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Health Care Reform: Are Doctors the Real Problem?

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Health Care Reform: Are Doctors the Real Problem?

The villains in the battle over health care reform in the U.S. are obvious, right? The insurance and pharmaceutical companies are not-so-quietly lining the pockets of their corpulent, greedy CEOs, who sit in corner offices adorned with centuries-old pine wooden desks and golden toilets, while doctors, patients, and businesses small and large are getting squeezed dry. But real reform requires a less one-dimensional examination of the industry, one that reveals a much more systemic assortment of maladies plaguing the system as a whole. President Obama has made prevention a pillar of his health care reform plan, suggesting patients’ poor diets and exercise habits are partly responsible for the astronomically rising costs of care. (According to the National Coalition on Health Care, health care spending represented 17 percent of the country’s gross domestic product in 2007, and is expected to reach 20 percent or more in the next eight years, and yet U.S. health care is ranked 37th by the World Health Organization.) Rush Limbaugh, he of the beer belly and hunger for prescription drugs, mocked Obama’s assertion, inanely postulating that it’s not the overweight or physically unfit who are the biggest burden on health care, but the physically active, who, he says, sustain injuries that cost taxpayers millions each year. And they say laughter is the best medicine.

A few months ago I made a rare trip to my primary care physician. His office is a veritable hole in the wall, with a sign on the window of the front desk that reads, “Do not ask how long the wait is or how many people are ahead of you.” He overbooks his schedule, no doubt to make as much money as he can; I waited two-and-a-half hours to see the doctor despite having scheduled an appointment. After a tirade about how changes in the system have forced him to refuse patients who don’t have coverage or who simply can’t afford to make their insurance co-payments, he informed me that it would likely be over a week before my HMO approved his referral for a CT Scan. In the meantime, he sent me for lab work.

When I received my blood results, I noticed that one of the tests my doctor ordered wasn’t performed. I called his office to ask him about it, and was told that “everything is fine” and that if I wanted to talk to the doctor, I should make an appointment. I insisted but was again refused, so I hung up.

I eventually went for the CT Scan and received a call from my doctor’s office several days later once again telling me that “everything is fine,” but that the doctor wanted me to stop by and pick up a new script for additional lab work. After waiting for an hour and a half, he told me that one of the tests he ordered wasn’t performed. I informed him that had he taken my call two weeks earlier, he would have known that already, and that perhaps the CT Scan, the necessity of which he fought with my insurance company about, might not have been necessary after all. He explained that he prefers to talk to his patients face to face and told me not to worry about the co-payment, which I had no intention of paying anyway. It occurred to me that, co-payment or not, he was planning to submit this “follow-up visit,” consisting of a gratuitous thermometer in my mouth and a brief conversation that should have taken place over the phone, to my insurance company for reimbursement.

Judging by the overall conditions under which my doctor practices, his actions might simply be a necessity of survival—having been fought tooth and nail by the insurance companies to do what he told me loves to do: practice medicine. And as someone who despises how the health insurance industry operates, I can certainly empathize with his plight. But not when it’s at the expense of his patients’ financial and medical well-being. More importantly, I couldn’t shake the feeling that I was being made an accessory to insurance fraud.

I’ve been following the health care reform debate closely since I began paying for my own policy out-of-pocket several years ago, and while I’ve heard lots of buzz terms being tossed around (efficiency, waste, choice, competition, public option), I’ve rarely heard anyone in the mainstream media discuss the role health care providers have played in the crisis. Even Obama, who received a tepid response from the American Medical Association last month, has been loathe to criticize doctors. And then I stumbled upon an article in The New Yorker (not exactly a bastion of the mainstream) by Atul Gawande, a surgeon at Brigham and Women’s Hospital and a professor at Harvard University, that sets out to find an answer to why the health care costs in a poverty-stricken Texas bordertown are some of the highest in the nation despite having state-of-the-art technology and facilities.

One of the factors Gawande examines is the profit motive of providers, who enjoy kickbacks for admitting patients to hospitals and, presumably, referring them to specialists and other agencies. In some cases, doctors are even paid a percentage of the profits from tests and procedures performed at what are called physician-owned hospitals. Doctors in the small town in question were prone to “overutilization,” ordering procedures that, among other things, serve as a preemptive defense against malpractice lawsuits, and performing unnecessary surgeries when lifestyle changes and pain management would be just as effective—and cheaper. It’s possible that a significant number of “unnecessary” tests would rule out more serious conditions, and therefore reduce the number of more invasive (and expensive) procedures that may have been performed based on less accurate testing. But how many doctors who view their practice as a profit-based business feel compelled to order unnecessary tests simply to pay for the cost of running their business?

