Wednesday Morning

It's Wednesday morning, July 8, 4 am. I just finished my shower and at-home surgical scrub in preparation for going to the hospital, to check-in, not for same day surgery, but for a major heart operation. The insurance company prefers it this way, saving the cost of one night's hospitalization. I slept well, largely because we saw Dr. Rosenbloom yesterday morning. In what seems a sudden reversal (although he suggests we might have misunderstood him before) reminiscent of John McCain's 2008 campaign strategy, Dr. Rosenbloom now suggests, seems to even favor, and suggests he would do it himself were he having heart surgery, that, in the event I need two valves, he would put a tissue value in the mitral position. Maryka and I were both shocked, yet extremely buoyed by this reversal. I think this is why I slept as well as I did, and am happily blogging at this very moment.

Last post before surgery

It's Tuesday. We saw the surgeon, and now it seems that, if I need to replace the mitral valve, I can have a bio valve, for that one as well. That's a relief. Click, click, click, click, plus Coumadin off the have-to-deal-with list.

I'm keeping this post short. Matt is in town and I'm really enjoying our time together. I'll be back on line when I get home, or maybe before, from the Cooper Hospital Internet Cafe.

You've got mail

This week, Cooper Hospital sent me an envelope with information about my coming hospital stay. In an attractively designed folder, I saw pictures of an ecstatic looking, older woman with her daughter, beaming and hugging, next to a young couple tossing their gleeful children in the air, with three pictures of hospital staff, who seemed friendly but appropriately serious. The folder provided a compilation of fundamentally unnecessary information (parking fees, visitor dining options), blank legal forms (advance directives, living will declarations), internet options, and, of course, a prepaid return envelope, asking me for $200 before I get there. The internet options and the pre-admission charge are the topics of today's post.

I had assumed that I would be out of internet contact during my stay at the hospital, but, lo and behold, Cooper provides free wi-fi service. Explaining this option, they include the Wayport Connection Guide. It has a picture of a woman, smiling, sitting in her bed, with an identification bracelet and wearing a hospital gown, with a laptop on her lap. I wonder, "Where are the tubes?" I have been picturing myself lying in bed, with a ventilator down my throat, a catheter in my penis, and an assortment of other devices inserted in every possible entry into my body. I did not realize I was going to an Internet cafe.

But the real purpose of this communication is the $200. What if don't send it in? "Mr. Goldberg, we're sorry, but we canceled your operation. Payment was not made." And $200. When I was sick in February, the bill for six days, between two hospitals, was $80,000. I am guessing that this operation is going to be in the quarter million dollar range. Shouldn't we talk about this in person? No one really discusses the charges. Just $200, and I've bought an operation.

Let's backtrack. I said $80,000, but that's not what I paid (or could have paid if I wanted). My charge is $4500, the annual out-of-pocket in my insurance contract. I've already met it, so I shouldn't really owe them $200. But the $80,000 is an illusion. They're not getting $80,000. They're not getting $40,000, or even $20,000. The total payment my insurance company made was about $12,500: $63,000 adjustment, $4500 my responsibility, $12,500 from them. Even with $200 up front, that's less than $13,000 guaranteed, most written off, some they hope to collect from me.

A couple of weeks ago, I went to Massachusetts to help Sasha buy a car. We paid $10,500 for a used Honda. We did not walk out of the showroom, not knowing what the car would cost. Yet, there is no price list for my operation. I couldn't get one if I asked, since they have to see what the insurance company, not only pays, but what they allow. Just $200, and the heart operation is mine.

I've been trying to make sense of this financing issue in the face of the larger, national health care debate. What if I were not insured? Would I be sent a bill for $80,000? How would I know that the hospital would accept $17,000 instead? We hear about people going into bankruptcy, losing their homes, because of medical debt. But are we aware that this debt comes from a bill that is nearly 5X higher than the actual cost? I'm sure there are some justifications, for this practice, based on balancing a budget and allowing for indigent care. Yet, how is this not a bait and switch scheme, in which the buyer does not know what the product really costs?

I don't hear this in the national health care debate. We talk about rising hospital costs, but we don't talk about deceptive hospital charges. We talk about medical debt, but we don't talk about truth-in-lending. I think this is one more reason for substantial health care reform.

Four days to go

It's Saturday morning. Time is running short, and so will this post. I have many things to do before the operation. Only four days to go. Yesterday, I saw my last client and started my nose gel. Today and tomorrow, I'll be writing reports. I'm hoping to get everything done before Matt comes in Monday morning. I'd like to spend the last two days, relaxing, with little to "get done."

I played tennis this morning, and felt very well, causing me to have another brief moment of doubt. I have 30 reports left to write this weekend. It's been a very busy month. Carrie and I were talking about it, and neither of us can recall a busier month in years. So, here I am, continuing to work overtime, so I can check in Wednesday morning, and have a heart operation. I don't think they'll be using my story for an episode of House.

The Countdown

We recently completed a two year electoral process leading to the historic victory of Barack Obama. Maryka and I spent hours, glued to MSNBC, hearing the same news repeated minute by minute, waiting for something to break. Yet, the only true news that really mattered came at the end, with the election results. I remember sitting with friends at church, watching the TV, waiting for the historic moment, 3 seconds after the polls closed on the West Coast, declaring Obama the victor. From one week before the election, we saw in the corner of the television screen, how many days and minutes still remained. The countdown to the end, and then it was over.

