Healthcare update: no update

The quality of the healthcare you receive in the United States is determined by your income and the terms of your employment contract.   Why not?   It is delivered by for-profit corporations for the benefit of executives and shareholders.   Again, why not?   American healthcare outcomes are not among the best in the world, though they are pretty good for many Americans who have decent health insurance plans through work.  American healthcare is, far and away, the most expensive, and the most profitable in the world, so that’s something to be proud of, isn’t it?

I got the good news and the bad news yesterday about my kidney disease and the $88,000 treatment I might need in a few months.   The nephrologist’s receptionist called with good news that my recent tests came back rosy and that I don’t need another round of the fancy drug at this time.  The bad news is that the doctor won’t be picking up the phone, he told his receptionist to tell me he’ll give me all the details when I see him in a few weeks– three days after my deadline for purchasing health insurance for 2019 — and that we’ll test again in three months.  He emphasized to me at the beginning that this idiopathic disease is unpredictable and little understood, numbers can go up or down dramatically at any time and we cannot put much faith in patterns like the steady downward tic of the concerning numbers.

I called back today to ask to speak to the doctor for a minute.  Sadly, not possible.  I explained my insurance dilemma to the receptionist, that my deadline for choosing insurance for 2019 is three days before my appointment.   I told her I didn’t want to put her to any extra work but that I needed to know if they were likely to get pre-authorization for a drug that would cost me $88,000 “out of pocket” if it wasn’t pre-approved.    The alternative, the longtime standard protocol for my disease until this new wonder drug came along, is a much cheaper but more debilitating twelve month course of intravenous steroids and infusions of a more harmful immunosuppressive agent (as opposed to two infusions a month apart).     I’ll ask the doctor for you, she said.   I hope to hear back in the next few days, though, of course, one never knows.  Only the weak and fretful worry about these sorts of things…

I called the insurance company and punched in the option for pharmaceuticals.  Spoke to a very knowledgable rep there at the third party that pays drug claims for my insurance company (and many others), explained my dilemma.   She told me, after a long investigation, that since this drug is not sent directly to the patient but administered in a hospital, I had to go through the medical department of my insurance company, that this drug did not fall under “pharmaceuticals”.  

I explained to her that during my previous hour long call the medical department had referred me to her company, the third party that approves all pharmaceuticals, including hospital administered ones.   She told me this was not the case, that somebody at the insurance company had made a mistake.   I read her back the provider-side 800 number I was given by her company for pre-authorization.   She agreed it was the proper number, the number my doctor would have to call to get pre-authorization for this drug.  I told her it had taken me almost an hour to get that number but that it was not one I could call myself, being a patient, not a provider.   I was patient as hell itself.    She gave me an 800 number for patients to call for “Speciality Drugs” and then noted that I seem to have spoken to someone there last week.

I explained to her again that my worry and my question both appeared to be fairly straightforward.   In 2017 I had a QHP and Rituxan, the $88,000 drug, had been approved.  In 2018 I was on a lower tier plan, and it was uncertain whether Rituxan could be approved, particularly since it was on the “excluded list”.    “Unless the hospital gets pre-authorization,” pointed out the helpful rep.  She was unable to determine whether it was also on the excluded list for the QHP.

She simply could not tell me if in 2017 the drug was on the “excluded list” and had to be pre-authorized.   If that was the case, it would give me some comfort.  In other words, I was trying to determine whether the insurance  product I was about to be forced to buy for 2019 would cover the expensive drug I might well need in 2019.   Not a very tricky question, outside of an unregulated corporate environment where the primary concern is maximizing profits and the health and well-being of patients is on an as-needed basis.  

The confusing labyrinth of disconnected and walled off corporate sub-offices is perfectly allowable (and virtually unregulated)  under the terms of Obamacare and under the “Business Judgment Rule” (a given business is in the best position to make judgments about how it should be run).  These internal walls make it impossible for anyone within the corporation (or outside of it, for that matter) to have a global view that would allow them to answer a fairly straightforward question about what products and services are covered under a given plan.    The rep seemed a little offended, telling me she’d been working there for many years and had a pretty global view, but that I was asking a question that was just impossible to answer. 

The bottom line, it will take a lot longer than two hours, if ever, to get the answer to this simple enough question.   The helpful rep who tried to help was sorry she couldn’t give me the answer I was seeking, but it was simply impossible.  She could take a grievance from me, if I liked.  I declined her kind offer and thanked her for her time, somehow not giving vent to the bitter sarcasm that was flowing over my tongue like battery acid.

Foamy Urine

One from the Don’t Worry About It Department:

My urine had been foamy.   Not just bubbles, but real foam, like soap suds, or the head of a draft beer, or the top layer of a root beer float, to be most precise.   The urologist laughed when I mentioned, in passing, that my urine was foamy.  “Your urine is foamy?” he said with a big smile, like I was pulling his leg.

The first nephrologist told me I had permanent. irreversible scarring on my kidneys and would need a lifelong regimen of drugs, and regular visits to his office, to maintain the functionality of my kidneys.   When your kidneys go you die, of course, but, then again, whatever you do, you die, so there’s that, plus, I’d already lived to sixty, no mean feat.  The doctor was philosophical.  

He made his dire diagnosis with certainty, without having to run any tests, merely by noting the swelling from my knees to my ankles, bilateral edema, and, of course, the foamy urine, proteinuria.  The foaminess of the urine turns out to be an indication of protein being passed in the urine.  Normal kidneys do not allow protein to pass through their filtering system into the urine, the body has more important uses for protein than pissing it out.

Fortunately, the medical insurance I had at that time refused to pay this doctor, so he cancelled our follow-up appointment, when actual tests would have been done.  I found another nephrologist and had tests done.

