Sunday, December 30, 2007

Death Be Not Proud (But It Is Cost-Effective)

Even from where I was, in the bed on the opposite side of the room, it was possible to see the gruesome surgical-steel staples bisecting Miguel's head. They ran like a set of corroded train-tracks from ear-to-ear, just beyond the hairline which framed the top of his face.

I'd spent three days trying to figure out exactly what had happened to the man who was my roommate at the Cornell Medical Center Neurosurgical ICU. I watched the nurses run him through the daily regimen of post-op skill tests -- if you consider the ability to open your eyes, follow a finger held in front of your face or correctly state your own name a "skill." Likewise I watched Miguel fail many of these tests over and over again: He could barely keep his right eye open, at one point leading the nurses to get creative and use a piece of surgical tape to secure his open eyelid to his forehead; he never spoke in anything above a barely-audible mumble; his movements were languid and sluggish, as if his bed were sitting at the bottom of an invisible tank of water.

It wasn't until the day that Miguel's children showed up -- when I was forced to sit silently on the other side of the room and watch a tragic bit of theater play out in front of me -- that I finally worked up the courage to ask the nurse just what kind of catastrophe had taken place inside his ruined brain. Watching Miguel interact with his little boy and girl, or at least attempt to, was utterly heartbreaking. He seemed to barely notice they were there -- hardly respond when his wife, a short Hispanic woman who spoke little English and looked like she'd spent the past month sleeping on broken glass, stroked the palm of his hand. The nurses had been kind enough to put a patch over Miguel's dead eye and a Yankees cap on his head in the hope of hiding the most obvious scars of the surgery from his children, but even someone who had never met this man until a few days ago could tell that he was a mere vapor trail of what he had once been. Whoever or whatever had shredded his mind, it had done so with all the subtlety of a sledgehammer. Where Miguel had once lived, there simply wasn't anyone home anymore.

I wasn't even looking at the nurse when she explained Miguel's situation to me; I couldn't pull my eyes away from the sad scene unfolding directly opposite my hospital bed. In hindsight, it was the juxtaposition -- the image of the shadow man across from me set to the weight of the nurse's words -- that left me feeling as if someone had suddenly sucked all the air out of the room.

Miguel, as it turned out, was recovering from surgery to remove a brain tumor -- the exact kind of tumor that had been removed from the same place in my head just three days earlier.

He and I were basically the same person.

And yet there we were: One of us reduced to the mental and motor skills of a child, the other able to watch him intently and try to analyze why.

There was a simple explanation actually as to why I couldn't recognize myself in the mirror of Miguel's one good eye so to speak -- why the layman would never guess that he and I had once shared the same diagnosis. It was because everything that happened after that point had apparently been drastically different, all of it culminating in two forms of surgery which, despite having the same goal, went about achieving it in ways that were light years apart. The operation that Miguel underwent may as well have been done by Theodoric of York compared to the hyper-advanced microsurgical resection that was performed on me by one of the country's most revered neurosurgeons.

Miguel was left with a massive scar; I had none.

Miguel had been in the hospital for well over a week, and would likely be there much longer; I would spend only five days in the ICU, then be disgharged.

Miguel likely had years of mental and physical therapy ahead of him; In spite of a few problematic after-effects and a steady diet of medication that my body and brain would require for some time to come, I'd be back on my feet and feeling relatively normal within weeks. Right now, if I didn't tell you I had undergone surgery just a year-and-a-half ago to remove a tumor the size of a pinball from my brain, you'd probably never guess that anything had happened to me.

Same medical crisis -- completely different outcomes.

And as I sat there just a couple of days after my surgery, staring at Miguel -- at the mess his brain had become and the hardships he was now facing -- I reached one conclusion that seemed to be as obvious as it was offensive.

There but for the grace of my insurance carrier go I.

I work for one of the largest media conglomorates in the world. In fact, throughout the length of my career, I've rarely been employed by a company that wasn't wealthy, multi-national and in a position to offer its full-time staff access to the best healthcare money can buy. Yet something about this fact has always rubbed me the wrong way.

"The best healthcare money can buy."

An ironically sickening reminder that in the early days of 21st century America, there's nothing that's above having a price tag slapped on it -- not even your life.

The parents of 17-year-old Nataline Sarkisyan understand this all too well. On Friday, they laid their daughter to rest in Glendale, California -- one week after her death, which closed a harrowing three-year fight with bone marrow cancer. Hundreds were on-hand for Nataline's memorial service, including a few celebrities who had taken up the cause of saving the young girl during her last days. Their appeals hadn't been directed at God or Mother Nature -- two entities who tend not to listen anyway -- but toward a much more powerful body when it comes to deciding whether a human being lives or dies these days: an HMO, specifically Cigna Corp.

