Category Archives: health care costs

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Alcohol

Let’s talk about alcohol.

I am a family practice physician and I talk to people of all ages about alcohol. The current recommendation is no more than seven drinks a week for women and fourteen drinks a week for men, no saving it up for the weekend. No more than two drinks in one day for women and no more than three for men.

“What?” you say “No way. Come on, that’s ridiculous.”

My patients don’t say “That’s ridiculous.” After all, they are paying me to do a physical exam and a preventative exam. I am supposed to give them advice. But what is the basis for that?

One drink is defined as a regulation 12 oz beer or 6 ounces of wine or two ounces of hard liquor. If it is a high alcohol beer or wine or liquor, the amount is less.

It is NOT the liver doctors that have given us these numbers. It is the cardiologists, the heart doctors. One drink in women or two in men lowers blood pressure and in general, has good effects. Go over that daily and there is a rebound in blood pressure as the alcohol wears off. Alcohol works in the same way as benzodiazepines: it makes people less anxious and more relaxed and lowers inhibitions. Both alcohol and benzodiazepines are addictive for many people. That is, they develop tolerance, it takes more of the substance to have the same effects, more tolerance and then it takes more and more substance to try to feel half way normal.

Cardiologists qualify this recommendation as follows: there is no recommended daily amount of alcohol that is considered heart protective because there are too many alcoholics. The recommended daily amount of alcohol for an alcoholic is none. The recommended daily amount of alcohol for the general population is none.

Alcohol withdrawal can be very very dangerous medically. I think that the three most difficult things to quit are heroin (and all opiates), methamphetamines and cigarettes, but alcohol is more dangerous. In heroin withdrawal all of the pain receptors fire at once, so it is torture, but people don’t die. With serious alcohol withdrawal, the blood pressure skyrockets and the person can have seizures, a stroke, a heart attack, delerium tremens and can die. In the hospital, benzodiazepines are used to slow the withdrawal, replacing alcohol in a controlled manner.

Alcohol does more than affect the blood pressure. Over time, alcohol can damage the heart and lead to congestive heart failure.

Of course, you know that it can damage the liver and lead to cirrhosis. Cirrhosis is sneaky: as long as there are a few functioning liver cells, the lab work can look pretty normal. The liver makes proteins for the blood and makes proteins that allow our blood to clot. Once there aren’t enough healthy cells to make those proteins, alcoholics will bleed quite spectacularly. If the amount of the protein albumin in their blood is low, fluid leaks from the blood into the tissues: so whatever part is “dependent”, that is, lowest, will be swollen. Alcoholics can have legs with swelling where I can push with my finger and there is a two or three cm dimple. Alcohol also can lead to gastritis and ulcers. If someone can’t clot and they are vomiting blood from an ulcer, the doctor gets a tummyache too, from worrying. Ow. The liver is also supposed to filter all of the blood in the body. As the liver gets blocked with dead liver cells, the blood starts to bypass it. The bypass is through blood vessels in the stomach. Remember that person vomiting blood? The swollen vessels in the stomach are called varicies and we don’t like them to bleed. They are big and can bleed really really fast. The person can die. I don’t like transfusing and really don’t like transfusing 12 units of blood. In end stage alcoholism, the liver no longer lowers the blood level of ammonia. Ammonia crosses the blood brain barrier and poisons the brain. We haven’t even discussed the lack of vitamin B12 and thiamine which can cause unraveling of the myelin sheaths on the long fibers in the spinal cord: this means that the person gets permanent asterixis and “walks like a drunk” even when they are sober. I’m sure I haven’t remembered all of the consequences of alcohol, but that will do for now, right?

How much alcohol daily causes the above charming picture? We Don’t Know. Really. And it is not okay to do randomized double blinded clinical trials to find out. Same with pregnant women: we don’t know if there is a safe amount of alcohol during pregnancy and we bloody well can’t test it. It is safer not to drink while you are pregnant.

In clinic, I ask how much people drink. If they say 1-2 drinks daily, I ask what the drink is. Sometimes they look confused. I explain that I have one patient who has two drinks a day: however, it is a 12 ounce glass with a little ice and a lot of whiskey. I asked him to estimate how much whiskey and he said, “6-8 ounces.” That is, each glass is 6-8 ounces. His blood pressure is not under control and so far I feel like a failure as a doctor with him; he is NOT reducing the amount. In medical school, the two jokes were: How much alcohol is too much? More than your doctor drinks. And: How much does the patient drink? Double or triple what they tell us.

