community health

For the Ragtag Daily Prompt #69: community.

The photograph is from 2010, when the mad as hell doctors toured California to talk about single payer health care, medicare for all.

Small communities rolled out the welcome:

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In this community, every table was sponsored by local health groups: clinic, the health department, mental health, addiction treatment. In small communities everyone knows someone who has lost their health, their health insurance and/or their job and home.

Here we are setting up for another program:


People asked questions:

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And they listened and responded:

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The health care industry has money. The insurance companies are for profit and make enormous profits. But in the end you and I have VOTES. When we stand up as a nation and say that we want medicare for all, Congress will listen. Stand up.

The mandate for health care already is a law: no one can be turned away from an emergency room. But as things stand, we do not take care that the person in the emergency room has care after the emergency room. The hospital may take the person’s house. We already have the government doing no profit care for over 50% of the care in the US: Medicare, Medicaid, active duty military and the Veterans Association. It is time to shut down the for profit insurance companies that refuse medicines, refuse care, refuse to answer their phones, tell me on the phone “we don’t have a fax”, the parent company tells me a medicine is covered and then the part D drug coverage still refuses: it is BEYOND TIME TO SHUT THEM DOWN.

Is the goal of health care profit? Or is it care for our citizens, support for families, works like the police and the fire station: we all support each other. Stand up, shout and VOTE.



Why can’t I just call for a referral?

Why, you say, do you need to SEE your doctor for a referral? It’s so stupid!

Multiple reasons:
1. Triage.
2. Scarce resources.
3. Your primary care may be able to handle it.
4. The specialist only wants to see people that they can help.
5. You may think that you and Dr. Google have it figured out, but Dr. Google sucks.
6. For physical and occupational therapy, it has to do with caution and malpractice insurance.

Let’s go through them backwards.

6. People call for a referral to physical therapy. I say I need to see them. No, I can’t make a diagnosis through the phone. Arm hurts is rather vague. The person says their insurance does not need a referral. But then the physical therapist wants one: why? Well, my malpractice outranks the physical therapists, so to speak. If the therapist sees you without your doctor examining you and something happens… yes, things have happened.

5. Dr. Google. You’ve read extensively and you know exactly what is going on and you just need the referral. No, you have not gone to medical school or residency. Every quack who can say anything even faintly convincing now has a website. Dr. Google sucks. There are very very rare exceptions to that…

4. The gastroenterologist does not want to see your bladder problem. The neurosurgeons hate seeing the people that will not benefit from back surgery, but they have to because the back pain patient doesn’t believe me, so the patient has to hear it from the surgeon. The patient thinks I am “gate keeping” them from the specialist. I’m not.

3. Primary care learns to handle a lot of things. One frequent referral is a postnasal drip, to the Ear Nose and Throat specialist. I recommend trying an acid blocker first. The person doesn’t believe me. “I don’t have heartburn.” I sigh, and do the referral. $450.00 later, the ENT has put the scope through their nose and put them on an acid blocker.

2. Scarce resources: We had 8 neurologists on the Olympic Peninsula for about 450,000 people. We are down to two. I called one for a complex stroke-that-wasn’t and had to do a series of MRI/MRA studies looking for specific things. It was a vertebral arterial bleed. Rare. I called the neurologist back and he said, “Send them to the other one. I am swamped.” He is in the larger population area and two others quit. The rule is sickest is seen first…

1. Triage. What is wrong, what are we worrying about and how sick is this person? If they are really sick I will call the specialist to ask for recommendations, or which test to do, or see if they need to be seen within a short time. I am not going to interrupt the specialist unless I think it’s really necessary! That would burn through my carefully built credit with them! And I have had a person come in for a new patient visit for a “lung problem”. I call the specialist, get him seen and he has a heart bypass….

0. And I am a specialist too. I am a Family Practice physician, board certified and board eligible, three year residency. The internist, the pediatrician, we are all specialists and all special.

Health and teeth

For the Daily Prompt: toothbrush.

Here is a young rabbit. Their front teeth grow and get worn down eating. Their nails keep growing too and need to be worn down or clipped if they are pets.

