Tag Archives: health care

Saga Redux

In December 2019 I had surgery for prostate cancer after my annual PSA levels, which I’d beengetting since 2007, started to gradually increase in 2017. The surgical pathology report showed my tumor was more aggressive than the biopsies, and even though the resection margins were clear, the tumor had already started to extend beyond the prostate. Radiation treatment for a recurrence sometime in my future was likely inevitable. I would get PSA tests every three months for a couple of years, then every six months if they remained negative or stable. Eventually, if all was well, I’d get annual PSA testing for the rest of my life.

My PSA levels during 2020 were <0.014 ng/ml, below the level the test can detect. The first one of 2021 was 0.015 ng/ml, a very insignificant increase. My levels rose again slightly before hitting a plateau between 0.022 – 0.027ng/ml. In December 2021 Dr. Fine, my surgeon, recommended I get tested every six months. In June 2022 the result was 0.023 ng/ml, and I was relieved it had gone down.

Six months later my PSA was 0.044 ng/ml, almost double the previous level.

I sat at my desk for several minutes, starting at the results on the monitor. Intellectually I’d known this was a possibility, but now it had become reality and I wasn’t sure how I felt. It wasn’t a death sentence and the low level meant I didn’t have a large cancer with metastases. I was more worried about how Peg would react.

“My PSA was point-zero four-four.”
“Ok. How do you feel about that? It’s been a good three years.”
“I dunno. I’m not surprised but I’m not sure what to do next. I should probably ask Dr. Fine what he thinks.”
“Well, I’ll support whatever you want to do.”

Now, back in the good (or bad) old days, before e-mail, smartphones, and websites, I called patients on an antique, corded landline to discuss important issues, like abnormal Pap smears and biopsy results. Now most large health care organizations use MyChart, an application that allows patients to schedule their own appointments, communicate with their healthcare providers, view their medical records and test results and pay outstanding bills, all while adding another degree of separation between patients and said providers.

My health care organization, Suburban Medical Center, is more interested in efficiency and revenue than customer service; their medical providers are tightly scheduled and controlled. They prefer to communicate via email, often after hours or during a rare break. There are no direct phone numbers to any of the offices; one has to call the generic department number. If I want to talk with a physician’s nurse, the department personnel might try to contact her (usually her).

I sent a message to Dr. Fine through MyChart.

Me: Level has doubled. Now what?
Dr. Fine: Since lower than 0.05, I recommend repeat PSA in 3 months. We can follow it a bit closer. If it continues to rise, we would consider planning for salvage pelvic radiation therapy.
Me: Pelvic salvage sounds like a sunken ship. So is this likely tumor cells, residual tissue or Karma messing with me?
Dr. Fine: Not Karma Salvage RT sounds bad but can provide cure for you. We went 3 years with just surgery which is great for your very aggressive cancer. If you’d like, I can arrange a visit with our radiation oncologist, Dr. Howard.
Me: Only if you think we’re at that point. It seems the experts don’t agree on the threshold; 0.05, 0.1 and 0.2 are the numbers I’ve come across.

Whether to treat or continue monitoring depends on the level and the rate of PSA increase, but in the end it’s what the patient wants to do. Ultimately, I decided that continuing to follow PSA levels would only increase my level of anxiety and delay the inevitable.

I asked the office to set up a referral and ran into my first problem. Someone entered a referral to Hematology/Oncology. I tried the “Find a New Provider” option in the application, but Radiation Oncology didn’t appear on the list. I found Dr. Howard on the organization’s general website but there was no option for making an appointment. Round and round we go.

I thought making an appointment in person would be more expedient, given the office is only a few miles from my house. Carla, a diminutive, cheerful woman greeted me as I walked in.

“My name is Carla. How can I help you?”
“Is this Dr. Howard’s office?”
“Yes, it is.”
“I had surgery for prostate cancer 3 years ago and now my PSA levels are going back up. Dr. Fine suggested I talk with Dr. Howard about radiation. I’ve been trying to make an appointment and it hasn’t been easy.”
“How soon are you hoping to see him?”
“Sometime in January is fine.” (I didn’t want to ruin Christmas with potentially bad news).
“Well, let me see what I can find.” She looked at the schedule for a few minutes.
“He’s got an opening on Tuesday January 10. You’ll meet with his nurse at 8:30am and she will go over a lot of information, then you’ll see Dr. Howard at 9:00am.”

I knew Peg would want to come to the appointments because she cares deeply about my wellbeing and doesn’t trust the health care system as far as she could throw it. She also asks far more questions than I do. I mostly wanted to talk about whether radiation was a good idea, how long it would last and what side effects to expect.

