A Lot to Be Thankful for, I Suppose

I guess I should be thankful that I have insurance, even though BCBS of Texas just sent me a letter informing me that my 2009 premium will increase by 9%. Yeah, I am grateful to pay even more for bare-bones coverage that I haven’t used once since the 1/08 effective date. At least BCBS was nice enough to offer a couple of alternative, less expensive plans for me to consider. Both are HSAs like the plan I have now. One has the same deductible as my current plan ($2500), but I would have to pay 15% more in coinsurance for only an $8 reduction in monthly premiums. Not worth it. The other has a $5000 deductible (eeek!), but covers all INN (in-network) services at 100% after the deductible is met and offers a $23 reduction in monthly premiums.

Despite the intimidating deductible, the latter plan is worth investigating for me personally, especially since I confirmed on-line that the OOP (out-of-pocket) maximum is the $5000 deductible, meaning that if I incur stratospheric healthcare charges, I’m only out $5000 provided I stick with contracted providers. Although, it would mean a significant financial setback, I have the funds set aside to pay this amount if illness or injury should strike. This is in addition to the amount I set aside to cover preventative medical and dental care and a routine prescription on an annual basis. If the monthly rate reduction is $20 or more, I would be tempted to switch to the $5000 plan and plug the approximate $240 in monthly savings into my HSA, which I plan to fund to the $3000 maximum in 2009 if all goes as planned. I suspect, though, that given the 100% coverage perk, I would have to go through the underwriting process again, which is a major pain in the ass. Then again, since I just went through underwriting at this time last year, and I haven’t seen any healthcare providers since, there’s no new information to review. Maybe, they could fast-track me somehow. Naaaahhh!

The insurer sent along a new application for which I’m sure I’d have to pay a non-refundable fee, so I tried in vain to get through to customer service to confirm whether I’d actually have to reapply to switch to the $5000 plan, go through underwriting again, and pay a fee. But, of course, being the day before Thanksgiving, it appears that only two customer service reps are servicing the entire BCBS Texas membership because after wasting 30 precious daytime cell phone minutes waiting for a representative, I still couldn’t get through. I will try again next week before I resign myself to paying the 9% increased premium for my current plan. In the meantime, I’m thankful that despite suffering from a wicked cold at the moment, I enjoy good health, which affords me the privilege of considering a $5000 deductible plan. I’m also thankful that I’m not a chatty Kathy and can waste the occasional 30 daytime minutes on hold without incurring outrageous overage charges. I resolve to be a well of gratitude, at least until I attempt to contact customer service again.

Big Pharma Throws a Tantrum

The physician I work for operates two offices, and both are frequented by pill reps hocking everything from blood pressure medication to anti-depressants, and of course, oral contraceptives, since my employer’s specialty is OB/GYN. Most of the reps are obnoxious, but none more than this immature twit who throws a tantrum when she thinks we’re favoring other pills over her beloved Loestrin24.

This “girl” is in her mid-20s and not too bright, but she believes that since her father is an OB/GYN, she’s down with the healthcare professional crowd. She thinks the nurses and medical assistants are her friends and tells us all sorts of unprofessional TMI, such as how she spent most of her college years drunk like everyone else (say what?), that she has a learning disability (I’ll say!), and that she can’t find a good man to settle down with (the horror!). She also badmouths all other pills, even going so far as to tell me that the pill I’d taken for over five years was “a really bad pill.” I responded that perhaps I should sue my physician of twelve years who just happens to be on the faculty of a well-respected medical school for prescribing me “a really bad pill” that happened to do me a “hell of a lot of good” seeing as how I remained un-pregnant and symptom-free while on it. She didn’t have a response, but one can’t expect an articulate exchange to occur with this person who has no compunction whatsoever about revealing how she graduated with a 2.something GPA in some bullshit major.

Lately, she’s taken to pouting openly and slamming the sample cabinet doors to illustrate her discontent with our perceived disloyalty. My colleagues have tried to reason with this entitled dumbass by explaining to her the financial hardships faced by individuals in the real world, specifically that they cannot afford to pay $40-50 per month for any brand-name pill and that’s why we give them prescriptions for brand-name and generic medications, so they can get what they can afford. But, healthcare ethics and simple logic hold no sway with this ignorant creature who doesn’t know the first thing about women’s health issues. Perhaps, she has too few brain cells left thanks to her collegiate binge-drinking. Then again, maybe she’s just stupid.

In any case, something must be done about this brat. I don’t have much faith in my employing physician, since he tends to be somewhat of a pacifist with the reps. He mostly ignores them, Ms. Loestrin24 included, except to sign paperwork and sample the sweets they bring, leaving the staff to deal with their endless drama. Luckily for me and for her, our paths haven’t crossed since the escalation in her behavior. I don’t care too much for children and even less for childish adults. I won’t have any problem showing her the door after I lecture her about what “a really bad pill” she’s hocking.

They Want to Hire Me to Spy on You

I just received a personalized recruitment letter from Aetna urging me to apply for a telephonic Disease Management position in Sugarland, a Houston suburb. I know I’d be a shoo-in for this opportunity because I have tons of healthcare espionage experience with one of Aetna’s major competitors. Actually, I wasn’t a very good spy. I spent most of my time helping members sort out their claim issues, which was totally outside my job description. I was supposed to punt all these calls to a “Rapid Resolution” expert in the claims department, but I’m not a big fan of passing the buck, especially when the member has my direct number and will contact me for follow-up. I know just enough about the claims payment process to be a major pain in the claims department’s ass and a major asset to members.

I’m not surprised about receiving a recruitment letter even given the economy because turnover in these positions is high mainly, I think, because the nurses who apply have no idea what they’re getting into. Many of them are “getting older” (their words, not mine), are tired of hospital shift work, and like to talk on the phone. They think they’re just going to chat with people about their health and benefit plans. In reality, these jobs are where nurses come to die. Take a look at the following job descriptions in my recruitment letter:

Disease Management
Disease Management offers education and case management services for members who have chronic health conditions such as asthma, coronary artery disease and juvenile diabetes. As a member of our Disease Management team you will be able to view Aetna members holistically, considering multiple diseases or conditions across all benefits plans, and deliver individualized programs based on their unique needs and preferences.

AND

Beginning Right Maternity
As a Case Manager, you will utilize clinical skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options and services to facilitate appropriate healthcare outcomes for members. Your responsibilities will include assessing members’ health status and care coordination needs, including discharge planning. You will offer member outreach and provide information, education, and follow-up activities.

Oh, Aetna, could you been any more frickin’ vague? How about hiring Renegade RN to rewrite your job descriptions, so applicants can get a better idea about what the job truly entails? Here goes:

Disease Management
Disease Management offers harassment and stalker services for members who have chronic health conditions such as asthma, coronary artery disease and juvenile diabetes that cost the company a ton of money. As a member of our Disease Management team you will be able to view Aetna members as greedy consumers, considering how to keep the sicker-than-shit ones out of the hospital while keeping a close eye on their benefit maximum, so you can kick them off the rolls ASAP, and deliver canned healthcare advice anyone with access to a computer or a television or a functioning brain stem can find.

AND

Beginning Right Maternity
As a Case Manager, you will follow the company’s computerized script in a talk-to-the-hand-kiss-my-bureaucratic-chain-of-command process to harass, negotiate with, and manipulate the poor bitches by threatening to withhold payment if all parties won’t comply with your care plan in an effort to find the cheapest healthcare outcomes for greedy, knocked-up consumers. Your responsibilities will involve monitoring pregnant women’s every move with an especially keen eye on those aging, high-dollar heifers, their sicker-than-shit preemies, including figuring out how to boot all of them out of the hospital more quickly. You will offer targeted espionage efforts and canned healthcare advice anyone with access to a computer or a television or a functioning brain stem can find.

So, Aetna, can I get an interview?

Why Consumer-Driven Health Plans Screw the Consumer

This New York Times article mentions the increasing number of companies offering high deductible health plans (HDHP) for 2009. Some are shifting entirely to these so-called consumer-driven plans. The popular theory behind these plans is that shifting more healthcare costs to the consumer will result in decreased costs overall because people will choose their care more carefully, thereby increasing competition among providers and decreasing healthcare costs and wasteful spending. Never mind the fact that competition among providers in our current, unchecked system has not reigned in costs at all. They continue to skyrocket well beyond inflation. It’s true that consumers are less likely to utilize care when they have to pay huge amounts, which should decrease costs in the short-term, but it will do nothing to promote prevention and management of illnesses before they become severe or life-threatening, and of course, outrageously expensive.

A key problem is that consumers, even when they assume full responsibility for researching the most affordable, quality care, do not have all the information they need to make informed decisions. Namely, providers and insurance companies alike withhold critical information about costs and contracts, so that consumers are left with the burden of paying upfront, sometimes 2-3 times the actual amount, until they sort out the contracted rate many months later. For example, I have several years experience with an HDHP, both on a group plan with my former employer and now on an individual plan. While under my former group plan, I visited a specialist for a rather benign, yet chronic problem. Being a relatively healthy individual, I had not yet met my deductible, so the provider asked to be paid upfront for the full cost of the visit, or rather his version of the full cost of the visit.

