High-tech

When we originally - that would be last November - discussed this surgery with Dr. Smith, we found him to be a vigorous advocate of a computer-assisted laser-driven positioning device, whereby the new implant could be set in exactly straight to within a millimeter, level with the ground in all dimensions. This is best, I was assured, and that sounds sensible to me.

I had assumed that all the top-notch people were now doing it this way (as opposed to the previous system of jigs plus instinct), but apparently not. My physical therapist was puzzled by the two little holes in my thigh and also on my lower leg, and asked if they were drains or something. No, I said, that's where they mounted the lasers to signal this positioning system. She sees a lot of knee replacement folks, and she'd never seen this before.

I did a Google search, and this thing has been around at least since 1995, though most of the articles on it are in expensive medical journals where you can't get at them.

My surgeon is in love with this thing. He claims it's revitalized his entire practice, and this enthusiasm explains that big grin in the OR. I can see that. Not only does he get to play with a lot of very jazzy equipment, he now has the tools to get a much better result more reliably.

God alone knows, of course, what the equipment costs. [Note: today (1/29) I found out what it costs. The software comes in at $400,000; they "give" you the hardware with the software. There must be some reason for this odd pricing; I'm suspecting some tax reason. The software, like all software, is subject to update, for another fee, of course. Not really as much money as I thought.] Somehow someone or other talked Mills Peninsula Hospital, a tired old hospital (more on this later), into springing for this thing. I am told that knee replacements are big money-makers for hospitals, at least compared to the uncompensated care they're required to provide to a lot of people (anything's a profit center compared to that!), and since patients like me have a lot of alternatives about where to go for this surgery, and indeed, whether to have it at all (it's "elective" surgery, your other choice being to be in constant pain I guess), having the Snazziest Equipment is doubtless intended to be a selling point.

I'm not qualified to evaluate any of this. That's what I hired the surgeon for. If he says it's better, and if the proposal doesn't offend common sense, then I go with that.

Again, cost. Are they going to hit me or Blue Cross or both of us up for being yet again on the cutting edge? Well, yeh. Of course. The only question is, where will this expense be hidden in the bill, and what would the alternative cost?

And what am I willing to pay for a shot at a better result? Name your figure, people. Anything even remotely within reason.

The cutting edge, a bleeding tale

Let's talk about medical advances.

One of the risks of total knee replacement surgery is deep vein thrombosis ("DVT") afterwards, in which a blood clot forms in the calf and then migrates to the lungs or the heart or the brain - there's no real good place to have one.

To prevent this event patients are routinely given anticoagulants after surgery. I take it that these medications thin the blood, make it less likely to clot and therefore less likely to form a DVT. I have no idea how they work.

Lovenox is such a drug, and is taken by self-administered injection. They showed me how to do this in the hospital. All the muss and fuss have been taken out of this procedure. One is given an already-loaded syringe with a thin needle about an inch long. After swabbing abdominal skin with alcohol (they give you the swabs too, in little packets) you pinch up some skin and just jab the thing straight in. (No, surprisingly, it doesn't hurt.) Push the plunger all the way in, pull the thing out, push a little lever which shoots a plastic protector around the needle, drop the whole thing in a sharps disposal container. Once a day for ten days after coming home.

The list price is $200 per shot, for a total of $2,000 for a course of treatment. This is clearly off the wall, and Blue Cross of course has no time for this nonsense. There is, however, a $200 co-pay, again for the whole ten days.

So I called the doctor to ask if this trip is really necessary, and he said that there are lots of anticoagulants, notably coumadin aka warfarin aka rat poison. This stuff has been around since the early part of the last century, and is cheap as dirt.

So why are we using this pricey stuff? Because getting the dosage right for coumadin is a hassle. It requires several blood tests, and that they fiddle with it a lot. He got two sentences into the explanation and already we'd used up $200 of my attention. I have no idea whether the drug itself in Lovenox is better at its job than coumadin, but I can tell you that the dosage and delivery systems are far superior. The last thing I wanted to do at that point was tour all over the landscape having blood drawn.