Just before Thanksgiving, Nataline underwent a bone marrow transplant, complications from which caused her liver to fail. Cigna twice refused to authorize a liver transplant, despite a written appeal from her doctors (the company insisted the procedure was "experimental"); it was only after the case began to receive national attention and young Nataline Sarkisyan's picture began turning up in newspapers directly above captions calling her "the face of a broken healthcare system" that Cigna capitulated, reconsidering its death sentence. The company's chief medical officer issued the most public statement possible in an attempt to cast damage control as legitimate concern. He said that Cigna -- in a show of strength-through-mercy humorously reminiscent of Amon Goeth's decision to spare one life out of a hundred thousand in Schindler's List -- had decided to make an exception for Nataline "given our empathy for the family and the unique circumstances of this situation."

And the angry hordes picketing in front of their Philadelphia headquarters.

"We volunteered to pay for it out of our own pocket. We decided to bear the risk even though we had no obligation to," the good doctor went on to say.

It's a damn shame Al Gore already got that Nobel Peace Prize.

Unfortunately, in one of those unforseeable twists of fate, Cigna's big-hearted largesse came just moments too late. Nataline died a few hours after the decision was made to grant her the liver transplant that would've prolonged her life.

Well, as is repeated so often this time of year, it's the thought that counts.

Earlier this year, a lot of unnecessary controversy was generated by muckraking filmmaker Michael Moore's excellent indictment of the American healthcare system Sicko. I say unnecessary because, despite whatever feelings one may have about Moore or his politics, only the most ruthless capitalist would be unwilling to admit that the way we care for the sick in this country is almost irredeemably screwed up. We've given an entity as unscrupulous and indifferent as the free market control over the single most imperative decision in human existence -- literally, whether we live or die. Regardless of what Fox business-creature Neil Cavuto may have to say on the subject, healthcare and profit are two thoroughly antithetical concepts. Giving CEOs the authority to stand on the edge of the arena and issue a final thumbs-up or down while we lay incapacitated or dying is like charging a lion with protecting the Christians.

The most shocking and infuriating two minutes of Sicko, and the most effective, as Moore wisely allows the guilty parties to do all the talking for him, provide an irrefutable answer to the question of just how things got this way -- how a system that was once predicated on a commitment to good healthcare for all Americans became a cynical money-generating engine that's perfectly willing to let people suffer if it means turning a profit. Moore plays part of an audiotaped conversation between Richard Nixon and his flunkiesque Assistant for Domestic Affairs John Ehrlichman. The conversation is staggering insofar as the complete lack of shame on display (even from two men whose ignominy was already the stuff of legend). Ehrlichman advises Nixon on a plan to overhaul American healthcare that's being put forth by industrialist Edgar Kaiser -- the founder of Kaiser Permanente. Nixon says to Ehrlichman, in classic insufferable, who-gives-a-crap-about-the-little-people fashion, "You know I'm not keen on any of these damn medical programs." Erlichman reassures him by saying the magic words: "This is a private enterprise one. Edgar Kaiser is running his Permanente deal for profit. All incentives are toward less medical care, because the less care they give them the more money they make."

Nixon's reaction?

"Well that appeals to me."

Thus were sown the seeds of the modern HMO; the day after that conversation took place, on February 18th, 1971, Nixon proposed a new National Health Strategy based on managed care from private companies. It worked toward obliterating social medical programs -- because "Socialized Medicine" had long been dirty words, the product of anti-Soviet paranoia -- and masked greed under the guise of providing Americans with the best care money could buy, which was great as long as a patient had money to afford the best care.

Nataline Sarkisyan's family had health insurance, and maybe that's the most appalling aspect of her story. She never should have died because she was one of the "lucky ones"; the services were in place to save her life. Her parents fully expected that when their child got sick, there would be no questions, no arguments, no delays -- there would just be the care she needed. They lived in the most powerful, wealthy and technologically-advanced country in the world after all, and they both had good jobs and did their part to contribute to society. They were living the American dream. They were part of it.

Now they're left demanding answers -- wanting to know why, in this wealthy nation, there was even a question as to whether it was fiscally prudent to save the life of their daughter.

The fact is this: It's always cheaper to refuse care, and when making money is the motive, believing any consideration other than cost to be paramount isn't just naïve -- it'll get you killed. It's simply never a good idea to trust anyone who stands to profit.

The mammoth company for which I work made sure I had the best possible medical care when I needed it -- they paid for it. I never feared coming up with the money to see a doctor which meant that I discovered the tumor in my head before it grew to the size of a golf-ball which meant that it could still be removed through a procedure done by only three hospitals in the country.

It's because of all of this that I sit here today able to tell you about it.