The popular word in college used to be that you could drink one drink an hour and still be “okay”. “Okay” to drive and it would wear off. Sorry, nope. Breathalyzers are now pretty cheap; buy one if you are drinking more than the 1-2 per day. And the college students that are binge drinking 6-8 or more drinks on Friday and Saturday: it DOES have long term effects and it IS doing damage.

Lastly, sleep and depression. If you are having trouble sleeping, don’t drink. No alcohol at all. Alcohol is a depressant. It helps people to fall asleep. But they do not have “normal sleep architecture” and it works AGAINST them staying asleep. People often wake up as the alcohol wears off. And the blood pressure is having that rebound, remember, and often their heart will race. That is withdrawal. If you are having trouble sleeping or you are depressed, do not take a depressant. It makes it worse.

I saw a nineteen year old in clinic who admitted to “occasional” heroin use. “But I’m not addicted,” she said. I said, “Well, that’s good. But I took care of a bunch of people undergoing heroin withdrawal while I was in residency and it looked like one of the most painful things on the planet. So I would advise you to quit while you are ahead.” I saw her a year later and she said, “When I tried to quit, it WAS hard. I was addicted and didn’t know it. I’m off now and I won’t go back.” So if you tell me, no problem, I can quit alcohol any time, I say more power to you. Show me. And if it’s harder than you think, get help.

 

Originally written in 2009 and updated a little today. The picture is just a little fuzzy…like it might be if I was drinking…..

https://www.drugabuse.gov/about-nida/noras-blog/2015/06/addiction-disease-free-will

https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/what-standard-drink

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Your health care dollar

I have been writing posts about fraud in medicine: but I think I am using the wrong title. Instead it should be your health care dollar: how the US medical corporate system wastes your health care dollar.

Think about it. What do you want to spend that dollar on?

Do you want it to go to 1300 different insurance companies and their web sites, their advertising, their competition and their profit? Do you want your healthcare dollar to go to complex coverage rules and contracts, to forms for prior authorization, for the weekly postcards and emails that they send me telling me that they have changed your coverage? Is it any surprise that I have no idea if your insurance company covers a test? They may have last week and not this week. The overhead for medicare is 2-3% administrative costs. Now why would we privatize that when the overhead for the health insurance companies is 20-30%?

How much of your health care dollar do you want to go to corporate competition?

I don’t want ANY of my health care dollar going to corporate competition and profit. I want my health care dollar going to my HEALTH. We spend the most per person in the world, almost twice as much per person per year as the next most expensive: and we don’t guarantee care. Hello, the next most expensive and all of the other nearly 40 countries, first and second world, have universal care for all their citizens. So is our care twice as good?

No, no, no, and no.

Hello, new administration. Let’s put the health care dollar where it is paying for health…. in medicare for all and in a single payer system. We have guideline after guideline on how we should treat illnesses, here:

US Preventative Task Force

The guidelines are regularly updated. If we have medicare for ALL then I will KNOW whether a test is covered or not. I have memorized the entire list of medicare covered screening tests and all the details: screen for abdominal aortic aneurysm is covered in male patients age 65-75 who have smoked more than 100 cigarettes in their life and any patient who has a family history. I have the whole list in my brain.

You CAN make a difference. Write to your congresspeople, state and national. Call them. Email them. They all have websites. Tell them YOUR health care story or the story of a friend or family member.

Join Health Care Now and Physicians for a National Health Program.

I want my health care dollar to go to HEALTH CARE.

For the Daily Post Prompts: gone and interior. Interior because I am so angry at the poor spotty costly health care for my fellow people in the US. And gone: your health care dollars is GONE: let’s use the next one wisely.

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Doctors don’t charge for phone calls

Doctors don’t charge for phone calls.

Attorneys do: they charge in fifteen minute increments.

Doctors don’t charge for phone calls: oh, but actually that is a myth. And it’s raising the cost of health care in the US because the insurance companies are using this myth to their advantage. Not only is this costing every one of us more money, but it is driving doctors out of practice. And it’s making patients bitter and angry at the doctor, when it is the insurance that should bear the blame…

Why do I say this?

