At the time it was a splurge for us—thirty dollars—but how could we resist? Turns out the shop owner had just polished its brass base that very morning before putting it in the shop window. "I knew it would go quickly," he said, chuckling. The shop is gone now. Still, I'm sure he'd be happy to know it's given us many years of joy. Every time I hear its version of "Santa Claus Is Coming to Town," I have to smile.
(Note to Self: eat more root vegetables, and less sugar!)
(Note to Self: much more sex, much less [caloric] sugar!)
Acquire a new language.
(Pig Latin does NOT count.)
Experience new things, with total abandon!
(Unless they include black-outs, tattoos, or joining a cult.)
Two thousand words a day!
(More writing. Note to Self: skipping martini may do the trick…)
Or maybe "The Housewife Assassin's Handbook."
I'll go with the latter.
From "Pride and Prejudice, the Musical"
Music and Lyrics by Rita Abrams; Libretto by Josie Brown
#3: IT IS A TRUTH (Complete Song)
(Sung by Bingley, Darcy and Caroline)
Darcy and Bingley banter about the pressures on single men–particularly wealthy single men–to marry. But while Darcy is disgusted by it, Bingley's attitude is more benign–perhaps because he is already in the throes of enchantment with one of the local beauties, Jane Bennet.
THE HOUSEWIFE ASSASSIN'S HANDBOOK
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BN.com (99 cents)
The boats in the San Francisco Yacht Harbor have wonderfully whimsical names: Irish Whisper. Calico Dragon. Sea Hawk. Kookaburra. Nai'a. Daisy. Escapade. Effie Jane. Portola.
Then there's the one named, simply, "Sailboat."
Talk about putting things in perspective.
THE HOUSEWIFE ASSASSIN'S HANDBOOK
Over 150,000 downloads.
Find out why readers love it.
I think this is possibly the best public relations campaign I've ever seen an airline come up with. When you get to the end of the video and see the tears of joy and gratitude in the customers' eyes, you'll know what I mean.
Way to go, WestJet!
Murder. Suspense. Sex.
And some handy household tips.
FREE! Now in
BN.com (99 cents)
The skating rink and lit tree, in Union Square, downton San Francisco, California.
The model for the statue was a young local beauty, Alma Spreckels, who ended up marrying the sugar king (yes, she actually called him her "sugar daddy"–or as she put it, "I'd rather be an old man's darling than a young man's slave."
She also founded the city's Legion of Honor Museum, because none of the swells would take her money for the renowned DeYoung Museum. Many of her treasures came from France, which she helped during World War I. She was one of the most ardent patrons of Auguste Rodin.
The mansion the Spreckels built, on Washington at Octavia, was purchased by novelist Danielle Steel, lucky lady.
This article, from the New York Times, shows that as of today, we can be self-producing of clean fuels just by converting our garbage. This should be the most important US works project of the new millenneum.
ALL states should be doing this, don't you think? Maybe a writing campaign is in order.
We're Back to the Future–and just in time to save Miami.
But do we want to,
Trash Into Gas, Efficiently? An Army Test May Tell
By PAUL TULLIS / New York Times
THERE is an indisputable elegance to the idea of transforming garbage into fuel, of turning icky, smelly detritus into something valuable.
But big drawbacks have prevented the wholesale adoption of trash-to-gas technology in the United States: incineration is polluting, and the capital costs of new plants are enormous. Gasification systems can expend a tremendous amount of energy to produce a tiny amount of electricity. Up to this point, it hasn’t seemed worth the trouble.
Mike Hart thinks that he has solved those problems. In a former Air Force hangar outside Sacramento, his company, Sierra Energy, has spent the last several years testing a waste-to-energy system called the FastOx Pathfinder. The centerpiece, a waste gasifier that’s about the size of a shower stall, is essentially a modified blast furnace. A chemical reaction inside the gasifier heats any kind of trash — whether banana peels, used syringes, old iPods, even raw sewage — to extreme temperatures without combustion. The output includes hydrogen and carbon monoxide, which together are known as syngas, for synthetic gas, and can be burned to generate electricity or made into ethanol or diesel fuel. The FastOx is now being prepared for delivery to Sierra Energy’s first customer: the United States Army.
Ethanol has long been promoted as an alternative fuel that increases energy independence, and federal law requires the use of greater amounts of it. But most ethanol in this country is produced from corn or soybeans, and many people worry that the mandate is pushing upfood prices. Ethanol produced from trash — or agricultural waste, as others are trying — would allay such concerns.
Ineos Bio, a Florida company, announced last month that it had produced ethanol from gasified wood waste, using a method that it expects to be commercially viable, and KiOR Inc. will make one million to two million gallons of diesel and gasoline this year from wood waste at its plant in Columbus, Miss., according to Michael McAdams, president of the Advanced Biofuels Association. Mr. Hart said Sierra Energy’s technology should be complementary with the Florida company’s; the FastOx turns all municipal waste, not just wood scraps, into a gas that Ineos Bio could then transform into ethanol.
The FastOx gasifier is the brainchild of two former engineers at Kaiser Steel, patented by the grandson of one of them and commercialized by Mr. Hart. “It’s a modular system that can be dropped into any area,” Mr. Hart said, “using waste where it’s produced to make electricity where it’s used.” Once it’s off the ground, he said, “garbage will be a commodity.”
