Category Archives: rural doctor

by

Double standard: AI technology can take jobs but improving healthcare can’t

The United States could go to single payer healthcare, but one objection has been “People will lose their jobs with health insurance companies.” Yet no one seems to object to AI, Artificial Intelligence taking jobs. It’s technology so it’s fine! The wave of the future! Coming whether we like it or not!

One form of single payer healthcare is medicare for all. Expand medicare so that it covers everyone. At first, it only covered retired female teachers. Women were only considered for teaching jobs if they were single. A married woman was expected to work in the home. The teaching pay was low. Men were expected to be supporting a family, so they got more. Women were often supporting parents or children if spouses died or divorced or abandoned a family or were disabled. Early census information was a finagle: any male in the household was listed as “head” even if it was an elderly disabled father or a boarder or a teen. So the true numbers of women as head of households were obscured.

Single payer would improve healthcare. There would be ONE set of rules. Physicians would know if something was covered. Right now there are over 500 health insurance companies and they each have multiple different policies. Not only that, but the policies can change monthly in what they cover. Did you know that? I would get monthly postcards from multiple companies saying that I could go on line to one of the 500 different websites and see what they had changed and were no longer covering. I found little time to learn 500 websites. We spend enormous amounts of healthcare money on communication back and forth from insurance companies to hospitals and clinics. Trying to prior authorize CT scans, MRIs, surgeries, referrals, medications (even old cheap ones!) and then attempting to get the health insurance companies to pay for the care. Remember that the insurance companies are allowed a 20% profit: so for 1 million dollars of healthcare money, $200,000 can go to profit. The people and computer work is not in that profit, so what percentage of your healthcare dollar goes to attempting to prior authorize and get paid? How much of your healthcare dollar would you like to go to healthcare?

Medicare’s overhead is either 1.4% or 6%, instead of that 20% profit and the prior auth/collection effort. There are two different estimates (from here):

1. There are two different measures of Medicare’s administrative costs. One figure comes from the Medicare Board of Trustees’ annual report, while the other comes from CMS’ National Health Expenditure Accounts. According to the latest trustees’ report, Medicare’s overhead represented 1.4 percent of its total expenditures. According to the latest NHEA, Medicare’s overheard was 6 percent of expenditures.

2. The discrepancy between the two figures is due to Medicare Parts C and D. Mr. Sullivan wrote that the difference between the trustees’ measure of overhead and the NHEA measure “is due almost entirely to the fact” that the NHEA figure includes administrative expenses incurred by health insurers that participate in Medicare Advantage (Part C) and Medicare’s prescription drug program (Part D). In essence, the overhead associated with the private insurers involved with Medicare raise the program’s overhead by almost 5 percent, or $24 billion in 2010.

People worry about “socialized medicine” but really, the closest system to socialized medicine is the Veterans Administration. I don’t think anyone wants to take their healthcare away, and some of it is specialized depending on where they were deployed and what they were exposed to. I saw veterans in my clinic because we were more than 30 miles by car from a VA hospital.

What about medicare fraud? I saw way more fraud with the insurance companies. Companies will maximize revenue by sending equipment at the exact interval insurance allows (like sleep apnea equipment and diabetes glucometers). It doesn’t matter to them if it’s being used or not. After my father died, there were 16 full oxygen tanks full in his house. The company was happy to pick them up and no, they did not want to reimburse the payments. A biller told me that often the health insurance companies will pay less then the contracted amount. When challenged, they say, “Oh, that was a computer error! We will fix that!” She said, “I have never once seen the error in the physician’s favor.” When I had cobra insurance, they would not pay my bills and I had to call them every single time to force them to pay. It took enormous amounts of time and again they claimed, “Oh, computer error!” I finally called their counseling line and said, “I want to be counseled for your company refusing to call me back and screwing over this cobra policy, and by the way, I have a family member dying of cancer.” That finally made them fix it.

WHY is our culture ok with technology taking jobs, while improving healthcare can’t? Get rid of the health insurance companies! Medicare for all! If we all had secure health insurance, think of the work innovation in our country!

For the Ragtag Daily Prompt: finagle.

by

Wise fear

I don’t think the team of four taking down the four trunks of this cedar were fearless. They were sensibly afraid and stopped between each trunk. They discussed the next step and had all the safety gear in place that was possible. It was still very dangerous.

For the Ragtag Daily Prompt: fearless.

by

Numbers game #7

For Judy’s Numbers Game: 128.

I have enough showing up that it can be all beach. Brandt geese out in the early morning.

Let’s look closer at the eagle in the tree. Splotchy feathers, not quite fully mature.

Rocks and logs and sand.

The deer come down too.

A gull in the evening as the light falls.

by

Who is the scamp?

Is the sea lion the scamp? Or the ocean wave splashing up? Or the cormorant in front of the right hand sea lion?

