Obamacare

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Nobody asked (well, actually a couple HAVE asked, come to think of it), but I'm going to set down my thoughts on the whole "health care thing".

I am a business owner (25 employees), and a physician. I have dealt for over a decade with government and private health insurance, and it's my livelihood to understand the issues and costs surrounding health care delivery in America. So, I actually have a pretty good grasp of all the various sides of this issue. At this point, I'm still a little ambivalent about the whole health care reform attempt, but I'll let the points below speak to the specifics.

So, in no specific order, my thoughts:

ALL HEALTH CARE IS RATIONED. Let me repeat that: all health care is rationed. The complaint that "the government will ration health care" is idiotic. Of course they will. So will every private insurance, every time. At some point, the costs associated with your health care are too high for any insurer to afford. I work with some insurances that will not pay for allergy medicines, and others that will cover Wii Fitness. There will always be a balance. Rationing doesn't just happen at a cost level - it happens at an intellectual level. If your belly hurts and you want an MRI "just to be sure", that doesn't mean you're necessarily going to get it. If you watch a commercial for a drug and think that it's exactly what you need, but I as your doctor do not, you're not going to get it. And of course, for the 40+ million citizens who are uninsured, their health care is absolutely rationed.

ALL HEALTH CARE IS EVENTUALLY PAID FOR: Just because we aren't paying more taxes to take care of more people, doesn't mean we won't be paying to take care of them. It just means the costs will be shifted to other forms. At some point, if someone is sick enough, they will seek health care, or wind up in an ER, and be treated. The hospitals, doctors, nurses, and everyone else involved in that care will be paid for it. Maybe not directly, but they will recoup the costs of the patient who doesn't have insurance by charging the one who does much more, to make up the difference. That charge then is recouped by the insurance companies in the form of higher premiums, which are in turn absorbed by businesses who pass the costs along again (by charging more for their product or service, or reducing employee benefits, or passing it back to the taxpayer by dropping insurance). This type of system actually costs us all MORE, because when people wait to receive care till they have no choice, the problems are more severe and the care more costly. If more people had insurance, and preventative care, there would be less catastrophic care and less health care spending.

SINGLE-PAYER IS THE MOST EFFICIENT DELIVERY DEVICE: I don't really expect the US to ever adopt single-payer, I think it would take an utter catastrophic breakdown of the health care industry before this happened. However, with multiple payers you have the significant problems of inefficient duplication of services, and smaller risk pools. The amount of money spent on insurance duplication of services is criminal. Our business office bills over 20 different insurance plans, all with their own particular rules, contracts, payment and payee specifics and a thousand other processes, all with their team of middle managers in some insurance office building, all taking their piece out of the health care dollar. It is a HUGE waste. Additionally, as long as an insurance company can be selective about who it does and doesn't cover, insured lives (that's me and you) will be subject to the whims of pre-existing conditions, and other restrictions. And the smaller pool you're in (self-insurance vs. Wal-Mart employee plan) the harder time you're going to have getting coverage.

THE GOVERNMENT DOES NOT HAVE A GOOD TRACK RECORD IN HEALTH CARE DELIVERY: Despite all the people who tout it, Medicare, Medicaid, TriCare (military) plans are lousy. At least from my perspective as a doc and business owner who earns part of my living from them. (For the patients on the programs, the care and covered services are adequate, roughly on par with the lower-tier private insurers). While private insurances have to at least compete a little bit for our business, the government plans in most instances could care less about anything but the bottom line. Over the past decade, the amount I as a doctor receive from government insurance has consistently fallen in terms of real dollars. It was only when doctors finally made a public stink that got enough attention to worry lawmakers that the recent planned 10% cut in Medicare funding that was scheduled was halted. The government's take on paying docs is to basically keep tightening the screws till enough people complain to lawmakers that they can't see doctors. Add to that the ridiculous rules that say since health care has "traditionally cost less" in certain areas (like Oregon), the government will only pay me about half of what it will pay a doctor in Florida or Texas for the exact same service, and you can maybe understand why I am wary of the government having too big of a hand in health care payment. There are basically no primary care physicians in my city (McMinnville) who will take new Medicare patients. This is because above a certain percentage of Medicare or Medicaid patients, it is simply impossible to even meet costs, let alone make a living. For a routine 15 minute visit, for the exact same care, Blue Cross pays me $120, and Medicare pays me $35. To put it another way, every time I see a government insurance patient vs. a private insurance patient, I make 40-60% less money. And to put it yet another way: if I saw only private insurance patients, and dropped all my government insurance patients, I could work half as much as I work now and see no loss in my income.

