Being a grown-up is overrated

You know it’s true.

Like, way overrated.

I mean, I guess there are some upsides. Wine. There’s an upside. Unlimited cake. There’s another.

But right now I’m having trouble remembering all the others.

Today, I had to turn down what sounded like a really cool job. I turned it down because:

1 – it paid peanuts (when really, cash is my preferred currency)

2 – it had a fairly crappy retirement package compared to my current situation (and this proves just how grown-up I am – I seriously didn’t even bother signing up for the retirement plan with my first few nursing jobs because the stack of paperwork was intimidating and besides, I was pretty sure I was never growing old, like never ever), and

3 – it didn’t provide as much schedule flexibility, which suddenly matters when there are these small people living with you that share your DNA who kinda want you to show up for recitals and book fairs and ice cream socials, many of which happen at times and in places that conflict with your typical full-time job + 10 days of paid vacation time per year.

Despite these very material issues, this new job sounded super exciting. I’d have had tons more responsibility (plus/minus?) and a fancy title. Fancy titles feel like the emotional equivalent of a sparkly tiara. I love tiaras. Yes please.

So there I was, considering this peanuts-paying but sparkly-tiara-providing position where I’m being told how awesome all these strangers think I am, and yet at the same time…

being told by my current powers-that-be that – you know what? Maybe you’re not so special after all. I mean, don’t get me wrong, we’d like you to keep doing what you’re doing (and then some, and then some, always more please) but don’t get any ideas about getting a tiara of your own someday.

You know what pre-grown-up LB would do? She’d tell her current tiara-withholding powers-that-be to go screw off, and take the crappy-paying tiara-providing position elsewhere. Just to make a point. Fine, some might call it a tantrum. A tantrum with consequences.

But just to prove what a grown-up I am, I did the thing I knew I had to do. I looked at the numbers, realized I really didn’t have any other choice to make, and I turned down the elsewhere-tiara, trudging back to Land of Mediocrity Celebrated.

I know it was the only choice I could make. But it still sucks.

Because being a grown-up is overrated.

But at least I still have 2:1 matching on my 403B. And that’s certainly something.

 

*****

 

(Besides, that tiara was probably made out of twisted aluminum foil and stick-on plastic gems anyhow. Right? Right?)

 

*****

 

(Btw – I promise to get back to writing about actual health care stuff here soon. The last 6 weeks of my life have been dominated by professional uncertainty. Now that a few of those question marks have been taken care of, I’m getting back in the saddle.) (So to speak.*)

 

 

*no actual saddles will be harmed in the writing of this blog

Quantifying awesomeness

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So, I’ll admit that I tend to think of myself as being a pretty awesome NP. Kind of a rock star.

But I recognize that I might be slightly biased.

My mom, my husband, my kids are all similarly convinced that I, generally speaking, rock when it comes to being an NP.

And they’re, most definitely, totally and completely biased as well. (And more than a little unqualified to judge.)

Isn’t that human nature, though? To think of ourselves as being pretty damn good at what we do? Probably true for everyone, but maybe even moreso for clinicians?

I mean, this job can be hard. REALLY hard. Crazy schedules, crazy patients, crazy admins, crazy insurance companies. If we don’t think we’re particularly great at it, that we’re bringing something special and unique and AWESOME to the table – and I mean even more than that other guy over there – what’s the point?

But we all know that all clinicians are not equally awesome.

Every clinic everywhere has “good” providers and “bad” providers and “okay” providers. It’s not written down anywhere, but when a friend asks a friend who knows some things about who they should ask to see, certain names come up, over and over again, while others are conspicuously omitted.

I’ve been thinking about this topic recently because of a conversation I had with a certain administrative type from a certain clinic this week. While we were chatting about unexciting clinic business, he let slip that roughly half of the patient complaints the clinic receives are consistently about one particular clinician. He then brushed them aside because he thinks of this clinician as being stingy with prescribing antibiotics, so therefore the fact that 50% of the clinic’s complaints are about 1/10 of the clinical staff may not the best measure of the quality of this guy’s work. Besides, he sees A LOT of patients. Very, very quickly. No drama. Admins love a high volume:drama ratio.

