Annie's Song

(If you think this post has ANYTHING to do with John Denver, you're in the wrong place. But it made a good title.)

I'm not taking sides in the health care debate, but I do want to clarify something.

I see people on the news screaming that they don't want "bureaucrats" between them and their doctor, and are afraid that's what government health care will bring.

WTF? THAT'S THE WAY IT IS NOW, PEOPLE!!! I hear my nurse Annie on the phone all day trying to get approval from non-government insurance companies for tests, medications, physical therapy, ANYTHING that I order.

Look at your insurance card. Doesn't it say things like "in-network" and "formulary"? Who the hell do you think came up with those? Not us docs. Dat be dem dere byoo-row-kratz!

Look back at some of my posts (like this, or this). I routinely have medications (both brand name and cheap generics) and tests refused by insurance companies. For an excellent commentary on this from the pharmacy side, this was written by FranticPharmacist.

So if you don't want bureaucrats between you and your doctor- TOO BAD. They've been there for years. THE ONLY PEOPLE WHO DON'T HAVE THIS PROBLEM ARE PAYING CASH FOR EVERYTHING!

In fact, for those of you who don't want the government running this, THEY ARE ACTUALLY ONE OF THE BETTER ONES TO WORK WITH! Just ask Annie. Medicare doesn't question the majority of my tests, or meds. Yes, they don't cover everything, nor should they, but they don't fight with me over stuff like MRI's on stroke patients. Uncle Sam (unlike BCBS, Aetna, Cigna, United, Humana, and many others) tends to leave these things to the doctor's discretion. Annie prefers Medicare patients for this very reason - they make her life easier.

So what happens to you the way it works NOW, with your non-government insurance?

You come to me for some neurological issue, which requires further work-up. So I order, say, an MRI and MRA of your head.

Annie gets the order, and calls Bozo Insurance, Inc. (BII) to schedule it. BII refuses, saying they want more information. So they fax us a 5 page "pre-auth" form, which Annie spends 20 minutes filling out and faxes back. Then they say the form wasn't enough, and they also want copies of your office notes, so we send those, too (yup, when you joined BII you agreed that they can read your medical records).

So a few days go by. BII will claim they never got our fax. Or that we filled the form out wrong. Or that they don't cover Capricorns when the moon is in Pisces. And we don't know this until Annie calls back after a few days, because they're hoping we forgot about it.

Eventually they'll deny the whole thing, on the grounds that you don't meet criteria for an MRI and MRA. This decision is usually made by a non-medically trained person with a minimum of a GED. They do this because they want to see just how badly I want the test.

So they tell me I can appeal this via "peer-to-peer" review. Which means I need to personally call their "physician reviewer" to argue with them as to why I want the study.

So, during my insanely busy day at the office I have to call them. I'm promptly put on hold for 10 minutes, before finally reaching the reviewer. This person is a doctor- but NOT necessarily in my specialty. In fact, it's usually something like a retired dermatologist, who hasn't done neurology since medical school in 1938. Or an OB/GYN who hated his job, and is doing this now instead. Or some doctor who immigrated from Lower Swazbodiaczk and can't get a U.S. medical license (but your insurance company hired him to decide what medical care you need). But it's almost NEVER someone actually in my field, who might understand why I want the study.

So after telling your life history to Dr. Denial, one of 2 things will happen. They'll deny both studies, and want you to try medication or physical therapy or psychotherapy or holistic reflexology or whatever, and if you fail that THEN I can try to resubmit a request for the test. OR they will flip a coin and say they will cover the MRI, but not the MRA. Or vice-versa. They'll say that if the first test is fine, THEN I can start over trying to get the other covered. Maybe.

And many of these companies actually pay these "reviewers" bonuses based on HOW MUCH MONEY THEY SAVED THE COMPANY BY DENYING TESTS.

