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The Introverted Thinker whines

One morning, the Introverted Thinker was whining. She was about 8, she was tired, the alarm had not gone off.

“I.T., you are whining.”

She continued to droop and delay and whine.

I thought, “I hate whining.” I thought of my parents. My mother would say, “Go away and come back when you can talk to me without whining.” I’ve read parenting books that tell us to say, “I can’t understand you when you whine. Say it without whining.”

But I was in a vulnerable place myself. I thought, when we whine, we are feeling very vulnerable. And to be sent away until we stop expressing that vulnerability, well, is that the message that I want to send? I thought, what do I want to be told when I wish I could whine or when I DO whine? Certainly not to go away alone with my whiny self. I thought: I want to be loved anyhow, even when I’m behaving badly.

I hugged her right away and said, “I love all of you, even the parts that whine.”

She stopped. Instantly. She just stood there in the hug for a moment and then got dressed, ate breakfast and went off to school. She didn’t seem insulted or hurt. It was just as if I’d heard her and reassured her: I am present when you are vulnerable and I love you. The whole you.

Also published on an obscure writing website in August 2010.

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What would a sufi do?

I dreamed about a door all night last night.

First it was a door into a car. Over and over. I was not sure where the car was going, the driver wouldn’t listen to me, it was a race car. There weren’t any people that really had form in the dream.

The car was my friend Dave’s. A 1978 or a 1979. I don’t remember. He would care, I don’t. He has a racing harness instead of a regular seat belt in the driver’s seat. He can drive it like a race car, or close enough to fool me.

My daughter sat in the passenger seat and didn’t move when he drove. I sat in the back and went “eeeeeeee” and my right foot braked the whole time.

The last time I dreamed it there was just the door. A car door still. Lying in space, in the stars.

I woke up and thought about my say yes poems. And I thought, ok, Beloved, I don’t know where it’s going or what it will bring or who is driving but yes, I will go through that door.

And coming down the stairs I was thinking that I’ve been trying to communicate something to Dave but he doesn’t want to hear it. So I am not being a sufi. The sufis only taught the student who wanted to learn and who was ready. WWaSD? What would a sufi do? Stop butting my head against a wall.

I think that was the door.

I think of my consciousness at times as a table, and different parts of myself come to the table. There is the very small injured child, who gets healthier and healthier. She is healing. Somehow Dave has called up a sullen teenager who glares at everyone. The adult woman is annoyed and mutters “boys, toys and race cars.” The trickster sits and laughs. The doctor/psychiatrist is very interested in the whole thing and is mostly sitting back and watching.

Now perhaps a Sufi will come to the table. Or someone else. A fence is being built around my house. I envisioned a picnic table in the fence, on both sides, but it kept looking like Lucy’s psychiatric booth from Peanuts. I wanted to put up a sign: lemonade or the doctor is in, depending on my mood.

The fence is being built because someone stole our picnic table from the front yard while we were on vacation. I had bought it second hand and it was made of two by sixes. It was brutally heavy. I hope the theft weighs on them. Over 14 years we’ve also had a blue gazing ball stolen and two plastic pink flamingos. A bike was stolen from the back yard.

So now a fence. The picnic table/lemonade stand/psychiatric booth has morphed into a bench that goes through the fence, so that someone can sit on each side. And beside it in the fence is one of the little library boxes, for me to leave books and for others to trade or take them. It will have glass doors. We will have a pool on how soon they will be smashed. We are not cynical, are we?

Fences and doors. I think that I should put a sign in the yard, but perhaps I don’t need to. The new person at the table is the crone. I have gone through the door and I will think about doors all day. The crone introduces herself to the others at the table. The table gets more interesting every single day.

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You can’t make someone love you 

You can't make someone love you


How can we fall out of love?

I mean it. If we love someone, how can we fall out of 
love?