THE FREE MARKET DOES NOT WORK FOR HEALTH CARE: Whether or not you feel health care is a "right", you cannot apply or advocate for the "free market" to only be utilized in health care for one simple reason: we don't turn ambulances away at the emergency room door. If you want to apply the same capitalistic rules to the health care delivery business as you do other businesses, then you have to allow for only caring for people who can pay you. Medicine is the only private business I can think of where a business is required to provide someone a service, often a very expensive service, even if the customer has no intention or ability to pay. And since I can't imagine anyone wanting to live in a country where an injured child is not treated because the parents can't afford it (as DOES happen in other countries, by the way), to try to argue that we should let the private sector control health care is ridiculous.

WE'RE SPOILED, AND IT'S EXPENSIVE: Most Americans have access to MRI machines, complex lab tests, surgeries and specialists of every persuasion, medical devices and gear - all of which are cutting edge and very expensive. It is not that these things do not have or add value, but in many many cases, the costs far exceed the value. In many ways we expect care-on-demand, even for chronic issues. We expect the best tests, the top-of-the line medical devices, the costliest drugs and the most advanced therapies, and we expect them now. This is not necessarily a "bad" thing, but it is certainly a costly thing. People lived healthy and contented lives long before open MRIs and titanium hip replacements and laparoscopic gastric banding, but because these things are available now, we expect that they be an option for us no matter what the cost.

YOU WILL GET SICK AND DIE: This involves two issues: end-of-life care and personal responsibility. The medically costliest time by far in someone's life is their last 3 months. We have costly and invasive ways to extend life beyond limits we were previously able to. Without the acknowledgment that death is where we're all headed, we pay a high price to extend out as far as possible whatever life we have left, no matter how poor the quality. The end-of-life counseling that has been met with such mocking derision and fear by "conservatives" is not only a valuable personal aspect of health care, but a cost-saving one as well. We're not talking assisted suicide here, we're talking not instituting extraordinary interventional measures that do little besides extending the natural processes we all face. And on the personal responsibility part: stop expecting medicine to compensate for your bad habits. Most of the costs of health care (by far) in this country could be eliminated or vastly reduced by actions taken on an individual level: eating right, exercising, not smoking, getting preventative care. If we worked health insurance like we worked car or life insurance, the cost savings would be astronomical. Imagine if smokers paid more for health insurance, or those who never exercise had additional charges factored in. It's probably a slippery slope, and I doubt it'll ever happen, but know that we ALL pay the costs for those who simply choose to not make their personal health a priority.

SMALL BUSINESS PAYS A BIG PRICE: It is interesting to be on both sides of the private (and public) insurance dollar. We have routinely seen the cost of the private insurance we buy for our employees rise from 8-14% each year. We also negotiate with them for payments to us each year, usually to the tune of an increase of 3-5%. So clearly the additional costs are not being passed along equally. People are screaming about the tax costs to business of health care reform, and it's good to be concerned about that. But for our company of 25 employees to be paying in excess of $150,000 / year for health insurance (and this is only the 75% we pay), it seems like if there were a public option for our employees, even with a tax hike, we would be saving a lot of money.

OTHER COST SAVING POINTS:
- Tort reform. Despite what the lawyers tell you, the defensive and protective medical costs due to our lawsuit-happy society are huge. Any health care reform that does not also include significant tort reform is pointless.
- Drug Collective Bargaining. Medicare part D, in which Bush provided drug coverage with government dollars and DIDN'T do any type of competitive bargaining or formularies with the drug manufactures was a huge financial gift to the drug companies; one we all pay. Obama also has caved and not made this a part of the plan. Until the drug companies have to bargain for their use, they will continue to rip us all off with their vastly overpriced products.
- Preventative Care. I counsel someone for 30 minutes on healthy living, managing their diabetes (or avoiding it), reducing heart disease risk, and I get paid $90. I spend 45 seconds burning off a wart, and I get paid more. The medical payment system is slanted to throw money at "procedures" and pay lip service at best to preventative medicine. Until there is more of a financial emphasis on prevention, we're throwing money away.

POLITICAL POINTS: I don't want to get too political outside of the direct discussion about the plan. But, for all the people that bemoan "the loss of our America" or are afraid that this is some sort of master plan for Obama to usher in socialism: shut the hell up! If you get all your news from FOX News, or parrot back anything that Glenn Beck or Rush spew, you have no place in open and honest debate. I say the same thing to the "Obama can do no wrong" crowd, but they're not nearly as vocal these days.

