2010 MARCH

March 26

We may or may not see health care reform in my lifetime. They passed some sort of bill, but I’m not sure it will do much, even if the thirteen lawsuits filed 7 minutes after Obama signed it all fail. In the meantime, health insurers are doing their best to keep costs down.

Los Angeles County recently announced they are reducing reimbursement to emergency room doctors who care for the uninsured. If you need care in an emergency room, the county decides what fraction of the doctor’s bill is “approved,” and then actually pays some fraction of that. Last year it was reduced from 29% to 27%. But the county’s budget is strained, so they just announced the rate will be cut again—this time to 18%. This may seem like a huge reduction, but in fact it’s a big increase, since the county hasn’t paid anything since last July.

Then there’s the shell game known as “What’s My Disease?” If your doctor orders lab work or treats you for something and submits a claim to Medicare or your insurance company, every test, procedure, or consultation must be listed with the appropriate diagnostic code; otherwise, the insurers will refuse to pay for it. The problem is that as soon as you learn the secret passwords, they move the pea by changing the words. “Congestive heart failure,” for example, is a diagnosis originally made in Greek by Hippocrates. It is a very specific term understood and used by medical practitioners since then, but it is no longer an acceptable diagnosis. If you should happen to have some procedure done because of your CHF, you will end up paying for it out of your own pocket.

Third-party payers (that’s anybody who pays for your medical care except you) keep the pea moving because they figure if they deny the claim once, some doctors will never file a correction. This happens often enough to pay the salaries of all the employees whose job it is to reject claims. And it gets better: if you do refile and make some error (my doctor spelled my name “Micheal”) on the second claim, it too will be denied. By now several months have elapsed—they don’t do anything in a hurry—so if you have the temerity to try a third time, it will be rejected for not having been filed in a timely manner.

Obviously, before you can fill in the diagnostic code you have to know the diagnosis. It seem you can’t have a test to find out what you have until the doctor already knows what you have. An x-ray to “rule out pneumonia,” or any “rule out” diagnosis, is unacceptable.

The system (or systems—there are several) is pretty comprehensive; there’s a code for anything you can imagine and much you can’t. There is, for example, a diagnostic code for “accident involving spacecraft.” In case you were worried. There’s also a diagnosis I’m not sure I want to know more about: “isolated explosive disorder.” As I understand it, it’s not a term applied to people who wire themselves up with dynamite and stroll into the marketplace.

Much of the idiocy in the system is simply the idiocy in The System: changing the names and numbers is just bureaucrats finding something to do to justify their jobs and to justify not paying for services. You may recall that’s what I started out talking about, but don’t stop me now. Changing the names is only part of the story. There are new diseases every day, and as in every other aspect of our lives, money buys results. When the pharmaceutical industry comes up with a new cure for an as-yet unknown disease, their lobbyists have to convince the paymasters to recognize the new condition. Restless Leg Syndrome (333.94), Fibromyalgia (729.10), and Social Phobia (300.23) are now in the system. And although kidney failure is no longer a real disorder (it has to be called chronic renal disease), Hypoactive Sexual Desire Disorder is a new and approved—and compensable—disease. A doctor I know told me that used to be called “marriage” and you couldn’t get paid for it. But that’s a story for another day.

March 21: You are what you eat.

We humans have a certain disdain for carrion eaters. We can’t think of a vulture without a little sniff and a shiver of disgust. Which is strange, since most of us don’t eat live animals (although my sister comes close) or plants. I have occasionally and to my surprise consumed live worms, or worm halves, in the course of eating an apple. But not on purpose and not with any great pleasure.

Some primitive cultures believe you can acquire the courage of a valiant enemy by eating his heart raw. I don’t quite follow the logic of this, since if you are in the position to do that, you’ve pretty much established that you are already the greater warrior. Anyway, I think they confuse cause and effect. You have to be pretty brave already to slay your foe, then cut open his chest and…yuck.

There are a lot of things I might be able to eat if my head didn’t get in the way. As a boy I was eating corned beef once at a friend’s house and I was doing fine until his father said to his mom “This is very good tongue, dear.” Tongue? Oog. I still eat corned beef, but I always make sure that’s what it is.

Brains is like that, too. (Can you say “brains is?” Why is it singular inside your skull, but plural on your plate? Do they serve more than one? Do they mix a bunch together? Maybe if they’re from small animals, like squirrels, you need more than one to make a serving. I seem to recall reading that it takes several surgeons’ brains to make a pound.…) Whatever; I’m with Bill Cosby on this one: I don’t want to eat anything somebody’s been thinking with.

