The Target

Our cable television bill. $110 a month, and as the expression goes, hundreds of channels and nothing to watch.

The Social Experiment

The volunteers (well, they weren’t all volunteers): My wife and I, our 24 year old daughter and 12 year old son.  As in so many households, television had become a background narrative, a nightlight and a mind-sitter. I noticed that there was very little actual television watching going on. Nobody was saying, “I heard about this particular show, I think we should have a look”.

Instead, the TV was turned on usually around 4 PM and generally ran until 10 PM. The show selections made by our kids, while not offensive seemed to me to be the media equivalent of  Hostess Twinkies: Empty of value, unhealthy ingredients and consumed out of boredom.

I wondered what would happen in a household if cable television were summarily replaced by local television reception and pay-as-you-go TV provided by Apple TV, Hulu, Netflix and Amazon Video On Demand.

The Technology Before

We have a four year old 55” flat screen  / home theater in the living room, a small flat screen television in the kitchen for watching the morning news and an old tube-type television in my daughter’s bedroom for watching who-knows-what.

Our television service was AT&T’s uVerse with their digital video recorder that allowed us to record shows for future watching.

Separately, Cox Cable supplies our internet connection  for about $60 a month. Also, in the living room, we have an Apple TV box which allowed us to stream music from our music library, view family snapshots and watch movies rented from iTunes. Our Sony DVD player which we rarely used to watch DVD’s is also connected to the internet and allows us to stream Amazon video on demand, Hulu and Netflix and watch YouTube videos.

What We Watched Before

We enjoy NCIS, CSI, The Daily Show, Colbert Report, some Comedy Central shows and an occasional Myth Busters.  I liked the weekday morning news shows. We are also movie buffs. Sports- not so much. After that, it was the Great American Habit- channel surfing across The History Channel, Discovery, The Learning Channel and what I called trash TV, Spike TV and those shows with the incredibly annoying laugh-tracks that air on Disney between 4 and 6 PM on weekdays.
The Technology After

I decided to do this in phases- no cold turkey for this household.
I had heard that digital over-the-air television with an inexpensive antenna worked really well so I started there.
I discovered that I could enter my home address in Southington, Ct. at www.antennaweb.org.

It would tell me which channels I would receive, what kind of an antenna to get and even showed me a map of my neighborhood to help me point the antenna in the right direction.
Next stop was Amazon.com where I purchased an external television antenna and associated stuff. Total cost: about $55. Installation and hookup took about an hour.
The picture and sound across 16 channels was in a word, stunning. I get all the major channels, including CBS, NBC, ABC, FOX, Spanish channels.

If you thought cable and a good quality TV delivered great picture and sound, you should see over-the-air broadcasts. And because of the digital technology, there was no snow, static, etc. Another word came to mind: “free”.

I could not get my five year old LCD flat panel TV in the kitchen to work. I concluded that it was one of the older, non-digital ready televisions. I decided it was worth replacing, especially since a new one could be had for only about $140. Once done, again, stunning picture and sound, also free.
How we Watched Afterwards and Results of the Experiment
With almost all the shows we wanted to see available ala carte from someplace be it Hulu, Apple TV, Amazon, etc., I found it interesting to see which shows everyone  would be willing to pay for in order to watch.

Everyone wanted to see CSI and NCIS so we bought the entire seasons of each from Amazon Video on Demand for about $38 each- a little less than $3 per episode and in high definition.

Hulu gets us the Daily Show and Colbert for a monthly cost of $8 for their entire service.  I should note that all of these shows are current episodes available to watch the next day following their airing on the network/cable channels. Mythbusters (and I confess an occasional “Simpsons” and “King of the Hill”) purchased for around $2 each.

Plus, we’ve rediscovered some of the shows of our past. The old Mission Impossible, Superman, The Mary Tyler Moore Show and others- but only when we want. It’s also fun to have family YouTube nights. It’s amazing to see YouTube videos on the big screen.   As for movies, between Netflix, Hulu and Amazon’s Prime service, there are thousands upon thousands to choose from at no additional cost.

