Of Parisian Marathons, and Many Other Things

I just spent a week in Paris. It may have been the best week of my life, and I've had some pretty good weeks.

It all started innocently enough. I was looking for a spring marathon, and I thought, why not Paris? Why not indeed.

Things snowballed from there. My son's girlfriend is Parisian, and shortly after I mentioned the marathon I found myself on a team running for a wonderful French charity, Autour des Williams.

So many parts of this trip were like a movie that I hardly know where to begin. Walking from the Arc de Triomphe over to the Rue Balzac before the start of the marathon. Saying bonjour to the policewoman watching quietly from a doorway, then turning a corner and walking into a crowd of people wearing the same jersey I was wearing. They were from a variety of European countries - I was the only American. They took pity on my French, and we mainly spoke English.

The connections came at odd angles, and were forceful. Williams syndrome involves being born without approximately 26 genes. As I read online about the characteristic elfin features and the "cocktail party" personality, I remembered being in College Park, Maryland, a few weeks earlier. We were eating supper in a parish house during the walk from Philadelphia to Washington, D.C. This was part of my work for healthcare reform, and there, I understood in retrospect, I had probably met someone with Williams syndrome. He was very nice. Just a little off, and without the trip to Paris I'd never have had a clue as to why.

Christophe, at the morning meeting (we took a group photo), called it serendipity.

The team totaled 71. I, of course, was one of the slowest, but who cares? Not me. The weather was nearly perfect - sunny, in the 50s, and I had a great run. At kilometer 37.2 (out of 42.2) there was a cheering section for Autour des Williams. My family had gotten a bit turned around, and almost didn't make it. But then I heard, "Bill, Bill!" and running up behind me was Marie, my son's girlfriend, and then Ben, my son. You have to be 23 miles into a marathon, on a beautiful day, to know what that meant.

After the marathon, there was a lovely party in an apartment about a block from President Sarkozy's house. As Marie's parents were walking with us to the bus home, two of the police officers guarding the palace - one man, one woman - inquired about the medal on my neck, and with help from Marie's mother I managed to stammer through a very pleasant conversation. It was a bonding moment.

Did I mention that we ate very well? Marie's mother organized my personal pasta dinner the night before the marathon. And a few days later we had a superb dinner at a restaurant near their apartment, called Le Bouclard. Meanwhile, Ben and Marie steered us to several restaurants we'd never have found on our own.

Lois and I stayed at the apartment of Marie's sister, Loulou, and most mornings my daughter, Alicia, and her boyfriend, Alex, would come over for breakfast. They were staying at Marie's apartment. Did I mention that Parisian hospitality is astounding?

To round things out, yes, we saw the sights. The Venus de Milo at the Louvre, the Musée d'Orsay, the Rodin Museum, Napoleon's tomb at Les Invalides. And simpler, less expected, things. Running along the Seine in the marathon, and looking left, and seeing the Eiffel Tower. It was so large I felt I could reach out my left elbow and touch it.

Or walking with Alex in the Jardin du Luxembourg. We had momentarily lost Alicia and Lois, and I suggested that he look for two brunette women wearing black jackets and sunglasses. And, he said, "Bill, you've just described half the people in this park."

How to end? Oh yes, the volcano in Iceland. We left Thursday morning, and didn't even know it had happened. Alicia and Alex left that evening. There's a rumor they were on the last flight out before Paris - Charles de Gaulle shut down. I don't know about that, but I do know that Ben was supposed to fly out Sunday, and instead wound up running his own marathon of sorts, finally getting home on Thursday, four days later than he intended.

Oh well. He was in Paris. Not a bad place to be stranded, really.

Follow the Yellow Brick Road

One day a few weeks ago, I was walking on the shoulder of a commercial highway in Delaware. The weather was good, the footing less so. You may recall the snow and the ice. And, of course, snow and ice melt in the sun.

I was walking with a group of friends, some old, some new. We were walking the 135 miles from Philadelphia to Washington, D.C., to ask Congress to please – finally – pass a health-care reform bill.

It was a good group, with four to eight people walking at any given time. (I had to miss Day 1 because of a prior commitment.) As we walked along, we talked a lot, and we chanted some. “What do we want? Health care!” That sort of thing. But there were also quiet times, when I was left alone with my blisters and my thoughts as we walked down the road.

I found myself thinking of the Wizard of Oz. Or perhaps fantasizing would be a better word. As the cars whizzed past us, I pictured us walking on the Yellow Brick Road, on our way to Oz, where we’d meet the Wizard and get things fixed up. We had several Dorothies. I thought of myself as the Tin Man – quite stiff, but nothing that couldn’t be fixed with an oil can. We needed a Toto dog in a basket. We talked about that a lot, but never got one.