Falling in love, according to my understanding of the 
Jungian ideas, is projecting some of your best aspects 
on the other person. You see them in a haze of love, of 
perfection. I've seen something to the effect that 
falling in love is the only time that psychosis is not 
treated. That is, when you are in love, you are psychotic.
You are crazy. You are nuts.

I, then, am currently nuts.

One of the things that I admire most about my ex-husband 
is that he is friends with all of his ex-girlfriends. And 
his ex-wife, that is, me. When we were first married, he 
told me about the ex-girlfriends. He was in contact with 
them, by phone or email. I was ok with it and admired it. 
We met dancing, jitterbug, east coast swing dancing. We 
would go to the live dances in Cabin John, Maryland. We 
would dance two dances with each other, say bye, and race 
off to dance with everyone else. Five hundred people would 
show up, for an hour lesson and three hours of live band. 
In the summer the guys would bring 4 t-shirts and change 
them as they were soaked. There was no alcohol in the park. 
No air conditioning. We didn't clap for the bands at all 
because we were too busy trying to find the next partner to 
dance with. You could signal next dance, one or two fingers. 
Not past two, because no one could remember.....

Anyhow, jealousy seemed silly. My ex-husband transformed 
each of those relationships with his ex-girlfriends from 
lover and partner into something else.

I think this is the right thing to do. If it is our best 
aspects projected on the person that we are in love with, 
then perhaps it is our own worst aspects that we project 
when we "fall out of love". We hate the person. They have 
broken our hearts. They have been cruel.

But have they? They were not required to be in love with 
us. Just because we love them does not mean that they have 
to love us back. Or really, they do not have to love us 
"that way". You can't make someone love you.

I want to be like my ex-husband. I want to continue to 
love the person that I love. As a small town doctor, I have
taken care of both halves of a divorcing couple. My brain 
managed to keep them entirely separate and not connect them 
until the day when I saw both. Even then, I had trouble 
believing that they were talking about each other: because 
what they said had almost nothing to do with what the other 
person was saying or doing. I said to my nurse, "Are they 
really talking about each other? Or is it at last name 
coincidence?"

She said, "Took you long enough to get it."

If I am rejected, I want to keep loving the person. Perhaps 
I too will fall out of loving them "that way". But if it is 
aspects of myself that I see in them and love, why would I 
turn to hate? I don't want to project the ugly parts of myself 
on them.

I'll save the ugly parts to project on the greedy corporations. 
Now, I am perfectly content and happy to hate them.......
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Say yes

At 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 everything

Each skit was a fight

He made us try
Saying yes to everything

Yes

We bloomed bloomed

And is that it?

All the Beloved wants?

He said
You learn to say things
Without a question
With a hint
With an idea
With a suggestion
The other actor responds

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

I need to learn
To suggest
To let them choose
To change their direction
Offer
Offer
Another idea

I need to learn
To listen
When they offer
Offer
Another idea

Say yes to everything

Is that what the Beloved wants?

I say yes
yes

previously published August 10, 2009 on everything2

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Cost comparison of brain MRI

I called Advanced Medical Imaging (AMI) in May 2014 to get a prior authorization for a brain MRI with and without contrast.

This is for a woman under 65 who is having short term memory problems. We are looking for treatable causes of short term memory loss. The blood work is negative. Next is the MRI.

Her MRI is already scheduled at the local hospital where I worked for nine years. It is the only hospital because we are a small county.

The AMI representative suggested that the patient get the MRI in Everett.

“The cost there is $917.00. It would be cheaper. It is only 29 miles away.”

“Yes, but Everett is across the sound. She’d have to drive around or take a ferry. What is the cost in Bremerton?” I asked. “At the radiology providers there?”

“The cost there is $967.00.”

“And where she is scheduled?” My local hospital has a “Rural Hospital” designation. Medicare will pay them more than other hospitals.

“$4585.00.”

I squeaked. “For the same MRI?”

“Yes.”

“Um. You should tell the patient.” Except that, is the patient willing to drive to Bremerton? And is the cost to the patient the same? And do they care?

“Do you want the prior authorization for that site.”