From concept to construction, the story of the FastOx is of one fortuitous accident after another. And while Sierra Energy has not yet proved to be a successful company — it will be a long while before your garbage is shoveled into a FastOx — its system has become the first waste-to-energy technology acquired by the Defense Department, which paid $3 million for it through an environmental technology program. (The California Energy Commission, which supports renewable energy development in the state, also gave Sierra $5 million, to cover the portion of Sierra’s costs that the Pentagon couldn’t.)
The military is looking for ways to reduce its oil consumption, and to make it easier to supply the front lines with the fuel it uses in all its vehicles and generators. “These days, the supply lines are in the battlefield,” said Sharon E. Burke, the assistant secretary of defense for operational efficiency plans and programs. “And we consume a lot of fuel, which makes us a big target.”
MIKE HART got into the energy business by way of a train. In 1993, he bought the Sierra Railroad, a small freight and tourism line in Northern California. During the California blackouts of 2001, he had an idea: “As the lights were going out, I realized every one of my locomotives creates 2.1 megawatts of electricity,” he said — enough to power many hundred homes. “It’s a rolling generator, and inexpensive.”
The train-as-power-generator idea never really left the station, but it got Mr. Hart thinking about alternative energy. Then, as part of a settlement after a fuel spill from one of his trains, he promised to convert his trains to nonpolluting biodiesel.
Biodiesel, however, proved hard to find, and Mr. Hart started looking for new ways to source it. In 2002, he was asked to judge an annual business plan competition called the Big Bang, at the University of California, Davis. That’s where he met Chris Kasten.
Mr. Kasten came to the competition with an idea to use a modified blast furnace to turn waste into fuel. His grandfather, Bruce Claflin, a retired chief industrial engineer at Kaiser Steel in Fontana, Calif., had given him the idea.
Kaiser used blast furnaces to make steel, and Mr. Claflin and a colleague, John Jasbinsek, were tasked with finding “a way to make the blast furnace more efficient and less polluting,” said Mr. Jasbinsek, who is now 86.
Like all blast furnaces, Kaiser’s emitted a flue gas out of the top. It occurred to Mr. Clafin and Mr. Jasbinsek that this gas might have value. The two came up with the idea of injecting oxygen, instead of the atmospheric air that steel makers had always used, to create the chemical reaction that heats the inside of the furnace. This would cut pollution while raising the energy content of the flue gas — in essence, giving the steel maker a second product. But pure oxygen made the system too hot, so they added steam. This gave the furnace a third product: hydrogen, which can be used to produce electricity in fuel cells.
After Kaiser decided to close the Fontana plant in 1983, workers were told to toss all demolition debris into the blast furnace. It was then that Mr. Jasbinsek and Mr. Claflin realized that the furnace could take garbage, too. “No matter what they put in, the furnace melted and gasified it,” Mr. Kasten said. This meant a potential fourth revenue stream — from taking municipal waste that would otherwise go to landfills.
When Kaiser wasn’t interested, Mr. Jasbinsek recalled, “we took the idea to other steel companies, too.” But “nobody gave a damn!” he said. “Now there are hardly any steel companies left in the U.S.”
Kaiser Steel went bankrupt in 1987, so the idea belonged to Mr. Jasbinsek and Mr. Claflin. They were nearing retirement, though, so Mr. Claflin told his grandson about it. (Mr. Claflin died before the idea could be commercialized.)
Mr. Kasten’s first fruitful step in developing his grandfather’s idea was meeting with Chris Soderquist, founder of Venture Lab. “When you run a technology incubator, you see a lot of crazy and half-baked ideas,” Mr. Soderquist said. But Mr. Kasten’s was different; Mr. Soderquist could see right away the value of multiple revenue streams.
Gasification is more efficient than incineration and eliminates toxic byproducts that come from burning trash. But it was especially appealing from a business point of view because it relied on a proven technology and used materials in wide abundance: blast furnaces being abandoned as the American steel industry was collapsing.
“What was compelling from the start,” Mr. Soderquist said, “was repurposing existing infrastructure into a generator of clean energy, with a second revenue stream from people paying you to take their waste.”
Mr. Soderquist helped Mr. Kasten prepare for the Big Bang competition. “For a grad school business plan competition, it was quite a plan he presented,” Mr. Soderquist said, and the judges agreed: Mr. Kasten, now 43, won a $2,000 prize.
Mr. Hart, 51, as a competition judge and a serial entrepreneur, was intrigued. He had started his first business at 12, operating a string of candy machines in high schools throughout what would become known as Silicon Valley. Next, while still living at home, he opened a sort of temp agency for teenagers doing odd jobs. There were a lot of other businesses from the late 1970s to 1993, and stints as a developer for Steve Jobs’s company Next, and for Apple. Mr. Hart also did some consulting until he realized that he would make more money buying whatever devalued company he had been hired to help, and turning it around himself. That was when he bought the Sierra Railroad.
Mr. Hart checked out Mr. Kasten’s gasifier and decided to buy the patents. Then he applied to a Pentagon program established to shepherd proven concepts to the production stage. Results at the Defense Department’s testing facility near Sacramento have been promising; after about four hours, one ton of waste creates enough gas to produce 1,580 kilowatt-hours of electricity, which would power an average home in the United States for about a month and a half — at one-third the emissions of coal — and 42 gallons of renewably sourced fuel. And that’s with a 12-ton-a-day gasifier; existing blast furnaces can handle as much as 2,000 tons a day.