There were several other people in the waiting room on our appointment day. Everyone had to wear masks, but for some people rules are mere suggestions. There was an old guy in a wheelchair whose daughter hovered over him while he took sips of coffee in between hawking up hairballs, sans mask. Why have a coffee machine in the waiting room if you’re supposed to keep your face covered.

Danielle, the nurse who does pre-consult counselling, called us into a room and, over the next 25 minutes or so, gave us an overview of radiation treatments, side effects and how to deal with them, and warning signs like rectal or urinary bleeding. I don’t remember a lot of details; you’d probably have to ask Peg. Having the nurse see the patient first is probably a good idea, especially with elderly patients, given that nurses tend to be far more patient. She gave us a packet of information and left.

A few minutes later Dr. Howard came into the room and gave us a warm greeting. He was a tall, thin bald guy who reminded me of Ru Paul. I shamelessly told him I was a retired physician; that often changes the tenor of the interaction. There’s no need to dance around delicate subjects like clinical judgement, diagnostic or therapeutic uncertainties, disability or death.

“We’re here because my PSAs have gone up relatively quickly in the past six months. Given my tumor was more aggressive than the biopsies and there was extraprostatic extension, I figured we’d be doing this sooner or later. Is there an advantage to doing this now over waiting and following PSAs?”
“I know what I’d do in your situation. Radiation is like battling an army. I can fight against 1000 soldiers or 10,000 soldiers. So, doing it now increases the chance of cure.”
“So, how do you know where you’re shootin’?”
“We direct radiation at the bed where the prostate was. Before treatment we run what’s known as a CT simulation and map out the area. It takes about 2 weeks for the radiation physicist and me to set up a program. We’ll call you when we’re ready to start treatment. You’ll come in five days every week, but initially we’ll be putting you in to different time slots. You’ll have a regular time slot in a week or so as other patients finish their treatments.”
“How long is this likely to take?”
“Usually about 37-40 treatments. We’ll start doing PSAs again in about three to four months.”

I left with an appointment the following Tuesday at 4:00pm for the CT simulation.

Preauthorization

There’s a meme on the Internet that exquisitely illustrates the differences between the American and Canadian health care systems. (Since I don’t know if this is copyrighted, click here to view.)

Breaking Bad Canada
You have cancer.
Treatment starts next week.
END

Just because you have insurance doesn’t automatically mean the insurance company will approve payment without question. They require approval for anything that is likely to cost them a lot of money. Our insurer is very good at authorizing treatment. Other companies make their subscribers jump through a lot of hoops, even for cancer treatment, looking for ways to weasel out of paying. (A friend of ours whose wife ultimately died of her second cancer had to fight for things our insurer would have approved without question.)

Peg works for our insurance company, which stresses the employees are the “first line of defense against waste, fraud and abuse,” and as such are diligent guardians of precious health care dollars. And did I mention she hates the health care system in general?

She called our insurance company to ask about preauthorization for my simulation and treatment. This started a week-long exercise in futility, prompting her to wonder, “How do they manage to open the doors in the morning?”

“I started with one of our care coordinators who was very helpful. I asked about getting a pre-authorization for the CT simulation and therapy and how much this was likely to cost us out of pocket. She told me Suburban Medical hadn’t submitted pre-authorization requests yet, so she called Linda in Radiation Oncology. Ultimately, they determined there was no need for the pre-authorization for the simulation because it’s not for diagnosis. We’ll need it for treatment, but they can’t provide a cost estimate until after the provider submits a treatment plan.
“So, then I called someone else to try and get a ballpark figure for radiation treatments. He found general cost estimates for prostatectomy and brachytherapy but nothing for radiation. He suggested I call Suburban Medical, which I did but I left a voicemail and haven’t heard back.”

A week later she tried again.

“I called the care coordinator again; she hadn’t gotten a pre-auth yet, even though it’s been ten days since your consult and your simulation was at the beginning of this week. Suburban Medical told her she wouldn’t get any requests until the imaging results were available. It usually takes a couple of days to approve it, but she said she’d fast track it for us before treatment starts.
“I called Suburban Medical but whoever I spoke with couldn’t supply any cost estimates. She suggested I call our insurer back, which I did. Our rep said the provider should have this information easily available since this is their business. He’d need more information because estimates are based on the individual provider, the specific plan and reimbursement contract. He did say, ‘You’re likely to blow through your deductible and out of pocket before this is over.’
“I finally gave up and went to Google. Estimated costs for radiation therapy for prostate cancer recurrence range from $33,000 to $67,000.”

Wow!

I’m fortunate having insight into the health care system as well as a tenacious woman looking out for my interests. Imagine, though, the aggravation and anxiety a person with little disposable income has to endure, navigating through a confusing bureaucracy and wondering how to pay for several thousand dollars of treatment while coping with a cancer diagnosis.