Doctors in the U.S. perform more operations than doctors in any other country in the world, and there’s no evidence to suggest that we’re any better off because of it. (The U.S. ranks 45th in life expectancy, below Cuba.) And the cost of certain procedures—like CT Scans, for instance—is also more expensive, but that doesn’t mean the quality of care or the accuracy of the results is any better. Due to subsidies, the equipment required for a CT Scan reportedly costs 40% less in a third-world country like India than it does in the U.S., and the average cost of one contrast scan here could pay for dozens of similar tests in Mumbai. So what accounts for this discrepancy?

The U.S. is a nation filled with the best and brightest physicians and technicians who have attended some of the most respected and expensive universities in the world. The cost to our providers is bound to trickle down to their patients. But radiology isn’t brain surgery; the cost of interpreting a CT Scan simply doesn’t justify the exponential cost incongruities being shouldered by Americans. Technical and professional fees are part of the problem, but that doesn’t explain how the cost of a test like a CT Scan varies so wildly in the U.S. (The fact that one has to “shop” for the best deal when it comes to potentially life-saving tests is obscene, but that’s a whole other topic.)

One factor might be that the cost of treating the uninsured—or the underinsured, which was the subject of a front-page article in The New York Times last week—is built into the cost paid by those who can afford to pay. The radiology clinic where I had my CT Scan offered to drop off the contrast fluid I had to drink prior to my test and gave me a ride to and from the clinic on the day of my test. This was a service provided by the clinic and wasn’t billed to me or my insurance (I know because I asked—twice). It was generous and helpful, especially since I’d never been there before and don’t have a car, but they no doubt offer this “free” service to all of their patients, not just those who are insured. Someone has to pay for it. A country with 45 million uninsured is bound to see its health care costs skyrocket.

Universal coverage isn’t feasible if large segments of the population are being priced out of the market. Blatant profligacy within the system, specifically of the variety Gawande has unearthed, means that prices won’t be dropping any time soon. But ironically, it also means reform isn’t a hopeless venture. Taking care of everyone doesn’t mean the country has to go bankrupt or that we have to saddle our grandchildren with even more debt. If we’re indeed wasting money, and that’s recognized as a reality on both sides of the aisle, that means at least one buzz term, “efficiency,” truly is the key to reform. Obama may be pointing one finger at the overweight, but as Gawande shrewdly observes, “the idea that there’s plenty of fat in the system is proving deeply attractive.” We just need to admit who the fat ones are.

Changing the culture is essential to solving the problem. Defensive medicine costs tens of billions each year. And doctors whose focus is not on patient care but on money—whether it’s profit-motivated or simply a matter of survival—might not even realize they’re part of the problem. The discussion draft of the House bill provides incentives for accountable care organizations, which are comprised of doctors and specialists who collaborate in networks—not for profit or kickbacks, but for results. These kinds of networks would purportedly discourage profiteering by changing the way doctors get paid through Medicare—paying physicians for results, not the quantity of service. Policymakers close to the bill say the details—how or if those changes are going to happen—haven’t been worked out yet, but what Congress seems to have realized is that Medicare is a barometer for the entire health care industry. As Medicare goes, so goes the nation.

It’s easy to blame one part of the system for the failure of the entire thing. But like the human body itself, health care is made up of the symbiotic relationship between separate but inextricably bound parts: providers, insurers, and patients. The House bill looks at the issue of reform from both sides: reforming delivery systems—how doctors are paid to create incentives for efficiency and quality—and adding a public plan to keep costs to consumers down. And while those goals might prove to be tricky (The Washington Post reported this week that a panicked health insurance industry is in full-on lobby mode, which means that even if a bill passes, it will likely be watered down), it’s still only one part of the solution.

Legislating cultural change is an essential component to reform, and while that’s likely to prove even more difficult, there has been some progress. At the beginning of the year, lawmakers introduced the Physician Payments Sunshine Act of 2009, a bipartisan bill that failed to make it through Congress two years ago but which, despite even stricter regulations, stands a better chance in the current economic and reform-happy climate. The legislation would amend the Social Security Act, requiring transparency in the relationship between physicians and pharmaceutical and biotechnology companies. The bill is currently under review, but even if it fails to pass a second time, the pressure has already forced companies like Pfizer and Merck to voluntarily disclose the amount of money they’re spending on things like consulting gigs, speeches, meals, and gifts—and to whom.

