I haven’t written in a while because I have been looking for a way to describe what’s been going on in healthcare.

the American healthcare system

As a provider

There has been a weird unhappy vibe in the  American hospitals these days.. It’s like nothing I’ve ever felt before in the last 15 years.  There has always been a collective feeling of frustration among providers; but it’s usually sat somewhat untended, like a slow cooker slowly simmering away..  These frustrations were related to our inability to provide the best for all of our patients, our frustration with the broken-ness of a health care system so rife with waste, yet with so little help for our vulnerable populations, and those in dire need.

It was manifested by occasion individual grumbling; during case management meetings, during conversations with faceless insurance companies as we explained yet again, why our patient:

a. really needed XYX treatment and

b. how it was actually more cost-effective in the long run..

But it was isolated for the most part, and the majority of providers still felt like they were helping people – and enjoyed the job satisfaction that went along with that..

It seems like a lot of that has changed over the past year.. I don’t know if it’s fear of coming changes, and the uncertainty that goes along with that..  But most providers are actually in favor of the Affordable Care Act – or the concept, anyway.  It’s something else, maybe the forced implementation of governmental changes like clunky and poorly functioning EMRs, the continual threats of “pay-for-performance” or a cummulative effect of all of the above, but many providers seem to have reached the breaking point in frustration.

For the first time that I can recall, a lot of really excellent physicians and other providers I know are just burned out to the point of complete mental and physical exhaustion.  People I’ve know for a long time, people I consider my mentors, my inspiration are talking about retiring early or leaving the field to do something else entirely.

It’s also the first time that I’ve ever seen doctors, nurses, and others as a collective to seem so broken in spirit.

Patients are people, not check box diagnoses

I am feeling a bit of it myself – a kernel of hopelessness that sparks in my heart.. a sinking feeling when I order a standard medication (but individualized for a specific patient/ condition) and enter in the computer – and receive a message telling me that dosage is not permitted.  A follow-up phone call with the pharmacist continues the charade.. Since it doesn’t fall into a specific category between two mandatory dosing schedules (for diagnoses that differ from what my patient has) then – they don’t know how to categorize it on the computer – and thus my patient can’t have it..  This makes no sense to me, I am following best practices, the current literature and evidence-based practice, but somehow my patient’s condition hasn’t been coded somewhere down in the pharmacy, so they won’t release the medication.  Too scared of the consequences I guess – or too apathetic to care that the medicine is for a real, living, breathing person and not a statistical table somewhere.

– and I argue the realities of this individual scenario but the bureaucratic mentality on the other end of the phone doesn’t care..  How am I supposed to do my job; to care and protect my patient in a system like this?  It’s only going to get worse as the government gets more and more involved in patient care.

What?  My patient isn’t a peg, it’s a person – and if this person doesn’t fit the pre-specified check box doesn’t matter to me  (in this specific instance)- what matters is that my patient keeps his leg (which he may not, if he doesn’t get this medication at the dosage I ordered in consultation with his surgeon).

As the consumer – losing my current plan

At the same time that this brokenness is affecting providers nationwide – I have fallen into the dilemma of many of my readers. As a locum tenems provider, I am self-insured.  My current plan, which was flexible, affordable and provided coverage which suited our needs (low monthly fee, low deductible, reasonable co-pay, and two free wellness checks a year) is being discontinued.  It was also a flexible plan that allowed my family and I to see providers nationally.  So if I was working in Texas for six months, I could see a doctor in Dallas. Or Massachusetts, or California, even back in my home state of Virginia.

Now, I am spending most of my days off on the phone and the internet – looking for a policy that doesn’t limit my coverage by location.  Most of the time, I can’t even find the correct phone numbers to talk to the right people.  The numbers listed online at the marketplace are incorrect, or out of service.  The representatives that I do speak to after being on hold for thirty minutes and routed through a computer automated system are sometimes nice, (often completely indifferent) but can’t answer my questions.

