little woozy, but mostly necessary isolation even from the EP who has advanced to a negative test. I yearn to follow.

Click to enlarge.

After some mild bureaucratic obstacle jumping, my Kaiser doctors prescribed paxlovid -- and I just want to share that the drug's packaging is a revelation. Pictured above.

Why don't most drugs come with packaging which embodies the instructions as this does? You just do what it says ... it is even color coded.

I raise that because, right before I caught the Covid, I'd been taking a week long course of an antibiotic as a preventive precaution when having a tooth extracted. You know -- I was prescribed a neat little bottle of 21 pills to be ingested three times a day. And within a couple of days, pre-Covid, I found myself confused: had I really taken the morning dose? Or the midday one? I just did the best I could.

I know that there are specialized pill boxes for this sort of thing. Or I could have created a card to check off the doses as I took them. But wouldn't it be better if the packaging the drug comes in did the trick, easing compliance? 

In particular, Medicare should require drug companies to package all drugs we old timers might take in this instructive way. Just a thought.

Keep them in dialysis until they die

A few years ago I found myself taking a small role in helping a friend survive kidney failure. The story had many twists and turns, but for the purposes of this post, what matters is that before she was lucky enough to receive a transplanted, healthy kidney, she spent several months on thrice weekly dialysis. Dialysis is a procedure which pumps out the toxic byproducts of normal metabolism usually removed by your kidneys by drawing out your blood, filtering it, and pumping it back into you. If that seems nasty and drastic, it is.

The commercial dialysis center where she went for the procedure was in a dreary urban shopping center, across from a rundown Safeway, some fast food outlets, and some liquor stores. This plaza used to serve the core of the San Francisco Black community back before Blacks had been largely driven out of San Francisco by too much tech money chasing too little housing. Many, perhaps most, patients at this center were still older Black people. We saw the same folks, week after week.

My friend escaped this sad facility, through a combination of grit, luck and a measure of white privilege.

Most people don't escape. Anne Kim at the Washington Monthly provides a devastating picture of who commonly suffers from kidney disease, how they mostly end up sentenced to years of dialysis, and even some suggestions about how this corrupt, discriminatory system could be made more just -- and more kind -- for sick people.

Of the 661,000 Americans with kidney failure, about 468,000 people—more than a third of whom are black—are on dialysis. In the District of Columbia, where the prevalence of kidney failure is the highest in the nation, according to the Centers for Disease Control, there are twenty-three dialysis centers, mostly in Northeast and Southeast Washington, the predominantly black parts of the city that are also ground zero for diabetes and high blood pressure, the two conditions most linked to kidney disease. Another 100 dialysis centers are within a twenty-five-mile radius of the city, again concentrated in the suburbs with the largest minority and low-income populations. ...

Like check-cashing outlets and payday lenders, dialysis centers—the vast majority of which are for-profit, like DaVita and U.S. Renal Care—are now fixtures in the urban commercial landscape. “We used to say there’s a liquor store on every corner,” said Clive Callender, a transplant surgeon and professor of surgery at Howard University. “Now we say there’s a dialysis unit on every corner.”

The prevalence of dialysis centers in minority neighborhoods is a reflection of policy failures that encourage—indeed institutionalize—class and racial disparities in American health care. These failures include more than just disparate access to the primary and preventive services that could help high-risk patients stave off kidney disease. Public policy effectively steers low-income and minority patients with kidney disease toward dialysis and away from superior options, particularly transplants.

***Everyone with kidney failure, also called end-stage renal disease, is covered by Medicare. And Medicare guarantees payment for every dialysis session. As a result, the treatment of kidney failure is a volume-centered business aimed at keeping dialysis centers running. “You fill up a facility with so many stations, you make sure somebody is sitting in each of those chairs around the clock,” said Dennis Cotter, president of the Medical Technology and Practice Patterns Institute. “It’s the Henry Ford production model.”

