This is a sad day in our home–we’ve lost an old friend. Our fourteen-year-old Persian cat, Smokey, had to be put to sleep today.
About one year ago, he began to develop some weakness in his hind legs. He was evaluated and found to have some lesions in his spinal cord, which were originally thought to be a parasitic infection called toxoplasmosis. The diagnosis was never confirmed for certain, and several courses of antibiotics were of no avail.
Nonetheless he remained stable over the past year, and was comfortable, although he sashayed when he walked, and had increasing problems with incontinence. This morning he awoke quite ill, unable to eat and with total incontinence. The vet confirmed that he had a severe bladder infection and a paralyzed bladder. We all knew the time had come, and he was put to sleep at noon today.
Mopey–as we always called him–was a special cat in so many ways. Possessed of the laid-back disposition so common to Persian cats, he spent the better part of his life sleeping on his back, and virtually all of the remaining hours looking for food. His culinary tastes were eclectic, to say the least–he loved vegetables, especially green beans, chickpeas, and broccoli. His few athletic moments were in such pursuit, stretched to full length to get at the butter dish on the top cabinet shelf, or trying to open the cabinet latch to get at his cat food, just out of reach. Unlike many cats who self-regulate their eating, Mopey was positively Bacchanalian in his dining habits–watching him eat was like witnessing a Roman orgy. Thus engorged, he would stagger over the to furnace intake vent, where he would loudly meow, the echo amplifying his voice as he envisioned himself the great hunter on the plains of Serengeti, roaring his satisfaction at the kill to impress the pride. Then he would stagger off to sleep in some bizarre configuration, spine twisted, legs in the air.
His pursuit of food was legendary. There was the morning I left my lunch in a paper bag with cord handles–the type Starbucks uses when you buy coffee beans–as I went to brush my teeth. On return, I found him with his head in the bag–not the easy way, mind you, noooo!–but stuck through a handle. I yelled at him, and he took off–racing through the house, me chasing close behind, dragging the bag along with him, enleashed by its handles. Screaming at him to let go of my lunch as I chased him was to no avail, as his normally-ponderous frame leapt forward at a pace to make a cheetah proud. Only a torn handle saved my repast from his ravenous appetite.
Cats are meticulous in their cleanliness–but personal hygiene was not Mopey’s bag. Too much work. He had a spotless area on his chest–the only area he could reach with his tongue without straining; everywhere else was the domain of the great unwashed. His oddly-misaligned teeth reminded one of a scene from Deliverance–you half-expected the banjo to start pickin’ in the background. And then there was the nightly holler: locked away in the laundry room for the evening, he began howling in a rising crescendo, sounding somewhere between a brain-damaged infant and a demonic Dantean vision. Strangers were startled and typically headed for the doors at the sound, politely excusing themselves with stories of children to bed or an early rising which loomed. It was an unsettling sound, even after hearing it for years.
But we will hear it no more, and the loss brings tears to the eyes and a tightness to the throat. He was a friend, a companion, a member of the family, a source of many laughs and the particular aggravations which domestic animals seem uniquely able to inflict on their keepers. Our animals are our friends, God-given gifts to entertain us and foster our most affectionate and protective impulses. They are a blessing–but a blessing which departs all too quickly, their candles extinguished to remind us of our own mortality and the power of love and loss.
We love you, Mopey, and will miss you greatly. May your feline heaven bring you endless meals and long naps in the sun.
We certainly understand this kind of grief at our house. We’ve had to put down several dogs, in the past 6 or 7 years, and our first cat fed a coyote, last year. Our pets are all you said, and more–for which there are no words.
Thanks for sharing the video! After reading your (characteristically well-written) post, I needed the laughs!
I feel your loss Doc. We had Bear for over 16 years before internal tumors (some form of cancer) devoured her from the inside and turned her into a shell of her former, loveable self. Though I have seen most of the cat video clips before, it was still enjoyable and gave me cause to laugh out loud at one point. Thanks for sharing.
i am sorry for your loss – we just had our cat simon, who was diagnosed with a heart condition – put down in may. it was very difficult.
What started off in concept as a few posts on some of the craziness in the medical billing and reimbursement arena has been turning into something of an opus magnum on the subject–yet surprisingly, even at that has not even touched upon all of the complexity or contradictions inherent in this maze of regulations, bureaucracy, and inefficiency which we call our health care system. Such systems–complex, increasingly unworkable and counter-productive–do not arise by design, but rather by a sort of perverse evolution, growing a brier here and a bramble there, creeping tentacles and spiraling vines sprouting to address difficult problems, but increasingly choking the life out of their intended benefactors, strangling both those in need of help and those committed to providing it.