This can at times become comical. One of my patients is a doc who works part-time as one of these insurance company "physician peer reviewers". And when he needed an MRI, guess what? HIS OWN COMPANY DENIED IT! He paid out of pocket for it (and yes, it was abnormal).

So how did I get on this tangent? Because yesterday I was walking by Annie's office, and heard her losing it over the speaker phone. And, as always, she was totally awesome.

Annie: "I'm calling because you people denied an MRI on a stroke patient?"

Pinhead: "Before we discuss this, I have to inform you that this is a recorded line."

Annie: "Oh, good, hopefully someone will actually be listening to me then. Thus far it hasn't happened."

Pinhead: "Let me look up the tracking number... Okay. I have to inform you that we are unable to approve this study. Your doctor will need to make a peer-to-peer call."

Annie: "Oh, now THAT's a surprise."

Pinhead: "What do you mean?"

Annie: "Is this line really being recorded?"

Pinhead: "Yes. It's to improve customer satisfaction."

Annie: "Oh, goody, because I'm sure not satisfied, and neither is the doctor, or the patient. Your company, and whoever is listening, never approves anything. In fact I can say that 100% of the time you require peer-to-peer review."

Pinhead: "We do this to save our customers money on unnecessary testing."

Annie: "Okay. Then let's just stop wasting each others time. Forget the intake coordinator, forget you. Since your only job is apparently to tell me that my doctor needs to call your doctor, couldn't your company save money by firing you?"

Pinhead: "Um, I hadn't..."

Annie: "Think about it. You have benefits and a salary, right? I mean you're not doing this as a volunteer job, are you?"

Pinhead: "No, but I..."

Annie: "So wouldn't your company save money by firing you and instead getting a computer that automatically denies every damn test and sends a fax telling us to call for a peer-to-peer review? Then we can just let the doctors talk directly to each other from the beginning, which is what you bozos want anyway. Think of the money saved by cutting all of your jobs."

Pinhead: "Oh, but you can't mean that?"

Annie: "Oh but I do mean that. And I'm glad we're being recorded. Let's consider the current situation. You are basically a worthless automaton. A computer could do your job for far less. And at this point you've incurred the wrath of all the medical professionals in the country as well as the patients. You and all of your superiors ought to be out of a job due to your blatant inefficiency. And don't think we don't save your denial forms, and your names, and document it all in the chart."

Pinhead: "I..."

Annie: "Nothing personal you understand, just a suggestion. I'll have my doctor call your doctor. Have a nice day".

Pinhead: "No, wait! I..."

Annie hung up.


So bottom line here: if you don't think bureaucrats are currently between you and your doctor- THEY ARE! GET REAL! IT'S BEEN THAT WAY FOR THE LAST 10 YEARS OR MORE!

My High School Class...

Have had some interesting comments about my high school reunion post from earlier today.

When my 20th reunion came around a few years ago, I heard about it quite indirectly- from my mother, who happened to run into somebody else's mother at Local Grocery.

When I looked at the 20th anniversary website, I was listed among the missing- students who, in spite of the best attempts of my classmates, couldn't be found (and this was well into the internet age).

I found this amazing, for many reasons:

1. I haven't changed my name.

2. My parents still live in the same house and have the same phone number as when I went to high school

3. My neurology practice is less than 5 miles from the high school I went to.

4. I am listed in the yellow pages under my own name.

5. If you type my real name into Google, one of the top hits is for my practice's web page.

So I personally felt the fact that none of them were able to find me was a comment on THEM more than ME.

And nothing further need be said.

Religious Awareness 101

Dr. Jewish is an internist down the hall from me. A mutual patient is having problems, and I needed to talk to him about the case. Since I had a minute I walked over to see him, and was ushered back into his office.

While we were discussing things a young lady, one of his office staff, wandered in.

Dr. Jewish: "What's up, Cindy?"

Cindy: "Mrs. Goldbergstein called. You wanted to see her this week, but she just called to cancel it."