We did better in the Wizard department. On Day 8 of our walk, we got to Washington, where we were joined by hundreds of supporters for the last leg, from Union Station to a rally in the Dirksen Senate Office Building.

At the rally we were joined by six U.S. Senators – or Wizards, as I prefer to call them. Majority Leader Reid spoke to us, as did Senators Dodd, Harkin, Specter, Casey, and Sherrod Brown.

I was glad to hear their words. We walkers were all very tired, and our feet hurt, but there was a euphoria in that room. I heard later that a “virtual march” on Day 8 had generated 1 million messages – phone, fax, email – to Congressional offices in support of health-care reform.

I did this walk for my children. My wife and I have two, a boy and a girl. They’re both grown now, and living up in New York, where they have good jobs that they really like. My 30-year-old son, though, has a chronic medical condition. Almost all the time, he’s just fine. But on any day he can have a flare-up – without warning – that can land him in his doctor’s office or the emergency room. This is a kid who has to have medical insurance, and on occasion he’s had double coverage just to make sure that there were no gaps as he navigated from college to jobs as a paralegal and then to law school and his current job as a public defender.

Double coverage is expensive, but it’s a small thing compared to what might happen if he lost his insurance. If he loses his job, he won’t be able to get an individual policy because of his pre-existing condition. And in these economically insecure times, who can say that they will not lose their job, or their insurance? Certainly the budgets of public defender offices across the country are being cut, and cut again.

My wife and I talk about these things a lot. She tells me she doesn’t worry so much about his medical condition, because it’s manageable. What keeps her up at night, worrying, is his health insurance.

How have we come to this place in America? I hope the Wizards can fix it. In fact, I’m counting on them.

Coming to Terms With It - Or Maybe Not

In February my employer of sixteen years – the CIGNA insurance company – eliminated my position. This event was hardly a surprise. Sixteen years is a good run at a place like CIGNA. As an executive told me shortly after I was hired, "Well, Bill, you've got the job. Now let's see if you can hold on to it." And so, as I joke to friends, I spent the next sixteen years playing Beat the Reaper, and doing a little work on the side.

So it wasn't a surprise when my number came up and I found myself tossed into that great metaphorical sausage machine called severance. Still it was a shock. I found that I wasn't angry, and I wasn't sad. Occasionally I had twinges of anxiety about the future. But mainly I was just at loose ends. Work had been the main thing in my life (large corporations demand this), and now there was a void on center.

Because I'd been at CIGNA for quite a while, I got a nice severance package – pay continuation for several months, subsidized medical coverage, even a seat at an outplacement agency, where I met people who were angry, sad, and sometimes just in a state of disbelief.

Gradually I began to come to terms with the tectonic shift in my existence, and I even began to discern the outlines of a new life. A rather pleasant life, actually. My retirement savings will be substantially short of plan, and my wife and I are definitely not buying a house in the south of France, but she still has her job. Is it possible that the Great Recession doesn't look like the Great Depression because of the two-income family? After all, lose one job, you still have one left. Just don't lose the second one.

I do want to get a job. I like to work, and we could use the money. The outplacement agency gave us classes, and I enthusiastically threw myself into the job hunt, but gradually, as the weather got warmer this spring, it became clear that I wasn't going to get a job anytime soon. This recognition came slowly, and I had time to come to terms with it. I keep looking, and I think one day I may fall into something.

In the meantime, I've discovered that there's plenty of work in the world, as long as you don't ask to be paid. I started my volunteering back in the winter, working on Michael Turner's campaign for district attorney in Philadelphia. Michael lost in the May primary, but my volunteer career continued to flourish. I became a volunteer runner at Back on My Feet, a running and rehabilitation program for people who live in homeless shelters. Billy, one of our members, recently completed the Philadelphia Marathon. I tutor at Mighty Writers, an after-school program for young students in South Philly.

And, after an interesting internal evolution, I started working for healthcare reform. I was helped in this process by Wendell Potter, an old friend and former chief corporate spokesperson at CIGNA, who started speaking out on healthcare reform in the middle of the year.

It's not easy to say that you spent sixteen years working at something, and that the result was failure. But that was the conclusion I came to. It may be hard for outsiders to understand how strongly we were focused on trying to control costs in health care. Let's face it: We failed. Time for another approach. I came to terms with it.

