An Insiders View of "Sicko"

Like Bob, I haven't seen MM's newest "documentary" (although, to be fair, I'm not a big movie guy; the last film I saw was the new James Bond flick). But it appears I really don't need to:

"Ask any Cuban who has recently left the island (because they can’t talk freely about this inside of Cuba) about their health care system and they will tell you that it is often a challenge just to get aspirin and they often have to get it on the black market. The run-down, dilapidated and unsanitary conditions in the facilities that the average Cuban must go to for care are a far cry from the hospitals and clinics reserved for high-ranking members of the communist party or the military. There are actually special facilities in Cuba that serve foreigners who can pay in foreign currency."

Read the whole thing (scroll down, since the site doesn't use permalinks).

Why isn't health care compulsory?

[Welcome Junk Food Science and Industry Radar readers!]

I say it’s time for Congress to face up to Americans’ needs, and make health care compulsory.

I’m not talking about health insurance. I’m talking about health care. Health insurance is not the same as health care. Who calls their insurance agent when sick or injured? Who calls an actuary? Don’t real people call their doctor or go to the emergency room? Yet our so-called leaders go on and on about compulsory insurance as though insurance is what we need even though it’s obvious that health care is what we need. The public is being sold insurance when we should be buying health care. If anything needs to be made compulsory, it is health care – not health insurance.

Once this concept is understood, it's clear what must be done. First, all health care professionals become employees of the Federal Government, paid a living wage from public funds. Second, hospitals, clinics, labs and other facilities are nationalized and their staffs also become employees of the Federal Government. Fair compensation is paid to the former owners just as for the condemnation of any other private property for public use. Third, the Federal health care professionals examine any person who wants health care, and issue health care orders to anyone who is determined to actually need health care. Fourth, it is illegal to seek or receive health care from anyone except a Federal health care professional. Fifth, everyone in the country is included in the plan; however the full cost (plus an administration fee) for non-legal aliens' health care is charged back to their home country via the home country’s foreign exchange account maintained at the U.S. Treasury. Finally a system of regional Federal Health Tribunals will be established.

The Federal Health Tribunals are empowered to impose heavy fines upon individuals who shirk their civic duty to follow health care orders, including refusal to alter lifestyle when so ordered (e.g., exercise, stop smoking, lose weight). The Tribunals also have authority to order health shirkers confined until treated. Depending on the seriousness of the condition, the confinement may be in a hospital or if hospitalization is not required, to (a) the Governors’ mansion, (b) the home of any elected State or local official, (c) any residence maintained by a member of Congress, or (d) any private home larger than 3,000 square feet.

The Tribunals also have the power to order a provider who refuses to deliver care that is ordered by a regional Federal Health professional, to perform unpaid community service within the Tribunal’s region.

Refusal by a health shirker or a health care provider to comply with an order of a Health Tribunal will carry penalties similar to contempt of Court and may involve fines or imprisonment or both.

Making health care compulsory would address actual need. Public funds to pay for compulsory health insurance would not be wasted on “insurance” but would be spent directly for health care. Everyone would then be healthy, happy, and handsome, and all our children would be smarter than average. Overnight, our life expectancy would be the highest in the world and infant mortality would drop to zero.

I call on Congress to enact this plan now.

USFL has left the Building

As one might imagine, folks with diabetes, cancer survivors and other folks with significant health problems often find it difficult to obtain life insurance. For one thing, a lot of agents represent only one carrier, which are often picky. Even independent agents, though, aren't always aware of alternative markets for their difficult-to-place cases.

For a long time, most of us "in the know" have relied on US Financial Life as our "go-to" source for social smokers, folks who've had recent bouts with cancer, mutliple-bypasses, and the like. USFL has been "aggressive" in its underwriting, often taking cases that other carriers either declined or rated so drastically as to render the coverage unaffordable.

But the industry is changing, and this time for the better; today, I received an email announcing that the "impaired risk market served by USFL is limited in size and has come under economic pressure as traditional carriers are increasingly expanding into substandard risk classes. Given these challenges, AXA Financial has decided to discontinue writing new business at USFL." [ed: apology to readers; I'm still looking for a linkable version of the announcement]

In other words, more "regular" insurers are willing to look seriously at "problem cases," which means more choices for consumers. I've placed a few cases with USFL over the years, and been happy to have them in my "quiver of carriers," but I also like the idea that my clients will have more choices, and competition should help drive down costs.

