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The Joys Of Health Insurance Bureaucracy

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From a health perspective, I am grateful to be doing well. I have only one active medical condition that is fully treated by one prescription medicine. I have been taking this medicine since I was 18 years old. I recently bought myself a personal health insurance plan (my first that was not tied to employment) and simply wanted to resume regular purchase and use of my medicine.

I was pleased to note that purchasing my medicine through the new insurance plan would save me a little bit of money (about $25/month). So I presented my card at the local pharmacy and was told that my medicine was not covered under my plan without pre-authorization from my doctor. I called my pharmacy benefits hotline and had them send a pre-auth form to my doctor. Then I asked him to fill out the form and fax it back. That was over three months ago.

When I called to inquire about the pre-auth forms, the benefits folks told me that they had no record of the fax. So I asked my doctor to send another fax form and I waited another week. When I called the benefits people, they again said that they had no record of the pre-auth documentation. They also said that I could not be transferred to the pre-auth team to figure out why it was missing (wrong fax number perhaps?) because they only speak to providers.

So out of curiosity I asked what the usual process was for obtaining a prescription medication once it has been authorized. The benefits staff didn’t know. I asked who would know and they said that only the “experts” in the pre-auth department know how medications are obtained by the member after being approved. I wondered how I’d ever figure this out if I wasn’t allowed to speak to them and I was told that I might be able to get an answer if I asked a customer care representative to request information on my behalf from the pre-auth experts. But… the pre-auth team was not in the office at the moment and I’d need to call back on Monday. (Parenthetically, the team is physically located in Pittsburgh, Pennsylvania, though I’m a member in Charleston, South Carolina.)

I asked the benefits team if they generally mail members their meds (I had heard this was the case) or if I could pick them up at my local pharmacy (my preference). They said they didn’t know, but I could call customer care on Monday.

So far, my experience with my new plan – to save $25 dollars/month on one prescription – has cost me 3 months and 1 week of waiting time, two form completion episodes with my doctor, discussions with several pharmacy benefits reps in a state far away from where I live, denial of communication with the only people who know what’s potentially holding up my prescription approval, and about a half hour of completely unhelpful discussion of basic prescription drug purchasing processes that staff at the drug benefits company themselves don’t understand.

And I’m healthy, I’m a healthcare provider who knows how to navigate the system, and I only need one prescription. What do sick people do? (I know, it’s awful out there.)

Life was much simpler when I paid for my medication out-of-pocket without an insurance middle man.  I have often wondered if health insurance bureaucracy is purposefully designed to wear patients down to the point where they’ll just pay for things themselves rather than experience the pain associated with getting an insurance company to cover their portion of the cost. (The only other explanation is that health insurance company ineptitude comes from being administrative behemoths with too many moving parts and processes).  It’s probably a mix of the two. Or maybe the latter supports the former so there’s no real incentive to pursue true efficiency.

But one thing I did notice – the insurance company was incredibly efficient at figuring out how to direct debit my premiums within 24 hours of signing up for the plan, and have increased my premium once already – by about $25 a month.

You can’t win, my friends.

If you’re healthy, get yourself a high deductible plan, pay as little in premiums as possible, and sock away some money in case of a catastrophic event. Pay cash for your primary care, and do whatever you can to stay healthy and out of the hospital. That’s my plan and I’m sticking to it.

***

Update: My medicine was finally approved/authorized, but I was informed that my doctor would need to send a new Rx form to them before I could receive my prescription. The Rx needed to be on their company’s form, so they had to fax him the request first. I asked how I would pay for the prescription and where I could pick it up and was informed that I’d save about 15% if I agreed to have the medicine mailed to my home (but delivery would take 2 extra weeks).

So I agreed to have it mailed to my home and offered to give them my credit card. They said I should call back with it once my doctor’s Rx had been received. I asked them how I would know when that had occurred. They said that they couldn’t call me to tell me when the Rx had arrived because I had selected “text messaging” as my preferred method of contact, and they don’t inform members of Rx form receipt via text messaging. So I agreed to switch my preference to calls (instead of text), and now I’ll probably get automated prescription refill information in the form of incoming calls on my personal work phone from now till I die. That’s if they don’t sell my phone number to telemarketers in the mean time.

And how annoying is it for my doctor to have sent out two faxes and one new Rx form for ONE prescription (not to mention reading the email explanations from me regarding correct pharmacy benefits plan form usage)? He was uncompensated for his time in this matter…

How Tanning Beds Nearly Killed Me

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When I was a teenager I did some stupid things, but looking back I think that the worst decision I made was to go to a tanning salon. At the time I remember tanning salon staff assuring me that it was “safer than the real sun” and the fastest way to get a healthy-looking glow. “You could bake in the sun all day, or spend 20 minutes in a tanning bed for the same effect” said the staff. So after trying several sunless tanners in varying shades of orange and having them slough off like patches of dirt, I decided to make my alabaster skin a nice, even shade of light caramel with months of tanning each year.

