Nosing Around Complex Medical Choices
Why health care is so expensive.
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Long, long ago, I read in the Readers' Digest that any sore which would not heal was a sign of a possible cancer. I ignored the small sore on my nose for a while. It would form a scab and the scab would fall off, but the sore was still there.
After a few cycles of this when it still didn't heal after several months, I brought it to my doctor's attention and he referred me to a dermatologist.
The doctor chopped out the sore as a tissue sample and found a smallish lump on my forehead caused by ingrown skin cells. This would probably lead to an infection. I requested that she take it out then and there so I wouldn't have to come back. She grabbed a tiny ice-cream scoop with sharp edges and spent maybe 30 seconds "excising" it. Doctors are very sensitive - they don't like terms like "carve" or "chop."
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| Cancer? |
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| No, just a $300 - er, $3,900 hole. |
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| Hole fixed. Job done? |
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| $2,660 later. Was it worth it? |
Some weeks later, I discovered that my insurance company had accepted a charge of $300 just for this minor "excision", plus a fair bit more for all the other odds and ends involved. Since I hadn't met my deductible for the year, I ended up paying $300 for this one 30-second procedure. $10 per second seems a bit high, but that's OK - Mr. Obama has promised to bring down medical costs somehow, real soon now.
The Revelation
This doctor's office had unusually wonderful reading material - a two-volume opus entitled Dermatology. It was edited by a great many MDs who are also professors of dermatology and was published by Elsevier in 2003. A brief glance at the profusion of pictures revealed that this was a book I'd like very much to own but alas! Elsevier has been out of my price range for quite some time.
The book declared that the primary function of your skin is to provide an environment in which your DNA can reproduce itself. I thought that the emphasis on reproduction was a little odd, but the sheer genius of describing the skin in this way became clear later on.
Page 25 lists the main sub-functions of the skin: "prevent infection, maintain a barrier, repair injury, provide circulation, communicate, provide nutrition, regulate temperature, and attract attention." Listing "attract attention" as a fundamental medical purpose of the skin began to make the authors' methods of furthering their profession a bit clearer. After sections describing each of the sub functions, they explained "Attracting Attention."
An important function of the skin begins with the desire of humans to 'attract' other humans for social and sexual purposes. In fact, the presence of beauty, as seen in photographs or paintings, tends to attract attention, sometimes intense attention. It is easy to imagine that these responses are coded genetically, because high attractiveness would seem to increase the likelihood that DNA survives and also, that the species survives. In sum, without any confirming data, we assert that the desire to be attractive helps to ensure the selective survival of human DNA. [emphasis added]
How unscientific can you get! Here's a worthy, weighty medical tome written by a bunch of professors, and they reach a conclusion with profoundly far-reaching economic consequences without any confirming data! Indeed, they openly admit that they have no scientific support, but stolidly press on with their assertion anyway.
As it turns out, their peers are inclined to accept their conclusion no matter how unscientific it is because it means money in their pockets. Does, indeed, the skin have an evolutionary function of "attracting attention"? We'll never know; MDs assert that it does, however, and that makes it so, at least for insurance purposes.
The Biopsy
The tissue biopsy showed positive for cancer, so I was referred to a dermatological surgeon. He carved out the cancer, leaving a hole in my nose. Then he stretched the available skin to cover the hole and stitched me up.
As a result, my nose has more or less assumed its former contour, though my wife says different. Fortunately for me, my skin performed its evolutionary function of "attracting attention" some decades past and no longer needs to do that.
In discussing the "attract attention" skin function with my surgeon, I learned that when he was studying surgery years ago, his professors were skilled either in carving out - sorry, "excising" - bad tissue or in restorative surgery, which is the polite term for plastic cosmetic surgery. At the time they had trained even further back in the past, there were relatively few who trained in cosmetic surgery because it wasn't paid for by insurance.