Additionally, nonprofit organizations like Area Health Education Centers are taking steps to offset Pharma’s influence on physicians. It’s a little disturbing to think that your local doctor’s office could be serving catered sandwiches for pharmaceutical reps who are hoping to peddle their latest inventions to the community via your family doctor, but that’s exactly what’s happening across the country. Doctors shouldn’t have to choose between what’s in the best interest of their patients and what’s in the best interest of keeping their practices in business. And we shouldn’t have to worry that our doctors aren’t on our side.

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Review: That Was Something Lays Bare the Ephemeral Desires of a Lost Youth

By the end, the lesson we’ve learned is that the stories we tell ourselves about the past have always been revised from a previous draft.

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That Was Something

Film and theater critic Dan Callahan’s witty debut novel, That Was Something, chronicles the young adulthood of Bobby Quinn, a gay Midwestern transplant who’s just moved from Chicago to Manhattan to attend New York University. Retrospectively, it examines his obsession with the two leading players in the story of his early days in the city in the late 1990s: the enigmatic Ben Morrissey, an irresistible fellow student destined for fame in the art world, and the mysterious Monika Lilac, a dramatic and performative slightly older cinephile whose devotion to silent films is emblematic of her entire character. “I was looking for the keys to the kingdom, and I found them or thought I did in Manhattan screening rooms, in the half-light and the welcome dark,” Bobby declares to the reader in the novel’s opening, and so begins a provocative—and conspicuously wine-drenched—narrative that serves both as a paean to a bygone era and an emphatic testimony about how we never really leave behind the people, experiences, and places that shape us into who we are in the present.

For a fleeting period of time, the lives of these three characters become intertwined and united by their shared passion for the cinema—and for each other. While Ben and Monika enter into a tumultuous romance, Bobby watches from the sidelines as he privately explores his own sexuality, mostly in dalliances with anonymous older men who he meets at bars in Chelsea, having learned to offer himself up “as a kind of virgin sacrifice.” Throughout, Callahan’s frank descriptions of Bobby’s early sexual experiences are a welcome departure from metaphor, while still seeming almost mythical in the way that Bobby recalls them, just like how all of the liminal moments in our lives—the moments in which we cross a threshold and permanently abandon whoever we had been before—seem to mark our personal histories almost like the transitions between the disparate chapters of a novel.

Bobby has been deeply in love with Ben ever since the two met for the first time in a common area of their shared dormitory at NYU, and Ben keeps Bobby only barely at arm’s length—sexually and otherwise—throughout the dazzling weeks, months, and even years of their relationship as young men. He constantly reminds Bobby that they would probably be lovers if only Ben were gay, which is obviously music to Bobby’s ears, fueling many of his private fantasies. And Bobby is also the prized subject of Ben’s budding photography career, often photographed in the nude, and both the photographs themselves and the act of bringing them into the world blur lines of sexuality and masculinity as the friendship between the two young men deepens and becomes increasingly complex.

Callahan cocoons his characters in what feels like a time capsule, capturing them at their most beautiful and glamorous and then presenting them to us as if on a stage—or on a screen, which the characters in the novel would agree is even more intimate, even more akin to a grab at immortality. Other characters drift in and out of the central narrative in the same way that one-night stands and people we’ve met only at dimly lit parties can sometimes seem blurry and indistinct when we try to recollect them later, but the love story that Bobby is most interested in sharing with the reader is that of a queer young man’s obsession with his larger than life friends during a time when everything for him was larger than life.

Callahan’s previous book, The Art of American Screen Acting: 1912-1960, demonstrates the author’s talent for dissecting the subtlety and nuance of the many nonverbal ways in which the icons of the screen communicate with one another, and here too in That Was Something is close attention paid to the power of performance. The novel is also a story about falling in love with a city, even in retrospect—and even after the version of the city that you originally knew is gone forever. And in the familiar yet always poignant way in which the sights and sounds of a lost New York typically wriggle their way into a novel like this one, the city is at first a backdrop before it inevitably becomes a character.

