Boreal B[l]og

Despite difficulties with the Affordable Health Care Act, I have had no problem with Medicare, “big government” medicine.  I have, however, had problems with one private insurance company.  I will call it “X,” to avoid any semblance of libel, although I am not telling an untruth.  Part D was enacted by the Bush administration, and while a step forward, I expected perfection, since Bush was a Republican.  I did not expect a “doughnut hole,” cost overruns, and failure to negotiate with pharmaceutical companies.

Anyway, I signed up online with X and a local pharmacy for my two prescription medications.  I used my Arizona address, because at the time I lived there. I soon discovered that I got what I paid for.

I take Drug “A,” 2 mg, 2 pills twice a day, 240 mg monthly.  Drug A has 3 sizes:  2, 5, and 10 mg.  Representatives from company X told me that Medicare regulations limited the number of pills per month to 90, in order to prevent falls, a potential side effect.  This restriction was not true, I later learned.  Rather than to ask my physician for an emergency authorization to take my usual dosage, I procured a prescription for 5 mg, 60 a month, although I needed to take my daily dosage in a different fashion.  It wasn’t ideal, but I could live with it.  Notice that I could take 300 mg a month.  That was a tipoff that Medicare restrictions were not the issue, private business restrictions were.

I called a special number to X and had a 3-way conversation with their clinical pharmacist and their sales representative.  I had no problem with Medicare’s restriction; I did have an issue with the monthly allowed dose, which made no sense.  Knowing the answer, I asked my next question:  How many 10 mg pills may I take a month?  They both answered: “120”.

I continued:  “So, I can’t take 120 pills of the 2 mg dosage a month, or a total monthly dosage of 240 mg, right?”  They agreed.

“But,” I continued, “I can take 120 pills of the 10 mg dosage a month, 1200 mg total, 6 2/3 times the allowed 2 mg dosage, right?”  I teach high school math; I knew this stuff when I was about 6.

There was sudden silence on the line, then, “we need to talk to our supervisors.”  In other words, apparently somebody at X realized the restriction of dosage for the smaller amount did not obviate the issue of prescribing a larger number of pills for the larger dosage.

That is Part 1.  On 7 March, I went to the pharmacy to get my prescription, only to be told I had been “disenrolled” from X on 28 February.  No reason was given.  Nobody at X answered the telephone on the weekend, so now I was without Part D coverage.  Suppose I were 75, on chemotherapy, needed a key anti-arrhythmic, didn’t have money, and had moderate dementia?  These things occur, even to elderly Republicans.

Becoming concerned about coverage, I called AARP-recommended United Health Care, spoke to a person, and enrolled, effective 1 April.  I will have no coverage during March.  Fortunately, I have enough medication.  If I didn’t, and the medication were expensive, I would be in trouble.

One may change address for coverage of drugs under Part D, and I planned in March to inform X that starting in April, I would be living in Eugene, not Tucson.  I don’t know how X got my Eugene address, except private information is easy to find nowadays.  Amazon, most of West Africa, and every medical organization worldwide appears to have mine.

On 14 March, I received a letter from X, dated 7 March, saying “Your Prescription drug coverage ends soon” .  In fact, when I got the letter, I was already two weeks without coverage; when the letter was written, I was already a week without coverage. Given the letter was written in the future tense, I wonder how X treats the past.

I quote part of the letter, my comments in bold:

“Thank you for letting us know about your change of permanent address”  (I didn’t.  I would have in March, had I not been disenrolled.)

“You now live outside X Prescription Drug Plan service area. To be a member of our plan, you must live in X’s service area, although you may be out of the service area temporarily for up to 12 months. How did you know the address wasn’t temporary? For that reason, we’ll disenroll you from X’s Prescription Drug Plan on 02/28/14.  “Because” is a better word than “for” in this instance.  The tense was wrong, they waited several days to send the letter, it was dated a week after the fact and took 7 days to travel 2000 miles.  

X did nothing illegal.  On page 107 of my coverage document, the wording was quite clear.  It wasn’t in fine print, but I wonder how many people go through these documents word by word, especially elderly folks, who may not understand a lot of these terms.   The individuals involved at X did not appear to know the English language, judging by the tenses; further, they did not mail the letter in a timely fashion, I had no chance to appeal, and without warning, I lost my coverage.  That was not mentioned on page 107.

While the Affordable Health Care Act has become a whipping boy for all that is wrong with medicine, this is an insurance company issue. The one organization that has worked is Medicare.  I suggested two decades ago that we would do well to expand Medicare to cover everybody:  It would be a one page bill, solving many problems. Costly?  Sure.  What cost can one place on not having insurance and being ill?  A lot of people pay that cost, especially the ill person.  Is that what America is about?