Now that the Pentagon is convinced that the FastOx will work as advertised, the system should be providing electricity later this year at Fort Hunter Liggett, a training base in Monterey County, Calif., and fuel for vehicles and generators in early 2014.
“California produces 30 million tons of garbage a year,” Mr. Hart said. “If it decided to turn its waste into clean fuels, at that rate it could meet all its oil consumption needs and still export more fuel than some OPEC members.” That is, if the FastOx can do what no other waste-to-energy gasification technology has done before: take any kind of trash, in any succession, without additional separation or preparation.
Sierra plans to license its technology and to sell systems to make electricity or ethanol from the syngas produced by the FastOx. The first will be small and cost about $3 million. But Mr. Hart said he expects to sell larger systems to municipalities and biofuel makers that will go for much more.
Any waste-to-energy plan, however, must overcome a major hurdle: the wild inconsistency of the waste stream. “Until you’ve demonstrated that you can handle it all, nobody’s interested,” Mr. Hart said. “I can understand it; they’ve heard similar promises before. We’ve got 150 cities, communities and businesses lined up to be Serial No. 2. Nobody wants to be No. 1.”
NOBODY, that is, except the Pentagon. The Defense Department is the country’s largest single consumer of energy, spending $15 billion a year just on fuel.
“The mission drives this,” said Ms. Burke, the assistant defense secretary, “and the mission is inherently energy-intensive.”
The FastOx could reduce the military’s reliance on oil overseas and the grid at home. “I have a $24 million-a-year electric bill at Camp Pendleton” in Southern California, said that Marine base’s commander, Brig. Gen. Vincent A. Coglianese. “If I can reduce that cost, that’s more money I can put into training Marines and sailors.”
Ms. Burke added, “Something for military operations has to be really rugged, deployable, simple to use — all of those things.”
Consultants and municipal sanitation officials who’ve looked at the FastOx say it meets those criteria. John Conger, the acting deputy under secretary of defense for installations and the environment, who oversees management of military bases in the United States, says Sierra Energy’s technology should provide energy security for the military in the event of a blackout and provide budget savings as well.
The military’s cost of petroleum, when the costs of transporting and guarding it are factored in, can run as high as $50 a gallon. Moreover, about half of United States casualties in Iraq and Afghanistan between 2003 and 2007 were of servicemen and servicewomen moving and protecting fuel convoys, according to an Army report.
The appeal of Mr. Hart’s Pathfinder system is that it would produce fuel on site, eliminating the need to truck in fuel to dangerous military outposts. It would also reduce the need for trash-burning on bases, which creates pollution and noxious odors that have contributed to locals’ distaste for the American presence in Iraq and Afghanistan. As a result, United States forces in Afghanistan are working to close burn pits.
“Waste is a problem,” Ms. Burke said. “So if we could dispose of waste and create energy at the same time, that would be a silver bullet.”
This article has been revised to reflect the following correction:
Correction: August 20, 2013
An earlier version of this article referred incorrectly to a product of Sierra Energy’s gasifier system. It produces hydrogen and carbon monoxide, which together are known as “syngas,” for synthetic gas; it does not produce “synthetic natural gas.”
This article has been revised to reflect the following correction:
Correction: August 20, 2013
An earlier version of this article referred imprecisely to Fort Hunter Liggett, a training base in Monterey County, Calif. At more than 165,000 acres, it is not a “small” base.
(c) 2013 New York Times
My latest novel is
The Housewife Assassin's
Vacation to Die For
Now out, in
Having just been biled $260 for a six-minute earwax removal procedure (oh yeah, minus a whoopdeedoo $180 "credit for being a Blue Shield member), I can tell you I'm truly fed up with the egregious cost of American healthcare. How about you? This New York Times article certainly puts things in perspective — Josie
For Medical Tourists, Simple Math
By ELISABETH ROSENTHAL | Published: August 3, 2013 / New York Times
Josh Haner/The New York Times
WARSAW, Ind. — Michael Shopenn’s artificial hip was made by a company based in this remote town, a global center of joint manufacturing. But he had to fly to Europe to have it installed.
Mr. Shopenn, 67, an architectural photographer and avid snowboarder, had been in such pain from arthritis that he could not stand long enough to make coffee, let alone work. He had health insurance, but it would not cover a joint replacement because his degenerative disease was related to an old sports injury, thus considered a pre-existing condition.
Desperate to find an affordable solution, he reached out to a sailing buddy with friends at a medical device manufacturer, which arranged to provide his local hospital with an implant at what was described as the “list price” of $13,000, with no markup. But when the hospital’s finance office estimated that the hospital charges would run another $65,000, not including the surgeon’s fee, he knew he had to think outside the box, and outside the country.
“That was a third of my savings at the time,” Mr. Shopenn said recently from the living room of his condo in Boulder, Colo. “It wasn’t happening.”
“Very leery” of going to a developing country like India or Thailand, which both draw so-called medical tourists, he ultimately chose to have his hip replaced in 2007 at a private hospital outside Brussels for $13,660. That price included not only a hip joint, made by Warsaw-based Zimmer Holdings, but also all doctors’ fees, operating room charges, crutches, medicine, a hospital room for five days, a week in rehab and a round-trip ticket from America.
“We have the most expensive health care in the world, but it doesn’t necessarily mean it’s the best,” Mr. Shopenn said. “I’m kind of the poster child for that.”
