Category Archives: rural medicine

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Dream: home surgery

Yesterday I ask a friend to drive me to pick up my son, on his way home from college for spring break, an hour to a nearby pick up point and back. I can’t walk without limping horribly: apparently the recent stress in clinic has made my muscles mad.

F. drives. He has just finished reading Reinventing Collapse: The Soviet Experience and American Prospects, by Dmitri Orlov. Mr. Orlov says that I, as a physician, should start moonlighting as a midwife for barter to have a back up plan for when the economy collapses.

I laugh. “Not very helpful where the median age is 55.”

“Not to mention people want to use their pathetic health insurance.”

Home and I go to sleep. Dream: I am at F.’s house. There are two other men, one of whom needs abdominal surgery. We argue for a long time but he has no money and finally I agree to do surgery with F. assisting. The other man is to help hold the young man down. We do not, of course have anesthesia. I go over what I am going to do, force them to pay attention, discuss sterile technique, boil everything. Not ideal….

We don’t have a cautery or suction either. But there is almost no bleeding and the two things that need to be removed come out easily, I am very veryΒ  gentle, so I don’t cause other things to bleed. Never mess with the spleen.

Now I need to close the abdomen and I don’t have absorbablesutures. I am going to do a figure 8 from the surface, in skin, out the abdominal fat, across into the fat, down through the fascia, crossing very delicately up into the fascia on the other side, out the fat, in the fat on the other side and out the skin. Then slowly pull it tight, tight, and tie it off. It’s thick nylon. Nonabsorbable. Usually you would take the nylon out in 7-10 days but I am wondering how long I would need it for the fascia….I thought that would take 6 weeks to heal. I am worrying.

But now F. and the other man are not holding my patient, they are backing off and congratulating each other. My patient gets up off the table. “Lie back down!” I say, “Your guts could fall out the opening! We haven’t closed! F!” Surprisingly his guts are not falling out, but it’s because I have done such a beautiful low abdominal incision, bikini style. “Get back on the table or I will make you go to the hospital to have it closed!”

He reluctantly gets back on the table. F. and the other guy are still being morons but are calming down….

….I wake up.

 

The photo is in my yard during sunrise last summer: spring forward today….

music: https://www.youtube.com/watch?v=aEi_4Cyx4Uw

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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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practical medicine

This week I see a patient that I sent to a specialist that I don’t know well.

“How is he?” I like to get feedback on the specialists.

Q grimaces. “He knows his stuff. But…. he’s by the book. I complained about a side effect. He says it is not listed. But I go on line and there are lots of people complaining about that side effect.”

“Hmmm.” I say.

“He doesn’t really listen if it doesn’t fit…. if it’s not in the book.” Q brightens. “But I am going to call the nurse line for the drug and see what they say.”

“Cool.” I say. “Some doctors are very by the book. I’m into practical medicine: use it if it works. Don’t care if it’s witchcraft.”

Q giggles.

“What about the rash?” I say.

Q pulls up a pant leg. There is almost no rash. “He said it wasn’t related to the problem.”

We both look at Q’s leg. “Looks better to me.” I say. “Looks a lot better.”

“Yeah,” says Q. “It does. It looks nearly gone.” The rash was what initially triggered the testing that led to the diagnosis that led to the specialist.

“I use whatever I can figure out for people.”

Once I had an elderly woman with an intestinal bleed. She is transferred to Virginia Mason and goes through every possible test to localize the bleed. Upper endoscopy, lower endoscopy, swallow the camera, CT scan, probably pet scan and bone scan. Can’t find it. It is too slow a leak to use radioactive tagged red blood cells. She comes back.

I transfuse her every three weeks. This is not good. She will develop antibodies eventually.

She goes back to Virginia Mason. They do it all again. The surgeons discuss opening her up. “No.” they say. “Too frail at 88. She will die on the vent.” They send her back.

I am still transfusing her every three weeks. I am grumpy as hell.

Her daughter says, “I have a friend in Canada who knows a scientist. He is studying aloe vera. They said take aloe vera twice a day. What do you think?”

“Well I don’t have anything! Try it! We will test a chem panel in two weeks and watch the blood count!”

She takes aloe vera twice a day. Her blood count stabilizes. No more transfusion. Happy dance. Not absorbed or at least doesn’t bother her kidneys or liver tests….

