Category Archives: rural doctor

by

Say yes

In the improv tryout
for Lark in the Park
Joey said

Say “yes” to everything

He said

It is easier to say “no”
But then the improv ends

He made us try
Saying “no” to everthing

Each skit was a fight

He made us try
Saying “yes” to everything

Yes

We bloomed

And is that it?
All the Beloved wants?

He said that you learn
To say things
Without a question
With a hint
With an idea
With a suggestion
And the other actor responds

I’ve noticed
People don’t respond well
When I say
Don’t do that

I have to learn
To lead
Without leading
To suggest
To let them choose
To change their path
It doesn’t work
To drive them
Offer
Offer
Another idea

Say “yes” to everything

Is that what the Beloved wants?

I say “yes”
“yes”

published on everything2 August 2009

by

In my parents’ house

I wrote this poem when I was in college, I think.

We still have the family quilt that is in the poem.

My mother made two teapots that are cream colored, with the poem on the teapot.

My sister read this poem at my mother’s funeral.

A friend read this poem at my sister’s funeral, because I was in the hospital.

My sister’s teapot was sent to me and I gave it to my sister’s daughter.

I had to get the poem off my teapot, because I think that’s the only copy that I have…. or had.

In my parents’ house

love is dispensed in teacups

–  –  –  –  –

When they notice you

Pacing in some empty mood

Or with that blank deserted face,

Eyes shutters into an empty mid

They say, “Would you like a cup of tea?”

–  –  –  –  –

The warmth of the cup in your hands

And the hot liquid, sweet and milky

On your tongue works wonders

And binds your soul to your body

–  –  –  –  –

When my sister was twelve

She embroidered a patch for a quilt

In yellow flosses, a cup

With steam curling upwards

And the words, “Such a comfort. TEA.”

by

Mad as Hell Doctors in California: October 6

Mad as Hell Doctors in California (http://madashelldoctors.com/) October 6, 2010

Up at 6:30, quiet tea in SoCal, with steady soaking rain outside. Not the image I really have of SoCal.

Our hostess fed us french toast with yohgurt and applesauce and we discussed single payer, medicare for all and the current insane insurance, billing and coding systems. My host asked, “Why does my bill say one amount and the insurance company pay another, much lower amount? What is that “adjustment”?”

The amount a doctor is paid has little to nothing to do with the amount that we bill: that is, if we are “preferred providers” and “take insurance.” Did you think that “preferred provider” or “in network” had to do with the quality of the medical care? Don’t be silly. It has to do with money and insurance profits. Here is the back story:

In starting up my own clinic, I’ve interviewed billing companies. Every billing company tells me not to worry about coding, they’ll go over each chart, they will let me know about mistakes. They will take care of it.

The thing is, I know that every place that I’ve been employed and in residency and in medical school, not one place had good coders. What is a coder? Every medical visit in the United States must have ICD-9 codes for every diagnosis. High blood pressure is 401.1. Diabetes, type II “not stated as uncontrolled” is 250.00, but there must be at least 30 different codes for diabetes. Diabetes, type I, uncontrolled, with kidney problems, has a specific ICD-9 code. Words are not ok, I have to provide a number for every diagnosis and if the number is not specific enough, the insurance may say that it is “not a covered diagnosis” and they will reject the bill. So I can’t use 250, that is not specific enough. It doesn’t matter that that code means diabetes, I have to specify it out two more digits. Does the patient feel better or get better care if I say 250.00? No. Do I give better care? No. The system benefits the insurance company because every bill they reject add to their profits.

Now, that is just the first number I have to provide. I also need to put a CPT code on every bill. That is the procedure code. A visit to the doctor for a code is billed as a procedure: for a level of visit. Doctor notes have gotten longer and longer to try to satisfy all of the requirements for documentation so that an insurance company can’t “downcode” to a lower level and pay less. Surgeries all have procedure codes and lab tests and strep tests and immunizations, but as a family doctor, most of my “procedures” are talking visits. Talking, explaining, asking questions, teaching, and gentle nagging: studies have shown that if doctors remind people to quit smoking, they are more likely to quit. The most common CPT codes for me are 99213 – a straightforward office visit, and 99214 – a more complicated office visit.

The CPT codes each have assigned RVUs- Relative Value Units. These attempt to put a value on each procedure. This involves a three part formula: and then each state pays a different amount for medicare for that CPT code. It doesn’t matter what the doctor bills: if they are contracted with medicare, medicare pays whatever is assigned for that state.

