Monday, August 25, 2008

America's Health Care System is broken

This has been perking in my head for almost a month now, but yesterday and today pushed me over the edge.

One of the problems with the system is that it is dependent on employment. My current health insurance is scheduled to end with the end of this month. I will "suck it up" and pay the COBRA to be sure that I (and my dependent) continue coverage. We have health issues, and need the continuity of coverage. That alone indicates that the system is broken.

Here are the three issues which pushed me over the edge about speaking out:
  • who choses the medication?
  • who pays the bills?
  • why does it cost so much for insurance?

First: medication choices

I have a medical condition where, at the moment, there is one medication which works for me. I have tried the generic and it does not work. Here is the story. I had bad, continuous heartburn. I was diagnosed with GERD (Gastro-Esophogeal Reflux Disease). I started with one name brand, it stopped working, and I changed to another. It also stopped working, and I moved to a third. All was good for a couple years. Then I changed jobs and therefore health insurance. The first time I renewed my prescription under my new employer, the pharmacy went back to brand #1. I did not fight, and after a couple weeks, I was in agony again. I talked to the pharmacy, and I was back to what worked. Last July, my employer changed health plan providers. Suddenly I was dealing with a "formulary" process. This is, in my opinion, nothing less than a price-fixing cartel process where the insurance company, for whatever reason (which may include discounts...) did NOT include my drug. Suddenly I went from paying $10 per month to a random amount, usually over $35. Fair? I don't think so? This summer I renewed my prescription, and the pharmacy again provided the generic. I refused to take it. Why? In January, I had taken the generic for two weeks, and my symptoms returned! Would you? What price is your health worth?

Why can someone in an insurance company, who has never met me, and not ever even talked to me, decide that I cannot have a prescription drug that I want. I can tell you that I spent almost 10 hours on the phone and in emails dealing with trying to get the medication which keeps me from having constant heartburn.

Second: Doctors and business practices

The more recent incident has to do with doctors offices and their willingness to deal with health carriers. My current carrier is technically a "cooperative" and is fairly local. My daughter is many states away. I chose a health plan which provides for "out of network" services. Well, my daughter's doctor's office management are a bunch of (well, I will be kind) dorks. (I have not decided if I will call them out publicly.)

Because my health insurance provider actually has a person answer every phone call, and does not use "voicemail hell" to screen calls, but is not a big player on the national scene, that office does not deal with them. The first time I called they referred to my carrier as "non-par." As a lay person, that sure sounds like "sub-par" which is not a compliment. Each time I called, they used "insurance-ese" even though they knew I was not an insurance person. They consistently refused to even talk directly to the insurance provider, and once when the insurance provider called were "more rude than anyone [we] have ever dealt with." And that was according to one of the experienced "member services" staff of my insurance provider. The fact that a medical office would refuse to deal with the insurance carrier of one of their patients absolutely boggles my mind. It is so antithetical to the customer service attitude which we in libraries try to provide.

I may be telling my daughter to find a new doctor for the rest of the time that I am responsible for the medical insurance. How else can you send a message?

Third: Insurance costs

I think I have known this for some time, but it has recently been driven home to me when I received my official COBRA paperwork. For my personal situation, it will cost me over $1,800 per month for insurance. Where does that money go??? That is $21,600 per year. I know that is more than many library workers are paid! I guess I always knew that it was expensive, but I had not really paid attention to the level.

Now, I don't begrudge any of my caregivers what they receive. When it costs $150 for a doctor's visit, I know that only a small part of that goes to the doctor. There is money for the rest of the staff (receptionist, nurses) and overhead (space costs, utilities), and even worse for them, malpractice insurance. Medical personnel must have to see a large number of people each month to meet the bills (plus have money to eat -- and to pay for their own health insurance!). But the amount paid for the insurance seems to me to be outrageous. Even more so when I remember that in July 2007, my employer changed providers when the prior provider wanted to boost rates by more than 50%!