Dr. Jewish: "Did she say why?"

Cindy: "She said something about 'John Kipper is coming'. Maybe she's having a guy visit?"

Dr. Jewish: "You mean Yom Kippur?"

Cindy: "Whatever, yeah, his name was something like that, and she said he's coming. So she moved the appointment to next week."

After she walked out (and I started giggling) he put his head in his hands and said "Cindy is my office manager's daughter, too".

Mrs. Grumpy Writes

She just emailed me this (she's a school nurse):

"One of the Spanish teachers just came into the office. She's putting together some sort of Luau themed class party for next week, and wanted to know if anyone knew how to say 'Aloha' in Spanish"!

The Nerve!

One of my > 20 year High School reunions is coming up.

So I went to the website last Friday and filled in the updated "Where am I now form" (just in case anything had changed since the 20 year reunion).

Since then I've received 3 emails from former classmates asking questions about their headaches.

I responded with an email that said:

"Ibee Grumpy will be attending the reunion.

Dr. Grumpy can be seen by making an appointment. Call (999) 999-9999."

Thanks, Craig

When I was young and active (i.e. before kids) I played pick-up basketball a lot. So I have a bunch of raggy mens tank-tops in my closet from those days.



I don't wear them anymore, because (between them shrinking and me expanding) they show off my midriff, sort of an unsexy Britney Spears look.

So yesterday afternoon Craig found one in my closet, held it up, and said "Dad, why do you own a dress?"

My Readers Write

I have the most boring lobby in the world. Chairs, table, water cooler, some magazines. If you want to wait amongst plasma screen TV's, Louvre-quality paintings, and free Wi-Fi, go see Dr. Bigtitz, the plastic surgeon upstairs.

I follow the advice of The Bible - no mirrors, clocks, or music out there.

Anyway, I'm rambling about this because last week I received an email from Dr. Stingray, who says he's an internist in Florida, commenting on office decor issues:

"Years ago I subleased from a neurologist, Dr. Sousaphone. He only saw Alzheimer's patients, and believed in having an office that would rival any art museum.

"One day, for whatever reason, he decided to install a fountain in the lobby. This wasn't some little desktop thing, but a fairly large contraption of copper and stone. He thought its gentle sounds would relax his demented patients.

"Unfortunately, it was more relaxing then he'd anticipated. 2 days after it's debut an elderly, demented man (to his wife's horror) walked over to it, unzipped, and drained his bladder into the relaxing waters. Another disinhibited gentleman thought this was a good idea and promptly joined him.

"This performance stunned Dr. Sousaphone (not to mention my waiting patients) who hadn't anticipated the fountain's effect on demented males with enlarged prostates. After they cleaned the fountain he had a sign installed that said "Please do not urinate in the fountain. It is for decoration only" (Dr. Grumpy comments: Wow! If you saw that sign in your doctor's lobby, what would you think?).

"The effectiveness of the sign was matched only by his patients' fading memories, and after 3 weeks Dr. Sousaphone's staff got sick of cleaning the fountain and made him remove it."

Mrs. Grumpy Hates Me

Tonight Mrs. Grumpy took me and the tribe to an outdoor party for the kids at the school where she works.

So we're sitting up in the bleachers watching a free-for-all volleyball game with about 50 kids on each side hitting these HUGE oversized beach balls back and forth. While this is going on the Principal comes over, and Mrs. Grumpy introduces us.

Then Ms. Principal looks out at the game and says "those are the biggest balls I've ever seen."

I said "Why, thank you."

I'll be sleeping on the couch tonight. Possibly longer.

Where Am We?

Introduction: Mr. Fried, a pleasant refugee of the 60's (think Reverend Jim, from "Taxi"), saw me 8 years ago, when he used to live here. He then moved away, but recently moved back and came in to re-establish care. Please note the state names have been changed to protect the identities of myself and the states. Mr. Fried needs no protection, as he has no idea who he is anyway.