There's probably more I could say, but even I'm bored at this point.

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Boise Ironman 70.3 Race Report

Boise Ironman 70.3 Race Report (2009)

2009, 2008

Swim: 40:09, 41:26

T1: 5:07, 8:31

Bike: 3:05:00, 2:57:40

T2: 3:56, 2:49

Run: 1:59:31, 1:59:01

Total: 5:53:43, 5:49:27

PRE-RACE: I’m never satisfied with my preparation for these races, but it seemed really weak this year. I’d jumped into a ½ ironman training plan with 5 weeks to go after running the Eugene marathon in May. So my running base was ok, but I hadn’t done a lot of speed work, and my swimming and biking work was not deep at all. I had done one 2.5 hour long ride on the bike, but that was all. Also, for many reasons (poor roads, no regular riding partners, crazy drivers, being tied to home due to call, etc…) I do ALL my bike training on a CompuTrainer. As realistic as this is, it just doesn’t prepare as well as actually getting road miles in. I drove to Boise, stopping overnight at a campground in Eastern Oregon and sleeping in the back of the minivan. Expo was fine, and I dropped my bike off at T1 the afternoon before the race. Ironman 70.3 Boise has this 2:00 pm start time, which was just a totally new experience for me. I went back to the hotel later that evening and cooked up some Mac & Cheese on a backpacking stove in the bathroom. I also had some avocado, baby spinach leaves, and an Odwalla Superfood (detailed enough for ya?). It was weird to sleep in the day of a tri, but I got up at 7:30 and had a normal cereal and yogurt breakfast at the hotel’s complimentary “buffet”. I drove to a parking garage in downtown Boise about 50 yards from the finish line and got there about 3 ½ hours before my shuttle bus left. I dropped off my T2 bag, and bought lunch at a local restaurant (turkey sandwich) which I ate about 3 hours before my start time. Then I basically killed time laying out in the back of the minivan in the parking garage, watching old Scrubs episodes on iPod and occasionally listening to my triathlon playlist to psyche myself up. Took the ½ hour bus ride up to the reservoir where the swim start was and got there about 45 minutes before they closed T1. I filled my two bike water bottles (I took off my aero drink bottle for this race, it tends to just give me trouble), each had already about 4 scoops of Perpetuem in them, and put salt tabs, some sport beans, and a power bar into my bento bag. Helmet, goggles on the aerobar, along with my Garmin wrist unit (my bike computer had busted). Got my tires pumped up to 120 psi by the bike crew there (bringing your own pump was discouraged) and cleared out of T1.

SWIM: My wave was 2^nd to last, bleah. It this point in the day, it was about 2:00 pm and quite warm. Put on my sunscreen and waited till about 20 minutes before we had to get into the chute to put on my wet suit. Walked around in my wetsuit just pulled up to the waist, feeling a bit conspicuous with little spot bandaids on my “chest”, but ya know, with all the rain, I’m only too glad they were there. Anyway, last year the swim was bitterly cold, my worst swim experience ever. This year I brought my full wet-suit (used a sleeveless last year, what was I thinking). I also bought this excellent Tyr thermal cap at the expo which is sort of in-between a regular cap and a neopreme hood. I have the neopreme hood, but the chin strap makes me feel like I’m being strangled, so I hate it. I have a latex allergy, so I need something under my colored swim cap anyway. The combo worked great, and the water felt at an excellent temperature, even getting in (water temp was 64 degrees). By the time our wave started, a wind had kicked up, and it was pretty choppy. The swim was not too noteworthy otherwise. I don’t have the straightest stroke, and always tend to veer left, so I had to keep aiming to the right of the buoys to not get too far off track. It wasn’t too crowded, but I did get one good smack to the face that made me have to clear my goggles, and I think I accidentally did the same to someone else. The timing mats at the end of the swim are up a 50 yard hill. They had wetsuit strippers which, if you haven’t ever used them, are so nice. You lay down and two people grab a hold of your wetsuit and just yank that puppy right off.

