Another Brief Insurance Rant.

Yesterday, I saw yet another example of stupid insurance company tricks. This time, it was Tufts Health Plan. I used to think they were decent. Apparently, they will only pay for one routine visit per year. This is all fine and good if you're healthy.

In this case, my patient has diabetes. The guidelines for diabetes is that the patient should have quarterly visits with the primary care doctor. This allows me to adjust his medications appropriately and encourage him to double down on diet and exercise if his blood sugar is rising. Diabetic patients who attend their quarterly doctors' appointments tend to have fewer complications and ultimately cost the system less. So why would an insurance company want to discourage this behavior?

Because the current healthcare system (regarding this sort of issue, Robamney care is the same as our system has been for 60 years) is a game of musical chairs. Tufts Health Plan is gambling that by the time he has complications his employer will be contracted with a different insurance company, and that company will have to swallow the costs. Meanwhile, the patient swallows the costs of standard of care treatment. Just another example of how insurance companies don't save money for anyone but themselves.

Thanks, Demopublicans for locking this system more firmly into place! (And don't let Republican politicians off the hook. Despite their howling, Robamney care was conceived by the conservative Heritage Foundation and originally pushed by Republicans.) Incidentally, thanks also, AFL-CIO for coming up with employer-based health insurance 60 years ago. Other countries' labor movements had the foresight to hold out for better, more economical systems.

Viral Creeping Crud

Last week, I felt really sick--sicker than I have felt in years (with the exception of those few hours with killer vertigo). But so did K. And so did B. (B was only sick for about 12 hours and then went back to bouncing around like a pinball.)

So it was not cancer, nor was it an infected PICC line. Neither K nor B have a PICC line. I know. I've seen each of them without their clothes. It was some kind of viral illness. Now I am better. K is still recovering.

Meanwhile, other than last week's viral creeping crud, I feel better than I have in years. This may be due to:
a: a manic break,
b: enforced regularization of my sleep schedule by twice daily IV antibiotics,
c: treatment of what has been a chronic, smoldering infection around my clivus, or
d: I'm snorting cocaine so sneakily that even I am unaware of it.

I suspect the answer is either 'c', or a combination of 'b' and 'c'. Clearly, after the IV antibiotics are done, the long term maintenance of this feeling of well-being will require either surgery or chronic, low-dose antibiotics (like the ones they feed all conventionally raised livestock so as to breed resistant bacteria).

In any case, the possibility of feeling more energetic for a long time is very pleasant.

I NEED A COMPUTER GEEK!

I NEED A COMPUTER GEEK FOR A GOOD CAUSE! PLEASE HELP ME FIND ONE. I have a NO-moneymaking, but, I think, simple and worthy idea for a shareware program to make it easier for primary care doctors and public health departments to communicate with each other (without using confidential info). All I need is a public-minded geek who can program an add-on to Windows 7. HELP! (PS, might be able to make an academic publication out of it if you want.)

Follow-up to Aetna's Dumbest Denial of Service Award

(See 2 posts ago for background.) I try to limit this blog to nonpolitical musings on my health and my day-to-day experiences as a doctor, but these days, politics invades the practice of medicine all the time. In a previous post, I decried the behavior of Aetna in denying payment for patient's procedure contrary to their own written policy. Yesterday, I spoke to my patient's gastroenterologist. She had already called Aetna. It took a day of yelling at them over the phone, but they, eventually, conceded that their own policy supported paying for the procedure and went ahead and did it.

This is a shining example of why Robamney Care is a crock. Aetna just wasted hours of a highly-trained specialist's time. The doctor will have to charge everyone else more to make up for the time lost haggling with a moron, and the system will lose the benefit of several hours of expertise. Insurance companies are not designed to save money for the system. They are designed to save money for themselves whether they lower or INCREASE costs to the system.  They are not part of the solution. They are part of the problem!

A Splinter!

A couple of days ago, I had my follow-up appointment with Dr. Prince Clivus and the infectious disease guru, Dr. Bug. My clivus problem has been downgraded again. There was never any osteomyelitis (bone infection). Instead, all the pathologists found was dead bone covered with a patina of infectious glop (i.e. mutant booger from hell). The dead bone was acting just like a splinter--a haven for wayward bacteria that was safe from the bodies defenses. (This doesn't mean I'm off the hook for antibiotics. I have at least another month. Hooray.)