After a year she says, “Can I try stopping it?”

“Sure,” I say. “We will check a blood count in 2 weeks.”

It drops. She goes back on aloe vera.

Practical medicine. If the book has nothing, try something else…..

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Four myths about death

Currently I see myths about death and dying in the United States. These myths are very strong and lead to a disconnect between medical personnel and non-medical. The medical personnel talk about end of life and want the answers to certain questions. But we often fail to address the persons deep fears and concerns because medicine sees them as myths, and so there is a disconnect between what the patient and the medical person see as important about the discussion of death.

Here are the four questions and fears:

1. How can I avoid being kept alive on a machine?
2. How can I avoid dying in pain?
3. How can I avoid having too much done, too many resources used, and dying in a hospital?
4. How can I avoid dying of starvation or thirst?

1. How can I avoid being kept alive on a machine?

The myth here is that we can keep someone alive on a machine. We almost never can. Comas are extremely rare. There are a very few people who survive a high spinal cord injury, like Christopher Reeves, and can be kept alive for a period on a ventilator. Or people with a disease that leads to the failure of the breathing muscles: Steven Hawkings with ALS has outlived all predictions.

But for the most part we can’t. I have tried: I have had two patients in 25 years with brain death who had signed organ donor cards. When brain death is established, an organ donor team will fly in to a rural area. Meanwhile, I was to attempt to keep the patient’s body alive. One lived long enough and the other did not. I could not stop the death with machines or drugs and that person was already on a ventilator.

Part of this myth is fear relating to hospital settings. ICUs, intensive care units, frighten people. There are alarms going off and machines with blinking lights and it is brightly lit and quiet and alien. Why? If a person is on a ventilator, they are sedated. Otherwise they will automatically pull the breathing tube out or the urinary catheter or the iv or all of them. It is instinctive. They are sick, may be delirious or injured, they are not in their right minds, they are not logical. So they are sedated. Most of the alarms are rightly ignored by the nurses: most alarms are going off because the patient has moved and the machine is not picking up. The nurses learn to filter automatically which alarms are trivial and which alarms do need attention and are an emergency.

I wanted to see an elderly aunt. When I arrived, my cousin said I couldn’t because she was in the emergency room. I said that I am pretty comfortable in emergency rooms and thought I could talk my way back to see her, since I am a physician. We had to wait in the lobby for a couple of hours, but then they let me back.

Part of the drama and horror that shows up in ICUs is the family’s feelings. Family members may feel guilty or angry or afraid and they often lash out at each other. Families are both at their best and their absolute worst when someone is critically ill. I have a friend who still doesn’t speak to a sibling after their father died in hospice three years ago, because they disagreed so strongly on how he should be cared for. The hospital staff and nurses and doctors and maintenance people and laundry people and dietitians are used to families crying or arguing or even yelling at each other. We try to support the patient and the family. But we cannot make them agree and don’t try.

We will return to the “in hospital” death later.

2. How can I avoid dying in pain?

Wear your seatbelt, wear helmets, don’t drive in blizzards, change the batteries in your smoke alarm, don’t text while driving….

That seems like a joke, but not really. Accidents are in the top ten causes of death in the United States currently. People do die in pain if shot, in car accidents, in falls. If we can’t get to them and get pain medicine on board in time.

When death is coming, the fear is that we will die in pain from, for example, cancer. However, most people that I have seen dying of cancer DECREASE the pain medicine rather than increase. There are at least two reasons. One is that they want to be awake. As the kidneys fail, the pain medicine lasts longer. They may not need as much. If they are in hospice and have family present, my experience has been that they say “Turn it down. I don’t want it. I don’t need it.” They want to be awake with their family.

The second reason is that it really may hurt much less. When people stop eating and go into ketosis, some pain receptors are turned off. This is very interesting. I have been using it in clinic: my patients with osteoarthritis who try a ketotic diet say that the joint stops hurting when they become ketotic. One patient said that when her right hip stopped hurting entirely, she realized that the muscles from the left hip were very sore from limping. “After two weeks, I tried one piece of bread,” she said, “And the right hip joint pain came right back.” So a person with end stage cancer or end stage dementia, who does not want to eat, may have little pain or different pain.

