Health Care Bills: Rambaling Perspective from the Wild West

Disclosure: I work in a small family run, nationally respected, innovative, trail blazing, conservative, effective, essential, medical/dental, chronic pain practice, with one doctor/dentist. We serve our entire state and plus parts of our surrounding states. We are the only game in town and this is not by choice. Our doctor will be the president of a national academy concerned with TMD. Primarily we treat TMD (TMJ) and secondarily Sleep Apnea. We are innovators in quality of care, conservative treatment, treatment coverage, patient advocacy, narcotics prescribing, dealing with narcotics abuse and TMJ care under a medical model. We have many patients with private insurance, such as, BCBS, MVP, Cigna, UHC. We have many patients with government run programs, such as, Medicaid, Medicare, V-Hap and Tricare. We have been closely involved in the development of policy that has opened up coverage opportunities for patients and improved the lives of thousands. We are unique in our experience, perspective and success, mostly because of the reality that only one other state has the TMJ law we have.

I am a patient. I am the son-in-law of the doctor. My wife and I are the clinic directors: we are involved in running the clinic, the business, solving technical issues, training staff and we see patients. I have virtually no medical training or perspective out side the context of this office. I did grow up in a household that provided a perspective on Mental Health Care, which I do value, as much as chronic pain care. I know something about both of these areas, do to my father and my father-in-law. I grew up with great healthcare coverage because my father worked for Kaiser and I did not want for anything medical. This lead me to be stereotypically concerned with healthcare in America and for myself…I did not see it as a huge issue until I worked for my father-in-law and I did not take care of myself to any great degree until more recently. I am relatively healthy luckily. I have a masters in fine art and am a licensed art teacher. I am part of a trailblazing generation of cartoonist with an education in cartooning. I am one of a handful of cartoonist with a BFA and MFA in our field. There for I am expert on the unique role comics in American culture and in its role in the essential value of art education (there is a need for more public and governmental support in these areas). But I am not an expert in Health Care. If you want to actually call on someone for advice I would recommend my father-in-law, Dr. Jeffrey Crandall. Who is a Republican. I am a Democrat; emotionally libertarian, intellectually socialist. This brings me to my perspective, which surprises even me.

Partisanship:

This is a Bipartisan issue that does not need Bipartisan support. It is too important to be bogged down in politics. The regrettable manipulation of this issue by Washington insiders has lead to a furry that on some levels speaks to real concerns, but truly has distracted from effective communication.

Co-Ops

On the surface this seems like a great idea, as long as it is divided into small manageable numbers of participants. In other words a national Co-op would be to bureaucratic and take to much away from advocacy. But to small of a Co-Op will be insufficient in negotiating appropriate rates with hospitals. There would have to be mandatory requirements to provide availability to all who want to participate regardless of income level, a member run board with truly transparent process for claims and clear requirements for coverage that approach true concerns of efficiency and effectiveness of treatment that is not discriminatory to body parts or preexisting conditions. If done intelligently I would prefer this option to any public plan.

Public Option

If I did not work in the medical field, I would blindly be in support of this option. However, I must underscore that the three public plans we currently accept in our office are truly not what I consider an acceptable model. They are not good programs. They are broken programs. Tricare is the worsted of the three, in the fact that they treat our veterans and military to a bureaucracy that fails to support their care and hinders our ability to care for patients. I can’t tell you how many staff meetings we have had where we have discussed the option of dropping Tricare and we know the essential need and duty we have to serve our military. At times, Tricare makes it impossible and our patients just woefully agree and accept their fate. Medicaid pays, sometimes late, but at a rate that relies heavily on our charity, which we have in abundance. Medicare is not as bad, but their reimbursement rate governs our rates and we are not seeing the rises in revenue reported in other areas of Medicine. We just raised our rates for the first time in over a decade and it was by less then 10%. I am worried that another public option will be another broken program, made more expensive and inefficient by bureaucracy. By the way, the low payouts are passed onto other patient’s insurance premiums and out of pocket expenses.

Universal Health Care

A single payer system does work for many countries, much more efficiently then ours. And the longevity of life is greater, in part do to this. But the care for chronic illness is poor in these systems, complex issues are miss handled and miss treated. There are benefits in our chaotic, but independent system that meets needs for some patients more effectively then these other systems, unfortunately the numbers of patients that are benefiting in our country is shrinking.