Insurance companies have followed suit, so to be a “preferred” or “in-network” provider, the doctor has to contract with each separate insurance company. Each contract is different and they all frequently change, so to try to track what is billed, verses what multiple insurance companies, medicare, federal medicaid and state medicaid have agreed to pay, is a nightmare. At this time, the administrative cost to be a “preferred provider” is $65,000 per primary care doctor per year. This is the cost of contracting, keeping track of the contracts, filling out all of the applications to be a preferred provider, and having employees to submit bills, keep track of bills, to resubmit bills that have been rejected and argue with insurance companies when they refuse to pay a bill. Quite a privilege, right? And maybe YOU thought that “preferred provider” meant really good doctors that your insurance company carefully screened. Don’t be so silly, this is about corporate profits!

I asked one billing company how they keep track of all of the rules. For example, now medicare will pay .03% more on a bill if I e-prescribe and put a special CPT code on the bill. Try remembering that. “Well,” said the biller, “That code is to your advantage this year, but next year it would net you more to use the special code for having an electronic medical record. You can’t use both. That would be illegal.” Ok, my head hurts. I’m supposed to keep track of this AND see patients? Biller, “Honestly, we try to keep track of the big insurers, Blue Cross, medicare, medicaid, but we just give up on the rules for the little ones. And we track whether each big company is paying you what they agreed to pay on the contract. Often they don’t. When we contact them, they say, oh, that was a computer upgrade, we misfiled Dr. X. We see these “misfilings” all the time, but honestly, we’ve never once seen one in the doctor or patient’s favor.” Huh. 100% of errors pay less to the contracted physician. That is some really creative corporate planning, don’t you think?

I have met one set of good coders. My previous employer hired coding auditors, who would check 10 charts per doctor per year. Last year I asked them to review one of my high risk obstetrics charts. Remember, I got nearly no education on coding and billing and frankly m career has been about taking care of sick people, not billing and coding. They said I was doing one part wrong. That means that my employer’s internal coders have not caught the error nor given me feedback for the last 10 years. How much lost revenue is that?

So I called the coding audit company and asked them to recommend a billing company. I have the name and now a very good set of questions that I have to answer before they will consider working with me. Usually they work with cancer doctors, not primary care. But they will consider it.

The medical bill for any insured person is “adjusted” down to the contracted amount. So who gets the full bill? You can guess, can’t you: the uninsured people and the underinsured people, the sickest and those who can least afford it. And maybe if they take all their tax and employment information to a clinic or hospital, they too can get their bill “adjusted”, though that may not be enough. The people who go in to bankruptcy from medical bills are most often the insured: one million US citizens per year now.

by

Mad as Hell Doctors in California: October 5, 2010

October 5, 2010

Today I rejoined the Mad as Hell Doctors (http://madashelldoctors.com/) on the road trip, this time in California. This day was a mix of planes, trains, cars, single payer health care, social justice and neoprene.

The Mad as Hell Doctors have been two weeks on the road in California, doing town halls for single payer. Some doctors are there for the entire trip, some have come for a week at a time, many local chapters of Physicians for a National Health Program (PNHP http://www.pnhp.org/) have local speakers and local providers join us at the events. Each event is different, with a mix of our team and the local team. One more week to go, ending in Chico, California on October 12th. I am leaving my practice and my children for one week, the last week of the trip.

The previous trip was from Portland, OR to Washington DC, 26 cities and more than 30 town halls, a road trip across the United States. I joined the Mad as Hell Doctors in Seattle and participated for a week. I flew home from Colorado and then rejoined them for the last 5 days, ending in a rally across the street from the White House.

Up at 3 am and quick finishing my packing, left at 3:40 after kissing the kids. Drove from home to Sea Tac, about two hours, down through Bremerton and across the Tacoma Narrows Bridge as the sky is starting to lighten and then north on I5. I5 luckily not busy and not backed up. Left the car with some company on International Boulevard and rode the van to the airport. At the scanner after I checked one bag, security found a jackknife in my carry on. Rats. I did not have time to go back around and mail it home. I wonder what really happens to all the confiscated knives. On to the gate and the flight was boarding. Nice flight down to San Diego. We left at 6:50 am and arrived at around 9 am. I felt disoriented as soon as I stepped outside: the sun was too high in the sky and those palm trees are just wrong. The air is so dry after the Pacific Northwest.

I checked on a van to go meet my Mad as Hell Doctor compatriots, but it would cost $170. “No? How about $150? How much can you afford?” The 3 pm train was $17.00 so I waited for that. I checked my bag at the train station and wandered around San Diego for a while, had breakfast.

