Wednesday, September 16, 2020

A Brief Journey through the American Healthcare System...via Medicare (Copyright 2020 Virginia Zurflieh)


Author’s note: I’ve published this account on my Boxer Underground Blog, but be forewarned, its only relation to Boxers is the fact that my son and daughter moved in and cared for my three Boxers (and me) while I was in the hospital, and later, while I was recovering at home. Thanks, Linda and Rob! (Photos of Uno, Emma and Remy by Robert Zurflieh)


A Brief Journey through the American Healthcare System

…via Medicare

Copyright 2020 Virginia Zurflieh


What was I thinking? Apparently, that I was going to glide serenely through life from my 77th birthday to my 100th (thereby topping my mother’s record by 57 days) and arrive at a painless oblivion sometime thereafter…in my sleep.

I didn’t purchase a Medicare supplement and I hadn’t updated my six-year-old “homemade” will. I intended to have plenty of time to take care of things like that later.  I did sign up for the prescription coverage part of Medicare (Part D) – which is basically private, for-profit insurance – when I retired 12 years ago, but dropped it shortly thereafter. The insurance provider had steadily increased their rates, despite that from that date in 2008 to the Saturday morning in 2019 on which I went to the hospital, I was filling only one $10 prescription a month, plus the odd antibiotic for a dental procedure or sore throat now and then.

Then…WHAM…a trip to an urgent care clinic early one Saturday morning, a CT scan, a trip by ambulance to the hospital, more CT scans, exploratory surgery and a 28-day stay in the hospital followed by a 20-day stay at a “rehab center” – really a nursing home and a truly awful place. Also, three subsequent week-long stays at the same hospital and three months of home healthcare.

In addition to learning how totally unprepared I was for a major medical emergency, I also gained some insight into several facets of the American healthcare system that I would never have been aware of if I hadn’t been personally confronted by them.

1.    Immigration (yes, immigration): Judging by the hospital I stayed in, immigrants are utterly essential to the for-profit American healthcare industry, especially in Florida. My first stay was 28 days on an ICU floor. A large percentage of both the professional and support staff were immigrants. Many, but by no means all, were Hispanic. My surgeon was Croatian; the cardiologist was Indian as is my primary care physician (PCP); the GI specialist was Middle Eastern. Everyone that I encountered was competent and courteous. Most spoke fluent English. The same was true in other areas of the hospital in which I stayed during subsequent admissions. I can’t imagine how this hospital could have functioned without its immigrant staff.


The staff at the “rehab center” at which I spent 20 miserable days was also largely comprised of immigrants, but although most of them were helpful and kind, some spoke almost no English and were clearly several rungs down the status ladder from their hospital counterparts.


2.    Pain Management (as opposed to pain relief): Because of the current opioid addiction crisis, doctors these days live in fear that their patients are going to become addicted to the pain medication they prescribe. So, they prescribe as little as possible for as short a time as possible.  For me, it was simply a matter of trying to time one of my steadily decreasing number of pain pills per day to a half hour before the wound-care nurse came to change the wound vac three times a week. For people with unbearable, long-term pain – cancer, a broken hip, a condition that cries out for heavy-duty opiates on a regular basis – the prospect of their physician’s new pain management protocol must be terrifying.**


3.   Physical Therapy: PT joke: “I’m a Personal Torture Instructor…I Mean Physical Therapist.”  I’m sure many people benefit from physical therapy – people who’ve had orthopedic surgery to repair or replace a knee or hip, for example.  But I wasn’t in the hospital for a hip replacement and attached as I was to IVs and other medical paraphernalia, wasn’t even up for a walk to the bathroom. Nevertheless, because physical therapy providers contract with hospitals, rehab centers, etc., for so many hours of PT per patient whose PCP has prescribed it (mine was a PT believer), and because they only get paid if they perform the stipulated number of hours of PT, I was confronted several times a day by a pair of chirpy, gung-ho twenty-somethings who were determined that I was going to get out of the bed where I had been trying to catch up on sleep (ironically, the hospital was not a very restful place) and do anything that counted as PT, even just sitting up in the chair beside the bed for 30 minutes; or when I finally got to a bathroom sink, helping my daughter help me wash my hair. Torture – no; constant annoyance – yes.