Still, to paraphrase The Godfather, it was nothing personal; just business. As I said before, I wasn't angry. Then the letter came. Because of my age, when CIGNA eliminated my position it also effectively made me a retiree. So, after a few months on COBRA (COBRA is health insurance for fired people, and the COBRA subsidy was one of the smartest ideas in the stimulus package), I signed up for CIGNA's retiree medical program. It is the only connection that I still have with my former employer.

CIGNA subsidizes a retiree's coverage through a complicated formula. The price was higher than I expected, but much better than the prices on the open market. I came to terms with it.

Then I got the letter. As of January 1, CIGNA is increasing my premium by 48 percent. There's a very complicated explanation for why this is happening. I actually ran the calculation, and it all makes sense, as long as you're living inside that algorithm. I don't live there any more.

I think I'm less annoyed than astonished. And I don't think I'll be coming to terms with this any time soon.

Lafayette: We Were There

Lafayette Avenue is, to my mind, the best part of the New York City Marathon. Other parts are more spectacular – running across the Verrazano Narrows Bridge, with New York harbor and lower Manhattan on your left hand, and the vast expanse of the Atlantic Ocean on your right. Other parts are more quaint – Williamsburg, with its Hasidic Jews and young people, and Greenpoint, which seems to be Polish and again young people. Other parts are more manic – the noisy battle up First Avenue in Manhattan, where the leaders usually sort themselves out and the rest of us grind it out on concrete pavement to the Willis Avenue Bridge, all to truly intense spectator support. And other parts speak to my childhood – Fifth Avenue and the jaunt through Central Park. But for me, the best is Lafayette Avenue, near Fort Greene Park in Brooklyn. It's about eight miles into the race, so you're still fresh, and the wide open spaces of Fourth Avenue squeeze down to two lanes of runners, surrounded – cradled – by autumnal trees, brownstones, and many happy spectators. It's where I got to hug and high-five family and friends – people who helped me get where I was and then came out to support me. I had a great race from start to finish, but Lafayette was special. It felt like home.

Do Health Insurers Add Value?

“We need to really spank them.” There we were, in a conference room in a hotel in Philadelphia, a bunch of insurance company bureaucrats, listening as a well-paid consultant outlined our future. This was several years ago, when it became clear that managed care, after some initial success, was failing to control costs in the healthcare system.

The consultant’s “them” – the Other – was the patient. And the new tool – which we would use to spank patients – was called consumer-directed plans. The central idea behind this new tool was that individual consumers didn’t know how expensive health care really is. So we would show them by shifting a lot more of the cost onto their shoulders.

I had my doubts. Not about selling the plans to employers. After all, as the individual’s share of the cost went up, their share would go down. That’s not a tough sell in corporate America. My concerns centered on the unexamined assumption that improved knowledge of costs would alter a patient’s behavior. Would someone in the middle of a heart attack actually stop and shop for the cheapest emergency room? Or even want to go to the cheapest emergency room? Death trumps money, or something like that.

In medicine, we’re often dealing with forces far more powerful than a balance sheet.

I had been a fan of managed care. With its emphasis on wellness and preventive care, I thought there was a real chance to bend the cost curve down. And the messages were simple, the actions within an individual’s control: stop smoking, wear a seat belt, eat right (five servings of fruit and vegetables a day). Get a mammogram, and (gasp!) maybe get some exercise.

All these changes in behavior ran up against deep-seated habits: I didn’t think they would be easy. But I knew they worked.

The real flaws in managed care were less obvious to me at the time, but in hindsight they’re clear.

A Command Economy

First of all, the managed care system was effectively a command economy. This means that a few people at the top make all the decisions. The classic example is the old Soviet Union, with its bottlenecks at the top, where people made decisions slowly and often badly, at least partly because they didn’t have the right information.

In managed care, the insurance companies took on the command role, effectively telling doctors how to practice medicine, often in great detail. Of course this also meant that the range of options available to the patient was restricted.

This could be annoying, often in small ways. I remember years ago going to the doctor with an inflamed cyst on my neck. I wanted it lanced. I had had a similar cyst on my shoulder, years before, and lancing the cyst had worked fine. It did not occur to me when I went to the doctor that I would not get my wish. Instead, my physician, my healer, looked me in the eye and told me that lancing involved a surgeon, and surgeons involved money, and I was going to take aspirin and use warm compresses until the inflammation went away. Which I did. I’m still annoyed. If he’d offered me a range of options, and outcomes, and prices – in other words, a market economy – I think I would have been happier. I might even have taken his advice.

Capitation Completes Role Reversal

The managed care system reached its logical culmination with something called capitation. The insurance companies correctly saw that the fee-for-service system – in which the doctor is paid for each service performed – gave doctors a strong incentive to provide extra services. The command economy was supposed to eliminate this, but it didn’t. And so came the idea that the insurer would pay a set fee for each patient in the doctor’s care – capitation. (Caput means head in Latin, but the doctor actually got the whole body.)