So, if I were Empress for a Year and running the newly fixed American health care system, would I opt for coumadin or Lovenox in this situation? In the coumadin scenario, remember, although the drug iself is cheap, that's not the end of the story, it takes up the time of professionals to draw the blood and fiddle with the dosage, and that costs money too, of course. Would I require patients like myself to pay extra for convenience, or would I just say, "The heck with it, give everyone the little syringes and move on"?

As we dig a little deeper here, why is Lovenox so expensive? Is it made of ground up grass seeds from an itty-bitty grass that grows only in Siberia or something? Of course not. It's expensive because the drug company that holds the patent is sticking us up (or, legitimately trying to recover development costs, your choice) in preparation for the day when Lovenox goes out of patent and can be manufactured in generic, at which point the price will drop.

Does this make the drug company a bad guy? Not necessarily. Whoever they are, they had to do a lot of development and testing on this stuff, along with a lot of other stray ideas that didn't come to anything. They put this money in because they hoped to make a profit if Lovenox panned out. If we expect them to continue to do all this R&D we have to reward them with some profits when things work.

In the big picture, Lovenox is an improvement. Effective and easy of dosage, no muss no fuss. I don't much like sticking myself with needles, but I'm getting over it. Is it essential? Probably not, we could lump along with warfarin perfectly well, but isn't improvement in care desirable? I think so.

I don't know the answers to any of the questions I've proposed. And if you'll excuse me now, I have to go stick myself with a needle.

One way to get well

There's physical healing, but you know, my knee didn't just walk into the doctor's office by itself. Emotional and psychological healing are important too.

So since all our cars are more or less junkers and/or hard to get into or out of, we rented a pretty snazzy late model sedan for the weekend, at my husband's suggestion, and took a long drive today. To Pescadero, out on the coast.

Now back in the day, 35 years ago give or take, we used to hang around Pescadero a fair amount, and especially at Duarte's, the town bar. (It isn't much of a town, but it's a heck of a good bar.) Duarte's has been there since the late nineteenth century, pretty much in the form it was in in 1975. Of course I assumed it would have been changed all out of recognition since then.

Pleasant surprise time! The place might as well have been put in a jar, along with the whole rest of the tiny settlement. The same family is still running Duarte's, courtesy of Cindy Duarte, fourth generation, and they still serve artichoke omlets!! Of which I had one, and a couple glasses of wine, and felt pretty good.

Now I hobbled all over on crutches, and didn't keep my leg elevated, and drank wine when I probably shouldn't, given the pain meds.

But you know what? My optimism, which had kind of flagged, was given a great big revival by this (actually quite short) journey.

The Surgery

Today is January 24, that would be nine days after surgery (January 15).

I haven't been avoiding blogging about this experience, exactly, but I haven't exactly been rushing up to the computer either, as some of you have observed to me.

That's not because we got a bad outcome. The surgery was a brilliant success according to Dr. Smith, the surgeon, who came into my room the day after, wreathed in smiles. "I don't have bad days, just good days," he announced, thus proving that he is well endowed with the unbelievable arrogance proper to surgeons, "but this wasn't a good day, this was a Better Day." Now I don't think he would necessarily have announced to me that he'd done a bad job if that had been the case, but he's a pretty understated kind of guy, and he wouldn't have rushed in to crow at me unless there was good reason for it.

I haven't avoided blogging, then, because I'm disappointed in the outcome, just because those five days - surgery and the hospital stay - are not days in my life that I'm anxious to dwell on, let alone re-live. But what do you expect, this was major surgery.

I was in very serious pain a lot of the time, in spite of the self-directed morphine pump. At first, I could hardly move. I didn't have a bath or wash my hair all that time, which meant that my hair felt as though someone had dipped it in glue.

If anyone here ever has this surgery, just know that you've signed up for one - hopefully only one - very bad day. That would be not the day of surgery, since the anesthetic takes a while to wear off (I did have a general it turns out, their idea, I guess I misunderstood). That would be the first day afterwards. They want you to get up and walk that day, too, with a walker. I could just barely make it to the door of the room, and I thought I was going to faint.

There are just a few memories I want to keep.

• the look on the surgeon's face when they took me into the OR. There were three giant electronic consoles with lights and colors, looking like the command deck of the Starship Enterprise - more on this later - and next to them was Smith, grinning from ear to ear like a pig in mud. I saw that there was nothing on earth he'd rather have been doing that morning than this surgery. I like a man who enjoys his job. What a positive message, too, just before they knock you out. I don't think he did it for my benefit, by the way, I don't think he's even aware of it. This kind of enthusiasm, you can't fake it.
  
• everyone who came to visit. My husband, steady and true. My clients, who brought the tulips. (This is clearly above and beyond the call.) My oldest son. My foster-son the doctor, who sailed in masterfully and reviewed the chart. So much emotional support.
• my roommate. Semi-private room, curtained, and the poor woman was really sick, much sicker than I was, but she had the zip to take care of me, harass the staff on my behalf when I couldn't muster the energy, say the encouraging word. If you'd asked me ahead of time I'd have said I'd prefer a private room, but if the choice had been, a private room or a room with Katie, it's a room with Katie, hands down.
• Many - not all - of the staff members. Particularly the folks lower down on the staff level, below RN. There will be some stories on this in posts to come.
  
• Last but not least, getting the heck out of there. Hospitals, like a number of other institutions (the Catholic Church leaps to mind, but this problem is hardly rare) have lost track of their original purpose. In the hospital's case, this would be, helping people to get well. But the way they operate the place, a lot of time they're working in the other direction.

Whew. So now that's over, this post. Now I feel free to make a bunch of others on more specific topics.

To see or not to see

I won't be given general anesthesia, apparently. Just a spinal. Of course everyone avoids general anesthesia whenever possible because of the risks.

So I asked the surgeon, "Just how awake will I be?" He said, "It's up to you. Some people want to watch; some don't."

My first reaction was, I don't want to watch and listen while someone cuts my leg off, put me out, but upon further reflection I've reconsidered. I'm sure it's fascinating, and if I were given enough of something so I didn't experience any anxiety it might be better to be present and to see. We are marvelously made, after all. And I'm sure the new knee is a marvel of a different sort.

Also, thinking about being present gives me the illusion of control.

It should make a great story to tell at parties too.

Am I part of the problem?

See the following article in the Washington Post (you may have to "sign in" to view it, but it's free) http://www.washingtonpost.com/wp-dyn/content/article/2009/01/09/AR2009010902296.html?hpid%3Dopinionsbox1&sub=AR

This guy is arguing that health care costs in the United States as well as elsewhere will continue to rise because of medical advances. This is undoubtedly true, but I'm not sure it's a bad thing. (What spending should have a higher priority than health? War?) He doesn't directly address the differential among the industrialized countries on this matter, however. Why is it that Germans, for example, are getting very good health care for half of what we spend?

Click around. In a related article it is stated that knee replacements are 90% more common in the US (per capita) than in other industrialized nations. I have no idea whether this is true or not, and I'm not even sure it's a bad thing. This surgery is freely available in the UK, to my own certain knowledge, with no more "gatekeeping" than a few months' waiting period, so if the English and the Scots and the Welsh are not having knees replaced at as great a rate as Americans are I'm not sure why not. Maybe more people in the UK should avail themselves of this option.

At any rate, I'm not proposing to limp around for the common good. This guy also seems to think that this surgery is free to me, but I don't know what universe he's inhabiting. We have very good health insurance, and this surgery is still going to cost us plenty out of pocket.

But...what is money for? I'll economize somewhere else.

Statistics

The United States ranks 45th in life expectancy among the nations of the world; in other words, 44 nations are doing better than we are, including, in additional to the usual suspects (that is, almost every nation in the industrialized world), such places as Puerto Rico, Bosnia and Jordan. For these numbers, see http://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy and sources there cited.

We rank either 33rd or 35th, depending on who you believe, on infant mortality, again meaning that 32 (34) nations are doing better than we are, including Cuba and Slovenia. This information is collected at http://en.wikipedia.org/wiki/List_of_countries_by_infant_mortality_rate.

Of course if you exclude people of color and/or poor people, the United States looks much better, but all that proves is that the relatively rich get very good health care here. We all knew that. If American doctors are not the world's best, they certainly rank right up there, and they are at least as capable of delivering cutting-edge high quality care as anyone else, and better than most. (In fact, wealthy people from other nations, including the nations who are beating us on the numbers, sometimes come here for care which they think is better than the care they can get at home.) Rather than being an answer to the statistics quoted here, the wide disparity in quality of care is a nice statement of the problem.

Remember, we are spending upwards of $6,000 a year for every man, woman and child in this country on health care, far more than is spent by any of the numerous countries who are beating us hollow in the statistics. Does it occur to anyone to ask why we are not getting what we are paying for?

What Does it Cost?

According to The Organisation for Economic Co-operation and Development (OECD) in 2004 (the most recent year available) the United States spent $6,102 per person for medical care. This includes both public and private spending.

This number is by far the highest in the world. Our next competitor, Luxembourg, spent $5,089; the next runner-up, Switzerland, spent $4,077 per person. France spent $3,159; the Netherlands, $3,041. You will guess, and accurately, that the statistical results of all this spending (in the form of infant mortality figures, longevity and so forth) do not put the United States in the forefront of medical outcomes. To say the least. That will be for another post.

For now it is probably adequate to observe that the Netherlands, which spends half of what we spend, per person, has far better health statistics than we do. It will not do to observe that the Netherlands is a lot smaller than the United States; these are per capita expenditures.

Perhaps European countries are going to need to spend more; that is under discussion. But before we authorize spending even more money here, I for one would like to know where all this money is going currently, especially if, as it seems, it is not producing superior results.

Reference: http://ocde.p4.siteinternet.com/publications/doifiles/012006061T02.xls
This is a spreadsheet.

Profit motive

I have alluded to the fact that the desire to make money motivates a lot of American health care.

I want to clarify. I don't think this is necessarily a bad thing, though it obviously has some less-than-optimal consequences.

Back to the medical history form - the one I turned in yesterday. It wanted to know if I've ever lived with anyone who had tuberculosis, and the answer is Yes. My father was diagnosed with tuberculosis in 1949, when I was 4 years old.

In 1949 this was a common disease. It had been around for uncounted centuries, and being highly contagious, accounted for hundreds of thousands if not millions of premature deaths. In 1949 there was essentially nothing to be done about tuberculosis. My father, like all such patients, was sent to a rest facility, given supportive care, and everyone just hoped that his body would overcome the infection (which it did). Now, of course, except for the new drug-resistant varieties, TB is cured by a course of medication, no muss, no fuss.

That medication was developed by a corporation which hoped to make a profit on it (and, I assume, did so). That there are other ways to develop medical innovations does not change the fact that this one (along with most of the "miracle drugs" we now have) was developed for profit. New surgical techniques and appliances, including the new knee I will receive next week, are developed here with the same motivation. And so on.

Like all other motivators, including government-sponsored research, profit has a good side and a bad side. (Those who think that such things will be done by purely disinterested beings for purely philanthropic reasons are, in my opinion, deluded.) Furthermore, doctors deserve to be paid, and they deserve to be paid well. Hospitals, nurses, the whole myriad of people and organizations involved in our health, the same. (I will observe here that while doctors and hospitals are doing all right, they are not getting rich off the current system.) I certainly don't mean to suggest the contrary, or to say that the profit motive is a bad motive, still less that it is the worst possible motive.

