bust

I took this in 2011, as a Mad as Hell Doctor, traveling around California talking about single payer.

We are losing more and more physicians. Our three counties, 450,000 people, are down from 8 neurologists ten years ago, to 2. The last one standing in the county of 350,000 says that he is really tired.

Single payer, medicare for all….. because I dream of other countries, civilized countries, countries where there is one set of rules, I can take care of any person who comes to me, I know what is covered and what is not, and I actually get paid….

 

Too long without touch

walk daily

without earbuds
without phone
without bluetooth

in the wild

walk daily

without family
without friends
without lovers

in the wild

no wild
you say

oh, the wild is here
there
everywhere

find a tree
find a park
find a path

dirt
ground
earth

walk daily

without earbuds
without phone
without bluetooth

in the wild

walk daily

without family
without friends
without lovers

in the wild

walk slowly

slow
each
step

in the park
in the trees
on the path

listen
to the trees
to the grasses
to the ocean
to the lake
to the desert

look up
at the birds

look down
at the insect
at the woolybear
at the mouse

walk daily

without earbuds
without phone
without bluetooth

reconnect

dirt
ground
earth

sky
fire
water
wood

walk daily

reality

connect

 

I wrote the poem this morning before the daily prompt: enlighten.

I am not enlightening you. I am enlightening ME. I need the touch of the dirt, the earth, grounding, daily.

Blessings. And this is playing: https://www.youtube.com/watch?v=u-wt7pRxWuw&index=12&list=RDTH5rqOjYAiM

 

primary care medicine: schedule

I see patients from 8:30 or 8:00 am until 2:00 pm.

We have people say, “You are off after 2:00.”

Well, no. Most days I work for 2-3 hours beyond the patient contact time. Sometimes I come in early and sometimes it is from 2pm to 5pm and sometimes it is the weekend or into the evening.

So what am I doing?

  1. returning phone calls
  2. doing refills. To do a refill I check when the patient was last seen and whether they are due for laboratory.
  3. reading specialist notes and updating medicine lists, diagnoses and contacting patients to get tests or follow up that the specialist has recommended
  4. reviewing lab results and sending a letter or signing to be scanned and to be available at the follow up visit or calling the patient
  5. reading emergency room notes and hospital discharge summaries and setting those patients up for follow up, updating medicine lists and adding to diagnosis lists.
  6. dealing with multiple stupid letters from insurance companies questioning the medication that I have prescribed. Mostly I mail these to patients.
  7. running my small business: long term planning, short term planning, advertising, commercial insurance
  8. 50 hours of continuing medical education yearly
  9.  Updating my medical license, medical specialty board eligibility, business license, CAQH, DEA number, Clia lab waiver, medicare’s shifting rules, medicaid’s shifting rules, tricare’s rules, and 1300 insurance company’s shifting rules and medicine rejections and prior authorizations even for a medicine a person has been on for 20 years.
  10. Worrying about small business costs as reimbursement costs drop: health insurance. Retirement. L&I. Employees. Malpractice insurance, small business insurance, the lease, staff costs.
  11.  Discussing and updating medical supplies and equipment, office supplies and equipment
  12. Updating clinic policies and paperwork per the change in laws. Have you read the Obamacare Law? Over 3000 pages. HIPAA. The DEA. Recommendations from the CDC, federal laws, state laws, internet security, patient financial and social security security.
  13. Trying to track what we collect. That is, say I bill $200.00. Since I accept insurance, the insurer will tell me what is the “allowed” amount per me contracting as a “preferred” provider. The “allowed” amount is really the contracted amount. Then the insurance company either pays it or says that the patient has a deductible. This could be $150 per year or $5000.00 per year. With medicare I then have to bill a secondary if the person has it and then anything left is billed to the patient. Oh, don’t forget copays, if they don’t pay that we have to bill it. So to get paid the complete contracted amount, aka “allowed” we may have to submit bills to two or even three insurances and the patient. We might be done two months after the patient is seen.
  14. Trying to convince recalcitrant computers and printers and equipment that indeed, it doesn’t have a virus, oh, or maybe it does, and fixing them.