By doing this, the insurers effectively shifted the risk to the doctors, all while continuing to tell them what they could or couldn’t do.

As a result, we had doctors trying to be risk managers, taking out reinsurance so they could stop their loss if a very sick patient threatened to cost more than the fixed rate the insurer was paying under capitation.

So the doctors were in the insurance business, and the insurers of course were effectively practicing medicine with their treatment mandates. It was a neat role reversal. Nobody was doing what they went to school to do. I mentioned this to one of the benefits gurus at work – a vice president. He smiled at me and said, “Bill, it’s not that simple.”

The Romance of Complication

It never is. I’ve often marveled at the love of complication that one sees in insurance companies. Executives habitually defend this complexity by saying they’re providing choice, but I think they just like it.

Years ago this impulse may have been manageable, but with the advent of computers the situation has gotten entirely out of hand. I remember I was at another meeting, this one also about the birth of consumer-directed plans. A very nice vice president from Connecticut was showing how we could empower consumers to build their own plans. In this model every possible option in a plan was placed on a grid, and the consumer was allowed to choose at every point. I believe the grid she was showing was 10 x 10, but this was only a simple example. She looked lovingly over her shoulder at the PowerPoint slide, then looked back at us and smiled. She loved her new toy.

So do these choices influence consumer behavior, or simply confuse the hell out of people? And let’s think about the poor people who work at the company, as call reps and claims processors. It’s not that hard these days to design a plan that’s impossible to administer.

The higher ranks of insurance companies are largely populated by accountants and actuaries. There are lawyers, of course, and even the occasional doctor, but mainly the people in the executive suites like to play numbers games. They think, they know – here’s that unexamined assumption again – that they can use price to influence behavior.

Economic Man and Behavioral Economics

Why are insurance executives so sure they can use price to drive behavior? Because they learned it in school, in economics class, where they met “economic man,” the rational actor who lies behind untold numbers of algorithms, always choosing the best product at the lowest price.

I do wish insurance companies employed more economists. Economic man is an older model. His rationality – his intense numeracy – has been significantly modified in recent decades by the rise of behavioral economics. The joke about the old economic man algorithms was, “That looks great in theory. I wonder how it works in practice.” Behavioral economics goes into the field and observes behavior, then attempts to explain it. It turns out that vendor relationships are “sticky.” In other words, people have loyalty. They may even have trust, say in their doctor. Price is not the only consideration. Who knew?

So playing with numbers only gets you so far. Human psychology – very messy, numbers people don’t like it – often gets in the way of rational decisions. Here’s the second shoe – I alluded to it before. It’s the structure of medical care. While people may shop for a good price when the situation is routine and when they can actually find out what the price is beforehand – I’m thinking of buying a new pair of eyeglasses – a visit to the doctor’s office may not be like that. You may go in complaining of shortness of breath, thinking it’s some kind of nasty cold, and the next thing you know you’re hooked up for an electrocardiogram. Did you remember to ask for the price sheet on that? Then, of course, there are the emergencies. You were crossing the street on a green light, and a driver busy writing a text message knocked you flat. You’re unconscious. How do you ask the ambulance driver for his price sheet?

We live in a world where information is often imperfect (something Hippocrates noted), and where the decision maker is occasionally unconscious. Take that, Economic Man.

Where to Now?

Insurers actually seem to perceive the failure of their efforts to use price to influence behavior. A sign of this is the new push – really, it’s all the rage – for wellness programs. You may remember that wellness was a big deal back in the days of managed care. Then, of course, the idea was that wellness would be managed by doctors and nurses sitting face-to-face with patients. Now we have four-color pamphlets and 24-hour help lines. Why? Because insurance companies don’t pay for doctors to chitchat with patients. They only pay for services rendered, and you’d better have the right ICD code on your claim. (ICD stands for International Classification of Diseases.)

It’s been an interesting several decades in healthcare – a long and winding road. I’d be tempted to feel sorry for the insurance companies if they didn’t have so much money. They’ve made a number of efforts to control costs in the system. They’ve basically failed. They have tried to fill roles better suited to physicians, and things haven’t gone very well there, either.

I haven’t even talked about the uninsured because, for the insurance industry, they are what economists call “externalities” – they simply lie outside the machine that makes the money.

If we look at the situation clearly, we have to ask ourselves, how are the health insurers adding value? Remember: Spanking doesn’t add value.