As the United States struggles to rein in its growing $2.7 trillion health care bill, the cost of medical devices like joint implants, pacemakers and artificial urinary valves offers a cautionary tale. Like many medical products or procedures, they cost far more in the United States than in many other developed countries.
Makers of artificial implants — the biggest single cost of most joint replacement surgeries — have proved particularly adept at commanding inflated prices, according to health economists. Multiple intermediaries then mark up the charges. While Mr. Shopenn was offered an implant in the United States for $13,000, many privately insured patients are billed two to nearly three times that amount.
An artificial hip, however, costs only about $350 to manufacture in the United States, according to Dr. Blair Rhode, an orthopedist and entrepreneur whose company is developing generic implants. In Asia, it costs about $150, though some quality control issues could arise there, he said.
So why are implant list prices so high, and rising by more than 5 percent a year? In the United States, nearly all hip and knee implants — sterilized pieces of tooled metal, plastic or ceramics — are made by five companies, which some economists describe as a cartel. Manufacturers tweak old models and patent the changes as new products, with ever-bigger price tags.
Generic or foreign-made joint implants have been kept out of the United States by trade policy, patents and an expensive Food and Drug Administration approval process that deters start-ups from entering the market. The “companies defend this turf ferociously,” said Dr. Peter M. Cram, a physician at the University of Iowa medical school who studies the costs of health care.
Though the five companies make similar models, each cultivates intense brand loyalty through financial ties to surgeons and the use of a different tool kit and operating system for the installation of its products; orthopedists typically stay with the system they learned on. The thousands of hospitals and clinics that purchase implants try to bargain for deep discounts from manufacturers, but they have limited leverage since each buys a relatively small quantity from any one company.
In addition, device makers typically require doctors’ groups and hospitals to sign nondisclosure agreements about prices, which means institutions do not know what their competitors are paying. This secrecy erodes bargaining power and has allowed a small industry of profit-taking middlemen to flourish: joint implant purchasing consultants, implant billing companies, joint brokers. There are as many as 13 layers of vendors between the physician and the patient for a hip replacement, according to Kate Willhite, a former executive director of the Manitowoc Surgery Center in Wisconsin.
Hospitals and orthopedic clinics typically pay $4,500 to $7,500 for an artificial hip, according to MD Buyline andOrthopedic Network News, which track device pricing. But those numbers balloon with the cost of installation equipment and all the intermediaries’ fees, including an often hefty hospital markup.
That is why the hip implant for Joe Catugno, a patient at the Hospital for Joint Diseases in New York, accounted for nearly $37,000 of his approximately $100,000 hospital bill; Cigna, his insurer, paid close to $70,000 of the charges. At Mills-Peninsula Health Services in San Mateo, Calif., Susan Foley’s artificial knee, which costs about the same as a hip joint, was billed at $26,000 in a total hospital tally of $112,317. The components of Sonja Nelson’s hip at Sacred Heart Hospital in Pensacola, Fla., accounted for $30,581 of her $50,935 hospital bill. Insurers negotiate discounts on those charges, and patients have limited responsibility for the differences.
The basic design of artificial joints has not changed for decades. But increased volume — about one million knee and hip replacements are performed in the United States annually — and competition have not lowered prices, as would typically happen with products like clothes or cars. “There are a bunch of implants that are reasonably similar,” said James C. Robinson, a health economist at the University of California, Berkeley. “That should be great for the consumer, but it isn’t.”
COMPARING TWO OPERATIONS
The American health care market is plagued by such “sticky pricing,” in which prices of products remain high or even increase over time instead of dropping. The list price of a total hip implant increased nearly 300 percent from 1998 to 2011, according to Orthopedic Network News, a newsletter about the industry. That is a result, economists say, of how American medicine generally sets charges: without government regulation or genuine marketplace competition.
“Manufacturers will tell you it’s R&D and liability that makes implants so expensive and that they have the only one like it,” said Dr. Rory Wright, an orthopedist at the Orthopedic Hospital of Wisconsin, a top specialty clinic. “They price this way because they can.”
Zimmer Holdings declined to comment on pricing. But Sheryl Conley, a longtime Zimmer manager who is now the chief executive of OrthoWorx, a local trade group in Warsaw, said that high prices reflected the increasing complexity of the joint implant business, including more advanced materials, new regulatory requirements and the logistics of providing a now huge array of devices. “When I started, there weren’t even left and right knee components,” she said. “It was one size fits all.”
Mr. Shopenn’s Zimmer hip has transformed his life, as did the replacement joint for Mr. Catugno, a TV director; Ms. Foley, a lawyer; and Ms. Nelson, a software development executive. Mr. Shopenn, an exuberant man who maintains a busy work schedule, recently hosted his son’s wedding and spent 26 days last winter teaching snowboarding to disabled people.
His joint implant and surgery in Belgium were priced according to a different logic. Like many other countries, Belgium oversees major medical purchases, approving dozens of different types of implants from a selection of manufacturers, and determining the allowed wholesale price for each of them, for example. That price, which is published, currently averages about $3,000, depending on the model, and can be marked up by about $180 per implant. (The Belgian hospital paid about $4,000 for Mr. Shopenn’s high-end Zimmer implant at a time when American hospitals were paying an average of over $8,000 for the same model.)
“The manufacturers do not have the right to sell an implant at a higher rate,” said Philip Boussauw, director of human resources and administration at St. Rembert’s, the hospital where Mr. Shopenn had his surgery. Nonetheless, he said, there was “a lot of competition” among American joint manufacturers to work with Belgian hospitals. “I’m sure they are making money,” he added.