Once in Paris I saw “cervelle” on the menu and I knew it was a word I recognized from my long-ago high school French class. I couldn’t remember exactly what it meant, but I was so happy to see a word that looked familiar, I ordered it. I guess the little smirk attending the waiter’s “Oui, monsieur” should have made me suspicious. When he brought out a nice steaming plate of brains, I managed to summon enough French to get him to take it away despite his protestations that “monsieu’, it is what you ordered.” I not only wasn’t about to eat it, I couldn’t eat anything else while that stuff was in full view on the table. By the way, can one of you French speakers explain why the thing in your head is masculine (cerveau) but the same thing on a plate is feminine (cervelle)? Maybe it’s like those warriors I mentioned before—if you’re eating it, the brain belonged to a vanquished, and therefore not masculine, beast.

Some things I won’t eat just because they’re so ugly. I’ve eaten artichokes, and while I don’t like them, they aren’t really that bad. But they look so awful, it puts me off. How about lobster? Lobster isn’t bad either, but can you imagine how hungry that first fisherman had to be to look at one of those and think: “food”?

Then there is a whole group of things I will call Idiot Foods, things prepared in other countries to serve to stupid Americans who will believe anything. Like bat soup, served in the Palaus with a whole bat in each bowl. How do you eat a whole bat with a spoon? Do you think the guy at the county fair who sells deep fried anything is missing a bet here?

Or like ikezukuri, which is sushi gone mad. The fish is not merely raw, but alive and flapping about. That’s not dinner, that’s a fraternity hazing.

March 14

Sorry I'm late. In the first place, it's an hour later that it should be, the latest diatribe about which you may read here. In the second, I am away from my desk, with limited access to the unreal world. That story is in progress, and will be available in due time as Chapter the First of Traveling Curmudgeon Volume V. Or VI, whatever we are up to now. In the meantime, chew on this.

I was talking about whether having high blood pressure in your arm is necessarily a bad thing. On the assumption that it is, doctors do whatever they can to bring the numbers down. But the treatment is even more peculiar than the disease. The first thing they tell you to do is lower your salt intake, which prevents you from retaining fluid, thus lowering the volume of blood in the system. If that’s not enough, you get a diuretic—the same effect in spades. Lower volume, lower pressure. But wait: lower volume, lower perfusion. Is that what I want?

Dilating the blood vessels, the next step, can also lower the pressure: you have the same total volume in a bigger set of pipes. This appears to be the rationale behind biofeedback in the treatment of hypertension. It teaches you to dilate the vessels in your hands and feet. It may make your hands warm, but there is a fixed amount of blood in the system and fluid is not compressible, so if the vascular system is full (it is) more in your hands means less somewhere else. If my spleen’s not busy it can do with less, but I’d rather have cold hands and a warm brain any time.

Drugs that dilate arteries are not specific: they dilate everything. Dilating all your vessels will drop your blood pressure all right, but if you overdo it, you’ll pass out every time you stand up. The heart is smarter than that, and if some important part needs more blood than it can get by opening up the plumbing, the heart will work harder or faster to meet the increased demand. Is that what I want?

My doctor says I’m all wet about the blood pressure thing. He’s a fine fellow and an excellent physician, so maybe he’s right. But medical science has stumbled so badly so often that the only thing we know for sure is that we can’t really be sure about the things we know for sure.

Like cholesterol. Now, I’m willing to accept that LDL is bad for you and HDL is good for you, but I have trouble buying the accepted methods of controlling them. Logically, you would assume that if you eat less cholesterol, your levels will go down. Except that cutting your intake down to almost zero has bugger-all effect on your blood level. I know, I did it. And drugs that inhibit absorption, which don’t work very well anyway, don’t do anything for your numbers either.

It’s not that diet isn’t important, it’s just that we don’t seem to know how or why things work. A diet high (very high) in oat bran (enormously high), which was briefly popular years ago, actually does lower your cholesterol significantly. I know, I did that, too. The trouble is you have to eat so many damn oat bran muffins you end up wishing you would choke on one and get it over with. And, contrary to all expectations, Dr. Atkins’ diet revolution, which is very low in carbohydrates (and correspondingly high in fat—you have to eat something) also works. But nobody can stay on 35 grams of carbs a day for very long. Yeah, I did that too.

So, let’s see: low cholesterol diet—no good; high carb (at least in the form of oat bran)—good; low carb, high cholesterol—good. So your doctor tells you to do the logical thing, which is unfortunately the least effective. You think maybe we’re missing something here?