Lastly, the most important pain when there is not a sudden violent death, is emotional pain. We may not want people to feel it, but it is better if we can stay present and let them. Stay present, stay kind, listen, do not shut them off. If we shut them off, it is because of our OWN fears.

3. How can I avoid having too much done, too many resources used, and dying in a hospital?

First, fill out a POLST form: Physician orders for life sustaining treatment. The first question is the one medical people want you to answer: if your heart and lungs STOP, and you are dead, do you want us to try to revive you? If someone is over 80, I don’t want to do CPR. I will break their ribs and if we DO get them back, they WILL have damage. People often say, “Bring me back if I will be ok.” I joke that we don’t have the little turkey pop up that says “Too late. Done.” But it is minutes until brain death. If you want to be revived, your best bet is to die in the emergency room in front of the emergency room staff. They can move very fast. The security guards in Las Vegas are also very very good at putting AEDs on people who drop dead from a big win or a big loss.

Living wills are better than nothing, but they often say “If two doctors agree that I am terminal within six months, no extraordinary measures.” This is entirely too vague. What do YOU mean by an extraordinary measure? A ventilator? Aspirin? An iv? No one has ever defined what an extraordinary measure is.

The other questions on a POLST form ask specifically about resources. Hopefully the medical person will explain a little: what is a ventilator, when would we use it, would oxygen be ok, are antibiotics ok, have you talked to your family about this? The POLST form can’t cover everything but it does give us an idea of what someone wants when they can’t talk to us. And it takes some of the burden off the family: father DID say what he wanted and it is in writing and he talked to his doctor about it. If you are the family, how are you going to decide what an extraordinary measure is?

Now: dying in a hospital. Our culture currently pays lip service to dying at home. Sort of. A survey of Veterans revealed THREE DIFFERENT IDEAL DEATHS. One: the Hallmark death, in hospice, at home, surrounded with friends and family making peace with the world. Two: Sudden death, no warning, no attention. Three: fight to the death. This person won’t go, will fight, a miracle is possible and they are NOT at acceptance. Do EVERYTHING.

And dying in a hospital. In residency in Portland I had two patients dying on my medicine rotation. One was a young man in his 20s, surrounded by family and friends, of HIV. He was in the hospital because that is where he felt comfortable and safe and could get immediate help. The friends asked if our team was tired of wading through a crowd to check on him each day. I replied, “No. I am so glad you are here. I have another person dying, and he has no one, an elderly man. He is alone except for me and the staff.” So we, the hospital staff, are the ones who try to comfort the elderly alcoholic dying, the cancer patient estranged from her family, the lost and depressed and solitary and addicted. And we don’t care what they did to get there, the sins committed, the regrets, the mistakes. We try to help as much as we can. I do addiction medicine in part because I felt so sad watching people with addiction die alone. So dying in the hospital is NOT a failure. Sometimes it is where the person feels safest or they don’t have anyone. And not having anyone is a failure of our culture, not of medicine.

4. How can I avoid dying of starvation or thirst?

When someone is dying of cancer or dementia or another slow disorder, they want to stop eating at some point. Sometimes the family gets them to continue eating and the patient will do so out of love for their family. They have no hunger or thirst. Renal failure sets in and the rising creatinine takes them into a gentle coma and then into the great mystery. This looks like a kind death to me: the brain is quietly sedated and put to sleep by the body, by the rising creatinine. Let them go. We will offer food and drink to anyone, but sometimes they are letting go….let them.

Read more: Life support: How long should it be maintained?
And here is a book I want and haven’t read yet: http://www.tc.umn.edu/~parkx032/AD-OUT-NET.html
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Admitting diagnosis: Old guy, don’t know

During my three months temp job in 2010 at a nearby Army Hospital, I was asked to help the Family Medicine Inpatient Team (FMIT) whenever a faculty member was sick or out, which turned out to be fairly often. I enjoyed this because I wanted to work with residents, Family Practice doctors in training. It was very interesting to be at a training program, watch the other faculty and work at a 400 bed hospital instead of my usual 25 bed one.

Two patients needed to be admitted at the same time on our call day, so the second year resident took one and I took the other. The report on mine was an 82 year old male veteran, coughing for three weeks, emergency room diagnosis was pneumonia.

