Camping and Botanica

More photos are now up on my Flickr stream from a camping trip in Colorado with Katie's parents and a trip I made to Wichita's Botanica Garden. Enjoy!

Health Insurance Reform (part 2)

(Part 1 here.)

One of the podcasts I listen to (Planet Money) has lately been exploring the health insurance reform from an economics angle. They had a guest on this last Friday (Aug. 21st 2009) who made an excellent point that further illuminates to me that something is fundamentally wrong in the way health care works in the US.

DNA testing is slowing and surely growing in common practice. We aren't even close to something on par with the ultra-fast and comprehensive testing portrayed in Gattaca but were clearly headed in that general direction. There are tests now that can identify genetic markers that have been correlated to many types of cancers and other common genetically-induced maladies. All other things being equal, these tests are valuable for patients because they allow us and our doctors a more insightful view of our health. With more information we can make better decisions and, depending on a situation, may have incentive to make lifestyle changes to counter-act some of our genetic pre-dispositions. Using a very broad brush, I would say genetic tests are good for patients health...

... except if that information is by some means conveyed to a health insurance company and they use it to deny coverage. If I know that I have a genetic marker for a certain disease and don't disclose this to the insurance company when I try to buy a policy on the open market (that is, not through work or some other group plan), the insurance company has the ability to cancel my policy if or when they find out (called a rescission) . There was a recent hearing in Congress where health insurance executives were called to account for abusing this area of the law; it was not pretty. I am better off not having this information if I am trying to buy an individual policy because it isn't lying if you don't know the truth. Ignorance of my medical condition works to my advantage...

... except that this is my health we're talking about. I don't want to avoid information that could help improve my health so that I'm eligible for health insurance to treat the life-threatening disease I am genetically pre-disposed to. You see the problem? The incentives in our current system are all wrong. The health insurance companies don't want to have to cover people who are more likely to develop serious medical problems due to genetic pre-dispositions and patients want health insurance but shouldn't have to remain ignorant of any the results of any genetic testing for fear that they won't be able to get coverage.

The problem, once again, is revealed in the semantics: health insurance isn't really thought of as insurance any more, at least not by patients. We all get sick, we all need to go to the doctor, we all will have medical bills to pay. It isn't a matter of "if" but "when" and "how much". For the health insurance companies, I think "insurance" is the right word. They are thinking entirely in terms of liability and risk. We are insuring 500,000 right now: How many are going to get cancer? How many will be in a car accident? What is the average cost per patient? What can we do to improve our odds of having to make a big pay-out? Its all a numbers game and they are in it for a profit.

The fact that health insurance companies would like to have as much genetic testing information as possible so that they can remove as much risk from their pool of customers shows that something is wrong: who is going to cover all of us with genetic propensities that are completely out of our control? The insurance companies want to make as large a profit as possible and, to the extent the law allows, are going to do what they can to maximize that profit. That corporations are interested in profits should not surprise anybody. They have a strong incentive to reduce and eliminate costs by being as selective as they can with who they cover.

Our system is broken when information that is good for our health turns out to also be too expensive to know for our own good.

First day of class

I had my first class of the semester this morning at 8am. The experience was completely unlike a year ago when I started my graduate work. Then I spent fifteen minutes wandering around campus trying to figure out which poorly labeled building I needed to go to. When I finally found the lecture hall, I entered to see a sea of students from south Asia; I was probably one of ten US citizens in that class of over 100. I knew nobody in there.

Today, I walked into the much smaller room to see eight other students (the other five showed up after me). I recognized all of them and knew seven of them by name. I was good friends with two or three of them. Today was much better.

Day before school

Since today is my last day of my summer break before classes start again and I've finally got all the computer stuff here at working the way it should be, I'm finally going to put some of the pictures we took in Hawai'i up. I'll just be putting a few here but you can see a good deal more on my Flickr stream. (One of these days I'm going to get much better at keeping it up to date.)

We spent a good deal of time snorkeling, a new adventure for both of us. Snorkeling is super easy and in waters like we experienced with lots of wildlife, it was fun, fun, fun.

