Medical necessity guidelines

Hmm! Look at this:

Coverage process-contractual definition of medical necessity, which includes the following criteria for establishing the medical necessity of a service: appropriate for symptoms, diagnosis, and treatment of a condition, illness, or injury; provided for diagnosis, direct care, or treatment; in accordance with the standards of good medical practice; not primarily for the convenience of the member or member's provider; the most appropriate supply or level of service that can be safely provided to the member. To determine what services meet this definition, Highmark has an information-gathering process that includes systematic reviews of published literature, a consulting program with practicing physicians, review of coverage decisions by Highmark managers, review by an independent Medical Affairs Committee.

This is a cut and paste from a site I Googled. Read the last sentence. Sounds like a constant review looking for ways or reasons to tighten a code. Kind of cold.

A Private Sector Big Brother

The debate on health care has turned to fear creation. Let's not have a debate or conversation, lets just say no and scare the hell out of the people who have insurance and feel a little insecure. Let's lie and say their are death squads, lets say that government will ration care. Lets create a fearful atmosphere that chokes off debate and the intelligent discussion of issues.

Two weeks ago I was hospitalized with an A-fib episode. It took 2 1/2 days to get the heartbeat straightened out. A week and a half later, today Friday August 28, 2009 I received a letter saying that my hospitalization meets the nationally recognized precertification procedures and therefore is certified. Which means insurance will cover the hospitalization. What if it had been a severe anxiety attack and I was fearful for my life. Would it have been certified? Who knows what the recognized national certification procedures are, I sure don't.

An employee of Arkansas Northeastern College who works for me is undergoing chemo treatment for a stage four cancer. The intravenous dose knocks him on his ass. The pills have their own side effects. Last week he had a pain in his left foot, it is a stress fracture of a bone in his foot brought on by the treatment. The guy has a lot of mental anguish. He is in his mid-30's. He has a daughter 3 years old, his wife is pregnant and due in October. The cancer has spread to two locations and is considered stage 4 even though each site by itself is stage 1 so it is a confusing issue. If it is truly stage 4 the five year survival rate is only 5%. A tremendous amount of mental anxiety yet you wouldn't know it.

Tuesday he was diagnosed with a blood clot in his lower right leg from the treatments. It is kind of like the shit is piling on. His doctor prescribed blood thinners, only he has to inject them because the oral type interact with his chemo. So he has a prescription for injection thinner and it is expensive, $2000. When he shows up at the Wal*Mart pharmacy he is told insurance will not approve the meds. It turns out that they have another source they use for the expensive stuff. So he has to go back to the doctor and fortunately the doctor has enough samples to tide him over until the prescription can arrive from the insurance company's source. Let's add a little more aggravation and mental stress to a guy who is already dealing with a life and death possibility.

It makes me wonder how in good conscience these assholes propagating the fear statements that have been debunked can make those statements. Hell we don't need death squads, they already exist. The rich will rule the day, the special interests groups will give up just enough so the politicians can claim a victory of sorts, and the American public will continue to put up with inadequate health care that is continually subjected to squeezing in the name of profits not care. Go to hell private sector.

Thoughts on some politicians.

Yesterday before leaving the hospital a man came into my room representing the hospital. He wanted to know if I was being treated OK? Were hospital procedures followed, and was the staff attentive? The answer was yes. I am very pleased with the treatment by the staff at NEA hospital. However, this isn't about the qualities of a hospital at all. This is about politicians.

The man's name was Al Brodell. I asked him if he was any relation to Hubert Brodell. It turns out he was, Hubert was Al's father. I know Hubert Brodell. Hubert was the mayor of Jonesboro for many years. I was told by Al that his father recently turned 80 and had back surgery. Hubert is active spending time between Jonesboro and Florida. He volunteers for some group and works still in helping his community in a volunteer capacity.

Then this morning I read a disparaging letter directed at Sen. Barbara Boxer from California. I know the incident the letter refers to and have thought for a long time that Sen. Boxer is an arrogant person who I believe does not act in the best interests of her electorate, but marches to her own drumbeat. So what is the difference?

I think it is the difference in the contact with the folks how have placed their trust in the politician. I do not know Hubert Brodell well, I would not call us friends. I ran into him for a number of years at a variety of functions around Northeast Arkansas and we would talk from time to time, but I observed his actions in his community for many of the years I've lived in Arkansas. Hubert seemed to try to do the best for Jonesboro that he could. There were things that happened that favored Jonesboro over Paragould, and Hubert was not friend to all. That is the nature of politics. Hubert's actions almost always were for helping Jonesboro grow, attract more business or improve the quality of life of its citizens. The same is true for a longtime Mayor of Paragould, Charlie Partlow.

I know Charlie, not as a friend, but I used to bump into him around Paragould and we would talk and I observed his actions. I recall the time that Paragould thought it had gotten the shaft in the placement of Highway 67 coming north from Newport. Two buses were chartered by Paragould residents and they came to Newport to a Arkansas Highway Department hearing over the routing of the highway. I remember Charlie, red-face with anger having a decidedly heated conversation with Nick Wilson a State Senator from Pocahontas. Nick was responsible for getting the route moved out of Greene County to Lawerence and Randolph county, his constituency. Charlie took on the issue and defended it well even though in the end the powers to be left the route alone. Charlie Partlow once again always seemed to act in the best interests of his constituency.

I feel the same way about the current mayor of Paragould, Mike Gaskill. I know Mike. He used to be the Manager of Hays Grocery store in Paragould, and I've agitated him for years at various Paragould functions. I have been impressed that Mike seems to act with the welfare of his constituents in mind and seems to be an honorable person.

However it seems the higher up the ladder you go the more our elected officials succumb to the lure of power. Special interest groups that pump money into campaign funds hold sway. I do not believe government should intrude too far into our private lives. However in areas where they should the actions seem prostituted and end up making me feel like our politicians think we have deep pocket books that can fund the engines of special interests. I really would like to see term limits for federal officials. When it comes to federal elected officials I do really believe in the old saw, "throw the rascals out!"

Darn, darn, darn!`

I know quite a bit about the operation of the human heart. Mine acts up. I have an irregular heart beat, it consists of something called premature ventricular contractions, pvcs and premature atrial contractions, pacs. I've had this condition for years although it was first diagnosed in 2000 at a Jackson, MS clinic. Once I was able to associate the sensation in my chest with what the doctor found on a EKG I realized I'd had that sensation for years before 2000. I did not give it much thought. As the result of the diagnosis in Jackson I underwent a heart cath procedure to see if I had blockage. I did not. So I was told the irregular heart beat is common and benign.

Fast forward to 2007, I underwent the stress of having a cancer diagnosis and successful removal of about six inches of my exhaust system to eliminate the cancer. Nonetheless to be told you had a malignant tumor creates a great deal of inner turmoil. Three months after the bowel resection I ended up in the local hospital with an A-fib episode which is a very irregular heartbeat. Once cleared up, I did take some medication for about a year until another heart specialist called an electrophysiologist or EP weaned me off the meds and I continued to march.

Monday morning, August 17 about midnight I woke up with that "old sensation." A-fib. I rolled over and went back to sleep, that is how numb you get to the problem after a while, and when it persisted for about 6 hours I told Terry that instead of going to work she and I were going to Jonesboro to the NEA Hospital emergency room. This is my fourth visit to this facility in as many years.

I was in A-fib and placed in observation for 24 hours. The problem still persisted after 24 hours, so I was admitted and moved to a private room. About 2:30 AM August 19 my heart converted to a good solid sinus rhythm. I was released and sent home with two new medications called rythmole, which I have taken before, and Cardizem which I have not taken before. I will probably be on these two drugs for the rest of my life. That is a sobering thought. I don't know why so much, Terry is a diabetic and takes insulin just ot stay alive. I take a blood pressure med and a cholesterol med, but I think of that as a part of life. I do not like the idea of a heart arrhythmia. Not that it is so scary, but I feel like I am being forced to give into age.

I am not happy with this situation, but quite honestly I did not get put on blood thinners yet. I hope I do not have to. In talking with the cardiologist I was told I have a slow heartbeat. The two new meds reduce the heart rate. I was told by the cardiologist that if my heart rate slows too severely I will have to have a pace maker to insure it keeps on a ticking. One of the interesting things is that a real slow rate is not a number, but is how you react. If you start having troubles rising from a seated position, or bending makes you dizzy or pass out, then that is too low a number.

None of this is doom or gloom. However, it is indicative of the aging process and I am very aware of that. So my heart is in actuality strong and will last a lifetime. It just needs some help. In the meantime my brain is dealing with another issue that marks the passage of time and the appearance of finality. Darn, darn, darn.

How do you describe? Part II

OK, a couple of days have passed and I have my wits about me. Two weeks ago lying under my truck sanding some electrical connections I had to tilt my head severely back and to the right to be able to examine the contacts I was cleaning through my bifocals. The minute that I did that I had instant dizziness and nausea. I got out from under the truck, staggered around for a few minutes while the dizziness passed and then sat for a couple of hours until the sick stomach sensation passed, then completed the job.

Friday morning I got up from a sound sleep to go to the bathroom and had the episode I described in the earlier blog. Friday night I did not experience any dizziness except when I rolled from one side to the other. I often start out on my left side then roll to my right when I really want to go to sleep. Moving 180 degrees caused a momentary spat of dizziness that passed about as quickly as it came. It was disturbing.

This morning I walked with the dogs for 40 minutes, no problem. I had thoughts of going to an Urgent Care Clinic run by the Doctor's Clinic Terry and I go to. Before doing so I remembered my brother-in-law Chap has had vertigo problems for many years. So I called him and visited about his condition. Seems like he often gets up in the night, aims for an open door and misses. He does nothing for the condition. He also told of a next door neighbor, just 50, who had a bout of severe vertigo that disabled her from work for a period of time. She is fine now. The reason I was checking was because I recall that when I had a severe episode of vertigo years ago that put me in the hospital the Neurosurgeon that came in to examine me for a possible stroke told me that a simple head tilting exercise would help keep vertigo in check and that other than that there was not much they could do other than surgery and that is a last resort because there is a hearing loss associated with that procedure.

So I did some internet checking and came across some information that detailed exactly what I had done, tilting the head back severely and experiencing some dizziness. Like the old story about the Dr. who was told by a patient that it hurts when he raises his arm told the patient, then don't do that. That was essentially the advice from the article. Be careful of head position if you are susceptible to this form of vertigo called BPPV. The treatment prescribed is a set of exercises and it usually goes away in several weeks, the exercises may speed the cessation of symptoms.

So, I decided not to go to the clinic and waste some money on what I already knew. I feel fine. I did some of those exercises this noon and determine it is my right ear as that is the side I get dizzy on when I do these exercises. In addition, that is the position I had my head cocked when the problem first came on. So on to other things. If it does persist for several weeks or more I will have it checked out. For now, I've other more important things to do.

How do you describe?

I woke up at 2:30 AM this morning and had to use the bathroom. As I walked to the facility I all of a sudden lurched forward as though I was going to fall on my face. I did not feel dizzy, but I did feel disoriented. After going to the bathroom I returned to bed and lay down. All of a sudden I became disoriented again, in the new position. Once again I was able to focus on objects, it was not like the room was spinning, but I did feel a little queasy. I got up again and did some head exercises a Dr. had told me about that consist of bending your head from one side then to the other so your inner ear mechanism that contributes to balance gets some exercise. I then stood on one leg with arms outstretched and held that position for half a minute, then the other leg. It is kind of a balance check. I kept having to flex my foot to stay upright, but I was able to maintain that position for a while. In the meantime you get scared.

Strokes can cause that disorientation. My brother Dean suffered a stroke while playing golf. His golfing partner told of the episode that when they got to the locker room at the country club Dean complained of seeing double. Some days later he passed away. My family has a history of strokes so I end up with some fear there. However, I also have a slow heart beat. Yesterday for example when I was in Wal*Mart I used the BP cuff and got a reading of 133/78 but my pulse was 58. The Cardiologist I have seen has told me that some day I may need a pace maker because of that slow heart beat. I have for a long time staggered from time to time when I rise from a prone position to upright, and have been a little unsteady on my feet once and a while, but not too often. My dad, in his later years, talked about walking like a drunken man from time to time, but didn't suffer any ill effects. Still one worries.

I came downstairs to just sit and get stabilized. I seem OK as I write this and my vision is not blurred nor do I feel lightheaded. Jenny, I know you will read this but I am typing this more for a record than anything else, so don't get upset or feel you have to call, although I do enjoy talking to you any time and look forward to hearing your voice.

I also know that people do have equilibrium issues over the years and live just fine. I have a problem with I want to feel perfect and when I don't I begin imagining which is not good for me. I really do feel I'm in pretty good health, I am due for a check up later this summer and will make sure I bring up this episode to the Dr., but I don't know what to make of things now. Perhaps I just sat up too fast and that caused some reaction, because I do feel normal sitting here typing.

As my Dad once told me years ago, sometimes you just can't let things bother you. You have to just go on because that is how life is. It isn't the same for every person. So I'm going back to bed and have a good rest.