The resident soon caught up with me because her person was too sick and got diverted to the ICU. Mr. T, our gentleman, was a vague historian. He said that he always coughed since he quit smoking 15 years ago and he couldn’t really describe the problem. He’d gotten up at 4:30 to walk around the assisted living; that was normal for him because he used to do the maintenence. He had either felt bad then or after going back to sleep in a chair and waking at 10. “I didn’t feel good. I knew I shouldn’t drive.”

He’d had a heart attack in the past and heart bypass surgery. Records were vague. The radiologist read the chest xrays essentially as, “Looks just like the one 3 months ago but we can’t guarentee that there isn’t a pneumonia or something in there.” He had a slightly elevated white blood cell count, no fever, and by then I did a Mini-mental status exam. He scored 22 out of 30. That could mean right on the edge of moderate dementia, or it could be delerium. I got his permission to call his wife.

“Oh, his memory has been bad since he spent a year in a chair telling them not to amputate his toes. And he was on antibiotics the whole time. He wasn’t the same after that. He just said he didn’t feel right and that he shouldn’t drive.” So his wife called an ambulance.

The third year chief resident came by and wanted to know the admitting diagnosis. “Old guy, don’t know.” was my reply. “Either pneumonia or a urinary tract infection or a heart attack maybe with delerium or dementia or both.”

The second year was helping me put in the computer orders, because I was terrible at it still. She could put them in upside down and asleep. “Why are we admitting him, anyhow? We can’t really find anything wrong, why not just send him home?”

“We can’t send him home because he can’t tell us what’s wrong. He might have an infection but he might not, and he has a really bad heart. If we send him home and he has a heart attack tonight, we would feel really bad. And he might die.”

I was getting a cold. I had planned to ask to work a half day but half the team was out sick so I just worked. But by morning I had no voice and felt awful. I called in sick.

At noon the phone rang. It was the second year. “You know Mr. T, who we admitted last night?”

“Yes,” I said.

“He had that heart attack during the night. Got taken to the cath lab. You made me look really good.” We had worked on the assumption that it could be early in a heart attack though the first labs and the ECG were negative. I had insisted on cardiac monitoring and repeating the enzymes. The resident had finished the note after I left and the night team had gotten the second and abnormal set of enzymes.

82 year olds are tricky. With some memory loss he couldn’t tell us much except that “I don’t feel right.” He was right not to drive and we were right to keep him in the hospital. And if it had all been normal in the morning, I still would not have felt bad about it. The residents are looking for a definitive diagnosis, but sometimes it’s “Old guy, don’t know,” until you do know.

 

Previously posted on everything2.com in April 2010. I am not sure if this branch was dead or not, but the moss grows on it here in the wet winter anyhow.

I took the photograph in the woods last weekend.

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nurturance

I love you I will miss you I am going
I am going to the Beloved I am going quietly
I am saying goodbye and bless you and thank you
for letting me love you but now

I want to be loved too and I am going
somewhere there are people who will love me
nurture me care about me and I can nurture them back
I have spent so much time loving people who don’t

love me or perhaps they love me but in a small way
in a limited way in a very closed off way
and now I am breaking the boundaries again but not
with the people who want these boundaries

I am looking for people who want to love and be loved
like the sky like space like the deepest ocean rift
who are not afraid of passion and arguing and loving
who are not afraid to be afraid to be joyous to be sad

I am looking for people who are not afraid to be afraid

 

I took the photo in a friend’s woods yesterday.

Also published on everything2.com today.

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Fraud in medicine: FAXMANIA!!

All right, the latest trend in the complete insanity that is the United States Medical Corporate Black Hole Eating The American Dream: FAXMANIA!!!!

I am a Veterans Choice rural provider. Well, I thought I was. But turns out even though the VA keeps calling me to accept new veterans who are more than 40 miles from the nearest VA, they have not paid me for one visit in 2015. And I did between 20 and 30.

Because, you see, even though they have me listed as a Veterans Choice Provider, the paper work is SPECIAL and it has to be PERFECT and we have to fax EVERYTHING.