Hmm.

Zoom out.

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There’s currently this great experiment underway to figure out how to measure which clinicians are particularly good at what they do, and to reward those who are the MOST AWESOME in an effort to inspire everyone to be even MORE AWESOME than they may already be.

On one level, this makes perfect sense. Why NOT pay more money for better care? Why not reward high quality? Isn’t that how the rest of the world works?

But measuring quality in health care isn’t the same as counting how many widgets an assembly worker makes, or how many five-star Yelp reviews you get.

Briefly, a probably-incomplete rundown of what seem to be most common approaches to quality measurement in healthcare:

a) Volume. How many patient visits can you squeeze into X minutes? Easy to measure – the greater the number, the greater the reward. In a fee-for-service environment, the reason for this relationship is obvious: more visits = more cash. But even outside the FFS world, this idea – that part of what makes one clinician better than another is how on-time they run, or how soon a patient can get an appointment – is a pervasive one. And who knows, maybe it should be. Access matters, right?

b) Patient satisfaction. How happy was your patient with the perceived quality of the care provided? If health care was just like any other consumer-oriented business, this would make 100% perfect sense.

BUT. Studies show that patients may not always be the best judges of the actual quality of the care they just received. Scores go up when providers hand out more antibiotics and more narcotics. Scores go up when providers order more expensive tests and procedures. Satisfaction matters, but so does averting a post-functioning-antibiotic future, avoiding the unintentional promotion of opioid addiction, and keeping medical costs from bankrupting the nation.

c) Adherence to clinical guidelines. How many patients got a flu shot this year? How about a Pap smear, or a mammogram? Hard to see what could be wrong here. Lots of people who know lots of things spent lots of time creating those guidelines. Flu shots are good. Early detection and treatment of cancer is good.

But what about shared decision making? Does judging clinicians based on their adherence to guidelines, above all else, result in strong-arming patients into taking medications, or having tests performed, or whatever it might be that they don’t want, or can’t afford, or may not even be considered appropriate care in 5 years? (cough mammograms cough)

Having a conversation with the patient and discussing guidelines, and the evidence behind the guidelines, in a shared and mutually understandable language is always a good thing. But is it possible that overreliance on adherence to guidelines as a marker of quality misses something?

d) Measuring outcomes. How many of your patients’ LDLs, blood pressures, and A1Cs are within normal limits? This, also, seems reasonable. Considering that part of our job (most of our job?) is to try to make these things better, it makes sense that we be judged on how well we do.

But we also all know that controlling chronic illness is harder in some populations than others. Access to care matters. Wealth matters. Community norms and expectations matter. Does rewarding clinicians who can show better outcomes unwittingly drive them away from caring for more at-risk populations?

**********

Back to this unpopular-with-the-patients clinician. Sure, he’s decent at avoiding prescribing antibiotics for colds. But I also happen to know he’s not great with the interpersonal skills. He also doesn’t bother to spend much time explaining what he’s thinking and why – to anyone, really, about anything, let alone his diagnostic and care plans with his patients. So you can consider me completely unsurprised to learn that he receives a far-greater-than-average number of “He did nothing!” complaints than the average clinician.

Not for nothing, but I’m also known for being stingy about prescribing antibiotics. And yet I consider it a point of pride that even my most pre-visit-antibiotic-committed patients leave their visit agreeing with me that their nasal congestion is viral.

I don’t actually have any answers here. I feel like each of these quality measurements dances around an aspect of care that matters, but also somehow misses the bigger point. It feels like there’s got to be a way to measure and reward the intangibles.

Any ideas?

HIPAA Fail

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Everyone knows what HIPAA is, right?

“Uh, yeah, obvs. It’s that law that means anything and everything about my medical record is totally confidential. I may not know anything about the ACA, because let’s face it, that thing’s completely impenetrable, but I know all about HIPPA. Starting with the fact that you spelled it wrong. Two Ps. Like hippo. I’m pretty sure about that one.”

Okay. First of all, it’s the Health Care Portability and Accountability Act. One P and two As. Check it.

Beyond that, you’re basically right. It does some other stuff that no one ever remembers about not losing your insurance when you change jobs, but mostly it’s about privacy.