A patient calls their health insurance. “I need x.”

The health insurance says, “Have your doctor’s office call for a prior authorization.” Now, we are definitely paying the health insurance to have someone say that to the patient.

The patient calls the doctor’s office and requests the prior authorization. There, a second person is being paid to get that phone call.

The doctor’s staff runs it by the doctor. The doctor says, yes, the patient needs that or no, I would like a visit to discuss this. More time that we pay for.

If the doctor says yes, the doctor’s office contacts the insurance by phone or on line to do a prior authorization. This means a different website for every one of 1300 insurance companies in the US. We are paying the doctor’s office staff to be on the phone and on the computer to fill out prior authorization forms to get permission from the insurance if your doctor agreed that you need x or that x would be helpful. We also are paying for all of those websites that the insurance companies have to slow down giving the patient care.

I don’t have an office staff to do this. I have a bare bones clinic so that I can spend more time with patients. I call the insurance myself with the patient in the room.

More than half the time the insurance company says that x is not covered under the patient’s plan.

But wait. The patient already called the insurance to ask if they could get x. And the insurance said have your doctor get prior authorization. So in the usual office, the patient is called and told that x is not covered. The patient is angry, because they think that the doctor’s office has messed up the prior authorization. The insurance does not want to tell the patient it is not covered. So our costs spiral up and up and up, because the insurance has realized that they would rather have the patient angry at the doctor’s office, not the insurance.

And we all are paying for it with our health care dollars…..

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Update on marijuana 2016

I attended the Swedish Hospital Update on Chronic Pain in Seattle two weeks ago on the stormy Friday. The power went out and we were without slides from about noon on.

The first two hours and three lectures were about marijuana. Including medical marijuana and one speaker for and one against. So here are some of my notes.

In 1960 and 1970, the marijuana had about 4% THC. Now some strains have 30% THC, so long term there is no data about what 30% THC will do to a person rather than 4%. THC in strains ranges from 0% to 30% and CBD from 0 to 3.5%. However, those two are not the only active ingredients, so to speak. 537 constituents have been identified that work at the cannabinoid receptor…. that is impressive. I think it might take a while to sort out what they do.

At any rate, we don’t know what smoking 30% THC will do, because it’s new. 4% had pretty minimal psychotropic effects. 30% has a lot more. The average now is 12%. Hashish is closer to 66% and hash oil 81% THC. A patient recently told me that she fainted within the last year. She got butter from the fridge at a friend’s and buttered her toast. Turned out it was THC infused butter and she was taken by surprise on a walk 30-60 minutes later. Luckily someone was with her and she was not hurt.

Recent data is showing that there is not much tolerance smoking 12% THC regularly. However, higher doses show tolerance in about 2 weeks in a study of HIV patients with dronabinol, which is 40% THC. Another study of multiple sclerosis patients with 15/15% CBD:THC reduced pain, reduced spasticity and did not show tolerance.

There is anecdotal evidence about seizures, but no study yet. There is some evidence that CBD reduces THC induced paranoia and/or hallucinations. THC side effects from dronabinol include drowsiness, unsteady gait, delusions, hallucinations, mood change and confusion.

The growers are being very creative in names and marketing. This is re recreational pot.
There are hundreds of names and hundreds of varieties and they make interesting claims as to effects. For example:

AK47 with 36.6% THC and 0.3% CBD ….. creative, euphoric and hungry
sage with 27.5% THC and 0.7% CBD ….. attentive
flow with 23.2 % THC and 0.6% CBD ….. happy, relaxed, alert
Super Sour Diesel 22.7 % THC and 0.8% CBD ….. attentive, giggly, hungry
707 Headband with 22.1% THC and 0.7% CBD ….. euphoric, lazy, inspired

How amazing the difference less than a percent of THC makes… oh, wait. There aren’t clinical trials on this, hon, this is MARKETING.

Onset for oral is 30-90 minutes
peak in 2-4 hours
half life 8-12 hours but sometimes 20 hours

sublingual tincture
onset 30-45 minutes
peak 60 minutes
half life 3-5 hours

Smoked onset quicker and I did not get those numbers.