Private Insurance

Don’t by their hype. While some do have well intentioned professionals in their midst. The vast majority of these companies in our experience pay 20% less then they should to doctors. They are just as bureaucratically inept as government programs. They stand in the way of efficient care for patients despite logic. They are just as big a part of government games as any other. They are the corrupt corporation conspiracy they are accused of being. Only government reform can keep them in line, and yet they are in the room making the reform.

Diagnosis v. Procedure v. Results

Our Doctor out of necessity takes more time to collect data and patient information then any other Doctor I am aware off. This results in the correct diagnosis, in what is a very complex issue. If all my doctors did this I would never get in, but on the other hand in our office we are efficient and we are providing a quality of care that is appreciated and has helped reduce redundant expense and avoided misdiagnosis. It is not unusual because of the nature of the complexity of TMD that we are the 7th Doctor in 20 years that has tried to help a particular patient. Yet there are doctors we know of who use this method of note taking to abuse their patients, because of a lack of research and understanding and the nature of victimization in our patient pool. That being said all you have to do is turn on Discovery Health to realize that there is little incentive for Dr. to take the time to discover what the problem is, before treatment. My wife went through this type of experience and we hear it in our practice every day. Dr. need to be reimbursed primarily for their Diagnosis and the validation of this diagnosis. Results are a great incentive, as long as they are not applied in a black and white manner that discriminates against chronic pain and terminal disease. Procedures should be the least important measure of expense. The system as it stands promotes redundancy and unnecessary procedures and has lead to the over payment of surgeons and dentist and the underpayment of PCP’s and TMJ “specialists.” As it stands if you want to make money, become a plumber.

Chronic Pain

While there is plenty of discussion about dealing with life threatening issues and preventative medicine there is virtually no mention of managing chronic pain. This is shocking because of the level of cost it ways on the system and how it affects our economic productivity, let alone our pursuit of life liberty and happiness. Many of the solutions to other problems efficiency effectively lead to discrimination and the care for chronic pain patients. These are problems that deserve efficient and accurate diagnosis, but leave a reality of long-term care that does not always result in fixing the problem, simply managing it and reducing progression of the problem.

TMD (TMJ Dysfunction)

It is time that patients with TMD are no longer discriminated against. The TMJ has always been cared for by dentists, but finally two states require medical insurance coverage for a problem that involves bone, nerves, muscles, tendons, joints, soft tissues, the mind, posture, breathing and yes teeth. I have heard that 25% of our population experiences some sort of jaw pain in their lifetime. We know from anecdotal and empirical evidence that TMD is a complex condition subject to miss diagnosis and requires sometimes coordination between Dentists, ENTs, Neurologists, Physical Therapists, Psychologists, Pharmacists, Orthodontists, Oral Surgeons, PCPs, Sleep Specialists and TMJ specialists (technically there is no such specialty, which is why we are not likely at any table in the room helping form the government healthcare proposal). And yet, only 16 states cover surgery and only 2 cover conservative treatment. Which in our office means that 95% of TMD patients are either paying out of pocket or not getting treated at all. There is a huge correlation between, domestic abuse, poverty, chronic head ache pain, TMD, drug abuse and borderline personality disorder. Yet, there is little communications between practitioners who deal with these issues that affect our communities nation wide. In Vermont, once we started offering effective care and there was insurance coverage we became a practice that helped solve virtually all the problems the health care bill is concerned with. We have a waiting list of 250 people all the time. We have serviced 1% of our states population to date. That is one Doctor for the entire state.

Dental Care

Should be covered under Medical. It is time the Dental Community start being respectably included in the care for the human body and at the same time not be able to get away with price gouging and elitism.

Malpractice

This is such a small issue. Important, but small in the context of inefficiency.

Narcotic Prescriptions

Our practice is particularly skilled and experienced at appropriate effect prescribing of narcotics for chronic pain. When other means are insufficient, it is appropriate to prescribe opioids, if they are effective in reducing (not necessarily elimination) pain. But you must have what we have in place a well written Opioid Contract, an effective Prescription Monitoring System, clear communication between law enforcement, Doctors, pharmacists, substance abuse programs and patients. With out this we have over prescribing, under prescribing, fear and abuse.

Staffing Shortage and Training

We know there is a staffing shortage first hand. Our state has been trying to recruit PCP’s, Dentists, Nurses and PA’s for a long time. Our office has searched far and wide to find a competent dentist to join us, and we had one of the worlds best ready to, but he decided to stay closer to home and stay at the Military hospital in Bethesda. We need another TMJ “specialist.” But we have exhausted most hope. It could be very likely that my father-in-law will be forced to retire or die before we find a replacement. Where will our state be then? We need more trained professionals. The problem being that the best Dr. are working with patients, not students. There are not enough schools and not enough teachers. There needs to be an effort to fix this issues. Canada is having the same issue, so it does not matter if it is universal or not, if you don’t have the doc you don’t have a shot.

