tag:blogger.com,1999:blog-35032412024-03-13T15:10:25.147-07:00the dark goddess of replevin speaks::..an irreverent look at lawyers and technology. now with bonus healthcare..::
::..blawging since 05.05.2002..::the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.comBlogger336125tag:blogger.com,1999:blog-3503241.post-29069106005111583922017-07-14T16:22:00.001-07:002017-07-14T16:22:20.660-07:00swimming to shore<div class="_5pbx userContent" data-ft="{"tn":"K"}" id="js_7k">
When
I experienced an injury that was temporarily disabling, I had certain
expectations of what was to come that I now realize were not
helpful.<br />
<br />
I originally thought that my recovery would be like flying on a
plane. Transportation (in other words, my progress back to health) would be essentially
passive; the discovery several months in that my injury was more severe than originally
thought would be merely a diversion to another airport en route for bad
weather (round two of surgery); and it would be clear when I had reached my destination and
would be able to disembark. Oh, and I would be able to get work done inflight.<br />
<br />
Well, it hasn't been like that.<br />
<br />
The last year
or so has been more like swimming across a lake fully clothed.
Transportation (making progress back to health) has been arduous. Just when I thought I
was reaching the shore, the water got deeper on me again. I'm back
in shallower waters again, feeling my feet on the ground, but I'm still
struggling to get to dry land with waterlogged clothes. I can't
tell for sure where the edge of the water actually is. And trying to get all the way out of the water is still requiring all my
concentration (heck, I still can't walk and talk at the same time), so I'm not getting anything else done. Which is a
constant disappointment to me.<br />
<br />
I imagine those around me have
been puzzled as well as disappointed in my persistent lack of
productivity, but I now realize: they think I've been on a plane, but
all along I've been thrashing around in the water.</div>
the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-39722983627050617272017-06-16T07:54:00.001-07:002017-06-16T07:54:34.942-07:00financially-driven medical decision-making One of my assumptions about medicine is that continuity of
care--that is, working with the same set of providers for a long
time--has benefits. They flow mostly from the trust that is established
with a primary provider, but can also come from information-sharing.
This is something I really work at: I took my kids to the same
pediatrician and followed him from a convenient office near our house,
to a le<span class="text_exposed_show">ss convenient office in another suburb,
to a really inconvenient one in yet a third for twenty years. I also
make sure records get sent between specialists, etc., etc. IOW, I'm kind
of a pain in the ass in the interests of making sure me and mine are
well-cared-for.</span><br />
<br />
<div class="text_exposed_show">
I need to have a dilated eye exam every year because of one of my chronic conditions, and I'm due for that exam now.<br />
<br />
I went to the same ophthalmologist for many years (as have my other
family members who need eye doctorin'). He dropped out of our network last year, for which I do not blame
him one bit. <br /><br />
Because I don't need my current doc's artistry with
vision correction any more, having two bionic eyes, I found a new guy in the state to which I am moving by referral from my main provider in the new state a few weeks ago. I made an appointment for September (the earliest available) to
establish that new, coordinated relationship.This was a little later
than ideal, but I can live with it.<br />
<br />
Found out yesterday, however,
that our high deductible, which we
have already satisfied for 2017, *resets* at the end of July. So my
options are: (1) go back one last time to my long time guy, and pay the
high out-of-network rate; (2) keep my September appointment with the new
guy and pay his in-network rate, but applied towards our reset deductible; or
(3) find a rando in-network before I move, and have a single eye exam at the cost of our modest co-insurance. It's a several-hundred dollar decision.<br />
<br />
After due consideration, I conclude that establishing a relationship with my new eye guy next year rather than
this year, since I'm not having eye problems right now, is probably not
worth paying that much. Sigh.<br /><br />The layer of complexity that financial considerations add to what should be a simple scheduling decision is exhausting at times.</div>
the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-29028231840161015332017-05-10T09:57:00.000-07:002017-05-12T07:47:27.216-07:00we must all cultivate our gardensAs it turns out, the federal government is <a href="https://www.ers.usda.gov/agricultural-act-of-2014-highlights-and-implications/crop-insurance/" target="_blank">heavily involved</a> in
managing/subsidizing crop insurance for producers. "Under the Federal crop
insurance program, private-sector insurance companies sell and service
the policies, and USDA’s Risk Management Agency develops and/or approves
the premium rate, administers premium and expense subsidies, approves
and supports products, and reinsures the companies."<br />
<br />
It's easy to see why the federal gove<span class="text_exposed_show">rnment
has stepped in to play a role in this. After all, if our farmers go out of
business, and there is a famine because there are no farmers to grow our food, people
will die. We certainly want to prevent starvation. Well, I do. Maybe
some will extend the free market even this far, but I personally will draw the line well before famine as a market correction tool.</span><br />
<br />
<div class="text_exposed_show">
As I understand how the crop insurance program is administered, we don't spend a lot of time
worrying about whether the farmers are <b><i>bad </i></b>farmers. We don't moralize
about their <b><i>poor crop choices</i></b>. We just insure them, because a harm to
the farmers is a harm to the public if there is not adequate food.<br />
<br />
If you agree that the federal government has a legitimate role in providing crop
insurance, but does not have a legitimate role in providing health
insurance, please explain how you view the goals of these two programs as
differing. Because it seems to me that although people die more quickly
from lack of food than lack of health care, they do die from <a href="http://www.nbcnews.com/id/24482102/ns/health-childrens_health/t/million-children-die-lack-health-care/#.WRNFuMa1tPY" target="_blank">both</a>. Although I suppose you have to offset the number of people who <a href="http://www.npr.org/sections/health-shots/2013/09/20/224507654/how-many-die-from-medical-mistakes-in-u-s-hospitals" target="_blank">die from botched health care annually</a>. <br />
<br />
In the case of both food and medical care, insurance provides the safety net for our economy as currently
structured. If you're okay with one, why not the other?</div>
the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-9036718377612470212017-05-08T09:41:00.000-07:002017-05-08T15:40:26.610-07:00suppose it's an obligation, and not a right?<div class="_5pbx userContent" data-ft="{"tn":"K"}" id="js_2ou">
Suppose we frame the current health insurance* debate in a different way?<br />
<br />
*It is about insurance. "Health insurance"=/="health care," although the former should lead to the latter.<br />
<br />
Rather than arguing whether American <i>individuals </i>have a <i>right </i>to
health care (beyond what you can already find in EMTALA, and please God
let's not consider repealing that), because people get very huffy about this concept, can we ask a different question?<br />
<br />
Should we Americans
collectively assume an <i>obligation </i>to "<a href="https://www.archives.gov/founding-docs/constitution-transcript" target="_blank">promote the general Welfare</a>" by providing everyone access to basic
health services, in the way that we have obliged ourselves to provide
all children with access to a free public education (largely from each state's constitution, with the exception of protections for disabled children)?<br />
<br />
Consider this: we have already agreed, by enacting <a href="https://www.cms.gov/regulations-and-guidance/legislation/emtala/" target="_blank">EMTALA </a>in 1986, that
as a society we don't want to see people die because an ER turns them
away if they can't pay. We have already assumed <i>that</i> obligation. But
waiting until people are very nearly dead before we assume any
obligation for their care is <i>extremely </i>expensive, and in the case of
many ailments, just cruel. Think heart disease. Think diabetes. Think
cancer.<br />
<br />
We have already agreed, by enacting <a href="https://www.cdc.gov/vaccines/imz-managers/laws/state-reqs.html" target="_blank">mandatory vaccination laws</a> (although we have wobbled a little on this one with
exemptions), that we have an obligation to protect the herd by requiring
this simple public health measure. We also have <a href="https://www.cdc.gov/quarantine/specificlawsregulations.html" target="_blank">quarantine laws</a> to
fulfill our obligation.<br />
<br />
We have already agreed that we have an
obligation to provide <a href="https://www.epa.gov/sdwa" target="_blank">safe water</a> to all (<i>coughs </i><coughs>Flint <i>coughs</i><coughs>), also pretty basic for health.<br /><br />We have also agreed, via our Supreme Court, that it is a violation of the Eighth Amendment prohibition against cruel and unusual punishment to deprive prisoners of necessary medical care in <a href="https://www.law.cornell.edu/supremecourt/text/429/97" target="_blank">Estelle v. Gamble</a>, 429 U.S. 97 (1976). Let me repeat that. <i><b>People in prison have a right to medical care</b></i> (although <a href="http://www.npr.org/sections/health-shots/2015/09/30/444451967/even-in-prison-health-care-often-comes-with-a-copay" target="_blank">even they can be charged co-pays)</a>.</coughs></coughs><br />
<br />
It does not seem like that far a reach to propose that we have an <i>obligation </i>(collectively) to provide people who are not incarcerated access to health care