There was a lot of drama the next year or so, and three or four other nephrologists, the second discovering elevated levels of anti-PLA2R autoantibodies in my blood work.   The presence of these antibodies correlates highly with the presence and progression of a kidney disease called idiopathic membranous nephropathy.   That doctor, though I liked him, was not on my new insurance plan, so I had to take his paperwork to another nephrologist.  

The third one argued vigorously about the meaning of “idiopathic” (which she eventually had to admit does mean ’cause unknown’) and urged me to undergo an immediate kidney biopsy and begin the twelve month immunosuppressive protocol without delay.   The kidney biopsy confirmed that I had this rare disease with the unknown cause.   The good news was that the biopsy also showed no scarring of the kidneys, organs which, in my case, continue to function in the normal range.

The last nephrologist I saw recommended that I have a short course of treatment borrowed from cancer treatment, infusion of a powerful immunosuppressive agent called Rituximab, or Rituxan.   It is tolerated well (far fewer debilitating side effects)  and requires only two infusions, as opposed to the twelve month course of infusions that has long been the standard treatment for this disease, a regimen that includes intravenous steroids and other powerful, potentially harmful chemicals designed to shut down the immune system, every month for a year.   Rituxan is expensive, the doctor told me, but apparently my health insurance in 2017 would cover it.  

When I showed up for the first round of infusions I was asked to sign a paper that included a paragraph where I stated that I’d been informed of the price of the treatment and agreed to pay any balance the insurance company refused to pay [1].  I asked the woman at the desk what the price of the treatment was.   She said she had no idea, and no way to find out, actually.   I asked her how I could possibly sign off on the paragraph I pointed to.  

“Cross it out, baby,” she said nonchalantly, and I did.  “They’ll tell you the price upstairs,” she told me, photocopying my papers.   

All they knew upstairs is that Rituxan is very, very expensive.

A few months later I learned the price when the insurance company sent me the EOB (everybody in America knows what an EOB is– Explanation of Benefits).   The EOB stated that the list price for the two small bags of immunosuppressive infusion was $88,000.   My insurance company had paid a small fraction of that, maybe 10% or 15%.

Since the infusions a year ago my blood and urine work has been heading steadily in the right direction, though my urine continues to be foamy, indicating that it still contains protein, and the numbers are still far higher than normal.  The last time I saw him the nephrologist suggested that, just to be safe, we do another round of Rituxan.   I asked if we could hold off on this, as I was just getting back toward 90% of my health and fitness levels from before the infusions had induced persistent asthenia (weakness, lack of energy).   He told me there was no harm to wait, that we should check in three months from now, which is currently about three weeks away.

It suddenly occurred to me, since I have only a few weeks to select my health insurance for 2019, that I ought to see the nephrologist before the enrollment period ends, to determine whether he still recommends another $88,000 round of treatment.  If so, I need to be sure the insurance I buy will cover it.   In 2018 I’m paying a fraction of what I paid in 2017 for my current insurance, based on my 2017 income.  My current appointment, December 18, is three days after the deadline to purchase health insurance for 2019 or be ineligible for a year.   Fair is fair.  He had no earlier appointment available but would discuss my blood and urine test results on the phone as soon as I could get them done.  I had them done last Tuesday.

Of course, none of this is anything a patient should have to worry about, which tier of the health insurance hierarchy he or she is on and what medicines and treatments are covered on each tier.    This is a profit-driven American sickness. Under the Affordable Care Act, the tier of medical insurance you may purchase is based exclusively on your income.   Your income level determines the level of medical care you may buy.  To purchase a QHP (“qualified health plan”) like I had in 2017, your income must be something like a minimum of 200% of the official poverty income.  If your income is only, say, 167% of that number, you will be required to buy what is essentially pay-as-you go Medicaid.    Medicaid famously does not pay for cutting edge treatments when far less expensive old standbys are available.

In other words, if you want to pay 10% or more of your annual income for health insurance, to ensure you can continue a medical treatment for what used to be called a “preexisting condition”, you are prevented by the ACA from doing this.  You must have an income sufficient to purchase a QHP.   If your income says you are too poor to do that, well, whose fault is that?

I no longer get bogged down in the philosophical issues [2].  If you are poor enough to be subject to a law that singles out poor people for a little extra nonconsensual sex, well, whose fucking fault is that?   I can howl at the moon, or figure out the odds of getting the medical treatment I need, to hopefully qualify for insurance, at more than ten times the monthly premium I am paying now, that will pay for a treatment that will only weaken me for three or four months, instead of for a year or more.

I called my insurance company to find out if the well-tolerated cancer drug was in my plan.   They really couldn’t say, beforehand, whether Rituxan is covered under my current plan.   The first rep told me it did not appear to be covered under my plan.   I gave her a svelte version of my rap about corporate “personhood” and the psychopathic self-regarding myopia of such “persons”.  She was sympathetic (I find most people are, if you remain calm and speak very succinctly) and asked me to wait for a rep who could actually answer my question.  The second rep was also sympathetic, but not the expert in pre-auth I took her to be.  She was not sure why the first rep had connected me to her.  I told her I wasn’t sure either, though it had been very nice talking with her.   She asked me to please hold for a third rep, someone who could definitely answer my question, hopefully.

For once the muzak was not oppressive.  It was an anodyne little jazz combo, led by a guitar, playing a completely innocuous, if uninspired, loop of jazzy blues in G. Better than most of the nerve challenging, blood pressure spiking shit the Mengeles out there use for hold music.

The third rep was the most sympathetic of all, and only 40 minutes into my call.   She told me that Rituxan was clearly on the list of drugs not covered by my plan, but that, if the doctor received a pre-athorization, based on medical necessity, it would be covered.  Although, sad to say, she had to check with another expert to be sure and hoped I wouldn’t mind holding.  “In for a penny, in for a pound,” I said cheerfully.

