Author Archive for Angus Brownfield

Guerrilla Health Care - 2

This is the second in a series of contributions to fixing the health care system without breaking the bank

(what system?)

You’ve been running three miles a day since God knows when.  One day you wake up and your knee feels grim.  Days pass; soon just climbing a flight of stairs makes you sweat.  You finally decide to get medical care to put you back in your Nikes and running shorts—you miss the road, you miss the endorphins.

In the process of mending your knee you see your family practitioner, two orthopedists, the radiology department of the local hospital, a physical therapist, the local pharmacy and a podiatrist who designs an orthotic to insert in your running shoe.

For this one condition you interacted with a pretty big swath of the Health Care System:  four doctors, a hospital, a physical therapist, a pharmacy.  But you also had most of your bills paid by an insurance company and there’s the orthotics lab that made the insert, the architect who designed the hospital, the contractor who put it up, the X-ray machine manufacturer, the universities that graduated and trained the doctors and the physical therapist, the manufacturers of the analgesic, the company that designed the hospital’s billing system, the agencies that licensed the practitioners, the boards that certified the physicians’ competency in their specialties, the agency that accredited the hospital and on and on.

AND, most importantly, you, the patient.

Where do you draw the line?  How much of the universe do you encompass within this health care system?

Of course that depends on why you’re taking a systems approach.  If I want to examine the appropriateness of medical care in my immediate medical market area, I’d draw a line on a map enclosing an area along the Interstate 5 corridor from Yreka, California, to Cave Junction, Oregon, with arrows pointing to San Francisco and Portland, where I might go once in a blue moon for super specialty care.

If  I were curious to know whether medical specialists in the Rogue Valley used the latest in medical knowledge in their practices, I might have to go very far afield, since specialty boards are national in scope and there is no telling where a physician was trained before he entered practice in the Rogue Valley.  I’d want to know what Oregon’s licensing agency requires in the way of continuing education.  I’d probably consult Oregon affiliates of national professional organizations.

If I were all wise and President Obama’s health care guru, I’d be looking at the whole shebang:  enabling factors, such as health insurance, dental insurance, Medicare and Medicaid; predisposing factors, such as life style, education, income, genetic predisposition to disease, and religious proscriptions; facilitating factors, such as the number and distribution of medical care resources, the public health sector, the state of biomedical research; system regulators, such as the Food and Drug Administration, the Department of Agriculture, the GAO, the Department of Justice, OSHA, the Department of Consumer Affairs, the antifraud unit of the Centers for Medicare and Medicaid Services.

Most of all I’d be looking for an accurate model of how the health care system operates, it’s inputs and outputs, its processes, and equally important, how its accomplishments (or lack of them) are monitored, where it’s out of kilter and where it’s outstanding.

In the process of constructing this model, I’d want to know what the system actually costs, not just in big numbers but in specifics, such as what it costs to treat a case of a certain variety of cancer.

I would also want to model the consequences of changes in the inputs and processes of the system.

What if, for example, doctors could prescribe membership in a fitness center for obese persons?  What if a doctor could prescribe not only nutrition counseling for the undernourished but also food?  Would investments in these products and services change the inputs to the system (e.g., obese persons or otherwise malnourished persons) sufficiently to reduce the costs of medical care?  Would old, infirm persons get more preventive health care if Medicare ponied up for taxi fare to the doctor’s office?

The health care system is vast, expensive, secretive and self-protective, inherently inefficient and, overall, under-regulated.  In coming posts I’ll speak to places where a systems approach can be fashioned to work within these constraints.

Guerilla Health Care - 1

(Potshotting the health care system)

If there’s something in this world I know something about, worry about the Obama administration getting right and feel compelled to opine about, it’s health care—both medical care services (narrow) and the people’s health (broad).  Hence a new category of posts: Guerilla Health Care.   — Angus, 3/6/09.

I got a glimpse of the real problem as I rode the elevator to my twelfth floor office.  As Director of Planning for the Los Angeles County Health Planning Council, my job was to create a fact-based plan that identified medical care resource needs for the county’s seven plus million residents five years in the future.  How many doctors of what kind would we need?  How many emergency rooms?  Where should they be located?

I shared the elevator that day with two women—middle-aged, affluent suburbanites—oblivious of my presence.  One or both had come downtown to visit her physician.  I stood quietly watching the floors go by as I eavesdropped on their conversation.

