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:

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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.

 

 

Long notes and unhappy patients.

A patient of mine saw a cardiologist recently.

His previous cardiologist has retired. The patient had a cardiac bypass in the past, he has a stent, he has known coronary heart disease and he’s in the young half of my practice. That is, under 60.

He had not seen a cardiologist for 2-3 years because he had a work injury, worked with Labor and Industries, the case was closed, he couldn’t go back to work, he found a lawyer. He lost his regular health insurance along with the job, so couldn’t see the cardiologist.

The L & I case is reopened. A physiatrist recommended specific treatment that was not done, and that allowed the case to reopen.

The specific treatment center then notes that he has heart disease and that he needs clearance from a cardiologist. I set him up with a new cardiologist.

“How was the visit?” I ask.

He shrugs. “The staff was nice.”

“I have the note.”

“The cardiologist spent under ten minutes with me. It was clear that she was rushed. She did not seem very interested. It was difficult to get my questions answered.”

“Her note is six pages.”

He snorts. “Great that she could get a six page note out of that visit.”

“Do you want a copy?”

“No.”

He is cleared for the specific treatment.

I have no doubt that the cardiologist spent more than 6-8 minutes on his visit and his note. But not in the room. Other people are entering the information filled out in the waiting room, medicines, allergies, past medical history, family history. Hopefully the cardiologist is reading my note and letter. But the problem is, doctors aren’t doing it in the room. So the impression left with the patient is that we spend 6-8 minutes on their visit, we are late, we are rushed. Doctors are looking at data. They are not listening to patients.

Medical Economics, a journal that arrives without me asking for it, says over and over that we need more physician “extenders”, that we need to have people doing the data entry, people doing the patient teaching, more people and machines….No. They are wrong. We need LESS barriers between us and the patients, not MORE. We need more time with patients. Every single extender we add burns physicians out more, because the salary has to be paid AND more patients seen faster to do that AND we are still ultimately responsible for knowing and reading and absorbing every single piece of information that is placed in that patient’s chart. An extender is NOT an extension of my brain and an extender is another person I have to communicate with and train.

Just. Say. No. to the managers who pile MORE barriers between the physician and the patient. NO.


It just makes me so mad that he lost his health insurance BECAUSE he got injured at work and so then his heart disease goes untreated as well… can’t afford medicines…if he then has a heart attack while uninsured we lifeflight him to Seattle, it costs a fortune, he loses his house and property and then is on medicaid and may end up on permanent disability, and what are the chances he returns to work? The US medical corporate money grubbing is insane. Single payer, medicare for all, make the US great again.

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?

 

Eeeeeee

My theme is happy things, though sometimes they are things where I am trying to find the perspective to love what is happening.

When my son was little, I had Dr. Suess’s ABCs memorized: Ear, egg, elephant, E, e, e!

My words today are everybody, embody and evening.

E for Everybody. Everybody in, nobody out! This is one of the calls for Healthcare for all, and I am still a Mad as Hell Doctor, working for single payer.

Our state representative was here a year ago and said that there is not a mandate for healthcare for all. I said, “I politely disagree. We already have a law in place that emergency rooms cannot turn anyone away. They cannot refuse to treat a person. This is a mandate for care. Unfortunately, the emergency room is the most expensive and inefficient care, unless you are about to die. The emergency room cannot do chronic care: it cannot help people stop smoking, help lower blood pressure, help people with chronic illness such as diabetes, do preventative care like pap smears and checking kidney function to stave off renal failure. We have the mandate: now we need the political will to change to a single payer system that gives good care. A patient can see me in my family practice clinic a dozen times for the cost of one emergency room visit.” S o, everybody in, nobody out. The law that insurance companies can ONLY keep 20 cents of every dollar does not comfort me: I want my dollar to go to health care for everyone and not 1/5 to profit!

Embody: what do I embody? What do you embody? Do you treat your body well? Do you thank it? What is it carrying?

I see people so fixed on success and progress and getting goals, that sometimes we don’t pay any attention to our bodies. We treat the body like a tool, like a hammer or a wrench, use and abuse it, try to make it conform to some idea of external beauty, get angry when it breaks down. Fix me back to where I was three years ago, when I could work 12 hours a day and never ever paid attention to my body. Bad food, tobacco, alcohol, marijuana, gallons of caffeine, energy drinks, sugar, illegal drugs, no exercise… and then we are surprised when it breaks down? Even exercise is seen as an inconvenient and necessary job, like buying new tires for the car. When people say get me back to where I was, I ask, “Back to working the 12 hours a day that caused this damage? Do you think that is a good idea?

And I include myself in that! I have had pneumonia with sepsis symptoms twice. The second time I thought, how dumb I am! My father died and I did not take any time off. I just kept working and added executor to my jobs and cried daily. Is it any surprise that after a year of that I became ill? Now my goal is to not do medicine for more than forty hours a week and to listen to my body and to take breaks!

Evening: the sunset. I am so grateful for the day, for the night, for the light changing and the world turning, for the stars and the moon and the sun and the glorious, gorgeous, generous world.

E

This is an evening photograph from Mauna Loa last week.

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I took this in 2011, as a Mad as Hell Doctor, traveling around California talking about single payer.

We are losing more and more physicians. Our three counties, 450,000 people, are down from 8 neurologists ten years ago, to 2. The last one standing in the county of 350,000 says that he is really tired.

Single payer, medicare for all….. because I dream of other countries, civilized countries, countries where there is one set of rules, I can take care of any person who comes to me, I know what is covered and what is not, and I actually get paid….