Posts Tagged ‘health insurance’
Sunday musings 7/8/12
Sunday musings…
1) Wimbledon. Breakfast at Wimbledon. Why thank you, yes, I think I will.
2) ESPY. Kyle Maynard is up for an ESPY. Go find a place to vote for him.
Now.
3) Life? Billy Ray (not his real name, of course) turned off his implantable defibrillator (ICD) yesterday. Billy Ray is 44.
In my day job I was asked to evaluate him for a problem in my specialty. I was told he was about to enter hospice care and assumed that he was much, much older and simply out of options. I admit that I was somewhat put out by the request, it being Saturday and the problem already well-controlled. Frankly, I thought it was a waste of my time, Billy Ray’s time, and whoever might read my report’s time, not to mention the unnecessary costs. I had a very pleasant visit with Billy Ray, reassured him that the problem for which I was called was resolving nicely, and left the room to write my report.
44 years old though. What was his fatal illness? What was sending him off to Hospice care? I bumped into his medical doc and couldn’t resist asking. Turns out that Billy Ray has a diseased heart that is on the brink of failing; without the ICD his heart will eventually beat without a rhythm and he will die. A classic indication for a heart transplant–why was Billy Ray not on a transplant list? Why, for Heaven’s sake, did he turn off his ICD?
There is a difference between being alive and having a life. It’s not the same to say that one is alive and that one is living. It turns out that Billy Ray suffered an injury at age 20 and has lived 24 years in unremitting, untreatable pain. Cut off before he even began he never married, has no children. Each day was so filled with the primal effort to stop the pain he had little left over for friendship.
Alive without a life. Alive without living. Billy Ray cried “Uncle”.
I have been haunted by this since I walked out of the hospital. How do you make this decision? Where do you turn? Billy Ray has made clear he has no one. Does a person in this situation become MORE religious or LESS? Rage against an unjust G0d or find comfort in the hope of an afterlife? Charles DeGaulle had a child with Down’s Syndrome. On her death at age 20 he said “now she is just like everyone else.” Is this what Billy Ray is thinking? That in death he will finally be the same as everyone else?
And what does this say about each of us in our lives? What does it say about the problems that we face, the things that might make us rage against some personal injustice? How might we see our various infirmities when cast in the shadow of a man who has lived more than half his life in constant pain, a man alone? The answer, of course, is obvious, eh?
The more subtle message is about people, having people. Having family, friends, people for whom one might choose to live. It’s very easy to understand the heroic efforts others make to survive in spite of the odds, despite the pain. Somewhere deep inside the will to live exists in the drive to live for others. The sadness I felt leaving the hospital and what haunts me is not so much Billy Ray’s decision but my complete and utter understanding of his decision.
Billy Ray gave lie to the heretofore truism that “no man is an island”.
Go out and build your bridges. Build the connections to others that will build your will to live. Live so that you will be alive for your others. Be alive so that your life will be more than something which hinges on nothing more than the switch that can be turned off. Live with and for others so that you, too, can understand not only Billy Ray but also those unnamed people who fight for every minute of a life.
Be more than alive. Live.
I’ll see you next week…
Posted by bingo at July 8, 2012 7:17 AM
Does “MD” = Manic Depression?
“Manic depression is touching my soul.”
You’re up; you’re down. You’re happy; you’re sad. You have the best job in the world; thinking about going to work makes you sick to your stomach. You’re so good at what you do, everybody loves you; everyone is out to get you.
You are an American physician.
Recently I’ve been asked at least a dozen times why I became a doctor, or why I became an eye doctor. I’m not really sure why this has come up now, because most of the people who are asking have known me in some way for many years. Why I became an eye doctor is really rather simple, and I have written about it HERE. The question “why did you become a doctor” is much more complex, much more involved, and frankly I’m beginning to wonder about that myself.
“Why do you want to be a doctor” was at the same time the easiest and most difficult question for me to answer, especially during medical school interviews. I grew up in a small, dying mill town in Massachusetts. The happiest, most fulfilled, most IMPORTANT people in that town were the doctors, of which there were very few. The busiest surgeon in town, Dr. L., could possibly have been the happiest person in the entire town. Beautiful wife, attractive, intelligent, athletic children, really big house. He was even a decent golfer! I don’t think I ever saw him without a smile on his face.
