Brutally Honest

Part 3 - Or, there are too many people in this bed

Posted by guest blogger Mommynator.

(Part 1 can be found here.  Part 2 here).

So let's move onto other contributing factors to the cost of healthcare in this country. The primary bed partners in this mess are the government, the insurance companies themselves, lawyers, doctors and patients. Did I miss anyone?

A Brief History of Medicine - The Good Old Days

Ah yes, the good old days of the family/community doctor, who delivered and buried just about everyone. He knew all the secrets and kept them all. He sat by your bedside, maybe even held your hand as you died, was considered wise and almost godlike in knowledge.

Trouble is, at the time this was true, doctors knew next to nothing compared to what we know now about anatomy, physiology, disease and treatment. They had limited tools and medications and procedures and sometimes the best they could do was offer palliative care. Maybe.

A small cadre of scientists started teasing out many of the secrets and complexities of the human body as the tools for observing and experimenting became better and more precise. Darwin's black box (originally referring to cells which were originally though to just be blobs) gave way to discovering the true complexity of each different type of cell in each organ system and tissue. It's true what they say - "I may not look like I'm doing much, but at the cellular level I'm very busy."

And discovering the chemistry of how everything works! Hormones, fluids, exchanges, balances and levels, electricity even - it can make your head spin at how complicated everything is.

With all these new discoveries came new treatments - medications, surgeries and other alleviative methods. We got aspirin, penicillin, saline, blood typing. Surgical procedures like appendectomies, tumor removals, repairs and modifications became more common with better outcomes and restoration of health.

Hospitals changed from places where obnoxious things were done painfully, mostly resulting in death to places of healing for the most part, and life. I remember my husband's grandfather refusing to go to the hospital because his experience in the late 1880s/1890s was that if you were admitted, you were dead. Nowadays, the majority of people who are admitted are released to at least partially restored health and life.

People with strokes can regain more than ever thought possible. Cancers can be persuaded to at least go into remission. Transplants can restore almost normalcy. Reattachments, microsurgeries, therapeutic plastic surgery and reconstruction. Prosthetics that really work. Therapies and medications that address neurological problems even to restoring chemical balances leading to depression. Medications that address many diseases people automatically died from in the past, most notably insulin and other medications for diabetics.

It's an amazing time we live in if we really think about it. But it comes at a cost. Somebody has to pay scientists while they do what they do. They have to buy and sometimes develop new equipment to carry out the research and eventual testing of new procedures and medications. And then comes the rubber-hitting-the-road moment of human testing and refinement.

All this scientific discovery also led to moral and ethical questions many of which we still struggle with to this day. When does life begin and end? To what extremes should we go to preserve life? What is the value of a human being and his life when there is an anomaly that cannot be cured? As much as scientists would like to sometimes, they cannot live, breathe and perform science in a neutral ethical environment.

Part 2 - Insurance. Please practice pre-emptive face palming.

Posted by guest blogger Mommynator.

(Part 1 can be found here.)

Here I sit in the sleep lab having spent most of the day trying to solve insurance problems so we don't have to cancel anyone's sleep study. End result - I had to cancel one patient. The rest of the patients are go, but only because their insurances require minimal to no precertification for this particular procedure as long as the doctor can provide justification. My direct manager and I get paid for this ulcer-inducing part of our job. Add that to your doctor's visit.

Having said that, there are four major types of insurances floating around right now, not including Medicare, Medicaid, Health Savings Accounts, and privately-funded company or union plans.

These are Traditional, Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Point of Service (POS - please don't go there).

Traditional

Traditional policies started somewhere in the late 50s, early 60s. Originally, they were designed to cover large hospital costs - longer stays and the like. Major medical policies covering physician and lab fees became more common later. The most common traditional policy involved the insurance paying 80% of the fee after the patient met a deductible. The patient would also be responsible for the unpaid 20%.

These policies were rather easy. You could see any doctor or specialist you chose, have tests and procedures, and the insurance didn't really interfere. As long as the doctors, labs and hospitals involved had documentation, things were pretty much a go.