Fortunately, the little jazz combo was still playing that short bluesy loop in G, and I nodded along and made marks with ink, this time with a brush, for about ten minutes, at which time the third expert was on the line with a fourth.   They gave me the number the doctor needed to call at the third party that handles such things for the insurance company.   Tell the doctor to press 1 for “preauthorization” and then 5 for “medical necessity”.  If the doctor can prove Rituxan is a medical necessity, your insurance will pay for it.  If not, take what is behind door number two.

After submitting a few vials of my blood, and a small screw top jar of my foamy urine, I walked over to the doctor’s office where I left Deirdre with a note containing the pertinent numbers from the paragraph above.  She assured me she would follow-up once the labs came back, and that I would get a call from the doctor about the test results.

One last thing for me not to worry about.  Unlike in December 2016 when I was able to merely state my income, for purposes of paying a premium ten times more than I’m paying now for insurance that covered the treatment I need, there is apparently a brand new requirement.   To purchase a QHP you must submit a copy of your 2017 tax filing, showing the income that qualifies you to buy a qualified health plan.   I’ll cross that fucking bridge when I come to it, yo.

 

 

[1] The practice of trying to make the patient pay the balance, the difference between the rate the insurance company has agreed to pay and the sticker price billed by the provider, is called ‘balance billing’, apparently.   Of course, if a provider accepts insurance, the negotiated rate is all they are entitled to be paid. Balance billing, while not ethical, proper or strictly legal, is common.  Of a billion balance billing bills sent out, I’d imagine many millions are paid by conscientious consumers who don’t want to damage their credit rating.   Columbia Doctors recently sent me this kind of bill for $250, only 900% more than I actually owed for the visit.  Balance billing, you dig.  They can do this because there is no government agency in New York State that one can really complain to about this common practice.  Caveat emptor, bitches!

[2]  Though it has not been easy to come by this fragile new dispassion.  You can read some of my selected struggles with this merciless American health insurance and pharmaceutical industry-authored scheme  here.

 

 

 

Only in America, folks

Fortunately for me, I write quickly.   I dreaded having to write this note, but it took me only a few minutes once I sat down to do it.   Nobody should have to write this kind of note to their fucking doctor.  

Matt:

When I was “50 years young”  (12 years ago) you introduced yourself to me as Matt and gave me a card with a number where I could text you, and you were very good about responding to the one or two I sent.   Your current card has only a generic email address [1], so I am sending this there, to the attention of Glenice, who was kind enough to confirm that I should have been able to see you during my October 25th consultation with you.

On that date I saw only Nancy S______, ANP, who ordered tests, prescribed Flomax and told me I have to begin taking it immediately.  She also instructed me how to stand so that she could give me a prostate exam, though I had one quite recently and we agreed not to do another at that time.

On October 5, 2018 my urine was a brownish ketchup color.  On the following day I painlessly passed a blood clot, and that was the end of the blood tinged urine.

Screen shot 2018-11-11 at 3.16.20 PM.png

Nancy informed me that this is called gross hematuria, a condition the Mayo clinic states is sometimes impossible to determine the cause of.   She ordered a CAT scan, which I had on October 30, and a cystoscopy.   She also told me I’d retained a few ounces of urine in my bladder and had to begin taking Flomax, no matter the side effects I complained of the last time I took it, years ago.   The cystoscopy was scheduled for November 8.  A few hours before my appointment I had a call from your office rescheduling the exam for December 6.  I called Glenice who promised me a return call from you that I have not yet had.

I understand the imperatives of corporate medicine, but I don’t think you could defend this to your urology students as good medical practice.   I have no results from the CAT scan, have been given no medical opinion, have not seen the doctor I paid to see on October 25, have had no return call from him after the cystoscopy was cancelled.   Might the CAT scan results eliminate the need for the cystoscopy?  What, if anything, did the CT scan show?    Is this isolated instance of gross hematuria something I can safely put in the rearview mirror or should I be worried about the possibility that it may be a sign of late stage prostate or bladder cancer?  

I am currently being treated for idiopathic membranous nephropathy and my initial call was to my nephrologist.   He told me hematuria is not a known effect of my kidney disease and said I should call my urologist.  I got the earliest appointment with your office.  A month later I still know exactly nothing.

You can email me, text me at ______, or call that number any time after 1 pm. I don’t think you — or anyone–  would be satisfied with this kind of treatment from your doctor (leaving aside the very long waits for a blood test– which neglected to include the creatine test required for the CT scan– the appointment with your ANP, the hours waiting for the CT scan, the month long postponement of a diagnostic test).   Please advise.

Eliot

(I discovered, after writing it, that there is no place to actually fucking send it… you’ve got to admire corporate medicine, baby.  During regular office hours I can call and possibly even get an email address to send it to)

USA!  USA!!!!

 

[1]  Correction,  one always has to read the fine print carefully when dealing with corporate vampires.   There is no email contact information available for the department of urology, this is where the URL on the business card takes you, to the corporate not-actual-contact page of these Hippocratic oath taking corporate dickheads.   I can’t wait to get the hospital’s next solicitation letter telling me about the wonderful, selfless work they are doing, without profit, for the community.

 

Healthcare as a human right

The radical right is consistent, most of the time, I have to say that for them.   They latch on to something like “Right to Life” (no abortion under any circumstances) or “Right to Work” (the legal right of the employer to fire your ass at any time, with or without cause) and ride it to the end.   Their disciplined relentlessness is impressive, even if it’s not always good for democracy, people, animals, plants, children, old people, babies, the environment, health, human dignity, human survival.   The important thing is that they give their supporters a rallying cry to scream, a cry that never changes, if it works.   That these phrases may not bear much scrutiny as ideas in the marketplace of ideas is not the point.  Winning is the point, the only point.