Unless you’re a young adult covered by your parents’ health insurance.

Now your chart, the medical record in your health care provider’s office where we write down all the details about your visits and file your lab results and whatnot, IS protected. So when you come see me about starting birth control, our entire convo about how your boyfriend really doesn’t like condoms and you’re afraid you’ll have trouble remembering to take a pill every day and btw there was that oops/hookup with your ex last weekend… all that stays inside the walls of our clinic, unless you specifically request we send it over to someone else.

But as soon as you use your health insurance to pick up the prescription I gave you, or to get the STI test I gently yet firmly recommended (c’mon, you know it was overdue), there’s a chance your parents could find out. Why?  Because of this obnoxious little thing called the Explanation of Benefits.

Here’s what happens: your health insurance provider pays for some sort of service related to your medical care – a lab test, a prescription, an imaging study, a clinical visit, whatever. Then, because the insurance company wants to justify its existence with whoever pays the premium every month, they send that person an EOB to detail all the stuff that they’ve paid for. The EOB doesn’t include test results, but it may include the name of the test performed.

I’ll be honest. I never really look at my EOB. Probably because it looks too much like a bill for my comfort, and bills stress me out, so I usually decide it’s best just to pretend it doesn’t exist. I know. Mature. But say what you will, the decision to ignore that EOB is mine to make. (Before you get all judgey on me, remember: not actually a bill.)

Not everyone is as chill about their EOBs as I am. Let’s say, for example, that you’re an anxious mom of a college freshman. After 18 years of micromanaging every moment of your child’s life, you’re having trouble letting go. You spend your weekends driving to campus and hand-delivering care packages of tissues and snack packs. So when an EOB for services rendered to the youngest enrollee on your family insurance plan arrives in the mail, chances are good you’re going to pay attention. And if that EOB uses words like “CHLAMYDIA/GC DNA PROBE” and “HIV ANTIBODY”, well, now you’re really paying attention. Cue the frantic call to your technically-an-adult child, forcing that awkward conversation that you’ve both been avoiding since s/he was in middle school (and is probably way too late for anyhow).

If you were the timid college freshman with the neurotic mom and you thought there was even a slim chance of this scenario playing out, would you make that appointment? Of course not! Everyone knows your mom is CRAZY. And you know she’ll tell your dad. And then he’ll give you that LOOK when you’re home for Thanksgiving break. Like something fundamental has changed about the way he sees you.

No thanks. Besides, you feel fine, you probably don’t need that STI test anyhow. And condoms aren’t so bad, even if you have trouble using them 100%…70%…50% of the time. Or ever.

See what I’m saying here?  This is a problem.

Keep in mind that because of the ACA, you can now stay on your parents’ plan until you’re 26. Great news for all those recent college grads still looking for a halfway-decent job that comes with benefits, since your parents’ insurance is way better than no insurance at all. And yet: even though you retired your fake ID years ago and can spend your meager entry-level paycheck on overpriced drinks at the bar like the rest of us, your parents still get to know every time a strep test, chest x-ray, or STD TEST is performed.

As you can imagine, your more thoughtful college health providers (AHEM) will have a few workarounds for you: directions to the pharmacies with cheap-o generic pills, negotiated rates for paid-up-front STI tests with the lab company. But not everyone has these options. And remember, these are people WITH INSURANCE – they shouldn’t NEED access to super-low-cost health care services.

The good news is, HIPAA has a way around this, but you have to know about it. And it takes a little effort. But it’s worth it.

What you need to do is call your health insurance company, as well as any health care providers/hospitals/labs where you’ve been receiving care, and ask them to send all the bills and EOBs TO YOU. If the uninformed lady on the other end of the line says she’s not sure she can do that, you just tell her that HIPAA says so. Because it does. (You’re allowed to use a snotty voice here.)

But if you do this, you have be willing to put in a little extra work. You need to remember to call them whenever you change your address, or cell phone number, or email address. Actually setting up your voice mail might be a good idea too. (Just saying.) And you can’t ignore the bills that keep getting sent to you. Even though it sounds like a lot of effort, I promise it’ll be worth it, since it means that you can finally feel comfortable accessing any and all of the health care services that your hefty insurance premiums entitle you to.