Here’s the rub. If I fulfill my end of the bargain by seeing an in-network (INN) provider, I am obligated to pay only the contracted rate for services, not the wildly inflated cash price the provider thinks his services are worth. Each INN provider negotiates contracted rates with particular insurers. The rates may be different for each insurer, but the two parties know what amounts will be paid and under what circumstances. But, neither of them will divulge this information to patients aka consumers! In my case, the billing department said they didn’t know the contracted rates. This is a lie, and this lie is being perpetrated by many providers who are too lazy to look up the contracts. In their defense, I know they may have hundreds of contracts and it’s not really feasible to have all this information at their fingertips, but this is no consolation to the HDHP consumer who gets screwed because she or he has no idea what the actual cost is.

In short, I was asked to pay $360, which I begrudgingly did because I had no way of knowing the contracted amount and needed to see the doctor for a follow-up visit. I certainly wouldn’t be allowed to come in for a follow-up if I hadn’t paid for the first visit. They essentially had me over a barrel. When I received my Explanation of Benefits (EOB) several weeks later, it showed the allowed amount for the entire visit was $120. The provider charged me three times the contracted rate, and it took six weeks and three phone calls to the billing department to get my $240 refund. I was told on multiple occasions by the provider that they had not yet received payment and that all refunds were processed on a monthly basis. Not only did they overcharge me, but they enjoyed over a month’s worth of interest on my hard-earned money, which I complained about to the billing manager. She acted surprisingly nonchalant about the amount I was initially charged as if this was no real concern to her.

And, it isn’t, of course, because the bottom line is that unethical providers will collect as much as they can knowing that most consumers are simply too ignorant, sick, or frustrated with the system to demand the fair price. They are not bearing any financial risk when they overcharge patients who comply with their usurious demands. They are no better than the Wall Street fat cats and predatory banks and lenders who are mostly responsible for the economic debacle we’re experiencing right now. And, it’s the little people who are losing. The insurance companies wash their hands of responsibility by stating that contracts are private and cannot be disclosed even to the those whom they directly affect—healthcare consumers.

So, to all the free-market-will-cure-all-of-healthcare’s-ills acolytes, I ask how consumers are supposed to determine the most affordable care if they are not privy to contracted rates and the true costs of services. Sure, some insurance companies have websites showing average costs of care for certain procedures, but these are marginally helpful and inaccessible to a large portion of the population that doesn’t have internet access. Moreover, even knowing the supposed going rate for a particular service does little to help one bargain with a provider who prominently displays a sign in the window stating, “Payment is expected at time of service.” Insurance companies should be legally required to disclose contracted rates for every billable service at the consumer’s request. Likewise, providers should be legally prohibited from charging more than the contracted rates for any billable service. Only then will we have the transparency necessary for the consumer to get a fair shake in determining the best care at the most affordable price.

Out-of-Network, But Not by Choice—How to Get Your OON Care Paid at the INN Rate: Part II

Congratulations! You survived your emergent illness and/or injury, and you’ve been discharged home to convalesce in peace. Not so fast, trooper. You may have gleaned some useful tips from my previous post on getting your OON emergency claims paid at the INN rate, but now you face the even bigger hurdle of getting your medically necessary, non-emergent OON care covered at the INN rate. I know you think that you won’t be using OON providers once you’re discharged because you plan to see your established INN physicians, and hopefully, this is the case. However, there are a few scenarios where access to outpatient INN care is incredibly burdensome and/or nonexistent.

For instance, if you happen to reside in a rural area where there are few healthcare providers (e.g., physicians, laboratories, physical therapists, home health agencies, durable medical equipment [DME], etc.), you could find yourself limited to OON providers. Moreover, your condition may require care from providers that typically aren’t contracted with any insurance companies. These providers are usually highly specialized physicians—hand and retinal surgeons and pediatric neurologists come to mind—or niche service providers, such as prosthetists, infusion companies, and respiratory therapists. These specialty providers are often OON because quite simply, they don’t have to be INN to garner their fair share of patients and healthcare dollars. Their skills are rare and in demand, and thus, they can be reasonably certain that when their services are needed, insurance companies will have no choice but to pay up and handsomely!

So, what recourse do you have if you find yourself facing one of the above scenarios, and the insurance company balks at paying for OON care at the INN rate? You can contact your insurance company’s preauthorization line and ask for a coverage GAP or network exception. You will need to be prepared to explain the extraordinary circumstances that leave you no option but to receive OON care (i.e., that you live in a rural or medically underserved area and/or there are no INN specialists available to treat your condition). The GAP exception request will be reviewed to confirm whether what you are contending is, in fact, true—that your care cannot be furnished by INN providers. If it is approved, you can expect that your OON care will be paid at the INN rate for at least a limited time period.

Insurance companies do not advertise the GAP exception process because they would love nothing more than for poor, ignorant you to believe you have to utilize your OON benefits, or worse, pay whatever the provider charges if you happen to have no OON benefits. The reality is that most companies have policies in place to address true “gaps” in their INN service areas. For example, the large insurer I worked for had the policy that if the nearest INN healthcare provider was located more than 60 miles or 30 minutes drive time from the member’s home address, we were obligated to honor GAP exceptions and pay OON providers at the INN rate. The same goes for treatment from providers like the aforementioned who are generally never INN.

Of course, this does not give you carte blanche to access services not explicitly authorized by the insurer. Just because you received the okay to have OON care at the INN rate from one provider does not mean the same goes for other services. Everything has to be reviewed individually on its own merit. Also, understand that your insurer will never agree to pay for OON charges at the INN rate indefinitely, so do not assume anything, and always request the authorization of services in writing. As always, you will need to remain vigilant in reviewing your EOBs to ensure your claims are being paid correctly going forward. Remember the electronic billing morass I discussed in the previous post? It will continue to be the bane of your existence.

I won’t lie to you. Negotiating the GAP exception process is a bitch, but the alternatives are to fork out your own big bucks (if you’re lucky enough to have discretionary funds) or forego care that could quite possibly save your limbs and life. Aren’t these reasons enough to summon your inner bitch and fight a system that is perfectly content with allowing you to deteriorate and die for lack of affordable treatment? Yeah, so you need one hand to steady your walker. There’s no reason you can’t raise the other and make a call, okay multiple, frustrating calls. You get my point. Stand up for what’s rightfully yours!

Nurse Wannabes: I'm on to You!

I dislike posers of all stripes, but especially those of my own profession. Nothing chaps my hide more than to have a patient haughtily announce that she’s a nurse, too, and come to find out, she’s a medical assistant or a nursing student or worse, is still trying to pass the licensing exam. Word to dumb, dumber, and dumbest—you are not an RN or an LVN/LPN until you pass a licensing exam! So, please do not attempt to intimidate me with your ignorant bravado as I prepare to start your IV. I just might miss and have to stick your poser ass again. It serves you right for defiling the profession.

How do I figure you as a scammer? Well, if it’s not your idiotic, nonsensical chatter about medical conditions you learned about by watching ER and Grey’s Anatomy, then it’s your dyslexic interpretation of commonly used abbreviations in the medical profession. You see, we have our own jargon, and when you massacre it, we know you’re not one of us. Surprise!

I want to give a special shout-out to the woman who prattled on about being a nurse, yet wrote “NDAKF” next to the “Allergies” portion of her medical history form. Nice. I know you were wondering why I inquired about your allergies given your thorough, oh-so-medically-informed, answer. The truth is I’m pretty sure you meant “NKDA,” which refers to “No Known Drug Allergies,” but I just wanted to confirm you weren’t on some higher, more evolved plane of nursedom that I have yet to achieve. Turns out, you weren’t. You were just trying to pass yourself off as one of us, and you failed miserably.

Here’s some advice for next time: know your role and shut your hole! I worked hard to earn my degree and to pass the licensing exam, and I’ll be damned if I’m going to sit by idly while you make a mockery of my profession. Contrary to what you may think, I have a right to question you, especially when I think you don’t know what you’re talking about. Better study up next time, girlfriend. Renegade RN is one hell of an examiner, and you better have your A-game on if you want to play me.

Out-of-Network, But Not by Choice—How to Get Your Emergency Claim Paid at the In-Network Rate: Part I

You collapse at work, and a co-worker calls 911. An ambulance is dispatched to take you to the nearest hospital where you are admitted. While hospitalized, you undergo multiple x-rays and procedures, utilizing the services of radiologists, pathologists, and anesthesiologists—physicians that you will likely never see (while awake, at least) and whose names you probably won’t recognize when you receive their bills. You’re finally discharged to home sweet home, which just happens to be in a far-flung rural area where there are no INN (In-Network) specialists who can treat your condition within a 60 mile radius. You’re understandably shaken by this sudden turn of events in your life, but you’re focused on getting well as quickly as possible, so you can return to work. All is progressing nicely, until multiple EOBs (Explanation-of-Benefits) start arriving in your mailbox indicating that you owe thousands of dollars for OON (Out-of-Network) services that your insurance plan either doesn’t cover at all or covers only at a paltry percentage (e.g., 40-50%). Your stress quotient increases exponentially, and you teeter on the edge of sheer panic at the thought of owing so much to OON healthcare providers that you had no part in choosing due to the emergent nature of your illness and/or the special circumstances involving continuity of care. Moreover, the idea of battling your insurance company on the legitimacy of the astronomical charges while convalescing is enough to send you back to the ER.