Those afternoon Disney shows? Can’t find them.  After a little 12 year old grumbling, they were replaced with READING (as in with books- ok. Comic books but who cares?) and PLAYING WITH FRIENDS (as in with neighborhood kids outside)!

The family also discovered that with television watching becoming selective, we would make note of shows that were receiving good reviews and search them out. We discovered “Criminal Minds” this way (causing my 12 year old son to decide he wants to be a Profiler when he grows up) and also “American Horror Story” (which is not appropriate for him but great for grown-ups with twisted senses of entertainment)
The bottom Line:
Up front costs: Television antenna and new television for kitchen: Total $195

Recurring monthly costs: Hulu and Netflix: $16

Purchased shows over the last two months: $114 for entire seasons of three shows which can be watched anytime we like on our flat screen television, or a laptop or iPad anywhere anytime, plus another $26 for other miscellaneous shows purchased when the mood struck.

Money not paid to AT&T so far: $220 and counting.  We have no plans to go back.

Downside:

There is no “cable guide” so it can be hard to find a show we’re looking for, requiring us to check between Netflix, Hulu, Apple TV and Amazon video on demand.

Some shows / networks still haven’t gotten the message about consumers wanting to watch on any kind of a device with a screen. For example, unless I happen to catch “60 Minutes” at 7 PM on Sunday nights, the only other place I can see it after that is on an iPad or laptop, but it is impressive there.

It was a great day when I called AT&T to tell them I was cancelling our service. They asked if there was anything they could do to keep us. I said, “No- there isn’t.”

Note from George Gombossy

Another downside is that premium cable series like Homeland, Boardwalk Empire and Game of Thrones will not be soon available. But hey, that is the reason you have friends with cable right?

Keith is a wheelchair user who writes that he is appalled at the prices often charged for items supplied to the disabled. As an example, a replacement battery charger for his power wheelchair was billed at over $480 and he was personally responsible for paying over 30% of the price with the insurance company paying the remainder. Keith didn’t say if this was billed to his private insurance company or if he was a Medicare beneficiary, but he thought that the right price should have been in total the amount he had to pay, $160.

Keith, the Healthcare Consumer couldn’t agree with you more. But before we offer our opinion, in the interests of full disclosure, we should tell you that one member of the Healthcare Consumer team runs VidaCura, a company that sells these kinds of items.  Nevertheless, you’ll find our perspective interesting and considering the national dialog on healthcare, very relevant.

First of all, Keith, you’re talking about the area of healthcare that is referred to asHome Medical Equipment” or “Durable Medical Equipment”, or DME / HME for short. HME products include walkers, wheelchairs, oxygen supply devices, scooters, things to make trips to the bathroom easier, hospital beds used at home and the like.

Let us introduce the participants in this drama:

A Medicare Beneficiary might be you, Keith or someone else who qualifies for participation in Medicare, etc.  By the way, people assume that just because you are using Medicare that everything is covered including all HME. This is not true. There has to be a proven medical need, CMS-imposed conditions must be met and even in cases where the need is proven, generally the beneficiary must pay a percentage of the price. (We could write an entire other column on those late night TV commercials that promise to get you a power scooter for free!)

The Centers for Medicare and Medicaid Services (CMS) is the federal agency that administers the Medicare, Medicaid and CHIP health insurance programs. CMS produces a fee schedule that lists the items they will pay for and what they will pay (“reimburse”) for each of those items.  This fee schedule is public information. You can download and look it over here if you have Microsoft Excel. CMS also sets the rules that all medical providers including doctors and HME dealers must abide by if they desire to accept Medicare/Medicaid patients. One important and relevant rule to this column says that if you are a Medicare provider, you may not sell a particular item to anyone for less than Medicare pays.  Put another way, CMS sets the “floor” price for all HME items. As you can guess, because of the massive scope and size of the Medicare program, it influences most other areas of healthcare.

