Shopping Around

Macy's in New York City

“She doesn’t have physical exam coverage and her insurance only allows three office visits per year. No lab coverage. No preventive care coverage. She needs her blood pressure and diabetes meds refilled but she cannot come in for a physical.”

I’ve seen this a lot lately.

“No problem. Tell her to come in for a regular office visit so we can at least check her blood pressure. I will code a 99214 and she may get a 30% discount off that as a cash pay patient. I can send her to a discount laboratory for labs that will save her hundreds of dollars. In October she can get a $99 mammogram at one of the local imaging centers. Her flu vaccination she can get cheap at the health department. We will just have to postpone her PAP another year.”

So she came in….

Crying.

“I pay over $700 a month for this insurance.  I work for myself and with my diabetes no one will cover me otherwise. I can’t afford anything else. They told me that all of my doctors were covered and my meds were covered. They lied.”

She did not read the fine print. Not that she really had any other options available to her… 

It used to be like this ten years ago. People with expensive but essentially useless policies. Here we go again. Now, at least, I have access to a discount laboratory. 

OMG. What A Day….

Some days are just…. just a crazy mad dash to the finish line. I am exhausted but I promised one of my most favorite people in the whole world, Craig Boyack, that I would invite him over to talk about his new book The Enhanced League.

I’ll let him tell you all about it while I draw myself a nice warm bath and soak my weary body in some lavender bubbles. 

*****************************************

Thanks for inviting me over today to talk about my newest book, The Enhanced League. This one is a little different than anything I’ve released before, and I’m kind of excited about it.

One short story, called The Enhanced League, was on my list when I wrote my second Experimental Notebook. I wrote it and intended to include it in that book. It had a nice twist ending, and almost a Twilight Zone feel about it.
The story wouldn’t leave me alone. When I assembled the Notebook, I left this one out and placed it in a new folder. I knew The Enhanced League had more to offer than just this story. I started making a new list of story ideas about one year in the professional baseball league where almost anything goes.

One day, while commuting to my paycheck job, I was listening to MLB Radio on Sirius-XM. They had a kind of spoken word anthem, narrated by Tommy Lasorda. If you’ve followed baseball much, Tommy is one of the legends and he has a distinctive voice. If I told a baseball fan to read the rest of this post in Tommy’s voice, it would immediately come through like that.

The piece was wonderful, but MLB Radio chopped it into sections with broadcast highlights. I wish they’d left it alone. I heard it a few more times, but never without the interruptions. This attracted my Muse, and I decided to do something on my own.

I sat down and wrote out a baseball anthem in a kind of second person point of view, just like Tommy’s. I liked it, and decided to keep writing them. Then it occurred to me that the broadcast interruptions were a kind of message to me.

The broadcast interruptions were intended to enhance Lasorda’s spoken word poetry. I don’t know what it was, so I’m calling it an anthem, and I called mine anthems too.

After I wrote the first one it became easier. My own imaginary Tommy Lasorda just wandered in, took a seat on the couch, and started talking. All I had to do was write down what he said.

My blog followers and regular readers know I’m always up for something new. These anthems were fun, and I think they enhance The Enhanced League. I peppered them throughout the book, and think they really add some fun human elements to the story. I hope you enjoy them too.

Oh, and I still can’t read one without hearing it in Tommy Lasorda’s voice.

***

cover

Blurb: The Enhanced league is a collection of short stories and anthems centered around a year in a fictional baseball league. It has a slight science fiction background. This league has a lot more pomp than you might be used to, and nobody seems to care if the players use performance enhancing drugs.

Stories involve existing heroes, up and comers, and falling stars. While there are the obvious stories that take place on the field of play, there are also human interest stories that take place around the baseball gyrations. These stories involve scouting, trades, ruthless business decisions, and even relationships.

I enjoyed researching and bringing you The Enhanced League, and I hope you enjoy it as much as I did. — CB

Click here to purchase!

boyack
I was born in a town called Elko, Nevada. I like to tell everyone I was born in a small town in the 1940s. I’m not quite that old, but Elko has always been a little behind the times. This gives me a unique perspective of earlier times, and other ways of getting by. Some of this bleeds through into my fiction.

I moved to Idaho right after the turn of the century, and never looked back. My writing career was born here, with access to other writers and critique groups I jumped in with both feet.

I like to write about things that have something unusual. My works are in the realm of science fiction, paranormal, and fantasy. The goal is to entertain you for a few hours. I hope you enjoy the ride.

Craig

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Cash Flow

Fountain at the Alamo in San Antonio

“You tell that doctor to write me a prescription for something affordable!”