Monika Lilac hosts a silent film-themed party at her house during which the guests have been cleverly instructed to pantomime their communication to one another rather than speak out loud, and to write out any absolutely necessary dialogue on handmade title cards. At the end of the party, the various revelers—wearing only their underwear, at Monika’s command—all together “streamed out into the night and ran like crazy” through New York City streets while being pummeled from above by heavy rain, not caring at all who was watching. And Bobby, from the vantage point of years in the future, recalls:

In any other place, we might have been harassed, arrested, or the object of wide-eyed stares. Not in Manhattan. And that has its flip side, too. Because Manhattan will let you do whatever you like, at any time of the day or night, but it won’t ever pay attention to you. You can be world famous, and Manhattan still basically doesn’t care, most of the time. And if you aren’t world famous, Manhattan regards you at several ice-slicked levels below indifference. And sometimes, on less wonderful days and nights, some attention might be welcome.

In a blurb on the novel’s back cover, Wayne Koestenbaum describes That Was Something as “The Great Gatsby on poppers,” and there’s definitely something of Nick Carraway in the voice of Bobby Quinn as he looks back at his disappearing New York and the people who populated it, the ghost of a city that disappeared forever the moment he looked away. Callahan’s novel enters the canon of the queer roman a clef—as well as the literary New York novel—by mixing vibrantly realized memories of a fleeting youth, ruminations on the origins of desire, and a deeply felt nostalgia for the way things once were into a cocktail that tastes exactly like growing up and growing older in the same city in which you were once young. And the hangover after a night spent knocking them back in the dim light of a Manhattan dive, as anyone who still occasionally haunts the haunts of his youth can tell you, is always brutal.

Bobby is now many years older as he narrates That Was Something, his desires tempered or at least contained by realistic expectations of how and in what ways they might be satisfied, and his relationships with Ben (now famous) and Monika (now vanished) are either nonexistent or else greatly demoted from the centrality that they had once firmly occupied in the narrative of his life. But there’s still urgency in what Bobby is telling the reader. In the novel’s brilliant final pages, we come to realize that the act of looking back at our younger selves is both masturbatory and transitory, mostly an exercise in framing. Bobby has been explaining how age has made him wistful about his moment in the sun, but then he’s suddenly remembering a fantasy that he once enacted alone one afternoon in his dorm room, back when he was still a virgin—and back when all of his fantasies were about Ben Morrissey:

I entered another place with my mind. It felt like what stepping into the past would feel like now, maybe. It was forbidden, and I was getting away with it. … Looked at from the outside and with unsympathetic eyes, it would be pitiful and grotesque, maybe even laughable. So why am I still so certain that something else occurred?

The lesson we’ve learned by the end of That Was Something is that the stories we tell ourselves about the past have always been revised from a previous draft. Just think of all that film that ends up on the cutting room floor during the editing process, to be forgotten and swept away with the garbage after the best take has been safely delivered. Only with the benefit of hindsight can we wipe away the shame and growing pains of early stabs at love and failed expressions of desire and instead render the past beautifully, artfully, just as the cinematic film frame limits our perspective so that all we can see is what the director has meticulously manufactured specifically for us. The equipment that made the image possible in the first place has been painstakingly concealed, so that all we notice—all we remember—is whatever ends up remaining beneath the carefully arranged spotlight.

Sometimes a great novel, like a great film, can at once transform and transport us, offering a glimpse into a lost world made all the more beautiful by the distance it asks us to travel into our hearts and minds. At the end of one of the last film screenings that Bobby attends in the company of Monika Lilac, she says wistfully to him, “You know, you’re downhearted, and you think, ‘What’s the use?’ and then you see a film like that and it speaks to you and suddenly you’re back in business again!” And the film they’ve been watching, she has just whispered to Bobby as the credits rolled in the emptying theater, was the story of her life.

Dan Callahan’s That Was Something is now available from Squares & Rebels.

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Blu-ray Review: Peppermint Soda Gets 2K Restoration from Cohen Media Group

Diane Kurys’s poignant debut powerfully evokes the bittersweet feelings of leaving behind the halcyon days of one’s youth.