During one of our boat tours we saw both a monk seal and a sea turtle. It was humbling and awe-inspiring to see them both move through the water so easily and unencumbered.

There is a great deal of elevation change on the island that afforded some fantastic views

And of course, sunsets over the ocean are always great.

Like I said, there's more to see on my Flickr stream. Vicariously enjoy as the school year starts up again.

Health Insurance Reform

I don't know much about the specifics of the current discussions and debate regarding health insurance reform. Since Congress has not finalized a bill in both houses prior to their August recess, I believe a lot of the details are still up for debate. What I do know about is my experience with health care and health insurance when I injured my back a few years ago. Based on that experience, I have some thoughts and opinions on how this system should work. More specifically, my thoughts are more along the lines of identification of problems I experienced. Its much easier to point out flaws than develop solutions and after thinking over this stuff for a few years, good solutions still allude me.

The trend in health-insurance I've noted is the move to HDHP (high-deductible health plans) and HSA (health savings accounts) and which usually are presented right along with the buzzword-BINGO term of "consumer-driven health care". The idea behind consumer driven health care is to bring a market-based approach to making health care better and more affordable.

The first part in this plan is the HDHP. Deductibles are raised to several thousand dollars in an effort to make the health-care recipient have "skin in the game". The "consumer" (more on the use of that term later) aka "patient" is responsible for paying all of that deductible and so has an incentive to shop around and find the most economically efficient way to get the services he/she needs. Its the consumer's money paying for the service and just like consumers have for ages, they will force the market (health care system) to provide quality products/services at competitive prices.

The trick to making HDHPs work is the second prong of this new idea, the HSA. The HSA is a tax-advantages account that holds funds used to cover costs of health care for the account owner. Money from these accounts can only be used for approved health-care services (physicals are OK, going to the witch-doctor is not) and all contributions are tax deductible. Also, this account is independent of the employer; when I lost my job at Cessna I kept my HSA and can continue to use that money for any health expenses I may have in the future.

The first real catch in consumer-driven health care shows up when the question of who is mainly responsible for funding the HSA arises. At Cessna, the employee is. The company contributes about 20% of the annual maximum contribution and the employee can choose to contribute more (tax-deductible) money or not. In my case, as a Cessna employee, the result of this was a significant increase in the cost of health care by me, the employee. I was responsible for 80% of the annual deductible whereas before this change, it was more like %40. I know of two other companies that have HDHP/HSAs and the employer provides the majority of the funds. In these cases, the employee bears roughly the same cost burden as they might under a more traditional plan but now has an incentive and discretion to use those funds more wisely.

The HSA funds aside, though, "consumer-driven health care" has a fatal flaw that will somehow need to be addressed if it is ever to take hold. The root of the problem is actually revealed in the syntax: "consumer". Consumers are people who shop around, look for good deals, make informed purchasing decisions, do their research, drive markets to better value and better products. Very few of these apply in a health-care setting.

Firstly, patients have a SEVERE knowledge gap regarding what kind of treatment and care they need. This will always be true and this is why we go to doctors. Granted, if an individual has a long-term specific condition, he/she can actively educate him/herself and ask intelligent questions of the doctors. Cancer patients tend to become more educated over time because they have an incentive and the time to become more educated. But nobody, when presenting with a severe pain in the stomach for example, will wait to hear the doctor's diagnosis, go home and read up on it, and decide whether he/she agrees with the doctor. As patients, we must place or trust in the our doctors and do the best we can to be informed as we go through treatment. In this regard, we are never informed consumers in the health-care market.

Secondly, as things stand right now, patients/consumers have a very hard time determining the price for a given procedure. Have you ever tried to shop around for routine treatment, trying to get the best price? I dare you to try. I started and gave up quickly. The structure of the health insurance system right now is not designed to easily define the price of a given procedure; there is no price tag for a colonoscopy (as was my case).

