Healthcare Coverage -- Easeful or Aggravating?

I recently read The Nordic Theory of Everything and was amazed and heartened by what the author, Anu Partanen, revealed about the Nordic and American systems. More importantly, her theories resonated with my own experiences in medical practice.

Partanen’s perspective, backed by several annotated and well documented studies, is that when populations in the Nordic countries pay taxes, and a streamlined government administers those taxes into healthcare, disability, retirement, and primary, secondary and tertiary education – for everyone – the population then has, in fact, more independence and more freedom. People aren’t tied to jobs because of the need for health insurance; parents don’t mortgage their houses to pay for their children’s education; people don’t go into hock and get stressed out when they have to pay and care for their aging parents; and school quality isn’t dictated by the neighborhood where people live. When these core needs are taken care of, people are free to base their relationships on what Partanen terms “the Nordic theory love”, and not on dependency and obligation.

And, by the time you figure the American out of pocket costs for healthcare, tuition, disability etc. etc. added to the taxes paid, the amount Nordic populations pay in taxes to pay for every one of these services is quite comparable – and equitable. That sounds pretty intelligent to me.

With respect to healthcare, it’s universal and uniform, and therefore the administration costs are streamlined. There is no privatization, no advertising, no competition, and no convoluted calculations for what’s covered and what isn’t.

I wrote about my experience as a physician with the misdirected explosive growth of administrative complexity in my memoir Lonely Refugee. Here is an excerpt:

When I began to work at Group Health [in 1984] there were no treatment record forms (TRFs) or billing forms to fill out. All I had to do was see patients and write good chart notes – good by peer review standards. My practice kept me jumping for sure, especially on days that I saw up to thirty patients in eight hours, but I spent most of my time coordinating patient care and leaving clear tracks in the charts. Back then there were no copays, no deductibles, no exclusions that patients were obligated to cover. All patients paid for were their monthly dues. That is all they paid for! And there was pretty much one single coverage plan – no deluge of coverage options from which to choose, and through which to navigate. One basic healthcare plan served practically all. At the time, I didn’t realize how lucky I was.

Twenty years later, myriad levels of administrative complexity had seeped into my practice. I had treatment record forms I had to fill out to document the level of care I provided, and to account for every procedure I performed, from paring corns to performing endometrial biopsies and suturing lacerations. A plethora of billing codes for every possible diagnosis and procedure inundated my work life. I could only charge higher diagnostic billing code levels if I followed the required documentation guidelines. I had to write my clinic notes in minute detail, using the exact mandated language. If I failed to follow the strict rules, I risked Medicare fraud charges: billing for work there was no evidence for in the chart . . .  

Hundreds of administrative non-patient care positions and system “upgrades” surfaced to cope with the tsunami brought about by the new changes. I was astonished at the magnitude of the upheavals: clinics were remodeled to create registration areas where newly hired clerks collected copays and determined insurance coverage; business departments exploded with coding technicians, billing clerks, and computer programmers; huge infrastructures materialized to develop, monitor, update, and maximize data capture and optimize reimbursements. And to keep up with and compete with the nationwide healthcare chaos, Group Health expanded its insurance coverage options and now offered literally hundreds of plans – so confusing, that I no longer knew how or whether the tests, medications, referrals, and procedures I ordered would be paid for by my patient’s coverage plan.

When patients asked me, “Is that lab test covered, doc?” I could only shake my head. “I don’t know. You’ll have to check at the business office.” . . .

Patients would then have to decide what they could pay for and what they couldn’t afford. I had to let them know the risks of not getting the tests done, or I had to scramble to find less expensive care options. All this required extra time, and inconvenienced both my patients and me. Care was occasionally compromised when patients didn’t check back after heading to the business office, or if they waited until they could come up with funds to pay for the medications and tests that I ordered. Many times patients became disgruntled with the costs they had to bear, and some became irate when the drugs or tests to treat their particular illness weren’t covered. I resented having to spend more of my clinic time documenting widgets of care and acting as the gatekeeper and mediator with my patients.

I was sickened to see how, with all the new changes, the focus had shifted away from patient care. Our medical staff meetings that once provided educational case reviews and clinical lectures, were now replaced by coding and charting classes to train providers on how to comply with the Medicare standards and maximize reimbursements from the government and insurance companies. The coding specialist frequently showed up at our meetings, giving us the latest code changes. For diabetes alone, hundreds of coding options were created – and they were updated almost weekly. The administrators had to make sure that we were entering the newest and most complete classifications. Learning these codes, taking the time to make sure all the parameters needed for the appropriate level of service were included in my charting, keeping up with the frequent updates and “corrections,” consumed more and more of my time. It drove me nuts.