<i>before </i>they show up at the ER, if for no other reason than to <a href="http://kff.org/report-section/the-uninsured-a-primer-key-facts-about-health-insurance-and-the-uninsured-in-the-wake-of-national-health-reform-how-does-lack-of-insurance-affect-access-to-health-care/?utm_campaign=KFF-2017-Uninsured&utm_content=53895642&utm_medium=social&utm_source=twitter" target="_blank">reduce the expensive ER visits</a> <i>that we are already obligated to fund.</i><br />
<br />
Given the way our system is currently set up, rather than nationalizing
the health care system, which sounds like quite the disaster, or
providing everyone with a government doctor (which also sounds like a
disaster, given how the VA has been struggling), making sure everyone
has health insurance coverage seems the least disruptive path. Although
nationalizing the insurance companies has a brutal appeal to me, and
eliminating the middlemen in the long run through gentler measures will
probably be helpful.<br />
<br />
So for those of you who don't want to grant
other people individual rights in this area, ask whether you might be
shirking the societal responsibility that you have already undertaken. And see also this interesting analysis of the <a href="http://there is a reasonable argument made that as a society we do not want anyone to face high medical bills, and potentially even medical bankruptcy, even if they knowingly chose to free ride. This sentiment certainly underlies existing arguments that even those who have been diagnosed with cancer or who are currently pregnant should be allowed to purchase “insurance” in the marketplaces. Is there a national consensus about this? We are not sure. Should there be a two-tiered system, so that those who knowingly free ride are forced to obtain care at “lower quality” providers (perhaps some county hospitals fit the bill)? We are not sure of this either. Is anyone asking these hard questions besides us? We are sure they are not." target="_blank">free rider problem in this area</a>.<br />
<br />
Not your brother's keeper, you say? Can we have a talk about the corporal works of mercy?</div>
the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-35177643917054969282017-04-30T19:44:00.000-07:002017-05-01T16:50:13.649-07:00bite meI had what should have been a routine dentist's appointment a few days ago that ... wasn't. It took me a while to figure out why this bothered me so.<br />
<br />
I live in an upscale suburb of a major metropolitan area. The area is rife with dentists, all of whom are trying to outdo each other in their <i>luxe </i>experience, starting with a fancy lobby with a nicely stocked refrigerator, continuing on to the offering of a wide array of cosmetic services (whitening, veneers, Invisalign) to creature comforts such as warm blankets and sedation. <br />
<br />
Until this week, the practice I selected (which I shall not name) just cleaned and examined my teeth and otherwise more or less left me alone (they replaced an ancient filling last year to keep a tooth from falling apart). My teeth are straight enough, and they are as white as I can ask them to be given my love of coffee. My fading beauty is unlikely to be revived by any changes to my teeth, and no one there ever pushed cosmetic dentistry on me. I suppose this makes me a not particularly lucrative patient.<br />
<br />
This week, I had my teeth cleaned by a dental hygienist who is new to my dentist's office. I will give her credit for two things: she was very personable, and she did not push <i>cosmetic </i>dental services on me.<br />
<br />
But.<br />
<br />
We began on a strange note. Although I arrived at the office when it opened, right on time for my 8 a.m. appointment, she asked if she could take a moment to brush her teeth before we got started. I said, "Sure," because I'm not a monster, but at the time I wondered why she couldn't have done this before work. My appointment began about ten minutes late because of this.<br />
<br />
I needed to give her significant updates to my recent history, including my second round of orthopedic surgery after my last dental appointment in October, and my stellar current A1C.<br />
<br />
The hygienist took one look at my mouth and we were off to the races. She told me that I should have the dentist replace all my "silver" (more properly called amalgam) fillings, because "we don't like to see people with more than one or two." She said that they "probably" had decay underneath them. Mind you, there was no sign of decay in my bitewings taken six months ago, and no mention of decay by the dentist, so it was unclear on what she was basing her conjecture. In looking at this babe's blog afterward, I confirmed that she recommends removal of amalgam restorations because she deems them to be "unsafe." The American Dental Association says that this is <a href="http://www.ada.org/~/media/ADA/Member%20Center/FIles/2016_ADA_Code_Of_Ethics.pdf?la=en" target="_blank">unethical</a>.The research she was touting to "prove" the lack of safety was an associational study of mercury <i>levels </i>in people with more than eight amalgam restorations (from what I can tell through the paywall). Which is not me. But I digress.<br />
<br />
At this point, I felt like saying, "Excuse me, I did not realize that today's quiz was going to be on amalgam restorations. I only studied the material on fluoride. This is not fair." <br />
<br />
Then it got stranger.<br />
<br />
After checking my tongue, which I naively assumed was for signs of oral cancer, she informed me that I had a "moderate tongue-tie" and recommended that I have a <a href="https://en.wikipedia.org/wiki/Lingual_frenectomy" target="_blank">lingual frenectomy</a>. As she rattled off the problems caused by ankyloglossia, I couldn't help but notice that they were largely moot, for example difficulty in nursing. I contented myself in telling her that my mom had not reported any difficulty in nursing me when I was an infant. Meanwhile, the clock was ticking, and she still had not touched my teeth.<br />
<br />
Next, she took a sample of plaque from my mouth (finally! She picked up an instrument!) and put it on a slide to inspect with her phase contrast microscope. "Say," I said, "I have never seen one of these in a dentist's office before," thinking that this was a new practice. She proudly informed me that she had been using this microscope in her work since 1985. I have been in various dentists' offices frequently since 1985. If no one else is doing this, that tells me something about the value of this practice.<br />
<br />
After cleaning my teeth, the hygienist showed me the "bugs" (her term) on the slide, and pointed out a spirochete, a few white blood cells, and a few red blood cells for me. Did she think I was still blissfully unaware, at the age of 58, that the human mouth has bacteria in it? What made me even more skeptical of this piece of dental theater was her followup that if I had a healthy mouth, we "wouldn't see any movement" on the slide. Huh, so my mouth will be a sterile field? Right. She didn't make any attempt to quantify the bacteria, identify them specifically or record her observations in my chart. Since then, I have tried to determine to what uses a phase contrast microscope is typically put in clinical dentistry. The most honest article I found came right out and called it a "<a href="http://www.dtic.mil/docs/citations/AD0731983" target="_blank">highly useful motivational tool,</a>" which the other articles I found in places like <i>Dental Economics </i>also implied. Okay then. It's show-and-tell.<br />
<br />
She dispensed with taking any actual measurements of my periodontal pockets with a probe, the tedious process with one person calling out numbers to another who records them, probably because the dentist was not there. She opined that there were "changes" in my gums since they were checked in "2005" (actually, it was 2016, oops!) and that I now had periodontal disease. This meant, she said, that I would have to come back for an hour-and-a-half appointment, which might not be covered by insurance, of course, we would then come up with a "plan" for "oral wellness" for me, and she would be my "oral health coach." Then she hustled me out the door. <i>I never saw the dentist</i>, who had "not arrived yet" by the time I left. In other words, a dental hygienist had just diagnosed me with a condition, which is <a href="http://app.leg.wa.gov/wac/default.aspx?cite=246-817-550" target="_blank">beyond her scope of practice</a> (she is allowed to inspect and measure my periodontal pockets, but not make a diagnosis).<br />
<br />
At this point, I figured that my situation must be dire, and expected an immediate recall appointment with the actual dentist for the massive overhaul of my mouth that was apparently necessary. Imagine my surprise when the receptionist booked me six months out. Not a dire emergency after all. I have, of course, canceled that appointment already. <br />
<br />
Now that I have had the opportunity to reflect, here is what bothers me about this dog's breakfast. It had surprised me to hear that my gums looked worse than the last appointment (assuming for the sake of argument that her perception was accurate). After surgery in December that put me on crutches, I started flossing a <i>lot, </i>because there wasn't much else I could do, so I had been expecting a glowing report. Rather than exploring possible causes of this condition with me further, however, I gather she assumed that I am just bad at oral hygiene. She quickly loaded me up with a ton of new tasks, some of which contradicted what the last one had told me, so she could get back to the important work of trying to upsell me on her "oral health coaching" using meaningless demonstrations.<br />
<br />
What she didn't bother to understand about her own patient is that the <a href="https://www.ncbi.nlm.nih.gov/pubmed/22910536" target="_blank">cumulative complexity</a> of my medical care is already high. It was arrogant in the extreme for her to presume that I would want to place her in the center of my medical care as my savior, when in fact I am already working with a health coach, dietician, physical therapist, surgeon, pharmacist, primary care physician, ophthalmologist and <i>dentist</i> as necessary. This hygienist is not going to become the star of my medical show.<br />