We'll have to wait and see on that last, of course.

Oh, and what about in-force policies? According to USFL's prez, Tim Herr, "(e)xisting coverage will continue for clients: the terms and conditions of their policies will remain in place."

As it should.

Cavalcade of Risk #29: Submissions Due

Just a reminder that submissions for next week's CoR are due Monday (the 2nd). Our hostess, Wenchy at Wisdom from Wenchy, asks that you PLEASE include:

■ Your blog's url

■ Your post's url

■ The post's trackback URL (if available)

■ A (brief) summary of the post

You can submit them via Blog Carnival or email.

PLEASE NOTE: Due to the July 4th Holiday, next week's Cav will be posted on the 5th.

Also, we still have Fall '07 hosting slots available. Hosting is fun, easy, and gets you off the "nag" list. Just drop us a line!

Hospitals v Bloggers

Paris (Texas, not Hilton) is home to the Paris Regional Medical Center.

And so, you ask?

Turns out, a disgruntled blogger has been busy pointing out sundry (and alleged) nasty items about said health care institution.

Apparently, the bloggers* -- who have thus far remained anonymous -- claim that PRMC has engaged in various criminal enterprises, including Medicare fraud. In fact, it appears that the bloggers have been fed specific information from actual hospital employees, which raises a number of issues, not the least of which would be potential HIPAA privacy violations.

[*ed: At this point, it's not certain whether the blog is run by one person or several, so I went with the multiple to keep it simple]

The hospital is hardly taking this lying down; they've convinced a court to order the bloggers' ISP to disclose their identities.

As in the case of Dr Flea, there are a number of issues in play here. As The Assertive Patient notes, there are competing interests: "Is the blog uncovering wrongdoing by the hospital? And is the hospital retaliating by bringing the suit? Will the blog be protected by the First Amendment, as other publications are?"

It's not immediately clear that so-called "Shield Laws" will apply in this case. After all, these are not journalists, but bloggers. There's an argument to be made, however, that bloggers are "citizen journalists," and I wouldn't necessarily argue against that characterization. But it seems to me that this is far from clear-cut.

In the meantime, I suspect that this story will become the most recent cause celebre (literally, Celebrity Cruise) for the medblogosphere, and we'll keep IB readers informed as we learn more.

(h/t Industry Radar)

FFS & Medicare

According to Medicare, a Fee for Service (FFS) plan is "(a) type of Medicare Health Plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan's payment. The insurance plan, rather than the Medicare Program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have extra benefits the Original Medicare Plan doesn't cover."

In other words, a FFS plan stands in for Medicare and Medigap (aka MedSup or Medicare Supplement) plans. It takes one's Medicare reimbursement and liability "offline," and makes it more of a one-on-one arrangement with your provider, rather than the traditional third-party arrangement we've all come to know and (ahem) love.

With FFS plans, Medicare pays a private insurer (e.g. Blue Cross) so many dollars per month on your behalf, and the carrier pays any claims out of that stipend. If they miscalculate, or your health declines, they may end up paying out more than they got from the gummint; likewise, if you're relatively healthy and have few claims, they get to keep the difference.

Not exactly rocket science.

In fact, if you're so inclined, the folks at Medicare have made available a handy booklet that explains all about how these plans work, and can help you decide whether or not one is "right for you."

Once one has decided to give the FFS system a whirl, one needs to sign up (enroll) in whichever plan is currently offered and available. There may be more than one, or none at all. What's different is how companies that offer FFS's "incentivize" folks to choose theirs. For example, many (most?) folks find that the traditional Medicare system leaves a lot of gaps in their coverage, so they buy Medicare Supplement policies, often sold by insurance agents. Of course, these agents (such as yours truly) are paid a (very modest) commission for each sale. These commissions are paid by the insurance carrier with whom the policy was placed.

Until recently, Medicare Advantage plans (of which FFS's are a subset) were sold directly by the carrier, not through an agent. But FFS plans may be sold by agents, who are paid a fee (similar to a commission) for the sale. So far, so good.