In my county there are no dentists who take the state Medicaid for dental. And in some states Medicaid covers orthodontia for children but not in mine. Teeth are not covered on Washing ton State for my Medicare or Medicaid. And there are still battles going on about covering mental health including addiction. Is mental health not part of health? Are teeth not part of health? Why do we put health insurance profitable before basic life saving health coverage that covers all of us?

Health care should be like a toothbrush. We all need it. We all should have it.



What comes to mind for today’s Daily Prompt: substandard?

As a rural Family Practice Physician, what comes to mind is the United States current health care system.

There is nothing substandard about our health insurance system: it does what it is supposed to, which is earn money for owners and investors. But it is frankly terrible at delivering health care, health care is not the goal, and we spend twice as much per US citizen as the next most expensive health care system in the world. And we do not have universal health care for our citizens and we rank below 30th in health care measures.

Wake up, US citizens. Let’s buy health care with our dollars, not health insurance. Single payer, one system, low overhead, clear rules and coverage and everyone in, no one out.





For the Daily Prompt: cringe.

I took this on the ridge on top of Mount Zion yesterday. Absolutely gorgeous hike, with the rhododendrons floating among the tall trees and tons of wild flowers. Here are little wild strawberries…. we will have to come back in September.

Cringe: I cringe when I hear the discussion on the news being about health INSURANCE  and not health CARE. We need to change the focus.

We HAVE a mandate that anyone in the US can have health CARE. That is, the emergency room cannot legally turn anyone away. But the bills can bankrupt you and take your house away. Not only that, but the emergency room is the most expensive and worst way to take care of people in the world. The emergency room cannot treat cancer, cannot treat hypertension, cannot help a person with depression, cannot do the long term chronic care that I do. Per person in the US we pay twice as much as the next most expensive country and they have universal care. What is the matter with the citizens of the US? We care more for corporations protecting their profits than we do for our citizens health. And I think this will bring our country down….. we will collapse.

I am a physician but I also run my own clinic. I am a small business owner. And I really expect that health INSURANCE will force my clinic to close.

Call Congress. Say we want health CARE not health INSURANCE.



I took this about a month ago, on an evening walk with my daughter. She is airborne: her feet are not quite touching. I have pictures of both my kids airborne at the beach. Water, wind, air, sky: I think that is their effect….

The new health care bill would cut medicaid by billions. That is our poorest Americans and most disabled. Is that how we make America great? Great for whom? Call Congress and say no….. Call again and again and again. They listen to money but in the end they need votes.


Nearing the end of a beach walk with my daughter at Fort Worden, the Strait to the west had a line of silver at the horizon. Gorgeous in all weather….

The vote today by Congress would remove the minimum services that insurances must offer in the US. Steps backwards, where cancer screening or hospital services or life flights or pregancy may not be covered. VOTE NO!!!!

And we still need medicare for all, single payer, so that 20% of every healthcare dollar is not going to insurance company profit…..Can’t they see?

My clinic and the state of medicine

January has been the busiest month in clinic since I returned to work in April of 2015 after the ten month systemic strep A hiatus. It took another ten months for my fast twitch muscles to start working again. I was working “half time” for the first ten months after I returned.

Right now, though, my receptionist and I are about maxed out. We saw 4-8 people a day in January, averaging 6.5, and with Martin Luther King’s birthday off. I see patients five days a week, try to stop by 2 pm and then do paperwork until 4 or 5. Lately I have been going in at 7 am, because I am feeling behind. Three very sick patients, one who has been sick and hospitalized nearly weekly since October, are each taking 1-2 hours a week and I can’t get to the routine paperwork. Labs, referral letters that need to go out, reading referral letters that come back and updating the med list, xrays, pathology reports….

Yes, we could hire someone to scan it all faster, but scanning it does not mean it has been read. And it is me that has to read it. One of the complex patients has five specialists and four different electronic medical records are involved. I had to call the rheumatologist, because the doc was not responding to the patient’s calls. I had sent the rheumatologist letters and updates: turned out the doc didn’t read any of them until the patient missed a visit because their car broke down. And another of the specialists said they “didn’t have the notes” from the other hospital. I wrote a letter to ALL of the specialists and said, the notes are in there because I faxed them to our hospital myself. Unfortunately scanned notes are difficult to find in the EPIC electronic medical record. Ironically both hospitals use EPIC but the two versions do not share their information. This is REALLY REALLY BAD. It is bad for patient care and bad for this specific patient. Not only that, but when one of the specialists orders something, the report doesn’t get sent to me as well as them. I tracked down labs and I tracked down an xray report and sent him back to the hospital at that visit. I do not know if the hospitalization could have been averted, but….I’ve told the patient and spouse that if ANYONE orders a test, call me. So I can track down the results.