*Click*

My medical assistant glanced up at me with a shocked look on her face. There was no need to repeat the conversation. I had heard every word.

“That does not make any kind of sense. It is a generic medication. It should only cost $40. Max. Call his pharmacy and find out what that med is going to cost him there.”

Later in the day I read the computer message that said it was going to cost $340 for a one month supply. Hell. I wouldn’t even pay that. 

I typed out a quick message and routed it back, asking why it was going to cost that much.

It is the brand name. If you want them to fill the generic you have to write for the generic. 

Except that I HAD written for the generic. I always write for generic. 

I sent back a stongly worded message pointing this out and telling them to fill the frickin’ generic. 

This was followed by a string of other patients with similar complaints all from the same pharmacy chain. Insurance companies refusing to cover prescriptions that patients had been getting without issue because the pharmacy chain was filling brand name instead of the generic option. It makes them more money. I would have never known this was occurring if the insurance companies had not denied coverage. 

From a drug coverage standpoint we love to hate on insurance companies but pharmaceutical company and pharmacy shenanigans are one of the reasons healthcare costs in the US are skyrocketing out of control. 

So I tell patients to be aware of what they and their insurance companies are paying for. If there are significant changes, please ask questions. Shop around to other pharmacies. The variability of cost from one pharmacy chain to the other is astonishing. AND, talk to your doctor. The only way I find out about these kinds of things is from patient complaints.

Just maybe don’t yell at my staff… 

Veracity


He chuckled to himself. Potassium level?

Let’s make this one 6.5….

He hit enter then scanned down the list. 

Ahhh… a 90 year old woman. Perfect!

This time he picked the sodium level. 

126

In thirty minutes he had changed the results on over three dozen patients. Just one or two per provider, not enough to cause much of a stir…. Since none of the docs at the various system clinics spoke to each other.

*******************************

Potassium level 6.5? No eveidence of hemolysis noted. Damn.

She sighed and dialed the patient’s number, hoping he would pick up.

“Hello?” a male voice said

“Mr. James?”

“That’s me…”

“This is Dr. Stephens. I was calling to discuss your lab results. Do you have a second?”

“Sure, Doc!”

“Your potassium is showing as rather elevated. Most of the time this ends up being an error but at this level, if it is true, it can kill you. We need to get it rechecked. The best place to do that is the ER. They will recheck the levels and do an EKG and if it is really elevated they can bring it down.”

“Are you sure?”

“Yes, sir. I know going to the ER is not a cheap proposition but I don’t feel like at this level we have much of a choice.”

He sighed audibly. “Ok, Doc. If you say so. Should I go right now?”

“Yes. I’ll call ahead and let them know you are coming and why.”

She had alerted the lab to these abnormal results several times. Each and every time it seemed they were proven false. It had been occurring since the mandate that all providers had to use the system laboratory instead of sending their samples to an outside place. Invariably she was told it must be a problem with the way staff was drawing the blood. 

Only it wasn’t… She knew that was not possible.

*********************************

The board gave a standing ovation. Revenue for the system had reached an all time high. It had been a banner quarter. Things had been looking grim for so long….

A nondescript figure in a dark suit with a light blue silk tie sat silently in the corner, arms crossed, smiling to himself. 

Impact: Chapter Seven

Chicago in lights

“Next.” 

I stepped forward to the granite counter top and managed a weak smile. The woman in the bank’s uniform half-smiled back at me. Her striped blue and red scarf was tied jauntily at her neck.

Like a flight attendant.

“How can I help you?” She sounded bored. In her mid fifties, the woman had amazing hair with just the right amount of wave and body. 

I felt the familiar envy. I stared at that hair, wishing my own head was not covered with the flat, lifeless, straight as a board hair I had been cursed with. It was a dull mousy brown until I started to dye it blonde. At least the blonde helped. Speaking of which, my roots were showing. I needed to make a hair appointment if I was going to have to start interviewing for jobs now.

Times of stress always left me to dwell on each of my own flaws. My thighs were probably going to come up next. Maybe the crows feet. I was getting old. I looked closely at the woman’s eyes. She had great skin, too. I focused on her chin looking for hairs. 

Please let there be whiskers. Please let there be whiskers.

Nope. Not a single one. 

Damn it.

“Ma’am?” Irritation was in her voice and any trace of smile had now left her face.

“Oh. Sorry.” I felt my cheeks flush. “I need to make a deposit.” 

I pulled the paper paycheck, my last paycheck, out of the envelope. “Wait. I forgot to sign it.” 

