Prior authorization: call for comments

The Washington State Medical Association has called for comments on prior authorization rule making for insurance companies. https://wafp.net/prior-authorization-rulemaking-oic-call-for-comment/

Here is my reply:

I have a small solo family practice clinic. My business plan was arranged to spend more time with patients. I have an office manager and no nurse, no back office.

Thus all prior authorizations are done by me, with the patient in the room. Often patients have talked to their insurance company the day before and have been told “your doctor’s office needs to call us”. More than half the time, when I call, we are told that the patient’s insurance company does not cover that service. The patient says, “But I talked to your company yesterday.” The insurance representative responds: “I only talk to physician’s offices, that is another part of the company that speaks to patients.”

This is triangulation, where in the “standard” office, the patient has called their insurance. They call the doctor’s office as instructed by the insurance. The doctor’s office requests prior authorization. The insurance says it is not covered. The doctor’s office notifies the patient, who then assumes that the doctor’s office did something wrong, not that it’s not covered.

This is unacceptable.

I have stopped telling insurance companies that I am face to face with the patient, because some representatives say “I am not allowed to talk to patients, take me off speaker phone.” I document the name of the insurance person in the chart, the length of time for the phone call and I bill for time: counseling and coordination of care. Review by coders say that this is legal.

I suggest that every WSMA physician pick one day to call a prior authorization themselves with the patient present. This would reduce the insurance company triangulation.

I think that insurance companies should be required to tell a patient if a service is not covered, and not be allowed to say, “have your doctor’s office call us” for a service that is not covered.


Feel free to send YOUR comments to the WSMA! https://www.insurance.wa.gov/secure-forms/rules-coordinator/

I like slugs better than health insurance companies.

Does back pain mean a disc?

Does back pain mean a disc?

Does sciatica, pain down the sciatic nerve, all the way down the leg, mean a lumbar disc is out of position and you need back surgery?

Ninety nine times out of one hundred: No.

No? What? Really? Doesn’t back pain and sciatic pain mean a disc is pressing on the nerve?

Nope.

Sciatica means that the nerve is annoyed. It is sending pain signals. It can be irritated and inflamed anywhere along the entire path of the nerve. When the nerve is inflammed or there is surrounding inflamation, the nerve sends pain signals.

But… if it is not a disc, WHAT IS IT?

Muscles that are injured, inflamed, irritated, contracted or torn, that in turn put pressure on or inflame the nerve.

The sciatic nerve is made up of multiple nerve roots coming from the spinal cord: L3, L4, L5, S1, S2, S3. And then variants. The nerve roots bundle together and then dive through a group of muscles and go down the back of the leg: deep in the muscles. Why deep? To protect this very big, very important, bundle of nerves. Branches veer off and innervate muscles and bone and tendon and fascia, all the way down to the toes. There is not a spinal column in the leg, to protect this nerve.

It dives in between the superior gemellus and the piriformes muscle, deep in the buttock. Under the gluteus maximus and the gluteus minimus. Then it goes down the leg, under the semitendonosus muscle and the biceps femoris muuscle, the big hamstrings.

Now, let’s go back up to the low back. Why does it hurt? With or without sciatica? There are six layers of muscles in the back, all way smaller than those hamstrings. The top is the latissimus dorsi, down 5 more layers to the small longus and brevis rotares muscles, which connect each vertebral bone and allow subtle and complex movements of the spine.

What happens when a muscle is torn or injured? People look blank in clinic when I ask. I say, “Think of a piece of steak, what happens when you cut it?” They still look blank. “It BLEEDS, right?” When a muscle is torn or injured and bleeds, it and the surrounding muscles cramp up as much as they can, to try to prevent further bleeding and tearing. If it is an extremity, ace wrap, elevate and ice, as soon as possible, to slow the swelling and bleeding and pain. If it is the lower back muscles, ice as soon as possible and applying pressure won’t hurt. No heat for 48 hours since muscle bleeding and swelling and inflammation usually peak at 48 hours. After 48 hours apply heat, then gently stretch, then ice after stretching.

Think of the muscle fibers as torn. They take about 6 to 8 weeks to fully heal. You want to stretch them and rehabilitate them without tearing them in that 6-8 weeks. You want every muscle to be fully functional, to be the right length, to not heal shortened or scarred. Get those fibers working again…

….or….

But doctor, my back has been hurting for FIVE YEARS!

Then it will take longer than 6 to 8 weeks to rehabilitate, retrain the muscles, gently break down the scar tissue, get it all functioning. Your muscles are doing their best. They told you they were hurt and you need to listen to them.

Covering it up with ibuprofen or alcohol or any number of substances or trying to ignore what your muscles are trying to tell you is a bit counter productive, don’t you think? Pain is information. An advil can help with the pain, but it does NOT fix the problem. “Drug me so that I can go on ignoring it.”…. uh, no. That is not ethical and it also doesn’t work.

And just think, if those back muscles continue tighter and tighter… they are constricting and pulling on the spinal bones.  They pull on those bones and then a disc might be thinned or crushed and might protrude and then press on a nerve. And then for surgery, what do they do to get to the disc? Cut through the six layers of muscle….

Does pain mean danger?

Does pain mean danger?