4.    Big Pharma, Big Medical Bills and the rest of the story:

Here again, my ignorance of the American healthcare industry showed. When I signed up for Medicare Part D again in November 2019 after I got home, I learned that although the cost would have been $87 a month for the Part D insurance had I signed up when I first enrolled in Medicare and kept paying the premiums, it was now going to be $87 plus a $40 a month penalty…for the rest of my life. In other words, the insurance company was going to get theirs one way or another. Nevertheless, because Part D lowered the cost of one of my prescriptions from over $500 for a 90 days’ supply to $135, and because I had (due to dumb luck/reasonably good health) avoided the cost of that insurance for over 12 years, I didn’t say a word.


Another thing I learned was that neither my family doctor nor the cardiologist who prescribed the expensive medication seemed to have any idea what prescription medicines cost these days. Because my new Part D prescription coverage didn’t go into effect till January 2020 and I couldn’t afford $500+ for the medicine the specialist insisted I take, my doctor persuaded him to provide me with free samples. Then my daughter spoke to his office manager and she gave me a coupon for a free 30 days’ supply, which tided me over till January. (Who knew there were coupons? Not the cardiologist, apparently.) The last time I tried to order a 90 days’ supply, the pharmacy clerk told me I’d reached a “coverage gap,” and 90 days’ worth was going to be well over $300 (the dread donut hole?). I was able to order 30 days’ of the medication for only $45, however, so I took it and will worry about the coverage gap when I run out again at the end of the month. 


That was just one example of the outrageous cost of many prescription drugs for which there are apparently no cheap generic equivalents…but which miraculously become affordable once one purchases the Part D insurance.


As for big medical bills, Medicare came to the rescue again. The hospital bill was nearly $34,000. Medicare paid over $32,000; my copay was $1364. Certainly not a small amount, but compared to $34,000, a pittance.


The bill for my surgery was $89,700. And keep in mind, the anesthesiologist, radiologist, and other medical groups involved with the surgery and hospitalization billed me separately. The surgical group sent an itemized bill, but looking back over it, I can’t figure out what Medicare paid and what Medicare disallowed, or “adjusted,” (a term used numerous times in the surgeons’ bill). In the end, however, if my copay – less than $500 – was 20% of the amount Medicare approved, Medicare staff obviously adjusted the charges down to a tiny fraction of the original amount billed. No wonder some doctors don’t want to accept Medicare patients. 


The Rest of the Story: When I began this account, I intended it as a paean to Medicare. Even after I put $10,000 in copays and related expenses on credit cards and ended up with a $240 monthly premium for Medicare Parts A, B and D (deducted every month from my Social Security check); and even after I realized that I would not be off the hook for private, for-profit insurance if I wanted to avoid bankruptcy on a government healthcare insurance program that I had paid into for 55 years, I’m still profoundly thankful that I was covered by Medicare. But every time I feel a little twinge in my side, I wonder how I’ll manage financially if I have to be hospitalized again (I won’t qualify for a supplement for two years, if then, and if I can afford it then); and I also wonder – considering the Covid-19 Pandemic – what is happening to the millions and millions of Americans who aren’t covered by Medicare.



Monday, April 13, 2020

Dr. Bruce Cattanach on Breeding from White Boxers

Editor’s note: This very timely piece is one of the last articles I received from Dr Cattanach, and was published in the May 2019 Boxer Digest along with some wonderful photos from his website of Dr Cattanach with Ch Steynmere Nightrider.

When my ex-husband and I started out in Boxers in 1973, we quickly learned not to question (at least not openly) the American Boxer Club’s proscription against white Boxers: to wit, “reputable” breeders were not to register, sell or even “place” the white puppies that appeared with great frequency in flashy x flashy litters…despite that backyard breeders were free to sell “rare white boxers” for many times the price of a plain brindle puppy from a champion-sired litter. The rationale for that proscription was the alleged poor health and genetic inferiority that accompanied white coat color.