The fallback, since decreasing intake doesn’t work, is to attack the other source of cholesterol, your liver. Statins are so effective some doctors think everybody should take them. They work by poisoning your liver so it can’t make cholesterol. Niacin in large doses works just as well a lot cheaper, by the way, and for the same reason. I’m sorry, but I have trouble believing that poisoning your liver is likely to be good for you. I’m still waiting for the other shoe to drop.

March 9

I’ve been doing business with the same bank for over a quarter of a century. It was recently gobbled up by a different, larger capital-I-Institution but the people I deal with are still the same. It’s kind of like a marriage—we’ve had our little squabbles, but they usually forgive me my little mistakes and I try to be patient with their big ones.

The other day I got a notice from them to the effect that my safe deposit box, which had been free for the last 25 years, would now cost $50 a year. Furthermore, if I didn’t authorize the bank to deduct the fee from my account automatically, there would be an additional “invoice fee” of $10.

I dropped into my branch the other morning to have a chat with the manager and confirmed that yes, they were now charging for the box and yes, they would send me a bill for sending me a bill. And if I didn’t pay it on time, there would be yet another bill: late fee. “Face it,” Amanda said, “if the old PFF had charged for these services, we might still be PFF.”

I’m not saying US Bank is cheap, but they don’t put stickum on the back of their post-it notes. Really.

I was very calm—you’d have been proud of me—but I bridled a bit considering that they have my money essentially for free since banks pay virtually no interest these days. Amanda said she understood, that she’d had to speak to quite a few disgruntled PFF carry-over customers, but it was a business decision, policy from on high, and nothing personal.

And that’s the problem. Bank of America may be one of the most hated institutions in the country. They don’t care. I think they should, and I hope that someday their attitude will hurt them where they do care. If that’s the direction US Bank is going, I’m not coming.

I had 3 weeks before my payment was due, and there are four other banks within walking distance. I told Amanda I would take some time to consider my options and let her know my decision before the deadline.

Honestly, having watched businesses slowly erode services into revenue sources over the years, I expected to find that the banks’ policies would all be pretty much the same and if I wanted to change, it would be because of something like the color scheme in the various branch offices. So I was surprised to learn that, of the four other banks in the area, three still offered free checks and free money orders, and two provided free safety deposit boxes as well. And all four pay a higher interest rate—twice as much, in two cases—on money market funds than does US Bank.

I thought about it, but in the end I decided to stay where I am even though no prudent financial advisor would approve. Because it is personal.

Follow-up: I’m thinking again. Amanda had told me the fee for the box would be $25, but the confirmation they sent in the mail said $35. No one in my branch or at the home office could explain this, but my personal banker discovered that if she told her computer that I was a senior, it would take off another ten bucks. So in two weeks, when the payment is due, the computer will automatically deduct some amount from my account. They aren’t really sure how much, so I am supposed to check back on that day and if they did it wrong, they will credit the difference back. So I have to tell them to correct their mistake, then check to see if they correctly corrected their mistake, and tell them to correct the correction. Chase bank is looking better and better.

March 5

A moment of silence for our long-beleaguered newspaper. It has come to this:

Today’s paper has sold out the entire front page for a movie ad. This is actually an outsert, or whatever is the opposite of an insert: a four-page ad with the whole paper, including another front page with what they call news on it, folded inside. The “real” front page also features a banner ad for the same movie, and the Calendar section has banners at top and bottom. There’s a four column above-the-fold “news” article in the Business section about how this same movie, which hasn’t even come out yet, appears “headed for one of the biggest winter debuts ever.” Yesterday Kenneth Turan’s review, including another huge picture, took up two-thirds of the Calendar’s front page and another half-page inside. He panned it.

Alice is not advertised in the sports section, or in the classifieds, though admittedly I didn’t look carefully through the automobile ads. Word is the production cost $200 million, but clearly the marketing costs will double that figure.

I don’t know if this will rescue the L.A.Times print edition. I don’t even know if it matters.

March 4

A scandal erupted at the National Spelling Bee this year when one of the finalists tried to buy a vowel….

Myself, I am a man of few words. They are verbose, prolix, and loquacious.

Why doesn’t “morose” mean it doesn’t have enough sugar?

The opinions expressed herein are those of the author and do not necessarily reflect--well, yes, come to think of it, I guess they do.

all materials on this site ©michael grossman. all rights reserved.

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