When the codes were first introduced, the office billing clerks corrected the ones that I had flubbed and added codes that I couldn’t figure out. These employees were godsends! But when electronic charting was initiated, my backup system went poof! I had to enter every darn diagnostic code myself. To my chagrin, the computer wouldn’t allow me to order any labs, prescriptions, X-rays, treatments, or referrals unless I entered the exact diagnostic code.

Many a time I would flounder when with a patient. “Just a moment, Mrs. Smith. I’ll have to go find the right code number so I can order your X-ray . . . I’m so sorry for the delay, Mrs. Smith. Let me quickly finish up here and get you on your way.” But by now, I would be ten or fifteen minutes farther behind in my schedule. “Crap,” I would think to myself. “I’m going to be here until all hours tonight!”

I didn’t question that the electronic charting system improved access to medical records and therefore served patients and clinicians well. What I was at odds with was how most of us docs were staying at least an hour or two later to finish up with our charting and paper work. I had to ask myself if the high complexity level of billing, coding, coverage, and reimbursement systems also served to create better health, and I knew the answer to that – I didn’t think it did! And that made my extra work harder to accept. My disillusionment with the medical system grew.

What do you think?

I highly recommend The Nordic Theory of Everything, and I dearly hope that the U.S. will come to its senses and institute more effective and efficient medical care – and education – and retirement – and disability – coverage.

The Traveling Dress Photo Shoot

I was up before four a.m. to help with a photo shoot. Stephanie had been awarded the honor, along with seven other professional photographers, of showcasing a layout taken with a “traveling dress” that was mailed from photographer to photographer, over several weeks. We drove to her chosen locale: a solitary dock jutting into Lake Washington. My inspired, on fire daughter began shooting well before sunrise.

I was her assistant, tasked with guarding the camera and tripod that she carefully positioned before running out onto the dock, swaying, prancing, dancing, her layers of tulle skirts swirling, flowing, and glowing in the backlight. She set the camera to take one hundred shots at a time, reset the hundred over and over, moving the camera here and there, checking the angles, the exposures, scrunching her face when not pleased with the results, grinning with an I like that one . . . pretty! with ones that captured her creative spirit.

In the flow, she braved splinters and gravel on her bare feet; her legs seized with charley horses as she crouched and squatted; she gazed into the searing sunrise for that look-directly-into-the-camera picture. She chuckled when the voluminous layers of tulle snagged on weathered planks, and dipped into the water. The “holy-water” drops on the gown served as grace-filled glitter, a blessing on her project.

At one point, a policeman drove by and motioned to Stephanie. He was concerned when he saw her dashing toward the edge of the pier, thinking she would jump. She and I later mused at the vivid image of “doing a Virginia Wolf exit from the world”.

My heart clenched to hear Steph’s response to the officer: I’m just playing.

My hard working and relationship challenged daughter could so use more lightness, more playtime in her life. She deserved beauty, pleasure, and amusement. She deserved to be admired, cherished and loved.

Stephanie shot for over two hours, taking thousands of images. Self-portraits galore, each showing a different aspect of the glory of the woman she is: beautiful, regal, talented, sensitive, vulnerable, strong.

I glow in her glory.

Here’s the link to her website post The Traveling Dress

Woes and Hopes in the World

The Reading Through It book club at the Seward Third Place Bookstore began in the aftermath of the last presidential election when many, shocked by the results, wanted to explore who we are as Americans, where we were going, and how we might fix our greatest problems.

We have discussed several sobering books, all outside my usual genres of literature, romance, mystery and fantasy. These have included Dark Money by Jane Mayer, White Rage by Carol Anderson, No Is Not Enough by Naomi Klein, Man Without a Face by Masha Gessen, and Evicted by Matthew Desmond.

This last week, we discussed Killers of the Flower Moon: The Osage Murders and the Birth of the FBI by David Grann. I came away that evening dejected and down, and my inner analyst poked and prodded me to draft some insights.

First: human depravity and greed and cruelty have been around for a long time – centuries if not millennia, and that makes my optimistic ideals flag.  I fear for the future.

Second: I am glad that there are journalists like Grann and Anderson and Klein that do a good job in documenting these travesties so we can open our eyes and begin/continue the work of improving the world.