BIKE: The run to the bike is in this big parking lot, full of gravel, so by the time I got to the bike, I had to sit down and try to get the gravel off my feet. I shoe up before the mount line (never really worked out for me to keep the shoes clipped in), so I put on my socks, shirt, helmet and goggles and ran out to the bike start. I knocked my bike over at the start (I can’t remember why) before getting on it; one of my bottles fell out. Some kid on the other side of the barrier asked his mom “How come his water is all brown?” The first 2 miles of the bike are downhill. At 8 minutes into the bike course, the rain started. RAIN was definitely the hallmark of this race. About ¾ of the bike course was in the rain, and about half of that was torrential downpour. The rain didn’t bother me too much, but I was (excuse my French) shitting bricks about lightning. I’m not sure where a healthy respect ends and outright phobia begins, but if I don’t have lightning phobia, I’m as close as you can get. The bike portion is out on this high plateau with basically nothing around you but flat high plains. You can see the weather systems for miles in every direction, and for most of the ride, you’re the tallest thing around. I heard thunder twice, and saw lightning bolts twice also. During the 3 hour ride these systems would move through, and the whole sky for a good 100 degrees of the horizon would be black, with the streaks of rain visible on the sides where there was enough light to see it. Most of the systems skirted to the East of us, but not all of them did, and when they went over, instead of the drizzle, we would get a downpour. I had my Oakley Blades on, but it was near impossible to see, and there was nothing dry on me to wipe my goggles with. Of course, everything on me was soaked. There were occasional periods of no rain, lasting for up to about 20 minutes, but most of the time it was wet. At one point, at about mile 30, the sky looked like the sky looks on that TV show Storm Chasers, and some rider next to me was making cracks about tornados. The wind was very strong as well, which sometimes worked to your advantage and sometimes not. I was glad I didn’t have any disc wheels, because there was enough buffeting around as it was. There are a few hills on the course, which was also a little trickier because the brakes were only working about 20% due to the wetness. The last 5 miles of the race are through the outskirts of town , and the crews due a great job of opening up all the roads for the race, but the traffic is backed up for miles. The end of the bike portion (for me) was during another hard downpour. The other weird thing about the bike was how dark it was. All the clouds and the evening hour it was after 5:00 near the end, made for dusky / dark skies. With my shields on, it was like riding in the fading light of evening, and was a little disconcerting.

RUN: T2 went ok. The volunteers are great, and someone came and helped me unload my bag and pack up what I needed. I stopped at the porta-potty before heading out on the run. It felt SO good to finally get off the bike, mostly because I made it without getting hit by lightning. My legs felt surprisingly fresh at the start of the run. I did the first couple miles at an 8:00 minute pace, which is a little slower than I would have liked, but I was sopping wet. My stomach got a little queasy after the first couple miles, and I remembered I hadn’t taken ANY salt tabs. Usually I need to replace 1-2 tablets every hour, and here I was 4 hours into the competition and I hadn’t taken any. But, I wasn’t sure how much I’d sweated since the rain had provided most of the sweat for me and luckily, the GI stuff settled down. The first 6-7 miles felt pretty good, and I was optimistic that it’d stay that way, but it didn’t. It was raining for most of the run, and the course was full of big puddles so my feet were soaked (had been the whole race, actually). At about 9 miles I got some stronger fatigue setting in, and my pace dropped considerably over the next 4 miles. The run is a double loop, and the first loop takes you about 25 yards from the finish before sending you out for another round. It’s a little cruel since some of the people you’re running with at that point get to finish, while you turn around for another 6 miles. The last ½ mile felt good, lots of die-hard fans cheering us on, even in the rain.

POST-RACE: Not a ton of food but I picked up a little. One of the sponsors was Idaho Beef Council, so they had beef tacos at the finish. Not really my thing after a race, but the pizza was warm and salty and tasted good. I picked up my clothes change bag, went to the van and did a Handi-wipes bath, put on fresh clothes and picked up my bike.

ADDITIONAL STUFF: The winner of the race was Craig Alexander. He came riding by in the other direction when I was at about mile 10. Still, how cool is that? Craig is the current Ironman World Champion, and here we are in the same race. That’s one of the things I love about triathlon, average guys like me get to be in a race with the pros. It’s like being in a golfing tournament with Tiger Woods or at a swim meet with Michael Phelps. There were other professionals in the race as well, but I won’t drop any other names. I’m still deciding if I like the afternoon start. On the one hand, it was cool to not have to get up at 4:30 am and sort through your T1 stuff in the dark. On the other hand, afternoon races in thunderstorm prone areas are probably not the best idea, and having the race so late in the day gives you a lot of time to just sit around and be nervous about it.

Ok, that’s plenty.

