America’s shame? Yes, but Britain’s hands aren’t clean.

The racially motivated terrorist attack/hate crime against the peaceful bible study participants at a Charleston church this week by one very sick individual has outraged our country and the world, opening us, yet again, to attacks by other countries–safe in their holier-than-thou gun control laws, convinced that these types of things wouldn’t happen elsewhere. They do. Mental illness is universal. Random acts of violence, by their very nature, are impossible to prevent except by excessively strict police states that we as a nation have not embraced–yet.

But America has a very real problem that this attack has turned the national spotlight on again. Good. As Jon Stewart said in one of the opening paragraphs of his scathing monologue, “I’m confident . . . that by acknowledging it, by staring into that [abyss of the depraved violence that we do to each other and the nexus of a just gaping racial wound that will not heal, yet we pretend doesn’t exist] and seeing it for what it is, we still won’t do jack shit. Yeah. That’s us.”

I wish Bill Nye, right as he is, were the voice we all listened to: “The color of our ancestors’ skin and ultimately my skin and your skin is a consequence of ultraviolet light, of latitude and climate. Despite our recent sad conflicts here in the U.S., there really is no such thing as race. We are one species — each of us much, much more alike than different.”

Tribes exist, even in the animal kingdom. Cultural differences? Oh yeah, we’ve got those. White people are historically terrible at talking about race, but pretending that a “gaping racial wound” doesn’t exist because underneath our different skin colors, we’re really all the same? I’m a scientist at heart, and Lord know I’m an idealist, but even I know that’s not the answer.

We bleed racial differences. In our diverse schools, our gospel churches, our black pride parades…we are different. This is beautiful. This is terrifying. Black culture is different than white culture in America, is different from Muslim culture is different from Jewish culture is different from the many other wonderful ethnic cultures that are part of our not quite melted melting pot, and it is okay to recognize that. Violence associated with it is not. Tribal differences are part and parcel of being a hairless ape. Stereotypes are wired into our brain, probably somewhere deeper than the frontal cortex. To open our eyes and see the person underneath the skin adapted, more or less, to ultraviolet radiation–this is being human.

We have a long way to go. But we have to get there.

After the Charleston murders, Britain called us a nation of “too many guns” and “racially divided.” “America’s Shame,” their headlines said. But America is not alone. We did not, alone, cause this gaping black and white racial wound. Between the seventeenth and nineteenth centuries, eleven million women, men, and children were stolen from their African homes and taken, against their wills, to the Americas. Though the destination was almost always somewhere in the Americas, often the American South, the predominant slave traders were European, including the British. According to the National Museums Liverpool, “The London-based Royal African Company was the most important [slave trading company] and from 1672 had a monopoly of the British trade.” The main European nations involved in slaving were Portugal, Spain, Britain, France, the Netherlands, Denmark and Sweden. That’s a lot.

Abolition was also not exclusive to the Americas–in 1808, slave trading was banned in Britain, and elsewhere. It continued illegally until shortly after the Civil War put an end to legal slavery in America.

But the scars remain. Scars caused by a slave trade driven by the European Imperialists, on one end, and the American market, on the other. No one’s hands are clean. Britain shares a part of that “gaping racial wound,” even if it’s not bleeding on their soil.

So don’t blame our gun laws, Britain. The weapon is not the killer. This was an act of terrorism, an act of hate, a horrible, horrible, crime. It was committed by one individual with hate in his heart, fear oozing from his pores, and illness in his mind. It highlights the shame we all feel for the terror that was committed against the African people many years ago, the consequences of which we are still trying to figure out how to make amends for. Our racial division is our shame, but if we look deeper, into the roots of history, we will see that it is not ours alone.

It might have begun when one white man walked onto a continent of people who looked not like him. He felt fear in his heart…and chose hate as the response. Echoes of Charleston this week?

For the record, except for some accidents of history, it could have happened the other way around.

But it didn’t.

It didn’t.

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One physician’s creative response to bureaucratic frustration

A few days ago, one irate physician spent hours on the phone with a pharmacy benefit program. He was trying to get a prescription covered for his patient…that she was already on. What follows is the complete text of the actual letter (and bill for consultation) he mailed them. It is a glorious stance against bureaucracy.

Image

My dear fellow people who may someday need health care:

I am writing today to express my dismay and boundless frustration at your “prior authorization” process.

By way of introduction, I am a board-certified sleep disorders specialist, practicing in an academic sleep disorders center with full accreditation from the American Academy of Sleep Medicine.  All of this is relevant background, because most of the medications I prescribe end up in the vile netherterritory of “requiring prior authorization” when it comes to commercial medication management systems like ExpressScripts.  I therefore have had numerous interactions with your company, and today I had an experience which deserves telling.