Staffing

I am reasonably compensated for my work. When and if I am lucky enough to get a teaching positions (another subject) I will get a pay cut. We need hardworking, empathic, professional, intelligent staff…there’s your job growth…oh wait you can’t hire teachers of my caliber, because of the ones that are already there so there for our educational system cannot produce the type of staff we need to run the system.

Research

The elephant in the room ir research. I cost us a lot, but brings us untold benefit. It should the included in the cost and the costs should be shared in a system that is efficient.

Pharmaceutical Companies

The amount they pay on research is substantial and relates directly to the amount American’s pay for prescriptions. But it is marketing that is the most expensive part of their operation. Marketing prescriptions is ethically immoral and should be stopped. Then prices should be lowered. But there should be some effort on our part to support increasing prices over seas for our pharmaceutical products sold to those nations that can afford it, why should we have to pay. At the same time we need to increase the availability of cheep prescriptions for nations that cannot afford it, particularly African nations.

Electronic Medical Records

There should be a universal system, that is made affordable for both hospitals and small individual practices like our. We would benefit greatly from Electronic Medical Records that could be manipulated easily to serve our clinical, scheduling and insurance needs. It would increase efficiency and quality of care greatly. We have tried to convert our self, but the expense and effort is to costly on our own.

Administrative Cost

I have heard that administrative cost accounts for 30% of health Care costs. This speaks to the problem with both government run and privately run insurance.

Supplies

Supply cost are just as bad as Rx. I can get the same quality tool from a jewelry catalogue as from a dental supply catalogue for 20% of the price.

Conclusion:

I am sure I am forgetting points I would like to make, but this is certainly enough to chew on. Some of this is already being considered and some may be new to you, but old in the on going discussions of healthcare. This is a major issue, above the importance of Art education and education in general, and certainly a developed respect for comics as America’s visual/literary cultural art form. But all of this is interconnected. And in my mind honestly is secondary to the more prudent necessities regarding the intertwined issues of global warming, energy independence, our security and our economy…oh wait there we have it healthcare and education again. All I know is if we can solve global warming we can save more lives and more money then we would solving healthcare. But I have little faith in either, because as Fereed Zacaria recently pointed out if it isn’t a Crisis, America can’t fix it. Still I show up every day and try to solve issues on my end, it would be nice to have better help. More TMJ docs, better insurance coverage, electronic medical records, better training and communication, a full time Art Ed job for me, more funds to reduce my carbon foot print, a health insurance plan with no deductible (I didn’t even get into that, but I do have personal story there too), and some pay for all my cartooning work. But I know you are facing impossible odds and constant bickering. Makes you whish our for fathers dreams of a Republic had come to fruition sometimes. That’s coming from someone who wants government to leave me alone and stop embarrassing me, but paradoxily provide all the help I need to pursue my potential, life, liberty, happiness and a future for my daughter and her kids.

The Bill

Paul Krugmen has said there is simply not enough in the Economic stimulus plan to solve the issues. Republican’s are instinctively resistant to the size of the bill…I have this instinct as well…But I can see Obama’s position that we have to stop the spiral before we balance the budget. These are extraordinary time and if you are not into revisionist history you know that FDR’s approach was effective. I think there should be some separation of issues here (putting healthcare in a comprehensive health care bill). Also there is the Tarp bill which should be tweaked and can help with much of the same issues. My bottom line is that we should be using the necessity of changing our energy policy as an opportunity to get out of the broader economic issue. I am not alone in this thinking and Obama is attempting to do this. This imperfect bill may do it, but I am worried it is not enough. And then I am also worried it is to much. If we focus on info structure and renewable energy we will create the next great economic opportunity, we will reduce our dependence on foreign oil (an important part of our security needs), we will improve our environment slowdown in global warming, we will revitalize the American Auto industry…on and on…this is a no brainer.
Breakdown of House and Senate bill commentary:
It is scary that the numbers in both the house and senate plans seem so low to provide aid to poor and unemployed. Particularly the only 1 Billion for heating.
The direct cash payments seem much better in the senate bill, but again provide roughly a week to two weeks worth of relief. This maybe significant for those who live check to check and can be disciplined enough to save the amount they are given…this is an unlikely reality. When I was living in this category it would have been gone immediately.