I know I won't get this exactly right but here is how the billing system worked when I was under the health insurance at Cessna. The health care provider has a number that most closely approximates the sticker price for a given procedure. If you were independently wealthy but had no insurance and walked in and asked for that procedure, that's how much you'd pay. If you do have health insurance, though, your insurance company has signed up with one or more "networks". I don't know all that goes into being part of a network but I do know part of it: price control. My health insurance, by being part of a given network, had gotten the health care providers to agree to charge a certain amount for a given procedure. By being in that network, the health care provider has a greater likelihood of seeing more patients because the health insurance company provides financial incentives to the patients/consumers to use in-network providers. So, if I go to in-network providers, rather than charging me the sticker price for the procedure, they charge me the lower network price and the provider sees more people like me who are trying to control their own health-care cost. You still with me?

Now, with the reduced price, the health care provider sends the bill off to the insurance company (as a courtesy to the patients, rather than making them deal with this mess). The insurance company takes that bill and looks at the specific agreement they have with me, the consumer/patient to determine what, if any part of this they will pay. Have I met my annual deductible? Am I in the cost-sharing payment zone? Is this preventative care that the insurance company pays for entirely? Is treatment even covered? (Have I gone to the witch-doctor who is then trying to get paid by the insurance company?) The health insurance company runs the claim through their computers and comes up with the amount they will pay the health-care provider. A payment for that amount is made.

The ball is back in the hands of the health-care provider. Odds are, the amount that the insurance company paid is not sufficient to cover the bill they sent. The provider then has a choice; do they bill the patient for the remainder or do they just absorb the loss. Most of the time, I'm guessing they bill the patient. To me, the end consumer/patient, this is my actual out-of-pocket cost.

Do you see all the machinations that number went through before I eventually got the bill? Trying to predict this number can be very difficult. The health-care provider should be able to quote the in-network cost they will bill the insurance company and it should be possible to call the insurance company and, if given the right information, they should be able to have a very good estimate on how much they will pay the health care provider but I'll let you guess how easy and how many phone calls it would take to figure out the final cost to the consumer/patient. If it was two phone calls totaling less than 30 minutes, I would be thrilled. In my experience, it was nowhere near that simple.

(As a side note, this billing shenanigans is entirely avoided for organizations like Kasier Permenante, a health care provider that is also an insurance company. There is no external billing, no passing-the-buck. All of these costs are monitored and set in-house and because there is no distinction between insurer and provider, the final cost is much more easy to determine up-front. Also, the patient never has to wonder if a given procedure is covered by insurance; if the doctor's prescribe it, the procedure is covered.)

In my case, it gets worse. As an example, my doctor recently suggested I have a colonoscopy done and I started trying to look into how much this would cost. It turns out that there are several parties involved in a colonoscopy. There's the facility (provides the location for the procedure), the doctor (the one actually doing the procedure), an anesthesiologist (keeping the patient safely unaware during the unpleasantness) and if a biopsy of something in the colon needs to be done, a pathologist of some sort. In the case of my health care provider, my doctor would perform the operation and the clinic I went to had a colonoscopy suite. When I called asking about prices, my clinic was able to quote to price they would bill the insurance company with a high degree of certainty for those two parts of the bill. The anesthesiologist, though, was brought in from out-of-house and any one of several may be used during that procedure. Each anesthesiologist has a different cost, I had no control over which one was used the day of The complications for the pathologist was similar.

So what I am supposed to do as an empowered consumer in this consumer-driven health care? How am I supposed to compare prices when there is literally no define-able price tag? Do I go look for a larger clinic here in town that also has a colonoscopy suite and also staffs an anesthesiologist and a pathologist so that all costs could be known ahead of time? That wouldn't even solve the problem because then I would only have a price for that clinic and not knowing what I was getting for that price doesn't really help me. How can I compare prices when I can only get one place in town to even get me a quote, anyway?

My point, if it is not utterly obvious, is that consumer-driven health care is dead in the water until a price tag for procedures is readily available. There is no way it can work until I can call five colonoscopy providers in Wichita and get five prices. Even then, I face the difficulty of not knowing what I'm getting for my money? Do I go with the cheapest provider? Do I go with the provider I know best? How do I learn about each of these providers? Online reviews for doctors? Ask around?