And to my fellow college health providers: let’s be proactive about this. Create a policy, handouts, cheat sheet talking points, whatever it takes to make sure our patients are informed about their right to keep their most intimate health care secrets away from their nosy family, so they can get back to using their health insurance to pay for the kind of health care they need the most: contraception and chlamydia tests.

How to fix health care, and other easily solved problems

I’ve been thinking a lot about our health care system. I’m a part of it, technically, as a health care provider, so I get a lot of questions from well-intentioned acquaintances about how to fix it. As if we’re all part of an enormous cabal holding the secret to health care reform, just waiting for the rest of the nation to ask.

Most days I think about it at the micro level. Me and my patient, in a room. What are we doing wrong? I (try to) do my part by minimizing unnecessary tests and treatments. The patient (ideally) does their part by not demanding unnecessary tests and treatments. Success! We’re totally gonna turn this ship around, you and me. Now, if only we can convince the everyone-elses, all the other providers and patients who aren’t being as reasonable and responsible as we are, to aspire to our shared level of greatness, this country might just have a chance.

But there are glimmers, hints, around the edges of my day, that point to the fact that it’s probably more about the mind numbing complexity of the system we’ve found ourselves with after all these years than how many CT scans I personally order.

Like when a patient asks me how much their Pap smear will cost, in the event that their out-of-state insurance doesn’t cover labs, and I am completely unable to give them an answer. And I’ve tried! Or when the patient with international student insurance – which covers basically nothing, unless you lose a limb while studying project management in The States – asks how much their chest x-ray will cost, and I’m again – well, you get the idea.

I give them a range – “probably somewhere between $100 and $1000!” delivered with a hopeful smile – but am forced to admit that I don’t have any way of knowing for sure.

THIS IS BANANAS. If you went car shopping and the salesperson wasn’t able to give you even a possible price range, you’d tell them off and stalk out. And then give them a crappy review on Yelp. “Can you believe this place? Their very existence offends me. If I could give them ZERO stars, I would. One star!!!!!!”

So now I read something this morning about the “new era” in health care (http://commonhealth.wbur.org/2013/10/health-care-shopping) where suddenly we’ll have price transparency because of a new law. You can check price tags, just like at TJ Maxx. We will all be the masters of our own healthcarespending destiny! WOW, I thought. How did I miss this?? And here I thought I was part of the cabal. (sad face.)

But then I read the article. The reporter describes the process for getting this “price tag”. All you have to do is spend a minimum of 20 minutes entering information that most patients don’t know exist, let alone possess – like NPI numbers and CPT and ICD-9 codes – and then 48 HOURS LATER you get a possible price range, maybe even with a several hundred dollar spread! IT’S A NEW ERA!!!! Sunshine and rainbows from hereon out!

So, um, yeah. I think we have the answer as to why health care costs so much (or at least a solid 70-80% of the answer, with responsible ordering and tort reform and reducing duplication blah blah blah making up the rest).

Because if health care pricing is so unbelievably complex that this is the best effort that a multibillion dollar insurance company, with their thousands of staffers, can put forth when asked for a quote, then it’s time to simplify your process.

Et voila. SYSTEM FIXED.

A history lesson

Dear daughter of the future,

I’d like to tell you a little story about a crazy thing that happened in this (still? I hope?) great country of ours when you were still an adorable, clueless kid.

So, once upon a time, a bunch of important people, whose job it is to make laws, followed all the rule-making rules and passed a big new law to make sure everyone can have access to health care. (I don’t know why I’m talking to you like you’re still 6. I’m sure you’ve had US History and basic Poli Sci by now.) There were some other people who got their panties in a bunch over it, for reasons that are still unclear to me, because everyone gets sick and wants to see a doctor when they’re sick, but whatever. Panties bunched.