As someone who’s intimately familiar with the labyrinthine bureaucracy of health insurance companies, I understand the unfairness of erroneous OON charges to plan members’ bottom lines. I offer the following tips to getting your OON charges justifiably reprocessed at the INN rate:

*Contact your insurance company ASAP about OON charges incurred due to emergency situations. In some cases, claims representatives can simply send your claims for reprocessing with the information you’ve given them. However, in most cases, you will have to appeal the claim in writing following strict guidelines set forth in the EOB. Keep detailed records of dates, times, and names of people you speak to, and send all documents via certified mail.

Insider Information: OON charges are a nightmare with electronic claims processing because the system will automatically deny the charge (in the case of no OON benefits) or apply the OON deductible and rate without noticing that the claim was related to an emergency. The only way to process these claims correctly involves a critically thinking human who manually overrides the system to pay the claim at the INN rate. Profit-driven payers loathe paying humans to perform processes they deem automatable even when it means plan members’ pocketbooks will be harmed. They care about volume, not quality of service or ethics.

For life-threatening situations, insurance companies cannot demand that plan members adhere to INN rules. Plan members cannot be expected to waste time locating an INN ambulance provider, and ambulance providers are often required to transport patients to the nearest facility capable of providing care regardless of its network status. Insurance companies do not advertise that they are obligated to process OON charges incurred due to true emergencies at the plan member’s INN rate because they are counting on you to grumble, but not fight the erroneous charges. When you don’t balk, they win big because the burden of higher costs rests with you, the plan member, not them. If you balk with confidence and perseverance, they will eventually capitulate.

*When you appeal, have all your documents in order and stick to the point. Gather necessary records to prove your case (e.g., a copy of the ambulance provider’s trip report and/or your emergency room evaluation showing your disposition, especially if you were admitted). Write a letter with a concise chronology of the events and make sure to emphasize that given the emergency situation, you had no control over the providers who treated you and that you expect all charges to be reprocessed at the INN rate. Be sure to include copies of all EOBs received, and if the appeal involves faxing, request confirmation of receipt, and always follow-up with an appeal in writing submitted via certified mail.

Insider Information: Insurance companies are incredibly fragmented; they are black holes. You can safely assume your information will be lost multiple times, hence the need to maintain meticulous documentation of all correspondence. Resist the temptation to digress in your appeal. Frankly, most insurance company employees could care less about the injustice of your situation, and they don’t respond to emotional pleas. They work in a profit-driven, amoral industry. The common refrain from insurance company executives is that they are not denying care, only payment, as if care and payment are mutually exclusive in our current system. The insurance company knows damn well that if it denies payment, providers are most likely not going to treat for free. They also know that most people in this situation will be unable to pay out-of-pocket, yet they wash their hands of the moral dilemma. So, save your strength, and stick to the facts. To cut through the red duct tape, ask for a medical director (an MD) to review your case.

*If your appeal is denied, you still have options. If you’re covered under a group plan through your employer and your employer is self-insured, you can appeal to your health plan administrator within your human resources department for assistance with getting your claim processed correctly.

Insider Information: It’s been my experience that when self-insured employers learn of egregious decisions like refusing to cover emergency care at the INN rate, they go to bat for their employees and complain loudly to insurance executives. After all, they’re paying the insurance company to perform all administrative duties, and they don’t take kindly to fielding complaints about poor service that waste their time and resources. When all else fails, contacting your HR department usually leads to a favorable outcome. Just make sure to reveal only as much private medical information as necessary for the particular claim you’re contesting. You don’t want to set off alarm bells with your employer that you are a liability because of increased healthcare costs, either real or perceived.

If you have an individual policy or work for an employer who is fully-insured, your options are more limited and time consuming. You can contact your employer to act as a liaison, but their effect will be minimal because they are probably a small account that has little financial clout with the insurer. And, there may not even be a human resources department to whom you can appeal. You can, however, contact your state agency responsible for regulating insurance companies and file a formal complaint, or you can reach out to your elected representatives to intervene (hopefully) on your behalf.

Clearly, these actions require Herculean effort and saintly patience, and there’s no guarantee of positive resolution. But, if you’re one who believes in principle and you have the physical and emotional strength to keep fighting, please persevere. If you live through getting your OON emergency claims paid at the INN rate, see my next post on how to get OON specialty care at INN rates when there are no INN providers in your service area. The battle continues…

Funny Fridays

The following is an excerpt from a patient’s self-completed medical history questionnaire:

Question: Have you ever been diagnosed with a medical condition or experienced any symptoms not listed on this form?

Patient’s response: “seizures when I was a little kid, but not grandmaw [sic] seizures”

But, what about grandpa seizures? Those are the worst! For the record, it’s grand mal seizures.


An overheard telephone conversation with a patient:

Patient: “I had my tubicle ten years ago, and I need to get it fixed.”

Co-worker: “I’m sorry. Did you say tubicle? What exactly did you have done?”

Patient: “You know, a tubicle, so I can’t have no more kids.”

Co-worker: “Oh, you mean a tubal ligation. Well, the first thing you need to do is have your operative report faxed to our office, so that the doctor can review it and determine if you’re a suitable candidate for the reversal procedure. Then, we can schedule a consultation.”

Patient: “Why do I have to do that? I had a tubicle.”

Renegade RN: “No one doubts that you did, ma’am, but the doctor needs to review your operative report to see how your tubal ligation was done and if he can, in fact, reconstruct your tubes. Have you had any other surgeries on your female organs?”

Patient: “No, just my tubicle.”

Score—Patient: 1, Nurse: 0. Some people you just can’t reach.

This Is Why Nurses Leave the Profession

Incidents like this remind me of why I left the hospital bedside. Granted, we’re told there’s more to the story in this particular case of a nurse who was punished by management for bringing an AWOL patient back to the institution without following some asinine protocol. Perhaps, if management were more forthcoming, I might have a clearer picture of Ms. Diasparra’s alleged transgression and feel differently about the outcome, but I doubt it.

Nurse Joyce Diasparra was on her way home from work when she noticed an escaped patient wandering along a dark road. She didn’t have a cell phone to call for help. Fearing for her safety confronting a potentially unstable and violent patient on her own, she did what any prudent nurse or reasonably sane person would do. She went back to her place of work to summon help. Not only did she enlist the help of the security guard, but she went with him in her vehicle back to the scene, retrieved the patient, and escorted him back to the institution. She could just as easily have passed by the patient without notifying anyone, and she certainly didn’t have to retrieve him herself. This is where we witness the dedication of a 15-year employee and the compassion of a true Good Samaritan.

Apparently, management had other ideas about Diasparra’s behavior. According to them, she broke a cardinal nursing rule of never leaving a patient in an unsafe situation. So, we should expect this lone nurse to coax a potentially dangerous patient into her vehicle, subdue him if necessary, and transport him back to the institution without incident. Does this sound like a safe scenario to anyone? Maybe, she should have just tailed him along the road, flashing her lights and shouting frantically at passer-bys to call 911, until he got agitated enough to run for cover, or maybe even into a line of traffic! Yeah, that makes a lot more sense, since, technically, she would never have left his side and broken the pesky rule.

And, playing devil’s advocate, so she may have pissed the patient off earlier in the day as management contends, and based on his interaction with her (we don’t know), the patient decided to make a run for it. This is all the more reason for her to have left him on the side of the road and kept mum. Trust me, nurses don’t relish caring for—how to put this delicately—“difficult” patients. I’m sure if the two of them butted heads, Diasparra most likely wouldn’t have been jonesing to care for him on her next shift. The bottom line is she upheld her duty to care for the patient when she could have looked the other way, and no one would have been the wiser. Her behavior was reasonable and brave, but since it didn’t conform to a hypothetical ideal, she was punished for it.

Sadly, incidents like this are all too common, especially in healthcare institutional settings where the top brass forgets that nurses are humans who care for other humans under extraordinarily stressful and unpredictable circumstances. Nurses have to assess the situation at hand and make the best decision for the well-being of everyone involved often on a moment’s notice. This means some rules are going to be broken, but when the best interests of the patient are served (as they appear to be in this case), we should all have enough common sense not to penalize people for doing what is right in a society where so many think nothing of doing wrong as long as the wrong hurts someone else.

Administrators, educators, and politicians yammer on about the nursing shortage and how to increase enrollment, recruitment, and retention, but they fail to recognize that this maltreatment of dedicated clinicians leads to sinking morale and burnout that ultimately results in nurses leaving the profession. I respect the need for general policies and procedures, but I want respect for my critical thinking skills and my ethical actions that won’t always fall within the confines of policy. Management needs to pull its hypothetical head out of its bureaucratic ass and demonstrate some common sense in these situations, or risk getting left on the side of the road, at least the next time I pass through.

The People Have Spoken.

And, what a joyful noise they have made! All hail the new Decider, President Barack Obama! I am thrilled for him! I only wish I could have listened in on McCain's concession phone call to a supposed terrorist sympathizer and, gasp, socialist. Now, hopefully, we can get to work cleaning up the messes of the past eight years of sheer debauchery.

I don't agree with some of President Obama's views, particularly on health care. He's just not socialist or godless enough for me! However, I think he's taking steps in the right direction, and I'm willing to take baby steps as long as I'm not being led over a cliff. Eventually though, we need to bring the troops home and declare war on the corporate terrorists like insurance companies and Big Pharma. Now, there's a war worth fighting for! Imagine what could happen if we reappropriate $10 billion per month for this cause. Let the revolution begin.

