Another Tale in the Heathcare Saga

I’ve spent a ton of time in this blog bemoaning how difficult healthcare has been for us on the road and this blog is going to be another example of that.  Even now that I have “good insurance” again that doesn’t guarantee us good healthcare.  I continue to talk about it because we started this journey in fantastic health.  We went to the doctor annually and rarely had any issues.  Five years later and five years older that is no longer the case.  We are both taking medications that need to be prescribed and we have both have had issues, minor and major, while traveling on the road.  For the last three years we were making that work by seeing the same doctor annually in Portland, but since we knew we would not be going back there this year I needed to find another solution.

A huge part of the problem for us is we came on the road without a primary care physician (PCP) in a home base.  We loved our doctors in Keene, but knew we would not be able to get back there once a year for physicals.  We probably could have stretched that to two years because of the long term relationship, but Lee was unwilling to commit to be anywhere year after year.  That might work if you aren’t on any medication, but once he had the heart attack and was taking five different pills the scenario changed dramatically.  My compromise was to try and find him a new PCP in Charleston.  I thought we would be passing through to see Oliver at least once a year and maybe we could start a new relationship with a doctor.

Not knowing any doctors in Charleston, we talked to our daughter and she recommended hers.  Since we are here for a long stretch of time I was able to get Lee an appointment and last month he went to see her.  The point of the appointment was to transfer his medical records to her and since Lee was also having pain in his right arm that was unusual he decided to talk to her about that.  She sent him to get a couple of X-rays and they discovered calcium deposits on his shoulder.  Lee specifically stated he did not want to take any kind of an addictive narcotic for the pain, and she said that was fine she would call in a prescription by the end of the day that should help.  She also referred him to an orthopedic specialist.

After calling twice, the next day he learned that she was refusing to call anything in because of his heart condition.  She was being ultra cautious because of the other medications he was taking.  The ortho appointment was also in three weeks.  At this point Lee’s pain level was very serious.  He was only getting about 2-3 hours of sleep each night, and the pain was pretty intense and constant. He didn’t feel he could wait three weeks and by changing the doctor was able to get an appointment in a few days.  In the meantime,  we did some research and learned that he didn’t just have a calcium deposit but a bone spur.

 

Lee suffered through four more days of pain and finally the appointment day came.  He waited 80 minutes before seeing a resident and then saw the ortho for approximately 8 minutes.  The doctor told him he never gave cortisone shots (we later learned this is pretty standard treatment) and recommended physical therapy and eventually surgery if 8 weeks of PT didn’t work. He also was very hesitant to prescribe an anti-inflammatory but after Lee pushed hard he recommended something but made Lee got back to the PCP to get it prescribed.  The entire situation left Lee feeling really upset.  Lee was honest about saying we were just passing through and felt the doctor just didn’t want to deal with that.  Once he learned we wouldn’t be in town for the surgery he washed his hands of us.

I would love to say this was the first time we had seen this behavior but it was not.  Medicine is a business, and when you are a higher risk patient with minimal financial reward associated with you it is harder to get care. Practically we both understand that, but when you are in need and in pain it’s hard to stay calm about it.  We both grew up in the old days when it seemed doctors had a higher calling.  It is different now, and although really good doctors exist, you need to take the time to build a relationship with them.  That’s hard to do when you are traveling all over the place and don’t have a home base or regular route.

Oddly enough emergency care works pretty well for transients, but those in between things that are out patient still require a decent PCP to shepherd you through the process.  Yes you can do your own research and make your own appointments with specialists now, but those appointments can take weeks to get and you have no idea if you will run into a bias because you travel when you go.  I didn’t mind so much fighting through all of this when we were reasonably healthy, but as we have gotten older and had more health problems the situation has become very difficult to manage. And that was with me having an ace in my pocket.

What I mean by that is my brother is a doctor in Columbus.  He’s a darn good one, and over the last several years whenever I was concerned about medical care I would call him and get a free second opinion.  It wasn’t just him either.  He has a network of specialists he works with and trusts and would call them if he wasn’t 100% sure. Most people don’t have that resource available to them and I would have been much less likely to “wing it” if I didn’t have him to talk to.  Over the years we have talked about making him our PCP, but held off for a couple of reasons.  In my case I wanted to see how this would all play out and write about it.  Lee felt strongly that it shouldn’t be necessary and for a long time he was willing to figuratively die on that hill.  More recently though when actual death was a factor he felt differently, and yesterday he called my brother and talked through the situation and asked him to be his PCP.