This system creates an incentive for clinics to keep patients on dialysis until they die.

That’s one reason why low-income patients have a tougher time getting transplants, which is the best treatment for kidney failure: their clinicians may not tell them it’s an option. And the longer they stay on dialysis, the poorer their health is likely to be, making them less viable as transplant candidates.

... Medicare currently pays dialysis clinics $231.55 per treatment. That means a clinic like the one in the Southeast D.C. strip mall, with twenty-five chairs, can make $5,788.75 every four hours if all chairs are filled. Assuming three shifts a day, six days a week, that’s $5.4 million per year.***
... the most tragic consequence of a system that incentivizes keeping people, especially poor people and minorities, on dialysis is that it also keeps them from getting what is beyond doubt the best treatment for kidney failure: a transplant.

“A successful transplant gives you almost a normal life expectancy, particularly if you’ve never been on dialysis,” said GW transplant surgeon Joseph Melancon. Between 76 percent and 85 percent of transplant recipients survive five years after transplant, compared to just 42 percent for patients on traditional hemodialysis.

In 2014, of all patients suffering from end-stage renal disease, fewer than one in five black patients with kidney failure were transplant recipients, compared to just over one-third of white patients.

What to do to replace this racist and cruel system? That's not so hard to imagine once we become aware of the economics involved. It might even reduce medical costs in the end:

... give low-income and minority patients a fairer shot at getting a kidney transplant. That means, at a minimum, making sure Medicare pays for lifetime coverage of immunosuppressant medications for transplant patients, instead of just thirty-six months. The original rationale for the current policy, established decades ago, was that transplant patients would eventually get jobs and private insurance, but the instability of work in the modern labor market and the price of coverage make this reasoning far less plausible today.

A likelier explanation for the policy’s continued existence is lobbying by the dialysis industry, which benefits from keeping patients on dialysis and not “losing” them to transplant.

... Democrats who want to move toward single-payer or a robust public option must figure out how to lower the cost of delivery to have any chance of succeeding. Fixing how Medicare treats end-stage renal disease, which accounts for 7 percent of its budget, would be a good place to start.

I knew nothing about this system until I saw it through my friend's experience. The least we can do is spread the truth about this racist distortion of "health care."

Why can't Medicare "go paperless"?

This will come as no surprise to anyone who reads this who is on Medicare, but it sure isn't hard to suggest some obvious measures that would help the program save money.

Every month I receive an envelope that displays, on the exterior, this phrase:

Inside, the enclosure is headed with this:

 The government takes my payment directly out of my bank account. The monthly mailing is just a receipt.

Unlike any other big institution I deal with, there is no option to "go paperless." My bank statement is paperless; my electric bills are paperless; the water bill is paperless. The IRS even takes my taxes out of my bank account by way of online filing. But for some reason Medicare is still sending me mailings, mailings I might easily find confusing or frightening. This doesn't make sense.

*** And that doesn't even go into the difficulties I had setting up automatic payment from my bank. Now I know most people get their premiums deducted directly from their Social Security -- but I haven't taken Social Security yet. But I certainly didn't want to have to write the government a check every month, so I figured they ought to be able to do direct withdrawal (everyone else does.) Not so easy. It's not as if there's an online way to request bank withdrawals. I had to call up and talk to a nice man who answers inquiries; he had to mail me the correct form; I had to fill it out and mail it back; and then I had wait six weeks while they processed it.

This is nuts. The municipal garbage authority can do this immediately, online. Why not Medicare?

*** Don't get me wrong -- I'll fight to the death any politician who wants to cut or privatize the system. But I look forward to the day when Medicare lumbers into the current century.

A nice fantasy for the New Year

As I write, the "fiscal cliff" talks seem to have collapsed. Maybe those guys in Washington will put them together again, maybe not. I can't bring myself to care.