And, Yet Another Sign of Troubled Financial Times…

Forget the shrinking GDP, increasing unemployment, and imploding financial institutions, there are far more telling indicators of the current economic crisis in the exam room. Yesterday, my co-worker watched from afar as a patient stuffed her purse with maxi pads and pilfered through the exam room drawers until she found a box of gloves, which she then attempted to stuff in another bag, until the co-worker intervened. Here’s how the confrontation played out:

Co-worker: “Ma’am, you’re welcome to take a couple of maxi pads, but we need the rest for other patients. Please put them back.”

Patient: “But, I need them.”

Co-worker: “Yes, I understand, and that’s why I want you to take a couple, but we can’t supply you with a whole box worth. And, you need to put the gloves back, as well.”

Patient: “But, I need them.”

Co-worker: “What do you need a box of exam gloves for?”

Patient (haughtily): “I need to clean my house, and I paid for my procedure.”

Co-worker (incredulous and exasperated): “Well, you can buy a box for a buck at the Dollar Store. We need the gloves to take care of other patients, and they’re not included in the cost of your visit today. Please put them back now.”

The patient complied and left the office in a huff. People are desperate, and desperate times call for desperate measures, I guess. I’m inclined to think that if someone is scamming feminine hygiene products, she probably really needs them, so I don’t fault her too much—only for her blatant disregard of other patients like herself who might like to have just one of the multiple pads she pocketed. But, the gloves, come on! The nerve of some folks is truly priceless.

All is Unfair in Love and Healthcare

I mentioned in an earlier post that I loved my HDHP and associated H.S.A., so far. Well, after reading this article, my mood has soured, since I feel like I’m getting shafted simply for being female. I’m healthy and don’t utilize any health services other than preventative care on an annual basis. In fact, my insurance company hasn’t paid one cent in claims since my individual policy became effective on January 1st of this year, and they most likely won’t given that I have to pay out-of-pocket, even for well-care, until I’ve reached my $2500 deductible. I bypass them completely for the one prescription medication I take because I can get a far better deal from Walgreen’s 90-day plan for $12 (with an annual membership) than I would with the insurer’s negotiated price, so they aren’t incurring any costs here. Essentially, my insurer will make a $1740 profit off me for 2008, which represents a cumulative twelve months of premiums debited from my checking account. They’re clever enough not to accept credit cards for payment, so they aren’t facing a 2-3% skimming charge for premiums paid.

Now, I’m aware that my insurance premiums are fairly low for a mid-30s female. But, as the article points out, I do not have maternity coverage that drives up the cost of care for women in their child-bearing years. I also don’t have mental health coverage, another expensive benefit that insurers restrict heavily for both sexes. So, I’m not sure how my insurer justifies charging me a much higher premium than a man my age and with a similar health status on account that I’m a woman in an age class with a higher utilization rate. Hello! I can’t utilize the frickin’ benefits for which I’m supposedly being charged the higher premium. And, why do insurance companies push routine care as a cost-containment strategy, if they’re just going to punish those who heed the calls for regular check-ups and primary care more frequently (women) than those who don’t (men). Yes, in general, men are less likely to seek routine care, but why should this derelict behavior be rewarded with financial incentives (i.e., lower premiums)? It’s only going to cost us all more in the end when the men show up in an ER near death because they’ve neglected their health until the moment of crisis.

I am so tired of the backassward logic that permeates the healthcare industry where all the players tout the benefits of preventative and routine care, yet dump the financial ramifications on the shoulders of compliant patients who are trying their best to stay healthy and avoid unnecessary use of the healthcare system. Does nobody in politics understand the basic problem with our healthcare system—that true health is not rewarded, but illness is? Is nobody concerned about the dismal inequities in quality of care? Has no one caught on to the fact that competition within the industry has not resulted in decreased costs? Does no one care about widespread sex discrimination in the individual health coverage market where everyone is literally at the corporate players’ mercy? Hmm, I guess this rant makes me sound like a socialist. Well, if believing in fundamental egalitarianism within the healthcare system (and all aspects of life) is socialist, then sign me up!

When Checking Your In-Box Means Checking Your Box, Literally

If you received an e-mail stating that you needed to get checked for STIs (sexually transmitted infections) because someone you slept with in the past has been diagnosed, would you disregard it as spam or a practical, malicious joke, or would you hightail it to the nearest clinic? According to this article, the public health website, Inspot.org, enables those diagnosed with STIs to send e-mails to former sex partners in various cities. E-mails can be sent anonymously, hence my question. Given the level of denial and grief I deal with when notifying patients by phone that they have an STI, I wonder if e-mail recipients from anonymous senders would take the message seriously. I also think there’s a high likelihood that the site will be abused by jilted lovers and pranksters, even though its FAQ section expressly discourages insincere behavior.

This seems like a novel approach to notifying people of their possible exposure that may prove worthwhile. The site will even forward local health resource information along with the “you-may-have-been-exposed” message. I’m all for embracing technology when it’s used to truly empower people, giving them relevant health information in a clear and concise manner, along with cost-effective resources to address the issues.

Still, I think e-mail is a pretty impersonal venue for telling someone you may have exposed them to an STI, clearly if it’s sent anonymously. Yes, maybe the exposure occurred during a hook-up or one night stand, but I think you still owe that person an honest and overt conversation. It’s a simple issue of respect. At least, that’s what I hear in the tearful conversations I have with patients about their STI status. Of course, if we’re talking about a single encounter, you may not have any way of contacting the person other than by e-mail address, which you can often find with a quick Google Search. And, there’s always the issue of outreach to those who do not have access to the internet or telephone service—the working poor, homeless, and prison populations—that will require additional funding and innovative, community-based efforts to promote sexual health.

In the meantime, I’m curious to see whether this mode of notification takes off. Who knows? Given the current obsession with texting, maybe we can just bypass email altogether. I bet receiving “U got the clap! TTYL!” in their inboxes will distract some people for at least a moment or two, hopefully long enough to get them to contact their physician or clinic ASAP.

A Message to Self-Insured Employers: Just Say No to the Disease Management Sales Pitch

A few posts ago I warned readers about the perils of offering up their personal health information to a nurse calling from their insurance company or some organization affiliated with their employer’s health plan initiative. At the end of this post, I promised a future discussion of how self-insured employers pay lip service to the health promotion paradigm by implementing these so-called health promotion programs that are usually provided by the insurance company in tandem with claims management services or are outsourced to stand-alone disease management companies. These programs usually entail regular telephonic outreach to at-risk members (identified by claims data and contact with the system through preauthorization) where nurses or other health professionals educate plan members on their benefits and encourage them to get preventative care and remain compliant with cost-effective treatment regimens. There is also a big emphasis on smoking cessation, weight loss, exercise, and stress management—all laudable goals. By purchasing these disease management/health promotion programs, the self-insured employer’s expectations are that they will enjoy decreased healthcare costs overall and greater presenteeism from a well workforce. At least, this is the sales pitch they’ve swallowed without question.

Here’s the truth from someone who actually worked in disease management and telephonic outreach: these programs don’t work. Why? Well, for one, employees are far too busy with work and family issues to talk on the telephone to random persons, even nurses, especially about their sensitive medical information. The ones we do reach are often rightfully wary of speaking with someone from their insurance company who is also pushing wellness initiatives from their employer. They get the suspicious connection and are unreceptive to our wellness cheerleading tactics. Moreover, stressed-out workers suffer from the same illness paradigm that infects the entire healthcare system, and they often don’t seek care until their condition is urgent due to costly deductibles and co-pays, concerns about missing work, and cultural considerations, such as language barriers. So, here we have a situation in which the employer has paid, perhaps, millions of dollars to an insurance company to provide ineffective disease management services, money that could have easily gone into reserve for future spikes in healthcare costs are better yet, used to implement sweeping organizational changes on an internal level that would have far greater impact on long-term workforce health. What type of changes?

How about a sound investment in employee health through the widespread provision of onsite clinics where members can seek routine care without leaving work, including regular blood pressure checks, blood sugar monitoring, and pap smears? How about working with executives to implement a wellness paradigm that encompasses all aspects of the organization, including nutrition services? Yes, this means ridding the cafeteria and vending machines of all junk for staff and visitors. How about investing in onsite exercise facilities or subsidies for local gyms, yoga and exercise studios, or home equipment vouchers? How about instituting your own disease management program in which your own employees advertise wellness initiatives to their colleagues? How about mandating top-down involvement where your top brass actively participate in the programs and promote them to employees, instead of hiding out in their executive suites stuffing dingdongs into their already expansive waistlines and wringing their hands over spiraling healthcare costs? There’s nothing like modeling the behavior you want to see in others.

Are these radical propositions? Absolutely, but true transformation never comes from half-ass changes. And, that’s what I’ve seen time and again from the self-insured employer community. They all want to jump on the health promotion bandwagon, so they lap up the delusional “we-can-make-it-all-better” Kool-Aid served by the insurance companies who dazzle administrators with charts and figures that promise a huge ROI if only they purchase additional disease management services along with claims administration. With visions of saved dollar signs dancing in their eyes, employers sign on the dotted line and offer up the cash that will find its way into insurance executives’ deep pockets while their workforce grows sicker.