The HME manufacturers and dealers who make, sell and then deliver durable medical equipment to homes and medical facilities across America. When a manufacturer produces a new product or device, they lobby CMS first, for their new item to be paid for by Medicare in the first place. And then, if CMS consents to that, then they lobby for a fee schedule price. (Are you as tired as we are of hearing about lobbying?) As for the dealers, most HME dealers are so heavily dependent on Medicare that following CMS rules and accepting Medicare payment rates for the most part, govern how they run their businesses.

Health insurance companies like Aetna, United Healthcare, Blue Cross, etc. have their own fee schedules as to what they’ll pay. There are two things you need to know about insurance company fee schedules. The first thing is that if we’re talking about an item that appears on the Medicare fee schedule, the insurance company must pay more. It must be this way because since most HME dealers also accept Medicare, they cannot sell to a private insurance company for less. The second thing you need to know about insurance company fee schedules is that they are secret.  Insurance companies don’t want you to know what they pay. Lastly, they can and often do change the rules about coverage for HME on the fly leaving the insured to pay a percentage of what the insurance company paid instead of a flat co-payment.

So let’s compare business models:

In the healthcare model:

A power wheelchair manufacturer decides to market an extra battery charger as an accessory or if the original one is lost or broken. They lobby CMS to allow their product to be reimbursable and then to convince them to make the reimbursement rate as high as they can. They do this ostensibly for several reasons; first because then they can charge the HME dealer more for the item and secondly, on behalf of the HME dealer, the price needs to be high to make up for the fact that the federal government often takes an inordinately long time to pay its bills.

Then, by law, private insurance companies set their price for that same item, making sure that its even higher than the Medicare fee schedule price but we don’t know how much higher for sure. What we do know is that if the prices are too high, the insurance company simply raises the premium charge to your employer possibly risking your job or future raise and you will need to pay 20-40% of [a much higher] secret number.
A not-so-hypothetical free market model:

A laptop computer manufacturer decides to market an extra battery charger as an accessory or if the original one is lost or broken. Their marketing people meet with one or more of their dealers and collectively make some guesses as to what the consumer would pay for it presuming that the dealer makes a reasonable profit and agrees to all the other terms including how fast they will pay the manufacturer.

Together, they bring it to market and the consumer sees it on the shelf. If the consumer believes the price represents a reasonable value, they buy it and everybody is happy. If the consumer doesn’t think it’s a fair price, then one or more of the following things happen:  the manufacturer stops making it; the dealer stop selling it, they lower its price if they can or another manufacturer steps in and makes one available at a lower price.

So there you have it Keith. While the Healthcare Consumer is a staunch believer in universal healthcare as a moral imperative for all Americans, even with the recently passed reform there is more work to be done. That so many are claiming that the reform package doesn’t do enough to control costs is true. But it’s not just a matter of weeding out inefficiencies. The process needs to be re-engineered.  The Healthcare Consumer has an answer. We believe that if health care consumers (that would be all of us) are given the tools to be intelligent shoppers, including price visibility and information to allow intelligent choices to be made that they will be encouraged to do what they already do for big screen televisions and digital cameras.  Lastly, if you really want to change buyer behavior, change the system so that the consumer has skin in the game.

By the way, VidaCura doesn’t accept Medicare so they don’t have to be encumbered by the minimum pricing rules. Larry believes that if an item is priced to represent good value in the first place, that most consumers will do the math and realize that the price is in line with whatever the percentage of a much higher price that they would have had to pay if Medicare or an insurance company were involved.

The Healthcare Consumer is written by Larry Berk and Delaney La Rosa,RN,  healthcare and insurance professionals with over 25 years of combined experience. Larry is the President of VidaCura, Inc. a health and wellness products company. VidaCura can be found online at www.vidacura.com. Delaney has been a healthcare professional for more than 18 years with a background in healthcare fraud investigation and is a registered nurse. Got a question, comment or suggestion for a column? Write to them at thehealthcareconsumer@yahoo.com.

Larry Berk and Delaney La Rosa are bringing their health care and insurance expertise to CtWatchdog.com.

While much has been written about the H1N1 “swine flu”, we think some concise information is worth providing.