Jet Boats

Jet Boats on the Willamette.

Ana and I went on her field trip a while back, to the Jet Boats in Portland. This is a video I threw together. I had it on facebook, but it was taken down by the copyright police.

So, let me say that the music (the snippet as it were) in the background is PINK FLOYD. The song is "Learning to Fly", off their album "A Momentary Lapse of Reason". You can buy it wherever music is sold, probably.

Perspective

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This is one of those rambling entries that I am starting but have no idea how I'm going to finish.

I had to get "talked down" tonight from a typical insomnia-induced on-call self-pityfest. Kate, having known me for coming up on half my life is pretty good at reading my moods, and did a great job of pulling me out of my frustrations and suggested I go for a walk (not a RUN, a walk), which I did. And it did give me some needed perspective.

On the one hand, perspective really gets to me when dealing with some of my patients. After 15 + years in this business, I've seen a lot of stuff, and it makes it difficult to abide some people, some of the time. I have patients who suffer the worst illnesses and setbacks who manage to keep a positive outlook, stand strong against the toughest struggles, and persevere in a way that just boggles the mind. And I have other patients who have not the smallest measure of tolerance for the most trivial of ailments. When you know enough of the former type of person, it makes dealing with the latter particularly difficult. I had a lot of the latter today.

It's not really kosher in medicine to interrupt someone and say, "For the love of all that's holy, would you please just shut up and quit whining, it's NOT THAT BAD". I also know that the ability to handle setbacks and illness is a complex mixture of life lessons, modeling, experience, intelligence, perspective, previous pain (emotional and physical), and a thousand other factors. That is why I don't behoove people to stop whining, because I know I never see the whole picture. A small ailment suffered alone is worse than a larger ailment shared with others. Still, as empathetic as I try to be, I have to imagine some pretty traumatic upbringings and rocky lives to possibly justify the sheer amount of hysterical drama some people bring into the folds of a sore throat or a bout of the flu.

My walk tonight did me some good. It was nice to get out and just walk. Usually the only time I'm outdoors further than the mailbox is to put in 10-20 miles on a training run, and the simple act of walking brought a reminder of some of the pleasure of just being outside and taking it at a slower pace. I passed houses where families I know are dealing with profound illnesses, and layoffs, and separations, and that perspective made my sleep deprivation and on-the-job frustrations seem fairly petty. I returned home to a house full of life, with my 6 year old staging an impromptu theater production for the rest of the family, and things were a whole lot better.

We'll see if I get any sleep tonight...

Inauguration 2009

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Perhaps it is a comment on the world today, that I blog, while watching the inauguration on streaming video on my other computer screen.

It's amazing that the documents so masterfully set forth in a very very different America 200+ years ago can carry this changing nation to the historic ceremony we are witnessing today.

I tried to capture a sunrise today, to reflect the new dawn of this nation and to reflect Obama's campaign symbol, but I had the aperture set wrong, oh well. Maybe there's a lesson in there somewhere...

9:06 AM --- Obama is now sworn in! His inauguration address is underway, and I will stop here to listen and to take it all in.

We live in an amazing country, and I'm as proud as I've ever been to be a citizen of the United States!

God Bless America!

Shake-cam

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This is a shot of Bourbon street, with my hotel on the right.

The view out my window. In that open-air patio there were jazz bands that played.

YIKES! It's been a while since I posted. Last weekend I was enjoying a hotel room on Bourbon St. in New Orleans, listening to the noise and jazz coming in the window from the crowds (Sugar Bowl) below. I was in Mississippi (Jackson) over the weekend for the Mississippi Blues Marathon. This was my make-up Portland (OR) marathon that got delayed for 8 weeks after I broke my toe last Summer. After the race a week ago, I decided to make the drive down to New Orleans since I had almost two days before my flight back (and since Jackson, MS is not too exciting a place). So I was in New Orleans for about 24 hours. It was a great time! I walked around a lot, taking in the various sites. I went to sleep on Bourbon St. with a raging Deep South thunderstorm outside, it was awesome. I caught the movie Slumdog Millionaire at a theater by my hotel, and then drove back to Jackson, and caught a plane home the next day.

This weekend (with additional days on each side) I'm Mr. Mom while Kate's in OH with her sister and parents.

We got the Christmas lights down today with no broken limbs (trees or human).

Finally, I'll post a video I made while running the marathon. Facebook followers have already seen the YouTube link (be warned, it's very shaky, and really not too exciting).



That's all folks!
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