As Republican icon Ronald Reagan said, either being pithy or already in the first throes of dementia: “the right to life ends at birth.”   “Right to Life” means that the right of a fetus to be born is absolute, more absolute than a mother’s right not to die from complications of pregnancy, far greater than the right of a fourteen year old girl not to have to go through the trauma of giving birth to her rapist’s baby.   Like every right extended, except to wealth that has perpetual life (corporate folks, persons just like you and me except they never die) it terminates at a reasonable time.   In the case of an unwanted baby, the right to life ends as soon as the poor bastard is born, breathing air and crying.   When the unwanted child is born society says “you’re on your own now, motherfucker, we protected you for nine months, your own mother wanted to kill you, but we saved you from that murderous bitch.  Now get the fuck out and get a job, asshole. And try not to stink so much… can’t you change that sagging diaper already?  No self-respect, you little shitass…”   Nothing to see here.

The way America’s wealthiest and least scrupulous organized themselves to make sure Obama was not able to get bipartisan support for anything, especially his hated plan to give access to healthcare to more Americans; priceless.  Jane Mayer reminds us that when Ted Kennedy’s death in 2009 left a vacancy in the Senate, a flood of dark money was unloosed immediately before the special election in Massachusetts.   After that election unknown Republican Scott Brown would sit in the seat occupied by a Democrat (a Kennedy, in fact, Ted took over JFK’s seat in 1962) from time immemorial.   Read all about it here.  

The Koch influence machine (the Kochtopus, as admirers dubbed it)  had secretly pulled off a stunning, history defying upset in a blue state that hadn’t had a Republican senator in generations.   Wikipedia is pretty even-handed about the invisible tentacles of the Kochtopus:

As of January 8, 2010, Martha Coakley raised over US$5.2 million in total, and had $937,383 cash on hand. Scott Brown had $367,150 cash on hand. Brown spent $450,000 on television advertisements, while Coakley spent $1.4million.[99] A week before the general election, Brown raised $1.3million from over 16,000 donors in a 24-hour fund-raising effort. Reports also indicated that Brown raised an average of $1 million per day the week prior to the election.[100]

The effect of this historic upset was that the Senate, with Brown, was now 59-41 Democratic, meaning Obama’s majority in the Senate, although impressive, was no longer filibuster-proof.   The loophole now existed for the entitled vulture class to defeat the hated president’s hated, albeit mostly conservative-think-tank-created, healthcare proposal.   The compromise that became known as the Affordable Care Act, when it was passed, had many, many faults, none of them ever fixed.  The ACA contained a few huge improvements over America’s past ruthless health insurance regime, the biggest being the abolition of the vicious “pre-existing condition” loophole that allowed health insurance companies to only insure people who were good bets not to need massively expensive healthcare.   The business of America is business, how it is fair that some fuck with cancer expects to get all those expensive treatments and drugs paid by insurance?   Pre-existing condition, totally unfair to make the insurer pay!

Some socialist types, and others, believe that included among the rights of citizenship in a wealthy society is the right to decent, affordable health care, administered through a publicly supervised health care system.   Americans pay by far the highest prices for our health care, far more than the citizens of other wealthy, industrialized nations, yet our health outcomes are no better than most places, except, arguably, at the very top end of American medical care.   Wealthy patients can always seek out and buy that top high-end healthcare, if they want to pay for it (and why not? they deserve it).  

The rest of us believe we have a right to not die of the many preventable and treatable diseases that are always stalking us.  A “right to life” if you will.   50,000 or more dead Americans every year who die because their only access to health care is an emergency room where the ER doc will say to a family member “oh shit, if only we’d seen him two years ago…”   These unfortunate American dead and their loved ones unwittingly make a sacrifice for all of us, a small price to pay for the freedom of eternal, legally created “persons” to live in perfect liberty, enjoying maximum profits protected by a friendly government, with the populist cover of a manipulated mob of confused, angry, powerless people chanting “USA!   USA!!!”.

I get my health care through the problematic Patient Protection and Affordable Care Act.  I can tell you dozens of ways the law sucks, and have written about many of them here (click the category Obamacare to read ’em).   Top of my list is the difficulty of actually finding care in this corrupt, lobbyist-written regime.   After years of rabid Republican opposition to the law, and more than fifty attempts to repeal it in its entirety (check ’em out), some elected Democrats are organizing to fight back with the hated “public option” (something that already exists and works pretty well for millions of Americans 65 and older, as well as in most other wealthy nations).   Seventy Congressional Democrats have apparently formed a caucus to discuss lowering the age of Medicare to cover even that fucking unwanted baby who selfishly insists on its right to care after the government has already zealously protected its ungrateful little ass for nine long months.

Here’s the petty detail that bugs me today, as I work on rehabbing my aching knees.  It took me about a month to find and get an appointment with a sports medicine doctor for a referral to Physical Therapy (PT).   A rep for my health-insurance company (think of how fucking asinine it is to give people health care via private, profit-driven insurance companies…) assured me that referrals are no longer required by their company for things like PT.   Every place I contacted about PT disagreed.  Obviously, they said, you have to have a doctor’s referral before we can give you PT.  Made sense.   I finally was able to see the sports medicine doctor who immediately referred me for PT.   Then it was a few weeks of searching, not getting calls back from the “in-network” PT offices where I left  messages, until I finally hobbled over to a place I could walk to that accepted my insurance and where I could have PT.    

Note this:  every week I searched, without finding service, every obstacle I had to crawl over to get to the next step in finding treatment, was money in the pocket of the insurance company.  Multiply my search by a few thousand searches, by a million, and you begin to get the idea of how lucrative it is to make this basic of medical care, finding and seeing a doctor in your “network”, so difficult.