Fast forward twenty some-odd years and I’m in the surgeon’s office having a wide-margin re-excision of a melanoma on my back. I’d been wearing sunscreen since my early twenties, carefully protecting myself from UV radiation. I had realized the error of my ways after a serious conversation with a dermatologist, but I had “gotten religion” about skin protection too late. My fate was already set from the tanning bed exposure.

A new study in the British Medical Journal (BMJ) estimates that tanning beds may be responsible for hundreds of thousands of non-melanoma skin cancers per year in the United States. As for melanoma (the deadliest kind of skin cancer), the World Health Organization has determined that the risk of melanoma is increased by 75% when the use of tanning devices starts before age 30. In fact, they classify tanning bed exposure as a “group 1 carcinogen” – in the same class of human toxicity as asbestos, tobacco, and mustard gas.

I was surprised to learn how common tanning bed use is, especially in Europe. According to the BMJ study, 10.6-35% of people in Germany, France, Denmark, and Sweden have used a tanning bed at some point in their lifetimes. The global nature of this problem is daunting – and with research suggesting that tanning has addictive properties, it may be as difficult to get people to avoid tanning salons as it is to have them quit smoking.

As for me, I learned my lesson and I have the scars to prove it. I was lucky that a dermatologist caught my melanoma before it spread, but now I need to be on the look-out for more of them and redouble my efforts to stay out of the sun. If you’ve ever used a tanning bed and have fair skin and freckles, you should probably keep your dermatologist on speed dial. That temporary “sun-kissed glow” can easily turn into wrinkles and Frankenstein scars in the not too distant future – along with a potentially fatal cancer diagnosis. Trust me, it’s not worth it.

How To Have A Healthy Old Age: Food For Thought On Labor Day

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I’ve spent the last couple of weeks making house calls to “at risk” seniors in rural South Carolina. At the rate of about 7 house calls per day, I was able to make some observations based on a respectable sample size. I was both surprised and intrigued by the living conditions I encountered, and I’m pleased to report that I have now performed my first physical exam under the careful scrutiny of a cat, rooster, and hen team (photo at left). On another house call I was offered a pygmy goat as a thank-you for my efforts, and countless good-natured folk offered me home made iced-tea and such edible delectables as fish patties and peach honey.

But what struck me the most was that certain seniors were in far better health than others their age, and that the healthier ones all had one thing in common: strict daily exercise regimens. I realize that this is not ground-breaking news (that exercise is good for us), but the stark contrast between those who exercised and those who didn’t could not have been clearer to me.

One particularly charming 85 year old man gave me a tour of his vegetable garden, and explained that he bicycled into town six days a week to give away okra (and other veggies) to church friends and town folk. Growing vegetables and giving them away was his current life’s work, and although he lived in extremely modest circumstances, what he owned was tidy and clean. He was joyful, bright, and had the physique of an athlete.

Contrast this man to another patient in his 80’s who didn’t exercise at all, and stayed inside smoking cigarettes most of the day. He was blind in one eye, nearly deaf, struggled to breathe, had sores on his skin. He was depressed, over-weight, and swollen from heart failure. I was so sad to see his condition, and the relative squalor in which he lived. Urine and smoke odor permeated the house, and I wondered how much longer he would survive.

When I arrived at another octogenarian’s home, I noted that the garage was filled with watermelons of various sizes. Upon further inquiry, the gentleman said that he had hand-picked the watermelons from a plot of land that he owns 2 miles from his house.  He brought them back to the house with a wheel barrow… and had made many trips back and forth over the past week. He was taking no medications and had a completely normal physical exam.

And so my days went – back-to-back visits with seniors who either were engaged in an active lifestyle, or who were wasting away, cooped up indoors with advancing dementia and chronic disease. I realized that no medical treatment has the power to overcome the relentless damage that inactivity, smoking, and deconditioning cause. The secret to a healthy old age lies in lifestyle choices, not pill bottles.

As we enjoy the last holiday weekend of the summer, let’s consider how important labor actually is to our mental and physical well being. You’re never too old to haul watermelons down the road, grow okra for your neighbors, or simply commit to smoking cessation and daily walks. If you do this regularly, your health will surely improve – and your quality of life will be enhanced immeasurably. In the end, adding life to years is what medicine is all about.