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Peppermint Soda
Photo: Cohen Media Group

Diane Kurys’s Peppermint Soda is like flipping through a young girl’s diary, capturing as it does snippets of the small-scale tragedies, amusing hijinks, and quotidian details that define the lives of two Parisian teenage sisters over the course of their 1963-to-‘64 school year. Through a delicate balancing of comedic and dramatic tones, Kurys’s debut film taps into the emotional insecurities and social turmoil that accompany the awkward biological developments of adolescence with a disarming sweetness and subtlety, lending even small moments a poignancy that shuns overt displays of sentimentality or nostalgia. As evidenced by the opening title card, in which Kurys dedicates the film to her sister “who has still hasn’t returned my orange sweater,” Peppermint Soda’s authenticity arises from its specificity, both in its characters’ tumultuous inner lives and the detailed rendering of their friends and teachers, as well as the classrooms within which they passed their days.

Structured as a series of loosely connected vignettes, the film bounces between the introverted 13-year-old Anne (Eléonore Klarwein) and her outgoing, popular 15-year-old sister, Frédérique (Odile Michel), who both attend the same strict, bourgeois private school. While Anne’s concerns often verge on the petty, be it her frustration at her mother (Anouk Ferjac) refusing to buy her pantyhose or at her sister for preventing her from tagging along to social gatherings, Kurys depicts Anne with a uniquely compassionate eye, mining light humor out of such situations while remaining keenly aware of the almost insurmountable peer pressures and image-consciousness that are the driving forces behind most irrational teenage behavior.

Some scenes, such as the one where Anne’s art teacher ruthlessly mocks her drawing in front of the class, are representative of the emotionally abusive or neglectful relationship between Anne and many of the adults in her life, and throughout, Kurys understands that it’s how Anne is seen by her classmates that most dramatically affects her state of mind. In the heightened emotional state of teenage years, the sting of simply not having a pair of pantyhose can be more painful than a teacher’s overbearing maliciousness. But Peppermint Soda isn’t all doom and gloom, as the bitter disappointments of youth are counterbalanced with a number of droll passages of Anne gossiping and goofing off with her friends. Particularly amusing is a conversation where Anne’s friend confidently, yet with wild inaccuracies, describes sex, eventually guessing that boy’s hard-ons can grow to around six feet long.

In Peppermint Soda’s latter half, Kurys seamlessly shifts her focus toward Frédérique, broadening the film’s scope as current events begin to shape the elder sister’s political consciousness. Everything from John F. Kennedy’s assassination to a classmate’s terrifying firsthand account of the police’s violent overreaction to a student protest against the Algerian War lead Frédérique to slowly awaken to the complexities of the world around her. But even as Frédérique finds herself becoming quite the activist, handing out peace pins and organizing secret meetings in school—and much to the chagrin of her mother and her sexist, conservative teacher—she’s still prone to fits of emotional immaturity when it comes to her boyfriend.

It’s through these frequent juxtapositions of micro and macro concerns, when the inescapable solipsism of childhood runs head-on into the immovable hurdles and responsibilities of adulthood, that Peppermint Soda most powerfully evokes the bittersweet feelings of leaving behind the halcyon days of one’s youth. Yet the sly sense of whimsy that Kurys instills in her deeply personal recollections acts as a comforting reminder of the humor tucked away in even our darkest childhood memories. Sometimes it just takes a decade or two to actually find it.

Peppermint Soda is now available on Blu-ray and DVD from Cohen Media Group.

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Oscar 2019 Winner Predictions: Sound Editing

If it were biologically possible to do so, both Ed and I would happily switch places with A Quiet Place’s Emily Blunt.

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First Man
Photo: Universal Pictures

If it were biologically possible to do so, both Ed and I would happily switch places with A Quiet Place’s Emily Blunt, because we’d much rather give birth in a tub while surrounded by murderous blind creatures than have to once again write our predictions for the sound categories. As adamant as we’ve been that the Academy owes it to the nominees to air every category, which they agreed to after an extended “just kidding,” it might have given us pause had the sound categories been among the four demoted by Oscar. But no, we must now endure our annual bout of penance, aware of the fact that actually knowing what the difference is between sound editing and sound mixing is almost a liability. In other words, we’ve talked ourselves out of correct guesses too many times, doubled down on the same movie taking both categories to hedge our bets too many times, and watched as the two categories split in the opposite way we expected too many times. So, as in A Quiet Place, the less said, the better. And while that film’s soundscapes are as unique and noisy as this category seems to prefer, First Man’s real-word gravitas and cacophonous Agena spin sequence should prevail.

Will Win: First Man

Could Win: A Quiet Place

Should Win: First Man

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