“Can it be changed if I talk to the patient?”

“Yes, she can call us.”

The prior authorizations are now site specific. That is, I’m getting approval for the MRI at a specific place. I have no idea why.* Seems stupid. Seems like just another hoop to remember to jump through and if we get it wrong the insurance can say, “Oh, ha, ha, ha, we don’t have to pay for that. You do.” Chalk up some more profit for the investors. Mission accomplished, money made.

I called the woman and explained. She was willing to go to Bremerton and said that she would call AMI. I asked her to call us back if she had any trouble.

The cost really matters to my medicare patients and any patient that has to pay a percentage of the cost. If they only have medicare part B, with no secondary, they pay 20% of the bill. 20% of 4500.00 is a lot more than 20% of $900. But some of my frailest most elderly most confused don’t really have a choice. Going 29 miles might as well be going to the moon.

And this is a woman with memory loss, remember? She wrote down the instructions and repeated them back to me three times.

Every phone call to insurance is like this, and makes me wonder about our culture.

* Actually, the authorizations are site specific because some places are “out of network” and the insurance won’t cover anything done there. Though I think the whole point of health insurance in the US is to try to remove money from people and avoid paying for care.

This was first posted at everything2 on Friday May 9, 2014. The woman died last month.

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Comparison of cost of abdominal CT with and without contrast

I keep reading that the US Health System should be a “free market” with competition.

To have an free market, one needs to be able to check the prices. I want to compare price tags. I have a patient who needs a CT scan of the abdomen and pelvis with and without contrast. So can I, as a doctor, find out the price?

I start making phone calls:

I call AIM Specialty Health, a procedure clearing house hired by many insurers here, to get prior authorization for the CT of the abdomen and pelvis with and without contrast. They ask for the usual identifying information: my name, tax id, NPI number, patient name, insurance number, check my address, phone number, fax number. They ask for theICD-9 codes — codes for the diagnosis. I know those. They ask for the CPT code, which is the procedure code for the test. I have to scramble to find the book and look it up: 74178. With the brain MRI the other day they volunteered site specific charges. Not this time. The representative said they didn’t know. I asked for prior authorization in Poulsbo, since that was most reasonable for the brain MRI. I asked what the patient’s copay is: AIM does not know.

Call to Premara Blue Cross, which is the patient’s insurance company. They can tell me that the patient has a $10,500 deductible each year. She will have to pay that much before the insurance pays anything. I ask them what it will cost at different sites. They say they can’t give me that information.

Next I call 5 different sites to get the price for that CPT code/proceedure.
Call to my local hospital: Charged amount is $4200.00
Call to a free standing radiology clinic in Poulsbo: Charged amount $1416.00
Call to the hospital in Bremerton, south of us: $8958.00.
Call to a free standing radiology clinic further south in Silverdale:$1526.00 + $20.00 for contrast.
Call to the hospital in Port Angeles, north of us: $ 3101.70 for the facility fee. Gave me Radia’s number for the physician fee.
Call to Radia and left message.
Left message with patient.

Radia called back and the fee is $346.80, so that would be added to the $3101.70 at Olympic Medical Center.

Now I know the amount BILLED at five sites. However, that is not the amount my patient will PAY.

If the site is “in network” then the site has a contract with Premara Blue Cross, which states the amount that Premara is going to pay. The patient will get an EOB, an explanation of benefits, from the insurance. “Benefits” is an interesting choice of words. The patient has paid for the insurance so that they will cover the bills. Is that a “benefit”?

On the EOB, it will state the amount that was billed for the service. Next it will state the amount “allowed”. “Allowed” is misleading. To me it implies that the insurance has held the cost down. But the insurance “allowed” the site to be “in network” because the doctor/site signed a contract. So this is a contracted price or agreed upon price.

I want to know the allowed/contracted/agreed upon price.

Call to the WA State Office of the Insurance Commissioner. The office says that the patient should be able to request the allowed cost for a specific site. Each site has a separate contract with the health insurance, so the allowed cost could be different at each site.