It was Dr. Roy, though, my pediatrician, who really clinched it for me. There must have been another pediatrician in town–heck, there were 24,000 people there. For the life of me, though, I can’t ever recall any of my friends seeing any doctor other than Dr. Roy. He was confident. Secure. Always with a gentle smile whether in the office or on Main Street. My mom later told me that he was perhaps the most influential politician in town as well. Everybody looked up to Dr. Roy, no matter how young or old they might be. His was a happy, contented, full life, largely because he was a respected physician.
Can you name a single pediatrician now living and practicing in the United States whom you would describe like that?
Nevertheless, that’s mostly why I wanted to be a doctor. I want to be Dr. Roy. I wanted people to look up to me because I was good at doing something that was important, something that was meaningful to their lives. All of the doctors in town were like that.
Now? Well, I’m a 51-year-old eye surgeon and I am just like every other physician in the United States. I swing between the euphoria associated with a good outcome or a happy patient, and the bitter black hole that appears when a disease wins. My world is actually pretty good in this regard: for every defeat there are literally hundreds of victories. For every patient who is dissatisfied or unfulfilled there are hundreds who can’t wait to tell everyone in their lives how good their experience was. It’s just that there seems to be a couple more people who are less satisfied. A couple more each year.
Again, the success rate in my particular specialty is incredibly high, and these people who are less than satisfied have actually had an extraordinary good outcome if you look objectively. I think it all tracks back to the creeping consumerism in health care. It’s not good enough to have an outstanding outcome, it’s only truly even good enough if it meets the expectations of the consumer, the patient, no matter how outlandish or inappropriate those expectations might be.
I’m up. I’m down. The downs seem to hurt more because they are so much more, I don’t know, personal now.
I always got the idea that there was pretty much nothing to the business of being a doctor. All the docs seemed to have enough money, although none of them seemed wealthy. There was only one “girl” in the office and she made the appointments, gave you your bill, and took your payment. No back office or billing department. No special personnel responsible for charting, compliance, insurance communications. My “chart” was a couple of 5×7 cards stapled together.
Now? Oh man…the squeeze is coming from all directions. Private practice or big group practice, it doesn’t matter. You either deal with the external forces conspiring to make it more unpleasant to make a living as a doctor (insurance companies, the government, malpractice attorneys) or you deal with your boss (or more likely your boss’ secretary since you’re just another employee, after all). Your chart is now a legal document littered with land mines meant to ensnare even the most pious and dedicated among us. Most docs do OK financially, maybe not 1%’ers but pretty well. It just seems like so many folks go so far out of their way to make us feel like we don’t deserve our pay. Any of us. Any of it.
I’m comfortable; you don’t deserve it.
Now, if you are not a doc you could sit back and rightly say “quit yer whinin”. I’d get it. I just can’t shake the feeling that Dr. Roy, and all of the Dr. Roy’s of the day, got and gave more out of what medicine could offer than any of us do now, despite the fact that those of us who practice now have so much more at our disposal on the medical side of the equation. It just doesn’t feel as good. There’s just too much that comes between doctors and that sense of service, of satisfaction in those bygone days. It just seems so much like work now. I don’t think Dr. Roy ever went to work. I believe he would have practiced pretty much the same way if he’d inherited a million dollars.
You’re up; you’re down. You have the best job in the world; you can barely make yourself open the office door. Everybody loves you; you don’t deserve it.
“Manic depression is a frustrating mess.”
Anthem For A Single-Payer System*
*Sung to the tune of Janis Joplin’s “Mercedes Benz”
Uncle Sam, won’t you buy me, a Mercedes Benz.The Aetna guys drive Audi’s, I must make amends. Worked hard all through med school, make less than my friends. Uncle Sam, won’t you buy me, a Mercedes Benz.
Uncle Sam, won’t you buy me, a flat-screen TV. American Idol is trying to find me. I’m smarter than a banker; I’ve got my MD. Uncle Sam, won’t you buy me, a flat-screen TV.
Uncle Sam, won’t you buy me a night on the town. Big Pharma’s been busted, you’ve run them to the ground. Sold m’soul to my gov’ment, got pennies on the pound. Uncle Sam, won’t you buy me, a night on the town.
EVERYBODY!
Uncle Sam, won’t you buy me, a Mercedes Benz. The Aetna guys drive Audi’s, I must make amends. Worked hard all through med school, make less than my friends. Uncle Sam, won’t you buy me, a Mercedes Benz.