This answers several questions I had. Why didn't I feel sick? Why didn't I ever get a fever? Why were the labs usually associated with bone infections solidly normal?

But it leaves several more questions unanswered. Why the smell did I have that little stroke? They established that my vertigo symptoms could be explained by the location of the stroke. Then, they explained the stroke by saying that any inflammation on the skull base can cause a brainstem stroke. But can a splinter cause a stroke? Are you sure?

Then, there's the question of what happens in the long run. The inside of my head took a Fukushima vacation with all that radiation therapy, and some of the irradiated bone is open to the air. That means it's going to dry out and die again, and I'll have another splinter. Eventually, my entire skull is going to dry out, and they'll have to remove it. My head will look like a Dali clock. Obviously, unless I want to work in a freak show, that is not an option. The bone will have to be covered. This means another very difficult surgery is somewhere in my future. The tumor is gone, but the thrill goes on.

Meanwhile, in other news, a dear member of the extended family seems to have snatched the tumor torch from my hands. Enough already!

Aetna Wins the 2012 Dumbest Denial of Service Award

Today, on my desk arrived one of the most self-evidently stupid denials of service from insurance company I have ever seen.

"Information received shows you do not require this procedure [a capsule endoscopy] for the initial diagnosis of suspected Crohn's Disease when conventional diagnostic tests, including small bowel follow through or abdominal CT and a recent esophago-gastro-duodenoscopy (EGD) have shown no evidence of disease. Thus, this test is not covered under your benefit plan."

Now, allow me to explain for the non-medical types why this is such a profoundly stupid statement.

Crohn's Disease is a horrible, mysterious inflammatory condition that may afflict any part of the GI tract from the mouth to the anus. It causes severe abdominal pain and diarrhea, often creating gut abscesses and boring holes that lead from the gut to the skin surface or to other organs such as the lungs. These are just a few of its tricks.

The misnamed 'small' intestine is that squiggly tube in the middle of your belly. It is about 21 feet long. It is extremely hard to detect problems there if they are more than a few inches in. This patient's gastroenterologist has done all of the standard tests one would do to look for Crohn's Disease, and they have not shown anything.

The logical next step, if you really think the patient may have the disease, is a capsule endoscopy. The patient swallows a pill that has a tiny camera. As the pill travels through gut, it snaps flash candids of the whatever or whoever is there. The patient carefully watches so she can retrieve the little traveler and send it back home once it has exited the from where the sun does not shine.

I checked Aetna's own website for the policy cited in the denial letter.

"Aetna considers capsule endoscopy medically necessary for the following indications:

. . . 3. For initial diagnosis in persons with suspected Crohn's disease (abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated white blood cell count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including small-bowel follow-through or abdominal CT scan/CT enterography and upper and lower endoscopy (esophago-gastro-duodenoscopy (EGD) and colonoscopy; [italics added] . . ."

I showed this policy to my eight year old son, B. B felt that Aetna would consider the capsule endoscopy medically necessary. Now, B is a good reader and smart kid, but you would think that an adult who is paid to interpret insurance policies could do at least as well as a bright third grader.

Tomorrow, I'm going to check to see if the gastroenterologist has appealed this yet. Assuming he has not, and assuming I can navigate the phone labyrinth (which is a big assumption), I'm going to town on these idiots tomorrow.

The True Path.!

I have found the true path.! The path. to enlightenment! The shining path.! (Oops! Skip that last one.)

In any case, nearly one week sooner than I predicted, this morning (making me at least as accurate as people who get paid to predict recessions, presidential races, and the like), I received an e-mail from Dr. Prince Clivus saying that my pathology slides were complete. THERE IS NO SIGN OF TUMOR!!! It's all infection and necrotic bone, probably caused by radiation. Dr. The Jedi Master was the only one who was close to right. I'll send him the prize money tomorrow.