There was one last hoop to jump through on my ailing knees, now weeks and weeks, months, in fact, after they’d become acutely painful.  I’d have do be “evaluated” for PT for my knees, by doing a half squat with my back against the wall of the PT room.  I did the half squat and was told now all I had to do was go home and wait to see how many sessions my insurance company would approve.  You see, the doctor is not the one who decides what’s medically necessary, nor is the physical therapist, it is someone at your insurance company who decides exactly what course of treatment, under the current law, you are entitled to.  Fair is fair, they’re the ones paying, you dig.

They decided I was entitled to seven sessions of PT, twice a week.  If you do the math, the approved PT would last just over three weeks.  Not much time to fix a problem that had taken a year or more to get this bad, now I just had to wait until they got the go ahead from my insurance company.  A week later I was able to start PT.  It is slow going, physical therapy.   No long-festering physical ailment can be cured in seven sessions.   After session six I asked the receptionist at the PT place what I had to do to get more sessions.  Another referral, she told me.   I contacted the office of the sports doctor I’d seen for a second time a week or so earlier.  After session seven of PT I was told that once the referral arrived I would have to be re-evaluated.

Stand against the wall in the room where you’ve completed your seven sessions of PT and squat as far down as your creaky knees will take you, then just go home, without further treatment of any kind, and wait.   In about a week, if all goes well, they would get the OK from the insurance company, if your particular insurance policy authorized more physical therapy for you.  Then, the following week you could continue your PT, with only, at most, a short one or two week gap.   You see, it’s impossible to determine if you’ll need more than seven sessions until you’ve completed seven sessions, right?  That’s just basic logic, right?   No matter what your fucking know-it-all sports medicine doctor might have to say about it (the rehab could take several months of hard work, she told me sympathetically).  No matter what.

God fucking bless America, boys and girls!

Did the Nazis actually win World War Two? (part two)

The following series of frustrating interactions with corporations involved in my medical care got me thinking how thoroughly the world now seems to run on the principles laid out, for corporations, by the famous Nazi party that ran one of the most powerful modern industrialized nations in the world for twelve of their planned thousand year rule.  These principles extend beyond lying, advertising falsely, assuming no responsibility for anything, blaming the victims, into how individual customers are cared for.  Nazi methods, once shocking, are now the routine way masses of people with any kind of problem are treated. 

Sounds overwrought, I know, to compare the now standard corporate runarounds  to techniques perfected in the Third Reich, but bear with me and you may yet be persuaded I am not merely talking through my tin foil yarmulke.  The amount of stamina and self-possession needed to have a corporation fix it’s own error, no matter how minor, is incredible.  We are often exhausted and resigned before we actually get to speak to a human.  This too is part of Nazi-inspired design.  Think about it.

The burden for correcting corporate mistakes always falls to the consumer.  Fair enough, why would a corporation care about a mistake, as long as it’s getting paid?   Profit is the bottom line, not worrying about the gripes of malcontents here and there.  A series of hurdles are erected to limit the number of complaints the lowest paid workers of any corporation will be forced to listen to on any given shift.  

It is fairly standard to have to navigate 3-5 minutes of robotic prompts and advertising, along with requests to stay on the line for a survey about the “service we are about to provide” before being placed on hold to wait for human representatives who are all busy helping other customers.  They urge you to handle your problem via their website, which enables each problem to be dealt with in a fraction of the time (if at all) and at a tiny percentage of the cost of having humans talking to other humans on the phone.

I’m not naive.  I get it.  Hire enough representatives to help everyone you are providing poor service to, without the long waits, and you cut directly into the corporate bottom line.  A ten minute hold, with blaring, nerve jangling muzak, to talk to customer service weeds out a good proportion of the whiners waiting helplessly in line to express how pissed off they are about some trifle or another.  It is simply the way it is done today in our era of global corporatism.   Corporations do what is best for corporate profits and that’s that, ask the U.S. Supreme Court if you don’t believe us.  You got something to say?  Please continue to hold, we thank you for your patience, your business is very important to us.

I was hit with a nice triple or quadruple whammy the other day just trying to get renewals for prescription drugs I’ve been taking daily for the last few years.   After weeks of looking for a physical therapist to help me with my stiff, painful knees who accepts my insurance, I took a break from leaving voicemails that were never returned and walked up to a nearby address provided by my insurance company and next week I’ll be evaluated for PT.  

“Evaluated?” I said, “I just gave you the doctor’s referral, detailing exactly what PT services I need and why.”

“We have to examine you first and submit a report to your insurance company and wait for approval before we can provide any services, that’s the law,” the pleasant receptionist told me.   Then she said that this approval ordinarily takes no more than two weeks.   Which will only make a total of five weeks since I was referred for physical therapy by the doctor who examined me.  

I vented a bit about American medical care, making sure my satirical, semi-humorous presentation was coming through as nonthreatening and ironic.  I was rewarded with a sympathetic smile from the receptionist who told me kindly that it might be less than two weeks, sometimes it’s much faster.

When I got home I followed up again on the status of getting my prescriptions renewed, a blood pressure drug, a statin and megadose Vitamin D, after hours of wasted calls with the corporation who dispenses them.  I’d had a long discussion with a rep named Don, at CVS Caremark, on May 25th.  Don assured me that he’d contact my doctor and get the prescriptions sent over to CVS Caremark, that I’d have the pills long before my dwindling supplies ran out.  

He then asked me to hold one more time, this was 48 minutes or so into our call.  I asked if he needed more information from me.  He told me he didn’t and agreed he could call me back if there was any problem processing the order.