Third: there are good people, who with courage and singular intent, work for change and justice.

Fourth: it’s easy to get emotionally triggered and angered when talking about man’s inhumanity to man, as happened with some of us at the book club. It was important for me to take step back, to center myself, to smooth my own rough edges, and to share my calming thoughts with the group.

Fifth: I want to understand the problems, not get trapped in anger, frustration, hopelessness and rage and, most importantly, I want to move towards solutions.

So, what are the solutions for the woes of the world, for people that revel in human cruelty – in inflicting pain onto others, be it psychological, or physical; for people that crave power and money? Are these major flaws in the human condition?

What drives these insatiable destructive desires?

What is the cure? Is it love? Love is such an ambiguous term. How is it expressed? How is it measured? The scientist/physician part of me wants to know: how can it be “prescribed” throughout the world; how is the world’s ill health “dosed” with love in order to create healing, to cure the diseases of cruelty and avarice?

And perhaps, more importantly, how is cruelty and avarice to be prevented from coming about in the future? How do we raise children to avoid these pathological pitfalls in life? Much has been studied and researched in the areas of human development, attachment and trauma. What happens in utero, and in early childhood are the times in human development when healthy practices are so crucial. How do we as a society promote robust loving relationships during these critical times?

Vis-a-vis look at what’s happening today with the separation of young children from their parents at the Mexican border. Those children have been traumatized. Society will reap the consequences of that trauma as these children grow up and express their trauma in violent, cruel, and avaricious ways.

As I struggle with the huge scope of the tragedies and travesties, I always come back to the basics: it all begins with me. I take the time to connect with nature, with friends and family, to meditate, to find joy in my everyday adventures, to work in the world in a soulful manner. These are some of the ways I am centered in that physiologic state where my neurotransmitters are humming at optimal levels, where I am doing my best thinking and creating, and I am connecting most meaningfully. Over the years I have taken the time to work on my own attachment issues, my own anger, greed and cruelty. And I continue to do this never-ending work.

Following the book club, I was drawn to revisit Victor Frankl’s Man’s Search For Meaning for answers to my roiling upset, my yearning to find solutions to the world’s woes. Here was a man who found meaning amidst the raging cruelty and stark depravations of the German concentration camps.

I find solace – and hope – in his words:

When we are no longer able to change a situation, we are challenged to change ourselves.

I grasped the meaning of the greatest secret that human poetry and human thought and belief have to impart: The salvation of man is through love and in love.

A CALL TO BIG BUSINESSES TO HELP MY SEATTLE NEIGHBORHOOD FLOURISH

A few weeks ago, on one of my many drives past the corner of Rainier Ave South and South Henderson Street, I recalled a failed effort two years previously to draw in a name brand business. The grocery store located in the strip mall had gone out of business, and there was a call on the NextDoor blog site to come help make a video to send to the Trader Joe’s home office.

We want Trader Joe's in Rainier Beach

The hope was to attract the corporation’s attention and bring in one of their stores. Over one hundred of us showed up at the abandoned grocery store. We came with banners, I along with many others clutching my TJ’s grocery bags. Many were interviewed for the video, and we all chanted: We want Trader Joe’s. The cheerleaders from Rainier High School across the street represented the younger generation, and added some glitz and pizazz to the event. We were on fire!

Nothing came of our effort.

A Dollar Tree Store, a gym, and small businesses moved in – the strip mall remained faceless and dull.

That same day I drove on Othello past MLK, crossed over the light rail line, just a few blocks from my home. This is a road I have travelled countless times, and I mused on the four restaurants on that corner that have come and gone since I had moved in ten years ago. There seemed to be no long-term traction with businesses in the area.

And I asked myself: why is it that the big names don’t come to poor and not always safe neighborhoods like this? It seemed to me that if Trader Joe’s were to move in, they would have a profitable business – and they would raise the quality of the neighborhood immensely.

And what about restaurants? How would it be to have a Tom Douglas restaurant move into the Othello Station building? Why would that be such a big stretch? He has his ardent followers – which include me, and many others who live in this neighborhood – and we would come out in droves to support a venture like his. And, most importantly, with one or two big names in the area, it would pave the way for other lesser-known restaurants, ethnic restaurants, because the big names would bring in the “chic-ness” and the traffic would follow because more people would be drawn to the area.