New York Times Scratches The Surface Of A Festering Wound: The Truth About Bullying In Medical Training

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Dr. Pauline Chen recently wrote an interesting, if not slightly sterile, article about the prevalence of bullying in medical school. A survey published by JAMA in 1990 suggested that 85% of medical students had experienced some kind of mistreatment during their third year of training, and a quarter of the respondents said that they would have chosen a different profession had they known in advance about the extent of mistreatment they would experience.

One medical school (UCLA) took these sobering statistics to heart and implemented an anti-bullying program of sorts. Thirteen years after it was initiated, more than half of all medical students still said that they had been intimidated or physically or verbally harassed.

I recently wrote a fairly tongue-in-cheek blog post about why doctors are jerks. But I didn’t really delve into the more sinister side of the bullying culture. Some of my experiences in medical training were soul-suckingly bad, and just to add some flavor to Dr. Chen’s analysis, let me share some real-life anecdotes.

My worst experiences in medical training occurred during Ob/Gyn rotations. I don’t know if this has been the experience of other medical students, or if my gender had anything to do with it, but I spent time with a group of female residents who were so toxic to med students that the department chairman actually warned us about them ahead of time in a private meeting. He let us know that these residents had a history of “hazing” medical students, particularly females. I had always been a very conscientious and hard working student, so I presumed that they wouldn’t have much to criticize. My plan was to work hard, keep my head down, and get out unscathed. Unfortunately, nothing went as planned.

The tone was set for me the first day when I witnessed a female, Asian anesthesia resident slap a pregnant Hispanic woman who was in labor. The woman was frightened and spoke no English and was beginning to hyperventilate from pain. The resident was trying to put in an epidural anesthetic and the woman was moving around too much for her to get the needle safely into position. So instead of calling for a translator, the resident started raising her voice, eventually screaming at the woman to calm down. The woman was crying uncontrollably, so the resident slapped her, and told her that she was “going to lose her baby” if she didn’t shut up. The husband was also terrified and could understand some English. He translated to his wife that she was going to lose the baby and started begging her to be calm. I stood in the doorway with my mouth open. The resident told me to get the f-out of there as she threw her gloves at me.

I suppose the humiliation of being caught abusing a patient was enough to channel her hate towards me, so she told the Ob/Gyn residents that I was an incompetent medical student. For the rest of the month I was targeted by the hazing team, and like a pack of wolves they descended, bound to make my every moment a living hell. During the delivery of my first baby (a touching experience that moved me to tears), the new mom experienced a small tear during the birthing process. The residents blamed it on me, and convinced me that I had personally caused her harm by not “supporting her perineum” correctly. I was mortified and fell for the lie – hook, line, and sinker.

When a woman went into labor it was customary for the residents to page the medical student on call and have him or her assist with the vaginal birth or c-section. My peers were paged in a timely manner, while I was either paged at random times or paged to the wrong parts of the hospital so that I appeared to be late to several deliveries (especially when a senior physician evaluator was present to witness it). Once I caught on to this I had to remain awake 24/7 at the nursing station (rather than the more secluded med student lounge) so that I could follow visual cues regarding where and when to assist. After several shifts without sleep the residents began locking the chairs in their lounge so that I would have no where to sit or rest, but would be forced to remain standing “on guard” all night.

One page was particularly painful at the time (but almost laughable in retrospect). A resident took it upon herself to page me just to tell me some important news: I was the worst medical student in the history of the program.

Of course, my final resident evaluation was dripping with venom. I recall statements such as, “Valerie suffers from narcolepsy,” and “she is uniformly late and is never prepared… she doesn’t answers her emergency pages… she occupies valuable space at the nursing station instead of remaining in the medical student on-call room… her performance in deliveries borders on dangerous.” And on it went. I wish I had the maturity to take all of that in stride at the time and see that these women were nuts, and it had nothing to do with me personally. But I was too close to it then, and I bore the pain with a stiff upper lip.

I still think about that poor patient who was slapped, and I kick myself for not standing up to the resident who hit her. I guess I was in such shock that I didn’t know what to do. But living through this abuse helped me to become a stronger patient advocate during my residency years. Just two years after my brush with the Ob/Gyn residents, I gained a reputation for being the intern you never f-with. I know I saved the lives of some who were slipping through the cracks of the system, and I was willing to call in the hospital ethics committee if I had to. Yes, that pregnant woman’s suffering was not totally in vain – because she helped me to find my own cojones. And for that, I will always be grateful.

Case Report: Surgical Removal Of A Muffin Top

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"Muffin Top" Excision

At ten months of age I had a life-threatening condition that required risky abdominal surgery. The pediatric surgeon had to open my belly from end to end, right above my umbilicus. I lost most of my colon in the process, but the only apparent long term effect was an impressive seven-inch scar. After forty years of living, the scar had become “stuck,” resulting in a preponderance of skin slowly increasing its droop over the old gash. Basically, I had a non-clothing-induced “muffin top” and no amount of diet and exercise would improve it.