So I have to fax every single clinic note to Veterans Choice. Where, presumably, they lose it and have plausible deniability. Also, when a patient comes to see me, they are only approved for ONE NEW PATIENT VISIT, TWO FOLLOW UP VISITS, WITHIN THE STATED DATES, which is two months. Then I have to fill out a form and send it to Veterans Choice, who sends it to triwest, to get approval to continue to be my patient’s primary care doctor FOR ONE YEAR ONLY. Then I have to remember to do it again. AND I have to fill out a form to send to Veterans Choice, who sends it to triwest, for every single referral or test more complicated (read: expensive) than an xray AND for labwork AND don’t forget to fax a copy of every clinic note to Veterans Choice so they know I did it AND now for one patient’s medicine, I have ALSO fax a copy of every note to his VA PRIMARY CARE DOCTOR so that she will refill his pain medicine because: Hell if I know, apparently it’s EASIER to fill from her than me because the VA has no frigging idea who I am.

And the Veterans Choice 40 mile rule? We have two patients now from Whidby Island. They have to take a ferry to see me. Yes, they can bring a car on the ferry. Yes, they can get here except when the ferry is canceled for very low tides or weather….Yes, it’s insane.

Meanwhile, this note from the State of Washington Health Care Authority, aka medicaid: “The Contractor shall require that when subcontracted provider organizations with certified EHRs see an Apple Health Managed Care enrollee, they send a care summary (CCDA) from the providers EHR to the WA Link4Health Clinical Data Repository beginning no later than February 1, 2017.” Translation? Oh, we have to send bloody proof that we saw the bloody patient in the form of a CCDA electronically OR ELSE! OR ELSE WE ARE BREAKING THE LAW! They wouldn’t want to fire us but you betcha they would love to fine the hell out of us. Note: This requirement only applies to provider organizations who have already invested in certified EHR technology.

Hi, Big Brother.

Now, fax is HIPAA compliant, as long as we include the cover disclaimer that IF WE SENT IT TO THE WRONG PLACE SHRED WITHOUT READING OR YOU WILL BE STRUCK DEAD BY LIGHTENING FROM THE SKY GODS AND/OR THE ORBITING LASER HIPAA POLICE.

And meanwhile I have lab order forms for the three labs in town (all completely different and even with different panels) and one in Sequim, also 6 different forms for 6 different places for xrays, CT scans, MRIs, a form for the Vascular imaging, a form for cardiology, different ones for each physical therapy office. Now the DMV disabled parking form must be accompanied by a prescription on legal Washington State prescription paper saying yeah, he is disabled. Why use one piece of paper when you can require two?

When I fill out lab orders for the local hospital, the patients sometimes say, “Can you fax that over?”

“Yes,” I say, “but they lose 50% of them.” No, really. We fax them and keep a copy and then the patient goes in and the lab calls and says, “We don’t have the order.” I am not sure if they are “lost” or just in a pile to be entered into the TIME SAVING ELECTRONIC MEDICAL RECORD COMPUTER SYSTEM THAT MAKES EVERYTHING FASTER AND MADE US PAPERLESS EXCEPT FOR THE TEN MILLION FAXES DAILY. “You are better off picking it up and handing it to them, or I can mail it to you.” The other day a patient asked if that was malice, since I am not in the hospital system. “No,” I said, “I think they have laid people off until there aren’t enough and the corporation dumps the long timers that know stuff and cost more.”

Once I was working on a holiday Monday. I had a patient who I thought had a new arrythmia. I called the hospital and asked the tech if we could do an outpatient ECG on this holiday.

“I don’t know.” the tech said.

There was a silence. I wondered if the tech would ask someone in authority.

“I’m new.” said the tech. “They’ve laid a lot of people off.”

Someone in authority WAS present. “We can do one on a holiday.” I said firmly. “I will send her right over. Call me when it’s done.” So the tech did it.

Where medicaid goes, medicare follows and then the insurance companies will too. Next, I predict that we will have to fax every note to the appropriate company every single visit, and to the secondary insurance too. And then they will install a video camera in each office and videotape every clinic visit…. and I will either be a physician in another country or be doing something else….

 

What, you say, does the shack have to do with this? I can always go live there, off the grid, if I can’t stand the paperwork and hoops I have to jump through. It is a play house at my family’s land on a lake in Ontario, built in the 1970s. Friends and I put a new roof on this year: their 6 year old was delighted. It would be frightfully cold in the winter and anyhow, I can only stand straight in the middle….