You see, we aren't consumers when it comes to health care; we're patients. There may be some areas of health care that could eventually fit a market-based model. Colonoscopies are routine; it may be possible to create a health-care system where a consumer can effectively shop around for a colonoscopy using a traditional consumer mind-set. Maybe there will be online reviews for colonoscopy providers. Maybe a clinic in town will specialize in colonoscopies and find a way to provide a cheap and effective way of doing the procedure and they end up doing most of the colonoscopies in town. It could happen and I don't necessarily think it would be a bad thing. I also agree that one way to control health-care costs is to provide incentives for patients to get the least expensive, best treatment they need. Having skin in the game is not a bad thing at all.

But we're patients, not consumers. We're not customers and clinics are not merchants selling wares. At some point, health care is a highly personal and personalized/customized system. Whatever the reform brings, if it forgets this point we all loose. There is no other way to keep people healthy than by treating, handling, and caring for them on an individual basis, case-by-case. This is why we go to see doctors in person, often ending up waiting longer than we'd like in some lobby. We need that individualized care and market-based models, if permitted to control the entire system, do not afford the individual.

Scooter is sold!

Today I finally realized one goal I had for this summer: the sale of my scooter. In late March I replaced my scooter with a more traditional motorcycle but due to a lot of factors wasn't able to sell it until later in the summer, after we got back from Hawai'i. I put it up on Craigslist a while back and have had a fair number of inquiries, a few offering to buy at half the offering price, one or two that came by to looker, but no serious offers. Until today.

I was able to sell it for about what I hoped and I'll be able to get a refund on registration which is only a month or two old. As a bonus, we now have more space in our garage and my wife is very happy to be done with it.

Now that I'm done with it, I'm still can't say that I think it was the best choice for a first bike, especially given the fact that I was able to buy my current bike for less and I suspect it will last longer. The scooter did fill its role in providing cheap transportation for three years, though and in that regard, I can be satisfied. The funny thing is that now that I'm won't have to be commuting to Cessna this school year, I may not end up riding the motorcycle much since I'll be on bicycle much of the time. When that time comes, though, I suspect that I'll have an easier time selling the motorcycle than this scooter.

Officially Unemployed

Though I have not been working for the past 60 days at the request of my employer, August 7th was my last day of employment at Cessna Aircraft Company. Today I got three or four mailings from the Kansas Department of Labor outlining how employment benefits work and what I need to do to file a claim. I will be going to school this fall and it is not clear to me whether I will be eligible for benefits during that time. It seems kind of weird that, generally speaking, you can't earn unemployment benefits after being laid-off if you go back to school to re-train for another job (like I'm doing). One of the letters that I got made it very clear that I need to be seeking full-time work to receive benefits and I think from their perspective, schooling (even if for another job) keeps you from doing just that, at least if the school is during the day. We'll see how the state views my situation when I start back up with classes in a week.

In the meantime, Cessna may have hit bottom here in the past month or so. There are no new announced lay-offs at this time and engineers will be unaffected by the lay-offs on the 14th of this month. We'll see what happens when that day arrives but if no new announcements are made, then it will be the first time in about a year that the company will not be in a state of pending lay-offs. In fact, I've heard that in some engineering areas, it has become apparent that the company cut too deeply and that they are either trying to re-hire employees they laid off or are generally looking to fill some positions.

I don't know if my area is one of those that is trying to re-hire or not but I kind of doubt it. I certainly haven't been contacted to see if I would like to come back on. When the good times do return, my group will probably be in the same position it was for most of my time at Cessna: multiple open positions and having a hard time filling them. Cessna has difficulty hiring people for the job I had because the work is relatively specialized (compared to some of the other work for electrical engineers at the company) and it is hard for them to compete for talent.

Probably the biggest barrier to overcome in the labor market is one they have no control over: their location. Wichita, KS is not attractive to many graduates in electrical engineering when they could be working in a big city like Dallas or Chicago or more scenic places like California or Oregon. It would seem that to overcome this Cessna would want to offer something to entice people over; things like higher salaries, good benefits, etc. Unfortunately, in my experience, this doesn't seem to be the case. Many other companies offer higher salaries (though they may not be once cost-of-living is factored in), better benefits, and a better living location than Cessna can. In my move from Micron to Cessna, this was exactly my experience. I moved from wonderfully scenic Boise to the great, flat plains of Wichita, took a significant pay cut, ended up with three weeks less of vacation per year and higher health insurance costs. The only reason I accepted all these things was so that I could be with the woman who is now my wife; I think these material losses were worth it. There is no way I would have made this move, though, if it hadn't been for her.