<br />
I am grateful, though, to her, in the end, because in hate-reading her blog, I picked up on something that <i>she </i>could have realized if she'd just stopped blathering for a moment and listened to me more carefully.<br />
<br />
From my history, she knew or should have known that I am on several medications, middle-aged, and have type 2 diabetes. I think I shrugged when she asked about dry mouth, which is <i>very </i>common in type 2 diabetes, although <a href="https://www.ncbi.nlm.nih.gov/pubmed/27478847" target="_blank">the research is lousy</a>. I have been thinking about that question, however, and realized that I frequently <i>do </i>feel what I have been interpreting as slight thirst, but could just as easily be dry mouth (subjective) or hyposalivation (objective). Further research also tells me that hyposalivation can be present without the perception of dry mouth. Compared to my ongoing recovery from reconstructive surgery, it has been a trivial annoyance and easy to ignore, but it can have consequences.<br />
<br />
All the flossing and water-Piking in the world can't be expected to address my gum problems if I don't address my hyposalivation as well (if in fact I have it). I, therefore, as the director of my own healthcare, have started simple, harmless treatments for my (possible) dry mouth, with only indirect thanks to the hygienist. We will see what the <i>next </i>dentist says.<br />
<br />
And I can hardly <i>wait </i>to see what's on my EOB.<br />
<br />
<br />the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com1tag:blogger.com,1999:blog-3503241.post-7678863463490966242017-03-22T11:53:00.003-07:002017-03-24T14:39:40.486-07:00on mandates, and mandatesLet me begin with a rant.<br />
<br />
Look, I know headline writers and Twitterers have to shorten stuff up.<br />
<br />
But let's keep in mind that reforming "health insurance" is not the
same thing as reforming "health care." Because insurance for care is not the care
itself.<br />
<br />
Is the cost of care relevant to the care that people
get? Of course! Do insurance companies effectively practice medicine
when they deny coverage for expensive treatment? You betcha!<br />
<br />
But
relying on changes to only one component of a very complex system to
produce systemic *and positive* change strikes me as ... overoptimistic.<br />
<br />
Words are all we have to articulate our goals. Let's be clear about what our goals are.<br />
<br />
Now that I have that out of my system, let's talk for a moment about mandates.<br />
<br />
No, not that mandate. I want to talk about the mandate that, if you own a motor vehicle in the United States, you, generally speaking, have to have a verifiable way of making good on the damage that your car does to other people and property. The way vehicle owners do this varies from state to state. In most states, it's through automobile insurance. In Virginia, if you "go bare,"<a href="https://www.dmv.virginia.gov/vehicles/#insurance.asp" target="_blank"> you have to pay the state an annual $500 fee</a>. Mississippi lets you <a href="http://www.mid.ms.gov/consumers/auto-insurance.aspx" target="_blank">post a bond</a> (which is just another form of insurance if you squint at it) rather than purchasing conventional auto insurance. New Hampshire only requires you to carry auto insurance <a href="https://www.nh.gov/safety/divisions/dmv/financial-responsibility/insurance.htm" target="_blank">if the state concludes you're at high risk of damaging somebody</a>. <br />
<br />
The general principle is this: you are required to carry auto insurance (or its equivalent) to protect <i>other people</i> from your screw ups. And it's prudent, frankly to have auto insurance to protect yourself from your own. As far as I can tell, the idea that you have to carry auto insurance to protect <i>other people, </i>that is, <i>the general public</i>,<i> </i>is not particularly controversial.<br />
<br />
What is a requirement to carry insurance? It is a mandate.<br />
<br />
Fast forward to the much more controversial mandate to purchase health insurance, or pay a penalty to the feds--much like the Virginia uninsured vehicle requirement above. <br />
<br />
The most commonly-heard argument for the mandate has to do the economic necessity of getting young healthy people buying insurance they probably won't use to pay for the cost of old sick people using the heck out of their insurance. That isn't what I want to discuss in this post.<br />
<br />
There is an entirely different risk-sharing/policy setting issue. Maybe it is discussed a lot and I've been missing those discussions.<br />
<br />
Let's consider a young person. Our hypothetical young person ("HYP") is healthy, living independently, but of modest means. HYP therefore does not purchase health insurance, because it seems to be an unnecessary expense in a tight budget. HYP is gambling. Oh, <a href="http://www.imdb.com/title/tt0056541/" target="_blank">sweet bird of youth</a>!<br />
<br />
On a dark and stormy night, HYP, crossing the street in a clearly marked crosswalk, is hit by a speeding car which vanishes into the night (because this is a hit-and-run, we can't file a claim against the motorist's theoretically mandated automobile policy--if he or she even has one). HYP is rushed to the emergency room and proves upon examination to have a shattered pelvis, a ruptured spleen, a lacerated liver, and a possible concussion, and is also noted to have a blood glucose level of 330, suggesting hitherto-undetected type 2 diabetes. Okay, the last is piling on a little bit.<br />
<br />
Now. As a policy matter, we decided as a society in 1986 that the public should have access to emergency services regardless of ability to pay, by means of a <a href="https://www.cms.gov/regulations-and-guidance/legislation/emtala/" target="_blank">federal statute known as the Emergency Medical Treatment and Labor Act ("EMTALA</a>"). So the ER doesn't demand insurance information or cash up front from HYP, which is good, because HYP is unconscious and losing blood rapidly. The hospital just treats HYP. Because really, what is the alternative? Should we as a society say that it's OK to let HYP die? Or do we as a society assume the cost of HYP's care, one way or another?<br />
<br />
Because HYP doesn't have health insurance, HYP can't get the negotiated in-network rate from the hospital. In a certain sense it doesn't matter, though, because HYP is of modest means, and couldn't pay even the in-network rate, let alone the hospital's pretend rate for the uninsured (which is another complex issue for another day--what are the hospital's actual losses from uncompensated care).<br />
<br />
Patching HYP up even to the point where s/he can be discharged from the hospital is going to take some time. Meanwhile the bills are racking up, up, up. HYP might qualify for "charity care," depending on state law, or HYP can discharge the bills for the uncompensated care in bankruptcy. In either case, we as a society bear the cost when HYP gambles and loses. I personally would rather we bear this cost, as a policy matter, than let HYP die, or create a culture where we encourage our HYPs to just die already to save us all money. Having said that, I would still like to see a better method of risk distribution than we have now.<br />
<br />
In the public debate, I see an occasional (well, okay, frequent) strain of blaming the sick for being sick, which I think is quite unfair, for no other reason than that accidents happen (speaking as someone who incurred a catastrophic injury in the blink of an eye last year). And people fall victim to bad genetics all the time.<br />
<br />
In the realm of automobiles, Americans as a society have come to accept that accidents happen, that you're not "bad" just because you cause financial losses with your car, you just have to be a responsible adult and make arrangements for the unexpected. We agree as a society (other than New Hampshire, where you <a href="https://www.nh.gov/nhinfo/emblem.html" target="_blank">live free or die</a>) that the "arrangements" should be auto insurance.<br />
<br />
In the realm of bodies, it would make sense for Americans as a society to accept that accidents happen, that you're not "bad" just because you cause financial losses with your body (by having unexpected medical expenses), you just have to be a responsible adult and make arrangements for the unexpected. We clearly do <i>not </i>agree as a society that the answer is health insurance, even though having health insurance can protect <i>other people</i> from catastrophic losses.<br />
<br />
I am not sure why.<br />
<br />
Perhaps it is because insurance is such a boring subject.<br />
<br />the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com1tag:blogger.com,1999:blog-3503241.post-49088762932368927102017-03-06T10:04:00.001-08:002017-03-06T10:58:16.163-08:00the solution never works if you haven't identified the problemI have a bias, I admit it. I am sensitive to studies with a subtext of "those stupid patients, what are we going to do about them?" Read the following rant with that in mind.<br />
<br />
A pharmacy benefits manager a/k/a PBM funds a <a href="http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2605527" target="_blank">study of patients nonadherent to chronic prescription medication</a>. The premise of the study, Effect of Reminder Devices on Medication Adherence: The REMIND Randomized Clinical Trial (hiding behind a paywall, by the way), is that "forgetfulness is a major contributor to nonadherence to chronic disease medications and could be addressed with medication reminder devices." Thus, the intervention consisted of sending a population which included folks taking meds for schizophrenia and bipolar disorder either "a pill bottle strip with toggles, digital timer cap or standard pillbox" along with their mail order meds. There was of course a control group who received neither notification or a device. Surprise, surprise! Getting a prize in your Crackerjack box from your PBM does <i>not </i>improve medication adherence. Those stupid patients! Why won't they do what's good for them?<br />