At 3:00, the train moved out. San Clemente Pier was the third stop. The disembodied train speaker said “You should be going down the stairs and be ready at the doors: this is a very short stop.” I was ready and the only one to get off. I rolled my bag along as the train pulled away. No one was there. Then I heard my name and from the ocean side a man was running, sort of, in a black shortie wetsuit with one yellow flipper in his hand and the other on his right foot. I must be insane, I thought, and got a very wet oceany neoprene hug from Dr. Mike Huntington.

I changed into my swimsuit and joined Drs. Huntington and Sapir (http://madashelldoctors.com/2010/10/05/california-road-trip-day-14-san-clemente/) in the ocean, my suitcase tucked up on the lifeguard tower. No lifeguard. The water was at a crisp 68, which is better than the usual Pacific Northwest 56 degrees. I bodysurfed for half an hour until I couldn’t feel my toes and my hands were turning bloodless and white. Changed back into clothes and we played frisbee on the beach, me with enthusiasm but little skill. Mark Sapir said, “First chance to exercise in two weeks. I went running today and now everything hurts, so now we’re letting waves pound us in to the sand.”

We trooped back to the houses where they were staying and I met our hosts. Dinner with 14 people, kind and gracious hosts. Much discussion of medicine and politics. This was a day off for most of the [What I learned from my first Mad as Hell Doctors week|Mad as Hell Doctors], though Dr. Paul Hochfeld was at a talk given by a Physicians for A National Health Program California Chapter Fellow to medical students. He was back for dinner, reporting on the event.

This trip is streamlined. Currently there are eight of us. The trip is still 3 weeks, but with a little recovery time built in. Instead of staying in motels, we have stays arranged with PNHP members along the way. Phillip Kauffman is with us, saying that this trip is both easier and harder than the one last year. We have less paid support crew so more duties have fallen on him, but it is also a smaller group of people to coordinate. Dr. Hochfeld called him a “butterfly herder” in his blog yesterday, but I still think we’re more like cats. I don’t think of butterflies as having the same sort of egos or defense weapons as cats. And I am delighted to return to the group. They are incredibly dedicated and stubborn and willing to go on fighting for single payer. They, or we, are ignoring the people that say, “Why work on this? The health care bill passed. You won’t get another for years and years.” They might be right: but social change and social justice is not attained by sitting back, being apathetic or giving up. It takes dedicated people continuing stubborn work. I feel closer to these people after less than two weeks last year then some physicians that I have worked with for ten years: to be back on the road with the Mad as Hell Doctors is like coming home.

by

Old men never die, they just spout poetry

When I was in residency we rotated through the Veterans Hospital in Portland. Most of our patients were either very elderly or they were alcoholics or addicts in their 50s, starting to really go downhill medically.

One elderly patient is particularly vivid in my memory. He was in his 80s and black. He was weak and had various problems. I was not doing a very good job of sorting him out.

He wouldn’t answer questions. Or rather, he would give a reply, but it was not yes or no and I couldn’t figure out how the answer related to the question.

On the third day he gave a long reply to a question and I recognized it.

“That’s Longfellow,” I said. He nearly smiled. “We did a bike trip around Nova Scotia and read Evangeline aloud in the tents at night. The mosquitos tried to eat us alive. That’s Longfellow, isn’t it?”

He wouldn’t answer but the twinkle in his eye indicated yes.

So our visits were cryptic but fun. I would try to guess the author. He knew acres of poetry, all stored in his brain, no effort. I tried to relate the poems to my questions to see if he was answering indirectly. I wondered if he had schizophrenia and these were answers, but I didn’t think so. I thought he was just stubborn and refusing to answer.

I challenged him. “Ok, you are the right age. Come up with a song with my first name that is from early in the century. My father used to sing it to me when I was little. Can you?”

The next day he sang to me: “K-k-k-katy, beautiful Katy, you’re the only beautiful girl that I adore. When the m-moon shines, over the cow shed, I’ll be waiting by the k-k-k-kitchen door.”

We sat and grinned at each other. Soon afterward I moved on to the next rotation. I don’t remember his medical problems. But I remember him and remember wondering what he had done in his life to have a memory and a store of poetry in his head. A teacher? A professor? A man who loved poetry? I started matching him with my own store of poems, the Walrus and the Carpenter, songs, bits and pieces.  I felt blessed and approved of when his eyes twinkled at me, when I recognized an author or even recognized the poem itself. I looked forward to seeing him on rounds, daily. And he seemed to look forward to my visits. I was sad when I had to say goodbye and the next rotation was out of town. And since he had never told us his name, no way to stay in touch. Farewell, poetry man, fare thee well.

by

Mad as Hell: Good Insurance

My name is Katherine Temple Ottaway and I am a Mad as Hell Doctor!