“Mabel,” one woman asserted, “I told my doctor if he didn’t get me a CAT scan for my headaches, I was going to sue his ass off.”

The other woman applauded her pluck.

It happens I’d been pondering, for days if not weeks, why LA County, with seven million residents, should have sixty-three CT scanners, while Great Britain, where the contraption had been invented and with roughly eight times the population, had only three.

Now I knew why.

The real problem was the pseudo-quasi-free market model of the health care system envisioned by the system’s decision-makers, because of which every hospital that can remotely justify it gets the latest medical imaging devices.  (Five years later I’d meet a lawyer whose radiologist wife actually had a scanner in a trailer she pulled around the county doing curbside tomography.  Hey, driving downtown is such a drag.)

You have consumer demand, you have a payment system that permits payment-for “usual and customary” diagnosis and treatment-for pretty much whatever the consumer demands and the doctor okays.  You have a public who fervently believes in the health care system’s ability to ward off death, cure ills that a hundred years ago would have put you in your grave, make up for unhealthy lifestyle choices, and alleviate pain and the fear of pain.  -Or else.

Oh, and give us Cadillac health care at Chevrolet prices—without government meddling (except for approving drugs, licensing health care providers, funding most biomedical research, keeping the environment healthy and footing the bill when we get old, disabled, or indigent).

So why not, you ask?

Because, if we make sure every citizen has access to Cadillac health care, someone’s got to pick up the part of the bill that you or I can’t personally afford.  There simply is no cut-rate health care.  If a CAT scan for Mabel’s friend becomes “usual and customary,” you’re not going to get your headache treated without a CAT scan first.  Your doctor’s already paying more for his malpractice insurance than he is for his mortgage.  He definitely doesn’t want to risk your suing his ass off.

Hence the cry for “health care reform,” as if this will suddenly make everything better.  Health care reform, alas, is a shibboleth that has a righteous ring but a devilish price tag.

In the coming year I plan to explore what’s possible and what’s not in bringing effective health care services to the people, and what effect universal heath care will have on the people’s health.

Update: Coincidentally, the New York TIMES recently published an article (”Good or Useless, Medical Scans Cost the Same,” by Gina Kolata, NYT, 3/1/09) in which the author asserts, quoting a GAO study and radiologists on the staff of medical schools around the country, that perhaps half of all medical imaging procedures are useless, even though private and government insurers foot the bill for these.  It seems some scanners are past their prime, or some persons interpreting their images aren’t competent.  And the motive, in both cases, is economic.  She states that 95 million scans are done each year, costing $100 billion, of which Medicare pays $14 billion.  There are no standards for judging the appropriateness of most scanning procedures.

I’ll address some of the issues raised in this article in subsequent posts.

Abrupt Edge Diary - 15

This is the fifteenth in a series about the construction of the novel-in-progress, Abrupt Edge

14.  The risk

I have indeed been cobbling the bits together and tonight, starting on the sixteenth chapter of the third version, I am reminded of Martin Buber’s paean, in I and Thou, to the creative act.  In it he slips in a little warning: “. . . if I do not serve it [i.e., the creative work] properly, it breaks or it breaks me.”

Here is the thing:  I have no idea if my idea for this novel is going to work.  The story changes as the characters unfold.  It was going to be my Sanctuary (see Abrupt Edge Diary-4, the post of 11/15/08) and I have succeeded in getting some of the elements of Faulkner’s work into Abrupt Edge, like a virgin being raped, and her being installed in a brothel, but Asenath’s not standing still for being a degenerate—or is she?  She’s turning out to be a madam with a mission.  It’s not about making dough from the bodies of young women, it’s conquering men, the males of the species, by teaching them . . . sensitivity.

But what is the nature of what she’s doing?  Asenath is only incidentally making money off the bodies of young women, but she’s still defying a lot of the world’s moral imperatives by being the factotum who manages the main industry of this exotic world:  assuaging the sexual needs of fat cats in the most grandiose way imaginable.

And more and more I am heading in the direction of writing a novel about moral relativism and moral objectivity.  Not about, in the sense of preaching a sermon.  I’m not, in the name of art, advocating any particular set of moral standards.  I personally find the notion of hiring a prostitute, renting the orifices of a woman’s (or a man’s, if that’s your persuasion) body, to be repugnant, but I know there have been prostitutes since long before Judah met Tamar.

So, is this a dodge, telling a titillating story in the guise of treating a philosophical question?  It better not be, or I will find myself to be broken.