Unfortunately, my industry has a long history of shooting itself in the foot (cf: Single Premium Life), and the FFS biz is no different:

"Humana Inc., UnitedHealth Group Inc. and five other U.S. health insurance companies agreed to stop selling a type of government-funded plan for the elderly in response to complaints that sales agents forged signatures and enrolled dead people."

Gotta love that last: I thought dead folks only voted in Chicago; who knew they also bought health insurance in Peoria? And it's a non-trivial amount of money, in that FFS plans "account for about 20 percent of the $60 billion Medicare Advantage program." Ouch.

In the event, Medicare is working with the carriers involved in this little kerfluffle to determine guidelines, and they've temporarily stopped pushing these plans until there's sufficient oversight and enforcement in play.

I was particularly pleased to see Bloomberg quote fellow medblogger Bob Laszewski, who opined that "(i)t's a positive development in that they are doing something, but it's somewhat hollow...Someone came up with a fantastic public relations marketing, failing to tell people that 99 percent of all sales occur during the open enrollment.''

Bob's referring to the fact that, perhaps not coincidentally, the aforementioned carriers have ceased their marketing efforts at the same time that the Medicare Open Enrollment Period is in hiatus.

Not that we're cynical or anything.

So what's the bottom line: are FFS plans a good thing or not?

Well, that depends, really, on what one expects from one's insurance. I've always been of the opinion that there are trade-offs in such plans: cost vs availability, exposure vs access. If one saves a bunch of money, but can no longer see one's trusted family physician, is the trade-off worthwhile? Seeems to me that that's a personal decision, pne not to be taken lightly or without some serious contemplation. On the other hand, no one's claiming that the plans themselves are defective in some way. If one knows ahead of time that certain provicers aren't going to be available, but that one's monthly premiums are going to decrease substantially, then perhaps it's a worthwhile trade-off.

Food for thought.

Surgery & Guiness: An Update

Seems our erstwhile surgeon-in-waiting has attracted the eye of John Law:

"A 15-year-old boy who allegedly delivered a baby by Caesarean section in an attempt to set a world record as the youngest surgeon apparently fled as police prepared to arrest him on Tuesday."

The gendarmes have apparently already arrested the miscreant's parents, and are on the lookout for Doogie, as well.

This doesn't appear to be headed towards a happy ending.

Sauce for Goose, #4

For all the enthusiasm expended by those who want to see Canadian-style, big government health care implemented here, I think it's fascinating that those who actually live it aren't necessarily so hot on it.

And it's not just a few grumbling malcontents who seem to prefer a more, oh, private type of system:

"Canada's top doctor singled out New Democrat leader Jack Layton yesterday for "hypocrisy" for undergoing hernia treatment at a private Toronto medical clinic.

But Brian Day, president-elect of the Canadian Medical Association, was quick to note Layton is in good company."

Turns out, former Canuck leaders Paul Martin, Jean Chretien and Joe Clark have all been availaing themselves of these private clinics (of which there are apparently quote a few, putting the lie to those who tout this as an ideal system).

And even among those who do choose the services of the nationalized system, a little "some are more equal than others" appears to be the order of the day:

"(U)nion leader Buzz Hargrove, president of the Canadian Autoworkers, proved a master at "queue jumping" when he got in for an MRI within 24 hours of injuring his leg."

"Queue jumping." Heh. Careful there, Buzz, don't want to sprain an ankle and require any more free health care.

But even those accused of "bashing" the Canadian system (such as Dr Day) aver that "(n)o doctor in Canada I know wants a U.S. system."

Sure, whatever you say, Doc.

An Inspiring Grand Rounds

Wandering Visitor asked contributors to this week's 'Rounds to send in posts about "Things that inspire you."

And boy, did she get a boatload: over 3 dozen posts, most of which followed the theme. It was interesting to see what kinds of things medbloggers find inspiring.

Dealing with two teenaged daughters, I was particularly moved by Nancy Bown's post on parenting as inspiration. She draws on the Virgina Tech tragedy, as well as her own experiences. Quite inspiring.

Monday Miscellany

■ A co-worker's husband (a minister, no less!) is blogging his trip to Israel. He left a bit over a week ago, and has a week more to go. He's posted some beautiful pictures, as well as his own observations and thoughts on where he is and what he's seen. Worth clicking.