Self-insured employers, I’m surprised and appalled by your failure to see through this expensive, yet worthless charade. I know you’re desperate to control your healthcare costs and stay competitive. I know your own bosses are breathing down your necks to get this issue under control, but come on! Do you actually believe a bunch of nurses or other health professionals calling and borderline harassing your employees is going to bring your long-term costs down in any meaningful way? Puuhhlease. If I could get people to stop smoking, lose weight, exercise, and go to therapy just by calling them and praising the benefits of wellness, I wouldn’t be working for an insurance company. I’d be the next Tony Robbins or certainly a wealthy, healthy televangelist. Moreover, do you really think a bunch of overweight, stressed out, heavily medicated nurses can motivate your overweight, stressed out, heavily medicated employees to turn their lives around in a few phone chats? If so, then please pass that Kool-Aid.

Employers, I implore you to resist the insurance companies’ tantalizing sales pitch that they can help control costs even more if you pony up mega cash for their disease management programs. Trust me, the insurance sales posse is clueless about the logistical nightmares associated with implementing such a program, and since it won’t be their problem once the deal is done, they won’t be accountable. They’ll simply blame the nurse team for not doing their job, you know the job of magically changing human behavior with the snap of our just-as-fat fingers. Ridiculous!

Please, employers, when you go into contract negotiations with your insurance carrier, don’t fall for the “disease management-will-solve-all-your-problems” presentation. I guarantee it’ll be one slick performance you’ll have to resist. After all, everyone else is doing it, and all Gods forbid, you buck convention and do something truly transformative, like investing directly in your employees’ health instead of relying on a middleman who’s ultimate motive is shoring up his bottom line. Leave your rose-colored glasses at home, use the brain that actually got you in the position of negotiating insurance coverage for your company, and just say no to this useless frill. Oh, and it helps to bring your own drink.

Dear God: Please Tell Your Followers to Stay on Their Medication. Amen.

This article almost made me drop to my knees and pray for divine intervention if I weren’t so spitting mad about the sheer insanity (pun intended) of the subject matter. A recent study of 293 Christian church members who sought help from clergy regarding their own or a family member’s previously diagnosed mental illness revealed that almost 1/3 of them were told that they really didn’t have a mental illness. One expert quoted in the article contends that clergy are also advising people to stop taking their psychotropic medication, which is—HELLO—a huge health risk for the individual and the public at large! Have we all not sat riveted in front of the television as a number of cases have unfolded in which psychotic individuals, usually women with a history of psychiatric problems and relationships with abusive, controlling spouses and fanatical churches, have gruesomely killed their children out of some religious delusion mistaken as God’s command. I can think of two cases here in Texas—Andrea Yates and Dena Schlosser—in which each woman had a documented history of psychiatric problems, including postpartum depression compounded by multiple pregnancies, cessation of medication that eased symptoms, and adherence to strict gender roles within the family. Last but not least, both women were linked with fundamentalist, bordering on cult-like, religious sects. Schlosser’s pastor, Doyle Davidson, preached that mental illness was caused by demons and curable only by God. These cases are extreme, but they definitely illustrate the danger of counseling vulnerable individuals to disavow a mental illness diagnosis and cease medical treatment.

Clergy who adhere to belief systems that do not recognize the validity of mental illness are abusing their power as counselors, spiritual or otherwise, when vulnerable parishioners come to them for help. Clergy may be the only source of counseling for people who lack insurance or cannot afford their mental health co-pays. I fear that with our ever-weakening economy more and more people will turn to their churches for help on so many levels, none the least of which will be counseling for psychological stressors that precipitate and/or worsen the debilitating effects of mental illness. The aforementioned article also cites a Baylor study in which researchers found women’s mental problems were more likely to be dismissed by clergy. Well, this is no revelation to me as we women tend toward the hysterical anyway, and if we’d all just shut up, mind our husbands, and crank out progeny for the Lord’s flock, we could drive those demons right out of our pretty little heads. I hear exorcism works, too.

I don’t mean to totally denigrate spiritual counseling. I support those who choose it to enhance their every day lives, but make no mistake, it is NO substitute for therapeutic evaluation and counseling by a licensed mental health provider. And, clergy have no professional authority to recommend individuals stop taking prescribed psychotropic medication. Exploiting people’s religious faith to further the church’s antiquated agenda at a time when they desperately need humane, non-stigmatizing mental health treatment is morally reprehensible and spiritually offensive. I think these clergy could use some mental health treatment themselves for harboring grandiose delusions that they speak for God. Then, again maybe they’re just imbibing too much of the Communion wine. Whatever the case, the shepherds are clearly out of line. God, I pray you put them in check.

What to Expect When You Expect to Get Screwed Anyway: Tips on Navigating the Individual Health Insurance Market

Whether your current employer doesn’t offer health insurance, your COBRA’s about to expire, or you’re self-employed, applying for individual health coverage can be a confusing and intimidating task. In this market, there’s no one to hold your hand or offer a standard policy with clear premiums set in stone for the upcoming year. No matter your individual circumstances, you must be prepared to invest significant time and energy in choosing an appropriate plan. I offer the following tips to help you achieve the best outcome:

•The individual healthcare coverage market is one big quagmire of choices. It pays to do substantial research, and nothing beats the internet. Ehealthinsurance.com allows you to compare multiple plans side by side with ballpark quotes based on your age, sex, smoking status, and geographic location. You can also apply on-line, which allows the tedious underwriting process to begin more quickly. If you enlist the help of an individual agent, keep in mind that they may not be very knowledgeable about the plans they sell, and they have a financial incentive to push specific plans regardless of their impact on your bottom line.

•You are your own best guide. Decide what your healthcare priorities are, and choose your plan accordingly. Conventional wisdom holds that you buy the most expensive coverage you can afford, and in general, the higher the monthly premium, the lower the deductible, co-pay, and coinsurance amounts. However, so-called traditional plans with low deductibles and co-pays that you may have enjoyed through an employer-sponsored group plan are falling by the wayside for individual policy holders. They’re incredibly expensive, and insurers often don’t want to take the risk that you’ll use (or abuse, in insurance speak) your health plan too much and cost them more than they’re collecting in premiums. Having a good grasp of your past healthcare expenditures and current health status is critical when choosing an individual plan. If you are young, rarely get sick, and cannot afford a large premium, a high deductible health plan (HDHP) with a health savings account (HSA) may be the better choice, whereas if you have a chronic condition or have children who need frequent check-ups and prescriptions, it makes more sense to pay the higher monthly premium in exchange for lower expenses. The bottom line is you have to run the numbers to see what works best for you and your family. Don’t just guess; it could cost you dearly.

•Know the network status of your current healthcare providers. If you want to stick with your providers, check their network status with your proposed plans before applying. Most insurers have websites where you can check network status, but it pays to contact providers directly as websites and/or printed materials are often outdated. Also, by speaking directly with a provider, you may find that s/he doesn’t plan to renew his or her contract. You certainly don’t want to find this out in retrospect. Also, check the status of hospitals and outpatient facilities in your area, including any ancillary providers that you may use on a routine basis, such as pharmacies, physical therapists, laboratory, and radiology facilities.

•Complete the application thoroughly and honestly. Be prepared to write a thesis. Now is not the time to fudge your height, weight, smoking, or drinking status. It’s also not the time to disregard instructions or become lax about recording every single health problem you’ve ever had in your entire life or every reason you’ve visited the doctor in the last ten years. It’s tedious, yes, but if you are lazy or sloppy in your answers, the insurers regard your sloth as fraud because they will compare your answers to medical records collected from every single provider you’ve ever seen, and if there are discrepancies, you are essentially deemed a liar. Furthermore, if you fail to disclose having seen some providers, the insurers may already have access to your records anyway through large electronic databases that track and hold medical information for just this purpose—underwriting people for individual healthcare coverage and life insurance policies. You’ll pay a stiff penalty for inattention to detail. You could be denied outright, which will make it harder for you to obtain coverage through another insurer, or worse, you could be approved, incur a bunch of claims and then have your coverage rescinded retroactively because the insurer starts checking further into your records and finds that you failed to disclose a pre-existing condition.

•Be prepared for multiple exclusions, pre-existing clauses, and a higher final quote. State laws vary on individual health coverage, but generally, these policies are not required to offer some services that are standard on group plans, such as mental health or maternity coverage. Some may offer the services through expensive riders that individuals must request upfront. Inevitably, the insurer will find some pre-existing condition, and you can expect a non-coverage clause of at least one year. Some insurers will waive the non-coverage period if a member can prove s/he had coverage for the prior 18 months with no gaps in coverage. Others will not. In any case, your premium quote will most likely be increase based on this pre-existing condition even though the condition will not be covered in the beginning or ever.

•Pick up the phone and read your mail in a timely fashion. Insurance companies will often outsource the data entry of your application, as well as the collection and analysis of your medical records. You may get a call to answer questions about the information on your application or for help in getting records from your providers. If you want the coverage decision process to flow as efficiently as possible, you must take these calls. The callers do identify themselves and will ask specific questions about your application, so you can feel assured it isn’t some random person mining your personal medical info. Also, when a decision is made, it’s communicated in written fashion, and the individual has a limited time period in which s/he can accept the terms of coverage and pay the assigned premium. If you’re one of those people who reads his or her mail every few weeks, you’ll want to change this habit immediately. If you fail to meet the insurer’s deadline, you could find yourself without coverage and having to start the underwriting process all over again.