Some doctors won’t treat family, and we would have totally understood if he didn’t want to, but Eddie understands how difficult this is with our travel and has first hand knowledge of the sub par care we have often received.  In this case, he was surprised (but not surprised) that the standard course of treatment wasn’t done and validated once again that for some doctors there is a bias against higher risk, transient patients.  Lee and Ed talked through the best course of action and ultimately decided Lee would drive the eight hours to Columbus and get a cortisone shot.  While he was there, Eddie would try to get an MRI scheduled so they could see how much damage was being done. Once he saw the picture of the Xray, Ed was VERY concerned about the size of the bone spur and said that if left untreated there was a chance Lee could permanently lose function in that arm.

None of that was relayed to Lee by the specialist, by the way, and the discussion impressed upon Lee the necessity of not just bearing the pain and getting through it.  I don’t know if that would have been possible anyway, because the pain was getting worse, not better. By the time he made the drive to Columbus he had almost no use of his right arm. The anti-inflammatory medicine doesn’t appear to be helping much, but that may take more time.  He has to psychically go and see Ed because first he needs to be established as a patient and secondly the shot needs to be done in person.  Because we only have one car I would have had to go with him, except thankfully my mom is flying to Columbus on Monday and was planning on dropping her car off with me so she wouldn’t have to pay airport garage fees for several weeks.  That worked out beautifully and allowed me to stay in Charleston with the dog.

We did have some concern about Lee driving that far, but he felt he could do it and said he would take breaks as needed.  He can stay with his Mom once he gets there, so the cost should be somewhat minimal.  This matters because unfortunately all of these costs we will need to pay out of pocket.  When I started the new job I switched insurance and even though I went from one Blue Cross plan to another, the deductible (which was met from the heart attack) was not transferred.  We are starting all over again and all of this will be out of pocket.  We are hoping that the shot will give him enough relief that he can just get a series of the every three months or so and schedule the surgery sometime next year.  That way the costs can go towards a new year deductible, but at this point we really don’t know.

It does suck that we just finished paying off all of the medical bills from the heart attack and here we go again.  In this case though, it’s not like Lee did anything that caused this, it’s just one of those things.  Thankfully we have money rolling in now and can pay the bills whatever they are, but it is not lost on me that all of this would be a huge emergency if we were gate guarding in Texas as we had originally planned. Once again I feel grateful to have accepted the position and have a regular job, because dealing with this stuff while working hourly jobs would have been much harder.

So that is where we are, and I share this story (as others) as a cautionary tale.  If you are thinking about going on the road, really think about your healthcare plan in advance, and unlike us think in the long term.  If you talk to your PCP in advance you can hopefully work something out where they continue your care as you travel.  If that’s not possible, think about establishing a home base  and starting a new relationship as soon as possible.  You may not need it for several years, but when the time comes you want that relationship in place to guide you through whatever issues you might have.


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First Time Scheduling Physicals

We have been on the road 2-1/2 years now, and health and dental care continue to be an issue.  Challenges with high deductibles,  finding out of state providers, and the timing of being in an area long enough to get an appointment scheduled have resulted in minimal heath/dental care.  Since we have been on the road we have only visited one Urgent Care, got teeth cleanings in Mexico, and another cleaning and cavities filled in Alaska.  What we have not done is have physicals of any kind.  Since I turned 50 last August I knew I would need to find a way to schedule annual appointments, but was intimidated by the process of finding an out-of-state doctor.

The ironic thing is I am very well suited to finding health care on the road.  My parents and brother and sister are all in the medical profession and I have 7 doctors and 4 nurses in my extended family.  Yes, you read that right, the medical profession is the “family business”.  And even though I chose not to enter that profession, I have learned quite a bit listening to others at holiday dinners and of course I have a terrific set of resources right at my fingertips.  I mention this because you would think it would be easy for me to work the system and find healthcare on the road, but unfortunately that is not the case, and the fact it is so difficult even for someone like me should tell you something.