I rest my case. The system is broken. I wish I knew how to fix it.

Wednesday, August 20, 2008

Driving thoughts

I have done some driving this summer. One trip was back to Connecticut to collect the last of my personal possessions so that they are all together in one city.

I have been sporadically reading the various blogs on my list. One of the non-library ones I heard about via the Brown University alumni discussion list (which is sporadic in volume). It is a personal blog written by a Brown staffer, and the "listmom."

Earlier this month she posted about driving. It is a very thoughtful post which somewhat reflects my experience. In my work life I have driven with traffic flow and against the traffic flow, as well as short within the city commutes, and in the even older days, I took the bus.

I will note that her last experience reminded me of the one thing I miss about the longer commute: listening to NPR and "All Things Considered" each evening. [And in finding the link, I found this great Wikipedia article about ATC!]

Thursday, August 07, 2008

Cutting Hours or Cutting Materials

On PUBLIB today, there was a post which I am putting below. My comments will follow, and I'll post the link to my comments to PUBLIB. Of course, any and all are free to comment. Because I did not ask permission, I am not posting the name of the organization wrestling with this issue.

Hello out there,

I'm a new subscriber to the list, having just joined to post this question (although I was a subscriber many years ago). In these tough economic times, we're having to make some difficult choices. We are trying to find any data, anecdotal or otherwise, to support or refute a decision one way or another. We have been searching the literature but not doing too well - it's sort of a tough concept to put into search terms, due both to such common words and the many synonyms of them that appear in the journals.

Put briefly, is it better to cut hours/days of operation or acquisitions?

Or, the way it was phrased to us to look into:

XXX Library has been asked to consider cutting deeply into its Library Materials budget in order to fill personnel vacancies, which might allow some library branches to expand public hours. If you cut deeply into your materials budget, did your circulation and/or visitor statistics decrease? By maintaining or increasing public hours, despite cutting your materials budget, did your circulation and/or visitor
statistics increase?

Many thanks for any information you can share.

What is presented here is the proverbial rock and hard place question. Or when I was asked once at a City Council budget hearing "Which branch would you close?" I answered, "That is like asking me which is my favorite child, and I have three!"

There is no right answer!

When I first worked at the Bridgeport Public Library I was told that one of the reasons why that library had such a great collection was that during the Depression, the Library paid its workers with "scrip" which was honored at local stores to save its cash to purchase library materials. Even in the 1980's the result of the depth of the collection was evident.

I can say that as a business librarian, it really impressed me to walk into the [closed] stacks and see every single Moody's Manual ever published. And there are many more examples.

Unfortunately, in the 1990s, the City hit very bad financial times, and cut both staff and acquisitions, that began a death spiral for the reputation of the library. By the time I returned as City Librarian in 2000, my predecessor had done a yeoman's job of increasing both, but neither adequately to meet the needs of a city with so many economically disadvantaged. In my tenure, there was a constant battle to increase both, with only collection funds being increased more than the cost of living. We even reduced hours modestly once.

In the position I just left, the discussion is beginning for the Fiscal Year (January - December) 2009 budget. There will be some tough choices. In the last budget cutting cycle, that library was able to save collection resources by "being lucky" and having several long-term employees retire.

My ALA colleague (and dare I call him: friend?), Jim Casey, frequently argues on PUBLIB that cutting Sunday hours is punishing the public. And while I agree, I would also note that it is the very same public which pressures elected officials to reduce taxes, in nominal dollars, without thinking about the impact in real dollars or in services. The City of Eau Claire (Wisconsin), has used all possible options, and now is facing the prospect that the funding base (given the state-imposed "levy limits") will only support a city operation which is 2/3 the size of the current one. What will go?

I do not know the answer. I do know that cutting hours can send a strong message to the public, and *may* rally support (not will). As I told the staff at my last staff meeting, it is not a choice I like making, even if it sometimes in my job to make that choice!