I'm not sure Miguel could say the same.

And I doubt his wife and children believe that my life is worth more than his.


Anonymous said...

Well said, as always.

Ben Fleming said...

Sicko was one of my favourite movies of the year. I don't say "favourite" because it was entertaining, but more because it showed a powerful message and exposed the flaws in the american healthcare system. Being Canadian, the american healthcare system doesn't affect me much, but it still disgusts me to know the lengths that some people will go to for profit - even at the detriment of the patients they're supposed to be saving with that money.

It's terrible what happened to Miguel, and Nataline, and anyone who's ever been screwed over by the private healthcare practice.

I wish good luck to Miguel, I hope that however long it may take, he has a full recovery. I wish good luck to Nataline's family - you're in America! Sue the asses off of Cigna, they deserve it.

And, I sincerely hope, someone does something about the healthcare system. Michael Moore got it right: why does the world's strongest country do so little to care for their people?

lakelady said...

Until we can get pension funds and large institutions to divest from health insurance stocks I don't see any of the current mess undergoing significant change or improvement. How we get that to happen I have no clue.

And once again you have illustrated the predicament with shivering clarity. Thank you.

VOTAR said...

I don't say this overly often, mi amigo, but it's worth saying here: that was some of the best you've written.

Samantha said...

Thou I am an avid reader of your blog , this is the first time I am leaving you a comment.

Stories like these hit home too well with me. For 7 years with severe Crohn's Disease, I have been having my insurance company customer service reps tell me what medications and procedures that I can have. Not my doctor who has 30 years of experience, but a flow chart conducts my medical care.

I do everything in my power to not be sick and to stay in remission, why can't I have access to the newest and latest drugs that could possibly keep me in remission further, saving said insurance company, more money in the future.

The hours of phone calls and letters of appeals, all the time invested in trying to make my quality of life better. Our society does not euthinze their sick but when you deny proper medical treatment, isn't that exactly what you are doing?

Much love and continued support,


girl with curious hair said...

Beautifully written.

winged unicorn said...

many years ago, i was the plan coordinator at my place of employment. health insurance was skyrocking so they investigated a NEW concept, the HMO. back then, HMO's were not dissimilar to more liberal medical plans, the major drawback being you could only use their doctors. [yeah THAT long ago] this was considered a REAL BIG DEAL, geing limited on which doctors you could use. the idea that the plan, NOT the doctor would have final say in your care was beyond anyone's comprehension. now? it's all done by the number crunchers, the patients get screwed, the doctors get screwed, the poor people who work for the plans and get verbally abused all day by people like me get screwed. the only people NOT getting screwed are some of the bigwigs. canada looks better and better...

Lang said...

The story about Miguel was really well said... Made me appreciate my dad a little more... He's a neurosurgeon... Sometimes in my mind, he's just the dude snoring on the couch by the 5th inning of the Yankees game... I forget sometimes there's a reason he's so tired... he's kinda a miracle worker... (makes me feel really proud to write vos and cut dolphins highlights for a living)

In my very biased opinion... the health care system in our country blows because people who aren't doctors make medical decisions... Plain and simple... Between HMOs, malpractice, and drug companies... It's a racket... and the poor get fucked...

Thanks dude... Happy New Year

namron said...

Please kidnap all of the current candidates for POTUS and tatoo this post on their respective foreheads. Anethesia can be administered at your option.

Suzy said...

btw... that case i mentioned in my comment. part of the beauty of it was that it never got an ounce of press.

don't know if that made it into the text of the comment.

Anonymous said...

I heard this story and didn't realize cigna was the insurance company involved until reading your post. It doesn't surprise me though. I had Cigna when I was diagnosed with a terminal from of liver cancer. They tried to do anything possible to deny me coverage for treatments. For three years it was an ongoing battle. Not only was I undergoing chemo I had just had a liver resection and I was constantly having to call Cigna to find out why they weren't paying for and approving necessary treatments. I was paying hundreds of dollars a month to them plus deductibles and co-pays and now I'm being sent to collections over a bill they refuse to pay unless I go through some long appeal process. There is something to be said about having national health care because I have been on medicare for six months now and I have not had one single problem. Everything is paid for. Even a new cancer drug that costs upwards of $5000 cost me only five bucks. I hope Cigna pays for what they did to this family.

Juju said...