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Well, let's take the most basic first step and look at the evidence that the REMIND paper cited <i>in its very first footnote </i>to support its premise that patient "forgetfulness" is the problem. The paper cited is not, thank you very much, behind a paywall. Its very title should have been a tipoff: <a href="https://www.ncbi.nlm.nih.gov/pubmed/22510235" target="_blank">"Unintentional non-adherence to chronic prescription medications: How unintentional is it really?"</a> <i>This </i>study concluded that "For our study sample, unintentional non-adherence does not appear to be random and is predicted by <i>medication beliefs</i>, chronic disease, and sociodemographics. The data suggests that the importance of unintentional non-adherence may lie in its potential prognostic significance for future intentional non-adherence. Health care providers may consider routinely inquiring about unintentional non-adherence in order to proactively address patients' suboptimal medication beliefs before they choose to discontinue therapy all together [sic]" (emphasis added]<br />
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Reading further in the paper I've just linked to (which I highly recommend you do), "medication beliefs" include such things as "perceived need for medication"--statins, anyone?--and perceived medication affordability.<br />
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Let's go a little further and consider something obvious about clinician-patient dynamics in an era of managed care. How many clinicians take the time, or have the time, to initiate a thoughtful discussion with a patient regarding the benefits and risks of a course of long-term medication being recommended? A statin, say, or low-dose aspirin for primary prevention, in someone who feels just fine? How many patients will push through the clinician's subtle (or not-so-subtle) signals that s/he is pressed for time to initiate and then persist in a discussion, which might persuade a patient on the fence about the recommendation that there is an actual need for the medication? Or might even lead the patient and provider to jointly conclude that this long-term medication is not, after all, warranted?<br />
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Consider this: the more important you believe something to be, the easier it will be to remember to do it. "I forgot" is a convenient excuse we offer, after all, to our doctors. It is more polite, and less time-consuming, than initiating an uncomfortable conversation by saying, "I don't see the point of this/I am experiencing unpleasant side effects/I cannot afford this/I am overwhelmed by the '<a href="http://bmcmedresmethodol.biomedcentral.com/articles/10.1186/1471-2288-13-10" target="_blank">treatment burden</a>.' " Such comments can be taken as a direct challenge to the provider's authority, although they might stem from the provider's failure to communicate with/empathize with/educate the patient adequately in the first place.<br />
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A patient on insulin therapy is unlikely to forget to use insulin. It's obvious that insulin is important. This suggests another possible flaw in the study design. It excluded patients taking more than three medications, apparently because their dosing regimes are just too complicated (<a href="https://www.youtube.com/watch?v=NO0cvqT1tAE" target="_blank">math class is tough!</a>). It would be interesting to learn if patients taking more medications might actually be more adherent because they feel that the stakes are higher. Alas! We will never know, at least from the authors of this study hellbent on reminding these <i>silly </i>patients who just <i>cannot </i>remember what is good for them. Although the study design notably did <i>not </i>include smartphone apps such as Mango Health that "<a href="http://www.imedicalapps.com/2014/05/mango-health-app-financial-rewards-medication-adherence/#" target="_blank">gamify" taking medications</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5161780/" target="_blank">could use more investigation</a>.<br />
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I feel compelled to point out as well that patients getting their meds mailed from their PBMs are by definition not in regular contact with an overlooked, underrated member of the patient's care team: a flesh-and-blood pharmacist who reinforces dosing instructions, and provides that human touch. Yes, it is possible for a patient to make contact with an actual pharmacist at a PBM, but I wonder how many nonadherent patients are aware of that.<br />
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I should finally note that many patients view PBMs as an arm of their insurance company (which in fact they are) and may have viewed what appeared to be medical advice coming from their insurer as inexplicable and suspect. Indeed, "[b]ecause the study devices are currently available for commercial use and because participants received the devices by mail and could choose not to use them, patient-level consent was waived by Chesapeake Institutional Review Board." Not obtaining consent may have made the study less useful, but I'm sure it was cheaper, amirite?<br />
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The writeup of the REMIND study grudgingly concedes towards the end that "because nonadherence is a multidimensional problem, addressing forgetfulness alone may have been insufficient to improve actual medication taking." This spectacularly misses the boat. Because it's not truly a problem of forgetfulness at all. <br />
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<br />the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-60931596772392964622017-01-17T14:55:00.004-08:002017-01-17T16:03:44.833-08:00when a provider gets it rightI sent a thank you note today (from time to time, I like to use my powers for good).<br />
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<br />
<blockquote class="tr_bq">
<div class="MsoPlainText">
Dear Doctor X [Chief of Anesthesia at Big Hospital]: I wanted to take this opportunity to commend your entire
team for its thorough engagement with me after my inquiry about glucose control
protocols while I prepared for my most recent surgery at Big Hospital at the end of last
month. </div>
<div class="MsoPlainText">
<br /></div>
<div class="MsoPlainText">
Doctor Y herself [Head of Preoperative Clinic] took the time to review my
preoperative instructions with me the week before surgery, including explaining
the rationale behind stopping supplements, etc.<span style="mso-spacerun: yes;">
</span>On the morning of my procedure, which was mercifully scheduled as first
case, Ms. Nurse Manager made it a point to introduce herself upon my admission to the
pre surgery unit and to explain the improvements that Big Hospital is making, giving me
the chance to calibrate my home meter against the first reading taken. I noted
also an intraoperative and a postoperative blood glucose reading in eCare. I
would like to commend your team for their thoroughness in my treatment, which I
know encompassed much, much more than blood glucose monitoring, and their
detailed record-keeping.</div>
<div class="MsoPlainText">
<br /></div>
<div class="MsoPlainText">
As a person with diabetes, I am accustomed to managing my
own condition for the 99% of the time that I am not in contact with the medical
system. I take this responsibility seriously, and so I am prone to remain
somewhat vigilant even amidst the medical system absent a very clear handoff.
It was a relief to be able to turn over the reins, so to speak, of my diabetic
care with confidence for the time when I was unconscious.</div>
<div class="MsoPlainText">
<br /></div>
<div class="MsoPlainText">
Finally, I remain impressed that the "Patient
Feedback" button on your department's website goes straight to the top. It
speaks well of you and your team that you seek to interact with patients
without hiding behind rank. I can only say that my anesthesia experience has
proven very positive and I thank you all sincerely for your efforts, your time,
and your knowledge and skill.</div>
</blockquote>
the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-17323699820137571612016-12-13T08:14:00.000-08:002016-12-13T08:14:13.048-08:00more fun with PBM appealsThe PBM denied the first appeal (more on that later). <br /><br />
The form called "Important Information about Your Appeal Rights" provides a number to call "for information on how to designate an
authorized representative."<br /><br />I try looking on the PBM website first and cannot find an authorized representative form.<br />
<br />
I call that number to get the form. Person #1 gives me a URL that leads to a 404 notice (big surprise).<br />
She transfers me to Person #2 at a new phone number.<br />
<br />
I ask person #2 for the information on how to designate an authorized representative to file an appeal.<br />
She has no idea talks to her supervisor.<br />
<br />
She comes back and tells me that her supervisor says I have to fill out the form and send it in. <br />
I explain that I am calling because I need the form.<br />
<br />
"Oh," she says, "my supervisor says you have to get it from the website."<br /><br />I explain that neither person #1 nor I could find it on the website.<br /><br />"Oh," she says, "I have to transfer you to person #3 at yet another phone number!"<br /><br />At which point I am disconnected.<br /><br />I am in Hell.<br />
<br />the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-33831308571445465092016-11-22T14:38:00.004-08:002016-11-22T14:38:51.098-08:00i don't know how other people do thisI submitted a claim last month on behalf of a family member for a compound prescription medication (eye drops with a higher percentage of active ingredient than readily available).<br /><br />The claim was denied by our PBM because, according to them, it "contains non-covered ingredient(s). Your prescription drug plan does not cover this medication."<br /><br />The denial did not identify which of the "ingredient(s)" were allegedly not covered.<br /><br />The compound prescription had four (4) listed ingredients, including sodium chloride (at a cost of seven cents).<br /><br />Here is what I had to do in order to appeal the claim.<br /><br />(1) I looked at the original form from the compounding pharmacist and developed a hypothesis that there was only one active ingredient.<br />
