I was scheduled to have arthroscopic shoulder surgery today, to repair the anterior labrum tear from my dislocation this spring.  But I’m at home instead, due to a fascinating series of failures to answer my one simple question:

“How much will this cost?”

In my mind, for a non-emergency procedure, that seems like a completely valid and reasonable question.  It blows my mind that people would just show up on their surgery date with no idea how their operation might impact their finances.

Like I wrote before, medical services suffer from a tremendous lack of transparency that drives up costs for everyone.  I can’t think of a single other big-ticket purchase where the cost is hidden from the customer until they’ve already “bought.”  No other industry does business this way.

But as reasonable as I thought my question was, I spent the better part of 2 days learning it was not.  Among the answers I received:

• “We won’t know until we see the exact codes the facility sends us.”
• “You’ve met your out-of-pocket max for the year so you are covered 100%.”
• “This facility is out-of-network, which is subject to a $2000 deductible, a 40% co-pay, and a $6000 out-of-pocket max.”
• “This facility is out-of-network, but as agreed to accept your in-network benefits.”
• “Your insurance should pay for the whole thing.”
• “I see in your file an out-of-network gap exception has been approved.”
• “There is no out-of-network gap exception approved.”
• “Don’t worry about it. If there’s trouble with the bill, just give me a call.”
• “$265.21″

It was a sick 4-way dance between me, the doctor’s office, the off-site surgery center, and the insurance company.  And every step of the way I was greeted with disbelief that a customer might want to know their expense ahead of time.  Within minutes of each other, 3 different United Healthcare employees, accessing the same information, gave me 3 different estimates ranging from $0 to $6000.  (Let’s just say I’m thankful they’re not the ones operating!)

When I got an answer I liked, I asked to get it in writing, which of course was quickly refused.  In this high-stakes guessing game, it became clear the only one with any liability was going to me.

So not knowing who to trust or believe, I had to cancel the operation.  How many people could just show up for something that “should” cost nothing but “might” cost up to $6000?  No thanks, I’m not a gambling man.

It’s frustrating because I wanted to get this done ASAP to maximize recovery time for ski season.  Hopefully we can get it all sorted out and taken care of soon.

For extra usefulness / hilarity / melancholy and the infinite sadness, United Healthcare provides a “cost estimator” tool on their website.  As noted previously, they’re supposedly the experts but they really have no idea.  So if you choose “Out of Network,” they literally leave a blank where you can fill in your own estimate:

Nice, maybe this is their new crowdsourcing campaign?  But seriously, if people knew the cost, why would they be using your Estimator tool?

Bah.

-Nick

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My body went from 18 to 40 in about a year.  I used to be able to ski, snowboard, swim, lift, run, etc without much issue.  Now I’m in a constant state of soreness.  Never thought it would happen to me, and it seemed to happen almost overnight.

I interpret this soreness as a sign my muscles are weak, but then they are too sore to work out and strengthen them.  It’s a vicious cycle.

-Nick

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Five weeks removed from my dislocated shoulder accident, I’m happy to report it is healing nicely.  But for over $8000 (the total amount billed insurance so far — another reason I’m happy to be married), I expect better.  For $8000 I should be 100% healed, or better, perhaps with a new bionic un-dislocatable shoulder.

Aside from pain medications, literally the only “thing” a doctor did to my shoulder was pop it back into place.

So what have the miracles of modern medicine bought me?  In addition to the most expensive blog post ever, here are some of the highlights:

• $2200 for “ER Visit Level IV” — This is the facility fee, and apparently it goes up to Level V, so it could have been worse.
• $1500 for the before and after x-rays.  For comparison, my foot x-ray 2 months before was $75.
• $72 for a radiologist to read the x-rays.  Approximate hourly rate: $4320/hr.
• $262 for the doctor to pop my shoulder back in.  Approximate hourly rate: $5240/hr.
• $158 for “Surgical Procedure Level II” — The ER’s charge for the bed I sat on while the doctor popped it back in, curiously not included in the $2200 facility fee.
• $550 worth of pain meds.  Totally worth it at the time.
• $118 for a too-small sling.  (The same one is $20 at Amazon.)
• $2500 for an MRI.  Given the time and equipment necessary, and images produced, this should have cost WAY more than 167% of 2 x-rays.  Or more accurately, the x-rays were dramatically overpriced.
• $328 for someone to read the MRI.
• $400 in worthless visits to the orthopedic doctor.  He did draw me this nice diagram of a shoulder though, which now qualifies as the most expensive piece of art I own:

I don’t have a problem with doctors and nurses and hospitals making money.  I don’t have a problem with insurance companies making money.  These are all for-profit entities providing valuable services.  With the exception of the orthopedic doc, everyone was really professional and I was happy with their care and recommendations.  However, my inside look at the health care “system” was less impressive.