Hurray for the Distance Run!

What a wonderful race the Philadelphia Distance Run was this year! It was as close to a perfect half-marathon as I hope to see.

With the new wave start, I was able to run freely from the beginning. The course went right past the Liberty Bell and Independence Hall. The weather was nearly ideal­­ — I want to say high fifties and low sixties, light wind, low humidity, a big blue sky and a friendly sun. The food at the end was plentiful, varied, and good. The organizers even took the T-shirts to a new level.

Congratulations to everyone involved!

Don’t Get Sick in Florida

When my wife’s mother had a stroke in the spring of 2001, it launched our whole family on an odyssey that I hope we never have to repeat.

My wife and I and our two children were in Amsterdam on a family vacation when we got the call from her brother, Steven. Ada had had a stroke and was stable but paralyzed on her left side.

We flew home to Philadelphia, and our lives changed. Lois and Steven flew to Florida the next day, and for the next several months they shuttled back and forth, sitting at their mother’s bedside and attempting to manage the medical bureaucracy.

We learned things – things I would have preferred not to know. Both my parents had worked in medicine. They taught me at a young age that medicine has a curing function and a caring function. We found both to be in short supply in Florida.

Let’s take curing first.

Ada had gone to the doctor the day she had her stroke. She complained of numbness and an inability to move several of her left toes. Her doctor knew that she had had a previous stroke several years before, from which she had made a good recovery. He told her she had “nerve damage,” suggested she get a cane, and told her to make an appointment with a neurologist. So she went home and had the stroke.

That’s only the beginning. When Ada had her stroke, she fell and broke her left hip. The fracture was not diagnosed for two weeks.

Here’s the best construction I can put on this. It seems the initial fracture was a subtle hairline. It’s possible to miss such things.

After two days in the hospital, Ada was discharged to a rehabilitation center where she had physical therapy every day. The therapy involved her standing – in great pain – on her broken leg, which in the ordinary course of events would tend to make the fracture larger. Eventually a nurse, who I think had had enough, pointed to the way Ada’s leg was lying on the bed, and said that she had a fracture. The diagnosis was confirmed on X ray, and Ada got her hip pinned.

Now to the caring function. At the rehab center the nurses were, with a few exceptions, surly, uncommunicative, and unresponsive. The meds nurse – the one who dispensed medication – had apparently never heard of breakthrough pain. The nurse’s aides, again with a few exceptions, were surly, uncommunicative, and unresponsive. One of the exceptions, a lovely, caring woman, wound up taking a job in the county highway department because the pay was so much better.

Overall, though, the nurse’s aides were so unresponsive that my mother-in-law gave up trying to go to the bathroom. Even with my wife there, it took up to forty minutes to get an aide to answer a ring. Ada started wearing diapers. She wasn’t incontinent, but the staff made her act as if she were.

Eventually she was well enough to leave the rehab center, and we considered bringing her north. It hadn’t really been an option up to that point.

Ada still wasn’t in great shape, but she had lived in Florida for nearly 20 years, and she wanted to stay with her friends. We thought it might be okay.

She moved to an assisted living facility in Florida, and it was okay for a little bit. Then things started to go wrong. She developed acute pain in her left leg. Nobody (including an internist, an orthopedic surgeon, and a neurologist) knew what it was. An aide accused her of faking it. (There’s an ongoing theme that she was considered a “complainer.”) We added a geriatric case manager, and then we added a private-duty aide, a lovely, caring woman.

Finally Ada was readmitted to the hospital. The pain in her leg was caused by a blood clot – phlebitis, a condition which is life threatening.

The doctor at the hospital prescribed a blood thinner. Then Lois reminded her that Ada’s stroke had been caused by a bleeding blood vessel in the brain, and suggested that, in view of this patient’s history, a blood thinner might be contraindicated. Exit blood thinner.

The hospital also ran a chest X ray, and Ada had some huge tumors in her lungs. They hadn’t been seen on prior X rays – one taken when she had the stroke, and one a few months later.

We ordered up an air ambulance and moved her north, to a nursing home just outside Philadelphia, so she could be near her family at the end. A week later, and about seven months after her stroke, she was dead.

This ending was inevitable. What was not inevitable was the amount of suffering and humiliation she endured for seven months because of slipshod medical and nursing care.

People suggested that we sue for malpractice – and, of course, that brass ring of litigation, the award for pain and suffering. We were disinclined to do it because we didn’t think her pain was fungible – it couldn’t be converted to money. And I don’t believe that suing people causes them to improve their behavior – it simply causes them to improve their defenses.

I don’t have any answers. But I do know this. We need some.