(2) I went to the website of our PBM and searched their current formulary. I found the same delivery system of the same active ingredient (at a different concentration) listed, and printed out the page proving that the active ingredient was covered.<br />
(3) I went to DailyMeds and printed out the drug information, including the ingredients list, confirming my hypothesis about which of the four ingredients was the active one and also proving that the three inactive ingredients in the compounded prescription were also used as a buffer in the formulary drug.<br />(4) I filled out the appeal packet, explaining all this and attaching the denial letter, the claim showing the list of ingredients, the page from the formulary showing that the medication was generally covered and the drug information showing that the inactive ingredients were the same.<br />
(5) I mailed the appeal certified mail, return receipt requested, because I don't trust these people to keep track of anything anymore.<br /><br />The worst part of all this is that the compounding pharmacy charged us <i>less </i>than the listed price of the formulary drug. So going this route should save the PBM money.<br /><br />Of course, just denying the claim outright was even cheaper. <br /><br />At first.<br /><br />But I have to wonder. What do people <i>do </i>without good research and verbal skills and some knowledge of chemistry? the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-3798462221342812472016-11-11T10:53:00.000-08:002016-11-12T16:38:05.128-08:00the further adventures of radiology department aPart One <a href="http://ruthedlund.blogspot.com/2016/11/the-other-side-of-defensive-medicine.html" target="_blank">here</a>.<br />
<br />
I was looking at my <a href="https://www.healthit.gov/providers-professionals/faqs/what-electronic-health-record-ehr" target="_blank">EHR</a> with Radiology Department A two days ago, as one does, and I noticed that, despite my best efforts, an actual doctor there--let's call him Doctor X--took the time to reread my film a couple of days ago, and repeated his recommendation for followup testing. Sadly, this waste of his time took place a full week after I sent an agonizingly detailed letter documenting the results of the actual followup testing (including the radiologist's report from Radiology Department B).<br />
<br />
I faxed Radiology Department A another copy of the agonizingly detailed letter, with a cover sheet to the attention of Doctor X, apologizing to him for the waste of time, thanking him for his conscientiousness in followup, and reassuring him that I had not only followed his recommendation but provided Radiology Department A with a copy of the report a week before he reread my film.<br />
<br />
I called Radiology Department A and reviewed my fax with an office manager, whose name and direct line I now have. She said she would kill any ticklers in the EHR to end any further followup.<br />
<br />
I suppose I shouldn't have done this, but I went back to my EHR for Radiology Department A last night, just to double-check.<br />
<br />
And there I found a <i><b>Visit Summary</b> </i>for the followup appointment that I cancelled twice on the phone, and once in writing. This may be the fault of <a href="http://www.epic.com/software" target="_blank">Epic</a>. It really makes me want to pin somebody's ears back.<br />
<br />
I now await a bill/stern letter from Radiology Department A for my "missed" appointment. If this happens, I <i>will </i>start naming names.the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-6196370123205342292016-11-09T12:03:00.002-08:002016-11-09T12:10:37.615-08:00possibly the most boring post i will ever writeApparently, my health insurer Aetna, which is actually not an "insurer" at all but a TPA, is changing PBMs from Express Scripts to CVS Caremark.<br />
<br />
To decode that last sentence <i>and its significance</i>:<br />
<br />
A "TPA" is a third-party administrator of the health benefits that are being provided by a large company which is actually "self-insured." When you are dealing with health benefits you need to understand who is actually providing them because you need to understand the rules that govern them and the pressure points if you need to complain when things go awry. For example, generally speaking, a self-insured plan isn't going to fall under the jurisdiction of the Commissioner of Insurance for your state, so cc'ing them on a Stiff Note is really not much of an implied threat. Self-insured plans fall under the loving care of the feds, in particular the Department of Labor and the Internal Revenue Service, but they tend not to be that consumer-oriented. Also, they're really busy.<br />
<br />
A PBM is a "pharmacy benefits manager." This is a subset of TPAs in charge of arranging for payment (or not) of medications and (some types of sort-of DME, see digression below) prescribed by the clinicians who are paid for by the benefits administered by <i>another </i>TPA. Because that is more efficient (it actually may be, for all I know. Pardon my momentary cynicism).<br />
<br />
The PBM switch has apparently been in the works for a while, and I am pretty sure that
the transition was contemplated to occur in 2017 (like, January 2017).<br />
<br />
The <a href="http://www.aetna.com/about-aetna-insurance/sas/cvs-caremark-agreement/index.html" target="_blank">hotlink on Aetna's website to the press release </a>announcing its "strategic alliance" is, of course, broken (when I pointed this out to the <a href="http://healthadvocate.com/Home/" target="_blank">Health Advocate</a> she actually snorted).<br />
<br />
The "Q and A for Aetna Members" says "<a href="http://www.aetna.com/about-aetna-insurance/sas/cvs-caremark-agreement/questions-answers-members.html" target="_blank">we will keep your employer informed</a>."<br />
<br />
The employer (of the consort of the Dark Goddess) knows nothing of when or how the PBM transition will be implemented. For all I know the deal fell through or was blocked by the Justice Department on antitrust grounds.<br />
<br />
Our family is strong-armed into ordering a great deal of our medication (and certain types of sort-of DME, see digression below) through a PBM or
face stiff financial penalties for the "luxury" of using a retail
pharmacy. I have no information about how our scripts currently residing at Express Scripts currently eligible for
refill will or will not be transferred to CVS Caremark, and when. Maybe it will be seamless. I should note that historically there has been considerable lag time between the time when we mail our prescriptions from Washington state to the processing center, which always seems to be in Florida, and the time the prescriptions are shipped from some other far-flung part of the country. When I can coax a clinician into e-prescribing, that reduces the transit time of one leg, but only one leg, of the journey.<br />
<br />
My promised digression: one of the great oddities of my current PBM is that, if you get a "prescription" for medication that is available <i>over-the-counter </i>(for example, low-dose aspirin)<i>,</i> the PBM will provide it essentially free (because this sort of preventive medication is regarded as a good investment in your health). Also, there are certain types of "durable medical equipment," or DME, also available over-the-counter, but that if "prescribed" are also provided more cheaply than if just purchased at the store. The oddity goes <a href="https://www.youtube.com/watch?v=KOO5S4vxi0o" target="_blank">up to eleven</a> when you realize that DME includes items that are not durable at all because they get used up, for example, lancets and glucose monitor test strips. And the rules on what DME you are "allowed" to buy from a pharmacy in order to have coverage are Byzantine. This summer I found out that my pharmacy was not a DME provider for crutches, but it was a DME provider for lancets and test strips, which was a distinction that was never satisfactorily explained to me.<br />
<br />
Aside from the possible gap in fills, here are significant
differences between the 2017 formularies of the two PBMs (the new one, of course, seems more restrictive than the old), so which PBM will be in place for the future is actually important for me to track down.<br />
<br />
I have asked both Aetna and Health Advocates for information and we'll see who can clarify it first.the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-74445010964217254922016-11-08T17:11:00.003-08:002016-11-08T17:12:32.392-08:00i made a difference todayI found out this morning that my paralegal wasn't intending to vote today because she didn't think she was eligible for a
replacement ballot. Based on her quick check of the King County website, she thought her voter registration was no longer valid (she is an intelligent person, just intimidated by the process). I
asked her cautiously--I am her boss, after all--if she wanted me to talk her through the process of getting a replacement ballot, which she did.<br />
<br />
We went to the King County Elections website together, and were able to confirm
that she was still a validly registered voter and eligible to vote. With her
consent, I printed out a replacement ballot for her. Then I <span class="text_exposed_show">handed
it to her and told her to go vote for whomever the <i>hell </i>she wanted, but
to <i>please </i>go drop her ballot in the ballot box across the
street from the courthouse (two blocks from our office). And gave her time off to do it.</span><br />
<br />
<div class="text_exposed_show">
Someone voted today, because of me, who would not otherwise have had a voice. I feel good about that, and I really don't care who she voted for.</div>