Next post I plan to delve into what I consider to be a fiction writer’s biggest bugaboo, namely VerisimilitudeOhh, eeeh, ahh.

Abrupt Edge Diary - 14

This is the fourteenth in a series about the construction of the novel-in-progress, Abrupt Edge

13.  Cobbling together the pieces

I wrote five chapters-thirty-eight pages-of setting up the demise of Abrupt Edge, using the Mulee County Sheriff as the main witness for the reader.  It was shorter than the original Part I by about half, but it seems a complete piece and I’m leaving it that way.

Next I’ve taken the Version 2 Part I and made it the Version 3 Part II, the difference being this:  I’m concentrating on getting naïve, untested Jacob Gleason to Abrupt Edge with a foreshadowing of the moral dilemma his being there will cause.  Without planning it that way, I’ve dipped into Joseph Campbell’s The Hero’s Journey, giving young Jacob portents of struggle, temptations and obstacles and he makes his way from comfortable, secure Ashland, Oregon, to isolated, dangerous Abrupt Edge.

This is mainly a matter of picking out the chapters in Version 2 Part 1 that deal only with Jacob and rewriting them with the knowledge of what’s gone on in the chapters about the Glory War coming to light through the eyes of the sheriff.

I’ve run into one difficulty, and that’s the chapter where Gloria, who is becoming Jacob’s muse, gives him a thumbnail sketch of Isaac Wayman’s journey to Abrupt Edge.  If I leave that out, I really have to change to narrative; if I leave it in, shall I further foreshorten the thumbnail sketch, leave it with the same amount of detail, or actually expand it?

Probably leaving it out is the wiser course.  A really short thumbnail is going to sound like a synopsis.  Both leaving the thumbnail as is and expanding the amount of detail in effect gets into the next part of the novel, which is to be the origins of the rift between Isaac and Abraham Wayman and the immediate consequences of it.

I need to think about this.  I may need to experiment.  We shall see.

Abrupt Edge Diary - 13

This is the thirteenth in a series about the construction of the novel-in-progress, Abrupt Edge

12.  A new start to the novel

I’m now up to Version 3.  Don’t be alarmed - I’m not.  I figured out that what I would want, were I the reader, is a foretaste of things to come, plus a little mystery, some questions to be answered as I read.  I want my curiosity piqued.

So I started with the world - in the persons of some military technicians with eyes in the sky and an FBI agent on the ground - getting an inkling of Abrupt Edge’s existence - as it’s burning down.  As they start inquiries into the smoke plumes they’re suddenly seeing in the images of wilderness Nevada sent down from spy satellites, they ask the local sheriff what gives, and he feigns ignorance - even though he’s been taking hush money for years to ignore Abrupt Edge.  So have some state and federal officials.

As the sheriff and the FBI agent move through the ruins of Abrupt Edge they discover no living persons, only corpses - until a shot fired from the nearby mountain barely misses one of them.  Someone’s alive, and he doesn’t cotton to lawmen.

Well, actually, the sheriff’s already interviewed another survivor, a teenaged boy who’s in the hospital with two bullet wounds, who gives him a clue to why Abrupt Edge and, across the mountain spur, the equally secret fundamentalist LDS enclave, Glory, are ablaze.  It has to do with the daughter of Glory’s Prophet, a girl by the name of Marian, who ran away from home to join other ex-Gloryites who work in Abrupt Edge’s brothel, Carne Viva.

At this point the sheriff’s worried about two things:  his pension, and the penal code.

Meanwhile, two other persons have escaped from the fighting, Jacob Gleason and Gloria Bennett, lovers on their way to a new and enlightened life, driving away to a place where Jacob can write his history of the Glory War.

So now, in five chapters, I trust I’ve got the reader’s appetite whetted, I’ve introduced the main characters, I’ve made it believable that Abrupt Edge and Glory could stay hidden for so long, and the reader is going to know more than any of the characters, which Shakespeare proved is key to satisfying drama.

I remember when I was a kid seeing this movie where the bad guy has wired the phone so that when the good guy picks it up, he throws the switch and electrocutes him.  All the kids in the audience-this is a Saturday matinee and it’s all kids-who know about the bad guy’s scheme, are saying to the good guy, “Don’t pick up that phone!”

Maybe the readers of Abrupt Edge, at this point in the narrative, will be saying something similar to  Jacob Gleason.