 Flu activity is widespread- it has essentially affected residents of every state. The H1N1 strain of flu virus is turning out to be the perfect storm of illnesses because for certain high-risk groups of people it can be fatal, many are not taking it seriously, there are serious shortages of vaccine and government at all levels is not doing an effective job of managing distribution of the limited amounts of vaccine that are available.

 If you’re a resident of Connecticut as we are, the data will be particularly important.

 As of the end of last month, there have been about 3,000 laboratory-documented cases of H1N1 in Connecticut, but since most people with flu symptoms don’t seek medical care, we suspect the number of cases is much higher. About 350 of those cases included hospitalization. On the vaccine availability end of things, as recently as the end of last month, Connecticut was receiving only about 25% of the doses it ordered. 

National vaccine allocations are done based on population distribution by the Centers for Disease Control (CDC) – the states with greater populations will receive larger numbers of doses. But nationally, all dose shipments are falling far short of needs.

 Naturally, our Federal Government is pointing fingers at itself, saying that its performance is unsatisfactory and that the entire supply chain needs to be overhauled before the next breakout. Well, thanks for that helpful information, is all we can say. We’ll be sure to file it in the same folder we keep our New Orleans / Hurricane Katrina archives in. 

 Once the vaccine allocation amounts are indicated by the government, vaccines must be distributed.

The vaccine does not travel directly from the manufacturer to your private doctor or clinic. A distributor is involved in the process; often a large pharmaceutical or medical products company. These distributors provide a means for the medical community to order and pay for vaccines and related medical supplies.

 An interesting insider fact is that these companies make the final decision about which customers receive all or part of the vaccine ordered. While the standard practice is to use a lottery system to distribute vaccine to customers, lucrative accounts may receive preferential treatment or “first fill” status. This helps shed light on why your local physician may not have any flu vaccine while another clinic or physician practice does. 

 First, some facts:

Swine flu, aka H1N1 cannot be contracted by eating pork. The renowned World Health Organization has said that swine flu is not transmissible to people via properly prepared pork products.                 

H1N1 is not “just the flu”. In contrast to run-of-the-mill flu viruses, the H1N1 has the ability to infect cells deep in the lungs where it can cause pneumonia. What makes it so deadly is that onset of the infection can occur so quickly that it becomes out of control before treatment is sought. Seasonal flu viruses typically infect only the cells in the upper respiratory system and the body is much more able to defend itself against them.

 The vaccine is safe. While this vaccine was produced in an amazingly short time, results indicate that it’s very safe- certainly safer than doing without if you’re in one of the high-risk groups. Those groups are young children and the people who care for them, pregnant women, all people ages 6 months – 24 years all others with existing medical conditions.

 One last thing about the vaccine safety in general: there’s a scary trend, supported by several media personalities that encourages parents not to get their children vaccinated because of a misguided concern over the safety of the vaccines.

 The Healthcare Consumer’s position is that this is an unfortunate and dangerous trend, both at the individual level as well as at the societal level. Although you might think the safest thing to do would be to lock our children up and never allow them to be exposed to the outside world, that’s not practical. In fact, kids need to be exposed to germs in order to develop healthy immune systems. So, instead, we assess risk and then make a decision.

 By definition, vaccines aren’t 100% safe; but they’re darn close. To skip vaccinations is to potentially reintroduce diphtheria, pertussis, measles, polio and other horrific diseases back into a society which had effectively eradicated them.  If you’re concerned about vaccination, we recommend the information provided by the CDC here. 

Receiving the vaccine does not guarantee that you can’t get H1N1. But it does dramatically reduce the chances. This is actually true of all vaccines. The point behind vaccines is to stimulate the body’s own immune system to produce enough antibodies to protect against infection. In actuality, everybody responds differently and some may take weeks to develop immunity. 

Washing your hands doesn’t kill the H1N1 virus. …But, hand washing is still the best way to prevent transmission of most germs including the flu. The focus here is on “transmission”.