This would be a risk, true, for the big names, but really, they are doing so well already – in the chic parts of town. Tom Douglas has sixteen restaurants in the Seattle area – all of them in upscale neighborhoods. Could he not step into and help restore the more downtrodden areas of the city?

These ideas percolated in my head for several days, and then this past weekend I walked three blocks to the “Othello-Bration,” a gathering of different neighborhood groups and entertainers.

I spoke to a spokesperson for HomeSight a nonprofit organization whose mission is to create strong equitable communities. They are the developers of the Othello-MLK corner lot where the celebration was being held. I chatted with the spokesperson about wanting a big-name Tom Douglas restaurant to go in there – he said he was in contact with the Monsoon restaurant owner about just that. We had a good laugh! He shared that Columbia City was a scary place a dozen years ago – unsafe and with nothing much there. La Medusa, a very popular and well-respected restaurant was an early settler. Now that historic landmark neighborhood is thriving. I felt encouraged -- there is hope for the Othello neighborhood!

I also spoke to an Assistant Principal of the Rainier Leadership Academy a Green Dot Charter School. They are housed in temporary huts on the Othello- MLK lot and their students are flourishing. A permanent structure for the school is breaking ground in the next year.

I went inside a converted shipping container, which housed the community organization called Beet Box. This group of volunteers created a world herb garden, and they provide all kinds of gardening tips and materials. They also host gatherings such as book swaps and free barbeques.

Across the street, the SEEDArts group hosted a booth. This is another nonprofit whose byline is The Power of Art in Building Community. The organization supports an arts center, a loft for artists, a radio station, and they just funded the creation of a gorgeous mural on the side of the Othello Safeway store.

I am glad to have seen the upside of my neighborhood after being exposed to some of its underbelly – the sirens wailing several times a day – and through the night, the random gunshots, the unkempt figures muttering and swearing as they plod up the hill past my home, the cars revving and blaring expletive hip-hop, the bands of young men hanging about, heads bent together, pants hanging off their butts. Their piercing looks as I drive by send a frisson of fear into my gut.

Despite the underbelly, our community is out and about. I love to walk and jog and greet my neighbors along the Chief Sealth trail. I take my grandchildren to the park down the block from my townhouse and chat with other families. In the height of summer, my granddaughter frolics in the sprinklers at John C Little Park and in the wading pool at the Van Esselt Park. I love having a library branch a block away, and there are many, many community functions, block parties, and potlucks.

I believe my neighborhood is in transition, and I want it to flourish. I am grateful for all the good work that has been done to date, and which continues to improve our community.

There is more to be done.

I call on Tom Douglas, the leaders of Trader Joe’s, and other upscale businesses to take a risk. I challenge them to do their part to help make the Othello/ Rainier Valley neighborhoods flourish.

Rest assured that you will find support here.

What have you got to lose?

In Memoriam: For an Inspiring High School English Teacher

I just learned that my high school English teacher, Mrs. Vasey has died. I received the notification in the quarterly magazine of Loreto Kirribilli, the convent parochial school that I attended for eleven years in Sydney, Australia.

Mrs. Vasey inspired in me a love of reading. With a sparkle in her eye, she told us about the luscious history of “penny dreadfuls.” These cheap, sensational, highly illustrated novels and serials were the first to be distributed to the masses in Victorian England, and they launched a new era in literature. She used the “penny dreadful” term with affection, encouraging us to read for pleasure, much like the rank and file did in old England. But she also advocated quality reading. She disdained and dismissed condensed books in any form as an abomination. Some time later, when I came upon a condensed version of To Kill A Mockingbird, I understood why – the grace, the art, the brilliance and the soul had been ripped from the original.

Mrs. Vasey was a divorcee with three young children. Back in the sixties, that was a rare and scandalous state, even more so in Catholic circles. There were titters amongst some of the students, snippets of gossip, smirks when they witnessed her frustration with her sometimes rambunctious children.

Years later I experienced the pain, the guilt and the shame of divorce. I had two young children at the time, and some of my reflections are in Lonely Refugee: A Hungarian Australian American Memoir.

For me, Mrs. Vasey’s legacy is manifold. From her came the pure pleasure and love of reading, and the discrimination to seek out quality literature. From her I learned how to find grace and strength as a divorcee, as a professional woman, and as a single mother. She and I are part of that sisterhood. I am grateful to her for leading the way, and for forging the path for those of us who followed.

Your legacy lives on, Patricia Vasey. May you rest in peace.