the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-49564659425299062782016-11-04T17:13:00.002-07:002016-11-12T16:43:35.395-08:00hello, my name is...<div class="separator" style="clear: both; text-align: center;">
<a href="https://1.bp.blogspot.com/-g1SFKvM_HZY/WB0h25sLWTI/AAAAAAAAADA/D7ntFK8S70cNYouZvEXhn7ApZLY0xYKSgCLcB/s1600/hello.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="192" src="https://1.bp.blogspot.com/-g1SFKvM_HZY/WB0h25sLWTI/AAAAAAAAADA/D7ntFK8S70cNYouZvEXhn7ApZLY0xYKSgCLcB/s320/hello.jpg" width="320" /></a></div>
I competed for several years in extemporaneous speaking in high school.<br />
<br />
I took classes in college where the exams were 100% oral. And in Russian.<br />
<br />
I have been going to court since 1984. I make my living with my voice.<br />
<br />
I rarely use a word-for-word script any more. Sometimes, to show off, I have given major talks/arguments without any notes at all. Invariably, however, I prepare notes in advance, and they always start out the same way: <i>Introduce self. </i><br />
<br />
Then I put my name in parentheses in my notes. <br />
<br />
Why? <i>Because stress makes us stupid.</i><br />
<br />
Although it hasn't happened yet, it is still <i>entirely possible</i> that I might someday forget my own name at the beginning of a presentation.the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-7913604022354495092016-11-01T17:55:00.002-07:002016-11-11T11:01:11.819-08:00the other side of defensive medicineI wrote a stupid and annoying letter today.<br />
<br />
The letter itself was very polite. But I wrote it because I was afraid, and that is what is stupid and annoying.<br />
<br />
What was I afraid of? Being branded a "noncompliant" patient.<br />
<br />
Why am I afraid of this? <a href="http://well.blogs.nytimes.com/2012/11/15/when-the-patient-is-noncompliant/" target="_blank">It's like a stink you can never get off</a>.<br />
<br />
What did I do that created this fear? I cancelled a followup x-ray at Radiology Department A because I don't have a doctor at Hospital A any more. All the rest of my local care is at Hospital B right now, so I wanted the follow-up to be done at Radiology Department B where all my other doctors are.<br />
<br />
(Parenthetically, the <i>reason </i>that I don't have a doctor at Hospital A any more is that my doctor there quit Western medicine to become an energy healer, but that is another tale for another day.)<br />
<br />
I thought I was really on top of things when I called Radiology Department B to get them to request all my films, scheduled the new appointment when the films arrived, and then and only then called Radiology Department A to cancel, explaining that the follow up was being done at Radiology Department B because they still had doctors practicing evidence-based medicine there and I had no clinician at Radiology Department A.<br />
<br />
And then.<br />
<br />
The next day I got an anxious call from Radiology Department A. We need to you be seen. <br />
<br />
Well, I called and cancelled yesterday because I have the same appointment somewhere else. You just sent the records.<br />
<br />
Oh. We don't have a record of that. It's very important that you be seen.<br />
<br />
I explain <i>again </i>about my old doctor leaving Western medicine and my consolidating all my care to Hospital B.<br />
<br />
This morning I checked on the EHR portal of Hospital A. Sure enough, they're still flagging me for overdue follow ups.<br />
<br />
That's when I accepted: I'm in the Hotel California. Hospital A and Hospital B are, although nominally nonprofits, competitors rather than cooperators. There is no real system to track the transfer of care. Moreover, weeding out all flags from a big database is really, really hard. From their perspective, I represent a potential liability because they spotted a potential problem and recommended that I follow up. I get that. Unless I prove that the loop is closed they can deem me "noncompliant" and get rid of their exposure that way.<br />
<br />
So I sucked it up. I wrote Radiology Department A a letter today, thanking them for all the lovely care (and they really have been nice over the years), reminding them that I have transferred care, and why, and enclosing a copy of the results of the follow-up x-ray from Radiology Department B.<br />
<br />
Now that ought to do it.<br /><br />Update: <a href="http://ruthedlund.blogspot.com/2016/11/the-further-adventures-of-radiology.html" target="_blank">well, that was naive</a>.<br />
<br />the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-86482149941528686372016-10-20T13:11:00.002-07:002016-11-08T10:42:13.584-08:00dear sergeant<!--[if gte mso 9]><xml>
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</xml><![endif]--><span style="font-family: inherit;">I would
like to express my appreciation to you and your marshal for meeting with me on Tuesday
afternoon, October 18, 2016. We met to discuss the incident earlier that day in
which my personal mobility aid was confiscated before my entry to the Maleng
Regional Justice Center, and I was required to use a completely unsatisfactory,
presumptively unsanitary, and stigmatizing substitute mobility aid in order to
obtain access to the courthouse.</span><br />
<div class="MsoNormalCxSpMiddle" style="mso-hyphenate: none; tab-stops: -.5in;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormalCxSpMiddle" style="mso-hyphenate: none; tab-stops: -.5in;">
<span style="font-family: inherit;">Although
I appreciated the promptness with which we were able to conduct at least an
initial discussion of the incident (indeed, the very promptness and informality
with which the meeting was set up may have been a contributing factor), the
meeting itself raises an additional concern for me.</span></div>
<div class="MsoNormalCxSpMiddle" style="mso-hyphenate: none; tab-stops: -.5in;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormalCxSpMiddle" style="mso-hyphenate: none; tab-stops: -.5in;">
<span style="font-family: inherit;">I offer
the following thoughts for consideration of future meetings of this sort:</span><br />
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">You and your marshal, two very tall and imposing men in full sheriff's regalia,
directed me, an officer of the court, to a secluded conference room in the courthouse
library, to receive my concerns. I laid my cane down—which had been confiscated
from me by one of you just hours before as a dangerous weapon!—on the table
between us, within my reach, as we spoke.</span></div>
<div class="MsoNormalCxSpMiddle" style="mso-hyphenate: none; tab-stops: -.5in;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormalCxSpMiddle" style="mso-hyphenate: none; tab-stops: -.5in;">
<span style="font-family: inherit;">Many,
if not most, people would find providing unsparing criticism face-to-face with two
authority figures, particularly law enforcement, alone in a confined and secluded
space, a highly intimidating prospect.</span></div>
<div class="MsoNormalCxSpMiddle" style="mso-hyphenate: none; tab-stops: -.5in;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormalCxSpMiddle" style="mso-hyphenate: none; tab-stops: -.5in;">
<span style="font-family: inherit;">I am
not asserting that there was any conscious intent to intimidate me. Your choice
of venue for our discussion, however, which I was hardly in a position to
challenge as an officer of the court bound to cooperate with law enforcement,
reflects a lack of understanding of its effects. I would imagine that it is
automatic for you to seek to control any situation that you enter, given your
line of work, but there is such a thing as overcontrolling a situation. You may
also have been wishing to provide confidentiality for a discussion that might
be expected to touch on my disability. If so, I thank you for that, but there
are better ways to address that concern.</span></div>
<div class="MsoNormalCxSpMiddle" style="mso-hyphenate: none; tab-stops: -.5in;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormalCxSpMiddle" style="mso-hyphenate: none; tab-stops: -.5in;">
<span style="font-family: inherit;">It
occurred to me after the fact, but only well after the fact, that, had one of
you made a snap judgment, during this meeting, that I was making a “threatening”
or “aggressive” move towards my cane, and that I therefore needed to be
"subdued," I would have had no way of establishing that the facts
were otherwise. Given: the initial suspicion with which my innocent cane was
met (to the point where someone who actually had held it in his hand believed
that the head was made of metal, rather than resin); the intensity of my feelings
about the situation to which I had been subjected; and my tendency to wave my
hands around when I talk, I wondered in retrospect if I placed myself at
greater risk than I realized by acquiescing in your chosen venue for our
meeting. I also wonder now if I should have insisted on a witness/advocate on
my own behalf, which was not presented as an option for me, before going
forward with our meeting. Indeed, if our recollections differ about what was
said during this meeting, since it was not recorded, I have been placed at a
(numeric) disadvantage.</span></div>
<div class="MsoNormalCxSpMiddle" style="mso-hyphenate: none; tab-stops: -.5in;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormalCxSpMiddle" style="mso-hyphenate: none; tab-stops: -.5in;">
<span style="font-family: inherit;">You were
both clearly taken aback by the intensity of my distress, or at least the force
with which I articulated that distress. I am somewhat relieved, in retrospect,
that my impassioned plea for treatment with dignity was not misevaluated as
potential aggression.</span></div>
<div class="MsoNormalCxSpMiddle" style="mso-hyphenate: none; tab-stops: -.5in;">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormalCxSpMiddle" style="mso-hyphenate: none; tab-stops: -.5in;">
<span style="font-family: inherit;">Although
I was not daunted at the time by the venue of our discussion, I am sending this
followup letter because I suspect that my background and temperament make me unusual
in this regard. The difficulty of protest when deprived of access to an