Today, I received an email from the father of a patient of mine whom I’ll call Jane (not her real name).  She is a young woman, whom I diagnosed with idiopathic CNS hypersomnia back in October 2010.  For those of you reading this letter who may be unfamiliar with this diagnosis, idiopathic CNS hypersomnia is a disorder of the central nervous system, in which the patient feels impossibly sleepy, all the time, and no amount of sleep at night can fix it.  It leads to intense psychosocial dysfunction, poor work performance, and, sometimes causes people to crash cars.  Many cases don’t respond very well to stimulant medication, but, fortunately, Jane’s did.

At any rate, this is what the email said:

Dr. McCarty,

This is Bill Jones, Jane’s dad. Because of her heavy workload, I was asked to email you with a request. James, the Sam’s Club Pharmacist is having trouble getting Jane’s prescription for provigil processed and approved. She is having to buy one pill at a time out of her pocket until her new insurance gets what they need for approval. He said the doctor’s office needs to call this number ESI 1-800-235-4357  for prior authorization for this prescription. If there is anything you can do to help Jane with this, it would be greatly appreciated.   My wife and I appreciate everything you do for Jane.  If you have any questions or need to talk to me, please call.

Thanks again,

Bill Jones

At this point, I should mention that, since Jane’s diagnosis, she has been managed with low-dose modafinil, 100mg twice daily.  I suppose it goes without saying (after all, I’m a sleep disorders specialist) but I should mention that this diagnosis was made by me, in my sleep disorders center, in my lab, under my supervision.  So when I initiated therapy on this patient back in 2010, I recall answering the questions required for “preauthorization” and feeling they were quite straightforward:  I was asked her diagnosis (I told them); I was asked if the diagnosis was made by a sleep disorders specialist (check!) and I was informed that the drug was approved for a year.

This is where the trouble starts.  Since that time, I have had to undergo the same drill for this patient every year.  And every year, the questions and answers are the same.  This year was no different, but the weight of this process became achingly clear.

Today I called the number which was provided.  After multiple computer-generated menu-choices, I was placed on hold for a full 25 minutes.  When I finally spoke to a very nice young lady named Linda, she apologized for the long wait time, checked her file, and apologized because the number I really needed to call was 866-310-3666.  I was then transferred to that number, where I was then subjected to a whopping 50-minute hold time, before I could get through to a live person, to complete the “pre-authorization.” This is a short digression, but pre-authorization is imperfectly named, don’t you think?  It was pre-authorized back in 2010.  At this point, we are now well into re-authorizing, I would say.  Which, by the way, is just another way of saying we are re-doing something that doesn’t need to be done.  It’s redundant.  Doing the same thing over and over.  Repetitive.  (Annoying, isn’t it?).

Now, I hope you’re still paying attention, because here is the best part:   At this point, after having spent an hour and fifteen minutes of my day on the phone ON HOLD with your company, I was asked the same two questions that I answered, way back in 2010:

(1)  What is the diagnosis for which the prescription is being written?

and

(2) Was this diagnosis made by a Sleep Disorders specialist? 

OK.  Hold on.  You may have a hard time believing this part, so I’m asking now for the faint of heart among you to take a seat:

The answers were the same as they were back in 2010!

Holy smokes!  Who could’ve predicted it?

Now, if I didn’t know better, I would think that your company is deliberately setting up roadblocks to provision of covered services, because you know, deep down, that some of us doctors are just too busy, angry, drunk, or burned-out to stay on the phone for an hour and fifteen minutes to get “authorization” for a drug that has already been authorized in the past.  But nope!  You guessed wrong in my case.  Not me.  The longer you kept me on hold, the more determined I became to not let my patient down.  I knew that if I hung up,

(a)  my patient would be left in the lurch, spending her money on a service that you promised to cover as part of her contract with you (UNFAIR!)

and

(b) I would have to start the whole thing over and call you back (INCONVENIENT!)

So I hung in there, and eventually I was able to talk to a charming young woman in Saint Louis who secured the approval for Jane’s modafinil.  For a year.

So I did it.  I did it.  I gave you the consultation you needed, to make sure that this was still the right drug for this patient.  I provided the assurance you needed that this drug continues to be safe and medically necessary.

Don’t get me wrong:  I fully accept the proposal that you, Express Scripts* (NB: by the way, it’s charming how the name you chose implies speediness of service!  George Orwell could not have done so well!) should exercise some control over the prescribing habits of practicing physicians.  I agree that it is in your mandate to help control costs.  If part of this mandate requires “checking” with doctors again, to make sure that the diagnosis is correct, I agree, you should have this avenue available to you.  But this, my good people, will come at a price. It should be part of your cost of doing business.  I am happy to offer my professional consultative services in this capacity, and I will continue to do so at my standard hourly professional consultative rate.