The ABC has come a long way since then, bowing to the lobbying of many of its members, especially new members, who wanted to be able to acknowledge their white puppies and place them in loving homes, along with the fawn and brindle “pet” puppies in their litters. The relatively new AKC Limited Registration policy greatly facilitated the ABC’s official enlightenment on the subject.

Now, some breeders are discussing the possibility of being able to use white boxers in their breeding programs. The following is a letter sent by UK geneticist and Boxer breeder Dr. Bruce Cattanach to a group of Italian Boxer fanciers,

29th March 2019

Breeding from white Boxers
Dr. Bruce M. Cattanach
Steynmere Boxers

I have been asked to comment, as a professional research geneticist and experienced UK Boxer breeder and judge, on the belief of some breeders that white Boxers are prone to health problems, and that breeding from them therefore poses risks to the genetic health of the breed.
My short answer is that there is no basis whatever for this idea.
The rationale for my response lies primarily with the fact that the white spotting gene responsible for the white ‘colouration’ in Boxers (s^w)  is the same as that for the white coats in dogs of a number of breeds (Bull Terriers, Sealyhams, Dalmatians etc) and in none of these breeds have serious abnormalities been found.  There is however a variably minor incidence of deafness in these white dogs, but this is well known and understood. 

The validity of the above statement is confirmed by studies at the DNA level which have shown the same gene locus is involved in these ‘white spotting’ breeds.  That there are other breeds, such as Collies and Dachshunds, which have dogs with white markings that ARE associated with serious abnormalities, is irrelevant, as the gene, Merle (M), responsible for white markings in these breeds, is different from that in Boxers (s^w).  M functions in a different way from s^w, it is located on a different chromosome, and also has a different mode of inheritance.  The white Boxer is not at risk of any defects other than, as said, the low risk of deafness.

How large is the risk of deafness? 

I know of no scientific study on deafness directly in Boxers.  A best guess for incidence of deafness would be that it will be similar to that in White Bull Terriers, a breed in which the incidence has been found to be less than 2%.  This is a breed in which, like Boxers, there has been no selective breeding for the presence/absence of pigmented patches in whites.  The incidence of deafness is higher in Dalmatians (5% to 12%) but this higher incidence has been attributed to the heavy selection for totally white dogs in this breed (excluding the spotting which derives from a different mechanism); pigmented patches are not wanted in Dalmatians, only spots. And deafness correlates with pigmentation seen in the coat.

It may help understanding of whites and deafness if the mechanisms involved are explained.  Basically, the primary effect of the responsible s^w gene involves pigment cell migration.  Before birth, pigment cells in the foetus are confined to paired sites along the back near the spine, from head to tail.  There may be three such sites on the head (around the eyes, the ears, and the occiput), perhaps six on the body, and several on the tail (numbers are based on my own studies).  Pigmentation, as we observe it, is achieved by migration of the pigment cells from their starting sites to spread down the sides of the body with most of the migration ceasing prior to birth.  It often incomplete such that more distant regions (between the eyes, and on the chest, neck, belly and lower legs) may not be reached and therefore remain white.  The ending of this migration is best seen on the head where it continues for several days after birth (the white blaze gets smaller and the nose becomes pigmented).  The pigment cells also spread internally where they give colour to the eyes and have a role in the maintenance of the auditory hair cells of the inner ear.  If they do not reach the eyes, the eyes are blue rather than brown.  If they do not reach the ears, the auditory hair cells die within a few weeks of birth, when hearing is then lost (about 6 weeks).  The migration is not uniform; left and right forelegs, for example, may have different amounts of white.  Likewise, the eyes can be of different colours (brown and blue) and, with the ears, deafness can affect one or both.  There is a correlation between extent of white in the coat and incidences of blue eyes and deafness.  This is best documented in Dalmatians: dogs with the most white in the coats are more likely to have blue eyes and become deaf.  The extent of the migration is loosely inherited.