I’ll discuss the simulation and treatment in my next post.

Featured image © Can Stock Photo / bertoszig

The Prostate Saga, Part 2

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It’s a good thing Dr. Fine’s reputation preceded him, or I might not have stayed long enough to meet him. But first, a segue into the genesis of my ire.

When Corporate America took over health care administration, it decided physicians had wasted too much time taking care of patients instead of generating revenue. Large health care organizations began buying up individual physician practices and, in some cases, taking over hospitals. Younger physicians loved this idea: they got a salary, paid vacation and none of the administrative hassles of running a private practice. (I plead guilty, as I joined an HMO for those reasons. I was a poor businessman and I admitted it. The problem was, in many cases, I knew more about business principles than the people signing my paychecks.)

Older physicians balked at being controlled and some of them resisted as long as they could. If you didn’t play ball, The Corporation would find ways to shut you out. If you didn’t contract with the predominant insurers, you became “out of network” and a lot more costly to patients. Other older physicians saw the handwriting on the wall and retired early, the lucky bastards, to stay at home, engage in hobbies, travel or annoy the wife full-time.

We traded autonomy for financial security and ended up with neither.

The Corporation now controlled everything, including your ass, so it could dictate how you did your job. One physician I knew 25 years ago, a hospital employee, said, “I have guys in three-piece suits telling me what to do. And I do it.” Thus, the standard 10-minute appointment was created. No matter how complex the patient, physicians were expected interview, examine, diagnose and treat a patient in the allotted time before moving onto the next one. Or should I say “mooving on”, since patients were now herded through like cattle. (I often threatened to play the Rawhide theme in the hallway during my HMO days. “Head ‘em up! Move ‘em out!”)

If you were a specialist, you got 20 or 30 minutes for consults, even if the patient had cancer. No “wasting time,” like my gyn oncology professor during residency, who spent an hour discussing ovarian, uterine or cervical cancer with women who were still in shock from the diagnosis.

And now, back to our regularly scheduled blog post.

Dr. Fine’s office booked a 30-minute visit at 2:50 p.m. Peg and I arrived about 15 minutes early; she was still in a wheelchair after having foot surgery. I checked in, sat down and waited. And waited. And waited.

About 40 minutes later a nurse, nursing assistant or whatever, appeared in the door to the inner sanctum and bellowed, “David.” I got up and wheeled Peg through the open door.

Halfway down the hall, the nurse said, “David, what is your date of birth.”

I told her and she said, “Oh, wrong David.” So, I wheeled Peg back to the waiting room while the correct David was whisked away.

Twenty minutes later she reappeared. “David.” Once again, I wheeled Peg down the hallway, but not as far this time before she realized my date of birth didn’t match what was on her tablet. And, once again, I wheeled a now pissed-off Peg back to the waiting room.

Different women appeared at the magic door, calling names as if they worked in a cheap restaurant, and patients disappeared.

It was now 4:15 pm. I’m normally a quiet, patient type (you shaddap and stop laughing!), but even my patience was wearing thin. The first woman we saw opened the door and called, “David.”
“Which one?”
“Last name Rivera?”
“Yeah, that’s me.”

We were herded into a ~~pen~~ patient room and a few minutes later a very sweet assistant came in to verify my information on the computer terminal (paper charts have all but disappeared). She apologized for the wait and said Dr. Fine would see us soon, but he was running behind.

Peg smiled but said, “We’ve been waiting a long time. Dr. Fine better be a rock star!”

The SYT swallowed and assured us Dr. Fine was indeed was, figuratively speaking, on par with Jimmy Page.

We could hear snippets of Dr. Fine’s conversation with another patient. Another 15 minutes elapsed, then yet another nurse/assistant came in with two books. I don’t recall the titles, but they could be titled, “You and Your Prostate,” and “What You Need to Know about Prostate Cancer.”

“The doctor will be in shortly to discuss your diagnosis.”

Now I was pissed! “I’m a physician! I KNOW my diagnosis; Dr. Ky and I have talked about it and I’m here to talk about getting a surgery date scheduled!” I thought If you’d looked at the record before barging in here, you’d know what’s happened and why I’m here.”

Finally, Dr. Fine entered the room and I understood why he was running late. He greeted us and apologized for running late. “Discussing a new diagnosis of cancer with a patient takes some time and I don’t want them to feel rushed.”

Ok, you earned your rock star status.