I am a Family Practice physician. I live in a rural town of 9000 and I take care of people from birth to death. I have delivered babies for 18 years.

I am Mad as Hell because people are suffering and 30% of the money spent on health care goes to administration and profit, not to health care. 60% of bankruptcies in the United States are triggered by medical bills.

As we crossed the United States, doing town halls on single payer health care, I thought that we cared for our roads better than our fellow citizens. Rest stops and all.

My sister has “good” insurance, through the state of California. Four years ago, at age 41, she was diagnosed with stage IIIC breast cancer, advanced. Each year she pays a deductible of $500 and then a maximum copay of $3000 and then a maximum prescription copay of $1000 dollars. Last year she also paid a second deductible for her family, an additional maximum of 3000$ and the prescription copay for her family. Her cancer recurred in October of 2008 and the chemotherapy rolled over into January, so she is paying all of it again this year: at $4500 per year, that comes to $22,500 dollars over the last 4 years. And remember, she is lucky enough to have “good” insurance and she is lucky enough to have a boss who values her, so she hasn’t lost her job.

She was nauseated with her latest chemotherapy. Only one antinausea medicine worked. It was very expensive and the insurance refused to pay for it. She called them. They said, “95% of people on that chemotherapy have their nausea controlled with the other medicines.” “But I am in the other 5%,” she said. “We will not cover it,” they said. And they are lobbying Congress with $1,400,000 dollars a day. Where, exactly, do they get THAT money? My, they must have some really nice profits to protect.

My sister said to me sadly, “I wish I could save more for my daughter’s college.” Her daughter is 11. They rent and wish that they could buy a house. My sister said that she has nightmares about losing her job and them living on the streets.

And that is happening. People are making choices. They told us as we crossed the country. When a job is lost and the cobra insurance is $700 a month, it is often lost too. And then a cancer patient has to choose: treatment and my house will have to go to pay for it? Or do I preserve the house for my children and choose not to be treated? And possibly come to the emergency room at end stage, deathly ill, be treated with extraordinary measures in the emergency room and ICU. The house may still go.

I am Mad as Hell that we spend 16% of our GNP on health care, twice as much as the second most expensive system in the world, and yet are ranked 37th for over all health care. Our system causes deep suffering and horror for families. I am a Mad as Hell Doctor. Blessings on everyone that took Oct 15, 2009 to sit at health insurance companies. Peaceful social activism, to mourn the 45,000 Americans that now die prematurely from lack of medical care. Fight back.

by

What I learned from my first Mad as Hell Doctor week

I spent a week with the Mad as Hell Doctors, as a Mad as Hell Doctor, doing town halls about health care and about single payer, HR676. We went from Seattle to Denver, with 1-3 town halls a day, and then I flew home.

They are still on the road and I rejoin them tomorrow, for the last week. We will end in Washington DC, with a caravan and a white ribbon protest at Lafayette Park on September 30, 2009 and October 1, 2009.

I have been home for just under two weeks and am STILL trying to sort out what I learned and feel. I suspect it will take months.

1. I am not alone.

2. I am not used to applause.

3. People are brave and noble.

First, I learned that there are other doctors who truly put patients first and will go on the road for 3.5 weeks to prove it.

Dr. Mike Huntington, a radiation oncologist. He says that in the last 10 years of practice, the treatment for prostate cancer tripled from $17,000 to $54,000 because of fancier technology and computers. The result? Minimal to no better results for the patient. It horrified him. He quit. He is on the road.

Dr. Joeseph Eusterman, an internist. He did internal medicine, that is, adult primary care, for 25 years. He was in the military. He then switched to Workman’s Comp. He was horrified to find how deeply frightened Americans are of their supervisors, of being injured, of speaking up when they are injured and how dysfunctional the system is. He is retired, over 80 years old, and is driving Winnie, the Winnebago, across the country. I pray that I am that strong and determined to do right in my 80s.

Dr. Paul Hochfeld, an emergency room doctor. About four years ago, he got furious at the system and started reading and searching for the reasons our health care cost so much. He started with that question. The writing that made sense led him to call the experts and he asked for interviews. He made a movie, titled Health, Money and Fear. He is furious that our political system is run by money, corporations and that Congress seems to have forgotten the people, with all the corporate money that is thrown at them. He is fighting for reform.