The emergency rooms in Colorado saw lots of people who were “trying it” but if they had only tried smoking marijuana in the 1970s, a strain with a much higher percentage made many people sick or hallucinate or frightened. The gummi bears look just like the ones for kids, so kids got sick. More sick people with edibles, as some eat too much.

People using THC before age 25 who have risk factors for schizophrenia are more likely to develop it. Family history, other hallucinatory drugs, mental health problems. The age 21 limit should be taken very seriously.

In Arizona re medical marijuana, 90% of the prescriptions were from only 24 physicians. In Colorado, 94% of the patients applying for medical marijuana did so for “severe pain”. Two of my friends in their early 20sΒ  got medical marijuana permits in California for “back pain”, um, ok, hooey. Some people DO have severe chronic pain….

The history of medical marijuana is that Eli Lilly produced a medical version from 1850-1940 for pain. It was removed in 1942. In 1970 it became a schedule one, that is, illegal, drug. There are a few randomized clinical trials for pain, the best ones with high CBD/low THC treatments. Marijuana smoke alone has not been proven to cause lung cancer, but combined with tobacco or other smoke, the evidence is that it is synergistic and makes things worse faster. Dependence can occur, an increase in antisocial personality disorders and there is a withdrawal syndrome for dependent folks. For the small number of people I have had working hard to stop, sleep is the most difficult issue. Anxiety as well.

If people state that they use pot a small amount a couple of times a week, their urine sample should clear after a week. If it’s not clear they 1. couldn’t stop and/or 2. were using quite a bit more.

As far as Washington state law, it was described as a mess. Physicians can’t prescribe, they can only “attest” that the person has a problem treatable by medical marijuana. To attest, the physician has to sign a document saying that they are sure that not only has the patient READ the law chapter 69.51A RCW but also “understands the requirements of being a patient”. There are 24 sections. The physician doing this part of the talk said that he would only prescribe to non-driving MS patients in wheelchairs. Because he finds it hard to read the law himself, so the signing that the patient has read and understood it…. well, the driving legality issue is huge. And the provider, including NDs (naturopaths) and ODs (Doctor of Optometry) in Washington can attest. They are then immune in Washington but not at the federal level.

Every marijuana store is legally obliged to have a medical marijuana consultant present at all times that they are open. The medical marijuana consultant has 20 hours of training to get certified. Patients that are certified with an attestation can grow 6 to 15 plants but ONLY after they have been entered into a database which includes the person who signed the attestation and a photo of the patient. If they grow without being entered, they are breaking the law.

Use of THC long term, the risk of addiction is 25-50%. 17% of the addicted folks started during adolescence. Addiction is currently estimated at 9% of people who have tried it overall. About 30% of users have “problem use” and starting before age 18 increases the problem use 4-7 times. The DSM-V has diagnostic criteria for “marijuana overuse syndrome”, including not being able to stop even though the person wants to. Risk factors for addiction and problem use include early use, family history, PTSD (especially sexual abuse), bipolar diagnosis, ADHD, conduct disorder, oppositional defiant disorder. Mediating factors include parental disapproval, parental supervision, academic competence, higher perceived risk and availability.

And am I attesting? No. My MS patients get the attestation from the neurologist if they want it….

Medical marijuana consultant training: http://www.doh.wa.gov/YouandYourFamily/Marijuana/MedicalMarijuana/RulesinProgress/MedicalMarijuanaConsultantCertification
Washington State Medical Marijuana attestation form: http://www.doh.wa.gov/Portals/1/Documents/Pubs/630123.pdf
WA law: http://app.leg.wa.gov/RCW/default.aspx?cite=69.51A
And pain clinics getting closed down: http://www.seattletimes.com/seattle-news/health/pain-patients-scramble-for-care-after-clinic-crackdown/

The tree trunk is a bonsai from the Lan Su Chinese Garden in Portland. I like the thorns…..

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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.

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DIY cat fud

This is for Ronovan writes weekly haiku poetry prompt #87, words class and firm.

I try to stand firm
health insurance corporate
fraud stand firm with class

Boa cat brought her own breakfast in the other day. I am so appalled and horrified by the health insurance corporate fraud I see daily. The patients and I are the mouse and the health insurance corporations are the cat….. we have to stop them.