Anything that patients had to pay for out of their own pockets tended not to happen, so why learn how to do it? His professors made the rational choice and went where the money was.
He, however, going through school in an era when cosmetics was covered by most insurance plans, had been trained in both.
This does make a certain logical sense: after all, the best time to perform restorative surgery is immediately after the excision. As a side effect, though, this change has led to a whole lot more money being spent on cosmetic surgery than was before, and thus to higher medical insurance rates.
This shows once again, as if any proof were needed, that the most important attribute of any medical procedure is whether it's covered by insurance. If it's covered by insurance, medical students will learn how to do it and recommend it whenever they can. If it's not, it'll become a niche specialty.
The full genius of the writers of Dermatology stands revealed in all its profit-making glory. Without giving any supporting data, they've simply asserted that attractiveness is one of the major purposes of the skin, ranking right up there with preventing infection and regulating temperature. Given that attractiveness is a medical necessity, of course repairing unattractive skin should be covered by insurance!
The Reckoning
Having chosen the higher-deductible form of health insurance, I got the bill for this particular procedure. Medical bills are notoriously hard for the uninitiated to itemize so my allocation of costs may be a bit imprecise, but here it is.
I had no trouble with paying the $3,900 or so to whack out, sorry, excise, the cancer and clean up the mess - it would have killed me. That was money very well spent.
It would be a good deal for the country even if the government were paying for it, because I can't afford to retire. Since I'm still paying income taxes, the government would get its grand back via the withholding cycle in fairly short order whereas dead men pay no taxes.
I have a bit more trouble with the $2,660 or so for restoration. It's not that this is a clear overcharge - knowing just how much to stretch the skin and being able to stitch it all back together just so requires a lot of skill and practice. You can look at the pictures and judge for yourself whether the improved appearance was worth the money in my case.
Why should you care? In my case, you shouldn't, because I pay for my own health insurance. Sure, my employer negotiates the rates and sends the money to the insurance company, but they carefully deduct my share of the cost from my pre-tax income. The rest is paid for by my employer as a business expense, but in economic terms, it's part of my wages so I'm really paying for that too.
I say that I pay for it, but that's a temporary phenomenon. Assuming that the Republicans aren't able to repeal or defund Obamacare, the government will decide whether to cover such surgery or not.
Will the government decide that, as I've passed the prime child-bearing years, my skin has served its reproductive function and there's no reason to restore my appearance? They could even decide that since some skin cancers grow slowly, I wouldn't even quality for the excision. In that case, I couldn't have the cancer carved out even if I were willing to pay for it myself - Obamacare makes it illegal for a patient to go around the system.
That is why doctors are beginning to "retire" to other countries where they can practice medicine as before, and those who can afford to join them will do so.
The first doctor who took the tissue sample was amazed that I'd paid $300 for the excision - "I don't get paid nearly that much," and I tend to believe her. Where did the rest of the money go? Overhead? Paperwork? Negotiating fees with all the insurance companies? The surgeon was a bit embarrassed to find I'd had to pay so much for his services. It seemed that neither doctor had discussed cost with any patient, ever.
This small medical incident shows us why medical costs are so high. Doctors lobby to have more and more procedures covered by insurance. Patients don't care because they aren't paying. Insurance companies are happy to pay up, then file for rate increases based on having to cover more and more procedures.
Nobody really cares about the cost. Mr. Obama claims that government takeover will bring costs down, but I don't think that even he believes that.
Fortunately my cancer is gone - today. For tomorrow? Only time will tell.
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What does Chinese history have to teach America that Joe Biden doesn't know?
The nose looks good now though. I think it was probably worth it.
My GP takes cash, not questions. Most his patients are single mothers.
Having never had insurance i don't know the dilemma: like my car, if it's broke, I fix it one way or another, or go w/o- no one's problem but mine.