The realities of the situation remain the same: government has certain necessary tasks that it must perform for the common good. We argue about what those tasks are, but in the last election the majority of the people rendered some clear direction:

• The government should support job creation in every way possible;

• The economy should be made to work for ordinary people, not just for vulture capitalists;

• Elders should retain access to affordable health care through Medicare and there should be no cuts Social Security;

• Education should be accessible to young people who want it.

• We expect government to provide a safety net for people who have been crushed by an under-regulated economic system that privileges greed.

• No more dumb wars.

All these items except the last cost money. Roughly speaking, the policy of President Obama and the Democrats is to get the money for the government to do its job from the people who have the money -- that is, from rich people. It is the policy of the Republicans to put the government out of business. We rejected the latter option.

For the moment, the Prez and his fractious Democratic partners seem to be hanging tough, sticking up for the people who put them in office. The fantasy is that Dems will stay the course. The degree to which they do so will depend on how much heat they feel from constituents. We can't let up on them -- that's my fantasy for the New Year.

Beware of "reformers" if you like Medicare and Social Security

We've just passed the 15th anniversary of the "welfare reform" that Newt Gingrich and a bunch of conservative think tanks cooked up and that Bill Clinton signed in 1996.

Full disclosure: I worked alongside welfare mothers against this bill back in the day and I'm still mad about it. The former President's acquiescence in this punitive law took Hillary Clinton out of the running for me in 2008; perhaps that wasn't fair, but this seemed a core matter of principle: you don't advance your career by beating up poor people and get me on your team.

Just as we've seen lately that the Republican answer to sick people not being able to afford medical care is "just die," welfare "reform" said to poor mothers and their kids: "sink or swim."

There has been a lot of sinking. The law gave block grants to states with which they were allowed to assist the poor in a program called "Temporary Assistance to Needed Families" (TANF) -- these grants are no larger today than they were in 1996. Yes, that means inflation has cut the real value of the funding by 28 percent. Moreover, aside from a provision that barred most assistance lasting more than five years with federal funds, there were weak or no rules about how many poor mothers and children had to be helped, so states that were so inclined simply stopped paying for assistance.


The colors on this map follow a politically predictable pattern.

No state is generous -- how'd you like to try to live on 40-50 percent of the Federal measure of poverty in the better states? According to the Center for Budget and Policy Priorities:

In 2010, the monthly TANF benefit level for a family of three was less than the estimated cost of a two-bedroom apartment (based on the Department of Housing and Urban Development’s “Fair Market Rent”) in all states, and less than half of the Fair Market Rent in 24 states.

The "welfare reform" has proved remarkably recession proof. You'd think that with a financial collapse and unemployment nearly doubling there'd be some rise in the the welfare rolls. But although in 2009 the food stamp program saw a 57 percent increase, TANF participation has remained flat as economic hardship has increased.



Welfare "reform" has achieved its goal: it has swept poor children and their mothers under the rug and out of sight and of political discussion. Democrats are no longer burdened by the charge that they support undeserving free-loaders; Republicans always wanted the poor to drop dead anyway. These folks seldom vote; they can be squashed like bugs and they have been.

Who's next?

This post draws on articles by CBPP, and Jake Blumgart at the American Prospect. Ezra Klein alerted me to the anniversary.

No way to build confidence

This chart from the Center for Budget and Policy Priorities shows the varying estimates by the the government body entrusted with making the projections of when Medicare might take in less in taxes, premiums and fees than it puts out to the medical industry. It does not inspire confidence that these experts know what they are doing.

But the scary word "insolvency" hides a further misleading implication of this kind of estimate. In this context, "insolvency" means taking in less than enough to pay the bills -- even if that implies only a 5 or 10 percent shortfall. Medicare can still take in 90 percent of its obligations and be called "insolvent." That's not at all the same as going broke! It's more like hitting a bad patch.

If Medicare is in trouble, our politicians should fix it -- go where the money is (hint: rich people have it) and ensure Medicare can pay the bills far into the future. It would not hurt to get more people back to work and paying FICA taxes as well.