He talked at length about Gleason scoring in general. A Gleason score of 6 suggests one’s cancer is likely to grow slowly while a score of 8 and above is likely to be more aggressive and spread quickly. My score of 7 (4+3) put me at intermediate risk and was more concerning than a score of 3+4. Then he talked about Tumor, Node and Metastasis (TNM) staging and how that relates to overall survival; my cancer stage was T-IIa, meaning no metastases or node involvement. (For more information, go to the Urology Care Foundation educational materials page and download the Localized Prostate Cancer guide.)

Notes from our discussion of prostate cancer and treatment options

We then discussed treatment approaches. I talked about the risks of radiation in my previous post, but the biggest drawback is it turns the prostate to mush. If the cancer recurs, taking out the prostate is next to impossible. Doing surgery first leaves radiation as an option for recurrence.

Surgery removes the prostate completely and, potentially, all of the cancer, but has its own set of risks. Immediate problems include recovering from surgery, including having a catheter in one’s bladder for a week. The surgeon has to cut the urethra (that tube from the bladder to the outside) to remove the prostate, and then sew it back together. One is likely experience some degree of urinary incontinence once the catheter comes out; they recommended getting a large supply of “adult incontinence underwear” along with pads that look like what women wear after delivering a baby.

Surgery removes the seminal vesicles and potentially some nerves along with the prostate, guaranteeing temporary or permanent erectile dysfunction. I would be taking a low dose of the “little blue pill” (sildenafil) every day to “promote blood flow” back into a limp penis. I’d have a checkup six weeks after surgery and then go to the Austin Powers Swedish Penis Enlarger clinic to learn how to use a $300 “medical grade” acrylic cylinder and vacuum pump. For some reason they discourage procuring the much cheaper products available at your friendly neighborhood adult toy store as it could “result in injury.” (Like Ralphie getting his tongue stuck to the frozen flagpole in “A Christmas Story?”)

We agreed to a surgery date right after Thanksgiving. He gave me a card for the Patient Navigator, someone who is supposed to “guide you through the process.” I talked with her once; she told me someone from the hospital “will call you with a surgery date within a couple of weeks. Then someone will call you a week before surgery with questions and instructions.” I used to impart that information to my patients at the end of our visit and didn’t need someone to do it for me.

I saw one of the Urology Department P.A.s (physician assistant) to teach me Kegel exercises, which help control the inevitable leaking bladder after surgery. Women learn Kegels when they are far younger, since they have only one urethral sphincter to men’s three. I told her I’d been wearing protection for months to which she replied, “Welcome to our world.” The visit lasted only a few minutes. Peg had taught me abdominal core and Kegel exercises to do while driving to client’s houses. She did a better job and for free.

About a week later someone from the hospital’s scheduling department called me while I was driving to a client’s house. My surgery would be on December 2 at 7:30 a.m., a wretched time, as I’d have to be there about 2 hours earlier for preparation (which often takes about 30 minutes).

“I’m wandering around the Chicago suburbs so now isn’t a great time to talk. How about you give me a call next Monday when I’m home?”

“Ok, that would be fine. In the meantime, I’ll send you preoperative instructions through our website and we can go over them next week.”

She called and went over my medical history – current and past illnesses; the medications I took; allergies to medications – before going over the same instructions she’d sent the week before. I realize it may seem redundant, but there are people handicapped by a Y chromosome who don’t read or listen and need all the reinforcement they can get.

“Back in the good old days, I used to do all this myself.”
She replied, “You probably weren’t that busy back then.”

Bullshit. I routinely saw 25-30 patients a day in the office and worked in women with acute problems. I did my own preop H&Ps (history and physical) and dictated it on the hospital’s transcription line. Years later, wrote my reports in MS Word and hand delivered them to avoid hearing, “We can’t find your H&P. Did you forget to dictate it?”

Preparing for surgery

Physicians go through “informed consent” with a patient before surgery or a significant treatment. Ideally, a physician explains what s/he proposes doing, what it is meant to accomplish, the risks and benefits of the procedure (including risk of death, if appropriate), and what might happen if the patient refuses. Then the physician gives the patient time to ask questions, have those questioned answered and, often at the end, sign a permit for said treatment or surgery.

This ritual is supposed to ensure the patient makes a well-informed, intelligent decision while also minimizing the risk of litigation in the event of an adverse occurrence or outcome. In reality, a pissed-off patient can always claim “I didn’t know what I was agreeing to” and some lawyer will take the case. So, many of us believe there is no such thing as truly “informed consent.”

My approach to informed consent for surgery went something like this:

“You need to be at the hospital two hours before your surgery time. They will get you ready for surgery (but it doesn’t take two hours, so you’ll spend a lot of time picking your butt). When everyone is ready, one of the nurses will take you to the operating room, put you on the table, hook up EKG leads and strap you down, so you don’t roll off. (Sometimes we will pick our butts waiting for anesthesia to stroll in.) I will be there before you go to sleep. This procedure is going to take about x hours. You’ll go to the recovery room for about an hour and then sent to your room (inpatient) or sent home (outpatient).