The disadvantages to these plans were mostly in the preventive area. Things like immunizations were not covered under either half. I remember that when my son was born, Blue Cross did not want to pay for the bilirubin lights he needed. His level was near destructive to his liver, but I had to have a major argument with them to pay.

Health Maintenance Organizations (HMOs)

The majority of these plans started in the 1980s. There were two major ideas behind this shift in coverage. The first was prevention - pay for immunizations and other things that would help patients maintain their health for as long as possible, thus reducing everyone's costs. The second idea was that in order to reduce costs, people pick a primary care physician (PCP) who would be familiar with one's health status and be able to refer to specialists and testing as appropriate.

The immediate advantage of this kind of plan was that patients had a very economical way to do preventive care (especially children's immunizations) and having a doctor that knew you and your history instead of flitting about trying to figure out your problem. Copays were usually low and there were no deductibles. Medications could be included for low copays as well.

The eventual disadvantages sort of crept up on doctors and the insurance companies alike. The HMOs contracted with doctors to provide so many services for so much money. Doctors lost control over what they could charge for their services. They had to accept what the HMOs decided was the "right" fee. This led eventually to a spiral of doctors having to see more patients (thus spending less time with them), refer fewer outside specialists and procedures, and being reimbursed less as the HMOs tried to cover the costs of their plans. This was the origin of many of the lawsuits that forced HMOs to loosen some of their restrictions, which raised their costs and premiums, etc. Think circling the drain.

Things have kind of stabilized in this area, but HMOs aren't as cool as they were when they started.

Preferred Provider Organizations (PPOs), Point of Service contracts (POS)

This is where things get really confusing, because both PPOs and POS are hybrids - insurance genetic experiments if you will.

PPOs are the result of a marriage of Traditional and HMO insurances. Physicians and medical facilities participate by contract in PPOs, and are reimbursed at rates that depend on a number of factors - number of patients seen, quality of care (determined by patient outcomes, lawsuits, and a few other things), Medicare reimbursement rates (yeah, the government is in there) and some other lesser values. Patients with PPOs are not as bound to their primary care physician. For example, patients can see specialists within the PPO without primary care referrals. PPOs may or may not require authorizations for certain procedures, but these can be generated by the specialist, not the PCP. PPOs usually have copays that vary according to plan. Some have deductible requirements, while some deductibles are usually waived as long as the patient stays inside the network.

One advantage with a PPO is that a patient can choose to go outside the network. PPOs provide information of what the patient will be financially responsible for if they do. The PPO will usually pick up some of the cost of going outside the network. If there is a very very very good reason for going outside the network which can be documented, the PPO may decide to pay the whole thing as if it was in network.

PPOs usually have associated medication plans with a formulary of drugs in tiers. Depending on the tier, one will have either no copay, a very minimal copay or a more expensive copay. Generics usually have no to minimal copays. Drugs that have no generics are usually the most expensive, but many PPOs offer plans where a patient can buy several months' worth of medications at a discount.

Point of Service contracts (POS) is a marriage of HMOs and PPOs. Like the HMO, the contracted PCP plays a larger role in a patient's care and referrals. These plans are usually more restrictive and require more input from the PCP in terms of referrals. However, like the PPOs, they have procedures for going outside the network and have similar drug plans.

With most of these plans, as long as you follow the rules (and your number one rule should be to make sure you how plan works and what it does and does not cover), you usually have no problems. You can't just shove an insurance card at someone and expect it to magically pay for everything. Some companies are better than others, some plans more appropriate for you and your family than others, but usually most people end up with what their employer is willing to at least partially pay for.

Now that we got all that out of the way, Part 3 will be a discussion on why insurance and government in addition to all the doctor office stuff makes things even more expensive and less what medical care is supposed to be about.

Why your visit to the doctor costs so much - Part 1

Posted by guest blogger Mommynator.

The past few weeks have seen me watching the tennis match between supporters and rejectors of the Obama healthcare plan/reform/take your pick.

I have read many fine articles about why this push towards socialized one-payer medicine is the road to disaster and I agree with all that.

I have read many fine articles about alternatives, all worthy of thought and consideration.

I've even formed my own opinion of the whole debacle.