I wish the best for Cessna, especially as my wife is still working there, but I fear they may have painted themselves into a corner. We'll see over the next year or so how things turn out for them.

Mail-Order Monday

Yesterday was a great day to get stuff in the mail.

First up: rear baskets for my bicycle. When bicycling to school, I've been pretty unhappy with having to lash my bag to my rear bicycle rack with a bungee cord. It usually held but I tended to knock the wiring off my rear light and spend a few minutes each day trying to get it all plugged back in correctly. Katie and I looked around and found some baskets that seemed like they would work both for me going to school and grocery shopping when need be. Behold the Wald 582 baskets installed on my blue Breezer:

The baskets can also fold up like so to allow for easy storage:

Installation was straight-forward but not simple, at least with my rear rack. Three clamps secured by screws were provided for each side. I had to re-bend the clamps as they were clearly designed for a rear rack with a thinner frame. It was also a bit tricky to figure out how to get the necessary screw-driver and pliers in position to screw those clamps down tight. I don't know if there is an easier way of doing things but it definitely seems like an area of improvement.

The second package that arrived was actually addressed to Katie but when she got home she informed me that it was actually for me: a new (to me) iPod! Mine died a month or two ago and though I have easily survived without it, I am glad to have a replacement. There is a lot I like about this new one but the most significant is that Apple can replace the battery when it wears out; Apple didn't provide this service for the older ones I used.

The only order we've placed that still hasn't come in is the tile for our backsplash. It was supposed to be in Friday, then Saturday, then Monday... We were very happy with our shopping experience at this hardware store (Star Lumber) but actually getting the items we've ordered has turned out to be, while not frustrating, not an experience that is endearing us to them. Is it better than Home Depot and Lowes? Probably. The company is locally owned which is another point in its favor. Now they just need to get their act together and make the delivery experience as high quality as the sales experience. You only really have one chance to make a good first impression and they may have blown it here.

Greetings from the Land of Digital TV

I'm guessing you've heard that over-the-air TV is digital now. They made the switch back in February until they decided to really make the switch in June. Based on their fancy models, surveys and hopeful predictions, coverage for local stations would increase not decrease. Except when it doesn't.

Take Wichita, for example. For reasons I don't understand, our CBS affiliate has its transmitter over 40 miles from Wichita. When the switch to digital happened, we lost that station (along with a number of others) and got spotty reception on the rest. And it isn't just us. Almost everybody I know (who doesn't have cable or satellite TV) was adversely affected by the switch to digital TV. And I'm not talking about the whole converter box thing, either. That was a whole other mess.

The solution to this problem is fairly simple: buy and install a better antenna. Though back in the old analog days indoor rabbit ears worked just fine, they no longer suffice. In fact, almost all of the antennas sold in stores won't work either. For Wichita, an old-fashioned, eight-foot long, ugly collection of thin metal rods known as a roof-top antenna is needed.

You see, though the switch to digital was also supposed to push all the stations up into the UHF band where small roof-top antennas would work, that didn't exactly happen.

In Wichita, for example, both CBS and PBS are still on VHF which require much larger antennas, those with elements measured in feet. Oh, and these larger antennas cost $50-$100 new not including the hardware to mount them.

So for the past few months we've been without TV, only really being able to receive three channels, only one of which was a major network station. Then I had the bright idea to check Craigslist and was able to find an antenna for $10. We bought a mast at the local hardware store and had it up in just a few hours. After we first bought our house I spent a lot of time up in the attic doing things like installing bathroom vents, a ceiling fan, vents, all in preparation for having some insulation blown into the attic. Thinking ahead, I also used this time to run some coax from a connecting plate I installed in the living room near our TV up through the attic and under the eaves of our roof where I coiled most of the cable. It sat there for nearly two years until now when it was finally connected to our antenna.

And it worked. We now get all the major stations clearly.

Boy, I sure do love Craigslist.