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Fraud in medicine: prior authorization III

I see a patient who has had prolonged sinus symptoms AND her right upper molar has been irritated for weeks, but then Saturday it started hurting. She saw her dentist. The dentist did x-rays and said it’s her sinus. “But my tooth hurts too.”

On exam, her gum is bright red above the tooth, but not swollen as it can be with an abscess. No fever. No bright red spot over the maxillary sinus.

I call our independent radiology service and ask for a limited sinus CAT scan. She is off on Mondays only, it is Monday, she is out of town next Monday. Can they do it today? Yes, but she needs a prior authorization.

I call her insurance, after looking up the CPT code for sinus CT on google. As usual I have to enter numbers before I talk to a human:
patient insurance id number
my tax id number
my national provider index number
and others until I get a human.
Then I have to give the numbers AGAIN because the insurance company deliberately makes it inefficient, even though I have entered them into the phone it doesn’t transfer to the representative and you know that it COULD.
I give my name
patient’s name
patient’s date of birth
clinic address
clinic phone
clinic fax number
tax id
national provider index number
and finally explain: we need a prior authorization for a limited sinus CT and she has five ICD 10 symptom codes.
“She doesn’t need a prior authorization.” says the rep.
“What?” I say, “So it’s covered.”
“We don’t guarantee coverage, but we don’t give prior authorization.”
“What do you mean, you don’t guarantee coverage. I am calling to check.”
“We review the chart afterwards and THEN decide if it’s covered.”
“No. That isn’t good enough. I want to speak to someone who will check the codes and tell us if it will be covered.”
“I will have to transfer you to the (patient something).”
“Fine. Transfer our information please too.”
We go on hold. Time passes.
We are back to a recording:

TALKING TO A REPRESENTATIVE DOES NOT GUARANTEE COVERAGE OF A TEST. PRESS ONE IF YOU ACCEPT THIS.

No two. No other options are offered. I press one.
I talk to the new representative. “I have five diagnosis codes and want to know if the sinus CT will be covered. She is off and they can do it today. She is only off on Mondays.”
“We don’t do prior authorizations.”
“Isn’t there ANY WAY we can find out?”
“You can mail a letter to a PO box and we will review it and let you know.”
I am ….. hard to describe…. my head hurts.
“Would you like the PO box address?”
“How long does that take? Yes we want it. Don’t they have a fax?”
We get the fax number too. I hang up and look helplessly at my patient. “I think it will be covered. I would recommend we do it.”
“Ok.” She says. Her face and tooth hurt.

I call the independent radiology center and set it up for 2 pm.

They call back in the afternoon. She has a sinus infection and the tooth is bad too, they don’t quite look connected. I call the Ear Nose and Throat specialist who wants her on three weeks of augmentin if she tolerates it and then to see her. I thank him and get it rolling.

But….. ok, so the insurance companies contract with me and the patient say that they can change the benefits any time they want. They “notify” me with postcards with online links. Like I have time to read and remember the changes for …. 50 different plans? There are over 500 in the US.

When are we going to stop letting insurance companies take our money and refuse care and refuse to pay the physician and the radiologist? Medicare for all, one set of rules, I COULD LEARN THEM. I can memorize huge amounts of data: I am already busily memorizing the ICD10 diagnosis codes. There are only 48,000.

And I don’t know yet if her insurance will pay for the sinus CT…..

The picture is from Lake Matinenda in Ontario: no computers at our cabin, no outlets, phones mostly don’t work…. heaven.

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I will fight no more

I am tired of fighting
I am tired of fighting for justice
I am tired of fighting discrimination
I am tired of fighting for health care for all

I am tired of fighting insurance companies
I am tired of fighting medicare’s contractee
I am tired of fighting for prior authorization
I am tired

I will fight no more forever

I heal
I am a healer
I am trying to heal patients
I am trying to help patients heal

I am a healer
I help heal cancer
I help heal heart disease
I help heal PTSD
I help

heal cancer
heal heart disease
heal PTSD
heal addiction

I am a healer

heal the insurance company
heal the medicare contractor
heal the pharmaceutical company
heal

heal anxiety
heal depression
heal addiction

I will fight no more forever

I heal

The legs in the photograph don’t look delicate, do they? They are strong and beautiful and powerful. I took this at the National Junior Synchronized Swimming Competition in 2009. Those girls on the edge of being women are strong, they are a team, they work and play together. They have the skills and the strength to lift their bodies out of the water that far using their arms… think about the practice and strength needed to do that. We all want to heal and create fun and play and beauty. Let’s work as a team.

also on everything2.com

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fraud in medicine: prior authorization I

Prior authorization is where, in the insane United States medical system, the doctor orders a test or medicine. The insurance requires “prior authorization”, that is, the doctor or their office have to call or go on line to fill out forms to get the prior authorization. Otherwise the test or therapy or medicine or even surgery will not be covered by the insurance and the patient eats the bill. Over 60% of bankruptcies in the US are now over medical bills*.