The thing I have not seen is a step-by-step guide as to specifically why our current healthcare system charges so much from the patient-doctor point of view. This is my attempt to address that lack and how it might be changed for the better with what we've got at hand, with a few tweaks.

A Trip to the Doctor

The first thing that is entered on the doctor's bill is the staff person/people who makes your appointment. Many times, it's not just getting a time and date, it's the grilling you get about your insurance - is it the same/has it changed (because your doctor may not participate in your new insurance). This lowly person probably gets paid around $10/hr (maybe) and may not have benefits. They may be the best of the best or the surliest person on the planet or something in between. And having dealt with many doctor's offices, sometimes you get what you pay for (not good).

Then you arrive for your appointment. Hopefully you got there early so you can fill out some forms and update your information (if it's been awhile). One of the forms is the HCFA 1500, which is the form you fill out for your insurance company to pay the doctor. This form is further completed by maybe the same person who took your appointment OR the insurance billing specialist many doctors hire to expedite all the insurance claims.

The insurance billing specialist is either in-office, or is a service paid by the doctor to complete all insurance matters and submit all claims. The in-office insurance person gets paid slightly more than the appointment clerk, seeing as they have to have special training in ICD-9 and CPT codes. ICD-9 codes are a set of universal diagnoses that are assigned a diagnosis number. The CPT code is a set of universal procedures that are assigned a procedure number. Get this wrong or commit fraud, and both you and the doctor are screwed.

You are often first seen either by a medical assistant, nurse, nurse practitioner (NP) or physician assistant (PA) for the initial evaluation. All of these people are highly trained (even the medical assistants) and can evaluate you up to certain levels depending on their level of training. Medical assistants do your blood pressure, temperature, height and weight, ask what brings you to the office, etc. They can draw blood and prepare other samples for the labs. Obviously, nurses, NPs and PAs can do more and usually take a more thorough history. NPs and PAs can also diagnose and prescribe. Obviously, the higher the training, the more they get paid.

If the NP or PA sessions is not enough (according to state laws which vary from state to state) to be official to either the government requirements or insurance company, then the doctor will step in, quickly review your chart and pronounce from on high.

In addition to hiring an appointment (and maybe billing) clerk, billing person/service, or medical assistant (whether MA, RN, NP or PA), there are other major expenses.

Let's start with the doctor. If he's still in the early years of his practice, he still has student loans. Hundreds of thousands in student loans. Bachelor's, MD, specialty. Lots'n'lots. If you think they make too much money, think of you having four mortgages at once.

Then there's licensing and insurance. Every so often, a doctor has to renew their license, and every few years, doctors who have specialty initials after their names have to re-qualify in their specialty. This requires review, update and testing.

Then there's malpractice insurance. Doesn't matter if you are the perfect physician, your insurance costs will be driven up by every stupid shitty lawsuit some idiot patient decides to initiate. Even if the patient is 100% wrong and the physician 100% correct, his insurance rates will go up. Period. No "accident forgiveness". No review of the whole record. You get sued, you get paid more.

Same for the NPs and PAs, although here in NYS, PAs are covered under the practice insurance. NPs can set up their own practices and thus require their own malpractice insurance.

Guess who pays for all that.

Then think of the office and its furniture and equipment. Your waiting room, your staff area, your computers, your exam rooms equipped with everything from EKG machines down to bandaids and cotton balls. Also, depending on the specialty, there may be specialty equipment. Some general practices also have x-ray machines (and specially trained staff to run it).

Equipment must be upgraded from time to time, furniture replaced, PCs and their programs upgraded.

Is your head spinning yet?

Some doctors' offices are better than others. You get the occasional stupid clerk who can't even spell their own name let alone yours who messes up your billing which takes months to resolve. But there are also the PITA patients who make life miserable for even the best of offices and doctors. Most people are right in between.

Next time, we'll look at insurances - the types, the differences and how they add to the cost.

Are you satisfied now?

Posted by guest blogger Mommynator.

I truly hate coming off as a scold, but I just have to say this once and then I'll try to shut up about it in future.

Dear Mr. & Mrs. Conservative Super-Purist:

Are you happy now?