Dr. Cram, the Iowa health cost expert, points out that joint manufacturers are businesses, operating within the constraints of varying laws and markets.
“Imagine you’re the C.E.O. of Zimmer,” he said. “Why charge $1,000 for the implant in the U.S. when you can charge $14,000? How would you answer to your shareholders?” Expecting device makers “to do otherwise is like asking, ‘Couldn’t Apple just charge $50 for an iPhone?’ because that’s what it costs to make them.”
But do Americans want medical devices priced like smartphones? “That,” Dr. Cram said, “is a different question.”
A Miracle for Many
When joint replacement surgery first became widely used in the 1970s, it was reserved for older patients with crippling pain from arthritis, to offer relief and restore some mobility. But as technology and techniques improved, its use broadened to include younger, less debilitated patients who wanted to maintain an active lifestyle, including vigorous sports or exercise.
Narayan Mahon for The New York Times
Dr. Rory Wright at the Orthopedic Hospital of Wisconsin with two modern hip joint options.
In the first few decades, implants were typically cemented into place. But since the 1980s, many surgeons have used implants made of more sophisticated materials that allow the patient’s own bone to grow in to hold the device in place. For most patients, implants have proved miraculous in improving quality of life, which is why socialized medical systems tend to cover them. Per capita, more hip replacements are done in Britain, Sweden and the Netherlands, for example, than in the United States.
Motivated in part by science and in part by the need to create new markets, joint makers churn out new designs that are patented, priced higher and introduced with free training courses for surgeons. Some use more durable materials so that a patient requiring a hip implant at age 40 or 50 might rely on it longer than the standard 20 years, while other models are streamlined and require smaller incisions.
Zimmer got a big sales bump a few years ago when it began promoting its new “female knee,” a slightly slimmer version of its standard design, in an advertising campaign directed at patients. Hospitals on average pay about $800 more to buy the gender-specific knee implants, according to MD Buyline.
Many doctors say that for most patients, older, standard implants with a successful track record are appropriate. Expensive modifications make no difference for the typical patient, but they drive up prices for all models and have sometimes proved to be deeply flawed, they say.
In the last few years, joint manufacturers have faced lawsuits and have settled claims with patients after new, all-metal implants, which were meant to be more durable than the standard version, had unusually high failure rates. As for those “female knees,” a studyfeatured at the meeting of the American College of Orthopedic Surgeons this year concluded, “While we certainly use the female components frequently in surgery, we don’t detect any objective improvement in clinical outcomes.”
That is why Dr. Scott S. Kelley, an orthopedist affiliated with Duke University Medical Center, generally tries to dissuade patients who request “new, improved” joints. “I tell them: ‘That’s taking a big risk for the potential of a few percentage points of improvement. You wouldn’t invest your retirement account this way.’ ”
Can you relate an experience that has led you to feel that the price of American medicine does — or does not — correlate with the quality of care you received?
A Town’s Lifeblood
The power and profits of the medical device industry are on display here in Warsaw, which has trademarked itself the Orthopedic Capital of the World. Four of the big five joint manufacturers in the world are based in the United States; the other is in Britain. Three of these giants — Zimmer, Biomet and DePuy, a division of Johnson & Johnson — have their headquarters here, a town of 14,000.
An industry that began as a splint-making shop in 1895 has made Warsaw the center of a global multibillion-dollar business. The companies based here produce about 60 percent of the hip and knee devices used in the United States and one-third of the world’s orthopedic sales volume, local officials said. Nearly half the jobs in Kosciusko County, where Warsaw is, are tied to the industry. Residents joke that a mixed marriage is when one spouse works for Zimmer and the other for DePuy.
The industry’s benefits are evident. The county has the lowest unemployment rate in Northern Indiana, and the median family income of $50,000 puts it significantly above the state average. The town boasts lush golf courses and streets lined with spacious homes. The lobby of the elegant City Hall, which is in a restored 1912 bank, features plaques about device manufacturers.
“We eat, sleep and breathe orthopedics,” said Ms. Conley of OrthoWorx, which she said was set up to “plan for the future of the orthopedic industry here.” OrthoWorx’s board of directors includes executives from Biomet and DePuy.
With a high-tech industry as its lifeblood, Ms. Conley said, Warsaw needed to attract engineers and doctors from afar and train local youths for “the business.” It has upgraded the public schools and helped create programs at local colleges in orthopedic regulation and advanced machinist techniques.
Officials at OrthoWorx say the device makers do not discuss “competitive issues” among themselves, including the prices of implants, even as employees stand together watching their children play baseball. Still, it is in everyone’s interest not to undercut the competition. In 2011, all three manufacturers had joint implant sales exceeding $1 billion and spent about only 5 percent of revenues on research and development, compared with 20 percent in the pharmaceutical industry, said Stan Mendenhall, the editor of Orthopedic Network News. They each paid their chief executives over $8 million.
“It’s amazing to think there is $5 billion to $6 billion going through this little place in Northern Indiana,” said Mr. Mendenhall, adding that the recession has meant only single-digit annual revenue growth rather than the double-digit growth of the past.
Device makers have used some of their profits to lobby Congress and to buy brand loyalty. In 2007, joint makers paid $311 million to settle Justice Department accusations that they were paying kickbacks to surgeons who used their devices; Zimmer paid the biggest fine, $169.5 million. That year, nearly 1,000 orthopedists in the United States received a total of about $200 million in payments from joint manufacturers for consulting, royalties and other activities, according to data released as part of the settlement.