So it looks like five clinic days a week, seeing up to eight patients a day, will take forty hours or more. This is a rural family practice clinic. I cannot see any way to see more and actually keep up with the information coming in with my patient population, half of whom are over 65. And an additional one is in hospice and another on palliative care.

A fellow doc has retired from medicine, in her 50s. She is “med-peds”: internal medicine-pediatrics, which is sort of like family practice except they don’t do obstetrics, less gynecology and less orthopedics. I hear that she is retiring because every 20 minute clinic visit generates an hour of paperwork. The hospital considers 4 days a week, 18 patients a day, full time. Ok, that is 72 patients a week, seen in four 8 hour shifts. 32 hours plus 72 hours of paperwork. One hundred and four hours. Can’t be done.

I dropped to 3.5 days in 2009 when the hospital said we had to see 18 a day. So 28 hours, 63 patients. 28 hours plus 63 hours. That is 91 hours a week. I still could not keep up with the information coming back from specialists, labs, xrays, pathology reports, medicine refill requests, requests for those evil ride on carts, spurious nonsense from insurance companies, and families calling about their loved ones. All ten fingers in holes in the dyke and 90 other holes spouting water.

Something has to give and something IS giving. Care is falling through the cracks and providers are quitting. I am not quitting, I just am not making anything anywhere near to the “average family practice salary” in the US. And we hear that burnout is now at 54% of primary care doctors. Hello, US. If we don’t go to single payer, you might have to ask your naturopath to take out your appendix. And good luck with that.

If I see 7 per day, five days a week: that is 35 patients. I do longer visits and more paperwork in the room, so call it 45 minutes of paperwork per patient. I see patients from 8:30 to 12 and 1 to 2. 4.5 hours five days = 22.5 hours plus (35 patients x 45 minutes)= 26 hours and now I am at 48.5 hours a week. And then if I have three really sick ones: more.

If we hire help, they have to be paid. Then I need to see more patients in order to generate that pay. Then there is more paperwork that I can’t keep up with. An infinite loop.

Let’s look at my clinic population verses county and state.
Clinic: 2.4% under age 18
20.7% age 19-50
28% age 50 to 64
48.9% over 65
Jefferson county (2014): 16.7% under age 19
51.5 age 19-65
31.8% over age 65
Washington state (2014): 29% under age 19
56.9% age 19-65
14.1% over age 65

We have an older county and nearly half my patients are over 65, and 77.9% of my clinic patients are over age 50.

And I should be reading all the new guidelines as they come out. The newest hypertension guidelines say that the blood pressure should be taken standing in all patients over age 60. Those guidelines are now a couple of years old. My patients tell me that I am the ONLY doctor that they have taking their blood pressure standing. The cardiologists aren’t doing it either. Just this week there are articles in the AAFP journal explaining the blood pressure guidelines. But the doctors need time to READ the articles. The guidelines themselves tend to be 400 pages of recommendations and explanations and a list of hundreds of studies reviewed since the last guidelines. And ok, there are also hundreds of guidelines. On blood pressure, who should be on aspirin, what to do for heart pump failure, urinary incontinence, osteoporosis, toenail fungus.
Ok, that is a list of 96 guidelines, which doesn’t even include the hypertension ones. The hypertension guidelines are called JNC 8, for the eighth version:
Here is the two page hypertension JNC 8 algorithm: Memorize it and the other guidelines, ok?
And here is the Guideline Clearing House:

This week another clinic suddenly closed and we have gotten walk in patients and calls. About eight so far. We are booked for new patients out to April…..

I took this photograph from the beach as the sun set, camera zoomed. Different mountains were lit up while others were in shadow as the sun went down. This is Mount Baker and friends….

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.


I squeaked. “For the same MRI?”


“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.

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
Washington State Office of the Insurance Commissioner is at
Premara Blue Cross

* 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.