So off I went to the plastic surgeon, knowing that he couldn’t erase the scar but could improve the contours of my abdomen. In effect, I could retain my current appearance (that of a woman who had a permanent belly indentation caused by a lifelong history of wearing high-waisted pants that were two sizes too small) or I could opt for surgery and embody the look of an athlete who had picked a fight with Zorro. The choice was clear. I would settle for the long slice on a thin belly.

The problem with being a doctor under the knife is that you know exactly what the other guy is doing. This procedure was completed under local anesthesia, and so I was chattering away with my surgeon the entire time. Although it took us at least half an hour to numb the area, I could still feel every tug and pull, hear the click of forceps, and the crunch of clamps. It was a little unnerving to have one’s abdominal flesh wide open to the world – something I’d only expected of my patients previously. So my surgeon snapped a photo for my blog (see above) though I opted out of looking at the image in the middle of the procedure. I have my limits.

So why am I sharing this with you, dear readers? Well, I do have a few tidbits of advice for anyone who is planning to undergo a substantial cosmetic surgery under local anesthesia. I hope these are helpful:

1. Wear a comfortable pair of undies. The unisex/unisize disposable options available at the surgical suite do provide comic relief – if you think you’ll be needing that. The pair that I received were the color and texture of surgical booties and about the right size for a guy in the WWE.

2. Try not to kick the surgical assistant(s) during the numbing portion of the procedure (or during any other portion come to think of it). Let’s face it, lidocaine hurts. Each injection feels like a bee sting, and if you’ve got a lot of surface area to cover, you’re going to be spending the first half hour (or more) squeezing something with great vigor. Which leads me to my next tip:

3. Find something firm to grip during the procedure. I found the surgical table arms to be nicely padded and an adequate thickness for death grips. I did wonder if I should have brought one of those “stress balls” with me, or perhaps a pair of hand grip strengtheners from a local gym (see image to the left).

4. Be prepared to make small talk with your surgeon for an hour or more. Preparing some “talking points” in advance could have made my patter more amusing, I suppose. But the art of distraction is a valuable asset in wide-awake surgeries. Your nervousness may actually make you a little extra charming, so don’t worry about what you say. Just do what it takes to keep your mind off the situation.

5. Don’t put your hands in the sterile surgical field. At certain times during the procedure your surgeon is likely to happen upon a spot that isn’t fully numb. You will probably respond with a squeal (or kick) and a loud “Ow!” The surgeon will then ask you what you are feeling and you must resist the urge to show him/her by pointing at it. Many an abdominal wound has been accidentally poked by well meaning patient fingers. Be careful! Just say you feel something sharp and the surgeon will know where it hurts… because he/she just did something to cause the reaction!

6.  Get detailed post-op wound care instructions. You’ll probably exit the surgical suite with a lot of gauze and tape all over you, and it will occur to you later on that you haven’t the faintest idea when it’s safe to remove it. Can it get wet? Should you remove the steri strips? When do the stitches come out? When should you begin to use silicon scar gel? Do you need neosporin? Make sure you ask these questions before you’re released back into the wild.

7. Ask about movement restrictions and exercise precautions. You may be surprised by how restricted your movement should be in the first two weeks after surgery. I guessed that back flips would be counter-productive in my case, but didn’t realize that I couldn’t “walk fast” or twist at the waist. Make sure you understand what you can and can’t do to optimize your healing.

8. Take some pain medicine at least an hour before the local anesthetics are due to wear off. This was my biggest mistake. I asked if the wound would be painful later on and my surgeon denied any knowledge of potential post-op pain. So, six hours later when I felt as if someone had attacked my belly with a blow torch, I found some comfort in a maximum dose of ibuprofen and a vodka martini (and for those who know me well – yeah, I couldn’t finish the martini because it tasted gross).

9. Keep the scar protected and moist. Healing skin loves to be moist, especially early on. Ask your surgeon how best to accomplish that.

10. Get the stitches out on time. Don’t leave them in too long or you will be at risk for a larger or thicker scar. Disolvable stitches are convenient, but they do cause more inflammation which can lead to larger or more robust scar formation.

11. Tell your surgeon that you love the results (if they’re good!!) He/she will really appreciate the feedback.

I’m very pleased to report that my abdominal recontouring was a success, and I hope you’ll learn from my mistakes if you’ve got one coming up. Now I must strive to keep a new muffin top from growing by eating a healthy, calorie controlled diet (excluding real muffins!?) and exercising regularly. 😉

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