From a physician standpoint, sometimes the answer is “No.”

One example, sent by an alert friend, is a lump on the back of the neck, with pain radiating downwards.

This could be an abscess or an infected cyst, but since they didn’t mention infection, it is most likely an enlarged lymph node. This is one example where the doctor or nurse practitioner or psychic healer will look at it, say “Does it hurt?”, poke it and then be all cheerful while you wonder WHY they have to poke it* after you say, “Yes, it hurts.”

A newly enlarged tender painful lymph node is usually a reactive lymph node. It is swollen with cells from the immune system and is trying to heal something in the vicinity. A cut, irritated acne, a cold virus, that shaving accident, a low grade infection, an ear infection. Usually I talk about it and recheck it in two weeks.

The lymph node that will make your healthcare person worry is the one that DOESN’T hurt. A slowly or quickly enlarging lymph node that is not tender is worrisome for lymphoma or for metastatic cancer. Once it gets to 1 centimenter, I am calling the surgeon to consider doing a biopsy. We have lymph nodes throughout our body, but the ones that we can feel on the surface are only in the neck, the supraclavicular nodes, the axillas (aka underarms) and groin. The rest are under bone or muscle, though they can show up on CT scan or xray: enlarged mediastinal nodes along the great vessels and trachea in the middle of the chest.

So pain does not always correlate with the level of danger of an illness. The reactive nodes hurt because they swell quickly, and they usually go down quickly as well.

*They poked it to be sure that it is not fluid filled, that it is firm but not hard and fixed, so not an abscess or cyst, and doesn’t feel like a cancer.

I took the photograph last night with my cell phone, during a rare thunder and lightning storm here… beautiful.

End of Life Plan

My End of Life Plan and Wishes are as follows:

1. My plan is that my life should end after a half day of skiing for free at age 125 or 126.
2. My wish is to ski quite brilliantly, smoothly and gracefully, though not as aggressively as at age 110 and below.
3. My plan is that other skiers will ask who that brilliant skier is and that all the lift operators will know.
4. My plan is that I will have a delicious lunch, with a glass of champagne, in a condo overlooking the slopes.
5. I plan to have a hot tub and then a massage from one of the many handsome men who flirt with me.
6. My plan is that I will sit in a comfortable leather armchair with my feet on a foot stool, while three of my male friends vie to be the one to bring me the second glass of champagne.
7. My wish is that I will not need any cosmetic surgery or false eyes or ears or teeth or joints or heart valves and will retain my spleen, teeth, gall bladder, appendix and brain in full operating order.
8. My plan is that I will not be on prescriptions, medicines, vitamins, supplements, medical foods, or nutraceuticals nor under the care of any quacks of any sort.
9. My wish is that my male flirts will all think that I am not a day over 75.
10. My wish is that I will be listening to live music, a woodwind quartet or string quartet, just dropped in to say hello, along with three of my great grandchildren, showing off their olympic ski medals, summa cum laude graduation documents, or Nobel prizes.
11. My plan is that after the quartet leaves, I will fall asleep….
12. ….and not wake up, and that though my attendants are sad, none of them throws themselves off the balcony over the cliff and are all surprised at my true age and at the bountiful gifts I have left to each of them with proof that a long life and compounded interest have excellent results. My children, grandchildren and great grandchildren will live long and prosper as well.

death in childbirth

When I was in residency, one of the obstetrics-gynecology faculty asked us, “Women died in childbirth. What did they die of?”

We were silent. Stumped. Infection? Well, when there was no infection control and the male physicians went from room to room with no hand washing, yes… but….

Preeclampsia? No. Not that common. Eclampsia? Ditto.

“What if a woman is in labor and the baby is stuck? What do they die of?”

Ick. “Bleeding?”

“The uterus contracts until it ruptures. It contracts until it is thinner and thinner. If there is fetal malposition or a hand presentation or transverse or certain breech positions, the uterus ruptures and both bleed to death.”

We were all silent.

When I hear people bemoaning caesarean section and too much surgery and too many interventions…. I remember what women died of. All the stepmother stories. In the 1797 diary I am reading, the “lady” dies of a fever. She is 24 years old. There is no surprise, just sorrow. The author writing is the same age and grew up with her and grieves, but goes on.

We would like to think this is in the past, but it isn’t. It still is going on, right now, in  poverty stricken areas and war zones where the hospitals have been destroyed, the medical people have left, there are no services…

When I was still delivering babies, I would tell patients: my ideal labor plan is the baby comes out and I hand it to you. And the placenta comes out and the baby nurses and I don’t seem to be doing much. But that is not always what happens. I do not have control nor do you. I will only intervene if I think it is your life or the babies life or both….

http://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-14-43

http://www.msf.org/en/article/perils-childbirth-democratic-republic-congo

http://www.who.int/maternal_child_adolescent/documents/childbirth/en/

http://www.who.int/mediacentre/factsheets/fs348/en/

Donate:  http://www.doctorswithoutborders.org/

The picture is me on my maternal grandfather’s lap. I was one very lucky baby. My mother had tubuculosis through the pregnancy. She coughed blood in her 8th month. If there had not been medical care and a Tuberculosis Sanitorium to be born in, I would not be here.