“All surgery comes with some risks: risk of bleeding, infection and injury to something inside. You also have a 1 in 60,000 risk of dying from anesthesia, but you are much more likely to die driving your car, especially in the winter when there are a lot of idiot drivers around.” (For the curious among you, the risk of death from a motor vehicle accident is 1 in 103. I can’t find the odds of dying from stupidity, but the Darwin Award people keep a nice tally.)

If I was tying a woman’s tubes (tubal ligation), I added this:

“You also need to understand nothing is perfect, including tubal ligations. About three out of every 1000 women getting their tubes tied get pregnant, sometimes many years later. A few of those pregnancies will end up in the uterus, but many get stuck in the tube, causing an ectopic pregnancy which can kill you if not treated. So, if you ever think you are pregnant, you need to see a physician right away.” (I met a woman in Tennessee who had an ectopic pregnancy 13 years after her tubal ligation. She had been bleeding vaginally (and internally) for a few days, not realizing she was pregnant. I found 1300cc of blood in her abdomen.)

Now, that approach was too vague and informal for Ms. “Expectation Management” who thought researching every possible surgical complication was a fine idea, and then expected ME to grill my surgeon on how the team was prepared to avoid them.

Ocular edema – high pressure within the eyeballs from prolonged time in the Trendelenburg position, causing temporary or permanent blindness
Corneal abrasion – scratches in the cornea more often due to dust, sand, poorly fitting contact lenses or catfights
Brachial plexus injury – upper arm nerve damage making my arms useless
Compartment syndrome – excess pressure in leg muscle spaces from being in stirrups for a long time, muscle damage from which may necessitate amputation
Pelvic lymphocele – collections of fluid in the pelvic cavity from removing lymph nodes, or hydrocele – collection of fluid in the scrotum causing it to swell to the size of a cantaloupe
Atelectasis – collapsed lung tissue from not breathing deeply enough, leading to pneumonia or respiratory failure requiring ventilator support
Deep vein thromboembolism (DVT) – a clot in the deep leg veins which can potentially break off and travel through the heart and into the lungs, causing instant death from a saddle embolus

I know a lot of the possible complications, which is why I hated gyn surgery! I’m more like Peg’s sister, Michele: Ignorance is bliss.

The day before surgery I had to drink only clear liquids and do a bowel prep. I drank a bottle of magnesium citrate, which is far easier to take than the gallon of NuLYTELY® I had for my colonoscopy prep. But, because a bowel prep can screw up one’s electrolytes, they told me to drink a 20oz bottle of Gatorade four hours before surgery. Yep, 3:30 a.m. Sleep is overrated.

We arrived at the hospital parking lot about 5:30 a.m. and trekked what seemed like a couple of miles to Surgical Registration. I checked in with a woman who was too alert for such an abysmal time. We waited for about 20 minutes, then someone led us on another trek to Pre-Op where I changed into a hospital gown and hopped onto the gurney.

My nurse was an adorable, diminutive redhead with freckles and a pixie cut, too alert and too cheery. She put EKG leads on my chest, a blood pressure cuff on my arm, and poked my finger to check my blood sugar, and started an IV, all while telling me what I needed to do.

“You remind me of my wife.”
“Hey, you brought her here, I didn’t.”

I started laughing so hard she had to retake my blood pressure after I calmed down.

I talked with Dr. Pierce, the anesthesiologist, and reminded him of my paradoxical reaction to Versed (midazolam), a drug used for anesthesia induction and conscious sedation. Dr. Fine appeared a little after 7:00 am for some last-minute discussion and reminders. Surgery would take about two or three hours and I would go home in the afternoon if everything went well. Then the OR nurse put a bonnet on me, had me kiss Peg and rolled me down to the room. I slid onto the table while the anesthesiologist and the scrub tech introduced themselves and got me ready.
The last thing I remember hearing was, “This might sting a little as it goes into your vein.” Click here if you want to see Robotic Assisted Laparoscopic Radical Prostatectomy .

When I woke up 3½ hours later, it seemed as if only ten minutes had passed. I felt pretty good in large part to the local anesthetic injected around the trocar sites. Even the catheter wasn’t uncomfortable. I had something to drink and the recovery room nurse had me walk down the hall. I was home by 3:00 and really happy I didn’t have to stay in the hospital.

The following week wasn’t bad, either. I didn’t have to get up at night because of the catheter. Peg got up at 1 a.m. that first night to empty the bag, but I cut my liquid intake in the evening and emptied it about 11 p.m. which got me through the night. I had six stab wounds for the trocars but only one hurt if I coughed or move wrong, and that only lasted a week. I took three hydrocodone tablets, mostly at night, and used acetaminophen the rest of the time.

