Thursday, July 05, 2007

We Pause for this Important Message

Today, I'm tired of writing about eating disorders, (aren't you sick of reading about them?), so I'll focus on another issue, our nation's health care system, my diatribe inspired and fueled by my recent viewing of Sicko, Michael Moore's new flick. If you have any interest in health care, check it out--if nothing else, Moore's acerbic wit is sure to entertain. I actually found myself laughing out loud at a scene in which a woman, who had been in an accident, reported that the payment for her emergency transportation to the hospital was denied because she had failed to have the ambulance ride pre-authorized. It's funny. But it's not.

As both a patient and a provider, I've struggled with managed care. I've found myself wondering what universal health care would look like in the States, why we can't seem to get it right. Applying for Medicaid, which is supposed to insure even the most economically disadvantaged, isn't the easiest process to navigate. And, once you have Medicaid coverage, you don't get much besides the card. Most providers, at least in mental health, don't even accept Medicaid, and at horrendous reimbursement rates, that make a mockery of their advanced degrees, why would they?

Several years ago, I did a brief stint at a city hospital, where most of the patients were covered by Medicaid. My stint was brief because on my first day on the job, I was assigned 103 patients--any idea what a typical therapist's case load is like? Not 103 patients.

The objective was to meet with 10 patients a day, for 30 minutes each. Now, in the managed care and private pay worlds, patients are entitled to a bit more time. Not these folks. And, the frequency of therapy? Because of my 40-hour work week and various administrative demands, I was instructed to see each patient once every three to four weeks. Not the most ethical or medically sound care, given that many of the patients had major mood and/or psychotic disorders. Each patient in my case load required volumes of paperwork--I took to, and I'm embarrassed to say this, completing the paperwork in session, because it was the only way to get it done. For many, I was their third or fourth therapist in the last few months, due to incredibly high turnover rates.

In addition to the clinical overload, the work environment was, to put it mildly, sub-par. It took way too long to get my office up and running. My phone didn't work--not even a dial tone. So, I went downstairs to the telecom department, which was conveniently located next to the morgue, and spoke to Ms. Telecom about the problem. "My phone doesn't work. No dial tone, " I said. She handed me a slip of paper. "Here, call this number."

My computer, as luck would have it, didn't work, either. I went to I.T. They also gave me a number to call. Or, if I'd rather, they mentioned, I could log on to their trouble-shooting site. Every exchange, every moment at this hosptial, felt just like this.

Pretty soon into my stay, knowing that I would leave shortly, I visited the H.R. department to inquire about health insurance coverage. "I'm curious how long you have to work here in order for you to qualify for COBRA?", I asked. And, the director of benefits, housed in the hospital's H.R. department responded, "What's COBRA?" He also engaged me in a casual conversation regarding his recent vacation and his concern that there had been some Arab travelers aboard his flight. "You should be suspicious of the Arabs," he said. I quickly thought, "You should be suspicious of those who tell you to be suspicious of the Arabs."

So, who would work at facility with dysfunctional technology (and office clerks), dusty, likely asbestos-rich walls, and racist, incompetent H.R. staff? Let me tell you about my colleagues, each caricatures of a sort: One of the psychiatrists seemed to have some trouble reading social cues. Whenever he spoke to me, he never made eye contact, and I was always left wondering if he was talking to me or himself. One day, he said something to me in passing in the hallway. I had thought we were done, so I continued walking, but he kept talking, unfazed by my departure.

A social worker down the hall wore a white coat to work each day, as if he were an M.D. I asked him about it once, and he reported that many social workers wear white coats. No they don't. That's great, I thought to myself, there's a therapist with a delusional disorder working down the hall.

And our fearless leader? The clinic director, a psychiatrist, stood up at a staff meeting one day and stated how difficult it was for him to be the most intelligent person in the room. I'm not kidding. He's also the person who told me my first week, "If you and I get along, you should have no problems here," who referred to our clerical staff as "stupid" (yes, to their faces!), and encouraged his providers to commit Medicaid fraud. According to information gleaned after my departure, a thick enough H.R. file eventually resulted in the discipline of said psychiatrist. He was only kept on board with the provision that he must always have a third person present for his one-on-one conversations. He was castrated, but still allowed to screw.

Clinical care was substandard, morale was atrocious, and the building was falling apart. Can you see why I left? But, the thing is, this is the care that countless of Americans get. They wait hours and hours for appointments (one patient arrived for his scheduled 11 a.m. appointment at 8:30 am. because he was so accustomed to having to wait) to see providers who are overworked, mistreated, and not provided with the appropriate resources and administrative support they need to do their jobs. . . who then leave, despite their best intentions to make the world, or at least Manhattan, a better place, after just three whirlwind months. I wonder how, if we were to insure every American (and without extraordinary tax hikes), this scenario could be different, where folks who needed medical care could actually get it and not just instigate a paperwork trail that made it look as if they did.