In most doctors’ offices, the prior authorization is done in the back rooms. Employees are on the computer or on the phone trying to obtain the permission, the code number, the magic words that will help the patient. This is a HUGE business and a scam as well. Physicians for a National Health Care Program estimated in 2011 that it costs at least $82,975 PER PHYSICIAN PER YEAR to have a person calling.* Now, there is a person on the other end receiving that call or going over the forms. That person is paid with your insurance premium. Is that health care? It seems more like a barrier to health care. Let’s look at an example.

I do my prior authorizations in the room with the patient. I only have a front desk person, no back room people, and anyhow, if I do it face to face with the patient, I can charge the insurance company for the call. It is face to face counseling and coordination of care. I don’t get paid well for this, but it’s worth it for the patient education.

Yesterday I called for a patient. The insurance company first has a recording that tells me it is recording this conversation. I am too, in the chart note. Then it reminds me I could do all this on line. Well, that is sort of true. I could, but every insurance company has a different website, they all require logins and passwords and it would take me hours to learn them all. Nope, not doing that. After the message it says: “Please enter the physicians NPI number.” I do. Then it leads me through choices: confirm the patient is insured, check the status of a prior authorization, appeal a prior authorization, initiate a prior authorization. That one.
At 3 minutes 50 seconds, I get a human. We are on speaker phone.
“This is Rex. You are calling for prior authorization?”
“Yes. This is Dr. Lizard. Mr. X is in the room.”
“Please spell the doctor’s name.” They are not used to doctors calling.
“Please give the NPI number.” (ok, we typed that in. But every time you are transferred, you have to give all of the information again. I am not kidding.)
“Please give your clinic address. Please give your clinic phone number. Please give your clinic tax ID number. Please give your clinic fax number.”
I do.
“Please give the patient id number. Please give the patient name. Please give the patient date of birth.”
Ok.
My patient is looking amazed. This is how insurance companies treat the doctors who call them? Yep.
“What medicine are you authorizing?”
“A compounded testosterone.”
“Please list the ingredients.”
Crap. didn’t think of that. “Ok, we want to authorize an fda approved one.”
That is entered. “What are the instructions for the patient?”
“What is the dose or strength?”
“What is the diagnosis?”
“He has a condition from birth with no testosterone.”
I have to spell the condition for Rex.
“What is the ICD 10 code?”
I give that.
“Have you measured a testosterone level?”
“Yes. It’s zero. His body doesn’t make testosterone. Since birth.”
My patient is rolling his eyes.
“The form will be sent for review and you should get a fax within 24-72 hours regarding the authorization. Here is a number for tracking.”
“Thank you, we are recording this phone call as face to face counseling and coordination of care in the chart.”
Phone call is 13 minutes and 50 seconds. That is a fast one, actually. Most are 25-30 minutes and I fought for an hour once when a patient’s prescription coverage was cancelled.

I wish that every doctor in the country would do one prior authorization on the phone once a week with the patient in the room. The doctors’ heads would blow off. They might finally see what the current system is doing and how the insurance companies throw more and more and more barriers up to refuse people care.

And how is it a scam? One way is that the patient calls the insurance. The insurance has people who only talk to patients. That person says, “Have your doctors office call for a prior authorization.” The patient calls the doctor’s office. The doctors office calls the insurance, but they are talking to a different branch of the insurance company. That branch tells the doctors office “We don’t cover that.” The doctors office calls the patient, who then thinks that the doctor’s office has screwed up the prior authorization.

