By RICK PETERS

Last Friday morning, delirious, wasted, bone tired, driving home from the Emergency Room at 8AM in my beat-up little truck with only one speaker working. Amid all of us awash in the blogosphere thank the stars for NPR and professional journalism.  Steve Inskeep, from Morning Edition was interviewing Angela Braly, CEO of Wellpoint.  Perfect! Wellpoint is the largest health insurer in the U.S. in terms of covered lives. Also, Wellpoint, the former non-profit Blue Cross of California converted into a very profitable for-profit corporation, represents the epitome of for-profit medicine.

Mind you I’ve already thrown in the towel.  Any meaningful reform seems well past doomed. Harold and Louise are already back channeled through Newt and Sarah, and fringe lunatics are getting airtime, calling Obama a Nazi because they cannot understand the difference between National Socialism and Medicare. It would be comedy writ large if not for the gullibility of the American electorate. Oh well, here we go again.

The trouble is that our problems are so deep and fundamental that any sort of government driven health reform is destined to have limited impact despite the best intentions.  That’s what was so painful and profound about Inskeep’s interview with Braly.¹ If we are going to even start to move this mountain we are going to have to foster change from within the system. That change is going to have to come from all of us as a society and as patients, families, health care providers, health care organizations, and influential health care managers and executives.

Newt and Sarah know the game they are playing – they’re politicians.  Their party is out of power and they are using opposition to health care reform to rebuild their base by any means necessary. Braly and her compatriots are a whole different animal.  They know exactly what is at stake.  Listening to the interview you might wonder how this ditzy soccer mom every got recruited to run a major corporation.  It’s uncanny.  She does not answer a single question.  What she does do, however, is illustrate what will essentially kill not only health reform but also real change.  What Braly does is deflect responsibility to everyone else in the system and not once acknowledge that not only do we have a problem but that we all share the responsibility for getting here – Wellpoint, Braly, and every one of us in health care included.

Braly’s no fool.  She is the third highest paid health insurance executive having been compensated $9,844,212 in 2008 by Wellpoint.² Only Ed Hanway, CEO of CIGNA, and Ron Williams, CEO of Aetna, were paid more.  Wellpoint’s profit in the last fiscal year was close to 4% as even Braly admits, which is equal to or greater than the entire administrative cost of the Medicare program.  Inskeep calls Braly on virtually every statement she makes but as a pro, Inskeep just lets her dig herself in deeper.

I think I fainted.  I crawled out of the car and went in to go to sleep with it all blaring in my head.  My patient with gallstones diagnosed a month ago now with elevated LFTs and awaiting an ultrasound wanting to know if she could just go out a get a carne asada burrito and then come back for the test.  The Alzheimer’s patient who could not walk or feed himself or recognize anyone who fell out of bed and broke his hip and needed a hip replacement not only because he was full code, but because it is the only humane thing to do.  The health information systems we struggle with feigning silence when we know they are archaic and are killing our efficiency.  The practice variation and flaunting of evidence every one of us is guilty of as physicians.  The elderly couple with the husband with pneumonia who has to be admitted to the ICU with the wife pleading with us that the hospital copay will ruin them this month. The healthy forty year old female executive demanding a bone density test because she ‘paid for her insurance.’  The 340 pound 53 year old diabetic back again with an ischemic leg status post three resuscitations this year alone and over $125,000 in fully covered medical expenses now headed towards $175, 000.

Ms. BRALY: Our profit is in the 3-4 percent range – I think this year, around 4 percent. When you look, though, across health care, there are profit margins in a number of sectors around health care that are three, four, five times ours. If you look at biotech margins or pharmaceutical companies or device manufacturers, they’re three, four, five, six times the margin in the health insurance business. And the irony of that is it is our job to get to the efficiency of health care.

INSKEEP: There might be another irony there, as well, because if it’s your job to make things efficient and the cost of doing business keeps going up year after year after year, doubling in five years, as the president says, somebody might suggest you’re not doing a very good job.

The key is that none of us is doing a very good job but it’s too easy to point fingers and deflect blame.  I’m a pessimist about health care reform because I think the blocking and tackling have finally begun in earnest. I’m optimistic, however, about what we can and should still do even if we end up again with the status quo.

In that vein and with Matthew’s and the team at The Health Care Blog’s permission I am going to start a series of blogs called ‘Nuts and Bolts’ to talk about the incremental things we need to do no matter what happens in Washington. We need incremental changes throughout the health care ecosystem and while some need policy changes, others just need personal changes from each of us. The first installment will not be about ‘Death Panels,’ or policy, it will be about how critical it is for each of us to make our own decisions about our own lives and our own sense of death.  It will be called ‘Nuts and Bolts – Advance Directives.’ Then we can go from there.