Despite that penalty, payments continued, according to a paper published in The Archives of Internal Medicine in 2011. While some of the orthopedists are doing research for the companies, the roles of others is unclear, said Dr. Cram, one of the study’s authors.
Although only a tiny percentage of orthopedists receive payments directly from manufacturers, the web of connections is nonetheless tangled.
Companies “build a personal relationship with the doctor,” said Professor Robinson, the Berkeley economist. “The companies hire sales reps who are good at engineering and good at golf. They bring suitcases into the operating room,” advising which tools might work best among the hundreds they carry, he said. And some studies have shown that operations attended by a company representative are more likely to use more and costlier medical equipment. While some hospitals have banned manufacturers’ representatives from the operating room, or have at least blocked salesmanship there, most have not.
No Gift Shop
There are, of course, a number of factors that explain why Mr. Shopenn’s surgery in Belgium would cost many times more in the United States. In America, fees for hospitals, scans, physical therapy and surgeons are generally far higher. And in Belgium, even private hospitals are more spartan.
When Mr. Shopenn arrived at the hospital, he was taken aback by the contrast with NewYork-Presbyterian Hospital, where his father had been a patient a year before. The New York facility had “comfortable waiting rooms, an elegant lobby and newsstands,” Mr. Shopenn remembered.
But in Belgium, he said, “I was immediately scared because at first I thought, this is really old. The chairs in the waiting rooms were metal, the walls were painted a pale green, there was no gift shop. But then I realized everything was new. It was just functional. There wasn’t much of a nod to comfort because they were there to provide health care.”
St. Rembert's, the private hospital in Belgium where Mr. Shopenn had his hip replaced for $13,660. Thomas Vanden Driessche for The New York Times
The pricing system in Belgium does not encourage amenities, though the country has among the lowest surgical infection rates in the world — lower than in the United States — and is known for good doctors. While most Belgian physicians and hospitals are in business for themselves, the government sets pricing and limits profits. Hospitals get a fixed daily rate and surgeons receive a fee for each surgery, which are negotiated each year between national medical groups and the state.
While doctors may charge more than the rate, few do so because most patients would refuse to pay it, said Mr. Boussauw, the hospital administrator. Doctors and hospitals must provide estimates. European orthopedists tend to make about half the income of their American counterparts, whose annual income averaged $442,450 in 2011, according to a survey by the Commonwealth Fund, a foundation that studies health policy.
Belgium pays for health care through a mandatory national insurance plan, which requires contributions from employers and workers and pays for 80 percent of each treatment. Except for the poor, patients are generally responsible for the remaining 20 percent of charges, and many get private insurance to cover that portion.
Mr. Shopenn’s surgery, which was uneventful, took place on a Tuesday.On Friday he was transferred for a week to the hospital’s rehabilitation unit, where he was taught exercises to perform once he got home.
Twelve days after his arrival, he paid the hospital’s standard price for hip replacements for foreign patients. Six weeks later he saw an orthopedist in Seattle, where he was living at the time, to remove stitches and take a postoperative X-ray. “He said there was no need for further visits, that the hip looked great, to go out and enjoy myself,” Mr. Shopenn said.
The number of hip replacements has risen sharply in recent years, with much of the growth coming from people younger than 65.
With baby boomers determined to continue skiing, biking and running into their 60s and beyond, economists predict a surge in joint replacement surgeries, and more procedures for younger patients. The number of hip and knee replacements is expected to roughly double between 2010 and 2020, according to Exponent, a scientific consulting firm, and perhaps quadruple by 2030. If insurers paid $36,000 for each surgery, a fairly typical price in the commercial sector, the total cost would be $144 billion, about a sixth of the nation’s military budget last year.
So far, attempts to bring down the price of medical devices have been undercut by the industry.
When Dr. Daniel S. Elliott of the Mayo Clinic decided to continue using an older, cheaper valve to cure incontinence because studies showed that it was just as good as a newer, more expensive model, the manufacturer raised its price.
“If there was a generic, I’d be there tomorrow,” he said.
With artificial joints, cost-trimming efforts have been similarly ineffective. Medicare does not negotiate directly with manufacturers, but offers all-inclusive payments for surgery to hospitals to prompt them to bargain harder for better implant prices. Instead, hospitals complain that acquiring the implant consumes 50 percent to 70 percent of Medicare’s reimbursement, which now averages $12,099, up 25 percent from $9,645 in 1993. Meanwhile, surgeons’ fees have dropped by nearly half.
With the federal government unwilling to intervene directly, some doctors and insurance plans are themselves trying to reduce the costs by mandating preset prices or forcing more competition and transparency.
After concluding that hip replacements billed at $100,000 yielded no better results than less expensive ones, the California Public Employees’ Retirement System, or Calpers, told members that it would pay hospitals $30,000 for a hip or knee replacement, and dozens of hospitals have met that number.
Dr. Wright’s orthopedic hospital near Milwaukee has driven down payments for joints by more than 30 percent by resolving to use only two types of hip implants and requiring blind bids directly from the manufacturers; part of the savings is passed on to patients.
