November Under Way

If May is lusty, which I've never quite found it, then November might be reflective.  Thanksgiving gathers a dwindling cohort of family but still challenges my mind to arrange an repast second only to Seder and challenges my tenacity in executing it, with major cleanup the following two days.  Veterans Day was intended to be reflective but the hundred years since the original World War I armistice moved memory to history.  Still, a small moment of genuine respect remains for those who participated.

Medicare, of which I am now a beneficiary, has its Open Season, the chance to change supplementary options.  I've not raked leaves in many years but it used to be a major November initiative.  Some years, but not this one, Hanukkah arrives by November's end.  Even though it spans the Christmas season this calendar year, I reserve shopping time.  Partly I like to have it done before the Xmas crush, partly gift giving affords a chance to reflect on what each recipient is like and what captures their individual interests.

My father's yahrtzeit usually appears in November, now approaching its tenth anniversary.  But this being a Jewish leap year, it does not appear until December.  My mother's birthday was November 7, an annual day of celebration in her lifetime.  And since my wife's birthday appears just beyond the monthly transition to December, some November thought goes into that celebration.

November also marks the 2/3 point of my semi-annual projects.  I have a good inkling of what has gone well, what to pursue a little more, what be better abandoned or replaced.

Some years, but not this one, we vote.  Sometimes I'm with the majority, sometimes not.  But with this task, along with the others, November might really be about deciding what I stand for and pursuing it, whether at the ballot, with family, or the things I do on my own behalf.

To the Dermatologist

For several years I have watched a pigmented lesion at my left zygomatic arch.  Initial concern occurred maybe ten years ago.  Dermatologist in the building next to my office too a look at it, declaring it benign.  I did not intend the comprehensive skin inspection recommended for cancer screening for people my age and I had to get back to work so I declined the more extensive look-over and returned to my office reassured.  About two or three years ago, my doctor thought the skin exam was a good idea, recommending it without any prompting from me just based on age.  I have seen my share of malignant melanoma over the years, sometimes from patients who have had this in their histories when they come to me for something else, too often as hospital patients with metastatic disease.  Got it done, reassured the facial pigmentation was benign.

Time has proven that correct, though it is larger, and my wife found something that concerned her on my ear so it's time for another opinion, including whether it might be better just to have it excised.  The last dermatologist made a very good impression but she had moved on from her satellite university position, so it's back to the original office with a different doctor.  I waited quite a few months for the appointment.  They offered a sooner one with the Nurse Practitioner, but since the question of elective removal can require an intricate thought process and I was in no hurry, I waited to see what the fellow who does the surgery thinks.

It turns out that the lesion in question had started to get raised from the surface.  It is still benign.  Removal is possible but trades one discoloration for another and costs money.   It would be a hard sell to call this something other than cosmetic for Medicare to pay for.  We concurred, leave well enough a lone, take a photo with his good camera, and compare in a year.  The area on the ear is an hemangioma, which is what I suspected.  Totally harmless.  He noted scratch marks elsewhere.  I have some itching, usually in exposed areas and I scratch them but it never really bothers me and I never sought attention for this.  Leave well enough alone. 

I had been to that office some ten years ago.  It looked like a medical office.  There is now a presence of cosmetic dermatology everywhere, in-office presentations of topical everything and options for removing everything from freckles to tattoos.  But the doctor who tended to me yesterday seemed more energized by skin diseases than appearance, which probably subsidized the more serious elements of medical care.  He did professional examining, leaving the scribe work to his Physicians Assistant.  And on the walls, he had a warning to patients who needed modern biologics for their psoriasis, medicines that work well but pose a significant risk.  Diversion of medical attention from diseases to appearance would probably make me feel like less of a doctor.  We don't have that so much in endocrinology, though our diseases can have an adverse effect on appearance.  We do send women for hair removal.  Weight reduction surgery is an investment in health, in my mind, but sometimes the recipient seems more concerned about clothing size.  And we got into quite a lot of trouble prescribing Redux or Acomplia to make people look slimmer when the weight excess threatened their health less than the pills did.  Eye care for Graves seems entirely focused on protecting vision and the eye surface.

Since dermatology can be very lucrative and with a better personal lifestyle than may other specialties, with limited training slots, the best and most promising from each American medical graduating class in recent years seem to secure those slots.  Skin cancer, disabling pruritis, psoriasis, eczema, and cutaneous infections can be quite a challenge worthy of medical graduates of that caliber.  I'm less convinced that wrinkle stretching or botox injections should divert some of our best medical talent.  Give the public what they want and they'll come out in droves the Hollywood moguls accurately predicted.  And so we have professional dermatology teetering at the edge of vital medicine and patient vanity.