This week, I started my historic countdown to the big event. There has been a lifetime of waiting and months of anticipation. Hospitalized in February, Dr. Ginzburg later that month. Dental clearance in March. The surgeon in March, too. The transesophaghial echocardiagram, the determining test, in April. A call from the surgeon's office, asking me to set up an appointment, prior to the call from Dr. Ginzburg himself, announcing their final decision. May brought the crucial meeting with the surgeon to set the date, July 8. June 8, the earliest day I could have the needed, preparatory blood tests. These landmarks pale in comparison to what took place Wednesday this week, the historical beginning of the symbolic, but all important, countdown days. Yes, it was Wednesday, July 1, that I took that crucial step, stopping my fish oil, and the countdown began. Tomorrow, it's the antibiotic nose gel, twice a day, culminating in my last meal (well, let's not be that grim), Tuesday, July 7 (that's because I can't eat anything after midnight) and the long trip to Cooper Hospital as the show begins.

Five days and counting.

Seeing Dr. Ginzburg

I had an appointment with Dr. Ginzburg yesterday. He has been my cardiologist for the last 22 years. He is very cautious and was the last doctor on board for this operation. From a medical perspective, this was a completely unnecesasry visit, but I wanted to see him, once more, before the operation. Although I've always liked him, I felt a special humanity today. We all have habits, and I have become accustomed to Dr. Ginzburg's. He starts his office visits with a smile, a handshake, questions about how I am doing, a few light interchanges, the physical exam, feedback, and I'll see you in six months, possibly with an echocardiogram in between. We usually joke about one thing or another, and I'm out in about 40 minutes. Today, following the handshake, Dr. Ginzburg sat on a chair, crossed his legs, smiled and fielded my questions. He immediate recognized, and was sensitive to the fact that I was there for no reason other than to babble, and re-ask questions I had asked before.

Dr. Ginzburg chuckled a bit after reading Dr. Rosenbloom's (the surgeon) letter in which he mentioned that he gave me the choice of three valves. He did not expect that, and I don't think he had seen this before. Dr. Ginzburg said that they were all excellent valves, and that, in his experience, different surgeons simply get used to using one, and then keep using that valve. Who knows? I'm sure they all have well paid, manufacturer representatives who try their best to sway the surgeons in their direction. I certainly could see nothing, convincing, when I tried to review the research, to point to one or the other.

Afte I left his office, I realized that this was the first time I ever saw Dr. Ginzburg in which he did not conduct a physical examination. It was clear, he knew I was anxious and he was there, simply, to listen.

Picking a valve

When I was in the hospital in February, and there was serious consideration of doing surgery then and there, I was told that I had a choice to make. I could have a mechanical valve. I could have a tissue valve. The advantage of a mechanical valve is that it lasts forever. Its disdvantages are that I would have to be on lifelong Coumadin, an anti-coagulant, and that it makes noise. With a tissue valve, it would be silent and I would not need the anti-coagulant, although it may not hold up for the rest of my life. At 62 years of age, I am in a gray zone regarding whether I should go for the tissue valve, with its limited life expectancy, or the mechanical valve. There is one caveat, which pushes toward the tissue valve, and that is developing technology. There is a reseach project going on now, in which they are replacing heart valves through a catheter. If it is successful, and the doctors believe it will be, that technique would be available by the time I needed another operation. This would be like using a stent to treat a blockage in the coronary arteries instead of heart bypass surgery. If I had the surgery in February, my knowledge and choices would have been limited to the information I just gave.

With the operation in July, I have been given a larger number of things to think about. First, it is not completely clear that the surgeon can avoid using mechanical valves. I use the plural, valves, because he will not know whether he can fix my mitral valve until he sees it. If he can, that's one valve, the aortic, which will be replaced. He can use a tissue valve for that. If he has to replace the mitral valve, he is not willing to use a tissue valve for that (it does not last as long as an aortic tissue valve), so its a mechanical valve, with lifelong Coumadin. So as long as I'm taking the Coumadin, he would use mechanical valves for both.

My surgeon likes the St. Jude valve, a tried and true product, which has been on the market for years. There are some other valves, some he'll use, some he won't. Two valves he feels comfortable with are the On-X or ATS valve. He suggested I look them up.

For years, Maryka and I drove two cars, a Honda Accord and a Dodge Grand Caravan. The Accord, as I am sure you know, is a reliable sedan. The Grand Caravan is a family car, useful for transporting a caravan of young people, to school events, parties, and baseball games. More recently, I purchase a Hynundai Elantra, less flashy than the Honda, but clearly an econcomical, reliable car. With the children grown up, Maryka said she wanted a Mazda Miata. When she first said this, I did not exactly know what it was. But the name, Miata. Hm. Caravan? Miata? It speaks for itself. Sometimes, I drive her car, since she needs mine if she goes shopping, or has more than one passenger. Pretty neat, a 62 year old man, motoring around in a cool sports car.

So, I'm been thinking, am I going to settle for dowdy St. Jude's valve, or be hip this time: an ATS. Maybe, I should really get bold, and ask for the On-X.