I should also mention that if you receive a copy of your original application either on-line or in the mail, you should hold onto it for dear life. For one, you can refer to it if there are ever questions about its original content in the event a claim dispute arises. More importantly, if you ever need to reapply for individual coverage in the future, you will save yourself immeasurable time in recording your medical history on the new application. And, one final tip—Once you’re approved (hopefully), I recommend signing up for automatic bank draft of your monthly or quarterly premiums, so you can avoid any unintentional lapses in coverage due to snail mail snafus.

Women Who Get Sterilized and Live to Lie About It

“PATIENT’S HUSBAND DOES NOT KNOW SHE HAD A TUBAL LIGATION.” This statement is written in big red letters across the patient’s chart, and I’m thinking, WTF? The patient has come for a consultation about getting her tubal ligation reversed in hopes of becoming pregnant again with her new beaux. He’s with her and will be joining her in the exam room, and somehow, we clinicians must concoct a charade that glosses over the fact that she willfully tied her tubes in the past as we explain the reversal procedure.

I don’t know which aspect of this scenario troubles me most. First, she has lied to her husband/boyfriend/baby daddy/partner about her fertility in a pretty emphatic way. Perhaps, she’s afraid he won’t stay with her if she can’t bear his child, never mind the fact that she already has four and is fast approaching 40. Whatever, this is no excuse for the idiotic ruse in which we all now have to participate to protect her privacy of lies. What is she thinking? That they’ll try to get pregnant for a few months, and when nothing happens, seek treatment. Does she plan this strategy out in advance? That’s pretty damn manipulative. Does she tell him, “Oh, I know it’s me. I had some problems in the past…I’m all messed up down there, blah, blah, blah,” which brings me to my next disturbing thought.

Is he just too stupid, ignorant, or indifferent to ask questions about how she got “all messed up down there” in the first place? Does he not think it’s weird that her fallopian tubes need to be “reattached” as if it’s normal for women’s tubes to magically tie, and in some cases, cut and cauterize themselves? Why would any woman want to be with such a clueless man? Is she so overcome with baby-phoria that she cannot comprehend the pathetic gene cesspool she’s about to dive into?

I suppose what unnerves me the most about this situation, aside from the possibility that an innocent child could be the result of this fabricated union, is the fact that so many people have been forced into this ridiculous ruse and been made to put on Broadway-worthy performances to conceal a simple medical truth. This patient has taken advantage of our duty to protect her privacy in a brazen way, and I am disgusted by her penchant for drama. She drags her significant other along for moral support as we creatively address the “baffling” problems with her tubes and how we’re going to fix them. Moral, my ass! What did I say a few posts back about bringing someone whom you don’t want to know your full medical history into the exam room? Just. Don’t. Do. It.

The truly sad thing here is that this scenario is not an isolated incident. It happens often enough to keep me in such a heightened state of agitation, I feel compelled to write about it in an effort to assuage my vindictive tendencies. Still, I’m a big believer in karma. I suppose I’ll bide my time until this woman and her lying cohorts’ come in with a strange discharge that turns up positive for Chlamydia or Gonorrhea or Trichomoniasis, and then I’ll call and tell her in very explicit terms exactly how these illnesses are contracted and listen to her wax histrionic over how this could possibly be happening to her, for about two seconds. Then, I’ll curtly ask for a pharmacy phone number, tell her that her partner needs treatment by his own physician, no sex for three weeks, and hang up the phone—no sympathy, no “oh, poor-you,” absolutely no dancing around the sexually transmitted infection facts. I can’t imagine how she’ll worm her way through this one. Then again, she’ll more than likely tell him it’s some random infection like a cold in your vagina, and he’s too stupid—or, is it smart—to ask any questions, and she’s probably already knocked up anyway, which means I should just start drinking more and thinking less and accept the fact that the future will be procreated, in part, by liars and fools.

Even the Healthcare Till is Feeling the Financial Squeeze

In keeping with my concern about patients getting the shaft for physicians’ bottom lines, here’s an article that erases any doubts that the healthcare industry will weather the current economic crisis unscathed. According to the article, older physicians may delay retirement due to major losses in their retirement plans, which may alleviate immediate physician shortages in some areas, but may also result in those physicians being less likely to treat uninsured or underinsured patients, including Medicare and Medicaid, because the profit margin is so low or even nil. Also, aspiring physicians may find they cannot secure the loans necessary to enter or complete medical school with the credit squeeze, which could worsen the physician shortage in the long-term. Of particular concern is the abandonment of primary care for more lucrative specialties when primary care is where the most disease prevention and health promotion measures take place, essentially where the most bang for the healthcare buck is generated. And, of course, many hospitals are halting massive expansion projects for lack of credit, which is bad for their bottom lines because the more ill people they can admit, the more reimbursement they get.

The central problem here is that all these healthcare players’ financial destinies are linked to treating illness, and they need a steady supply of sick bodies to ensure their livelihoods. Insurance companies don’t pay well, if at all, for preventative care, and they certainly don’t pay hospitals for patients who never use their services. For all the grandiose talk about disease prevention that spews from hospital’s marketing departments and physicians mouths when they talk to wayward patients, there’s no financial incentive for physicians or hospitals to keep their patients well. It’s a delicate paradox because both patients who are too sick and too well are financial losers for physicians and hospitals. If they’re too sick, the costs of their care will outstrip the reimbursement rates, and if they’re too well, they show up maybe for an annual physical that is time intensive and poorly remunerated. The best financial scenario for the players is to maintain patients in a holding pattern of manageable sickness where they need care on a predictable basis. Am I saying that physicians and hospitals actually try to keep patients sick? No, but by complacently participating in a for-profit healthcare system that rewards treatment rather than prevention, they’re serving their bottom lines first and foremost, not patients and long-term public health.

The aforementioned article focuses on the economy’s impact on physicians and hospitals and totally ignores nurses and ancillary personnel that perform the majority of actual care within the industry. We certainly aren’t immune to the economy’s effects. Like older physicians, older nurses may have to stay on the job longer to recoup 401K losses, which might temper the ever-growing nursing shortage in the short-term. But, if nursing students can’t secure funding for their educations, there will be fewer nurses in the workforce in the long-term, which translates into harder, more stressful work at the bedside that ultimately increases the likelihood of injury, burnout, and job attrition for both new and seasoned nurses. And, even though the financial status of our patients doesn’t immediately determine our bottom line, like the bigger players, we’re caught in the same nonsensical illness paradigm that ensures we’ll have jobs, particularly in hospitals, for years to come if only our bodies can withstand the increased workload and of course, we don’t become ill ourselves. With the time-is-money dragon breathing down our necks, the endless paperwork, and the pressing needs of an even sicker patient down the hall, we have little time to spend on educating and empowering patients to make informed decisions about their health and positive behavioral changes.

What our adherence to this illness paradigm ensures is the continuation of a healthcare system with runaway costs, unjust delivery of care, and poor quality outcomes. A select few will find ways to get wealthier while the masses grow unhealthier. Envisioning a different system is difficult, I realize. But, it’s time we face the situation and swallow the bitter pill of change. We definitely need a new drug, one that we collectively create and market ourselves because given the zero profit factor, I’m certain Big Pharma isn’t up to the challenge. Are you?

Everybody’s Got A Hand in the Healthcare Till

Yesterday afternoon I witnessed firsthand the maneuvering that some physicians will resort to in an effort to increase their revenue, even though it results in greater costs to patients. The issue was over providing anesthesia for a surgical procedure that can be performed in the office setting, a surgical procedure that does not necessarily require an anesthesiologist’s presence. The anesthesiologist’s pitch to my employing physician involved hyping one particular type of device that enables the physician to finish the procedure very quickly, in about eight minutes. However, using this particular device results in more pain for the patient, thus requiring deep IV sedation administered by an anesthesiologist. The anesthesiologist has a cozy working relationship with the vendor of the aforementioned device. In fact, they basically go around to physician offices as a team assisting with these procedures.

The issue is that there’s another device on the market that was designed specifically for the office setting. It does not cause significant pain, thus obviating the need for anesthesia. It does, however, take thirty minutes to complete. A representative for this device was also present yesterday afternoon, but she could barely get a word in edgewise with the anesthesiologist’s blowhard antics about how “risky” this procedure is without anesthesia personnel present, irrespective of the device used, and how much easier it is to do the procedure with anesthesia. Well, yeah, it’s always “easier” dealing with an unconscious patient. You just move him or her around like a piece of meat. You don’t have to listen to complaints or answer any pesky questions. Basically, you don’t have to interact in a meaningful way. It’s a very paternalistic and disempowering approach to healthcare, and it’s common among physicians.

I could tell my employer was convinced by the anesthesiologist’s charming promises of more money for all parties involved, less time, and compliant (i.e., gorked-out-of-their mind) patients. He quickly dismissed the representative for the alternative device by asking her to leave the brochure and studies for his review. He’s a big fan of quick procedures with patients so sedated they’re practically comatose. I’ve had problems with this since the beginning, and I no longer assist with procedures.