These are sea lions rather than seals, in Puget Sound. The small ear flaps give them away. They are also just bigger than most of our local seals. Males are bigger than females, up to 390 pounds, while the females are up to 110. Here: https://www.eopugetsound.org/articles/california-sea-lion

For the Ragtag Daily Prompt: scamp.

We learned this one as kids and sang it very happily.

by

Andrews creek

Andrews Creek flows from up in the Olympic Mountains in Washington State. It empties into Crocker Lake. Andrews Creek exits Crocker Lake, empties in Snow Creek and Snow Creek empties into Discovery Bay.

I took the pictures and video yesterday.

For the Ragtag Daily Prompt: bubbles.

by

Less Long Covid if vaccinated

My cats are pound kitties, rescues that were still half-starved kittens when they arrived. They were supposedly six weeks old when I got them, so born in August 2021. This photo is from February 2022. They are still exploring and fascinated by water and faucets and showers. They are doing cat research. Meanwhile, Long Covid research continues.

https://dgalerts.docguide.com/ncov-home/article/lower-long-covid-prevalence-symptom-severity-in-vaccinated-individuals

This is a report on a study which started in October of 2020. “Participants were actively followed for severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) infection. In the study, Hannah E Maier, PhD, University of Michigan, Ann Arbor, Michigan, and colleagues compared the prevalence of symptoms and symptom severity between vaccinated and unvaccinated individuals.” People were enrolled for a year as they got infected, with demographic and health information recorded as they enrolled. They turned in information every two weeks and had blood draws every two months. After a year they were invited to continue for a second year. 3375 were enrolled, more than 1370 filled out Long Covid forms, and 1007 of the 1370 were vaccinated. Long Covid was defined after 90 days.

“At 30 and 90 days post infection, 38% and 13% of individuals reported persistent symptoms, and 6% and 2% reported ≥5 symptoms, respectively. Fatigue (19%), cough (15%), and cognitive dysfunction (12%) were the most commonly reported symptoms at 30 days, whereas loss of smell/taste (8%), fatigue (6%), and cognitive dysfunction (5%) were the most commonly reported symptoms at 90 days. The mean score of symptom severity was 3.6 and 3.9 at 30 days and 90 days post infection, respectively.

At 90 days post infection, 8% of vaccinated individuals reported persistence of any symptoms compared with 27% of unvaccinated individuals (relative risk [RR] = 0.31; 95% confidence interval [CI], 0.22-0.42). Similarly, vaccinated individuals were less likely to have ≥5 symptoms compared with unvaccinated individuals (RR = 0.34; 95% CI, 0.15-0.79).

Furthermore, vaccinated individuals had significantly lower average symptom severity scores at 90 days post infection compared with unvaccinated individuals (relative severity [RS], -2.70; 95% CI, -1.68 to -3.73).“

There also was more Long Covid in the pre Omicron group than Omicron and beyond.

This study is community based and most of the patients were not hospitalized. Overall it has a lower estimate of how common Long Covid is than studies in hospitalized patients. It is reassuring that Long Covid symptoms and prevalence are lower with vaccination, but some people are still severely affected even with vaccination. Vaccination does not stop Long Covid completely though I certainly wish that it did. Mixed good news, but vaccination still looks like the best bet other than moving to a bunker permanently.

The study is published in Open Forum Infectious Diseases: https://academic.oup.com/ofid/advance-article/doi/10.1093/ofid/ofae039/7585852. The quotations are from the DGAlerts article.

by

Numbers Game #6: 127

For Judy’s Numbers Game #6: 127. Many of the photographs that came up are from a trip to the Washington, DC area in 2018, and various hikes there.

A merganser enjoying the winter sun.

The George Washington Parkway, over our heads, as we hiked down a run.

The Potomac River, seen through the trees.

The Potomac River along the Tow Path.

Time to head home as the light fades.

by

Peace Plague

If I can be anything I want to be
today let me be a peace plague.

Let me be a peace plague, airborne,
spread fast in the air
just a breath of wind
two neighbors who are angry stand at a fence
one drops a rake, the other a hose
they stare at each other. “Come to tea,”
says one, and the other comes.
Someone stops writing a letter of complaint
and gathers blankets for the warming center instead.
A policeman aims at a kid with a gun
shouts “Freeze.” and then he freezes too
on an intaken breath, and the kid drops the gun
hands up, breathing my plague.
And in a war zone, one side chokes on the air
and stops firing. The other aims and stops as well.
Both fall to their knees and weep. After time,
some get up and start gathering the wounded. Others
tear sheets into bandages and yet others start moving the rubble
finding the bodies. The bodies must be found and buried
in holy ground before rebuilding. My cousin
opens her mouth to gossip again and inhales and chokes
and stops. She says something other than she had planned.
Peace spreads like a wave, like a plague, and everyone
looks for someone to help.