My goals are to give excellent care AND to work 40 hours a week. Half of my patients are over 65 and many are complicated, with multiple chronic illnesses.  When I saw patients 4 days a week for 8 hours, with an hour hospital clinic meeting every day, I also spent at least an additional 8 hours and more trying to keep up with most of those things above. The average family practice physician makes more money than I do. But they also report working 60-70 hours a week on average. I do not think this is good for patients or doctors or doctors’ families or their spouses or children. The primary care burn out report rose from 40% to 50% of the doctors surveyed.

We need change, we need it now, and we need to be realistic about how much work is healthy.

When I was still delivering babies, women would ask if I could guarantee doing the delivery. I would explain: “We do call for up to 72 hours. If you go into labor at the end of that, you would rather have a physician who is awake and rested and has good judgement. Besides, I’m a bit grumpy after 72 hours. ” And they agreed that they really don’t want an exhausted burned out physician.

I took the photograph of Mordechai, our skeleton, today. She is genuine plastic. I wish she would do some of the paperwork, but at least she lightens things by making us laugh. She gets various wigs and outfits and sometimes comes out to show a patient a hip joint.

I am NOT attracted to paperwork. I think I am repelled. For the Daily Prompt: magnetic.

 

Health and teeth

For the Daily Prompt: toothbrush.

Here is a young rabbit. Their front teeth grow and get worn down eating. Their nails keep growing too and need to be worn down or clipped if they are pets.

In my county there are no dentists who take the state Medicaid for dental. And in some states Medicaid covers orthodontia for children but not in mine. Teeth are not covered on Washing ton State for my Medicare or Medicaid. And there are still battles going on about covering mental health including addiction. Is mental health not part of health? Are teeth not part of health? Why do we put health insurance profitable before basic life saving health coverage that covers all of us?

Health care should be like a toothbrush. We all need it. We all should have it.

 

Substandard

What comes to mind for today’s Daily Prompt: substandard?

As a rural Family Practice Physician, what comes to mind is the United States current health care system.

There is nothing substandard about our health insurance system: it does what it is supposed to, which is earn money for owners and investors. But it is frankly terrible at delivering health care, health care is not the goal, and we spend twice as much per US citizen as the next most expensive health care system in the world. And we do not have universal health care for our citizens and we rank below 30th in health care measures.

Wake up, US citizens. Let’s buy health care with our dollars, not health insurance. Single payer, one system, low overhead, clear rules and coverage and everyone in, no one out.

 

 

 

sunrise

Joy  today. I am so deeply thankful that this health insurance bill has been voted down. Health insurance because it was not going to improve health care. It would have increased profits and worsened citizens’ health.

Our chorus performed last night and the music is still playing in my head… from a Shawn Kirchner piece. “It shall be well with you…..”

I took this in 2012.

But I don’t want to pay for the obese smoking couch potato

I wrote this in 2010 and I am posting it again. It’s TIME, Congress, time for single payer, medicare for all! Lots of Senators are all talk about repealing Obamacare. One part of that law is that your health insurance company can ONLY keep 20% of each dollar for profit. The other 80% must be spent on health care. Before that, health insurance companies kept 30% of every health dollar. So tell me, US citizens, WHY do you want to repeal that? So health insurance corporation owners can go back to keeping 30% of every premium? Call you Senator and say NO.

And by the way, Senators who want to repeal Obamacare. You could have been writing a new bill with transparency and honesty for the last seven years, but all you’ve done is say “We will repeal Obamacare.” Saying “We can do better,” is boasting: you haven’t done the work. Stop hiding behind closed doors. I am submitting this to the Daily Prompt: hidden.

From 2010:

I went on the Mad as Hell Doctor’s tour for a week. I went from Seattle to Denver with stops for town halls one to three times a day. We are talking about single payer, HR676.

One question or objection to a single payer system was: Why should my money go to pay for some obese person who drinks and smokes, doesn’t exercise and doesn’t eat right?