The woman raised an eyebrow and passed a ballpoint pen to me. It was attached to the counter by a chain that made a slapping noise with each stroke. Banks were always disconcerting… unearthly quiet despite the hard surfaces and volumes of people. I felt I was disturbing the peace just by scribbling my name.

I passed the signed check to the woman. Her name tag read Elyse.

She waited, expectantly. “Where’s your deposit slip?” She looked at me, incredulous.

It had been too long since I had manually deposited anything into my bank account. My checks had always been deposited electronically. 

“Um, I don’t have one.”

“What’s your account number?” I could tell she was holding back the disdain with great effort.

“You know what? I don’t know that either. I have my bank card, though. Can you pull it up from that?”

I pulled the card out of my keychain wallet and handed it over.

“Do you have some ID?”

I cringed self consciously as I showed her my awful driver’s license picture. It was from before the blonde. She nodded, handing it back, and I tucked it quickly into the safety of my billfold.

Curt typing ensued. Then a scowl at the screen. More typing. Finally, she looked up at me suspiciously. 

“It says here that you closed out that account yesterday.”

A wave of nausea came over me.

“What do you mean?”

“I mean that it says you were here yesterday and closed out the account.”

There was $20,000 in that account.

“Does it say if I took that money in check or cash?”

She manipulated her computer mouse and clicked twice.

“Cash.”

There was no way to trace it.

“What about my savings account?”

“Also closed out.” 

I had scrimped and saved, trying to accumulate enough to eventually retire, hopefully sooner rather than later. I didn’t know how long I could keep up working as an ER physician. They had a high burnout rate after all.

It was gone. Every bit of it.

What was happening to me? Should I say something? Report it to the police? 

“That wasn’t me,” I said softly.

“Customers are not allowed to cash out accounts, particularly NOT accounts that large, without notice and without proper ID. I can assure you that you did indeed close out that account.”

“It was not me.”

A “Hmmmf…” of disbelief was all she uttered. The woman offered no other explanation, no further assistance. 

“Can I just cash this check, then?

“Fine,” she said sharply.

“In tens and twenties, please.”

I weighed my options as I watched her count out the bills, one by one. Four thousand dollars was not going to last me very long. Not in Chicago. 

Not anywhere, really.

At least I had paid the month’s rent last week. I was good there. 

The wad of bills was thick. I registered that my work computer was still there as I stashed them at the bottom of my bag. That could be helpful. I wondered how long it would take for them to realize I still had the thing.

I walked the few blocks back to my apartment mulling things over. Who could I call for help? I needed advice. Six months ago I would have called my boyfriend. Well. I would have if my phone had been working, but now, even if we were still on speaking terms I realized I did not know his phone number. I had never had to know it despite texting and calling him thousands of times over the years we had been together. My phone made communication with him a no-brainer. 

There had to be someone else I could call. Surely. As I rode the elevator up to my floor, I wracked my brain but there was no one. I had no friends. Only work acquaintances. There was no one I was close enough to that I could call them up and confess that my world was falling apart. No one except for him. Having regular sex with someone allowed you certain lifelong privileges didn’t it?

Probably not, but I still had to try. 

Maybe I could look him up on the work computer if my password hadn’t been shut down already. Not his cell number, of course, but I could Google his office number. He’d be in clinic right now if it was not a hospital week. If wifi was not working in my apartment, and something in the pit of my stomach told me it would not be, I could find a Starbucks somewhere… 

I turned my key in the lock. It stuck a bit and I panicked as I jiggled the key and retried it. Finally the lock clicked and I pushed open the door, relief flooding through me. 

My relief was short lived, however. It evaporated when I saw what was waiting for me inside. Or rather, what was not waiting for me.

Nothing

There was nothing at all inside. Every scrap of furniture was gone. Every last one of my possessions, gone. All that remained were the indentations in the carpet where my couch and chairs and other furniture had once been.

I was exposed. Bare. Naked. Nothing was left of me. At least nothing of the me that I once was.

My life was being dismantled before my very eyes.

It was time to fight back.

———————————-

Want to know how we got to this point? Check out the other chapters of Impact:

Chapter One

Chapter Two

Chapter Three

Chapter Four

Chapter Five

Chapter Six

Shooting Stars

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“The per patient expenditure for your assigned patient panel the last quarter was up by $XYZ, so we will be dropping your rating on our website from five to four stars. Your patient satisfaction and preventive care scores remain outstanding. We will re-evaluate your rating at next quarter.” A letter from one of the big insurance companies a few weeks ago.