(Apologies for the non-eating-disorder rant. Regularly scheduled programming will resume next week.)


disordered girl said...

Sheesh, what a nightmare. I think it ties into eating disorder issues though. It seems like the majority of people who need serious ED help can't get it (or can't stay in patient long enough to get the help they really need) because of the effed-up insurance system.

It's depressing. I don't know anyone who doesn't have some kind of horror story/mis-diagnosis/near fatal mistake experience with healthcare.

Jeanne said...

First, I don't think this was off-topic at all. I was never on Medicaid, but my former health insurance wasn't that great - especially for mental health. I remember my therapist needing to write a letter to my insurance company defending my need of additional therapy (even though I was of a healthy weight and not engaging in ED behaviors regularly.) The insurance company seemed to think that just because I ate more than 1000 calories almost every day, I was "cured."

Luckily, I lost that job and found a better one with awesome health insurance (which includes mental health if not in parity, then better than any I've seen before.) Otherwise, I would have been without professional help the past two years and probably still cycling between bingeing and starving.

PalmTreeChick said...

Oh my gosh! So much to say. I was laughing and horrified at the same time. 103 patients?? Those people really are nuts!!

Wow, I can totally see why you didn't stay there long. What a disaster!!

Rachel said...

A few years ago I lost my job due to company discrimination for time taken off to treat my eating disorder. Oh, they found another reason to fire me, but that was the real reason. Anyway, that's an entirely different story.

Unable to afford COBRA on Worker's Comp, I had to go on the student health insurance plan at the University of Cincinnati. Despite boasting a world-class level 5 hospital, the university's clinic (where you HAD to go under the policy) was horrible. Everytime you went in you had a different doctor who knew NOTHING about you or your past history.

After much prodding and urging, I decided to get help for my eating disorder. To see a therapist though, I first had to go through a screening by the psychiatrist. I had lost about 140 pounds by this time, down from 300, and so was still clinically mildly overweight. But I had lost this weight in about 8-9 months, which was a remarkable feat.

The psychiatrist was automatically offensive, questioning the way I dressed, the piercings I have, etc... After listening to me tell him of my eating disorder hell, he had the gall to tell me I still had weight to lose. I lost another 20 pounds in three weeks. The school's therapists never did call to follow-up.

Sometime later, I found an outside therapist who I thought was covered under the school's insurance plan. Since I hadn't had a period in more than a year, she encouraged me to get a physical at the same clinic. I went in, told them my health problems and of the amenorrhea, and was promptly sent for a pregnancy test, despite my insistence I could NOT be pregnant. I later found out the insurance didn't cover the therapist after all and had to pay hundreds of dollars out of pocket.

Eileen said...

This is so sad! As a Social Worker, I get so frustrated with the system and all the crap that my families have to do just to get the basic coverage. There are so many who have none, and our school nurse can't technically put on cream without a doctors note (like an antibiotic cream or anti-itch). It breaks my heart! The waiting lists are so long for mental health services and on and on.
Thanks for the tip on the movie. I have been wanting to see it, I am going to try to go this weekend. I really like the way he puts his information out there, very effective. So glad you posted about this.

Jain said...

Dr,. Stacey, sorry but you really hit a hot button for me! I couldn't tell from your post if you were pro or con re socializing medical care, but your reaction has to be a big clue as to how you must feel about it - it DOES NOT WORK. Sure the dream is great - everyone getting medical care, but the reality is that there is oodles more 'taking from' such a system than can really be put into it! Fastest, easiest example is in a room of kids if everyone has a scoop of ice cream - they eat their and are happy. But if all that ice cream was put into a big bowl in the center for everyone to eat from - what happens is that the kids tend to turn the eating into a contest of who gets the most. And believe it that many get LESS than the scoop they would have had if served individually.

I and my husband have been without medical insurance for many years. We have had problems that required care and managed to pay for it ourselves. In the long run we SAVED lots of money that we could channel into investments which now can be a resource for medical costs as/if they occur. And we have gotten good at letting medical help know that we are NOT insured and getting 'a la carte' type service instead of the entire 'menu' that is the USUAL list of 'to do's a doctor would like to have done (CYA stuff mainly?).

Socialized medical 'care' - NO THANKS! One only has to look at the old USSR, and even the reality of Canada & other places where this ends up just like you wrote about - a SAD, unworking overload of 'sick' people. The ancient Greeks had it right - hospitals ought to be for ONLY those things that could NOT be done at home.

Health or illness care? At what price and to whom?