I do know that at a minimum my monthly expenditure for even the bronze “no frills” plans will double, and may even triple.  My deductible will also double or even triple, so in January, I will be literally paying two or three times what I paid last month (December) for a fraction of the services.

Paying a lot, and getting almost nothing in return

All of the new government approved plans are based on my home state – and some even limit coverage to my county only.  Since my county is rural – and the nearest major medical center is actually in a neighboring state, having one of these local plans is like being uninsured.  (Some representatives said they would cover out-of-area “life-threatening emergencies*”, but others weren’t sure).

this should be a significant concern for anyone in rural or limited medical access areas**.  For someone with my geographical needs, it’s become a major nightmare.   Even with the increased costs – I may still not have coverage for the majority of my time (for 2013 for example, I was home for a total of 1 month. In 2014, I was home for four months).  Since I can’t predict where I will be sent – I can’t pick a plan for another state.  Not only that – but even if I knew I was going to be posted to Indiana or somewhere like that – I am not allowed to buy a plan outside of my registered address.

No one knows the answers – and what they do know doesn’t sound good:

After another full day on the phone with representatives for the Healthcare Marketplace and different insurance providers, it looks like the answers are pretty ugly when they even know them.  Most of the representatives had no answers.  One of them even asked me, “Well, do you vote?”  They won’t even give a call back number or extension so that when they “accidentally” disconnect you during another of the “let me transfer you to another representative” spiel, you have to go thru the whole rigmarole all over again.

1.  If you have a plan that does not have out-of-network coverage – consider yourself uninsured if you become injured or have a medical emergency outside of your area (which may be as small as your county.)  The cheapest plan for two people on Blue Cross/Anthem/Blue Shield (my existing company) that offers out of network coverage is 594.00 a month (we paid 213.00 a month before).

2.  None of the plans cover medical tourism – even from companies that previously provided these options.  So, if you live in a county like mine (with no trauma center, and a tiny rural hospital) – you aren’t covered for the neighboring hospital in another area in an emergency.

Not only that – you can’t receive coverage for a non-urgent (elective) procedure for something like a knee replacement at another facility.  My town has one orthopedic surgeon (and he isn’t someone I’d ever chose to go to.)  Now I can’t go to Duke, UVA or another nearby facility – and they won’t pay for me to have the same treatment (at a fraction of the cost somewhere else like Bogotá.)

Here’s a typical example of what I’ve learned after several days/ weeks of reading & talking to representatives –

I’ll pay $5,112 in premiums with a $13,200 deductible with NO coverage of any conditions (except an annual physical and a flu shot) until I’ve put out a total of $18,300 (every year – not a one time deal).   Then the insurance will start to pick up the tab.. This is supposed to be affordable?  For whom?

And while some people will pay less in premiums based on their income level – they still have to come up with the $13,200 deductible.  How the heck is that supposed to work for someone making $30,000 a year?

So now we are calling all the other companies and reading, reading, reading all the fine print.  For now – it looks like I will paying an exorbitant amount for minimal coverage, and will need to rely on medical tourism for any non-urgent but essential treatment that either falls below my high deductible or isn’t even available in my home area.  Luckily, I am pretty healthy (but I am currently working in a trauma unit so I know how quick that can change) – but isn’t the whole point of insurance to prepare for the unexpected?

So what does that mean?

I don’t have the answers for everyon1e.. In fact, I don’t even have them for myself. But it may mean that I am better served by paying my premium and using medical tourism for all of my other (non-emergency) health care needs.  After all, $13,199.99 buys a lot of care in Colombia, Mexico and many of the other places I’ve researched and written about.

*And, if you survive – you may have to argue with some bureaucrat whether your illness was actually life-threatening or not.. I mean, it can always be argued that “how serious was it, really, if you made it home alive?”

** Limited access areas may include major cities.  For example, the city of Las Vegas has a very limited number of specialists.