Good Grief
By ALLEN FRANCES
A proposed change to psychiatry's Diagnostic and Statistical Manual of Mental Disorders would confuse normal bereavement with major depression.
http://www.nytimes.com/2010/08/15/opinion/15frances.html?th&emc=th
A startling suggestion is buried in the fine print describing proposed changes for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders - perhaps better known as the D.S.M. 5, the book that will set the new boundary between mental disorder and normality. If this suggestion is adopted, many people who experience completely normal grief could be mislabeled as having a psychiatric problem.
Suppose your spouse or child died two weeks ago and now you feel sad, take less interest and pleasure in things, have little appetite or energy, can't sleep well and don't feel like going to work. In the proposal for the D.S.M. 5, your condition would be diagnosed as a major depressive disorder.
This would be a wholesale medicalization of normal emotion, and it would result in the overdiagnosis and overtreatment of people who would do just fine if left alone to grieve with family and friends, as people always have. It is also a safe bet that the drug companies would quickly and greedily pounce on the opportunity to mount a marketing blitz targeted to the bereaved and a campaign to "teach" physicians how to treat mourning with a magic pill.
It is not that psychiatrists are in bed with the drug companies, as is often alleged. The proposed change actually grows out of the best of intentions. Researchers point out that, during bereavement, some people develop an enduring case of major depression, and clinicians hope that by identifying such cases early they could reduce the burdens of illness with treatment.
This approach could help those grievers who have severe and potentially dangerous symptoms - for example, delusional guilt over things done to or not done for the deceased, suicidal desires to join the lost loved one, morbid preoccupation with worthlessness, restless agitation, drastic weight loss or a complete inability to function. When things get this bad, the need for a quick diagnosis and immediate treatment is obvious. But people with such symptoms are rare, and their condition can be diagnosed using the criteria for major depression provided in the current manual, the D.S.M. IV.
What is proposed for the D.S.M. 5 is a radical expansion of the boundary for mental illness that would cause psychiatry to intrude in the realm of normal grief. Why is this such a bad idea? First, it would give mentally healthy people the ominous-sounding diagnosis of a major depressive disorder, which in turn could make it harder for them to get a job or health insurance.
Then there would be the expense and the potentially harmful side effects of unnecessary medical treatment. Because almost everyone recovers from grief, given time and support, this treatment would undoubtedly have the highest placebo response rate in medical history. After recovering while taking a useless pill, people would assume it was the drug that made them better and would be reluctant to stop taking it. Consequently, many normal grievers would stay on a useless medication for the long haul, even though it would likely cause them more harm than good.
The bereaved would also lose the benefits that accrue from letting grief take its natural course. What might these be? No one can say exactly. But grieving is an unavoidable part of life - the necessary price we all pay for having the ability to love other people. Our lives consist of a series of attachments and inevitable losses, and evolution has given us the emotional tools to handle both.
In this we are not unique. Chimpanzees, elephants and other mammals have their own ways of mourning. Humans have developed complicated and culturally determined grieving rituals that no doubt date from at least as far back as the Neanderthal burial pits that were consecrated tens of thousands of years ago. It is essential, not unhealthy, for us to grieve when confronted by the death of someone we love.
Turning bereavement into major depression would substitute a shallow, Johnny-come-lately medical ritual for the sacred mourning rites that have survived for millenniums. To slap on a diagnosis and prescribe a pill would be to reduce the dignity of the life lost and the broken heart left behind. Psychiatry should instead tread lightly and only when it is on solid footing.
There is still time to keep the suggested change from entering the D.S.M. 5, which will not be published until May 2013. The task force preparing the new manual could adopt a more cautious and modest estimation of the reach of psychiatry and its appropriate grasp.
For the few bereaved who are severely impaired or at risk of suicide, doctors can already apply the diagnosis of major depression. But don't change the rules for everyone else. Let us experience the grief we need to feel without being called sick.
Allen Frances, an emeritus professor and former chairman of psychiatry at Duke University, was the chairman of the task force that created the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders.