The Mad Scientist and his Tubes

Sorry about last Tuesday. I am a psychiatric nurse and last Tuesday the world was working up to the full moon. I was busy.

So the next part of this extraordinarily bizarre bill is Subtitle B on Medicare with the following subsections.


Subtitle B--Medicare
Sec. 1101. Closing the medicare prescription drug “donut hole”.
Sec. 1102. Medicare Advantage payments.
Sec. 1103. Savings from limits on MA plan administrative costs.
Sec. 1104. Disproportionate share hospital (DSH) payments.
Sec. 1105. Market basket updates.
Sec. 1106. Physician ownership-referral.
Sec. 1107. Payment for imaging services.

The donut hole is the poster child for why the government can not manage health care because they are a money based system and health care is a love based system. In case you are not aware, Medicare has a "gap" in its medication plans. At a certain level no meds are covered until the total cost goes up to an astronomical expense and then all meds are covered. But a person either needs to be below the gap or above the gap. Middle sitters are out of luck. There is no doubt that this "gap" was designed to stop unnecessary dependence on medication for every possible complaint. Though I cannot prove it, I suspect someone took actuarial tables and looked at the costs of true long term illness and needed dependence and placed the upper level resumption of benefits to make sure that these kinds of things are covered, but then pushed open this "gap" so that people could make choices about medication based on their own ability to pay over a certain amount, and not just lean on government money. But such rational, objective cut offs never work in real life when people and their lives are involved, so of course the donut hole is getting chopped up at a greater expense to the government. Now mind you, I'm not supporting the radical initial attempt to ruthlessly manage medicine coverage, but I know that whatever its original purpose, those people and the people who understood it, are GONE. All we have left is people who look at it now in horror and wonder how such ruthless decisions could have been made and then tear into it to save the day. No one even goes back to the understanding that before the "ruthless" plan, no body got anything. O.K. Maybe it wasn't quite "nothing." but the truth is, no law passes without a benefit to someone, and then each increased benefit (for the purpose of correcting those left out) simply ignores the original reality that nothing could have been expected before, so what is available now may not be quite as harsh as people say.

And there is the perfect example of Test Tube thinking. Since the "donut hole" is clearly such an unfair way to limit coverage, legislators don't go back to the original ground and say "Wait, maybe we should review and figure out whether Medicare D is functional." Instead they take this world where the donut hole is unfair and they put it in a nice sheltered think tank (test tube) to figure out how to solve that. Section 1101 of this Act eliminates that "bad, bad, unfair" donut hole, but does it address how money will be provided now that there is no stop gap for the spending? I don't think so. This is test tube thinking.

And as I read the other sections in this Medicare portion I began to think of the great complex of tubes that Dr. Frankenstein or any mad scientist of the horror movie age always had on hand. The intricacies could be thrilling with vials of liquid popping up here and there connected with tubes that bent and dipped and occasionally had a long rectangular flask connected along the way and at another point had an orb with tubes entering and exiting in opposite angles to each other.
This bill reads like such a concoction. It has five sentences of adjustment to myriads of former bills and laws that are supposed to make each more health care cost conscious. It won't work folks. The right hand not understanding the left is why the current situation is broken. Having the government substitute their own moments of test tube thinking into a new way of managing is just more of the same: different mistake maker.

Medicare was a crutch program that was supposed to give a little more money (by keeping the elderly from becoming indigents) to the health care system that was set up to care for indigents. Now that the health care organizations are no longer set up to care for indigents primarily but are set up to make money primarily, the original premise doesn't work and any adjustments based on the premise are by definition faulty. I learned that my first year of college: solutions based on a faulty premise are necessarily faulty. We are being administratively beat to a pulp because no one remembers the basis of resolution which begins by making sure you have a functional premise.

When people were outraged by the donut hole, they never should have removed it. They should have looked at why it was there, and made such major changes to Medicare that the financial protection of the donut hole would not be necessary. But Congress does not understand Medicare. That department is so large and complicated it probably doesn't even understand itself.

Healing is personal, but the payment method is impersonal. The two will never match, and that mismatch always works better when it is directly applied in the local and private setting, and not strung up on regulations that can not be upheld every time someone is angered with perceived unfairness.