■ A few weeks ago, I lambasted GE for its terrible customer service. In the meantime, I've had two extremely wonderful customer service experiences, which I'll share:

I recently "inherited" a Bang & Olufsen CD/Radio unit. It's quite beautiful, and I'm sure that it sounds great, but I had no way of knowing since I lacked the instructions. A quick perusal of the B&O website yielded no help, so I dropped the company an email explaining my plight. A few days later, I received a .pdf with everything I needed to know.

About the same time, I also "inherited" a whisk attachment for our Cuisinart Food Processor. Again, I was sure that it would be a terrific tool, but with no instructions, I had no idea how to use it. Same drill: cruise over to Cuisinart's website, poke around, no instructions, but a helpful contact form. Completed, submitted and waited. Lo and behold: last week I received a phone call from a Cuisinart rep, who offered to send me the instructions I needed, but lacked my snail mail address. The instructions arrived in todays mail.

Now THAT'S customer service!

Amazing Carnival Monday

This week, I was pleasantly surprised to see that we were included in both of the top finance-related carnivals:

The "Silicon Valley Blogger" (of The Digerati Life) put together a mind-numbing 91 posts for this week's Carnival of Personal Finance, all held together with a kind of fantasy-mythology theme. Believe it or not, it really does work; maybe a little better than most of us would have believed.

Of course, with that many entries, it's nearly impossible to pick out a favorite, but Kelly Bejelly, blogging at A Girl Worth Saving, tells of a harrowing experience with credit card/identity theft, how she handled it, and some pointers for the rest of us.

The Carnival of The Capitalists is at Management Professor Notes (II), hosted by Prof Sandy Kristin Piderit. The good professor presents 40 interesting posts, categorized and with helpful context.

Having recently written on the importance of customer service, I was drawn to Jason Rakowski's post which illustrated the concept of good vs bad customer service in an entertaining, and quite helpful, way.

Legal Eagle Carnival News

Regular Cavalcade of Risk contributor Eric Turkewitz recently tipped me to a weekly compendium of "(s)ome of the best of the recent blogs dealing with personal injury law (that I found)," the Personal Injury Law Round-Up.

It's actually quite interesting, and somewhat overlaps both the CoR and the Health Wonk Review. But it's different, too: if you've ever watched Perry Mason (or Boston Legal), then you won't be surprised by some of the antics chronicled by RU contributors. Check it out, you'll be glad you did.

Medical Tourism: Not What We had in Mind

Perhaps you've heard, but the son of not one, but two prominent Indian physicians has delivered a woman's baby.

And so, you ask?

And so: the young man in question is but 15 years old and no, his name is not Sumit Howzer. In fact, he's still in school (no, not med school, thank you very much). His father encouraged, and oversaw, the procedure because, well, "he wanted to see his son's name in the Guinness Book of World Records."

Well. Who could argue with that?

Oh, right:

"Amarilis Espinoza, a spokeswoman for the record book, said in an e-mail response to a question from The Associated Press that the organization doesn't monitor or endorse such feats because it would encourage the practice of "bad medicine."

Ooops.

At least mom and baby are reported to be doing fine.

Lose Some, Win Some

Regardless of where one stands on the gay marriage issue, it never seemed equitable to me that employers would offer "domestic partner" benefits to gay couples while giving hetero ones the cold shoulder. And now, it looks as if that whole kerfluffle may become moot:

"A Michigan court ruled in February that public employers may not offer benefits to unmarried partners, gay or straight, because of a 2004 amendment defining marriage. Government employers there had offered benefits only to gay couples."

Well, that seems to have settled that.

Or maybe not: there's an appeal currently wending its way through the Wolverine State's legal system, so we'll have to wait for the final word there.

■ Meantime, Kentucky's Attorney General has put the kibosh on two Blue Grass State universities offering those domestic partner benefits, again regardless of sexual orientation.

■ In Nebraska, a US Appeals Court upheld an amendment barring government agencies from offering such benefits to same-sex couples (although it didn't address unwed heterosexual partners).

■ And here in the Buckeye State, a lawsuit's been filed to prohibit my alma mater's (Miami University - Go Redskins!) from granting health and other benefits to same-sex partners of that institution's employees.

On the other hand, more and more employers are looking to "do right by" folks who adopt. According to USA Today, almost half of employers offer adoption benefits; that's a 25% increase from just a few years ago.