I loved my doctor in Keene.  I had a schedule, we had a relationship, and I rarely had to worry about whether my insurance would cover something.  I had one issue in the 15 years I lived there with an anesthesiologist not being in plan, and when I called the insurance company they advocated for me and made sure the doctor accepted what they would pay.  That is absolutely not the case now.  I have a Blue Cross/Blue Shield Florida plan and although I am lucky enough to have access to a national network of doctors I have to be VERY careful who I select to perform services.  That is assuming of course I can get an appointment.  I’ve made the mistake in Alaska of waiting too long to start making phone calls and setting up appointments and as a result ran out of time and was unable to schedule a physical there.  I thought about scheduling the physical in Texas and even made a few phone calls, but very few doctors in the San Antonio area were accepting new patients.  So I kicked the can down the road to Oregon and on one of my first days off I took a deep breath and sat down to tackle the problem.

In the interest of sharing information I am going to walk you through the experience, but fair warning, quite a bit of this is colored  with anger.  This really shouldn’t be so difficult. Hopefully though you will find something beneficial in the account.

I started on Wednesday morning about 10am and the first thing I did was pull up the in network list of caregivers online.  Since it was out of Florida, I needed to go to the expanded list of providers, but there was quite a good selection.  That selection narrowed significantly though once I checked the search criteria box for “Accepting New Patients.”  It’s surprising how many doctors were eliminated and mostly what was left were doctors who were part of large medical groups.  I personally don’t have an issue with large medical groups, my brother belongs to one, and they provide lots of benefits to the physicians by handling administrative and billing tasks for them.  It also allows the doctors to have more of a regular schedule because they can share on call responsibilities with the other doctors in the practice.  Many of these groups also have nurse practitioners and  as my mother was one for many years I have no issue with seeing one of these either.  As long as the nurse practitioner can “write all the orders” (i.e. order followup procedures and write prescriptions) I have found their care rivals that of physicians I have seen and most take new patients.

Another major benefit of nurse practitioners as an alternative is that they are generally much easier to get a timely appointment with.   The appointment I ultimately got was with one, and it was actually scheduled for Friday of the same week which was two days away and pretty amazing.  It’s extremely unlikely I would have gotten that quick of an appointment with a regular physician.  In order to get to that point though I had to get through the gatekeepers, and that was a difficult process.  Initially I called the phone number online and got a scheduling service for Providence Medical Group, which has over 600 providers in its network.  I was told that they needed to do an initial new patient appointment prior to scheduling the physical and when I asked how much that appointment would cost (because I would need to pay this out of pocket) was told between $200 – $700.  Obviously that was absolutely unacceptable and since the person on the phone was unwilling to work with me and my somewhat unique situation I asked to speak to a supervisor.  The most distressing part of this conversation was if I would have not asked the question and just followed their advice it would have cost me extra money.  In the old days I would have, but now things are different.  I have a $14,300 deductible on my insurance and do not have the luxury of spreading these appointments out over a 6 month period.  I need to consolidate appointments, keep my out of pocket expenses down, and work around my work schedule.  If I can’t get someone on the phone who is wiling to work through that with me (which is what happened when I tried to schedule an appointment in San Antonio) I simply have to move on.  I have learned that the hard way.

The supervisor, thankfully, was that kind of person.  I explained my situation and she found me a nurse practitioner who was willing to skip the first visit and go right into the physical.  The only reason they were willing to do this, by the way, was because I stated I was in excellent health.  In the case of seeing a new dentist or doctors they always want to have an extra appointment.  Those appointments are rarely covered by insurance (and delay getting the actual treatment you need)  so I get someone on the phone and explain I have a limited time period to get the work done and have no pre-existing conditions.   If we did have pre-existing conditions we would have to pay for those first visits out of pocket every year, assuming of course we had a different doctor every year.  And I should probably stop here and say our situation is somewhat unusual.  Most full timers we know go back to the same place every year and get physicals.  As a general rule they schedule those appointments to coincide with family visits and are able to establish relationships with doctors and dentists in the area.  This is a great solution, but since our family is all back east and we are exploring the west, it doesn’t make a ton of sense for us to drive across country for a doctors appointment and then drive back.  To solve this problem some people even fly back, but again they have family in the area they can stay with.  If one of us gets to the point where we are having a serious health issue we would definitely need to consider this and luckily Columbus, Ohio would be a good choice for us because we have family in the medical community there. For right now though we are trying this the hard way and hopefully we can find a solution on the west coast that allows us to travel.