The only problem is, reasonable as this may sound, that is not their corporate procedure.  If the customer does not stay on hold until the very end, the call is recorded as “customer disconnected” which was the notation Don made on my call, after assuring me everything was cool.  It was all cool for Don, why the hell wouldn’t it be?  The man has a job he loves, living the dream.  

Maybe Don wasn’t as amused as the receptionist pretended to be by my witty send-ups of our sickeningly broken profit-driven American health care system.  Maybe he was politely seething under his MAGA hat, imagining this demanding and ruthless prick he was dealing with, someone who expected to just be let off the line after only 48 minutes, at least five of them spent whining at tedious, didactic length, about the corporatocracy we all take for granted as simply the way the world is.

I learned my order was not being processed only by following up ten days later, when I hadn’t received the promised email confirmations of my order.   After only ten minutes on hold, and repeating all of my identifying info again, I was told the notes the corporation had for my May 25th call stated that the customer had prematurely disconnected from call, with the predictable result that no action could be taken on this jerk’s behalf.

An hour into my follow up call I conferenced in the doctor’s office where all the details were laid out by CVS Caremark rep Liz (only authorized to wait on hold for up to two minutes, exactly, she told me as she instructed me what to find out from the doctor’s office).  I put her on the line with the doctor’s receptionist, after a mere 35 second hold for Liz,  in a conference call and continued taking detailed notes.  Everything seemed to be straightened out, at last, and not a moment too soon.

This, sadly, didn’t result in the prompt resolution of my quest to have my prescriptions refilled.  One reason I prefer dealing with my local pharmacy, before they told me a few weeks back that my business was no good there.   I got an email from CVS in error, as it turned out, informing me that only one of my three prescriptions were listed on the order, which was pending.  

I followed the prompts and logged into the CVS Caremark website where I was able to confirm that only one of the three medications my doctor’s receptionist and the CVS Caremark rep had discussed was on order.  

I wrote a note to CVS Caremark in an attempt to fix this, have them update my prescription order, only to find myself in a permanent error loop “you have failed to update your email address” (which I had done by then two or three times).  Twenty five minutes of this was enough to convince me there was a technical problem with the ineptly written code for their website.  In order to get tech support with the website you must be able to send a message, after logging in.  Seamless and fucking brilliant, actually.

I thought of my former friend Andy and his ilk, mad fucking programmers and coders, well-paid guys on the Asperger’s Spectrum with no clue about humans, except as to erring like one.  The “Contact us” link on the website, of course, required you to be logged in.  You can’t contact anyone unless you update your email address in your profile, or even if you do.  Only option is to go through the standard four minutes of robot prompts and hold to wait to talk to a low paid human, who probably can’t help you anyway.  (Turns out she can’t).

Called the doctor’s office two days later to follow up on the status of the prescriptions.  The receptionist told me she’d left me a message.   My phone showed no messages or missed calls, then, when I went to renew the voice mail list, informed me again that it was unable to synchronize my messages because I  was not connected to a data network (I was).  

An hour call with T-Mobile tech support allowed me to hear the voicemail from the doctor’s office, a forty second tour de force of confusion and obtuseness.  I had Sekhnet leave me a voice mail to test it out, make sure the glitch with the voicemail was actually fixed.  “Error.  Unable to synchronize because you are not connected to the data network”.  

Another call to T-Mobile, another hour.  This time I got a $20 credit from the Nazi fucks (T-Mobile is a German corporation, originally) and delivered a few concise, impassioned but not overwrought, analyses of the inhuman treatment we are forced to take for granted in our corporate world that actually got great praise from the Indian kid I was talking to, the guy who granted me the $20 credit for the hassle I was in the middle of.   He “escalated” my complaint and I had a long pleasant chat with Leo, at the next level of tech support expertise, who couldn’t fix the problem either but promised to re-escalate my situation and get back to me ASAP with the fix (a mere 24 hours ago).  Leo sent me a text to this effect, with his identifying information.

 I am still unable to get voice mail, or log-in to CVS “Caremark” to update my prescriptions, but I am assured that everybody is working hard on my case(s) and I’m sincerely promised that everything will work out, as long as I’m as patient as…

By the way, remaining on the line the other day to the bitter end of a long chat with Liz (not to repeat the nonconsensual phone sex I’d had with untruthful Don), I  learned from the CVS Caremark rep that my pharmacy, who she contacted while I held one last time,  was not being paid by my insurance because they hadn’t updated my insurance information on their computer.  They had my old insurance policy listed, with a non-working customer ID number, and their bills submitted under that number were therefore rejected.

I dread to make the follow up call to CVS Caremark, now weeks after my original request to have the prescriptions renewed and filled by them, to find out why only my statin now seems to be on order.  (A few days ago only my blood pressure medication was on file).

In a country that was not obsessed with eternal, existential “competition” to separate God’s chosen winners (ubermenschen) from all the faceless fucking loser parasites (untermenschen, lebensunwertes leben, the “useless eaters”), masses of people with no rights a winner is bound to respect, it would not be quite so difficult to resolve simple fuck ups by the companies we deal with every day.   But that is the kind of dreamy sentiment only someone not sufficiently impressed with the importance of the corporate bottom line would express.  The dreamy Koombaya hallucination of a fucking born loser (note: most of us losers are born that way, as is the case for most winners).

“Please continue to hold, the Obersturmbannführer will be on the line shortly to facilitate your unrequested relocation eastward.  Meantime, try to control your fucking blood pressure without drugs, loser.  And dig this five second loop, played over and over at sudden wildly increased volume for the next ten minutes, by our house band, the Ultrasadistic Nervejanglers.  We think you’ll dig it, and if you don’t, oops.  Have a nice day and, please, for the love of all that is holy, continue to hold.”