accommodation, even for a person such as myself, means that such slights occur
much more frequently than are ever brought to your attention. In fact, I <i style="mso-bidi-font-style: normal;">did</i> find my initial interaction at the
courthouse entrance highly intimidating, and I had to compose myself before I
could place my initial call to the ADA coordinator. An intimidating venue, however
innocently selected, adds an additional barrier to such issues being brought effectively
to your attention.</span></div>
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<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormalCxSpMiddle" style="mso-hyphenate: none; tab-stops: -.5in;">
<span style="font-family: inherit;">I hope
that you can receive this additional feedback in the spirit in which it is
intended. You did ask me in my meeting what suggestions I might have for the
future, so I may I add to my suggestion that you develop a coherent policy for
mobility aids a suggestion that you use less discouraging venues for the
discussion of ADA complaints. I don’t know if there is a usual protocol for
these meetings that was bypassed in my case. </span></div>
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<span style="font-family: inherit;"><br /></span></div>
<span style="font-family: inherit;"><span style="font-size: 12.0pt;">As a family law attorney, I want safe courthouses just
as much as you do. But as a family law attorney, I also want everyone without
ill intent to have access to those safe courthouses. Arbitrary denial of access
serves no one. Remember: every cane is a “stick."</span></span><!--[if gte mso 9]><xml>
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<![endif]-->the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-24685238251747914862016-10-17T10:40:00.001-07:002016-11-08T13:56:16.186-08:00every cane is a "stick"I went to the King County Courthouse this morning, and had my walking stick confiscated (I got it back eventually). The deputy handed me a nasty bogus cane that someone had abandoned there for my use in the courthouse.<br />
<br />
The rationale for this was that my walking stick could be "used as a weapon" against me, and that they had taken it away from me for my own protection. The deputy never gave me a satisfactory answer to my inquiry about what would stop someone using the substitute all-metal cane against me as well. What he said to me was, "I <i>have </i>to let you use it," which to my ears sounded a lot like he was expressing skepticism that I was actually, you know, disabled.<br />
<br />
After making inquiry of the courthouse ADA coordinator, filing a formal complaint with the Sheriff's Office via email from my meeting, and hate-tweeting about it, which was probably useless but satisfying, I took a meeting this afternoon with the deputy and his boss, the supervisor of the security unit at this particular courthouse. This meeting was probably much more enjoyable for me than for either of them. <br />
<br />
Because of the apparent distrust of my disability, I began by putting my disabled parking permit wallet card on the table to establish the <i>bona fides </i>of my use of the cane, and it kind of went downhill for them from there.<br />
<br />
Here is my debrief of the meeting, more-or-less as sent to the ADA coordinator:<br />
<br />
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I believe that I have sufficiently convinced the Sheriff's Office that my
personal cane is not a deadly weapon, so that I will have no problem bringing it
into the courthouse in the future. They may hide when they see me again.</div>
<div class="MsoPlainText">
<br /></div>
<div class="MsoPlainText">
I was surprised to learn, however, that although the
Sheriff's Office does have a<a href="http://www.kingcounty.gov/~/media/courts/SuperiorCourt/Docs/ProhibitedItems.ashx?la=en" target="_blank"> detailed list</a> of permitted and forbidden items in
the courthouse (scissors have to be blunt, wrenches less than 7", etc.,
etc.), it doesn't have ANY guidelines on mobility aids and which of their features might cause them to be excluded from, or admitted to, the courthouse. <br />
<br />
The list prohibits
"sticks." <br />
<br />
I pointed out that every cane was a stick, and so this
policy could be used to arbitrarily exclude ALL cane users from the courthouse,
which would be discriminatory. It really didn't give me any guidance on
which of my walking sticks and canes might pass muster and which might not. Depending on the deputy and the day.</div>
<div class="MsoPlainText">
<br /></div>
<div class="MsoPlainText">
They used the example of knitting needles being
forbidden, but I pointed out that most people don't need to use knitting
needles to walk. Then they tried to distract me with a question about service
animals and whether people "need" them, and I told them to stop trying
to distract me because I could talk for hours about those policies.</div>
<div class="MsoPlainText">
<br /></div>
<div class="MsoPlainText">
They said that the "probable" reason that the
folks in the Seattle courthouse let me through (which happened a couple of weeks ago) was that they don't have any
substitute canes to hand out in Seattle the way they do in Kent. This reason makes no sense. If my cane is a danger in Kent, it's just as much of a danger
in Seattle. I am not sure they really accepted my point that you can't just
take away someone's personal mobility aid and expect them to be happy using
some random cane with a handle in a shape that they might not find useful
that's been touched by who knows what people with what diseases. And what do
they do about people in wheelchairs?</div>
<div class="MsoPlainText">
<br /></div>
<div class="MsoPlainText">
It ultimately came down to the guard at the time (1)
thinking that the handle to my walking stick was metal, which it was not, and
(2) not liking the (blunt) beak on the cane. Neither of which he bothered to
tell me at the time, he just made his weird proclamation about how it could be used as a
weapon against me. So I spent some time talking to the deputies about cane handle
designs, showing them, as an example, my additional cane with a "derby"
handle, which also has a similar shape, and a point on it, and pointing out how
the lack of guidance/understanding of the personal choices involved was a
problem. </div>
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<a href="https://3.bp.blogspot.com/-tpIEh8FZsIA/WAbRJVv324I/AAAAAAAAACw/cjgOOA1Yy5UYSgMtjAs9NBVZODvxt62egCLcB/s1600/14718700_10155312744550744_4685230382940798106_n.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://3.bp.blogspot.com/-tpIEh8FZsIA/WAbRJVv324I/AAAAAAAAACw/cjgOOA1Yy5UYSgMtjAs9NBVZODvxt62egCLcB/s320/14718700_10155312744550744_4685230382940798106_n.jpg" width="320" /></a></div>
<div class="MsoPlainText">
I said that when it came right down to it, I wasn't going
to make a scene at the metal detector, and they were the bosses of what comes
into the courthouse, but that it wasn't right that the burden should have been
on me to prove that my mobility aid was safe, or for me to be stigmatized by being forced to
use something with hazard stripes on it (really?!) rather than my mobility
aid of choice. They never really articulated to my satisfaction why my wooden
walking stick with a resin handle would "threaten someone's safety or
well-being" (to quote the <a href="http://www.kingcounty.gov/courts/SuperiorCourt/info/ADA.aspx">King County ADA website</a>) that much more than the
all-metal cane they made me use. Might it be *slightly* riskier? Maybe, for the
sake of argument. Enough to justify confiscating it? Ridiculous.</div>
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As a family law attorney, I am (statistically speaking)
as likely as anyone at the courthouse to be a victim of violence. I don't have
a problem with a no-weapons policy! I have a big problem with being required to
use mobility aids that look a certain way because the guards lack
even a basic understanding of how hard someone might try <i>not </i>to look disabled. </div>
<br />the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-83939157940324426272016-10-17T10:40:00.000-07:002016-10-18T18:33:31.656-07:00dear director of patient relationsI am new to your organization, so I have been reviewing carefully all the forms that were mailed to me in advance of my first appointment.<br />
<br />
[Of course, this isn't because I'm new. I will review carefully every form you ever hand me. Fair warning.]<br />
<br />
I noted with interest the following language:<br />
<br />
[This me trying to be tactful.]<br />
<br />
<blockquote class="tr_bq">
"We allow 30 days from billing for your insurance company to make payment. If your account is not paid in that time, we will ask you for assistance to obtain payment from your insurance company."</blockquote>
You may only want to allow my insurance company 30 days to pay up, but as a matter of federal law, ERISA gives my insurance company 30 days to make a <i>decision </i>on a "post service" claim, which, if you are submitting billing to them, is what we are talking about here. They also might be able to ask for a 15-day extension in some circumstances.<br />
<br />
What you seem to be saying to me is that unless my insurance company not only makes its <i>decision</i> on a shorter timeline than federal law gives them, but also gets a payment to you, <i>you </i>are going to start hounding <i>me</i>.<br />
<br />
I assume that you are relying on the "prompt pay" statute in effect in your state in setting forth this policy. Prompt pay statutes haven't been faring well in federal courts lately, so there's a good chance that the whole thing is preempted by ERISA. Even if upheld, your statute doesn't give me a private right of action, and only requires my insurer to hit the target on 95% of "clean" claims. I could be in the five percent, and I have no control over whether the claim as submitted will be a "clean" claim as your state statute would require.<br />
<br />
What I really want to know, as your new patient, is simply this:<br />
<br />