The pathology report came back by the end of the week:

Surgical pathology report
Prostatectomy Pathology Report.
A. Right neurovascular bundle margin, excision:
-Neurovascular tissue, negative for malignancy.
B. Prostate, radical prostatectomy:
-Prostatic adenocarcinoma, Gleason score 4+5 = 9.
-The margins of excision are negative for tumor.
-Focal extraprostatic extension, left posterolateral, for a total span of 5 mm.
-Uninvolved seminal vesicles.
C. Bilateral pelvic lymph nodes, excision:
-Six lymph nodes, negative for tumor (0/6).
D. Posterior bladder neck, excision:
-Fibromuscular tissue, negative for tumor.
E. Anterior bladder neck, excision:
-Fibromuscular tissue and focal urothelium, negative for tumor.

So, the cancer cells were worse than the biopsy and it had already peeked out beyond the prostate. Having negative margins means the bad stuff was confined to what was taken out. Surgery turned out to be the more prudent approach.

The catheter came out the following Monday. I had to change underwear frequently for a few days but was back to my pre-surgical level of incontinence by the end of the week. It felt strange being able to urinate like I did before my prostate started squeezing my urethra.

I had an appointment for the Vacuum Erection Device Clinic in January, but that is a whole ‘nother story.

An Epidemic of Stupidity

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I’ve declared the third week of July as National Health Care Stupidity Week, for I’ve never encountered such high levels before.

I saw an ophthalmologist for a problem with my left upper eyelid at the beginning of July and scheduled surgery for three weeks later. We asked the scheduler how much the procedure would cost but she said, “It depends.” That’s not much of an answer to a physician who understands the vagaries of CPT coding and insurance reimbursement. You give the insurance company the codes and your charges. The insurance company laughs their asses off and then tell you “No fucking way. THIS is what we’ll reimburse you.”

The scheduler said, “I’ll ask the doctor what he plans on doing and I’ll call you in two days with the charges.”

I can understand if the physician wasn’t quite sure what he was going to be doing right after seeing me, so we let it go.

The week’s aggravation started at Drugs ‘R’ Us, a national chain, which the threat of litigation prevents me from identifying. I’ve used a maintenance inhaler for life-long asthma, for which there is NO generic. The price has climbed from a $150 insurance copay for a three-month supply from a parasitic mail-order pharmacy benefit manager to $400 for one and NO insurance coverage until (my very high) deductible is met. I brought this up to my pulmonologist last month and asked for a little-known generic equivalent (different medications but should have the same therapeutic benefit).

He said, “Well, Thieving Bastards Pharmaceuticals have this discount card that will give it to you for free if you have insurance. It’s good until December 2018.”

I learned a long time ago there ain’t no free lunch, but if they are willing to part with it for free, I’m in. I took it to Drugs ‘R’ Us and, after 20 minutes or so of fighting with the computer, I got my inhaler. ONE inhaler. I have to go back every month for this charade.

The pharmacy’s robot phone said I could pick up this month’s inhaler. However, the pharmacy tech brought me a bag with three inhalers and a bill for $935 “because you haven’t met your deductible.” No shit, Sherlock. I have insurance with a high deductible and a health savings account (HSA) which is great at a certain income level but completely useless if you’re making minimum wage (in which case you probably don’t have any insurance and you’re a drain on society, at least according to the bastards who’ve been trying to undo the ACA for the past 8 years).

“Last time I got one and it was free! Here’s the card and I’m NOT going to pay almost a thousand bucks for this. I’d rather die a quick and painless death.” (I’m using that phrase more often these days.)

“Well, let me change it but I have to run it through the system again. It’s going to take some time.”

Fine. I sat in one of the uncomfortable chairs in the pharmacy waiting area and perused the local paper, which didn’t help my mood any.

Then my phone rang.

“Hi, this is Brunhilda from the Pretentious Suburban Surgery Center. Your insurance is going to pay 80% of the procedure after you’ve met your deductible, but you haven’t met your deductible, so we want your left testicle ($1305) as a down payment.”

“First of all, why? Second, what is this going to cost me in total?”

“Well, we ask everyone for a down payment.”

No, you said it was because I hadn’t met my deductible but, please, proceed.

“Why? This isn’t a cosmetic procedure and I’ve already signed the boilerplate insurance assignment form that says I’m responsible for the remainder. So, again, what is this going to cost me?”

“We can’t tell you what we charge, and the insurance company won’t let us tell you what they will pay us.”

“Why not?”

“It’s in our contract.”

“You’d tell me if I was paying for all of this out of pocket, wouldn’t you?”