I don’t agree with sedating patients unless it’s absolutely necessary, and I certainly don’t advocate deep IV sedation or general anesthesia for a procedure that can be performed just as well without it, albeit in a lengthier timeframe. I think there are too many risks involved with anesthesia to consider it so lightly, and it’s no consolation to me, despite the anesthesiologist’s enthusiasm, that she’s right there to help if a patient stops breathing or drops their blood pressure. Keep in mind, we’re still in an office setting, and just like everyone else outside the hospital, we have to dial 911. And, no, I don’t advocate having patients gnaw on a leather strap when they undergo procedures, but there are far less risky and less costly oral and local medications that can be administered for simple surgical procedures.

Speaking of costs, the anesthesiologist casually mentioned that her hourly rate is $700-800. Oh, and there’s a one hour minimum charge per patient. So, now, not only are we dealing with unwarranted anesthesia (since the procedure can be performed just as safely with the alternative device), but we’ve added a new outrageous layer of costs for the patient to assume. Of course, insurance will pay the anesthesia charge, at least until they wise up to the fact that there’s an alternative method that doesn’t require it. But, patients will still be responsible for unmet deductibles and co-insurance for charges that weren’t absolutely necessary.

It’s a real shame that this procedure and many others across medical specialties are described to uninformed patients by entrusted physicians as “better” because they take less time, and anesthesia means “You won’t feel a thing!” The truth is that there are limited healthcare funds available, and the main players are quite creative when it comes to squeezing all they can out of every single encounter. I’m not saying that care is being compromised on a wide scale, but I do think it’s overdone in a way that is potentially harmful to patients’ health and pocketbooks all in the name of provider profit. Patients really need to do their own research and ask probing questions about any strongly suggested treatments because chances are, they’re getting a sales pitch that favors the physician's bottom line.

Say It Isn't Socialism, But What's the Point?

One thing I forgot to mention about the healthcare reform rally I attended this past weekend was several speakers’ insistence that universal, single-payer health coverage is NOT socialism. I believe the exact refrain was “publicly financed, privately provided.” I was confused at first about why they felt it necessary to include this remark in their speeches—I guess for the benefit of any non-liberals in the imposing crowd of 50? I don’t have the typical American aversion to all things socialist, so I don’t feel inclined to defend my political stance against the charge. Apparently, the speakers didn’t feel this way.

I don’t understand the widespread disdain for some degree of socialized medicine in the U.S. given the gross inequities of our market-based system. Sure, I’m well aware of the horror stories of lengthy wait times and extreme care rationing in the U.K. and Canada that critics love to trot before our eyes whenever anyone even suggests we need a national plan that covers all residents. I also believe a publicly financed system might somewhat stifle our turbo-paced quest for innovative miracle drugs and technology. But, I fail to recognize what’s so miraculous about innovations that are extraordinarily costly, few and far between, and beneficial only to those who can afford them.

And, it’s not like we don’t have lengthy wait times here. In fact, you’ll wait until you’re damn near dead if you don’t have insurance. If you are insured, you’ll put off routine care with your “consumer-driven” health plan because you can’t afford your high deductible and coinsurance. Eventually, you’ll risk an unnoticed death in an ER overcrowded with the uninsured and under-insured who, by the way, aren’t really uninsured because they can always come to the ER for care, which they have in great numbers.

Oh, and care rationing is alive and kicking fiercely in our current system. Private insurers have their thumbs on all contracted providers. Take a look at your current health plan and note the number of limits and maximums in place. Anything short of a life-threatening emergency requires preauthorization. You think you’ve got choices, but you really don’t unless you’ve got the cash to buy your way out of the contract.

I suppose what it boils down to is that a lot of rich players stand to lose big if the government (i.e., the people) decides to, ahem, redistribute the concentrated wealth of the healthcare system to benefit everyone. Where will this wealth come from? Well, Big Pharma will have to learn to live off its bloated profits for a while because significant negotiation will drive drug prices down. Corporate hospital systems, if they want to survive, will have to get back to the basics of providing quality care to everyone in the community rather than investing in hotel and spa-like amenities to attract the rich. Private insurers will have to retrain themselves to provide some other service. Physicians will have to re-evaluate whether they’re really committed to health promotion and prevention when they’ll no longer be financially rewarded for service volume, but for quality of service.

Here’s a thought—let’s socialize the U.S. healthcare system with ruthless efficiency. The rich players will bleed out of the system; the market will adjust itself, right? Let’s make healthcare a right and a responsibility, but let’s get one thing straight. The only people who abhor socialism are those who are rich enough to buy their way out of the social contract and those who’ve been duped into believing they just might have a chance in proverbial-Hell of doing the same if only they’d suck it up and work harder. The truth is that the latter will continue dying early, needless deaths from inadequate care while the former will continue clucking their tongues at such a tragedy and championing individual responsibility as a cure for every conceivable social ill.

The injustice makes me sick. There’s no need for healthcare reformers to pander to the haters. You can’t wink your way around them. Deep down, it doesn’t matter what you call your plan because if you believe in healthcare justice for all, you will be labeled a socialist. And, right about now, a socialist isn’t such a bad thing to be.

Just Telling It Like It Is

1) A tubal ligation can be reversed; a hysterectomy cannot. But, if certain people get elected, we will certainly revisit this issue because any civilized, democratic society will make sure its women never do anything to interfere with their “natural” childbearing capacities for any reason, age or medical conditions be damned!

2) There’s a lot of stuff between a woman’s legs—a clitoris, urethra, vagina, vulva, anus, etc. Referring to your “stuff” when describing a symptom is not helpful. Telling me your “stuff is messed up” or your “stuff be hurtin’” or “somethin’ be all up in your stuff” does nothing to help me pinpoint your problem. Furthermore, I don’t want to play Where’s Waldo in your genitalia. Learn the proper names of your anatomy!

3) People lie; sonograms don’t lie. When your teenage daughter tells you she had sex for the first time two months ago, and the sonogram reveals she’s six months pregnant, please don’t pester me about how this can be possible since she only had sex two months ago. Think about it.

4) The “tip” of the penis is the most dangerous part. Once the tip is in, there’s no going back. For those of you shrugging your shoulders in disbelief that you are pregnant when “he only put the tip in,” you've just learned a hard lesson. Let's hear it for abstinence-only education!

5) There is no anti-aging medicine for your ovaries, and you are not entitled to pregnancy. You may not look your age thanks to Botox, but your eggs are still 45 years-old. Deal with it, please.

A Few Houstonians Rally for Universal Health Care…Sigh.

Yesterday I attended an underwhelming rally for universal, single payer health coverage at the City Hall Reflection Pond in downtown Houston. In a city of approximately 2 million, about 50 people gathered to hear from citizen activists and various organizations about House Resolution 676, a congressional bill introduced in 2005 that would establish a single payer, national health insurance program for all U. S. residents. I wholeheartedly support the cause, but I left the two-hour rally before it ended feeling dejected. I couldn’t help but think that despite the fact that many ordinary individuals admit that our current system is broken and unjust, if this tiny, ineffectual rally is all we can come up with to demand change, we’re doomed. I was reminded of Rage Against the Machine’s lyrics in “Sleep Now in the Fire”—“So raise your fists and march around, just don’t take what you need.” At this rate, we few are going to die in some fairly deserted public space, martyrs to our cause, the only dignity being our upraised fists stiffened by rigor mortis. What can we do better?

First, we must do a better job of getting the word out. I learned of this rally only by chance. I attended a lecture at the Rothko Chapel this past Tuesday and happened to overhear a woman asking an employee if she could pass out postcards about a healthcare rally. The employee told her this was not possible without the university’s permission. I stepped forward and asked for a postcard. I consider myself a fairly well-informed citizen who actively seeks local political and cultural events to attend, but I hadn’t seen this rally advertised anywhere. Basically, if you weren’t a member or supporter of one of the coalition organizations staging the event, you probably wouldn’t have known about it. I think this helps explains the low turnout. I understand that advertising takes critical funds from already cash-strapped nonprofits, but I believe this type of event is where extensive grass-roots mobilization efforts are most effective. You’ve got to send your people out on the street to interact with the public. To her credit, the woman at Rothko Chapel tried to do this, but was stopped short by the institution’s policies with which the coalition could have gained compliance by planning ahead.

Second, can we get a little organization, please? I realize some degree of disorganization is bound to occur whenever various groups come together for a commonly supported cause. The inevitable hazard is that everyone remains a little too wedded to his or her own cause and has a difficult time tying it into the bigger picture. In this rally’s case, there were representatives from Health Care For All Texas, NARAL Pro-Choice Texas, Healthy Women, Healthy Families, the Harris County Green Party, the Sierra Club’s local chapter, a small group of Houston nurses lobbying for collective bargaining agreements for Texas nurses and mandated staffing ratios, and an anti-death penalty group and various other organizations whose names I cannot recall. For the most part, speakers stuck to the healthcare reform script, but some wandered in their speeches and/or danced around sensitive topics. For instance, the moderator of the event mispronounced “NARAL” and introduced the speaker as having come “all the way from Naral, Texas” as if NARAL were some faraway town (like Austin), which led me to believe he didn’t have a clue about the organization. To make matters worse, the NARAL speaker did everything she could to avoid saying the word “abortion,” preferring instead to make repetitious, bland statements about the hardships endured by Texas women who lack access to reproductive healthcare. Granted, NARAL has recently and rightly (in my opinion) changed its strategy to encompass a more holistic view of women’s reproductive health with as much emphasis on supporting women who choose to carry their pregnancies to term as those who choose to exercise their right to abortion. Still, access to safe and legal abortion, as well as reproductive health screenings and birth control are huge women’s health issues, and I felt she could have done a much more passionate job of tying these access issues into the larger picture of universal, single payer health coverage. Meanwhile, anti-death penalty activists were passing out flyers that did not address inhumane healthcare conditions in prisons, nor access problems faced by parolees. I mean no disrespect to their cause, but where was the tie-in to the coalition’s goal—to highlight the need for universal, single payer health coverage? When the Sierra Club speaker ignored the point of the rally and began droning on dispassionately about the effects of global warming, I had to leave.