That’s it…
Fantasy Response
8:00 p.m. on a Friday night. An urgent page from Express Scripts. “Approval needed for sleeping medicine, Agnes Jones*. 800–333–4444.” Agnes Jones is a nursing home patient with a brain tumor.
4:59 PM, Friday afternoon. Telephone call from CVS pharmacy. “The nonsteroidal anti-inflammatory eyedrop that you prescribed is not covered by Mrs. Jones’ insurance company. We need your authorization to change to the generic version.” We told Mrs. Jones in writing that the generic version was inferior, caused pain, and had 10 times the complication rate. On Monday.
7:30 AM, Sunday morning. Telephone call from answering service. “Doctor, the prescription that you sent electronically on Tuesday for Mrs. Jones was written incorrectly. Please correct this and refile it immediately. Please remember that your status as a provider is contingent upon meeting our customer service standards.” Confirmation of receipt/prescription filled was received on Wednesday.
And, my very favorite, most recent telephone call, this one from the daughter of one of my patients. “Dr. White, NALC needs you to send them a letter proving that my father’s eye drops are not prescribed for cosmetic purposes.”
Welcome to the world of the American physician in the modern era. There are, of course, a host of entirely appropriate responses to all of these pages, beeps, and phone calls. However, this last one put me over the edge. I sat at my desk with the message in front of me, closed my eyes, and thought about how I’d REALLY like to respond. The totally, truly amazing part about this request to justify the eyedrop prescription was that, not only was all the information necessary to cover this already on file at NALC, and not only did a real, live human being actually look at this file, but she admitted that and gave me her name! Ya can’t make this stuff up.
“Dear Alex:
Thank you for this opportunity to express my thoughts about some of the pitfalls associated with the pending ‘meaningful use’ regulations for computerized health records. After you personally reviewing the record you requested information about eyedrops that I prescribed for one of my patients. There is apparently a concern about whether or not this patient is using said medication for cosmetic rather than medicinal purposes. As you know, among the more significant ‘meaningful uses’ of electronic medical records are to make sure that everyone has the same exact information about a particular patient, to utilize this information in such a way that proper care is ensured, and to be more time-efficient for the patient, doctor, and everyone else involved in the care process.
If you will open up your file again regarding the patient in question, JOSEPH Smith, you’ll see that, had meaningful use activity actually been applied, this entire communication could have been avoided. Had you actually read the file you would have seen that MISTER Smith is an 87 YEAR OLD MALE with a long-standing diagnosis of GLAUCOMA. As your software no doubt shows, the eyedrop Lumigan is a first line medical treatment for glaucoma. All of this information is contained in your database since Mr. Smith has been taking this medication for no fewer than five years, and the bill for his office visit was paid in full by NALC, diagnosis: glaucoma.
A copy of this letter will be forwarded to my US Rep. and two senators, the FDA, and CMS along with a note asking how they propose that all of their fancy new laws about EMR and ‘meaningful use’ will prevent lazy and incompetent file clerks from blinding my patients.
I trust that the information in this ‘old–school’ letter is meaningful enough to prove that Mr. Smith’s use of Lumigan is not for cosmetic purposes.
Sincerely,”
——————————————————–
“Dear Alex,
Attachment: Pic.JSmith.jpg
Seriously? Really? You would like me to prove that my toothless, 87-year-old patient named JOSEPH is not using his glaucoma drops for cosmetic purposes?! The guy with the electronic bill in your system with a diagnosis for glaucoma, taking three other glaucoma medicines, all for 20 years? The Joseph Smith who can’t be bothered to remove the 11 skin cancers growing out of his face like barnacles on a sun-scorched barge? COSMETIC?
This is a joke, right?
Sincerely,”
——————————————————————-
” Dear Alex,
You caught me! But please, don’t tell anyone else. We have the largest population of semi retired 87-year-old drag queens in America in our practice. They just can’t let it go! We have been prescribing medicines so that they could maintain their long, luxurious eyelashes forEVER. I mean, who WOULDN’T rather have long, thick, natural lashes, especially after a lifetime fussing with those falsies and all that icky, sticky glue. Joe has been SO happy!
It’s amazing how important it is for him and all the ‘girls’ to be able to bat their eyelashes at those cute boy orderlies in the nursing home.
Not that there’s anything wrong with that…
Sincerely,”
Sigh…
*All names are fictitious, of course. The examples are not.