So my physical is scheduled for Friday and from there I will need follow-up appointments for a mammogram and a colonoscopy.  It is EXTREMELY important that you make sure all of this work is coded as preventive.  You can slip in questions about health issues you are having, but if the appointments become all about solving those issues rather than general wellness, they will have to code the visit as diagnostic and you will be on the hook for the cost.  This is a fine line, and a tough concept for many people, Lee included.  He despises going to the doctor anyway, and the fact that he can’t just talk about what’s bothering him once he gets there makes him nuts.  I agree with him philosophically, but since that is the system we are stuck working with I don’t have a ton of patience for his aggravation.  The main point in all of this is we all have to be our own health advocates and the days of relying on our providers, and more importantly, their billing agents, to look out for our best financials interests are largely over.  It is just the way it is.

After scheduling the doctors appointment I also scheduled dental cleanings.  Thankfully I had a recommendation from the trainers we have been working with here and called McKinsey Dental.  They were willing to accept new patients but once again wanted two appointments.  When I assured her we had regular cleanings, no history of periodontal disease, and used ultrasonic tooth brushes she agreed to allow us to schedule one appointment that included a cleaning.  Since we will have dental insurance with the company we are working with as of August 1st, we scheduled the appointment for August 15th.  This is cutting is kind of close, especially because I might need more cavities filled, but it’s better to wait and have the exams and cleaning covered.

Lastly I scheduled an appointment with a dermatologist.  Once again I looked at the list of doctors in the area accepting new patients and this list was very small.  The closest one did have an appointment on June 6th and since I will be self paying, the initial 15 minute full body check would cost $200.  She couldn’t give me a price on what removing a mole would cost because there are various methods of removing them, but since she was friendly and seemed to understand cost was an issue I was OK with that.  It is VERY difficult to get prices on the phone when you call medical people.  Some of that is because the scheduling department and the billing department are so different, and in all fairness the procedures can vary as well, but how are we supposed to do a price compare if we can’t get basic pricing information over the phone? I hear quite a bit of political rhetoric about how being an educated consumer is going to change the face of medicine, but I can say from personal experience that is not an easy thing to be.  It actually reminds me a little bit of trying to get a quote from a car mechanic.  Unless you are educated about what actual costs are it’s hard to tell if you are being charged fairly.  In the old days I let my insurance company advocate for me (and themselves) but with these high deductibles it seems better to go with the discounted self-pay costs in which case you have to negotiate yourself.  In the case of the dermatologist I will go through insurance if they find anything complicated which I am hoping they wont.

I should probably mention here that I am going to a dermatologist because my mother was recently treated for basil-cell carcinoma.  I didn’t really understand what that was, but when we met in Vegas and she explained it I had her look at a spot on my cheek.  She was concerned and told me I needed to see a dermatologist right away and before I took care of any of my other medical needs, which she considered of lesser importance.  Since my mom is a very smart nurse practitioner and also my mom, I am doing what she told me to do. According to cancercenter.com “This type of skin cancer tends to occur in areas of the skin that receive the most exposure to the sun, like the head and neck. Basal cell cancers usually grow slowly, and it is rare for them to spread, or metastasize, to nearby lymph nodes or even more distant parts of the body. However, this can occur if the cancer is left untreated, so early detection and treatment is important.” Her main concern for me was it’s location, because the longer it is left unchecked the deeper they need to go to remove it.  Since it is on my cheek the eventual surgery could leave me with a pretty nasty scar and since she just went through this herself (thankfully in her case near the nose so it blends in) and if this is what I have she wants me to catch it as early as possible. If it is something, then we will also need to figure out how to handle it.  We have money in our HSA account but don’t want to wipe that out on one issue.  Hopefully if it is something it will be relatively minor to remove.

