rainshadow

Blogging from A to Z, the letter R for rainshadow, rehearsal, raise your voice! Only I did R yesterday and should be on the letter S! Sing, shout and shadow…there, whew!

My father and seven other people started Rainshadow Chorale in 1997. I joined when I moved here. He died in 2013, but we are still singing. Two concerts today and one tomorrow, and by yesterday they were nearly sold out. All three.

We had a dress rehearsal last night, with Rebecca Rottsolk, our brilliant director, doing the final touches. It’s the first time that we rehearsed in the space that we will sing in, so we pay close attention to how we sound there.

And raise your voice in song and praise! We walked this morning and traded songs with the birds: song sparrows, red wing blackbirds and quieter birds…the above photo of the bird slipping quietly through the ripples. Here is another view:

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I think that this is a Hooded Merganser, here. Hooray for happy things and the letter r. And the letter s too!

R

S

question

Blogging from A to Z, Q is for query, quest, question.

I took the afternoon from work yesterday to go for a walk with my son, who is visiting from Maryland. We went to Chetzemoka Park and down to the beach. More blue herons and more photographs! Hiking back, we saw a halo around the sun, above the ridge. I know that this is formed from a reflection of ice crystals in the atmosphere, more information here. It is magical! And there was something in the tree…. what is it? A quest with a zoom lens reveals:

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In the first picture the angle is different and the eagle is right by the trunk of the tree, difficult to see. We were watching great blue herons take off from the beach and land in  trees on the ridge but I heard an eagle’s cry and the silhouette is wrong for a great blue heron.

Queries and questions and quests: happy letter Q.

Q

P for prior authorization

The letter P and my theme is happy things. But what comes to mind are these P words: prior authorization,  pharmaceutical, payer.

Prior authorizations are NOT a happy thing. The latest twist from insurance companies, three different ones in the last week, is that they are requiring prior authorization for old inexpensive medicines. I ordered a muscle relaxant for night time only on Thursday last week for a person with a flare of back pain. Friday I was dismayed to see that the insurance company was requiring a prior authorization. I have to prioritize the order of urgency of all the work: I did not have time. I called the patient who had paid cash for it. The insurance company wins. They didn’t have to pay for a covered medicine because they made it difficult to get. They keep the patient’s money.

Prior authorizations are on the rise very rapidly. With over 800 insurance companies, each with a different website, each with multiple insurance “products”, no one can keep up with it. It is a shell game, the ball under the cup, three cups moving, but the ball is the money and it’s already palmed by the insurance companies. I predict that this will continue to get worse. We do need a single payer system for the simple reason that physicians will not be able to hire enough staff to learn and navigate 800 different websites. I do most prior authorizations on the phone in the room with the patient: the other day we spent 35 minutes on the phone only to have the insurance company say that we had called the wrong number. Call another one. Not the one on the insurance card. We could complain to the state insurance commissioner, but my patient is afraid of losing their insurance. Time’s up. The prior authorization is not obtained, and we are five minutes into the next patient’s visit. People are finding that the medicine they have taken for 20 years suddenly requires prior authorization.

And remember: prior authorization is your insurance company making rules and extra paperwork for your physician. It is advertised as a way to save money, but it costs YOU money. Back in 2009, the estimate was that physicians in the US had to spend 90,000$ per year EACH on employees to do prior authorizations by computer or phone. And YOUR insurance dollars go to the employees at the insurance company refusing medicines and dreaming up new medicines to refuse. They change the contract. Every year and during the year. The law is now that 80 cents of each dollar must go to healthcare, not profit, but those computer and phone employees are counted as healthcare. Do we really think that is healthcare?

Take CT scans. Medicare does NOT require prior authorization. But most insurance companies do. Think about that. Is age the difference? CT scans increase cancer risk over time so physicians don’t order them by reflex.

And for pharmaceuticals, insurance companies often have an on line formulary. But it is different for every insurance “product” in individual companies. A patient and I were trying to sort out a less expensive medicine on a website and we were having difficulty figuring out which insurance she had. Multiple abbreviations and color coding and we could spend the entire clinic visit just figuring it out. Is that what medicine is in the United States? You can say that someone else in the office could do it, but the more employees your physician hires, the less time the physician will spend with you, because he or she has to pay all of those people.

If there was one set of rules, one website, I would learn it. Medicare for all, single payer, when will the United States people wake up and tell congress: if you want our vote, make it so.

P

But wait, where are the happy things? I am so happy that I still am in business in my small clinic, p for patients and patience and prayer and single payer, we will have medicare for all in my lifetime. Whether I am still a practicing physician in the US at that time is uncertain. If I can’t afford my own health insurance, my clinic will close. Wouldn’t that be ironic?

 

Happy no

Name, noun, nut, gnome, know, no…

I have a nutty streak, a silly streak and love silly things. It helps me to balance clinic. Sometimes things are hard there, I hope to be able to do something for many people that I see. Half my patients are over 65, one is now 100, and no one lives forever even if I recommend the right things and they live a medically perfect life. I am always mourning for someone.

So my nutty streak comes out with listing words for the letter N and adding gnome and know. Are they N words or not? I think they are.

And my happy thing today is the word NO. How, you say, can NO be a happy thing?