Economic Stimulus. A True “Shovel-Ready” Proposal *
It’s the jobs, Stupid. That’s what should be on the office wall of every legislator at every level of government across America. Say what you will about Bill Clinton, but did anyone ever get it more than that first Clinton presidential campaign? A simple sign in their campaign war room reminded everyone of the central message: “It’s the economy, Stupid!”
It’s more than that, of course. Now, you could say, “It’s the jobs, Stupid!” What can you do to stimulate the creation of jobs now? Sure, you can take a page out of Rahm “Never Waste a Crisis” Emmanuel’s book and combat our crushing unemployment by pumping money into grand public works. Who doesn’t agree that our bridges, roads, sewers and subways are in dire need of repair? But everyone was enticed by President Obama’s promise of “shovel ready” public projects into which stimulus funds could be pumped, followed instantaneously by the hiring of willing hands to man those shovels. Stimulus I didn’t really turn out that way, so why would we embark on Stimulus II? Or III? Return on this investment was pretty much zero.
Nothing will get our economy moving faster and restore our national spirit than employing more people, and at a higher wage. Let’s take a quick look at the kind of job sector that would be most desirable.
Any industry into which we might pump money should have the ability to ramp up employment at the first dollar of public investment, or the first loosening of a needless regulation. OR BOTH.
Any sector targeted should be able to create and fill jobs across a broad range of salary, experience, and skill levels, and it should be relatively gender-neutral. It should reward achievement and educational advancement. Any jobs created should be domestic, although any hard products created must be attractive for export. It should be an American business sector that is expanding now, and poised for additional growth.
Pretty ambitious list of criteria, huh? Where will we ever find an industry or economic sector that could fulfill all of these criteria without some new genius discovery or mega-bureaucratic mischief?
Easy. Healthcare.
Think about it. Right now our country is fixated on cutting the money flowing into healthcare businesses such as hospitals, nursing homes, and doctors’ practices. Government regulations make it more and more difficult to make a profit while providing healthcare. Perhaps more frightening is the fact that similar regulatory agencies make it nearly impossible to bring new medical products to the market or build the sales of existing products.
Despite that, healthcare and related industries (pharmaceutical manufacturing, medical device manufacturing, health insurance administration and sales) continue to grow in all ways that we can measure, except the most important one: jobs.
I know your reaction. “We’re gonna go broke paying for healthcare as it is; how could we possibly pump MORE money into that?”
Hear me out before you dismiss my theory out of hand.
Every new regulation, every new requirement, every cut in payment for an office visit or a medicine or a hospital stay results in a net LOSS of jobs. And worse, pretty much no one in the entire healthcare and medical sector is hiring now, partly because of declining pay for services and products, and partly by the gloom caused by an assumption that the future holds nothing but more of the same.
We should try to identify regulations to remove. Start with removing the prohibition on drug companies marketing so-called “off-label” use of prescription drugs when it is clear they are beneficial. More sales of existing drugs means more jobs. More sales of existing drugs — along with fewer barriers to approving new drugs — means even more jobs.
People in healthcare and related businesses make a good wage, and there are jobs available across a broad wage scale. These folks buy houses, employ skilled trades, go out to eat and the like. As they advance, they earn higher salaries, and then they do the American thing: they spend it!
Pump more money into healthcare rather than less. Stop all of this talk of cutting payments to hospitals and doctors and instead index fee increases to inflation. Stop reducing Medicaid rolls and give doctors and hospitals an incentive to care for these people by increasing Medicaid payment to the levels of Medicare. That would create more jobs.
Education matters in all things medical, whether you are a doctor or someone working in a pharmaceutical factory. Generally, the more education you have, the better you fare economically. There is no systemic gender or race discrimination in healthcare. With doctors, nurses, hospital administrators, academicians, the only requirement is to be good at what you do. Same thing in related industries like medical device manufacturing; ambitious people of all types, men and women, young and old, can advance in their careers. Advancement means more job openings.
And guess what? More jobs means generating more income that can be taxed! More jobs create more spending and more sales that can be taxed! You could even encourage more of this by decreasing income taxes on those people most likely to spend that money, which would then create…wait for it…more jobs!
Oops. Sorry. Politicians are involved. Decrease taxes? That’s just crazy talk.
The next thing you know someone will propose some really crazy thing, like increasing the money we spend on healthcare.
*Credit for the idea to William J. Petraiuolo, M.D.