The long and short of all of this is we aren’t kids anymore, and these types of issues are going to be more common.  It would be more easily managed if we returned to the same area on an annual basis, but that is not how I want to travel at this time. That forces us to treat healthcare very differently though.  Back in April when we were in Vegas Lee went on a horseback adventure (a sunset walk kind of thing) and his horse went a little nuts and threw him.  He’s an experienced rider and has never been thrown from a horse before in his entire life.  Thankfully he was able to control his landing a little bit and avoided the rocks and hit the sand. But he landed on his side and we are pretty sure he cracked at least one rib.  Instead of rushing to the doctor, we did some research on Web MD and determined it likely wasn’t a punctured lung.  Then when we saw that the treatment for a cracked rib was leaving it alone to heal we decided to skip the doctor.  It probably would have cost $500- $700 for an appointment and an X-ray and since there was nothing they could do to help, what would the point have been?  Still, the whole thing just makes me angry.   All we need is reasonably priced healthcare with some wellness care, moderate deductibles, and a national network.  I had that type of coverage when I worked full time and everyone on Medicare has it as well, so I know it exists.  I don’t understand why as a self employed person I can’t have the same thing and it pisses me off. We are not the only ones dealing with this, of course.  Our fellow camphosts (the kayakers) are going through the same thing.  Mr. Kayaker has Medicare now, and according to them it is the best insurance they have had in years.  Mrs. Kayaker isn’t old enough though, and because she has a Florida based HMO can’t get medical care in-network out of the state.  She is thinking about signing up for the company provided healthcare for at least a couple of months so she can get some tests done.  The whole thing is crazy and I don’t see anything better coming along in the future.  That’s why I am pushing so hard to get all of these tests done, before we lose what little healthcare we have.

Friday morning Lee drove me to the doctor and the whole experience turned out to be terrific.  First and foremost I highly recommend making appointments on the Friday before major holiday weekends because the crowds were relatively light.  When I checked in to see my doctor, I discovered that the receptionist checking me in was from Keene,  New Hampshire.  She knew a good friend of ours Ernie and I Facebooked him while in the waiting room and let him know she said hi.  It always amazes me when I meet someone on the road from Keene, but it is indeed a small world.  Unfortunately, despite my lengthy conversation with the scheduler, Tiffany did not have anything in the system about me skipping the pre-exam.  I explained the situation and she asked her supervisor, who was noncommittal, and then I was called back.  The nurse took my vitals (I need to eat less donuts) and I explained that I needed to be set up for a Pap Smear.  At first I heard the party line, but when I said I had gotten approval from a supervisor she went ahead and set me up.

The nurse practitioner was great. Once again I explained the situation and then apologized if I was making her feel like an order taker at McDonald’s.  She immediately said nothing to apologize for, and said she was glad I was taking such an active interest in my own healthcare and wished more patients did the same thing.  I was careful though not to take up too much of my 40 minutes with talking though, and after running through my history pretty quickly we completed the exam.  If I was having any problems, or if I had a complicated medical history no way would I have gotten away with that. Since I kept it simple we had enough time.  She was pretty great about ordering the additional tests as well, putting orders in as we talked for a colonoscopy, mammogram, and routine blood work.  She also set me up on their online My Chart system so I could see the results (rather than waiting for them to be mailed) and best of all told me I could go right downstairs for the blood work.

So off I went for blood work, and after verifying during check-in all the blood tests were coded as “routine” I called to make my mammogram appointment while waiting my turn.  I tentatively asked if that had any appointments that day and she said as a matter of fact the entire afternoon was open.  I snagged the first available at 11:15pm and then went in to get my blood drawn.  My technician did an excellent job (minimal pain, only one stick required) which she said was a benefit of working in a busy center…lots of practice.  Afterwards I walked a couple of buildings over to the cancer center and checked in for my mammogram.

That was really nice.  Heated robes, tea and coffee while we waited, and a very nice technician.  We spent a little more time talking about my history prior to this test since I had a small piece of breast removed about 9 years ago, but once again I stressed this needed to be coded as a routine screening and not diagnostic.  The whole process started at 9am and I was waiting for Lee on the sidewalk at 12:00pm. Pretty awesome.  (I made much better use of my morning, going all around downtown Portland visiting camera stores in search of a pro sling strap since my daughter stole mine, and a few other things that I didn’t even know I needed. – Lee) The colonoscopy will of course be scheduled separately but I felt great about every interaction I had and would highly recommend the Providence Medical Group and their hospital if you are in the Portland area.  I’ll talk more about the remaining visits (and how Lee does in his visit) at a later date, but for right now I feel pretty darn good about the whole thing.  It required some upfront work, and vigilance throughout the process, but hopefully we won’t have any issues with the billing. (I do not expect my experience to be anywhere near as smooth, pleasant, or painless. – Lee)

Oh, and as an extra treat we stopped at Dean’s Homestyle Cafe for lunch and we got a bacon cheeseburger, hamburger, fries, and onion rings and left a $5 tip for a total of $20.  It’s not much to look at on the outside, but the inside had really comfy booths, the food was great and the portions were huge.  My kind of diner!!



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