My Visit with Mosch

Saturday, I flew to Albuquerque and spent the day with Mosch in the rehab hospital. When I parked and walked up to the building, he was waiting for me outside, standing with his sitter and with Nancy and another friend. I was astonished to see this guy who looked kind of like Mosch and then have it turn out to be actually Mosch. He recognized me as I walked up, which was awesome.

Back inside the hospital, we walked around some. He asked me to tell him about what's going on with me right now, so I did, taking a couple of videos of him on my phone. He wanted to play cards, so we fetched some from the room and played a 5-person version of War. He was able to cut the deck, deal cards to each player when it was his turn, and determine which person won each round. (The only card he didn't recognize, at least before he got a little tired out, was the Joker.) When we stopped, he was able to count his cards in his head, and arrive at the right total (15).

Mosch is walking now, which is great. When he walks, he wears a wide canvas belt around his stomach, and his sitter walks behind him, holding onto the belt. His balance isn't perfect - he walks a little like a drunk guy, basically. But one of the great things about rehab, vs. the hospital he was in before, is that he can walk anytime he wants, and has a sitter 24/7 to go with him. Before he was apparently spending hours restrained and frustrated, trying to get out of bed, which was terrible and unhealthy.

Talking to him right now is like talking to someone who is mildly mentally retarded and/or has alzheimer's or has just woken up from a compelling dream. He talks just like Mosch, with all the verbal tics of Mosch, but sometimes the things he says don't quite make sense (they make, to me, "dream sense"). For instance, Saturday night he kept asking everyone for a screwdriver, which he said he needed to "unscrew his screwdriver."

He was at his best and most alert when I first got there. He was just realizing how impaired he is, and he said to me, "My brain isn't working right, and it's so important to me, it's such a big part of who I am." (It sounded so much like normal Mosch.) Upon my saying that he was doing much better, he said, "Better than what??" He wanted to know whether he had in fact been good (smart or with it or whatever) in the past. At one point he asked if he always walked like he was drunk.

After lunch, Nancy went to the library for a while to return some books, and I sat with Mosch in his room. I told him that I knew a lot about his life, and he asked me to tell him about it, so I told him basically his whole life story as I know it, and then some more little stories about himself. Through it all he had his eyes closed a lot and was nodding, smiling with recognition. Afterwards he said, "Wow. I had no idea you could tell it like that!" When I asked him if he remembered specific things, he would say something like "vaguely." I really enjoyed that whole conversation, which felt very natural and Mosch-like.

He gets frustrated and irritated a lot. They don't really do therapy on the weekends, so there wasn't much to do all day. He seemed to be looking for a purpose a lot. He would ask, "What's next?" We would go somewhere and he'd want to know what we (his visitors) wanted to do, and we didn't really have an agenda, of course, but that was annoying too. Why did we come out here if you didn't want to do anything? was what he seemed to wonder.

At one point we had a long (for him) walk and when we got back to his room, he said, "This is the same place we started out from hours ago. This whole place is BULLSHIT!" I'm sure it's very hard to have so much energy and restlessness without having any attention span or anything you're supposed to be accomplishing. I hope it's better for him during the week when "What's next?" can be answered with the different kinds of therapies. It's obvious that he wants to work. (When we were in the dining area looking at the TV, he said, "I'm waiting for him to take off his clothes so I can practice doing that." They've been doing that in occupational therapy, I guess. While I was there I saw him unbutton and remove a long-sleeved men's shirt, twice, which is pretty great for someone who couldn't use his left hand just a week or so ago.)

He's not so easy on the nursing staff, because he's often not cooperative and doesn't remember instructions. If he wants to get up, he is supposed to let the sitter know, and then s/he will help him with the belt, but instead he usually just starts clambering over the bed rails or bolts up. He often tries to remove the belt, which I'm sure is a little uncomfortable, sometimes over and over again while it's being explained why he shouldn't. He can't seem to hold information about that in his head, or else he just doesn't care. But the sitters have pointed out that having that drive and energy will help him get better faster than if he were more complacent, and I'm sure that's true. Mosch has always been careful to call a baby "easy" rather than "good" and that's kind of what applies here - Mosch isn't an easy patient but he's a good patient.

Overall, I really enjoyed being with him. Of course, with a person who is fully unconscious, like he was on my other visits, you can imagine that they'll wake up and just be normal, and you can't do that with a person who is awake and functioning but not normal. But you can still get some of the Mosch personality and it's much more interesting to interact with someone who is walking around and talking. He seems to be improving day to day and (vastly) week to week, so now it's just a question of how far he will come in his healing process. I'm feeling pretty optimistic about his future.

Unfortunate Political Positions

I have finally been convinced, by much argumentation here and there (mostly by Megan McArdle, if I'm honest), that health care reform as currently envisioned is a bad idea. Unfortunately, I also believe that the current system is untenable, and the only kinds of solutions I can imagine are not currently under consideration, and don't seem likely to become so.

I remain reluctantly in favor of the passage of a health care form bill along current lines.

How Doctors Are Paid

I once read an article in Slate arguing (not that this argument is or was unique to Slate) that one of the big problems with health care is that doctors are paid on a fee-for-service basis. Obviously this encourages doctors to run more tests and do more procedures than are in patients' best interests. Of course, someone's life is also on the line in some cases, so it's not as though a doctor can't convince themself that a precautionary measure is a good idea. (At my last office visit, I was offered a $200 test - which might or might not be paid by my insurance - to check if I might have low Vitamin D, just in case I should start taking some additional Vitamin D supplement. I declined.)

Of course, the obvious drawback to not paying doctors on the basis of the services they provide is, well, what is then their incentive to do anything? Sure, you could pay them based on some stable of patients that they manage, but a fixed salary seems to encourage doing as little as possible to earn that salary.

Well, of course, you could try paying the doctors based on the health of that stable of patients. This will encourage good preventative care. It will also encourage doctors to not take on new patients who are likely to be sick, and it will mean doctors in richer areas make much more money (probably already true). I suppose you could pay doctors based on how their patients fare relative to expectations (the way some school systems try to) based on their socioeconomic status and starting health, but this gets into a lot of games.

And then, I enjoyed David Goldhill's article "How American Health Care Killed My Father" which argues (though I can't do it justice with a single quote)

The most important single step we can take toward truly reforming our system is to move away from comprehensive health insurance as the single model for financing care. And a guiding principle of any reform should be to put the consumer, not the insurer or the government, at the center of the system. I believe if the government took on the goal of better supporting consumers—by bringing greater transparency and competition to the health-care industry, and by directly subsidizing those who can’t afford care—we’d find that consumers could buy much more of their care directly than we might initially think, and that over time we’d see better care and better service, at lower cost, as a result.

Goldhill's point is that a big problem is that patients don't really pay for their own care and, if you happen to be paying for your own care, it's impossible to find out what anything will cost anyway. There is really no way for consumers to comparison shop or determine what anything is worth to them personally.

But returning to the issue of doctor pay, which is an open question whether we have insurance or government footing the bill. My best guess is that different doctors respond differently to different incentives and that, assuming one system doesn't categorically pay better than another, it would be good to have different systems (some fee-for-service, some fee-for-patient, some fee-for-incident, and so on) and let each doctor choose the system that lets them do their best work.