Working in the insurance industry (yikes)I see many problems with healthcare today. I hate it when I have to tell a client that is a small business who wants to provide the best for their employees that they are facing a 20% or more increase in their insurance costs. There are so many reasons why America's insurance is where it is today. And, unfortunately, a universal health care just doesn't seem to be an option. I see all the reports and the trends and the costs and it is scary. I went to a meeting by the PHC4 (Pennsylvania Health Care Cost Containment Council) and it was such an awakening. Their information on pay for performance and health care consumerism is honestly the best way to battle this problem. I've especially been thinking about it since my husband's recent health issues. Now, we just need it to work for us.

bionic bunny! said...

i try not to go into the details of how i went from "evil bunny" to "bionic bunny", but yes, it involved cigna. initally cigna HMO, who, in their infinite wisdom, decided that i did not need to see an orthopaedist, that i probably wasn't in as much pain as i said i was, AND refused to pay for the wheelchair rental and eventual purchase for the 2 years i was forced to use it. switching to regular cigna 80/20 type insurance, we discovered that i had been mis-diagnosed by the initial radiologist who read my MRI. i now have excellent surgeons, scoff at the wheelchair, and have access to pain meds when i need them. the story of course is much longer, but the fact that it was a switch from cigna HMO to regular cigna (and that we had the option to do so) is what made the difference in my life. i will be having my 4th surgery in as many years this spring and i no longer dread every movement i make.
i was following the poor girl's story closely as i'm also in SoCal, and i am enraged by the treatment she received. thank you for this post, and i also concur, beautifully written.

Anonymous said...

Straight through the gut...

I'm beginning to think the USA is not the strongest country in the world. It's the cheapest.

foolery said...

Miguel's story affected me deeply the first time I read it, when I first began reading your blog. It was even more powerful as you presented it here.

You have quite a gift, Chez.

Dusty said...

A tale of two surgeries eh? Damn if this story isn't duplicated around our fair country day after day after fucking day.

Sicko is a great movie..that doesn't deal with the uninsured's dilemma but the insured who get shafted ala Nataline's horror story that you so eloquently touch on.

As one of the 47+ million uninsured, I actually have a very fatalistic pov on the subject of getting horribly sick and not having insurance. Since I have 3 blown discs, it sure would be nice to have a pain-free day in my miserable existence..but that is not to in the cough..greatest..cough country in the industrial world.

But back to can happen to any of 'you' insured folks you matter how much money you make, or how great your insurance is..your carrier can turn on you in a NY minute.

Now, Blue Cross here in Cali has had the audacity to send a letter to their network of physicians demanding they turn in their patients that have 'pre existing' conditions..the nerve of those mutha fuckas. God bless the Corporatocracy! It will outlive us all...

neal said...

This article is vapid. You could imagine all the same arguments with socialized health care because there simply isn't enough money to keep everyone alive.

Boiling down this post, it's main point is "We've given an entity as unscrupulous and indifferent as the free market control over the single most imperative decision in human existence -- literally, whether we live or die."

OK, you don't like the free market, nor realize it is incredibly efficient. Better to have a massive indifferent government bureaucracy deciding.

Love the John Donne reference, though.

Chez said...

And I get to sleep well tonight knowing that something I've done has pleased your refined sensibilities.

Anonymous said...

I have to agree at least partially with Neal here. If the government was in charge do you really think everyone would get the super expensive treatment?

I think a lot of the people complaining about healthcare in the USA haven't experienced it elsewhere. Go live in England for a while. Experience the long waits before having a procedure done.

Talk to an American doctor who lived in England and ask for his stories about fixing the work done by the NHS. Ask about his policy at the time in case of him getting in an auto accident: that of not being taken to a British hospital no matter how much farther away an American military hospital might be.

To the poster gushing about medicare: medicare pays a small percentage of charged costs. Not enough to pay for rent, malpractice insurance, salaries for the xray tech, etc etc etc. Great for you, until the doctor decides not to accept medicare as he can't stay in business.

Medical utopia IMHO can't be done without massive taxes, and an overhaul of the malpractice situation. Doctors can't be expected to work for pennies with the threat of million dollar judgements hanging over their heads.

I suppose of massive taxes are acceptable, and if people are willing to put up with long waits for procedures and suboptimal care in all situations (unless they can pay someone - ooh how different from now) some national health care might work.

Anonymous said...

OK, I have lived in Germany, England and Italy before coming to the US. I always had very good healthcare, very short waits (no waits at all in Germany and Scotland). I have never been killed by taxes (lots of people cannot say the same about health insurance companies here). I am looking forward to going back.

shedcatwonders said...

Anon @ 2:07

I live in the UK and work for the NHS and take offence at your comments. The NHS isn't perfect but it's a damn site better than the excuse for a healthcare system in the USA, supposedly the greatest nation on Earth.

I've seen plenty of people die but I have never, ever helplessly watched someone die because they don't have money, or had to turf them out of a hospital because their insurance doesn't cover them. It's barbaric, it's backwards and it's wrong and your fear of "socialised medicine" is laughable. Get a ladder, and get over it.