Perhaps X is a good company.  In my experience, however, they drop people suddenly, then later use the future tense.  I teach English online to people in 90 different countries and know the difference between the past perfect and future.  Their letter was signed:  “The X Enrollment Team.”  I am old enough to remember the jokes about “the 20 Mule Team.”  This would be funny, if it weren’t so potentially dangerous to the elderly.

I must be careful; “scorn or ridicule” are part of the definition of libel.

When I was a first year medical student, I worked for a neuroanatomy professor 31 years my senior, who became a good friend.  He was still the professor, however.  When I once became upset, he became stern and calmed me down.  When I called a co-worker  “Little man,” (a college nickname), the professor, with the same last name as I, took me aside, told me my comment was demeaning and never to use it again.  I haven’t.

I offered suggestions in his research but never corrected him otherwise. Dr. Stuart Smith greatly influenced me, never knowing he was a big reason I became a neurologist. In 1981, I sent him a card announcing the opening of my practice.  His widow wrote me he had died two weeks earlier, at 63, from a ruptured aortic aneurysm. I wished I had written sooner. I can still hear his booming laugh.

I am now older than he lived to be and have had different experiences with those in their 20s.  One posted an article on Facebook about a scientist who had found a possible breakthrough that “might” help Alzheimer’s patients.  The individual wrote that the man deserved the Nobel Prize, hoping a grandmother, afflicted with the disease, would be helped.

I posted that the key word was “might,” and there was a long way from the lab to clinical practice.  I was measured in my response, not commenting, as I could have, that my grandmother also had Alzheimer’s, my mother died of a rapidly progressive dementia, and that doctors like the limelight, too, so any possible breakthrough is often taken directly to the press, rather than waiting to see whether it will work.  I didn’t add that I had evaluated thousands of Alzheimer’s patients and had seen many possible “cures” appear and disappear.  In short, I tried to inject a dose of needed reality into hope. Taking away hope is bad; giving false hope is worse.

The young person quickly retorted, “No, MIKE (caps added), the key word is hope.”

I am fairly informal about being called by my first name, but the Internet has allowed the young to call elders by their first name and slam them, because it is easier to write something nasty than to say it directly to somebody 40 years your senior.  On the bus, I am often called “Sir”; that is rare online.  I chose to remain silent, showing both restraint and wisdom.  I found the comment disrespectful and am not particularly eager to communicate again with the individual, whom I suspect would not notice.  I was once that age; the person has not been mine.

I never would have dreamt to correct Dr. Stuart Smith by using his first name and thinking I knew more than he did. He would have slammed me verbally, and he was one of the best English grammarians I ever met. Times have changed.

Many scientists want to report they have discovered a possibility that may lead to a possibility that possibly some day might possibly help somebody.  The use of the same base word here is deliberate, for new, safe, effective drug production is a long process.  There are few “miracle drugs” in medicine.  In my training, I learned an adage: “to write anything positive about treatment of multiple sclerosis is a good way to ruin your career.”  Forty years later, the adage is not far off the mark.  I have no doubt we will eventually prevent, stop, or cure MS, but that day is not yet visible to me.

The young person might feel I was too sensitive to take the comment as an insult. As both as a neurologist and as an older person who has seen and experienced far more, I was insulted.  Hope mattered a lot to the person, which I understand; realistic hope, however, based upon a great deal of experience, matters more to me.  Others in their 20s have said worse to me, but they were from other cultures, not familiar with mine, so I gave them more leeway when they said or did things I found appalling.

I can count on the fingers of both hands the numbers of patients in my practice I called by their first name.  I was formal.  I used “Mr.”, “Mrs.”, “Ms.” or “Dr.”    Thirty-five years after I met him, I still call the retired chairman of neurology where I trained, “Doctor.”  I always will. My parents resented being called by their first name.  I was furious when my dying father had a chest X-Ray performed by a technician, referring to Dad as “buddy.”  My father began his career as a science teacher and became superintendent of schools in three cities.  He wrote two science textbooks and could fix cars.  At 90, he was interested enough to see the Sandhill Crane migration; the following year, he explained to two young women why a lunar eclipse occurred and traveled alone to his 70th college reunion.

I think a key difference today is that the young have equal access to information that I have.  They don’t, however, have the same life experiences as I; many do not have critical thinking skills necessary to carefully analyze “breakthroughs.”  In my youth, every cashier could correctly make change, not now.  We learned grammar and how to hold a pen and write, uncommon today.  We called adults “Mr.” or “Mrs.”, less now.

Perhaps I should have apologized for being too old, sensitive and experienced to write what I considered a careful response.  I certainly know how to apologize, but felt then what I did was appropriate.  If not, I’ve had a lot of practice apologizing.  That comes from age, too.

Also from my parents, my wife, and Dr. Stuart Smith.