Call to Premara Blue Cross. This time they say that it’s not that they refused the information, it’s that it was not available. Now the representative says that they need the “units or minutes billed.” I don’t know what that is, but I will find out. I ask if that is the only other thing that I need. They say yes, but I cannot contact the same rep directly. I have to go through the rigamarole each time: my name, my tax id, patient’s name, patient’s insurance identification number, my clinic address, fax number, phone number, sometimes the patient phone number. Usually I have to punch 4 or five of these into the automated system and then have to repeat it all when I reach a human being.

Call to Poulsbo. The units refer to 100 units of contrast. Some patients will need more, up to 200 units.

Call to Premara Blue Cross again. I go over everything with representative Hailey, who then wants to know the amount that Poulsbo is billing. Explained that I was told only the units were needed. She put me on hold and checked with Poulsbo. She is quoted the same price.

Continuing with call to Premara Blue Cross. Hailey has entered everything and doesn’t get a result. She says she doesn’t know. I explain that they have a contract with Poulsbo that names an actual amount. She transfers me to another department after 25 minutes. The representative there says that she can give the allowed amount information to the provider doing the test, that is, to Poulsbo. I explained that the WA State Office of the Insurance Commissioner says that a patient can indeed request that information. I asked if they are refusing it to the patient. Rep repeats that she can give it to that provider but not me. I offer to have the patient in for a visit and get them on speaker phone and again request the information. Without the information, I will strongly consider filing a complaint with the state insurance commission. She decides to transfer me. That’s at 30 min and I am again put on hold.

The call to Premara Blue Cross ended after 45 min and 37 seconds and the third representative in the provider relations department states that if they get a call from Poulsbo that they could tell THEM the contracted allowable amount. Again stated that the insurance commissioner’s office says that the patient can request the amount. Are they and will they refuse it to the patient? Representative Whitney says that she has access only to provider accounts and that the contract with Poulsbo is proprietary information*. I say that I think health insurance is also a contract between the patient and the insurance and surely the patient can ask what it will cost in advance. I stated that I would be calling the patient and the state insurance commissioner’s office again.

I talk to the patient. She will now call the insurance and ask the “allowed” amount for this site. I give her the diagnosis code, CPT code and units billed.

She calls back. Premara says “around $600.00”.

I call Poulsbo and ask if they will check the contracted amount. They call Premara. They call me back.

If she only has 100 units of contrast, the CT of the abdomen and pelvis with and without contrast will cost her $641.00, as the “allowed” amount by contract between her insurance and the radiology site.

I still do not know the “allowed”/contracted amount for the other four sites, so I have failed in my attempt at comparing price tags. I only know the amount the sites would bill. The “allowed”/contracted amount for each site could be different. The hospitals bill more because they have a “facility” fee. I think this means that they are allowed to factor in various hospital costs. Even so, it seems outrageous that one hospital bills twice as much as the other two and more than six times as much as the least expensive site, but the allowed amount might be lower then the billed amount.

I don’t think this is a free market. I think it is an obscured market. And this is just one procedure and one single charge. Think of a hospital stay.
AIM Specialty Health http://aimspecialtyhealth.com/about-aim/guidelines
Washington State Office of the Insurance Commissioner is at http://www.insurance.wa.gov/
Premara Blue Cross https://www.premera.com/wa/visitor/
* When I called about the head MRI, why wasn’t the information about what is billed at different sites proprietary then?

This was initially posted on everything2 on Friday, May 16, 2014.

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sometimes the hummingbird

sometimes the hummingbird

Boa cat
meows
the meow that means she’s caught something
and wants to show me

and I go to look
it is a hummingbird
probably immature
dead

I pat her and praise her
Good Boa
I see what you caught

She taps the hummingbird
around the room a few times
but it is dead

so she eats it

and I’m crying

sometimes the hummingbird
gets eaten

and that is ok

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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.