Pharmaceuticals in America

I have no intention of researching and writing a piece about the folks who sell us legally prescribed drugs.   For a small, bitter taste, you can read this short bit about the wealthy family who helped bring us the Opioid Crisis.  Pharmaceuticals is a fantastically lucrative American industry up there with fossil fuels and munitions as far as the vastness of its profits.  I have to make a few calls today to line up a new drug dealer for my irbestartan and atorvostatin, as well as the weekly megadose Vitamin D, $2.50 a pill, that I’ve been prescribed.   The first two are generic versions of two famous patent drugs, Avapro and Lipitor.   Of Lipitor my mother used to say “I luhhhhhv Lipitor!”.   It seems to be lowering my cholesterol nicely, and not giving me any noticeable side effects, though I’m not sure I have the same passion for the little pill that my mother did.

Right after Obamacare, the Patient Protection and Affordable Care Act, became the law of the land I had a long chat with my local pharmacist, a sympathetic man named Bahdri.  He was lamenting what he expected of the new law.  He predicted that within five years all small pharmacies like his would be out of business.  The turf was being handed over to huge pharmaceutical distribution companies that were set up to deliver prescription drugs to millions of Americans under the PPACA.  It was the pharmaceutical version of Amazon.  No need to walk into your local brick and mortar store to get the shit you needed, just order it and pick it out of your mailbox a couple of days later.   Bahdri was gloomy about his prospects.

I liked my little local pharmacy.   I’d been having one of the drugs delivered to my home by an outfit called CVS Caremark, it was done automatically when the new drug was prescribed.   They’d send a ninety day supply of irbesartan.  I’d save five or ten dollars over the copay at the pharmacy.  I didn’t care about the few dollars, and arranged to have the prescription filled at Bahdri’s.  I preferred helping to keep a small neighborhood store in business.  As it turned out, I needn’t have been so solicitous.

Bahdri explained recently that the thirty day supply of one of the drugs cost the pharmacy $9 and my insurance reimbursed them a mere $1.37.   This did not seem fair to me either.  My new plan, a sort of pay as you go Medicaid, has no copay for drugs under a certain price (I paid a $10 or $15 drug copay on last year’s plan), and so Bahdri’s small store was getting screwed every time I walked in.  Bahdri informed me that the large chain pharmacy across the street would also not fill my prescription, certainly not the ninety day version.  He advised me to have the prescription sent back over to CVS Caremark.  I told him I would, and I will.

Yesterday, being out of one of the drugs,  I went to Bahdri’s to get four more 50,000 unit Vitamin D pills for the weeks going forward.   I take these because, after numerous skin cancers have been removed from my nose (and one from my arm) I avoid the fucking sun as much as I can.   The sun helps the body produce its own Vitamin D, or something like that.  The sun is very good in many ways, no doubt, but I avoid it.  This is no great sacrifice for me, as I stay up late, sleep late, spend my first few waking hours writing, wait for late afternoon most days to venture out.  I take most of my exercise around sunset or after dark.

Anyway I ran into Bahdri’s yesterday early evening to get the Vitamin D and his assistant (Bahdri wasn’t there) told me they no longer accepted my insurance and that Bahdri had told me as much the last time I was in.  I begged to differ, but my begging was not the kind of humble begging one usually associates with beggars.  I told him exactly what Bahdri had said and stated, with a lawyerly flourish, that Bahdri had never told me “your business is not wanted here any more.”  I suggested there was probably a law against a pharmacy denying a customer a prescription refill without some kind of prior notice giving the patient enough time to make other arrangements  (I doubt there is, of course, Big Pharma was in on writing the law).  I was beginning to get pissed off but reined myself in.  The pharmacist did his best to counter each of these points, but he was overmatched.

I demanded to know the price of the Vitamin D.  He hemmed and hawed.  I told him a few more times to tell me the price.  He consulted his computer.  The four pills were $9.95.  I tossed a ten dollar bill on the counter.  He told me he could not take my money, it was against the law, since I have insurance.   It was, he suggested humbly, sub silentio and without judgment, the kind of insurance only a homeless leper in his home country, an untouchable, might have.   Leper was my word, actually.  He was hurt that I had thrown the ten dollar bill at him.  He couldn’t understand it, as he assured me it was nothing personal, they just do not sell drugs at a loss to contemptible paupers like me.

I appealed to basic fairness, made another idle threat about using a law that almost certainly doesn’t exist.  He hemmed a bit, and then hawed some more.  I told him to save his breath.  He did. I was done strong arming him.  One of the kids who worked there handed me the four pills, I signed for them, and left, holding up poor Bahdri and his store once again.  Banned for life, like Pete Rose, from a store I have patronized for the last fifteen years or so.  

So today, as on so many days, I have to make some long, trying calls, try to navigate the hideous compromise with decent health care for all (except for at least 27 million or so odd Americans [1]) that President Hope and Change was able to negotiate with the health care free marketeers who wrote the law, folks who graciously agreed not to string him up as long as he didn’t try to fuck with their bottom line.

 Supreme Court justice Potter Stewart once said “Fairness is what Justice basically is”.  I’m not sure of the context of his remark, but I’m pretty sure they nailed that commie motherfucker to a cross and then burned the cross.   You can’t say stupid shit  like that here, not HERE, it’s just WRONG!  SAD!  Thankfully the guy we have now doesn’t need to be told any of this, or anything, really.

 

[1] This number went up somewhat dramatically in 2018 under President Highness’s rule, as he continues his tireless campaign to make America great again. As for the number of uninsured Americans cited above, it is based on the 2016 number, here is the  source

How It Is Done Here

I spent three hours at the opthamologist’s yesterday and left without what I went there to get.   I was screened for glaucoma and every other eye disease, after a very detailed vision test with the nurse.   Unfortunately, the doctor said, he could not give me a prescription for new glasses because nobody would pay him for it.   “I used to get $20, I’d charge $40 sometimes,” the solo practitioner with the crowded waiting room told me, with only a slight complaint in his tone.   In a few months, when I get the EOB from my insurance company, I’ll learn how much he made to spend ten minutes with me yesterday, above the $25 copay I had to make in cash. I’ll bet they pay him less than $100 for all those minutes.