I’ve written about health care reform before, but (thankfully) hadn’t really experienced how the system works (and doesn’t) first hand until now.

The biggest problem I have is the lack of transparency.  Medical services are about the last thing we buy that we have NO IDEA what they cost until it’s done.  Transparency has brought about more competition and lower prices in every market from cars and diamonds to software and shoes.  Once consumers know how much you charge and how much the competition charges, they can make an informed decision.  Add in ratings a la ebay and yelp and things get even better.

What’s even more interesting is even the insurance company has no idea what things cost, and they process thousands of claims a year.  According to the United Health Care Cost Estimator, a broken or dislocated arm treated at an in-network emergency room would cost between $1300-2100.  That huge $800 range itself is an indicator they haven’t a clue.  Here’s how their estimate breaks down so you can see how painfully inaccurate they are (and I will only use the high-end of their range):

• $950 in professional services.  Doctors, nurses, radiologists, etc.
• $1100 in facility fees.  Only off by a factor of 2.
• $38 for “radiology/lab/supplies”.  Compare to $1500+
• $1 for pharmacy.

I want to reiterate, these are the actual cost estimates from the insurance company, on what a similar ER visit should cost.  If they’re that far removed from reality, and accurately processing these claims is the central operation of their business, the average patient doesn’t stand a chance.

With health care, there is no transparency.  It turns out the hospital that was slightly farther away was significantly cheaper.  Had we known, we might have driven the extra 10 minutes.  Think of gas stations they’re required to visibly post their prices so customers can make informed choices.  For what we presumed to be a simple enough injury to fix, like filling your empty tank, why not pick the most cost-effective solution?

When I questioned the hospital about their pricing, I learned some very interesting things.  The first is that at the ER, the staff is not allowed to discuss treatment cost or insurance or the patient’s ability to pay.  The x-ray technician told me, “We don’t even need to take the picture, I can tell from looking at it you’ve got an anterior dislocation.”  What she didn’t say is, “Do you want to take them anyway?  It will be $1500.”

I was told the reason for this is liability; the x-ray tech could have been wrong and there could have been something more serious found in the images.  The medical industry is deathly afraid of attracting lawsuits, so it is far safer to overtreat than to undertreat.  That’s one reason why costs are so high.

(The counter argument is the car repair shop that finds a customer’s brakes in bad shape.  They have an obligation to tell the customer about it, but ultimately it is the customer’s choice whether or not to have the brakes repaired.  By informing the customer, the repair shop has done it’s job.  Transparency without the liability.)

The other reason for high prices is plain old-fashioned price fixing.  When I asked about the facility fee, the response I got was that the hospital communicates with other area hospitals about what to charge.  In other industries this kind of collusion is illegal, but in medicine it is apparently common and accepted.

So I don’t have a problem with the involved parties making money, just with the way they’re making it.  At a restaurant for example, you’re hungry, you get food, and you get a bill.  Usually you have a good idea what that bill is going to be for, and have some recourse if you were overcharged.  Not so with health care.

I was in a tremendous amount of pain, I got treatment, and I got a bill.  Did I want a $118 sling?  No, but I got one.  If $1500 is reasonable for x-rays, why not $2000 or $5000 or $15000?  When the customer has no recourse (they’ve already eaten their meal so to speak), why not gouge the shit out of them?

-Nick

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Last week I found what I thought was a money parking spot at the hospital.  Right near the front, just next to the disabled spots.  When I pulled in though, I noticed the sign, “Reserved for Clergy“:

Since I definitely don’t qualify, I figured it would be best to find another spot.  But it got me thinking.

• Do clergy have designated placards?  Or is this sign purely enforced by Jesus?
• There was only one reserved space.
• Oddly, I saw zero reserved spaces for “Brain Surgeon” or “Chief Cardiologist”.