You know what? Bite me. To my knowledge I am not wasting money. I take appropriate care of my patients.

But then it occurred to me, do patients even know that this is what those stars mean? How much money they and their physician cost the insurance company….

The Lost Dollars

img_2419

So there is this thing in the US that you may not have heard about. ACO’s, Accountable Care Organizations, are groups of physicians that have “joined together to provide high quality care” for Medicare patients. So says the CMS (Medicare) website.

What does this mean for patients?

Hell if I know. I don’t practice medicine any differently than I always have except that I find myself spending more and more of my time clicking the requisite buttons in the EHR (electronic health record) so patients get less of me. Quality care is quality care and should be given across the board to all patients no matter what bonus structure happens to be in place. I do have suits that come out and flash PowerPoint slides at me that tell how many of my patients ended up in the ER over the past quarter but I don’t pay attention. Frankly, I should not be making a decision whether or not a patient needs to go the ER based on what my “numbers” may or may not look like. 

What does that mean for physicians?

Supposedly, I get money every year that I can demonstrate that I provided savings to Medicare. If Medicare does not spend as much money but patients still get their colonoscopies and whatever else done (I have no idea how that is supposed to work), then I get a share of the “savings.”

How big is that check?

It is not like winning the lottery, that is for sure. I resent the insinuation that I need to be paid extra to do the right thing, but that is beside the point.

The healthcare corporation I work for requires me to complete some…. tasks… before I get this check.

For instance, I have to attend quarterly regional meetings and log onto two separate websites each and every month. To be honest, none of the physicians I know look at anything on those websites. They log on and log off to get the credit. (Of note, I have asked why it has to be two websites. Why can’t it just be one? No one gives me an answer.)

All of this, if it actually improved patient care, would be fine. But it doesn’t. Not one bit. It turns physicians into cute puppies doing silly tricks for their next treat and I refuse to participate. 

By not participating, however, the corporation gets to keep that check. I might not care about that if I knew it was going to go to helping indigent patients get access to care or some other noble cause but I don’t have the foggiest idea what they plan to do with it…

Personally, I think it should go back to Medicare.

A Life of Leisure

Chicago skyscrapers at night

“Doc, when was the last time you went on a mission trip?” He fixed me in his intense gaze. A few minutes before he had told me all about ending up in Rwanda right after the genocide, assisting with Ebola, and secret missions into Syria.

I looked down at my computer, pretending to type. In truth, I was just trying to avoid eye contact as I thought about his question.

“That would have been Cambodia in…. 2007.”

2007.

Had it really been that long?!???!??! 

I felt guilty.

“I’ve been avoiding anything too terribly dangerous while my kiddos were little. Now that they are bigger, I guess I could start thinking about it again.”

He nodded.

“I’ll send you some information…”

Judy Martin at Edwina’s Episodes asked what I would do if I did not have to work. You have all heard about the dream job that will never happen but if I did not need to maintain an income, I would volunteer as a medical aid worker, traveling wherever I was needed.

While I don’t see being able to do that in the foreseeable future, I can do some short stints, a week or two a year, right? 

Here I am in my forties and I still have these romantic notions about saving the world. Truthfully, though, I am not sure I am brave enough to do anything about it. I kinda like my life right now. I can talk a big talk but the follow through? 

Time will tell.

Doubling Over

IMG_5232

“Good news! We got the results of your coding audit and you missed only three things. Please add a 99214 with a modifier to these three office visits so we can post the charges.” The email went on to list the names and dates of service that I was to address.

I go through this every audit. They always find something to nitpick about every year. One year they tell me to do X. I start doing X. Then the next year they tell me I should never do X, I should be only doing Y. Y was what I had been doing before X. And so on….

I don’t like being wrong. I don’t like making mistakes. I don’t like being told what to do, especially if it is something they are going to change on me next year.

Feeling defensive, I looked back at the visits in question this time.

Seriously?

“No way in hell am I going to add those charges. If coding wants to talk to me about it, I am happy to have a discussion with them but I will not be making these changes to the superbill.”

The office visits in question were yearly physicals. Yearly physicals are considered preventive care by insurance companies and as such, the office visit and routine screening labs are covered at 100% by the insurance company. It is not applied to a deductible. There is no copay, no out of pocket expense. 

A “free” visit.

What the coding people wanted me to do was tack on a routine office visit charge in addition to the physical exam visit charge because I addressed something new, like back pain, or made changes to meds for one of their chronic medical problems, like increasing their blood pressure medication.