But just what does "adoption benefit" mean?

Well, that depends on whom you ask. Some employers provide cash-on-the-barrelhead for legal services, others give paid time off for folks to adjust to their newly-expanded families. The only downside is that, since these are not considered as benefits under 213(d), the proceeds themselves are taxable as income. Still, 75% of something is better than nada.

If you're thinking about adoption, you might want to check out this website for a list of which companies offer what additional benefits.

We Get Mail!

One of the great benefits to hosting a blog on insurance matters is that, from time to time, we’re offered the opportunity to help folks out. I really do mean that: all four of us really do enjoy helping people solve their insurance problems [ed: well, it sure ain’t for the money!]. We aren’t always successful, as you’ll see in this instance; what we’d really like is for our readers to offer any suggestions (and/or relevant experiences they’ve had). This can be done via the comments section, or by email. And now, our letter from Bruce*:

[*All names have been changed to ensure privacy. Content was edited for brevity.]

“I'm going to have a stroke or massive heart attack while talking to a medical or insurance institution.

I recently had a physical exam. My chief complaint was constant fatigue. The doctor said my lab tests were fine; it was most probably sleep apnea and I should go get a test to confirm.

I begin to wonder what this will cost. The web has informed me that the "test" is to spend the night in the hospital while being filmed and wired to recording devices. Sounds expensive [and] I wonder what the insurance will pay. I plan to ask the insurance company (BCBS), but know from experience that they do not like this question. I resolve to get the CPT ( Diagnosis code) and ICD9 (treatment code) from the hospital; the charges are $139 for ½ hour visit with doctor before the test and $3000 for the test.

I now call BCBS. I explain that I am trying to find out what my cost would be for a medical procedure before I commit to having it. [I am told] that the information I am asking for does not exist. Oh sure it does; I have the ICD9 code for her. She then asks me what hospital I am going to [and] her the hospital’s financial payer code. I do not have the answer, [so] this ends the conversation.

I really want to know, so I call again. This time I get Marvi [who] listens to my explanation and question. She asks me to wait a moment, and then comes back on line to say the ICD9 code I have given is invalid. I repeat the number in case we got it wrong. She is sympathetic but we can go no further. I now have the information that the insurance will pay for 90% of the usual cost after I pay the deductible. But of course without the ICD9 code I cannot know the "usual cost". One would think that the sacred ICD9 codes would be freely available on the web. I use Google and to my surprise I find the code. It is 89.17.

Now for the diagnosis code (CPT). I learned in another life that the AMA copyrights them and all users must pay a fee to have them. All I want is to be a responsible citizen and keep my medical expenses to those that I consider worth the money. This is a completely discretionary expense. I have no desire to have medical expenses that I don't need."

And there matters stand. The four of us have noodled this, and have thus far determined the following (which we’ve shared with Bruce):

1) He should consult with his HR folks to see what (if any) help they can be in this. (As it turns out, he had not already done so)

2) Determine if he has access to a Flexible Spending Account (to help mitigate his actual out of pocket costs)

3) Go to the carriers website to see if there are any transparency tools available.

So there you have it, dear readers. Any other suggestions?

Cavalcade of Risk #28 is up!

Julie Ferguson, of Workers Comp Insider fame, hosts this week's Cavalcade of Risk. She's put together quite the issue, with a record-setting 24 interesting risk-related posts. Please check it out.

And consider hosting a Cav yourself; Julie can tell you that it's easy, fun, and a nice traffic bump. Just drop us a line to sign up.

A Senior Moment

One of the neat things about SiteMeter is that one can see from whence our visitors have come. I've noticed that we've had several referrals from a new (to me) site, Health Management Rx. It's hosted by Jen McCabe Gorman, a Washington (DC)-based hospital/healthcare industry analyst and consultant.

Recently, Jen had coffee with an elderly gentleman with a unique -- and disturbing -- perspective on the state of elder care. Part 1 is here, and her follow-up is here.

Read both.

Dear Grand Rounds...

If you like Dear Abby (and even if you don't), you'll love this week's Grand Rounds. Geena, hostess of Codeblog, presents her 3 dozen-entry 'Rounds as an advice column, with some mighty fine entries.