This is a hospital, not a church.  It’s one of the most pro-science institutions you’ll find, and yet they’re going out of their way to make room for God.  And to the extent that everyone else has to park one spot farther away from the entrance, I can respect that.

When modern medicine fails, people have every right to turn to the divine for peace.  When I worked in North Carolina, I met a cancer victim who had been given six months to live.  Not wanting to spend his last six months under radiation treatment, he turned to his faith, miraculously the cancer went into remission, and he was still going strong five years later.  I don’t know the whole story, but this is just one of many case studies regarding the apparent success of faith-healing.

Science on the subject is inconclusive, which can only be seen as a victory for God.  (Because sending telepathic communications to your imaginary friend in the sky should conclusively have zero impact.)  I’d be the first to think that prayer would do absolutely nothing, but in certain cases when the sick really believe, it does seem to have some positive effect.  Although there are definitely limitations, the power of positive thinking is real, whether it’s called prayer or something else.

Of course I would exhaust every legitimate medical option before pursuing such a risky and unproven strategy, unlike these guys:

The great thing about faith healing is that when it doesn’t work, you always have the ultimate fallback: “It was all part of god’s plan.”  You can’t lose.

-Nick

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There I was, rounding first like I do several times a week without incident, when my cleats hit a hard patch of ground and come out from under me.  Instinctively I put my arm out to stop the fall.  In hindsight, that was dumb.  I heard a “noise” … snap, crackle or pop, and limped weakly back to first clutching my arm.

Ugh I could have had a double easily, maybe a triple.  Ok probably a double.

Instead I get a pinch runner and head to the dugout to see if it gets any better.  A half inning later, not so much.  So Bryn drives me to the ER.

Now I admittedly would say I have a pretty low tolerance for pain, but this was amazingly painful.  I’m breathing funny, sweating, and getting the shakes.  Yes yes, common symptoms of going into shock for you former boy scouts.

The ER service was actually really fast.  But even 10 minutes sucked.  At this point I make some comment about how I would be terrible if I ever got interrogated.  I’ll talk, I’ll talk!

For some reason Bryn brought her camera to the game so she documented the event.  Here we are in the waiting room fighting through the pain.

If it’s hard to tell something is messed up from that pic, take a look at this one.  That ain’t right!

At this point the doc comes in and starts pushing and pulling around on my arm a bit.  “Relax your shoulder,” he tells me.  And just like that it pops back in and he leaves.  Unfortunately the pain doesn’t go with him, so we’re laid up in the hospital for another hour and half or so getting loopy on pain meds.  During that time, they were kind enough to take an “after” x-ray to show what a shoulder should look like.  Much better:

Yikes that was a good distance from where it was supposed to be.  The orthopedic doc today looked at the first one and said, “Yeah you were way out in the woods.”  Thanks for that.  No wonder it hurt so bad.  Rec sports are dangerous.

While at the ER I saw a little leaguer who’d taken a grounder to the face.  It was a bad hop, his dad assured me, like I was judging.  It did make me feel a little better not being the only one there with a baseball/softball-related injury though.  And then I thought about how this kid was probably 10 years old.

I’m hoping for a quick recovery, although I’ve been told to take it easy for 3-4 weeks.  When I told the doctor I had 3 games next week, he laughed and made some remark about it being rec softball.  Which apparently is not something worth rushing back for.  (While I was on hold making the appointment I learned his office is the “official” orthopedic center for the A’s and Warriors, so I guess he’s got some perspective.)

Lame lame lame.

-Nick

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It took a while, but I finally finished Michael Pollan’s In Defense of Food: An Eater’s Manifesto.  You may recognize the cover with its lettuce and the book’s key advice: “Eat food.  Not too much.  Mostly plants.”  It was a very interesting read, thanks Chris for the recommendation.

Pollan believes our “Western Diet” is the root cause of our obesity epidemic and the ills that go with it: heart disease, cancers, and diabetes.  For centuries, humans around the world lived perfectly healthy lives on an incredible variety of local diets.  Then, food became a business, and the business became an industry, and the industry became a powerful government lobby, and everything changed.

The Western Diet is characterized by lots of processed foods, refined grains, dairy products, high fructose corn syrup and soybean oils, and cheap red meat.  As food became more industrialized, quality took a backseat to quantity, and we’ve paid for it with our health.  One interesting statistic Pollan cites is that in 1960 we spent 17.5% of our income on food and 5.2% on health care.  Now we spend just 9.9% on food but 16% on health care.  What kind of implications does this have for a government that heavily subsidizes industrial farming and now has to pass health care legislation partially to deal with the monster it helped create?