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Wean yourself

SoFarSoStu has tagged me for the three days, three quotations and tag three other people. This is day three, only I am a day late.

β€œThe rules are to post 3 quotes over 3 days and nominate 3 bloggers each time to carry on with the challenge.”

Today I choose Rumi’s phrase “Wean yourself” and post his poem. This is one of my two favorite Rumi poems.

Wean yourself
Little by little, wean yourself.
This is the gist of what I have to say.
From an embryo, whose nourishment comes in the blood,
move to an infant drinking milk,
to a child on solid food,
to a searcher after wisdom,
to a hunter of more invisible game.

Think how it is to have a conversation with an embryo.
You might say ‘The world outside is vast and intricate.
There are wheatfields and mountain passes,
and orchards in bloom.

At night there are millions of galaxies, and in sunlight
the beauty of friends dancing at a wedding.’

You ask the embryo why he, or she, stays cooped up
in the dark with eyes closed.

Listen to the answer.

There is no ‘other world’
I only know what I have experienced.
You must be hallucinating.

_____________

I love this poem. To me it’s about our human development and I love that we go from a searcher after wisdom to a hunter of more invisible game. Have you ever had the feeling that you have figured some part of your life out, that aha! moment? Smooth sailing now, you think…. only to find out that new challenges present.

I use this poem in clinic. When I am talking to a new patient I have to find out where they are, what some of their medical beliefs are, what their level of education is, what their prior experience with allopathic medicine is, do they see a naturopath, are they taking ANY pills? Prescription, over the counter, alternative, herbal, homemade? I read Rumi’s poem as a discussion about our levels of development: we come out of the dark to be an embryo. Where do we go from there? I have to understand at least some of my patient’s background in order to communicate with them: I have to meet them halfway. Sometimes I fail. Sometimes my doctors fail…. we experienced that when my mother was in hospice. We were not given instructions for how to take care of her nasogastric tube at home…. and it got blocked. I think that the inpatient nurses made assumptions and the hospice nurses may have too… or just didn’t know.

This poem also relates to how my thoughts about healing and health keep evolving. Currently I keep reading on the internet and hearing from patients that they want a stronger immune system. There are all sorts of “immune system boosters” being sold. I think this is interesting and I think it is a wrong approach. Why?

I have gotten seriously ill four times. Each was triggered by severe stress in my life: mononucleosis at age 19, influenza in 2003, systemic strep A in 2012 and systemic strep A in 2014. So… do I think that my immune system needs boosting? No. When I got symptoms in 2014, my thought was “I am so stupid.” My father had died in 2013. His will confused me, the house was full of his things, my mother’s things, my sister’s things, my grandparent’s things, all dead. I would work in clinic and then go out there and try to get things done and mostly sit and cry. I did deal with the estate, but what is wrong with this picture?

I ignored what I would tell a patient to do…. I did not take time off to rest and to grieve and to take care of myself. Rather than a failing immune system, I pictured my immune system marshaling troops. “She won’t rest. We are going to have to take her down AGAIN. Won’t she ever learn to listen to her body? When will she learn to REST? Let’s see, who doΒ  we have to knock her down…. ah, strep A! Great! Here, the door is open, take her out.”

And boy howdy, did it. I was out for ten months and ten months later am still on half time work. And I could have kicked myself! How stupid I am! If there is a major emotional loss in your life, cut back and rest and take time to let yourself heal!

So when people say, “I need an immune booster,” I wonder. I wonder what is happening in their lives, what their level of stress is, are they taking care of themselves. I worry that our culture thinks that we just need the right combination of supplements and then we can keep going and drive our bodies into the ground, instead of stopping and saying: “Oh. I am really cumulatively tired. I really need to rest, and sit at the beach and stare at the waves, or lie on the couch and read a silly novel, or just have a cup of tea and do nothing.” I don’t really like pills. I think that pills are often a band aid on a deeper wound than we admit. If I had rested, I would not have needed high dose penicillin: though I am deeply grateful to have another try at healing and health.

And three people to tag to do the three days of quotations if they so choose… everyone may be too busy at this busy time of year:

hargunwai

mindlovemisery

ohmyglai

The pink edged cloud looks like a giant paramecium or other bacteria, up in the sky….

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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