The doctor claimed, at 4:00, seeing me for my 1:30 appointment, that the optometrists’ lobby (who knew, but why wouldn’t they have one?) had made it virtually impossible for an opthamologist to write a prescription for glasses.  Then, twenty minutes later when the drops had fully dilated my pupils, he chided me for my reflex to close my eye when something with a bright light approached to touch my eyeball to measure it’s pressure.  

“It’s not a reflex,” he corrected me, possibly incorrectly, “you just have to control it.”   On the second or third try he was able to touch the sensor down on my right eyeball, move it around.  The left eye wasn’t as cooperative.   Three tries and I was still blinking when he tried to touch the probe to my eyeball.  He snarled at my lack of cooperation.

“I’m not trying to be a difficult patient, doctor,” I told this affable, slightly gruff eye doctor.

“But you are being a difficult patient,” he said, suddenly graduating from gruff to asshole.

Funny, I had no reflex to say “I might have been a less difficult patient after waiting, say, only 90 minutes, or a scant two hours, for this exam you already told me will not result in what I came here to get, namely an updated prescription for these fifteen year old glasses.”

Nor did it occur to me, angry, scrappy, no tolerance for assholes person I have long been, to say “nor is it a reflex to be a dick, particularly after keeping a patient waiting for almost three hours.  You can control it.   I don’t give a fuck about how much you used to be able to charge for a prescription.   Or how important you think you are, or how sincerely you believe your droppings emit no foul odor, nor any of the rest of it.   I’d be tempted to tell you to fuck yourself a little, but I’m trying to be like fucking Gandhi these days, so kiss yourself instead, my brother.”

The doctor also informed me I have something called blepharitis.   I asked him how one gets blepharitis.   “Bad eyelid hygiene,” he said conclusively, making another note in my new file next to the large printed circle that was one of my eyeballs.   He didn’t seem concerned about it, told me to buy eye wipes and gently scour the area between the hairs on my lower eyelid and the eyeball itself.   I asked how often I needed to do this.  Every day, he said, for the rest of your life.

This guy was just a hardworking American doctor running a successful neighborhood practice.  People are used to waiting as long as they need to in order to see a doctor.   This guy had a waiting room full of people the whole time I was there (though the number grew over the course of the hours I was there).   They were all fairly passive, patient, used to waiting as long as it takes to see the great man.  Every one of them using their cellphones, though the office was plastered with NO CELL PHONE use signs.  The doctor, in fact, snapped at me to turn off my cell phone as he escorted me back to his office.   Nobody but me, I suspect, had any second thoughts about why it took more than three hours to see the great wizard. 

My conversation with the nurse who did the actual vision test was a bit more interesting.  She looked at my paperwork and insisted I fill in my social security number, as requested on the form.    I resent this insistence on something that was once very private and is now required by every bloodsucking corporation one deals with.   I described to her how I’d worked for a bloated, amoral leech, a collections attorney, who had taught me the great value, to creditors and their attorney partners, of a social security number.    You can freeze all their bank accounts, for example, take whatever money they owe you by serving a restraining notice on the bank, sitting back and waiting for the panicked debtor’s call.

“People owe the hospitals millions of dollars they never pay,” she said indignantly.  “Millions!”

I, myself, have an unopened stack of bills from hospitals, and collection notices from an attorney for the most aggressive of them.   I said nothing about this, what was the point?   I told her how many corporations now obtain legally enforceable default judgements, obtained fraudulently by not informing the defendants that there is a case against them.   Since they have no notice of any court case, naturally the alleged debtor doesn’t show up, and bingo, Bird Wins!  Default Judgment.  Their unethical attorneys get bundles if judgements on default, worth many, many millions annually, by simply not serving the required legal notice on millions of suckers.  It’s called “sewer service”, create the legally necessary “proof of service” and put the required notice that your proof swears was legally delivered, directly into the shredder, or sewer, whichever is handier.  No harm, no foul, courts are too busy to inquire into cases where only the powerful side shows up.

I told her that American medical care, the most expensive in the wealthy world, also has far from the best health outcomes.   We argued this point for a moment, with her going on about how poor people in America have the best insurance in the world, then I made my next point, about medical insurance.  

A big part of the cost of expensive American health care is the army of private middlemen who take their cuts.  Why are insurance companies involved in health care, again?   It was an interesting talk, after I conceded her the last four digits of my social security number.  She gave me an excellent and thorough vision test, the results of which I, arguably, do not own.    We call this free enterprise, the free market, the right of entrepreneurs, large and small, to be rewarded as handsomely as possible for the risks they take to make a profit.

Dr. McGruff did give me a recommendation to a local glasses store where there is a young optometrist who seems pretty sharp.  I require a prism lens in my glasses, to make my eyes cooperate more smoothly with one another as they get tired from the endless tracking that is reading.  Prisms are tricky, the opthamologist told me, and I should go to a recent optometry school grad to prescribe the exact prism I need, slightly different from the ones I’ve been wearing for more than forty years.

The insurance company offered me “vision” with my health insurance plan.  It was about $10 or $20 extra a month, but did not include glasses.  It would, presumably, pay the $30 to $50 I will pay this young optometrist for the eye exam.  I figure for the $120- $240 it would cost me for the year, I will make out OK on this particular deal, just like I did with the $88,000 I was charged for Rituximab.  

God bless these United States, eh?  Will you do that, God?   Can I get a fucking “amen” here?