Because you folks couldn't offer up an electable candidate, and refused to consider the strongest of the "non-pure" candidates for President, the future of this country is in graver danger than it ever was under any civil war, plain war, terrorism or natural disaster put together. Innocent Americans are facing all kinds of personal disasters and are in danger once again of being attacked by foreign enemies because your delicate noses cannot stand the smell of the common need. Shall I enumerate?

Let's take my personal favorite candidate for President, Rudy Giuliani.

Oh, the horrors and vapors! He's pro-choice, divorced, re-married and any number of other icky things.

And yet, when he was Mayor of New York City he:
- TOOK ON ORGANIZED CRIME and beat it to death.
- LOWERED TAXES to where it was extremely noticeable on one's paycheck and property tax statements.
- REDUCED WELFARE by doing smart things and encouraging people to move to employment rather than be dependent on government for their lives.
- REDUCED ABORTIONS. Now that's a puzzler, all right, but not really. As people became proud of being independent and self governing, they learned that destructive behaviors like indiscriminate sex and procreation would destroy what they worked so hard for. So they straightened up.
- REDUCED ALL CATEGORIES OF MAJOR CRIMES by focusing on small things that led to big things.

The result was a vibrant, prosperous, joyful New York City the likes of which may have never been seen before in its history. Everyone benefited from the billionaire to the street vendor. It really did benefit the children and the elderly, too.

Do you really believe that our economy would have tanked like it has under Giuliani's presidency? Do you? Do you think that every last one of his cabinet appointments would have been rife with sleaze and crime and conflicts of interest?

Do you believe that the enemies of the United States, foreign and domestic, would be laughing and making their plans to complete our destruction if Mr. Giuliani was President of the United States? Do you?

Didn't think so. Don't even start again with your super-purist conservative "buts". You either stayed at home, voted third party or complained and bitched and moaned about it all and now we're stuck with what we have now.

Then there was John McCain. A very independent-thinking man. Does what he thinks is right and damn the party. Agree with him on everything? Nope.

But he has shown that he hates pork and abortion, and knows what to do about our enemies foreign and domestic.

Again I ask, do you believe that our economy would be swirling down the toilet and well into the sewage treatment plant if he was in charge? Do you think our enemies would be laughing and plotting our downfall?

Do you? No?

But you criticized and bitched and moaned about this and that and the other, and now we're stuck with disaster and mayhem and machinations and corruption in the White House.

These are but two of the candidates we had at our disposal.

You guys blew it totally, both by commission and omission.

I'm really sick and tired of you all.

Next time around, get a grip and think of all the people suffering because of your egotistical political prudery.

*leaves soapbox*

Happy and Sad: Life's usual schizophrenia

Posted by guest blogger Mommynator.

My oldest daughter is getting married April 25th. Her fiance is one of our son's best friends, and we've known him since he was about 14. He's now 28.

They got a hugely wonderful deal on an apartment - 1 bedroom with kitchen, living and dining room and lots of closet space for $800/month including utilities and she can have her kitty with her. The landlords basically want someone in the house to watch over things while they travel and enjoy their retirement.

So today was moving day for Joy. She's going to live there and Stu will join her there after the wedding (yes, we're all old fashioned like that, their church is old fashioned like that and keeps them accountable, his mother is old fashioned like that and is constantly making sure he's behaving).

This is not like when she moved to Queens to be near school while completing her bachelor's. We knew she was coming home after that.

This is it. All these years of parenting and raising her and teaching her are about to be implemented in a more permanent way.

And it's bittersweet.

We (Dad and I) remember how long we waited to know she was coming into our lives. We remember that icy February night when we had to borrow our babysitter's car to get to the hospital because ours just absolutely positively refused to start. We remember that first cry, holding her and being thrilled by her arrival. Bringing her home to her very excited and happy brother.

We remember all her girlishness and tomboyishness too. Her individuality, her tastes, her opinions, her growth. Our part is pretty much done.

Tonight, her Dad didn't get her the cup of tea he got me and her sister. Tonight he won't be leaving the front door unchained and the porch light on.

Just for tonight and maybe a couple more nights, we'll feel this loss that is really gain. Life will assume some new routines and expectations. It's a good thing, really.

But Mom just has to sigh a bit and eventually get over it.

Extubated and conscious

Posted by guest blogger Mommynator.