This weekend I wanted to do too much. I wanted to attend a retreat about change that went from 9:30 to 3:00 but I also was already tired. It would be with a  group of people that I don’t know well, so my introvert side would be on guard. My son was coming into town and I needed to make choices and save energy and say no to myself. I went to the retreat, but only for two hours. I wanted to stay longer but did not. And that protected my energy for the next day and this busy week.

Do you argue with yourself and want to do too much or something your shouldn’t or spend too long on something that you didn’t plan to? Look, I thought this would be a very short post to catch up….

N

There were three great blue herons on the beach the other night, and then an eagle in the surf. The herons were fishing but also watching the nearby eagle, the people on the beach, loose dogs going by, and each other. Their feathers were windblown and they made me think of teens at a dance, looking at each other with interest, but pretending they were more interested in fishing.

Happy Blogging from A to Z!

 

Love, labor, laughter

Blogging from A to Z, my theme is happy things. Love, labor, laughter, I love my labor, my work (except when it is driving me nuts, of course). I love my family, including my cat, my friends, taking photographs, writing and blogging, the list goes on and on. I have a very silly streak and love to laugh.

I love being in my local Rotary. I get to work on real world problems, local and international, meet exchange students, and work with a diverse group of people in my town.

The photograph is of Patrick, in Hawaii, with my “stealthie” shadow, up at 9600 feet.

And we found a Rotary meeting in Waemea and showed up and were welcomed. We had a delicious lunch. This photograph is of the club banners brought to their club from all over the world! I didn’t think to bring a banner from our club, but will take one on the next trip.

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I’m still a day late, but hooray for the letter L.

L

 

I for intent

My Blogging from A to Z theme is happy things. Three happy things with intent!

We took a beach walk two nights ago and the beach was full of birds. Three great blue herons, three oyster catchers, an eagle landed in the surf, crows, gulls and the flock of brant. There were various dogs being walked, who were not chasing any of the birds, hooray for that!

I love this great blue heron: so intent on fishing. What are you intent on? Intent, intention, attention, retention. So many tents….

I was intent in clinic yesterday. We had a packed schedule and I started thirty minutes early to add an extra patient and I had good intentions to run on time. I didn’t. By the last person I was running 20 minutes late, and three people were grumpy. No, four people were grumpy because I have to add myself to that. I had good intentions, but I can’t control what problems people bring to clinic and they don’t always fit in the time allotted!

Here is the eagle, also intent on dinner. I don’t think of bald eagles as surf birds, but this one had caught something and landed. We did not get close, not wanting to disturb things.

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The photographs are taken at the Port Townsend Bay beach below Chetzemoka Park. Happy blogging. 

I

 

 

 

 

hipaa, health insurance, and health information

Blogging from A to Z, my theme is happy things. Letter H is for HIPAA and health insurance and health information.

H is for hipaa: the Health Information Portability and Accountability Act, from 1996. I’ve been thinking about HIPAA and I have a question: if the patient handouts are supposed to be written at the fifth grade reading level for patients, why doesn’t Congress have to write laws at the fifth grade reading level?

Ignorance of the law is no excuse, right? Everyone in the US is supposed to follow the laws. Have you read them? I am supposed to follow HIPAA, right? I am supposed to follow the Affordable Care Act, (also nicknamed ObamaCare). It is 3600 pages long. It is written by Congress and attorneys.

What about health insurance? Have you read your health insurance policy? It’s a contract. If multiple US citizens have difficulty reading, why isn’t health insurance written at a fifth grade level?

CMS too and triwest and medicaid. I do not have time as a physician to learn the language of their websites.  I run my own small practice. It is infuriating to try to read, understand and follow medicare, medicaid and Veterans Choice rules and they change every year. We ask why health care costs so much, and then there are over 800 different insurance companies, each with multiple insurance plans, and more and more people are hired to try to navigate and understand the rules. It’s ridiculous. We need a single payer system so there is ONE set of rules. Everybody in, nobody out.

At the UW Telepain telemedicine, I said that I show chronic pain patients the link to the Washington State Law about opioids and pain medicine.

One of the faculty said, “Patients can’t understand that.”

I said, “Well, I’m supposed to follow that law and I am not an attorney. ”

My patients are all smart in something. Some of them can’t read well. I have had two recently that I recognized a reading issue in the clinic room when I gave them a survey tool to fill out. I promptly said, “Let’s do this together.” I read them the questions and the answers. They are not stupid, but I am not sure that their reading skills were up to the form.

I am not using the American Academy of Family Practice patient handouts much because I think they are too dumb. I use the Mayo Clinic much more. I direct patients to the CDC, to NIH, to the Mayo Clinic website. Sometimes my patients may not be able to read at that level, but I think everyone appreciates being treated with respect. I am also happy to go over and explain more about a topic. I also warn them that there are loads of crappy medical sites and pseudo scientific sites and misinformation on the internet. If they want to look something up, I want them on a decent site.

Now how are these happy things to think about? It makes me happy to question my own behavior and my own assumptions. It makes me wonder how our country can insist that medical information has to be at a fifth grade level but lets Congress write laws that I find nearly unreadable.

Now I am warning my patients that a federal law may go into effect in January 2019, about opioids, and that it will be different and override the state law. Change will keep coming.

H

The photograph is from the beach last night: brant. What would the flock think about our health insurance?