Medicare Coverage

As an employee or the spouse of one I had to do next to nothing other than choose my plan.  If DuPont, my wife's employer covered me, my wife chose the plan and DuPont paid part and deducted the rest from the paycheck.  No checks or credit cards needed.  As I became eligible for coverage as a medical network physician, if my share was available for less that $100 a month of my contribution, which it technically was but not a plan I would want, DuPont required spouses to purchase their coverage from their own.  I signed up for a pretty decent plan, one notch from the most expensive and maintained it through retirement.  No money changed hands, no bills came my way.  The employer paid most, my share came off my pay stub, which I rarely looked at.  While I became eligible for Medicare while still working, the company plan was much more suitable but once I retired, I joined most seniors in the Medicare whirl.  There is a base premium, not excessive, a surcharge assigned to my earnings history.  Doctors get paid well so this came to real money.  I needed a supplement plan, opting for a Plan F which also comes to real money.  And a Part D for medicines.  While my current potions are all generic, generating no bill beyond the monthly premium, I spent decades prescribing needed but financially ruinous stuff so without insurance beyond what Medicare offers, an uncovered Donut Hole would far exceed an annual premium in very little time.

As a result, my out of pocket costs, which had remained hidden for most of my working years and paid for by organizations whose revenues would amount to billions, became my responsibility, partly defrayed by the Medicare deductions from each of he last 40 years of paychecks, but with a check writing dollar amount far in excess of what I've had in the past.  Good health into my Medicare years being my good fortune, I've not used any benefits since retiring other than my prescription refills.  For now, the G-Men and their insurance company delegates are coming out ahead.  But for the first time I can see how all that medical care that I generated directly and indirectly adds up, and it's a lot.  Not that I want to become ill to get my moneysworth.

A system that size can also become unwieldy.  My Medicare statement arrived in the mail four days before the due date.  My supplement and prescription statements for the coming year still have not arrived with only ten days to go.  I called everyone, authorized credit card payment as the path of least resistance, even though the supplement carrier's records show my statement mailed a week ago.

Considering the massive nature of this enterprise, it works rather well but monumentally complex and therefore prone to snafu.  I wouldn't be surprised if each Member of Congress had to hire a staffer just to resolve Medicare inquiries from baffled voters.  And the more complex it is, the more you have to pay the maybe 10,000 people in America who actually understand it at a professional level, be they government employees, financial mavens, or attorneys.  And that's before any provider has even asked to be paid for what he or she did.

Premiums now up to date once my credit authorization gets picked up by the Postal Service tomorrow and somebody at the receiving end processes my credit card authorization.  Much too cumbersome though.

Herds

Haven't written about medicine in a while.  My quality scores got tabulated.  I looked at everyone's feet if they have diabetes and everyone's blood pressure got taken.  My Too High Hemoglobin A1c measure exceeded goals which doesn't surprise me since people are sent because their diabetes has been poorly controlled despite previous physicians' attempts to control it.  What they could not tell me is whether those numbers reflect my treatment or the treatment of the prior prescriber whose handiwork I inherited.   It makes a difference since my annual bonus is tied in some way to the effectiveness of my work though I may be economically victimized by my own willingness to take on some of the most intractable diabetic circumstances around and have high HbA1c scores assigned to my care before I've made my first medical decision.  The Management could not tell me how this assessment of lab results is assembled.  I did very poorly on smoking cessation measures.  Not because I encourage people to smoke or neglect the reminder that they quit.  There is a box that indicates whether you discussed it?  Absolutely checked YES.  Was it completed?  Of course not, they are still smoking?  However the right answer is also YES because the intent of the question was whether the discussion was completed.  So my scores on that are low, not having figured this out until a few months before Son of NextGen became our Electronic Record that I still do not know how to navigate on this four months after implementation.  And finally there is the requirement that a plan be created for every obese patient on every visit.  Nearly all my diabetics are obese.  They are not sent to lose weight but to reduce their glucoses so they are not both obese and hyperglycemic at the same time.  Insulin makes them heavier.  I have no means of changing how insulin works in storing nutrients.  And if there were effective measures of slimming people down short of having a surgeon reduce the efficiency of their innards, we would have been doing that decades ago.

Yet in the tradition of a Milgram Experiment, Obamacare has a provision for requiring the medically ineffective, and sometimes even the inane, and people in authority follow suit with little question on how this jives with the realities of medicine and even nature.  Now, somebody is willing to pay the hospital and ultimately me a premium for doing stuff like this so if they tell me how and it does not deter effective and justified medical care I'm perfectly willing to shake a few extra shekels from the Medicare Trust Fund too.