A regular question in comments throughout this series has been, “What, then, are your solutions?” Fair enough question–it is far too easy to dissect and depreciate the medical system we have at once inherited and created: it is, in soldiers’ parlance, a “target-rich environment.” A house built on sand cannot stand — and the mansion of American medicine, still rich in grand gables and ornate glass, is sagging from a rotting foundation, swaybacked from footings set on unsteady soil. The termites eroding its timbers are many, rooted in men’s souls as much as in Senate halls. We demand the finest care for ourselves, sparing no expense to others. We demand perfection of those capable only of imperfection. We hide behind our terror of death, unspoken yet unrelenting, seeking false hope in technology and technique against that dark looming fortress which stands unbending against our extravagant but ultimately fruitless endeavors. We pass law upon law and regulation upon regulation, engorging a byzantine monster so immense it can no longer ambulate–yet still we feed the beast, hoping against hope it may someday become the chrysalis which will carry us to a better world. It will not, and can not, for it has not the wherewithal to do that which is most needed: its own dismantling.
The complexity of our current system is both the cause and the result of its dysfunctionality. We have created an environment of perverse motivation and punitive legalism. Patients are shielded from the true costs of their decisions by insurance rendered nearly free to them by their employers or the government. Physicians, seeing their medical decisions challenged and checkmated by capricious clerks and aggressive algorithms, work the complex system to outmaneuver its clear intent to squeeze more work from them for less pay, while their patients are denied the care they have recommended. Insurers, pressured by employers to cut spiralling premiums, make cold calculations from afar which infuriate physicians and injure patients. Attorneys play Monday-morning quarterback, second-guessing complex decisions years after the fact, before gullible juries with Jerry Springer ethics, reaping personal windfalls far exceeding the benefits of their wounded plaintiffs. And government, having opened the financial floodgates of health care entitlements, now seeks to stem the rising waters by sandbagging the banks rather than repairing the dam.
Each player in this dysfunctional drama plays their part, driven in no small part by incentives which drive up costs and increase inefficiency and complexity. Health insurance, while necessary to avoid financial disaster in a health crisis, serves also to buffer patients from the cost implications of their health care decisions. Costly and sometimes unnecessary tests, drugs, or treatments are demanded because “insurance pays for them”–and because media and internet hype inflate their usefulness while minimizing their risks and costs. End-of-life care is extraordinarily expensive in part because patients and families refuse to accept the inevitability of death. Physicians play along, fearing lawsuits if they do not–while themselves refusing to recognize their own impotence against death and the futility of their own technological railings against the darkness. Government, desperately trying to reign in rampaging health care costs, responds by increasing regulation and complexity while decreasing reimbursements–greatly escalating pressure on physicians to manipulate the complex rules for their patient’s welfare and their own financial survival–and compounding the risk that by doing so they will run afoul of its legal and ethical clutches.
To restore a measure of sanity to this system we must return to core principles and truths, long since lost in the maze of regulations and rules we have allowed our health care system to become. In attempting to arrive at a better way to deliver health care, it may be best to start first with doesn’t work–and why:
♦ Managed care: Managed care works–or at least it used to–as long as you defined its success as the reduction of health care costs. Managed care uses several models. Most involve the use of a gatekeeper–a primary care provider who is the übermeister of who, when, and where you as a patient get care. Need a specialist? No go, unless Herr PfÃ¶rtner approves. Got to see that specialist (finally), who recommends you have an MRI or CT scan? Gotta get a piece of paper from the Gatemeister before you go. And in many arrangements, the primary care gatekeeper has strong financial incentives to Just Say No–or strong disincentives should he break down and say Yes. So for you to see that specialist, your family doctor has to: 1) do extra work, filling out and sending more paperwork and forms, and 2) lose money. Bet he or she finds some way to treat you without that visit or test. Even good, ethical doctors get beaten down by such a system.
Another variation on managed care makes the insurance carrier the gatekeeper, making decisions about what care you may have, under what conditions, by which doctors. If you like having your primary care physician giving a thumbs up or down on your tests and referrals, you’ll just love having this process run by insurance clerks, secret policies, and computer algorithms. Of course, the carriers constantly remind us they don’t practice medicine. They’re right, of course: no one would call making regular decisions about your access to referrals, tests, and medications purely for financial gain practicing medicine, no siree. Malpractice of medicine would be a better description.