When you wash your hands you are reducing the number of germs through friction, exposure to soap and water and by rinsing. If you have few germs on your hands, you’ll transfer less to another person, object, or even to your own eyes, mouth or nose. So don’t stop washing! Here’s something to think about when you shake someone’s hand: According to the American Society for Microbiology, one in five people don’t wash their hands after using the restroom.                                                                                                                                       

Resources and things you can do

Your state health department will have the most up-to-date information about H1N1.

In Connecticut, the main points of contact are:

• The Connecticut Department of Public Health who handles allocation of all H1N1 vaccine supply that comes into the state and can provide some additional information via phone (800) 830-9426 and via their website.
• The health department operated by the town you live in who coordinates flu clinics when vaccine is available.
•   Your primary care physician who can tell you if you’re in one of higher risk groups and who may also receive vaccine doses.
•    While many of the drugstore chains offer flu vaccinations we’re not aware of any who are providing H1N1 and we believe they won’t have the vaccine for the foreseeable future. 
•    If you supervise people at work, be aware that many employees with flu symptoms will not take time from work for fear of placing their job in jeopardy or as is often the case, because they won’t be paid for the time off. 
•   We hope you’ll be clear in your communications that a) sick people get better and can be productive again faster when they’re at home resting and b) a so-called “dedicated employee” who comes to work while they’re sick with the flu and transmits the virus to their coworkers has not done you any favors.
• Get a regular flu shot. They’re effective, present little risk and who wants to be laid up for a week with any illness?
• Be persistent with your government representatives. If you feel as we do, that your government has failed you by not doing as good of a job as they should have in anticipating this and then doing a mediocre job of distributing the vaccines, let them know. Sometimes it’s easy to forget, but they work for us, not the other way around. 

Vidacura

The Healthcare Consumer is written by Larry Berk and Delaney La Rosa,RN,  healthcare and insurance professionals with over 25 years of combined experience. Larry is the President of VidaCura.com a health and wellness products company. VidaCura can be found online at www.vidacura.com. Delaney has been a healthcare professional for more than 18 years with a background in healthcare fraud investigation and is a registered nurse. Got a question, comment or suggestion for a column? Write to them at thehealthcareconsumer@yahoo.com.

The Healthcare Consumer

Helpful things I learned recently about dying

Part 3 on Larry’s mother passing away

Last week I talked about the role that hospice played in the last months of my mother’s life.

If you spent even 30 minutes with her, the first words you would use to describe her would be “in charge.” She was in charge of her life. So it wasn’t a surprise to my sister, brother or me that she would want to be in charge of her death as well.

This week, we’re venturing into territory that many of you may find uncomfortable: the topic of a dying family member considering options to end her life on her own terms.

Some who read this may find the concept of the choice to die objectionable. To those readers, we ask that you step back and consider what your feelings might be if a loved one faced a similar situation: having one of the most painful cancers a person might experience. A brief web search (my mother found this on her own) will drive the reader to discussions and papers regarding the difficulty of controlling pain in the final stages of pancreatic cancer. My mother knew what she was up against, and we put aside our judgments to support her quest for a humane end.

Personally, a lesson I’ve learned over the past six months is that death IS a part of life and that a terminally ill patient deserves to know the options they have regarding pain and eventual death. It was an odd feeling that at the exact same time my siblings and I were struggling to get answers to our terminally ill mother’s questions about dying on her own terms, our national healthcare debate exploded with highly polarized views of end-of-life discussions.

I was incensed by the politicians who claimed doctors being paid for taking time with their dying patients to explain end-of life options were somehow wrong, that these would amount to “death panels.”

I reflected on my family’s current circumstances, the sometimes reluctance of my mother’s physicians to discuss dying, and the difficulty we faced in collecting information about end-of-life choices.

Personally, I want my healthcare insurer to give doctors payment for the kind of conversation we desperately needed.

Getting back to my mother; if you spent even 30 minutes with her, you would likely describe her as “in charge.”

She certainly was in charge of her life, so it was no surprise to my sister, brother or me that she would want to be in charge of her death. Initially, my mom wanted the option of hastening her own death to avoid unnecessary treatment and needless pain.

Unfortunately, that can be an almost impossible-to-satisfy request.