My step-father, due to some health issues, must use an electric "scooter" to get around. On the one hand, it's an acknowledgement that his health has declined; OTOH, it's pretty cool (a jazzy red number, with a basket and headlight). As a guy, though, I'm sure he'd love the new models from Porsche (yes, that Porsche). Read all about some new "alternate transportation" options at Science Roll.

Excellent Carnival Monday!

Wow: Two outstanding business/finance related carnivals this morning. Be forearned, though, both are chock full of posts (not a bad thing, BTW).

We'll take them alphabetically:

The Carnival of the Capitalists, hosted this week at Blog Business World, features 30 posts in 5 categories. Most include helpful context, as well.

The issue of ethics has been a recurring theme here at IB, so I was impressed with this post at the Sox First blog. In it, host Leon Gettler poses a series of questions to help new employees understand how a given company handles ethical conundrums.

Meanwhile, over at the Carnival of Personal Finance, host JD (blogging at Get Rich Slowly) offers up a mind-boggling 85 posts, most with helpful commentary. He's sprinkled some cleverly-chosen videos throughout - a lot of fun!

Since this edition marked the second anniversary of the Carnival, the theme was "favorite posts" from the past two years, and a lot of folks (including us) took that seriously. And you'd think that with over 7 dozen choices, it'd be hard to pick a favorite.

But it really wasn't:

Some 16 months ago, Jim at Blueprint to Financial Prosperity penned a heartfelt and important reminder that the map is not the territory, and we are not our assets, but so much more. Recommended.

Do HDHP's cause people to learn about health care?

The June 13 Wall Street Journal contained an article on the growing influence of patient groups on medical research. The article states,

“Online patient groups have become an increasingly powerful force for health-care consumers over the past decade, raising funds for research and offering patient information and support. Now, as the cumulative power of their memberships grows, these groups are becoming invaluable partners to researchers and physicians searching for cures.”

This reminds me that the debate about high-deductible health plans may be missing an important point: HDHP’s are not the fundamental motive for patients to become increasingly informed about health issues, and are not the reason patients are trying to be “better shoppers” for health care. Instead, those developments were happening already - and independently. Access to health care information via the internet was around long before so-called “consumer-directed” health plans tiptoed onto the stage.

Viewed in this light, the true significance of the high-deductible plans may be that,

· AFTER consumers have influenced their health care treatment for the better

· based on more-informed discussion with their physician,

· the patient may realize some financial benefit, in some circumstances,

· from the health care choice they influenced

· because HDHP’s remove the insulation from costs that too many insurance plans provide.

But I do not believe that HDHP’s are driving some fresh new search by patients toward more health care knowledge. That search was already well under way; the key enabler is the internet; and as more and more people access the internet, the search for health indformation will continue to broaden and deepen.

Can the general public handle this new knowledge?

I think so. No one expects patients to become the equivalents of physicians, even tho some, as reported in the Journal article, will become very sophisticated. The general expectation is only to become aware of alternatives, possibilities, and relative costs (including approximate out-of-pocket costs).

The U.S. Census Bureau has estimated that, in 2007, a total of almost 21 million Americans cannot read a newspaper; cannot add, subtract, or balance a checkbook; cannot write a complete sentence; cannot speak - or can barely speak; do not vote; and are incapable of self-support. [Table 094 Midyear Population by Age and Sex.]

I’m referring to the population age 4 and below. Does the present ignorance of this population mean that we should expect these individuals can never learn how to be functioning members of our complex, modern society? Is it preferable to keep this population ignorant because someone might argue that learning is beyond their grasp?

I think the answer is self-evident: of course we can educate our children. Of course learning is not beyond their grasp. And of course we can expect our children to mature into self-sufficient adults.

In a similar fashion, I think it is a mistake to believe that the general adult public is incapable of absorbing increasingly sophisticated information in regard to their own health and health care.

The trend toward increasing general knowldege of health care is continuing - and IMO cannot be stopped. The so-called “consumer-directed” health plans simply provide a means and a financial incentive for knowledgeable individuals to pursue superior and in some cases lower-cost health care alternatives. We need not worry obsessively today about the growth of these plans. They will grow in proportion to the expanding health care knowledge of the population.

ADDENDUM: For a fascinating, real-time example of almost exactly the kind of issues Mike mentions, be sure to check out this post at Dr Wes' blog, and especially the comments section. HGS