The Affordable Care Act tries to recoup some of the medical device manufacturers’ profits by imposing a 2.3 percent tax on their revenues, effective this year. But Brad Bishop, the executive director of OrthoWorx and a former Zimmer executive, said that the approach would harm an innovative American industry, and that the cost would ultimately be borne by joint replacement patients “whose average age is 67.” He argued that the best way to reduce the cost of joint replacement surgery was to rescind the tax and decrease government interference.
The medical device industry spent nearly $30 million last year on lobbying, according to the Center for Responsive Politics. The Senate moved to repeal the tax, and the House is expected to take it up this fall. The bill’s supporters included both senators from Indiana.
Mr. Shopenn’s new hip worked so well that a few months after returning from Belgium he needed a hernia operation — a result of too much working out at the gym. He was home by 4 p.m. the day of the outpatient surgery, but the bill came to $16,500. Though his insurance company covered the procedure, he called the hospital’s finance department for an explanation.
He remembers in particular a “surreal” discussion with a “very nice” administrator about a $750 bill for a surgical drain, which he called “a piece of plastic in a sealed bag.”
“It was mind-boggling to me that the surgery could possibly cost this much,” he said, “after what I’d just done in Belgium.”
(c) 2013 New York Times
Signal Press – eBook
I love this scene in THE CANDIDATE because it's a perfect example of yet another politician has been caught behaving badly, and instead of blaming himself, he lashes out at those who do their best to protect him — in this case, the book's hero, Ben Brinker, who is his campaign advisor.
A perfect illustration that scandals, such the Anthony Weiner texting scandal in the New York City mayoral race, aren't so much stranger than fiction.
“You sure are one stupid sonofabitch!”
Congressman Calder’s rant, roaring out of Ben’s iPhone, could be heard by each
and every wayward traveler in the Manchester Airport lounge, including the
bartender who was trying hard not to smirk as he slid Ben’s double Glenlivet,
neat, in front of him. “Damn it, Brinker, you told me you had that bitch under
a splitting headache, Ben cradled his cell as close as he could to his head,
then grabbed his glass as if it were a lifeline and took a swig. If he thought
the scotch’s numbing burn would muffle Dick Calder’s profanity-laced bellowing,
he was sorely mistaken. Worse yet, while Calder was screaming into one ear,
Chris Matthews was barking his own ruminations about “the politician and his
baby mama” on the lounge’s TV set. His guest pundits—Paul Begala, Bay Buchanan,
and Arianna Huffington, each wedged into a thin slice of the split screen—were
spinning their own theories on the first scandal of the election season.
down, Dick! I did take care of her. I always do, don’t I?” Ben ran his fingers
through his hair. Three strands—all white—dropped on the bar beside his napkin.
After today he wouldn’t be shocked to find that they’d all turned white—or that
they’d all fallen out. “I just talked to her yesterday in fact, and—Oh…wait!…Shit!”
look: Last night I didn’t have time to swing by there before my flight
with—well, you know, her little stipend. I called instead, and told her I’d
drop over tonight.”
all honesty, seeing Jenna never made Ben happy. He’d met her a decade ago, when
she was one of the many fresh-faced bright young things on the Hill. Having
just been hired on as a Staff Ass to her home state senator, she was a
small-town girl with a sunny smile and great legs: something admired by Calder,
among others—including Ben. And with so much going for her, Jenna wasn’t
exactly a saint. Then again, she wasn’t a Washingtonienne,
either. She truly believed Calder’s bullshit when he told her he’d leave his
wife for her.
least, those first three or four years they were together.
to say, when Jenna broke the news to him that she was pregnant, of course he
hit the roof. Still, Jenna did her part. She left the Hill before her pregnancy
could be discerned under her fitted suits.
discretion was part of her charm for Calder, whose wife gave him a wide berth
but had made it ominously clear that the gates of hell would open up under him
should any scandal threaten her hard-earned standing in Washington society.
the executor of little Cole’s trust, of course Ben knew otherwise.
though, Jenna had been fretting over what Calder’s presidential aspirations
would mean to her and Cole. She was no fool. Under normal circumstances she saw
him, what, twice in a month? If Calder were to get the Democratic nomination,
odds were he’d drop her like the hot political potato she was.
when he does, who’s going to hire me? No one!” she’d fretted to Ben last night
on the phone. “Not that Cole’s illness isn’t a full-time job. But without
employment, I’ve got no health insurance. Ben, these medical bills are eating
me alive, and that cheap son of a bitch Calder begrudges me every dime. I’m not
living high on the hog here. I mean for God’s sake, Cole is his son, too!”
wonder Jenna had sounded so anxious on the phone last night. Besides whatever
the Enquirer was paying, apparently
she’d hoped to get her cash before the Couric interview aired.
Calder turned icy cold. “Let me get this right,
Brinker: In other words, you blew her
not exactly. I mean—”
it, Kiss Ass. For once, you may have done me a favor. At least I saved a few
thousand there.” Calder’s cruel chortle sent chills up Ben’s spine. “It’ll be a
cold day in hell when that cunt sees another buck from me. Her little gravy
train is over. And so is yours, Brinker. It was your incompetence that lost me
was all Ben could do not to shout back into the phone, You did this to yourself, shithead. If you’d loosened your wallet, she
would have kept quiet forever.
he took a deep breath. “Can I help it that the Enquirer made her a better offer?”
retort was met with silence. Then Calder hissed: “That’s my point, you fucking
moron. You should have come up with a more permanent
solution. Like offing the bitch.”