Just a quick update - I asked you all to pray for my friend Michael's little girl.

Today we heard the great news that she was finally extubated and is semiconscious (she's still medicated).

Thank you for all your prayers and good thoughts.

If you've got 'em, hug 'em

Posted by guest blogger Mommynator.

As I type this, my good friend Michael who happens to also be colleague and family physician, is in Long Island waiting and watching his 3-year-old daughter in a hyperbaric chamber.

Details are rather sketchy at this point because the people involved in keeping us up to date are trying to do their medical thing and have little time to give more details, but it seems that Michael and his kids (he has two boys as well) were playing Guitar Hero, and when done with that, he set out the Wii aerobics pad and left the room for a call of nature. After a few minutes, one of his boys came rushing to him saying that his sister was sick.

Michael found her unconscious and not breathing. He did everything he could for her before she was whisked away to our hospital where she spent two nights in the ICU. It's suspected that she may have been shocked and had a seizure, and aspirated her tongue, saliva, whatever.

For two nights, her EEGs have been okay, but her oxygen sats could not be brought up to normal levels. Having exhausted all possibilities, she was sent to one of two hyperbaric facilities in NYC. Children breathe differently than adults, so where adults with pneumonia may respond well, children have a harder time getting rid of CO2.

Michael and his wife are excellent parents - intelligent, loving, firm when necessary. He had brought his little girl to visit us in the sleep lab last month and she is an adorable darling - everything you could want in your own little girl.

I was contemplating posting something about what I've learned in the last year in preparation for facing 2009, and the one thing that stands out the most from 2008 and previous years is that life is uncertain no matter how much we try to cushion ourselves against uncertainty.

Look at the Madoff scandal - how wealthy people are now financially ruined where they thought they could be comfortable their whole lives through. Just look around and you can see similar things happening to all sorts of people all over.

It's the eternal thing laid out in Job, and we can shake our fists and cry and spit all we want, but in the end we're on the ground, spent and broken. And we ask what the purpose of it all is. And all the parts of our broken heart still stand in defiance. Weren't we good enough? Were we evil? Just exactly why?

The only thing I've been able to come up with is that being God is a hard job. He has to make decisions on how to bring our broken, raving, lunatic, defiant selves to Him - and to work His work in the people around us as well. And because we are broken, raving, lunatic and defiant, it always has to involve pain. Loss. Pigsties. People ready to stone you. Gulags and concentration camps. Crosses. Broken hearts and lives.

Brokenness to heal brokenness.

I'm praying for Michael, his daughter, and his family because in all this tragedy and pain and waiting and anxiety, there is brokenness meant to heal brokenness, which can only be known to the participants in this particular case.

I'm hoping that a happy ending is part of this.

Hooray for synapses that still react well to their neurotransmitters

Posted by guest blogger Mommynator.

Just want to share with my friends here on Brutally Honest:

I got As in both my Biology class and its concurrent lab.

I'm 52, going back to school after 30 years out, and trying for nurse practitioner.

I must thank my family for their unfailing support, encouragement, cooking and doing laundry.

And I thank God for allowing those neurotransmitters to make it from the end of one nerve to the beginning of the next, with some certain level of storage in the brain.

Christmas Meditation 2

Posted by guest blogger Mommynator.

In addition to BroKen's beautiful meditation on Christmas and Narnia, this is one of my favorite poems. It was penned by George MacDonald, one of C.S. Lewis' favorite authors.

They all were looking for a king
to slay their foes and lift them high.
Thou camest a little baby thing
that made a woman cry.

O, Son of Man, to right my lot
none but Thy presence can prevail.
Yet on the roads Thy wheels are not
nor on the sea Thy sails.

My fancied ways, why shouldst Thou heed?
Thou comest down Thine own secret stair
to answer all my smallest need,
yea, every bygone prayer.

From Mommynator's home to yours, each and every one, we hope that this Christmas is especially blessed with joy, family, friends and all good things.

We wish for you a New Year filled with love and hope (the real kind) and joy in the middle of all the usual difficulties life brings to us, and the grace to become more like Jesus.

Merry, Merry Christmas!

I WHAT New York?

 

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