Silence

“Well, my financial adviser has told me that’s not a great idea. I’ve got an HSA funded with pretax dollars and if I overpay you and you then reimburse me directly, I might run afoul of the IRS, which is not known for being gracious. Would you be willing to talk with her as I have to leave town in a few minutes?” (Translation: “If I acquiesce to this extortion, Peg is going to ream me a new one. We’re going to play good cop/bad cop and I’ll let her ream you a new one. You really don’t want to poke this bear, but you’re gonna have to learn the hard way.”)

She says, “I’d be happy to!” and I hung up, snickering.

An older woman came to the pharmacy while I was waiting. She was bent over a wheeled walker, wheezing audibly as she shuffled up to the counter. I suspect she had long-standing COPD and it made my lungs hurt just to hear her breathe.

“They called me and told me my prescriptions were ready.”

“What’s the name?”

She wheezed her name.

“Your prescriptions have expired, and we put a call into your doctor’s office to get authorization for refills.”

“But someone called me and asked if I wanted all my prescriptions refilled. She even listed all of them and I said ‘yes!’ Then I got a phone call from you!”

“That is an automated system and we don’t have any control over it.”

This went on for several minutes with the poor woman protesting that she’d done everything she’d been told but slowly realized this trip had been for naught.

Finally, she sighed, said, “Well, what are you gonna do,” turned around and shuffled out. She was far more resigned than I ever would have been. ( is one of my all-time favorite revenge movies. Just sayin’.)

The pharmacist came out, handed my drug card back to me and said, “We put in a phone call to the company and we’re waiting to hear back. It shouldn’t be too long.”

Twenty minutes later I was still waiting. Finally, I got up and said, “I have to leave town. Can my wife pick this up?”

“That’s no problem. We’ll let her know when it’s ready.”

Then I asked her. “Is there a generic for this because the card expires in December and I can’t afford $400 a month for this.” I gave her the generic medication names.

“It looks like the only one is ‘Yerstillscrewed’ but insurance doesn’t cover it.”

“I KNOW that, but I can get a three-month supply using GoodRx for less than half of what one of the brand-name inhalers costs.”

It’s turns out that Thieving Bastards Pharmaceuticals changed the program so that it only covers that drug up to $200/month. You know, the drug for which they set the price at $400.

I left and started my drive to Springfield. I was just about at Joliet when the phone rang.

“This is Vinnie, the enforcer, uh, business manager from the doctor’s office. I wanted to let you know that your insurance is going to pay 80% of the procedure after your deductible is met, but you haven’t met your deductible, so we want your right testicle as a down payment.” (It’s been two weeks since the initial visit and less than a week before surgery.)

“Why?”

“It’s our policy.”

“I’ve had other procedures and visits, and no one has EVER asked for money up front. You just told me what my deductible is, and you know how much I’ve met, which means you also know I’ve been paying towards it. The surgeon’s fee and the surgery center charges are likely to eat up the rest of my deductible. Again, how much is this going to cost?”

“It depends.”

“What do you mean, ’it depends?’ That’s bullshit. There’s a CPT code for the procedure, and you have a charge for it. I know that because I’m a physician and I’ve had my own charge list. You’re going to give the insurance company a bill with a CPT code. They are going to send me an EOB (Explanation of Benefits) which will tell me what YOU charged, what they allow, what they’ve paid and what my obligation is. So, to pretend this is a deep, dark secret is disingenuous. The only thing that “depends” is how much the insurance company is going to pay you and your contract with them defines their reimbursement. So, to ask me for money up front is insulting. You’re making me sound like a deadbeat.”

“No, no, we do this with everyone.” (Where have I heard that before?)

“Yeah, well no one else has ever asked me for a deposit! No one asked for a deposit before my colonoscopy, or when I went to the ER for a doppler scan for lower leg pain. Look, at this point I’m ready to cancel the whole goddam surgery and find someone else!”

“No, no, no! I’ll talk to the doctor and let him know how you feel and you can discuss it with him.”

I called Peg, who spent the next three days dealing with the office, getting nowhere. Finally, she got a call from the new office manager, a far more reasonable person. They talked for a couple of hours about what appears to the patient to be a hostile approach to payment. It was both illuminating and infuriating.

High deductible health plans are sometimes several hundred dollars a month less expensive than plans with lower deductibles. Some high-deductible plans come with Health Savings Accounts (HSAs), a Republican wet dream Paul Ryan drags out as an alternative to the ACA. HSAs are funded with pre-tax dollars – a maximum of $3450 a year for singles and $6900 for families in 2018 – which can only be used for health care expenses, at least until the account holder reaches 65. Old goats like me (over 55) get to put away an extra $1000 per year in our HSAs. The plans still come with out-of-pocket maximums of $7,350 for singles and $14,400 for families.