How aggressive are you going to be about this language, given that you're a big institution, and my insurer is a big institution, and the dollars involved are more significant to me than to either of you?<br />
<br />
<br />
<br />the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-38368545369611564342016-10-11T08:41:00.001-07:002016-10-11T08:51:40.341-07:00don't judge a post by its titleSo the <a href="http://www.npr.org/sections/health-shots/2016/10/10/497040284/rethinking-automatic-insurance-coverage-for-preventive-health-care">article</a> was called <span style="font-weight: normal;">"Rethinking Automatic Insurance Coverage For Preventive Health Care" on the NPR website. Which sounds like a bad thing, right? Because of course it is good public policy (as opposed to a prudent business practice) to make preventive care "free" (that is, prepaid as part of health insurance premium) because it encourages more people to obtain the care. And so of course changing this policy sounds like some sort of skullduggery.<br /><br />Well, there is skullduggery afoot, but it does not come from the <a href="https://www.uspreventiveservicestaskforce.org/Page/Name/about-the-uspstf">U.S. Preventive Services Task Force</a> (hereafter "USPSTF," which is a horrible acronym), the entity recommending the uncoupling. <br /><br />Why are they making the recommendation? Mylan N.V., the company which has been jacking up the price of the EpiPen to the skies over the last few years, has been lobbying the USPSTF to list said EpiPen as a "preventive device," even though it is used to stop an allergic reaction, not prevent the reaction in the first place. I suppose you could say it prevents death, but by that logic <i>all </i>medicine is preventive. </span><br />
<br />
If EpiPens were covered as preventive medication, patients with health insurance could get
them at no cost. The price increases Mylan put in place would be <a href="http://www.npr.org/sections/health-shots/2016/08/25/491372193/discounts-arent-enough-to-halt-outrage-at-high-epipen-prices">invisible to consumers</a> and would be borne by the insurers.<br />
<span style="font-weight: normal;"></span><br />
<span style="font-weight: normal;">The USPSTF, not happy about being inserted into a dogfight between drug companies and insurance companies, is trying to depoliticize the recommendations.<br /><br />So were I the Queen of NPR, which is not likely to happen in this lifetime, I would call the article: "When Defining 'Preventive' Health Care Becomes Politicized." <br /><br />You're welcome, NPR.</span><br />
<span style="font-weight: normal;"><br /></span>the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-51732626601368487962016-08-03T08:04:00.003-07:002016-11-21T11:23:26.479-08:00when someone tells you who he is, believe himThe consort of the Dark Goddess has always provided health insurance coverage for the family. As the health insurance industry has changed over the years, so too has the packaging of our coverage.<br />
<br />
I recall a time in the late 1990's when HMOs were all the rage, so we
dutifully signed up for one. I wish I could remember the organization,
because I would definitely name it and shame it here (I might be able to
glean that data from my Big Book o' Medrecs, come to think of it). I do
know it wasn't Group Health, which I regard as <i>sui generis</i> in any event.<br />
<br />
The <i>very first action</i> of this HMO was to send us a lovely gift: a hefty paperback titled <i>Take Care of Yourself: The Complete Illustrated Guide to Medical Self-Care.</i> It didn't actually have the words <i>And Leave Us Alone!</i> printed on the front cover, but it might as well have.<br />
<br />
<br />
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<a href="https://2.bp.blogspot.com/-3laaGxzF5Og/WDNI9aYExAI/AAAAAAAAADU/lms4aFsZf3sxJdp64sizBTaLRhEhc-4YwCLcB/s1600/15181659_10155437612235744_319414372139606392_n.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://2.bp.blogspot.com/-3laaGxzF5Og/WDNI9aYExAI/AAAAAAAAADU/lms4aFsZf3sxJdp64sizBTaLRhEhc-4YwCLcB/s320/15181659_10155437612235744_319414372139606392_n.jpg" width="180" /></a></div>
<br />
<br />
I see from amazon.com that this book went through at least nine editions through 2009, and there are hundreds copies available for a penny each, so sending this book as a "benefit" to HMO subscribers must have been a pretty common practice.<br />
<br />
I wonder still about the thought process of the HMO marketing maven that
led to the conclusion that sending this book would be a good
introduction to the HMO. On the other hand, it has the rare virtue of
representing truth in advertising.<br /><br />ETA: I found the book! And I therefore can now name and shame the company: <br />
<br />
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When an institution tells you what it is, believe it.the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-77087366279043575372011-01-21T13:34:00.000-08:002011-01-21T13:34:26.327-08:00at least his partners know he has a blog<a href="http://www.abajournal.com/weekly/article/akin_gump_chair_hits_partners_personal_blog_post_on_ugly_indian_prayer?utm_source=maestro&utm_medium=email&utm_campaign=weekly_email">Akin Gump Chair Hits Partner’s Personal Blog Post on ‘Ugly’ Indian Prayer - News - ABA Journal</a><br /><br />His post, however, was not a good idea.the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-3515919052499526542010-10-19T17:39:00.000-07:002010-10-19T17:43:42.067-07:00brief means briefOh, come on now. <a href="http://www.law.com/jsp/article.jsp?id=1202473543818&src=EMC-Email&et=editorial&bu=Law.com&pt=LAWCOM%20Newswire&cn=nw20101019&kw=Malpractice%20Case%20Against%20Saul%20Ewing%20to%20Proceed#">104 issues raised on appeal</a>? If you can't win your case on the first 103 issues, why raise the 104th? <br /><br />Seriously, if you can't win on the first four issues, I don't think the additional hundred will help at all.the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-13548869823143722732010-03-17T17:09:00.000-07:002017-03-22T16:25:02.208-07:00Service Snakes<a href="https://casetext.com/case/assenberg-v-anacortes-housing-authority" target="_blank">This</a> has to be one of the funniest opinions I have ever read. God bless him, the trial judge played it perfectly straight.<br />
<br />
The hapless plaintiffs had two problems: <br />
(1) they wanted to use medical marijuana in federally-subsidized housing. True, Washington has a <a href="http://www.doh.wa.gov/hsqa/medical-marijuana/">law</a> created by initiative that provides an affirmative defense to prosecution under <span style="font-weight: bold;">state </span>law, but use of marijuana is still illegal under <span style="font-weight: bold;">federal </span>law;<br />
(2) more entertainingly, they wanted to claim that their snakes were "service animals [sic]" under the ADA.<br />
<br />
OK, what's wrong with this picture? Leaving aside the fact that a reptile is not, by definition, an "animal," the animal has to be individually trained to do work or perform similar tasks for the benefit of an individual with a disability. The guy's physician actually only stated that he suffered from depression and the snakes were his "therapy pets." (Right before he wrote him a recommendation for medical marijuana.)<br />
<br />
Now, I imagine you could train a bird to ask, "How do you feel about that," but a snake? After all, they speak with forked tongues. The case law is pretty clear that an owner's deriving comfort from an animal is not enough to qualify that animal as a service animal for ADA purposes. The animal/reptile has to have special training. Here the plaintiff lost because he was unable to show that he trained the snakes to perform specific tasks or that they had any other unique qualities.<br />
<br />
You get more of a sense of what this guy must have been like as a tenant from the dry notation in the facts that he "claimed an unlimited right to carry the snakes around with him, including when he paid his rent."the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com3tag:blogger.com,1999:blog-3503241.post-87000760313231699942010-02-02T10:57:00.000-08:002010-02-02T11:11:53.277-08:00grandfathered in, or perhaps grandmotheredThe Washington state legislature enacted <a href="http://apps.leg.wa.gov/billinfo/summary.aspx?year=2009&bill=1592">HB 1592</a>, effective last summer, ending the formation of new corporations sole. Existing corporations sole are--for now--continued to exist. <br /><br />HB 1592 also enacted an annual report requirement and imposed a $10 annual fee. Clearly, the legislature doesn't like corporations sole much, although I believe the behavior of mine has been exemplary. The House bill report noted: <br /><blockquote>The bill requires corporations sole to file an annual report with the [Secretary of State] and pay an annual filing fee, which is consistent with the requirements of non-profit corporations. Many illegitimate corporations sole will not be able to file annually because they provide false addresses. Washington is one of 15 states that allow corporations sole registrations. Oregon and Idaho recently prohibited the formation of corporations sole. Washington is on the Internal Revenue Service's radar for fraudulent corporations sole registrations. Disallowing further registrations will prevent new fraud. Between 1861 and 1990 there were a total of 82 corporations sole. As of today there are more than 4,000 corporations sole [in the state of Washington? Nationwide? Worldwide?]. The [Secretary of State] estimates that only a quarter of corporations sole are legitimate.</blockquote><br />The annual report, alas, doesn't give me much room to exercise creativity, only asking for name, place of business, and signature of the bishop, overseer or presiding elder. That would be me.the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com0tag:blogger.com,1999:blog-3503241.post-68036429574303798702009-12-18T09:38:00.000-08:002009-12-18T09:40:13.369-08:00the gauntlet is thrown<a href="http://www.abajournal.com/weekly/article/bankruptcy_judge_orders_lawyers_to_stop_using_capitalization_with_abandon">This judge</a> needs to Get Over It. Or perhaps Rise Above It.the goddesshttp://www.blogger.com/profile/11112799730463476712noreply@blogger.com2