First, we knew there was a high likelihood that my mother’s pain would reach a point that was difficult to control (this is a well-documented phenomenon in a very few cancers).

Second, the laws in place today prevent healthcare providers from assisting patients to end their lives under any circumstances.

My mother, a very pragmatic person, continually asked her caregivers for information about ending her life.

She simply didn’t understand that she couldn’t request a healthcare provider to assist or inform her regarding her death.

In her desperation to have a choice, my mother asked my wife and co-author of this column (an R.N.) to provide the information and support to end her life.

After a tearful conversation between the two, my mother came to understand that moral, ethical and legal restrictions prevented her from giving my mother what she wanted most.

My wife knew what my mother was facing, she had cared for others dying of pancreatic cancer, yet she was powerless to do anything but provide emotional support and comfort. This was a wrenching situation for both my mom and wife to face.

In her desperation, and without the benefit of guidance, mom came up with the idea of intentionally overdosing using an over-the-counter pain medication.

Again, my wife ultimately was left to describe the likely outcome of this attempt: My mother would likely live confined to the hospital for some or all of her remaining time facing the possibility of additional pain or organ failure caused by the drugs.

What she wanted more than anything and as we uncovered in our research is that she wanted to have a medication at hand that, should she decide to take it, would bring a peaceful end to her life.

Note that I said that she only wanted to have the medication “at hand.”

We have no idea whether she would actually have taken it, but we knew that it would have been of great comfort to her if she had the option.

With only a few exceptions, it’s unlawful for a doctor to write such a prescription.

Doctor-assisted suicide has been legal in Oregon since 1997 and in Washington state since 2008 when aptly-named Death with Dignity acts were passed.

In short, the acts allow terminally ill adults to obtain lethal prescriptions if they are deemed competent.

But the legal details are complicated.

You must usually be a resident of one of those two states and you must have an ongoing relationship with a physician there.

More recently, Montana courts have ruled that a terminally ill patient who finds his/her suffering to be unbearable has the right to receive self-administered medication to hasten death and that doctors cannot be prosecuted for providing that medication.

Their requirements are similar to those of Oregon’s and Washington’s.

Interestingly, in those states, although physicians have written many, many prescriptions, the actual number of instances where the patient has made the decision to take the medication is small. Clearly people who are near the end of their life want options.

We then discovered Compassion and Choices, a wonderful organization that provides consultation to people who are facing an imminent end to their lives.

They listen without judgment, answer questions and guide in the search for a peaceful, humane death.

I spoke to a counselor who agreed to talk with my mother. Something I really appreciate about Compassion and Choices is that they take over the painful and difficult discussions with your family member.

Finally, my mother had a source for information and some hope of controlling the circumstances of her death. They spoke on many occasions throughout the final two months of my mother’s life, and our family was free to go about making her final days as peaceful and fulfilling as possible.

Ultimately, my mom’s choice was simply to stop eating.  It wasn’t a hard decision for her. Food didn’t appeal to her. She remained in hospice and lost weight steadily, but remaining lucid until almost the very end. We believe she didn’t suffer, and we know she left this earth on her own terms.

As a footnote, it is generally unlawful in most states for a physician to provide aid in the form of writing a prescription for a lethal dose of medication in dying to a terminally ill, mentally competent adult.

But there are bills pending in 10 states around the nation to change this.

In Connecticut, Drs. Gary Blick and Ron Levine are asking a Connecticut court to rule that a physician who aids a terminally ill, mentally competent adult in their dying not be regarded as assisting a suicide.

We hope you’ll share your opinion on this emotionally charged topic. Ours is that people who are capable of making choices should be offered the ability to make them and the knowledge to understand them.

The Healthcare Consumer is written by Larry Berk and Delaney La Rosa,RN,  healthcare and insurance professionals with over 25 years of combined experience. Larry is the President of VidaCura.com a health and wellness products company. VidaCura can be found online at www.vidacura.com. Delaney has been a healthcare professional for more than 18 years with a background in healthcare fraud investigation and is a registered nurse. Got a question, comment or suggestion for a column? Write to them at thehealthcareconsumer@yahoo.com.