Dr. Grumpy: "Good to see you again, Mr. Fried."

Mr. Fried: "It's good to be back in Minnesota, Doc".

Dr. Grumpy: "We're in Oregon, sir."

Mr. Fried: "Yeah, that's what I meant."

Dr. Grumpy: "So I last saw you in 2001, before you moved to Alabama."

Mr. Fried: "I didn't know you moved to Alabama. I was living there, too."

Dr. Grumpy: "No, I was here in Oregon the whole time. You moved."

Mr. Fried: "I know. I miss Minnesota already."

Dr. Grumpy: "How are your headaches?"

Mr. Fried: "Are they why I moved to Alabama?"

Dr. Grumpy: "I have no idea."

Mr. Fried: "Do you know if I had them when I lived in Minnesota?"

Dr. Grumpy: "Mr. Fried, I've never lived in Minnesota."

Mr. Fried: "Neither have I."


It was a really long hour.

Life in Retail

(Annie's daughter, Evie, started working at Target this week. Today Annie sent me this email about how she's doing)

"This is Evie's first retail experience. They have her managing lingerie.

"Yesterday, they had a corporate head guy come through at 10 am. The store manager told her at 8am there was to be this surprise inspection at 10 and unfortunately the night crew had left 5 full carts of merchandise in her department to be tagged and shelved. He knew it was not fair, but he needed it done.

"She got it done, but just as the head guy was coming to her department here comes a woman with 5 unruly kids. Knocking over the racks, grabbing the bras and screaming "look mom I have boobs". Horrified store manager got the bigwigs to move on while kids continued to destroy department. Mom of the kids went into melt down and started beating them all with both her purse and one she grabbed off a rack.

"An hour later, while trying to help an elderly woman on a cane, who could not find the type of bras from her day... Evie innocently asked 'well could you try and describe it to me so I can help you find something like it'. The woman lifted up her shirt to show her the bra she wanted.

"Welcome to retail."

Helpful Radiology Results

This report came over the fax today:

"Impression: When compared to the previous study of January, 2009, the right carotid artery stenosis has significantly worsened and is entirely unchanged."

I'm Impressed

My 9:00 patient this morning called at 8:45. Said she was having "car trouble", and asked if she could reschedule to later in the morning. So we moved her to 11:15.

She shows up at 11:15, with her forehead and arms darkened, smelling strongly of smoke.

She apologized for not having had a chance to shower, but by the time she gave up on trying to put out the car herself, and the fire department left after doing so, and she found a friend to give her a ride here, she just didn't have time.

Two points:

1. I am in AWE at your devotion to me that you only moved the appointment 135 minutes, instead of to next week or month.

2. When the fire department is putting out your car, I consider that beyond "car trouble". I'd have been running in circles & screaming, and likely wouldn't have bothered to call my doctor about the appointment under the circumstances.

Mary's Desk, September 16, 2009

Mary: "Dr. Grumpy's office. This is Mary."

Mr. Needshelp: "Hi! I need to make an appointment to see Dr. Grumpy!"

Mary: "Okay. When would you like to come in?"

Mr. Needshelp: "Um, I don't know, you mean to come see the Doctor?"

Mary: "Yes. You said you wanted to make an appointment?"

Mr. Needshelp: "I do, but, um, I don't think I'm quite ready to actually schedule it. I'll call back another day. Thank you!"

Public Service Announcement

If you (hypothetically, of course) get a can of Diet Coke that has lost some taste due to sitting in a garage for too long, DO NOT pour a packet of sweetener into it.

The resulting reaction will cause the soda to foam up wildly, going all over your desk, keyboard, pens, MRI reports, notes, and anything else.

The tissue box on your desk will likely not have enough in it to stop it from pouring on the floor.

The patient across from you will be of no help whatsoever, and may post about it tonight on grumpypatientblog.com.

Again, this is a purely hypothetical situation.

Thank you.