If I can be anything I want to be
today I want to be a plague of peace.

by

Elder Care: Goals

I really enjoy elder care in Family Medicine. Mostly. Even some of the very difficult or very complicated people.

One thing I would try to figure out is what is the person’s goal? This can be quite funny at times.

“Can we talk about what you would want if you got really sick? If you were too sick to talk to us?”

“I don’t want to talk about death.” Ok, this person is in their 90s.

“That is fine, but if we don’t talk about it, your daughter and I have to guess what you want. And we tend to do more when we don’t know.”

That person glares at me. “Oh, all right.”

Sometimes a person says, “I don’t want to die of cancer.”

It turns out that this is an opening. “Ok, what DO you want to die of?”

“I don’t want to die!”

“Well, me either, but I can’t fix that. There are at least three “ideal” deaths that the Veterans Administration talks to people about. Maybe we could go over them. You could put your request in with your higher power.” I have written about the three here: https://drkottaway.com/2023/10/06/an-ideal-death/. The “Hallmark” or hospice death, sudden death and fight it all the way.

But, other than not dying, what is the goal? To stay in one’s home? To move to a retirement organization that has a nursing home and care until death? Home care insurance to stay home? I do have people imply that they will go into the woods or crash their car or something if they get very sick, but not very often. They are usually aware that I have to respond to any suicide threat. How much care do they want? People often say, “I wouldn’t want to be disabled,” but it turns out that life is often worth living even when very challenging. Most people want to be treated for cancer, for heart disease, for congestive heart failure, to go on.

Sometimes death comes from a cumulative load of chronic problems. We had a gentleman in his 80s in the hospital ICU many years ago. He had pneumonia, congestive heart failure and bad kidneys as well as a host of other problems. I sat down with him. “We are treating you, but when we give you enough medicine to help you breathe, your kidneys are getting worse. This is a small rural hospital. I could transfer you to the Seattle hospital, 2 hours away. You would have a cardiologist, a kidney doctor, a lung doctor. Here you just have me and the nurses. Either way, I do not know if you will live through this. What do you want to do?”

He chose to stay. “My family can visit me here.” His family was visiting daily. “I do not want a breathing tube. I do not want dialysis. If my kidneys go, let me go.” We discussed this with the family.

Four days later it was clear that without dialysis, he was dying. Dialysis might have slowed it, but he may still have died. He was no longer waking up. We withdrew the antibiotics and removed most of the monitoring and switched him to hospice. His family continued to visit and he died a few days later.

He did die in the hospital, and yes, we used some machines up until care was withdrawn, but this still seems like he got to make choices and his family understood. It can be much harder with memory loss when the person really can’t make choices any more.

He was complicated. To keep him breathing well without a machine, we had to give him diuretics, that were eventually too much for his kidneys. A bad heart, lungs with emphysema and pneumonia, and bad kidneys. Sometimes the liver is not working either, and then what is there left to work with? Nearly all drugs are broken down by either the liver or kidneys. Simethicone is not absorbed, so that’s the exception.

Sometimes people get along until too many things accumulate and then they end up in the hospital and on multiple new medicines. It can be very confusing. Regular maintenance is a good idea.

Sometimes the family wants something different from the patient. Or there is an elder parent and three adult children, who all disagree. My job is advocate for the patient. But this is Family Medicine, so I have a responsibility to the patient but also to the family. The person, the family, the community, how is it all fitting together? Sometimes functional, sometimes not.

I had one person who called me when he had been flown to a Seattle hospital. “I have to get home.” he says, “Can you release me? I have to take care of my wife!” I panicked for a moment. “Is your wife bedridden? Where is she? Why are you in the hospital?” She was not bedridden and she was fine. He was being more and more behaviorally squirrelly. He could no longer drive, but drove anyhow. His wife disabled the car, because he would disappear. I sent him to a neurologist for memory testing. The neurologist said, “Hmmm.” and sent him for neuropsych testing. The neuropsych report said dryly that his memory was fine, but he had certain long standing behaviors related to past heavy alcohol use. Oh. He was quite proud of not drinking and going to AA, but he also triangulated with his family and me. I sat him down and said, “Ok, I am not going to talk to a different one of your five children every time you see me in the clinic, because you’ve said, “Don’t tell mom I called you.” Pick ONE person for me to talk to and now you have to have a family member with you when you come to clinic.” He grinned and chose his wife. He had certainly fooled me about his memory, because he blamed his behavior on his memory. The neurologist was not quite fooled. The family calmed down and he did not drive any more, thank goodness. He was not an easy patient, but he was entertaining and educational too. And I felt that I had helped both him and the family.

Sometimes families fight. Sometimes a dysfunctional family will get way worse when someone is sick or dies. Sometimes families go on fighting. Other families are so kind and so good to each other and their elders. Every family is different.

For the Ragtag Daily Prompt: concentration.