Managed care saves money by restricting access to care–and hence it resulted, after its introduction, in a significant drop in health care costs. But patients got wise to the game, and became more demanding–and media stories about kids denied cancer treatment and women with breast cancer denied bone marrow transplants, made the managed care companies pariahs. And so, managed care was forced to become more flexible, allowing more specialty visits and looser restrictions on certain tests and procedures. The result? The savings melted away, and after several years of declining costs, premiums and costs for managed care are on the rise–at about the same rate as health care costs across the board.
♦ More regulations and harsher penalties for their violation: So here’s the plan: Medicare costing taxpayers tons of money, having covered all those eligible regardless of ability to afford care and opened the entitlement floodgates? Time to micromanage where all that money goes. Create highly complex rules about what services can be provided, under what circumstances, and then change them constantly based not on medical need or progress but simply to stem high cost areas. Make the rules so complex no one can understand them–then go after the bastards who are “cheating” the system by violating the rules. Well, fear works–up to a point. Most doctors will try to ignore the rules and simply code at lower service levels to minimize their risks and the time needed to master the maze; others will buckle down and try to master them. Then, when even this doesn’t work to stem costs, it’s time to lower reimbursement levels. Eventually, this brilliant plan–increasing the costs of providing care while paying less–will result in payments which fall below the costs of providing the care–and doctors either have to game the system to stay afloat, or stop seeing federally-insured patients. The end result: more “fraud”–and rapidly shrinking health care access for covered patients (the elderly, disabled and the poor). Brilliant theory, Einstein. Got any more like that?
♦ Paying for quality: This is one of the latest gimmicks the health care policy wonks have dreamed up, more commonly known as pay for performance. It’s based on the (highly disputable) notion that bad doctors are running up the cost of care by ordering unnecessary tests, recommending unneeded procedures and surgery, practicing costly medicine which lies outside the mainstream–renegades all, ransacking the health care treasury. The good guys in the white hats, on the other hand, walk carefully between the lines, following established standards of care, don’t cost the system nearly as much–and should be rewarded with better reimbursements.
Ten solid seconds of thought by anyone with an IQ over 50 should see problems with this idea. A superbly-trained physician saving the life of a desperately ill patient, on a ventilator in an ICU, will be spending a whole pile of money–whereas ol’ Doctor Feelgood, passing out antibiotics for your sniffles and pain pills like candy may not be spending many health care dollars at all. High quality — while not invariably more expensive–is often so. And what about those guidelines? Well, one problem is, by and large, they don’t exist — except in a few relatively straightforward areas of medicine. The reason, in no small part, is that quality medical care is a complex and constantly moving target: what was excellent care ten years ago may be marginal or even poor care today. Once you ossify guidelines into regulations governing payment, you run a great risk of freezing health care advancement. You will be paid for care meeting the guidelines–but not for better care, based on advances in medical knowledge and technology, which will tend to fall outside the guidelines. And any physician who thinks they’ll get paid more for following the guidelines needs a long session on Dr. Sanity’s couch: they will pay those physicians not meeting the guidelines a lot less, and the “good guys” better than them — but still less.
I could continue, but enough of bad ideas. More of the same is not the answer to our health care system. In my next post I hope to lay out a few ideas which are based, I believe, more solidly on reducing complexity and aligning our health care more solidly along the lines of simplicity, accountability, and transparency. Stay tuned, back soon.
With due regards, I take the liberty to contact you for an urgent business transaction which will be of immense benefit to all parties concerned. I am Mr Kingsley Chiugo, the Chairman of the contract Tenders Board of Nigeria National Petroleum Corporation, (NNPC).
My committee has the responsibility for the recommendation and award of contracts and supplies for the NNPC. In the course of our assignment, we did over-inflate the contracts for some supplies to the NNPC as a result of which the sum of USD $25.8m (Twenty five million, Eight Hundred Thousand United States Dollars only) is now outstanding. The original contractors who executed the jobs have since been fully paid off, leaving this outstanding sum. Unfortunately, we as civil servants are not allowed to own or operate a foreign account and it is also not possible for us to withdraw the money here locally.
We therefore need your kind assistance to transfer this outstanding sum of USD $25.8m to your account anywhere very safe. We shall compensate you with 25% of the funds for your assistance after the transfer. We the officials here shall have 65% while 10% will be set aside for any incidental expenses.
Oh, wait–you know about that one, and you’re not interested… OK, so here’s another–and this one’s for real: