Indefinite

My town's legislature is an open town meeting. When a question comes before it that the meeting, or actually its leadership, aren't quite ready to address it is "indefinitely postponed." This says that the question is a good one whose time has not yet come.

The question of my TN surgery has been indefinitely postponed.

I'm for this, and I didn't even have to argue for it. The neurosurgeon understood that as long as my TN is contained  within tolerable limits by drugs, no carrier in the US is going to cover surgery.

Contained is the word. My present trifecta of drugs is doing a good job containing the TN. I'm having to use Clonazepam very rarely, which is a good thing. Alone of my medications, Clonazepam can create clinical dependency. I didn't know that I had turned the corner into dependency until I began taking Baclofen and found that I couldn't take both at the same time. The pair of them knocks one out so fast that one barely has time to lie down. Cutting back K had to happen, which led to a fortnight of interrupted sleep and extreme crankiness. Not much of a dependency, for sure ( I hadn't increased the minimal dose), but enough to be a warning. One neurosurgeon I saw called Clonazepam "a witch." I know what he meant now, and I'm back to using it only when the neural pot is about to boil over. Trifecta + K + T=containment (where T is my absurdly increased pain threshold). 

It's all a high wire act in which every step has risks. I've hit the safe maximum on Carbamazepine and Gabapentin. It's a question for my physician whether running up the Baclofen would be any help at all. Clonazepam is addictive. My pain threshold is now so high that I run the risk of sustaining serious injuries without even noticing them.

I had the latest instance of that a couple of weeks ago when my platelet donation failed. Failure of the stick is an occupational hazard for platelet donors, because it involves needles that are nearly the diameter of the vein itself. I knew there is always a risk of a hematoma extensive enough to cause at least discomfort after any blood draw, and I knew what to do about it. 

Several days after this failed draw I noticed that I had a pretty extensive hematoma. It was big enough to cause discomfort at least. I felt nothing. Up to a point, pain can be your friend, but that friend is gone. It's hard to remember to check visually after any injury when every accident seems like an incident.

Let's not forget that people with chronic illnesses will be the first under the bus when the Trump Congress gets busy dismantling Federally subsidised health care. I don't know what my personal pharmacy costs every month. Unlike most people, I have the tools to find out, although even they are mostly linked to Federally mandated rates. When I have a moment, I should look at this.

And no, MassHealth and similar state programmes won't help for long. Once the Affordable Care Act is gone, and the Tinker Toy Trumpian "substitutes" are in place, there will be a seismic shift in coverage for care. Programmes like MassHealth are likely to be snowed under as carriers, especially from neighbouring states, dump their chronically ill  into them. (That happened before ACA to a small degree. I worked at MassHealth for a time, and screening the dumping attempts was part of my job.) There will be more on that later. 

Congress is doing magic that they don't understand. Once they have done it, neurosurgery in this country will be priced off the table, and it's unclear whether my meds will be similarly priced out.

It's a bleak future. For those who try to live with a chronic disorder, it may be bleakest of all.

Fiscal fallacies

We're shopping for a new dentist, and the reasons illustrate one of the cherished fallacies driving opponents of healthcare reform. This fallacy is that if providers don't have third-party payers to pick up the tab, then they will lower prices to the level their patients can afford (like two chickens or a couple of dozen eggs?).

That Hippocratic horse left the barn a long time ago.

Our particular tale begins with my wife's last semi-annual prophylactic visit a few months back. The hygienist thought she detected decay under one of my spouse's old fillings. Hold that thought while we move on to my semi-annual visit this summer. I told the hygienist that I was feeling a little sensitivity in the vicinity of my bridge.

See if you can detect the similarities in the next steps. In my wife's case, the dentist recommended a full porcelain crown, not a new filling, a cost difference of about $2000. In mine, although I got prescription toothpaste for sensitive teeth (which has worked, BTW), I got a recommendation to remove my nine-year-old bridge (which means breaking it, according to this dentist) and replace it with two crowns, an implant, for about $6000 more than the average cost of a permanent bridge.

"Of course," he said, even though we don't have dental insurance, my wife's flexible spending account (FSA) would cover the costs.

Oh no it won't. Even though FSAs are supposed to be usable at the discretion of the person who owns the account, her account informed my wife that they won't cover either crowns or implants, which they consider cosmetic. Even if they would cover these procedures, the total tab would still be many thousands more that the account would cover.

Two weeks ago, I told the dentist there was no way in hell I could afford such costly treatment. Now according to the Republican rubric, that should prompt a counter-offer from the provider. There has been silence, no more than I expected. We're both looking for second opinions, and also for treatment that we can afford: our budget isn't much over the two chickens level.

When we started with this dentist, I had a fair income and a good dental plan. Now we have neither. This dentist's treatment programmes and pricing models are indeed based on what the third party will pay. But when he deals with a third-party payer, he is obliged to justify his treatment. This is known in the business as proving medical necessity. He proposes A. The payer says, "if you can't prove the necessity we'll only cover B." Provider, patient and payer end up somewhere in the middle.

With a self-pay patient, providers have no incentive at all to hold down their costs. The can trade on the innocence of their patients to bill them for as much as they can. They know that once they present the bill, the law will be on their side when it comes to collection from a self-pay patient. That's why you can kiss that two-chickens payment model goodbye. As patients, our only choice is to say no to this dentists, and hope we can find treatment we can afford. If we can't, we'll go without.

Not even the Affordable Care Act helps much. Although good dental hygiene is now proven to be the first line of defence against many internal diseases, it remains glaringly absent from most discussions of healthcare. It's a frill, an extra. Most dental treatment can be shuffled off as cosmetic by payers, even those who sell dental insurance.

Opposition to real affordable care in this country is driven by equal doses of delusion and greed. Nothing about that will change until the bodies start piling up in the streets and frightening the horses.