Thursday, June 17, 2010

Just wait until they start pretending not to ration care

GL saw the orthopedist yesterday. He sees him every year. It's always a difficult visit for GL because he is afraid of the x-ray machines, with their cold tables, big, mysterious moving parts, and strange noises, and because he knows this is the doctor who uses the "s" word: "surgery". He also refuses to believe that there is any such thing as a doctor who doesn't give shots in his office, and is sure every doctor is secretly planning to stick needles in him.

His hip is fine, but we had actually moved this visit up because his ankles had got so much worse in the last months. He's walking on the inside of his feet again, and the medial malleoli nearly touch the floor when he stands without shoes. When we took him to have his orthotics adjusted, the orthotist said it wasn't the orthotics, it was because the insides of his shoes were worn down. So we replaced them, and he wore down the insides again. He's worn out four pairs of shoes since January. So I was hoping for new orthotics, maybe even going back to AFOs, if needed, and a new scrip for PT because he is obviously losing ground here, and his prior authorization ran out about the time his ankles took a turn for the worse.

I always get anxious preparing for a doctor visit. I feel like I have to gather all the right information, present it in exactly the right way, and present my kid and myself in exactly the right way, or my kid won't get the care he needs, and it will be all my fault. Yes, doctors are supposed to be observant, and treat everyone the same, but there are times when that just doesn't happen. And there are times when the doctor has obviously made up her mind before she even examines your kid. That doesn't keep me from second-guessing myself. "Maybe if I had said... or not said... Did she that think he's a malingerer? or a spoiled brat? Or that I'm some kind of a nut?... Is she jumping to conclusions about... and refusing to consider...? How could I have explained it differently?"

Like the first time I took him in for his ankles. They had looked fine, but as soon as he began to walk, there was obviously something wrong. The more he walked, the worse it got. At the only clinic Medicaid would pay for (I was a student at the time) a different doctor saw him every time. I booked an appointment. When the doctor walked in the room, she asked him a question. He refused to answer, so she immediately diagnosed him as nonverbal. (Like Donkey, sure, he talked, it was getting him to shut up that was the problem. Except around people he didn't like.) She insisted there was nothing wrong with his ankles, and wouldn't even let me take off his shoes to show her. The next week, I managed to get another appointment. I'd done some homework on the subject, but it wasn't necessary. Sure enough, we saw someone else.  She took one look at his ankles and referred him directly to the orthopedist. And he talked to her.

We had the usual anxiety at the doctor's office yesterday, plus more than the usual yelling and screaming. But we managed to get him on the x-ray table despite his protests. When, instead of a high, whistling whine followed by a shrill beeeeep, the machine made a boodeloodeleep, he actually giggled. Then it was back to the waiting room. Every time another patient was called, he would jump up and yell, "No! No! I won't go back there! You can't make me!"

When he was called, he put on a similar performance, and added, "No shots!"

The assistant who called us back wanted me to confirm the list of meds he is on. Sounds easy, with only one med missing from the list, but the list was all brand names, and his insurance only pays for generics. We could list his meds but, not being a nurse, she had no idea which  brand names they were equivalent to. We finally figured it out, but it took some detective work.

Another assistant performed the exam. She never introduced herself, neither by name nor by title. She could have been a doctor, a nurse, a receptionist, or a cafeteria worker who borrowed a white coat. We never did find out who she was. She asked a lot of questions, but we had to fill her in on the case, including surgeries that should have been in his records. When she was done, she left us waiting in the exam room for over an hour. Then the orthopedist showed up with a third assistant. This assistant performed an abbreviated exam while the orthopedist stood off to one side and announced that GL did not need surgery or new orthotics; he just needed high-tops. I showed him GL's orthotics and the wear pattern on his shoes. (In less than a month, the inside of the heels has completely worn away.)  He said that he doesn't want to put him in something more restrictive. I thought more restrictive was the point of high-tops, but I asked if PT might help to strengthen his ankles. He said that no, this was not a muscle problem, it was a ligament problem, so PT wouldn't help. So if his current orthotics aren't working, strengthening the muscles won't help, and AFOs are too restrictive, what will hold this kid's ankles off the ground so he can walk on his feet and not his ankles? And a month from now, when he's chewed up a pair of high-tops that aren't working, how long will it take to get another appointment, and what will he do then? Heavy sigh.