However, the downside of the profit motivation can result in what we may think of as "padding the bill." This factor seems operative in my case, though not to an excessive degree. But it remains true that there is little reason for me to have three pre-operative doctor appointments. Consolidation and data-sharing would save a lot of time and effort here.

Because of course the only professional who is involved in all three appointments isn't getting paid. That would be me.

Details, details

Yesterday I had a pre-operation appointment with Dr. Smith, the surgeon. I'm not certain what the purpose of this meeting was. Smith and I had already discussed this surgery in detail.

At this time I handed in a two-page "medical history" form. This form is unique to this doctor, but is roughly identical in content to the medical history forms I will give the primary care physician today and the anesthesiologist on Monday. None of these forms is in a condition to be scanned into a computer.

The surgeon's staff person took my blood pressure and verified that I have a pulse, and the surgeon reviewed the X-rays and glanced at the medical history form.

It strikes me that we are duplicating a lot of effort here. One medical history, preferably the lengthy and detailed one in my chart at my primary care doctor's office, should be sufficient, especially since so far as I can tell the three forms I am handing in now will not be compared with each other, or read carefully even. Furthermore, the anesthesiologist is a highly paid, highly qualified, board-certified specialist who surely has better things to do with his/her time than "meet with" someone whom he/she intends to anesthetize. What would anyone hope to learn from this meeting?

The real reason is probably the profit motive which runs all through this system. The anesthesiologist will bill me separately. This meeting may form some of the "justification" for this separate bill. I imagine that I am supposed to form some kind of bond with this person.

In other news, the primary care physician's office sent me a form requiring me to figure out whether or not the examination today is covered by my insurance. (Wouldn't it be the business of the doctor's office and/or the insurance company to figure this out?) In the course of exploring this I found out that the insurance company could not find the pre-authorization for this surgery in my file. I called the surgeon, talked to the ever-competent administrator in that office, Nevada (not her real name), got the authorization number, and called Blue Cross back. They had coded the date of surgery improperly.

I probably just saved us a lot of hassle later, since there is a "penalty" for not pre-authorizing surgery.

The Backstory

I am a 63 year old woman and I have painful arthritic damage in my right knee. I have been consulting with orthopaedists, I have had synthetic cartilage injections, arthroscopic surgery and other treatments, and I have come to realize that this condition is not going to heal by itself or with conservative treatment. On January 15 I am having total knee replacement surgery.

The knee is a hinge. A hinge is a point at which direction may change, in this case, the direction of force, the direction of bone structure.

Barack Obama will be inaugurated as President of the United States on January 20, 2009, just a few days after my surgery. This event too is a hinge, a place where directions may change.

I have an adult daughter who has lived in Europe with her family for over fifteen years. I spend a lot of time with her, everything considered, and one of the many things I have learned is that the American health care system as in effect right now, on January 9, 2009, is broken. And that it can be made better, since the health care systems of all other industrialized countries work better than ours, by any measure you chose to apply.

This blog will be both a personal story for the benefit of my family and friends, and a chronicle of my personal journey through our existing health care system, the latter with the hope that we may be able to use this time to change direction.

I am relatively wealthy and I have good medical insurance. My surgery will be performed by a highly qualified specialist at a very highly-ranked hospital in the San Francisco Bay Area. This will be a journey, then, through the top layer of a highly stratified health care system. I will not use the real names of my doctor, the hospital, or any of the people I meet. Mistakes will be made in the course of my treatment, because nothing human is perfect, but it is not my intention to identify individuals, either to praise them or to blame them. My interests here are both more narrow (in that I want to regain my mobility) and more broad (in that I am interested in the reform of our entire system of health care delivery).

Comments from readers are welcome.