Their undergarments were soooooooooo thoroughly knotted and twisted that they just COULDN’T. LET. IT. GO. Even as the good stuff from the law started to happen: young people getting to stay on their parents’ insurance… Preventative health services without a copay… No exclusions for preexisting conditions… Inarguably positive, happy shiny stuff. And even after the Supreme Court put its giant “CONSTITUTIONAL” stamp on the front page of the law (that’s what they do after they make a decision, right? I’m picturing a red stamp.), they continued to keep themselves up at night resenting it, even though it was actually based on one of their ideas but WHATEVER NOW IT’S SOCIALISM.

So 4 years later, when even the sorest of losers would have gotten over it already, they decided to react like absolute toddlers.

I know toddlers, which is why I recognize clear toddler behavior when I see it.

It’s like when your toddler passes the toddler-height candy display at the store checkout. Mommy goal: get out of the store with wallet, sanity and dignity intact, in that order.

“Mommy, can I have a candy bar?”

“No, honey, you can’t have a candy bar. Here are a million logical reasons why you can’t, all related to your physical and emotional health and well being. And also, the rules say I get to decide when you can and can’t have a candy bar, because I’m the mommy. Sorry, kid.”

Toddler responds by throwing himself on the ground and refusing to move until they GET THAT CANDY BAR MOMMY I WANT THE CANDY BAR WAAAAAHHHHHHHHHH IM NOT MOVING TIL I GET MY CANDY BAR WAAAHHHHHHHH

You get the idea.

You’re stuck. The fastest way out of that store is to buy the stupid f-ing candy bar.

But a) you can’t let that little terrorist keep you hostage in the store until you meet his crazy conditions. Leaving the store and buying the candy are and must remain two separate issues. You should NOT be asked to pay a candy ransom in order to be allowed to go home to bedtime and a glass or two of well-earned vino.

And b) If you cave this time and buy the candy bar, that’s it. You are committing yourself to checkout-line candy tantrums from now until college. Just go ahead and create the Mint spending category now – “checkout ransom” could work – so that you can accurately tag all future purchases appropriately.

Luckily, no one in that store bats an eye when you end the standoff by physically removing your screaming toddler from the store. Possibly being carried over the shoulder. A few dirty looks might come your way (oh sure, like they’ve never been there) but at least the crisis is over.

So there we are. Except with adults, so they don’t get to blame their behavior on their developmental stage. And instead of demanding a candy bar – low stakes – they’re demanding the defunding of the Affordable Care Act – high stakes for the millions of people who were about to be able to sign up for affordable health insurance. They’re so committed to not losing face (DON’T BLINK) that they’re willing to shut down the entire federal government til they get what they want.

OMG. I just figured out how to end the standoff. And create a new revenue stream for the Feds!

Because really, the question is, who WOULDN’T pay to see Obama throw Boehner over his shoulder and walk out of the Capitol?

(You can thank me later, B.)

So there you have it, DOTF. The entire federal government was shut down because a bunch of overgrown toddlers were angry that people were about to get health insurance. FIN.

Dear daughter

Hello beautiful girl!

Right now, you’re only 5. My biggest worries for you currently are whether you can stay on your unnecessarily strict teacher’s good side (please, it’s kindergarten. relax), if I can reliably convince you to stop trying to kill yourself at the playground, and how likely it is that I can keep you from asking to buy those slutty Bratz dolls.

But the day will come. Far, far too soon. You’ll be a teenager. Doing teenager-y things. You already have the attitude down, so, you know, that’s something. Go you.

And then, you’ll be a young adult. And OMG I CAN’T EVEN living on your own. Hopefully (?) at college somewhere. Probably somewhere at least a plane ride away, since you’ll hate your parents even as you love them, and you’ll think you need to get as far away as possible, as a way of proving to everyone around you (and yourself) how grown up and independent you are.

And this is why I’m starting this blog. This blog of missives to you, my still perfect (okay fine, less than perfect, but still pretty fricken fabulous) child.

Because in my other full-time job, the one that pays me in money instead of hugs, whining and bone-deep fatigue, I’m taking care of your future peers. I work at a college health clinic. All I see, all day, every day, are young people bringing me the results of their youthful indiscretions and poor decision making. Someday, that will be you.

So when one of my 18-22 year old patients says or does something particularly…inspiring, I’m going to try to write it down here. In the hope that learning from their mistakes will keep you from feeling to need to make them all yourself.