GL has been seeing this orthopedist for the last five years. Until now, we've had a good working relationship. He's always been happy to prescribe whatever GL needs. And I might be willing to trust him if I hadn't seen the same pattern with all of GL's doctors lately. They're afraid that if they prescribe or refer more than the insurance companies want, the insurance companies or the government will limit their referrals and prescriptions. Insurance companies don't make money by providing health care. They make money by collecting premiums and then denying as much care as they possibly can. So the doctors self-limit care to what they think will satisfy the insurance companies, who then set that level of care as the new standard, and try to cut claims even further.

Obamacare is going to be worse, not better. I'm not opposed to providing care for the poor and the disabled; I've just seen what kind of care the government provides. The poor and the disabled get Medicaid. Medicaid treats providers so poorly that it's almost impossible to find a provider who accepts it. Single-payer would have put everyone on Medicaid. "But doctors would have to take it," you may argue, "if it were the only game in town." For anyone with the brains and ambition to become a doctor, medicine is never the only game in town. They keep playing because payments haven't yet been cut to what they could make doing something else, but cut payments enough, and they will begin to retire earlier, go to law school, or go to work for insurance companies and lawyers, cutting claims further, and helping sue the remaining doctors. Medicine will become the province of the dedicated and the incompetent.

Think leaving practice for a second career is too big a move for an established physician? Based on population trends alone, for the next twenty years, we will have more physicians retiring or dying than entering the profession. Cut payments enough, and enrolling in med school begins to sound like a sucker's bet.

So, if we can't cut payments to physicians without cutting the quality of care, wouldn't it be a safer bet to put the government in charge than private insurers? No. If a private insurer cuts claims enough, customers will switch companies. There is at least that check on their power. A company that refuses to listen to its customers will eventually go bankrupt. If you're on a government plan, and they won't pay, what are your options? 1) Go outside the plan, and pay out of pocket, like many Canadians do, coming to the U.S. If you can afford this route, why bother with the government plan? 2) If you can't afford to go off-plan, you can settle for second-rate care. If you've never been on Medicaid, you don't understand how bad government care can be. 3) Lobby for legislation to force the plan to provide preferential coverage for people with your condition. With Boomers reaching retirement age, there simply won't be enough money to treat everyone for everything. Every disease will become a political football. Of course, by the time you have a condition, it is unlikely you can get the law changed in time to help you. You will suffer with poor treatment treatment or none at all, and either get well or die first.

With all the above-mentioned pressures on the medical and insurance systems, isn't it best to keep private insurance, but under close government supervision? No. In that environment, there would be two possible outcomes: 1) the government guarantees the insurance companies the right to make a profit, making them even more powerful, (that's why the insurance and pharmaceutical companies were competing to cast themselves as good guys and each other as bad guys in the healthcare debate) or 2) under heavy regulation, private insurers go out of business one by one, leaving the remaining insurers more powerful and less affordable. If insurance is mandatory, but costs more and more while providing less and less, many of us will be forced to buy some sort of minimum coverage until the government comes to rescue us from the situation it created with some sort of single-payer plan. Eventually, only the very rich and powerful will be able to opt out. The rest of us will be forced, one by one, into some sort of single-payer system, just like Obama wanted in the first place.

There. I vented about several things that were bothering me. I feel a bit better. If you want to leave a comment, feel free, but remember it is my policy to reject all anonymous comments. If you leave an anonymous comment, it will be rejected, not because I disagree, but because it is anonymous. And don't be the moron leaving an anonymous comment objecting to my right to reject anonymous comments.

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Blogger Arby said...

You are your son’s strongest advocate and fighting for him can be physically and emotionally exhausting. Keep the faith. Keep fighting for him. I speak from the experience of someone who has walked a tenth of a mile in your shoes. As for Obama care, preach it, brother! Obamacare will be the death of us.

June 18, 2010 at 10:02 AM  

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