Three answers to start with:

1. You already pay for them.

2. Put out the fire.

3. People want to change.

First: You already pay for them. As a society, we have agreed that people who show up in an emergency room get care. Suppose we have a 53 year old man, laid off, lost his insurance, not exercising, not eating right, smokes, drinks some and he starts having chest pain. Suppose that he lives in my small town.

He calls an ambulance. They take him to our rural emergency room. Oh, yes, he is having a heart attack, so they call a helicopter to life flight him from small town hospital to a big one in Seattle. This alone costs somewhere between $7000 and $12000. Now, do you know how many clinic visits he could have had for $7000? To see me, a lowly rural specialist in Family Practice where I would have looked at his blood pressure and nagged, that is, encouraged him to stop smoking. We would have talked about alcohol and depression. And who is paying for the helicopter meanwhile? All of us. The hospital has to pass on the costs of the uninsured to the rest of the community, the government is paying us extra, with a rural hospital designation. 60% of health care dollars already flow through the government. One estimate of the money freed from administrative costs by changing to a single payer system is $500 million.

Taking care of people only when they have their big heart attack is ridiculously expensive. It is a bit like driving a car and never ever doing maintenance until suddenly it dies on the highway. No oil, tires flat, transmission shot and ran into a tree in the rain because the windshield wiper fluid had been gone for a while. I get to take care of Uncle Alfred. He is 80 and has not seen a doctor for 30 years and is now in the hospital. “But he’s been fine,” says the family. Nope. He has had high blood pressure for years, that has led to heart failure, he has moderate kidney failure, his lungs are shot from smoking, turns out he developed diabetes sometime in the last 30 years and he’s going blind. Can’t hear much either. We have a minor celebration in the ICU because he doesn’t drink, so his liver actually works. He goes home on 8 new medicines.

Secondly: Put out the fire. When someone’s house is burning down, as a society we do not say, well, she didn’t store her paint thinner right or trim her topiary enough and she has too many newspapers stacked up. We go put out the fire. Putting out the fire helps us as a society: it keeps the fire from spreading to other houses. It saves lives and is compassionate. We think firemen and women are heros and heroines. And they are.

In the past, a homeowner would have to pay for fire service and would have a sign on their home. If the house was on fire and a different company was going by, that company wouldn’t put out the fire. We have the equivalent with health insurance right now. It would be much more efficient and less costly to have a single payer. Medicare has a 3-4% overhead: it is a public fund paying private doctors and hospitals. For private insurers the administrative costs are 30% or greater. That is, 1/3 of every dollar of your premium goes to administration, not health care. The VA is a socialized system, with the hospitals owned by the government and the medical personnel paid by them.

When someone asks why they should help someone else, I also know that they haven’t been hit yet. They have not gotten rheumatoid arthritis at age 32 or had another driver run in to them and broken bones or had another unexpected surprise illness or injury that happened in spite of the fact that they don’t smoke, don’t drink, eat right and exercise. Everyone has a health challenge at sometime in their life.

Third: people want to get better. Really. In clinic I do not see anyone who doesn’t hope a little that their life could change, that they could lose weight, stop smoking. True, there are some drinkers who are in denial, but I will never forget taking the time to tell a patient why he would die of liver failure if he didn’t stop drinking. He came back 6 weeks later sober. I said, “You are sober!” (We don’t see that response very frequently.) He looked at me in surprise: “You said I’d die if I didn’t stop.” He never drank again. It made it really hard to be totally cynical about alcohol and I can’t do it. People change and there is hope for change. I feel completely blessed to support change in clinic and watch people do it. They are amazing. But they need support and they need someone to listen and they need a place to take their fears and their confusion. Primary care is, in a sense, a job of nagging. But it is also a job of celebration because people do get better.

We are already paying, in an expensive, inefficient and dysfunctional way. It saves money to put out the fire. People want to get better. Winston Churchill said, “Americans always do the right thing after they have exhausted all other possibilities.” It is time to do the right thing. Single payer. The current bill is HR676. We can and we will.