The above graphic is from TheSocietyPages.org.

The food industry has done an amazing job of producing cheap calories; Americans consume 300 more calories a day than we did 30 years ago.  The problem is these calories don’t supply much nutritional value beyond simple energy.  We are bombarded with 17,000 new food product launches each year and are no match for the industry’s $32 billion annual marketing budget.  Other cultures spend more on their food, feel less guilty about what they eat, and live longer healthier lives.

One thing I would have liked Pollan to address is how much the increased food production was out of necessity to feed a rapidly growing global population.  Not everyone can grow their own organic food, shop at farmer’s markets, and join local CSAs, as he recommends.  Some degree of mass production is required to feed 7 billion mouths.  Only eating food your great grandmother would recognize as food is another difficult recommendation to follow in today’s world; it’s a very different place than it was 100+ years ago.

The more health-conscious we become, the fatter we get.  Pollan calls this the American Paradox, and warns against what he calls the growing cult of nutritionism.  Any food manufacturer can spin their product to make it sound like it’s good for you, so maybe it’s best to avoid packaged foods that make health claims.  When Lucky Charms can claim to be “heart-healthy” because of their whole grains, these claims have lost all meaning.

So all in all, very interesting read.  I found it a little academic in parts, but it touches on history, evolutionary biology (and suggests our bodies may eventually adapt to our new diet), business, economics, and politics, and covers a topic, food, that’s near and dear to my heart.

-Nick

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Switching up my lunch meal was another big shift for me.  I used to always have a grilled ham and cheese sandwich, an apple, some baby carrots, and some white cheddar Cheez-Its.

On a mission to reduce the amount of processed carbs I consume, I had to make some drastic changes, including getting rid of my beloved Cheez-Its and Safeway 15-Grain Bread.

Nowadays a typical lunch might involve Trader Joe’s Cumin and Chili Chickpeas (spicy and really good, and only $0.99!), cucumber, tomato, celery, almond butter, baby carrots, and hummus.  Since none of these items has as many calories as my delicious sandwich, I normally end up eating 2-3 smaller “lunch-snacks” throughout the afternoon.

Did you know that cheddar cheese was so high in saturated fat?  I had no idea.  And where I gained a ton of cholesterol from my egg at breakfast, I lost it at lunch from ditching the cheese and ham.  My new lunch was able to keep the total carbohydrates the same, but significantly increase the carbs from fiber, while reducing the carbs from sugars and “empty calories” in bread / Cheez-Its.

The percent of daily values figures are based on a 2000 calorie diet.  I’ve always consumed way more than 2000 calories a day so they don’t mean much other than as a proportional guide.  And even then, understand that the recommended daily values were established by a government body easily swayed by food industry lobbies and political pressures (at least according to In Defense of Food).  Do your own research and listen to your body.

Dinner hasn’t changed too much, aside from taking out a lot of rice and pasta, and substituting more veggies, beans, and lentils.  Spaghetti squash has become a new staple.  The first week was pretty tough; I think my body had been trained to need the fruit smoothie, cereal, and sandwich after having them 4-5 days a week for 2-3 years.  But after that it really hasn’t been a problem.  More of a lifestyle change than a fad diet I suppose.

And without any real end-goal in mind, I’m definitely not going to turn down a burger or some fried rice every now and then!

-Nick

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After reading The 4 Hour Body, I’ve made some changes to my eating habits.  I’m also working my way through In Defense of Food, which contains some similar (but not identical) recommendations.

Working from home, I ate a very consistent breakfast and lunch.  Some would call the lack of variety boring but I liked my meals.  For breakfast I would have a fruit smoothie and cereal.  The smoothie would have half a banana, frozen blueberries, blackberries, raspberries, and strawberries, orange juice, milk, and a little bit of protein powder.  The cereal would be a little bit of granola, a generous pour of Honey Bunches of Oats with Strawberries, and the rest of the banana.

Both books rail against the evils of processed carbohydrates (bread, cereal, pasta, rice, etc.), and Tim Ferriss even argues that fruit and fruit juice contain more sugar than your body needs, so I thought I’d experiment with something new.