As I have indicated, the white spotting gene (s^w) is primarily responsible for whites in Boxers but there are a number of versions (alleles) of this gene in other white marked breeds.  Only two of the versions now seem to exist in present-day Boxers:
-        the normal full-colour version (S) gives, in the double dose (S/S), solid Boxer which may still have a white chest spot and maybe white toes (the pigment cell migration is near complete).
-        the extreme version (s^w) gives, in the double dose (s^w/s^w), the near all-white dog, which may have occasional pigmented patches which are most often located around the eyes and/or ears on the head and more rarely elsewhere on the body. 
But the combination of the two versions (S and s^w) gives the intermediate, flashy Boxer that is generally favoured for show purposes. The white marking indicates the limitation of the spread of pigment cells.  In S/s^w dogs, the spread is less (more white) than in S/S dogs, and obviously far more than in near all-white s^w/s^w dogs.  Generally, the amount of white in the S/s^w dogs is less than one-third of the total, as actually required by the Breed Standard.

In summary, genetic studies indicate that white Boxers differ from flashy Boxers only by the more restricted level of pigment cell migration, and they are not at greater risk of major inherited disease that would validate their exclusion from breeding and showing.  They are, in any case, knowingly produced by the regular use of flashy animals for breeding.  Thus,
flashy x flashy produces  - 25% solid, 50% flashy and 25% white
But the Breed Standard does not disqualify the flashy white-producing dogs.  However, disqualifying whites from showing may be acceptable, but only for cosmetic reasons.   But to ban them for breeding based on imagined abnormality has no scientific justification.

If I may add my own view as a former Boxer breeder: I believe few serious breeders would want to produce high frequencies of whites, so matings of whites to flashy dogs would seldom be considered.  Likewise, matings between whites would also be avoided.  But if whites could be exclusively mated to solids, this could be seen as an acceptable breeding option and it would not ultimately cause any increase in the numbers of whites or damage the breed in any way.  Indeed, as all puppies (100%) from white x solid matings would be of the favoured flashy appearance, thus
white (s^w/s^w) x solid (S/S) can only produce flashy (S/s^w)
and these would breed exactly as flashy dogs from routine flashy x flashy matings.  It would leave open a further breeding option for show Boxer breeding. 

Added note.
I have bred from a number of white Boxers for experimental reasons, and always they bred exactly as expected, and none produced abnormalities of any kind. 

Bruce M Cattanach BSc  PhD  DSc FRS
(Retired as Acting Director of the Medical Research Council Mammalian Genetics Unit)

Saturday, April 11, 2020

A Tribute to Dr. Bruce Cattanach

Dr. Bruce M. Cattanach
November 5, 1932 – April 8, 2020

Like many of my readers, the Boxer breed has been an all-consuming passion for most of my life. And the high point of my life in Boxers was flying to England in 1999 with my good friends Stephanie and David Abraham and meeting UK geneticist and Boxer breeder Dr. Bruce Cattanach at the Windsor Show. After Boxer judging, we drove with Bruce to see an early generation of his Bobtail Boxers and then followed him home to meet his wife Jo Peters (also a geneticist) and his own Steynmere Boxers.  

Dr. Bruce Cattanach was a brilliant man who made a huge contribution to the world of genetics (see the Harwell tribute below) and as at least a working knowledge of genetics became more and more necessary to the “art” of breeding dogs, was an invaluable resource to dog breeders in their efforts to avoid hereditary disease, especially in Bruce’s chosen breed, the Boxer. Throughout the following week, we will feature several articles written by Bruce on genetics for Boxer breeders.
VZ – April 11, 2020

Medical Research Council Harwell Institute

Dr. Bruce Cattanach, former director of the MGU, has sadly passed away.
We are very sorry to announce that Dr Bruce Cattanach passed away on 8th of April 2020.
Dr Bruce Cattanach was an outstanding scientist who led the Mammalian Genetics Unit in its early years. Along with Mary Lyon, Bruce established Harwell as one of the great international centres for mouse genetics. He discovered the phenomenon of imprinting and was rightly considered a pioneer in this whole field. He also was a leading force in the field of dog breeding and dog genetics.  
He will be remembered as a gentle man who gave so much to all around him, family, friends and colleagues, with a wry sense of humour. He will be very much missed.