Lastly, I’m not convinced theatrical antics work in every circumstance. I was sort of embarrassed by a skit that involved Texas cowgirls decrying socialized medicine being enlightened by a white knight superhero named “Truth” who set the misinformed, cowboy boot-wearing cheerleaders straight on just what universal, single payer health coverage entails. I also winced when I was handed a flower to participate in a symbolic funeral to be held at the end of the rally. Don’t get me wrong, I realize symbolic gestures can be powerful in getting one’s point across. I know that thousands of people suffer and die needlessly because they are uninsured or underinsured, and we need to draw people’s attention to this tragedy. I just think Michael Moore does a much more effective job with theatrics in his films like Sicko than most amateurs in a public forum. The aforementioned skit delivered a questionably comical effect for a seriously important issue. I felt like the silliness detracted from the overall message that our current healthcare system needs urgent reform. On the other hand, I enjoyed listening to a poet express her personal frustration with her art, and I appreciated hearing from a bedside RN who articulated the problems of her own struggle to pay medical bills, as well as that of her patients to comply with unaffordable treatment regimens that often trap them in a never-ending cycle of hospital readmissions.

On the brighter side, I was heartened to see that at least a few others in this Red state support universal, single payer health coverage and that various social justice groups are attempting to rally together for this cause that affects everyone. Despite leaving the rally in a mildly depressive funk, I remain committed to the cause, and I need to get more involved, besides voting for candidates who will lead us in the right direction. I will definitely write more about my personal experiences as a clinician that will hopefully stir people to action or at least get them thinking about a solution they would never have previously considered. I will be more proactive in discussing universal, single payer health coverage with people who are intuitively hostile to the idea. Preaching to the choir provides personal validation, but it doesn’t shore up a movement. I guess that’s the main reason I was disappointed in yesterday’s rally. I didn’t hear anything I disagreed with, but I didn’t hear anything refreshing or challenging, either. I felt safe and comfortable but uninspired. Lack of inspiration is the death knell of any movement. Clearly, we’ve got a lot of work to do on this one.

Lean Waist, Fat Wallet: Ten Tips to Maximize Your Health with Minimal Costs

1) Wash your hands often with plain soap, and keep them away from your face. There’s no need to cultivate an obsessive-compulsive tendency with this practice, but definitely wash when you’ve been in a public place (e.g., restrooms, grocery stores, and offices) and before you eat. Your face has various entry points beloved by germs, including the warm mucous membranes of the eyes, nose, and mouth. When you absentmindedly rub your eyes, touch your lips, or ahem, pick your nose, you’re allowing a direct viral and/or bacterial invasion. There’s also no need to fork over extra money for anti-bacterial soap as the regular stuff works just as well. Cheap soap plus thorough hand-washing equals fewer nasty infections, which lessens the drain on your sick leave at work or literally keeps you “on” the hourly job with no benefits that you desperately need to make ends meet.

2) Halve your portions; chew slowly and mindfully. Eat on smaller plates, even saucers. This practice will force you to eat less. Of course, this doesn’t stop you from returning for seconds, but eating more slowly often creates the desirable side effects of satiety and leftovers. When eating out, immediately ask for a takeout box before digging in. Both your waistline and wallet will thank you in the long-term.

3) Limit or avoid meat and/or dairy products. If one avoids processed foods, a vegetarian diet is generally less expensive and healthier than one that relies heavily on animal products. Can’t one consume leaner cuts of red meat, fowl, or fish and still be healthy, maybe even healthier than those holier-than-thou vegetarians? Of course, but the point is to attain the best health for the least buck. Meat-laden diets tend to be higher in fat, and they contribute to the growing obesity and heart disease epidemics that greatly impact ever-increasing healthcare costs. A vegetarian diet is more time-intensive and requires a commitment to eating smart to avoid vitamin deficiencies, but if done mindfully, it will lessen the drain on your wallet in the grocery aisle and the doctor’s office.

4) Lay off the megavitamins. Focus on eating a varied diet that does not rely heavily on processed foods to achieve optimal health. Although they are appropriate for some medical conditions and strict diets (e.g. veganism), vitamins can be costly, so it’s wise to determine whether you really need a supplement versus a diet overhaul. Plus, you run the risk of overdosing on some vitamins, and for others, your body will simply excrete all the excess “good stuff” for which you paid dearly. Strive to overcome your obsession with obtaining health in a pill, and stuff the pill-popping dollars into your expanding bank account.

5) Fidget freely. Climb stairs, park in the spot farthest away from entrances, walk to a co-worker’s cubicle instead of sending an e-mail, or install your printer somewhere that requires you to get up to retrieve your document. Do anything that prevents your rear end from remaining in a seated position for hours on end. Join a gym or make one of your own with a few free weights, a step bench, or exercise bands—the options are endless. If you can’t afford a gym, then walk, walk, and walk some more. Check out exercise manuals and DVDs from the local library. Exercise like you brush your teeth, at least once a day, but twice is better, and after every meal is superb! Regular exercise and simply moving more throughout the day helps maintain a stable weight, increases cardiovascular fitness, and reduces stress, and it does not require loads of cash to perform.

6) Keep a clean mouth. Brush and floss with gusto! Flossing is critical to preventing periodontal or gum disease. The mouth is teeming with bacteria, and its high vascularity means that these bacteria can easily enter the bloodstream, possibly causing harm in other organs, such as the heart. Moreover, restorative periodontal/dental work is extremely expensive while most dental insurance policies have puny annual limits and multiple exclusions. Flossing is a two dollar prevention package for a thousands-of-dollars problem.

7) Sleep tight all night. Adequate sleep is essential to proper immune function, and it’s one of the healthiest and cheapest lifestyle factors to address. Banish work and pets from the bedroom, and insist that a snoring partner get an appropriate medical evaluation ASAP. If you’re the snorer, get thee immediately to a sleep medicine clinic. Invest in black-out shades/drapes or a white-noise machine. Establish a restful, personalized routine at night, such as taking a hot bath, reading a book, or meditating. Aim to retire and awaken at the same time every day. Sleeping pills are appropriate for short-term use only under a physician’s supervision, but they ultimately increase your healthcare costs and do not address the problems underlying your insomnia.

8) Drink tap water and lots of it. In most developed countries, barring natural disasters or other threats to the water sanitation system, tap water is safe to drink. Bottled water wastes resources and often contains tap water anyway. If you’re concerned about contamination, purchase a filter for your faucet or a pitcher with disposable filters. These options pose some costs, but they represent a justifiable trade-off for people who cannot fathom drinking straight from the tap, yet understand the importance of increased water intake to their overall health. Invest in reusable bottles that can be refilled when you’re away from home, thereby avoiding the purchase of outrageously priced bottled water or worse, soda.

9) Bliss out. Meditate, commune with nature, sing in the shower, write a love letter, re-read a beloved book, laugh with friends, do yoga, volunteer in your community, attend church—the point being to maintain your connection with yourself and others, which in turn, nourishes your mental health and boosts your immune system. Maintaining rituals that help you to decompress and having a support system in place to sustain you when troubles occur are essential to preventing a costly physical and/or psychiatric melt-down in the long-term. The aforementioned activities cannot take the place of professional counseling or medication prescribed to treat a new or ongoing mental health condition. But, they are relatively cheap, sometimes free, ways to engage more deeply with yourself and others, which enhances your ability to cope with life’s stressors instead of turning to drugs, alcoholism, overeating, and other addictive behaviors. Another option is to take advantage of employer-sponsored employee assistance programs that provide free or low-cost counseling services or referrals to mental health providers on your health plan.

10) Keep a well-stocked medicine cabinet and first aid kit. Focus on high quality, over-the-counter generic medications that you use on a fairly regular basis, such as anti-inflammatory agents, anti-bacterial ointment, band-aids, etc. Fund your stash preferably with FSA contributions. The purpose is to avoid getting caught in the unfortunate situation of needing some kind of minor relief, but not having anything on hand, and then having to go to the trouble of purchasing it in a hurry where you risk getting the more expensive, brand name or just plain wrong product all because you feel too rotten to care. Treating common ailments, such as routine headaches or colds with over-the-counter agents that offer symptomatic relief is much cheaper than hauling oneself into the physician’s office at the first sniffle or sign of discomfort. It’s also possibly healthier because by avoiding the physician’s office in these situations, you won’t be given unnecessary antibiotics that an alarming number of physicians feel compelled to prescribe because they believe you deserve something, other than their careful evaluation, for your time and money even when your condition doesn’t warrant it.