My new breakfast consists of a protein shake first thing in the morning.  This tides me over for a couple hours.  After that, I scramble 2 egg whites, 1 whole egg, and spinach, and then add some turkey bacon and steamed lentils.  Serve with a pile of salsa and enjoy.

There was no specific goal in mind.  I’m not trying to lose weight, and the abstract aim of “feeling healthier” is hard to measure.  (The other change I made was a significant decrease in running cardio.)  Over the past couple months, I can’t say I’ve noticed a huge difference in body composition, but there is a general feeling of better well being.  Could be 100% placebo, but maybe this dietary shift had some effect.

I don’t feel like I have more energy or less energy, which is significant given the sheer volume of calories taken out of my breakfast.  I rarely feel disgustingly full anymore, you know the feeling where you’ve eaten way too much.

It was really interesting putting together these numbers.  I’ve never really paid much attention (and have been known to select foods based on how many calories you can get for the price).  The new breakfast is lower in fat and sugars and higher in protein.  The big increase in cholesterol comes almost entirely from that one egg, and the potassium loss is almost entirely from removing that one banana.  Surprisingly, lot of the sodium in the new breakfast came from the salsa.

I think I’ll continue with my new routine, tweaking as I see fit.  We’ll take a look at lunch next.

-Nick

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In the wake of the recent Japan earthquake, tsunami, and nuclear reactor trouble, there has been a lot of discussion about the future of nuclear energy and its safety.

I found a couple interesting graphics.  The first shows the relative radiation of different events:

http://xkcd.com/radiation/ (opens in a new window)  Fascinating really.  I had no idea.

The second shows the relative death rate per TWH of various energy sources:

For the same amount of energy produced, coal power kills 4000 times as many people as nuclear power.  In developing countries, coal is even deadlier.  In China, for example, air pollution from burning coal kills half a million people a year — a rate 18 times higher per TWH than in the US.  Data and further details here.

Nuclear is scary because it’s complex and hard to understand.  And we never hear about it until something goes wrong.  To be sure, the occasional meltdown is tragic and devastating, but these events make news for the same reason plane crashes do.  They’re spectacular and horrific and deadly — and extremely rare.

The data show that even with several well-publicized disasters, nuclear energy is among the cleanest and safest we have, yet contributes only a small fraction (5.9% in 2008) of the global energy supply.  Based on this, a cleaner and healthier future will have more nuclear power in it, not less.

-Nick

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SmartWater is a brand of bottled water produced by the Glaceau company — the same company that makes those colorful VitaminWaters.  I was surprised to learn Glaceau is a subsidiary of Coca-Cola.  But what makes SmartWater so special?  Is it really any different from regular water?  Here’s what we know:

• SmartWater is “vapor distilled” water.  From what I can understand, pretty much all water is vapor distilled, meaning it originally came from clouds.
• According to their website, most SmartWater is procured from “municipal water systems.”  Read, “tap water.”
• Then the SmartWater goes through Glaceau’s proprietary filtration process, that removes just about everything from the water except two H’s and an O.
• SmartWater then adds back in the electrolytes calcium chloride, magnesium chloride, and potassium bicarbonate “for taste.”  I think the “for taste” part is important because the nutrition label still reads 0 mg of sodium, and the amounts of electrolytes added have essentially zero “gatorade-effect”.  In fact, the amount of electrolytes found in SmartWater is less than in other brands of “non-electrolyte-added” bottled waters.  Two independent taste-testers (Bryn and I) could not taste any difference between SmartWater and Brita-filtered tap water.
• They write in all lower case letters, which definitely seems trendy even if not necessarily “smart.”

It seems like the water in the SmartWater bottle isn’t anything amazing.  It’s not going to raise your IQ or replenish your body of lost nutrients any more than any other water would.

So what really makes SmartWater smart?

Its business of course!

• Globally, bottled water is a $100 billion dollar industry.
• Glaceau has found a “smart” way to buy tap water for a national average price of $0.002/gallon, clean it up, and sell it for more than $5/gallon.  A 250,000% markup makes for an insanely profitable business.
• By calling it SmartWater, Glaceau is basically calling every other bottled water brand StupidWater.  If you’re buying bottled water (arguably not the smartest activity to begin with), are you going to pick the regular bottled water or the SmartWater?  Good choice, Einstein.

-Nick

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