How do I know that? With the person in the room, the insurance tells me “No.” I have had patients say, “Your company told me yesterday that all I needed was for the doctor to call!” The insurance person replied, “I only talk to doctors. It is another part of the company that talks to patients.” I have also had an insurance person say “Take me off speaker phone, I am only allowed to talk to physician’s offices, not to patients.” Riiiiiight. I took him off but put him right back on. My patients are outraged and furious: at the insurance, not me. The insurance companies are doing brilliant business plan triangulation and I hope whoever thought it up and whoever allows it as a business plan roasts in hell. No, instead I hope that they wake up and realize how many people they are hurting and I hope that they turn and work to heal a broken sick system.
*http://www.pnhp.org/new_bankruptcy_study/Bankruptcy-2009.pdf
http://www.pnhp.org/sites/default/files/docs/Bankruptcy_Fact_Sheet.pdf
**http://www.pnhp.org/news/2011/august/us-doctors-administrative-costs-4-times-higher-than-in-canada
http://www.pnhp.org/news/2014/august/adventures-in-prior-authorization

I took the photograph at Lake Matinenda in August 2015. It is of a storm. A storm is here in medicine: people versus the corporations who prey on us. We need to heal the system and heal the fear and greed.

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Fraud in medicine: medicare application

Medicare quit paying my clinic at the end of July, on the 31st.

I was still half time in clinic, we were interviewing a new receptionist as my receptionist of five years wanted to retire by August first. We got some sort of notification from medicare, but their letters are very cryptic.

My new receptionist was needing orientation and help and I was really tired after July. I redid the medicare application and sent it in. We continued to see medicare patients and turn in the bills.

Our medicare contractor is noridian. They sent us a cryptic letter saying that something was wrong with the application. This was, mind you, a renewal. I had been seeing medicare patients for five years in my clinic.

I call them. I am given a name and a number to identify the call. I have two Ptan numbers, one for me as a physician and a second for the clinic. The first call said that my personal Ptan application was correct but the clinic one wasn’t.

I did it again and mailed it. Second day air. He said that our payments should be released in 10-14 days.

Ten days. Nothing. Fourteen. Nothing. I am pulling from savings to run the clinic. I call a second time. Again I am given a name and a number. She said I had to CALL to get paid once the application was received. I said the first guy didn’t say that. She said another 10-14 days.

We wait. After ten days I call. A third number and person. Once again I have a cryptic email. I ask about the PTan number on the email, which is not my clinic’s Ptan number. Oh, says the man, that is what is wrong with your application. He says to do form (numbernumbernumber B) not form (numbernumbernumber A). And it will be 10-14 days after they receive it.

I do it AGAIN. I do notice that all of the old copies of the form in our file have the PTan numbers wrong. Weird. They have been paying me for five years.

Ten days. I call a fourth time. She says that it will be 30 days not 10 to 14 until medicare lets me know if my application is correct. Or they might pay me after 10-14 days. They aren’t, so I argue that something must still be wrong. What is it? She can’t tell me. I want a supervisor. She says that I can talk to a supervisor in 10-14 days. We figure out that the Ptan number on the application is correct. I say, “I am writing my congresswoman.” and hang up.

So I do. I find my Senator’s email and I write to her. I have been a rural family practice doctor for 25 years and I saw a 98 year old yesterday and a 91 year old today and I LIKE my elderly patients, but I have HAD it with medicare, at least with the contractor noridian that is running medicare for my state. I list the phone call dates and names and identifying numbers and I say FIX IT because otherwise I am for the first time in 25 years seriously considering quitting medicare.

Two days later noridian sends an email saying they are releasing my payments.

The next day we get a direct deposit for $9000.00. That is a START.

One week later we get a call from noridian explaining what is wrong with our application. Not just one thing. Noridian doesn’t seem to have a copy of our business license from five years ago. We have to put the personal Ptan on page xgyb-14. They want details about the nursing home. Do I do home visits?

The noridian person explains that our application has actually been wrong for five years, but now they are getting audited so they have to get everything cleaned up.

So THEY have KNOWN it was wrong for five years, but held my payments since July, while they try to get their act together and tell me what the hell is wrong with it?

I want to be paid INTEREST for all the time I have spent on the phone and redoing the cryptic application.

And many thanks to my congresswoman, for keeping my clinic open.

I took the picture at the Kinetic Sculpture Festival here in September. The outfits make more sense than dealing with noridian, that’s for sure….

first posted on everything2.com on 11/30/15