This is a great idea if your income level allows you to part with a few hundred bucks a paycheck and you’ve got a tidy sum in your bank account. It sucks if you don’t have the income, the savings, or if you anticipate ongoing medical expenses.

Here’s the problem. Lower income people get high-deductible plans because the premiums are affordable, but they are at greater financial risk because they don’t have the savings to cover the deductible. They may avoid preventive care if they are unaware that most high-deductible plans cover it with no out-of-pocket costs, opting to take a chance they won’t develop a more serious (and costly) illness later. Because they often can’t afford the deductible, they are more likely to default on outstanding medical bills. Hospitals and physicians have caught on and now demand money up front.

Asking for a down payment would be far more palatable if it applied to everyone. It’s no different than a contractor asking for money up front for a pricey remodeling job. Pay some now, pay the rest when the job’s done. But framing it as something required only of people who haven’t met their deductible implies they are deadbeats and is insulting. Further, waiting until a few days before surgery to extort money is infuriating. It should all be explained up front when scheduling the surgery.

The logical solution is universal coverage, but Congress lacks the political will and there are too many people making waaaaay too much money off the current system.

Hang on, because it’s only going to get worse.

Jurassic Doc

2 Replies

I don’t recall the exact moment I realized I was sliding towards obsolescence, but by that time it didn’t matter because I didn’t care.

I did my residency during the early days of ultrasound; images looked more like a Rorschach inkblot than pelvic organs or babies. We all believed radiologists made shit up when they read ultrasounds. Few things were more irritating that having one emphatically identify a non-existent tubal pregnancy, committing us and the patient to an unnecessary exploration.

We used one of the first TV cameras adapted for a laparoscope, a rather bulky attachment whose picture was as atrocious as it was fascinating. The attending physician watching the monitor while the residents tied a patient’s tubes laparoscopically said, “Maybe I DON’T want to see what you are doing.”

The hospital where I did my internship bought a Computerized Axial Tomography (CAT) scanner, a great advance over simple x-rays and a fortuitous event. One of the radiology interns volunteered for the initial scan and discovered he had a brain tumor. Word got around only after people began questioning the sudden onset of baldness.

Technology’s transition from medical advance to hospital marketing tool started in the 1990s. Physicians touted “minimally invasive surgery,” which some patients interpreted as “painless and risk-free.” Magnetic Resonance Imaging (MRI) replaced CT scans and generated new revenue as outpatients sites opened. (One small town boasted five MRI machines.)

Administrators became enamored with robotic surgery in the early 2000s, buying a toy that cost $2 million and came with a $150,000 annual service contract. Initially acquired by large private and university healthcare systems, robots found their way into small community hospitals looking to attract more customers to augment declining revenues.

I’ve always been cautious; I was never the first to embrace that which was new and heaped with promise. My choices were often met with incredulity. “What? You DON’T treat warts and cervical dysplasia with a laser?” No, but thirty years ago I saw physicians willing to plunk down fifty grand for an office model, even though they had no idea how to use it. Those contraptions are likely catching dust in a closet, having been supplanted by the far simpler wire-loop cautery known as LEEP.

I never cared for doing surgery exclusively with a laparoscope. I could take out a tubal pregnancy through a small incision and be finished in the time it took to set up all the laparoscopy equipment. I didn’t get on the Laparoscopic Assisted Vaginal Hysterectomy (LAVH) bandwagon, having watched my colleagues turn a 45-minute procedure into a seven-hour ordeal. I learned “new” wasn’t necessarily “better” but was always much more expensive.

I preferred delivering babies to gynecologic surgery, and most of my subsequent jobs were for obstetric coverage. I stopped doing major gynecologic surgeries in 2007, relieved. Then earlier this year an office nurse said, “Any woman who has a big scar on her belly from an abdominal hysterectomy should sue her physician for malpractice.” I’d passed the point of no return and was on the way out.

I don’t mind being a dinosaur, partly due to the direction my profession has taken. We spend far more money than twenty years ago for very little tangible benefit. Younger physicians rely too much on lab tests and scans and too little on actually listening to and examining their patients. I don’t want to talk with a patient while typing notes into a laptop—the health care version of texting during dinner. And I don’t want to take ten minutes to generate a prescription from an electronic medical record (EMR) when I could do it with a pen in 30 seconds.

I’m looking forward to retirement and I’m happy to pass the baton onto a younger generation. My only regret is that I probably won’t be around in thirty years to witness the same realization cross their once-eager faces.

A Little Perspective, Please (Part 2)

Notes from Dr. Dave

Musings from forty plus years as an OB/GYN and a writer.