The amount to be spent on Infrastructure is a big chunk at 46-47 billion, but is not significant enough. I know the reality of needs in Vermont is significant. I also realize that there are likely unfunded plans in the Midwest and Gulf Coast that have not finished and are great health and safety concerns. Don’t get me started on Earth Quake engineering needs.

Health care is an integral part of everyone’s economic reality and significant pointing of fingers, corruption and pushing the ball down the road has lead to an even bigger issue. Also I know of potential growth economically in this sector (we have shortage of nurses, dentist and TMJ specialist in our state). But I do wonder if this is not just throwing money out. I would prefer that it was part of a more comprehensive, well debated, thought out bill that was a permanent solution to this growing issue…I have much more to say on this issue.

Education is the foundation of our economic system and never been fully treated as such. There are calls for more efficient, effective and pervasive investment in education of all areas for all students; these calls are coming from rural communities, inner cities as well as the top executives in the silicon valley and energy companies in Texas. This is because they are all concerned about the future…not just for everyone else…but for themselves. Both bills provide some relief, but there have been finance promises dating back to the 70’s that still need to be paid for. This like healthcare is huge issue to tackle and one that cannot wait. It should be comprehensive and extensive. With lively debate. My top concern as an art teacher is the cutting of funding for arts education…which I argue is just as important as science, math and English.

Energy is just as important to invest in this bill as Infrastructure. In fact I think the two have the best option to build for the future while effecting positively the jobs market and individuals income. The senate number at 40 billion sounds better…but I still think it is way low. Every home should have the option to have energy provided by solar power. Every community should benefit from wind and hydro. Every car should have one of the options for alternatives to gas. The car industry should be working on all fronts not just one solution. All the energy providers should be investing in renewable energy. The days of coal, gas and oil should be ending.


Why is Homeland security in this bill. Other then in the context of eliminating foreign oil there should be no security components to this bill. (There I just saved us 4.7 billion). We have spent enough on this military crap…time for them to tighten their belts. Is this not pork.

Law enforcement I think the military budget should take some of their extensive funds and donate it to Law Enforcement so we don’t need it in a stimulus bill…there I saved another 3.5 billion. Is this not pork.

Housing has virtually no difference in the two bills…I side with John Stewart show has been suggesting we take these funds and the Wall Street bailout money and use it to pay down individual debt based on individual needs. This way the banks would get their money the right way and people who are hurting will be helped directly not accidentally if at all.
Tax credits are nice and all, and the plans to move closer to the reasonable tax plan Obama campaigned on. But again comedian John Stewart made a great point…what about a payroll tax…it would benefit workers and employers. From what I know about this bill it does not address it.
Expanded college credit is a nice idea, but again helping reduce student loans would benefit more people. I do think increasing the pell grant is vital.

The Home energy credit is a nice start, but is it enough…see above.

The senate’s Unemployment leaves me conflicted.

Bonus depreciation is out of my league…can someone explain this.

Money losing companies plan sounds good…is it?

Government contractors seem to be getting a brake…do they really need it?

Energy production tax credits are essential, I am wondering if the number is high enough at $13 billion.

Repealing bank credit is a great provision.

Bond subsidies is unfortunately needed, if you are aware of local bond issues nation wide this is a huge issue that needs to be addressed as part of the infrastructure and education needs. The senate version is better, because is includes infrastructure.

I am curious about the benefits of $11 billion to make interest payments on most auto loans and sales tax on cars deductible in the Senate bill.

Any thoughts?