Alright. I can now really breathe. Honestly, three weeks ago, I was thinking about calling hospice and hiring Justin Bieber to sing at my funeral. (Things have really dried up for him since he was caught snorting a Le Whif, so he's looking for work.) Then, I was worried they would take out my whole clivus, and, without this essential bony support, the inside of my head would collapse onto spine, so I would look  like a giant Pez dispenser. But it was not to be.

There is a saying in medicine based on the fact that common things happen commonly. "When you hear hoofbeats, don't look for zebras," meaning that to spend too much time looking for a rare disease to explain symptoms caused by a common one is foolish.* However, I have always been a zebra. But now, I'm not a zebra. I'm a friggin' Okapi. Even the experts were confused (except the Jedi Master, who had been around the block enough to suspect the truth).

Now, what to do about that rotting rest of my clivus after the antibiotics? That's a question for another time and another set of doctors.


*. . . or, a horse is a horse is a horse of course.

The Dreary Life of Daily Intercourse*

Antibiotic Ramblings

Life is returning to semi-normal. I'm on a full menu of antibiotics to cover all the inhabitants of the mutant bone booger. For breakfast, I start with a metronidazole tablet. (I really would like to strangle whoever came up with this formulation. How hard can it be to put on a little coating so it doesn't taste like Bitrex the minute it enters your mouth?) Then, Kathleen hooks my PICC line up so I can mainline some premium vancomycin for the next hour and a half. Lunch is light, but disgusting--another metronidazole. In the evening, I get an appetizer of IV ceftriaxone and another hit of vancomycin. Dessert is another metronidazole.

The technique of antibiotic choice in serious infection is to start by covering all likely pathogens until cultures can give you a more precise diagnosis. The menu is not exactly what was started in the hospital. Instead of ceftriaxone, I was originally on ciprofloxacin, but that made me a little hypomanic (a little happier than is good for me, but not over-the-top) and gave me nightmares filled with people who had a strange and disgusting disease that caused them to be completely covered (including their eyes) in black, lint-like hair and shrink to the size of dolls. They chased me around a haunted house begging me to cure them even though I couldn't help them and could catch the disease myself. For that, and, I surmise, because my cultures are not growing Pseudomonas**, I was switched to ceftriaxone.

I hope that further cultural developments, so to speak, will allow more narrowing of my regimen, specifically, I would love to get rid of the metronidazole. I am afraid that the vancomycin infusions are here to stay for at least five more weeks.

In other news, I inadvertently freaked my parents yesterday. I called to brag about what B's teacher had told me and Kathleen during our parent-teacher conference. My father answered. When I told him to put Mom on so I could tell them both about 'something', he practically wet himself thinking it was going to be bad news about pathology. The excitement of parenthood never ends.



*I stole that phrase from a high school classmate of my mother's. She was reciting the poem Tintern Abbey, by William Wordsworth. She stumbled over the line, "The dreary intercourse of daily life, Shall e'er prevail against us, or disturb. Our chearful faith that all which we behold," and created comedy gold.

**If Pseudomonas is bad, is Monas worse? I checked. The etymology was apparently not spelled out when the term was coined, so I can only speculate. Monas is a type of amoeba which bears no obvious resemblance to Pseudomonas and is not particularly pathogenic. The etymology of Monas may be from the Greek Monas, meaning 'unit', or may derive from Monad, which is an old way to refer to any single-cell organism or to Adolf Hitler. If this last is the case, I can say with certainty that a fake Hitler is less virulent that a real one.

Pathology!

Yup! They called me today, on a Sunday, no less, to announce the identity of the mysterious entity from the middle of my head. It's a Dick Cheney Homunculus! That's how they reproduce.

With thousands of siblings at a time, the microscopic, agamogenetic Dick Cheney larva exits a specialized orifice in the parent and becomes airborne. Inhaled by a susceptible host, it sheds its calyx and pupates in the host's clivus. There it will grow for fifteen months. Then, depending on the time of year, it will eventually either burst full grown from the head like a neocon, sex-changed, foul-mouthed Athena, or it will possess the host's body. The primary symptoms of the latter are the acquisition of a fake Texas accent (particularly in Yankee Brahmin) and the irresistible urge to start wars for no good reason.

Made you look! Final pathology won't be back for another week-and-a-half or so.

Happy April 1st.