The problem with this is that particular charge is not a preventive service. It will go to the patient’s deductible. They will get a bill for another $120-140 (or whatever the contracted rate is for their plan) and for most insurances, that means the patient will be paying that entirely themselves out of pocket until their deductible is met. Meanwhile, I get paid for two office visits in the time slotted for the one.

I have been practicing medicine for over ten years. I have known for a long time that it was within my rights to do this but I rarely chose to except for a handful of times in the most extenuating of circumstances.

Just because we can do something does not mean we should do it.

When I have patients skipping specialist referrals and imaging and labs and meds that they really need because of the increasing costs, it bothers me. I need to make money. I do. I have to be able to purchase supplies, pay my staff, and pay the office rent. I need transportation. My kids need clothes, food, and a roof over their heads. The kids will need to go to college and I will need to retire eventually. I make more than enough for this right now, though. I don’t have to double dip. 

The thing that puzzles me at this point is why is coding making it an issue now, this year? It isn’t anything new. There is a lot of paranoia in the medical world about what the future holds for physicians financially, especially with all of the crappy changes to Medicare reimbursement, and that may be part of the reason corporate is starting to pressure us further to maximize our bottom line. I do have to make money for them to make money, after all.

And then I start to wonder. Is there something they know that I don’t?

Should I be grabbing everything I can now and retire early… get out of this business entirely before it collapses so I can go do volunteer work somewhere I am really needed?

In the Nick of Time

interior, Shed Aquarium in Chicago

It was a lovely spring morning. We were outside on the back porch coloring in a circus themed coloring book. Road construction was going a few streets over and a loud thumping repeated, shaking the ground as the workers broke up the concrete.

“Do you hear the elephants?” I asked.

My toddler son nodded, his eyes going wide.

“I think they are coming here! Let’s get some peanuts to feed them!”

He nodded his blonde head vigorously, grinning from ear to ear.

I ran inside and grabbed a bowl, pouring some peanuts into it. 

Then I saw the cashews. 

I’ll throw some in for fun!

I ran back outside and showed him the bowl of nuts. He grabbed a handful, as did I, and put a single cashew into his mouth. He chewed it, still smiling, and then swallowed.

Within seconds, his face turned ashen and his eyes were vacant. He stared off into nothing and would not respond to me at all. He was breathing was labored. His pulse was thready.

Then the hives appeared all over his body and he started to puke.

My son was having an anaphylactic reaction to cashews. 

He survived.

After that, I purchased an epipen and kept it on hand, just in case. 

He has had subsequent severe reactions to pistachios and kiwis. 

I say all of this to say that when I paid for the epipen the first time, it was $150 for a pair of them. Each year, I buy a new epipen to replace the expired one. Each year, the price goes up. Each year, I never have to use it I am throwing away hundreds of dollars. I hate that. Still. It’s my kid we’re talking about here. What kind of parent complains about spending money to protect their kid, right?

The other day I had a patient tell me that they just could not afford the cost of the epipen for their own son. With their high deductible plan they would be paying over $600 for a medication that they would hopefully never have to use. The price increase didn’t really matter so much to patients until the high deductible plans started to become the norm. The price difference before was picked up by insurance companies. Now, it is the patients getting stuck with it.

Yesterday, I ran across this article from the Washington Post about the soaring cost of epipens. Epipens have been around since 2004 but the cost has increased over 450%.

One quote in particular stood out to me:

Mylan (the manufacturer) itself is tight-lipped about the cost increase, saying only that it “has changed over time to better reflect the multiple, important product features and the value the product provides.”

So just how much are you willing to pay for your child’s life? For any child’s life? For a grown up’s life? Because that is what “value” is referring to here. They are holding my son’s life, your child’s life, for ransom. As for important product features…. it injects epinephrine. With a needle. 

Meanwhile, Heather Bresch, the Mylan CEO who has been with the company through the epipen price hikes, has had a substantial pay increase. Her salary in 2007 was  $2,453,456. Last year it was $18,931,068. Which makes me ask the question, how much money does she need?

Dearlilyjune asked what I thought was the greatest health crisis of our time. This is it. The sky rocketing cost of medical care. Pharmaceuticals. Imaging. Hospitalizations. Charging exorbitant amounts just because they can. There is nowhere quite like healthcare where they have you by the balls. Want to live? Want to have a good quality of life? Great! Pay some fat cat through the nose.

It is the worst in the US right now, but I figure it will be only a matter of time before this sort of thing catches on elsewhere. You cannot argue that the strategy makes money. It’s legal, even if it is unethical. 

Greed is powerful.