What the hell?
okay. Lying to the media, to donors, even to his candidates’ wives was one
thing. And these days a payoff (to a dirty cop who could be convinced to “lose”
an arrest warrant, or a blackmailer, let alone a loudmouth mistress) was just
business as usual. But arranging a hit?
even I won’t sink that low, thought
knew the bartender had overheard Calder’s taunt, too, because the stocky
Irishman stopped polishing the counter mid-wipe and scrutinized him through
hooded eyes. Ben pretended not to notice, but a moist trickle of shame inched
its way down his back.
turned his head in the hope of deflecting the man’s stare. Then with as much
dignity as he could muster, he muttered, “Seriously, Congressman, what do you
take me for, some sort of thug?”
cackled so hard that Ben had to hold the iPhone away from his ear. “A ‘thug’?
Frankly, that would be a step up for you, Brinker. Hell, a cockroach would be a
promotion. For Christ sake, you’re just a fucking political consultant. Or have you forgotten that?”
cell hadn’t chirped as the line went dead, Ben would have faked some sort of
face-saving kiss-off for the benefit of the bartender and anyone else who was
still listening, but why bother? Everyone was watching the television, anyway.
eyes gravitated there too when he realized what they were staring at: his
photo, which had suddenly appeared on the television screen as Matthews spit
out his name:
it just me, or has there been an epidemic of political scandals lately? Seems
like the only thing they have in common is the same political consultant: Ben
Brinker. Remember the congressman from Utah who was caught last month
soliciting teenage girls over the Internet?”
screen cut back to the pundits. “Well, yeah, that was Ben’s candidate, too.”
Begala’s nod was accompanied with a grimace. “But hey, Chris, we political
consultants don’t carry crystal balls. And the ‘Mr. Smith Goes to Washington’
types are few and far between—”
remember correctly, Brinker also handled that governor who recently got
indicted in a construction kickback scandal.” Bay shook her head in disgust.
“And didn’t he work on the campaign of that senator whose diplomatic
aspirations went up in smoke faster than you could say ‘back taxes’?
Whitewashing the depraved makes you just as culpable, in my book.”
“Granted, there are some pathetic losers up
on the Hill, but there are also some really great statesmen—and stateswomen.” Chris was just warming
up. “They just don’t hire creeps like Brinker.”
line is that Brinker’s the best at putting lipstick on pigs and running them
for office.” Arianna’s icy chuckle pierced right through Ben. “But seriously,
how many political consultants can survive in D.C. with those kind of
‘see-no-evil, hear-no-evil’ antics? It may work if you’re a candidate’s wife,
but not a campaign strategist who wants to stay on K Street.”
Damn, that’s harsh, hon. Well then hell, don’t
count on me blogging anytime on HuffPo…Yeah, okay, so it’s a long shot that,
after this Calder crap, you’ll ever ask me again.
something else is going on here!” Matthews was on a roll. “Maybe some lousy
karma. ‘Bad Luck Brinker’ is some sort of political cooler who jinxes his
set off a cacophony of supposition, innuendo and balls-to-the-wall blarney from
his guests. Above it all Matthews roared his patented, “Tell me something I don’t know! Be right back–”
eyes in the bar turned to Ben.
with the realization that his income stream had just dried up—worse yet, that
he wouldn’t be able to replace it because he’d never live down this latest
humiliation—the Tilt’n Diner’s signature whoopee cake pie crawled back up Ben’s
throat, along with his Glenlivet neat.
hard, he tossed a ten on the bar and, with what dignity he could muster, walked
to the men’s room.
inside, he kicked open an empty stall, and promptly threw up.
(c) 2013 Josie Brown. All rights reserved.
I'm a total Woody Allen fan, and even had a Woody sighting myself, when he was filming his latest flick, "Blue Jasmine," here in San Francisco.
I think the trailer looks great. I love seeing all the San Francisco/Marin County shots, including a scene on the Muni F Line (the 1947 Philadelphia trolley car); several locales in Belvedere, California, across the Golden Gate Bridge; the bar, Aub ZamZam, in the Haight; Market Street; Geary Street; the Sunset District–
And of course, Ocean Beach.
Hey, even the quaint Mount-Tam-hugging town, Larkspur, California got into the picture.
It's a wonderfully updated take on that Tennessee Williams classic.
I love it that Alec Baldwin is Woody's new Every Patrician.
Definitely worth checking out, for the eye candy alone.
Because we always rely on the kindness of strangers (and no one is stranger to us than family),
Signal Press – eBook
In all online bookstores June 15, 2013!
Seduction and intrigue are rampant on the campaign trail when a political campaign adviser discovers that Washington's power broker elite have embroiled his presidential candidate in a plot involving an act of terrorism on US soil…
Democratic political campaign consultant Ben Brinker can’t remember the last time he was excited by a candidate’s vision. He feels he’s lost his way, both emotionally and professionally. Worst yet, his show-me-the-money policy seems to have finally caught up with him. Two of his recent clients have been disgraced in one way or another: a senator is caught in lurid sex scandal, and a congressman is indicted in a kickback scandal. In no time at all the political pundits are calling Ben a "candidate cooler." Now Ben is desperate for any campaign gig he can get.
As luck would have it, Andrew Harris Mansfield, the charismatic junior senator from North Carolina and former Marine pilot, asks Ben if he wants to run his soon-to-be-announced campaign for president.
Little does Ben know what's in store for Andrew, or their country–
Nor does he realize that the key to saving both have been placed in his hands.