Portrait of a TMJ Office

Let me preface that yesterday was hell…that is 3 hell days out of the past five. The highlight yesterday was one of our employees being threatened by a patient and a restraining order being filed. That was in the midst of about everything else going wrong.
Who or what causes this..so called hell? We have one doctor that sees all the Orofacial and chronic pain patients with TMJ issues (jaw) in the state…with a few exceptions. In addition we service a number of out of state patients because of poor coverage or care in their area. It is said that 25% of the people in the US have an issue with TMJ at some point in their lives. Their care can increase the cost in comparison to other patients by over 50%. (these stats are off the top of my head and I am not as sharp as I use to be…my point is they add a significant burden to the overall cost of healthcare and are a prevalent patient population). In our practice and nationwide the vast majority of patients with TMJ issues are women (due to a combination of abuse, genetics, habitual, trama and stress issues). This is why we consider it a women’s issue and in that context it is also why we were able to make significant changes in the law in our state (presented this way to Gov. Dean’s wife a doctor the law began to take shape and be implemented). TMJ is covered under medical issuance in our state, but currently is only treated in this context by one dentist , ours. Why medical? Because it involves a complex combination of teeth, bone, disk, ligament, muscular, nerve, brain, psycho/social issues. So why a Dentist? Because traditionally dentist have always treated TMJ, because the medical community has not wanted to deal with it, discriminated against it and dentist have been happy to treat it in a system that is a pay out of pocket fee for service system for a issue that has had very little research around it. With medical insurance involved…well it takes a certain type of doctor to want to tackle the complexities of treatment and business hurdles, ours…who happens to be a dentist. There is only one other state in that nation that has the type of coverage available in our state. So every other state has a huge underserved community of patients that are being bounced around from doctor to doctor, primarily being treated and diagnosed incorrectly and costing the health care system even more. If they are treated and it is covered they go directly to surgery…only 5% of our patients need surgery. But we are a small family run practice so despite some recognition nationally, most people who make real decisions about healthcare coverage, treatment and diagnosis…do not know that we have solutions here. There also is a great number of dentists and doctors who can not see past their experience and knowledge in order to treat patients as efficiently as we do…this is why we only have one doc in the state that does this…along with a shrinking dentist population over all. I do not boast this fact…it is actually a tragedy. If you want to be seen as a new patient you are waiting 6 months (many with acute chronic debilitating pain); treatment begins over a month after that. If you are an existing patient we can schedule you 5 months out. Our call list for new patients is 200 people. The call list does help (for all types of visits). Because just as many people have acute issues (meaning it is there and then it goes away) as chronic issues. They typically cancel their appointment, because we can not get them in while there is an issue and they assume it is over. A significant number of these patients we see some other time when things are worse and more chronic, missing the opportunity to help them more preventatively.
All of the above contributes to making the “hell,” but what stresses us most is a significant portion of our time is spent/wasted dealing with people who lack common decency, ethics ect… Pain is a motivator for patients to be seen, it is also what makes them miserable people to deal with. We recognize this happens in people who are generally good people. Pain changes you…so I am not talking about these people. I am talking about a more complex case. It may have started with pain and then they did not have the life tools to navigate these set backs…eventually their lives become so unwieldy that they abuse and are aberrant by nature. They do not show up to appointments (time that could have been spent with a patient who needed to be seen). The are argumentative, harassing, they lie, they manipulate, the threaten, they are violent, they are accusatory, they don’t listen, the are unempathetic ect… Who are these people, stereotypically speaking? Drug seekers, people who milk the system (Medicaid ect…), Criminals, Wimpy men, the uneducated, the unethical, the thoughtless, OCD’s, egotists, people with poor dental hygiene, the week, the lazy, the angry, the self righteous, hypochondriacs, unethical zealots, self righteous naturalists and the liars ect…
So why do this job!?! Because for everyone here in Vermont that causes you a head ache (pun intended) there are; farmers who work every day of their lives in pain, single mothers who have escaped abusive relationships and drug dependency to find themselves in school and moving on for themselves and their child, there professionals who do good work and can do better work if they were not in pain, there are teachers who do not use their profession as an excuse, the person who finally feels relief after seeing 7 doctors and been through years of misdiagnoses, along with, misjudgment, the intellectual who can finally think, and the person who appreciates what you have done.
Can we and will we do this forever? No. At some point we are going to retire from this profession. We hope and work at recruiting someone to take over. No real takers yet…time is running out. Over 10,000 people that we know of will be in trouble if no one takes up our offer. In light of the new administrative change we hope they have the foresight to find out that state mandates can provide a vital service to a community. We hope that Obama is serious about resisting the temptations of Arisa. We would be overjoyed if someone other then people already in the know came to our small little office and realized…TMJ needs to have conservative const and medically effective treatment covered in all states under all medical insurance plans. We hope that the system begins valuing and paying for diagnosis on par with procedures, so there is incentive for doctors to get it right the first time. If these things happen, medical insurance cost will go down, people will be properly effectively ethically and cheaply treated. Peoples efficiency as contributors to our society and economy will improve and we will find another method to help us out of the current economic and social climate we find ourselves in…perhaps those people who don’t get it and contribute to out “hell” will see how to behave. Or perhaps we have to bottom out first. I just hope it happens before our doc retires.
The End.

PS much of the above…well all of it is off the cuff…in the midst of battle. Those who work with me can correct any error or add on. For those of you who do not…please let me know what you think, or if you find similar issues in your life. This office is a bubble sometimes.