Dr. Robert Seward, an internist. He is horrified that 60% of bankruptcies in this nation are because of health care bills. Think of all the press on people losing their houses: the fact is, they are losing their houses in large part because of health insurance companies and the failure of health care in our nation. He spoke with a Canadian man on the trip, who said, “Why don’t you Americans take care of your people?” That is still echoing among us. Dr. Seward says, “I was ashamed. We don’t. We Americans don’t take care of our people and we could and I am ashamed.”

Dr. Margaret Flowers, a pediatrician. She is working for Physicians for a National Health Program (PNHP) as a Congressional Fellow. She wants single payer on the table in the Congressional discussion. She was arrested for refusing to leave Senator Max Baucus’s office in May 2009. She is fighting for single payer.

I had never met these people before I joined them in Seattle. I was nervous about it: a road trip with strangers and talk into a microphone? But it was like coming home and it felt right.

Second, I learned that I am armored against criticism: it’s praise that I don’t know how to handle. The day before the trip, I spoke to one of the doctors on the phone and he said that I wouldn’t be on the panel of Mad as Hell Doctors in Seattle. I would watch the first town hall and then be on the panel at the next, in Spokane.

At the last moment, they said, oh, no, you are on the panel. I hopped up and left my purse at my seat. I remembered it 45 minutes later and thankfully was able to retrieve it. It would have been difficult to fly home from Denver otherwise.

Each doctor had 1-3 minutes to say why they were Mad as Hell. I winged it, and that was not a problem, because I AM Mad as Hell at our present medical system, the drug companies, the insurance companies and could go on for hours. Other doctors at my hospital would no doubt roll their eyes and say that I DO go on for hours.

I am used to being ignored, marginalized, told “we’re concerned about you”, told “we want you to succeed,” pressured and fired. There were secret meetings about the call schedule that I was not told about because they didn’t want me there. I’m stubborn, used to it, speak up anyhow and armored.

But in Seattle, I said a 2-3 minute piece of what I’ve been arguing about for 20 years.

People clapped. Applause.

I sat down. I wanted to crawl under the table and hide behind the white sheet covering the front. I was dumbfounded. I didn’t know how I felt. I concentrated on what the other doctors were saying, one after another, instead.

The other doctors thanked me, glad to have a woman doctor, glad to have a family practitioner and a rural one to boot. At each town hall, we talked to anyone who came, before and afterwards. The program itself was about 90 minutes but with the time talking to people before and afterwards, it was more like three hours. We did one to three programs a day and drove in between. It was physically and mentally tough. Residency trains us to put away emotions until later, so that’s what I did. The doctors are all tough and no one wanted to complain too much with our 80 plus year old gung ho and tough as a boot.

After I got home, the strongest feeling was wanting to weep. My Death Panel writeup had been in the local paper and four people thanked me in three days. I didn’t know what to do with that either. Under all the armor is someone who wants to be appreciated and loved. I’m used to criticism but praise went through the armor straight to my heart and to a part of me that I didn’t know was there. That person appears to be rather young and undeveloped. She is going to take some bringing up. Meanwhile, I asked for help in the form of my improvisation teacher. How, I asked, do I handle applause? He gave me clear specific instructions. I can do what he said, even if the emotional stuff inside is hiding under the table. Doctor training kicks in easily.

Third, I learned how people from Seattle to Denver, across the country, will stand up if given the opportunity. Part of the program was the Mad as Hell Minute. ANYONE, whether they agreed with us or not, could come forward, say their name and be on camera. They said why they were Mad as Hell about health care. They did not have to agree with us, with single payer, they could argue the opposition. But everyone was supposed to listen. Adam Klugman, our creative director, spoke of how it was an exercise in speaking up to our friends and community members and an exercise in listening to each person. And anyone who spoke, might show up on Youtube.

At some programs, one person would get up to speak. People were shy. Then a second would get up, then two more and then we would have a line. Not everyone spoke, but most of the people at the indoor town halls spoke. They told heartbreaking stories of family members, friends, their own loss of a job with a loss of insurance and people who weren’t being treated, or died because they could not afford treatment.

They were brave and honest and that made me want to weep too. And it was inspiring, to see people speak up. I hope that Congress is watching the Mad as Hell Minutes. These are the people they should be listening to and responding to, not the 1-2 million dollars in lobbying paid for by the insurance companies DAILY.

I have been cursing up a storm in my diary. I’m going back on the road, leave tonight for Seattle, take my daughter to her grandmother, and rejoin the Mad as Hell Doctors for the last 6 days. I feel blessed. The cursing is to balance me out; there’s no room for the grumpy, irritable, argumentative part of me on the trip so it is having a field day before I go. Back to hear people’s stories and applaud. And I have faith that change is in the air.