Therefore, for the time that I spent on the telephone, waiting for you to get accept my call to obtain my professional consultation regarding the necessity of this medication, (a consultation you deemed necessary prior to allowing my patient to have access to a medically necessary prescription which is fully covered under her insurance for her indication), I have submitted a bill, for which I expect payment in full (attachment, below).  For new prescriptions (ie: those for which you do not have any clinical information at all), I will, in the future, waive this consultation fee, but for subsequent consultations (if the information has not changed) I will plan to do the same.

In the future, I would suggest that you consider the following:

  1. Create an allowance for diagnoses that are durable/unlikely to change with time, and allow longer authorization periods.  For a diagnosis such as idiopathic hypersomnia, I would use 5 or even 10 years.  Other diagnoses (such as narcolepsy) are lifelong.  By authorizing for five years at a time, you will be able to decrease your consultation fees with me by a whopping 500%!
  2. Create a telephone system that allows a single number to achieve service. This will allow shorter hold times, and also will reduce your consultation fees.
  3. For specialty medications, keep a roster of physicians who, like myself, specialize in the field for which the medication is being prescribed, and cut us some slack.  This may cut out a large majority of your consultation fees.  This element may require some explanation, because I don’t want to come off as an arrogant jerk (I’m actually a very down-to-earth and likeable person!), but, when it comes right down to it, I know what I’m talking about, and if I say a patient needs a medication, it’s because that patient NEEDS THAT MEDICATION.  If your authorization people have an issue with my judgment, I’d be more than happy to go a few rounds with your peer-to-peer reviewer about whether a sleep-related medication is medically appropriate.  Again, my consultation fees would apply, but I’m succinct, and I will be happy to provide written documentation of my opinions, complete with literature references, so your reviewers can be educated (and therefore avoid the requirement for more consultations!).

My final words before parting:  I had several conversations with colleagues about this incident before I chose to write this sharply-worded communication.  I got eye-rolls and groans from all of them.  Everyone I interviewed has felt what I’m feeling, and your company in particular has garnered a lousy reputation for giving doctors a hard time.  One colleague said (and I quote, verbatim): “They need to know that their service is the worst ever.  It’s even worse than Medicaid.  In fact, come to think of it, Medicaid is a breeze compared to Express Scripts.”

I think that says it all.

I implore you.  Fix this problem before you burn all of us out.

Sincerely yours,

David E. McCarty, M.D., F.A.A.S.M.
Associate Professor, Division of Sleep Medicine
Department of Neurology
Louisiana State University Health Sciences Center
Shreveport, Louisiana

Attachment
INVOICE for SERVICES RENDERED

To: Express Scripts

From: David E. McCarty, M.D., F.A.A.S.M.

RE: consultation fee

Date of service: 10 January 2014

Time in : 10:15 a.m.

Time out: 11:30 a.m.

Total time: 1.25 hours

Hourly Rate: $350

_________________________

Total: $437.50

Payment due upon receipt.

Please remit payment to:

Dr. David McCarty
University Health Sleep Disorders Center
1501 Kings Highway
Shreveport LA 71130

Thanks for your business!  🙂

————————————————————————————————————————————–

Heather’s Note:

Express Scripts is a pharmacy benefit management organization (PBM): They administrate prescription drug programs for insurance companies, either paying for drug claims, or providing cost-saving measures such as mail-service pharmacies and electronic ordering for physicians. In my own experience with Express Scripts, who just happens to be the PBM for my insurance company, I tried out the mail-service prescriptions for three of my four migraine drugs. It was cheaper and convenient: I could get 90 days at a time instead of 30 (although why my local pharmacy couldn’t give me 90, I was never told). Unfortunately, two of the drugs were different—and for me, inferior—formulations. When my side effects increased (somnolence), I switched back to my local pharmacy. After a few months, the price went up. Although I was never moved to write a letter of complaint (my fix was easy and relatively cheap), I still get the drugs at my local pharmacy. I throw out every letter from Express Scripts imploring me to go back. There are many. When I came across this letter through a friend and former colleague, I readily agreed to post it for the world to enjoy. And hopefully spread.

Neil deGrasse Tyson – My Hero

Neil deGrasse Tyson talking asteroid physics with a 9-year old

Great asteroid science, explained so even a 9-year old can understand it. Well, so a 9-year old who throws around words like “non-Newtonian solids”, that is. The look on Dr. Tyson’s face is priceless. Also, enough material for a library of science fiction books.

A fascinatingly disturbing thought

(Which actually comes around minute 8, after many interesting thoughts, including the suggestion that we are descended from Martians)

The components of the universe, in decreasing order of frequency, are:

Hydrogen
Helium
Oxygen
Carbon
Nitrogen

Which equal the components of us, in decreasing order of frequency, minus helium, which is inert. This is NOT the fascinatingly disturbing thought.

The man expounds on aliens, life on other planets, DNA, and chimpanzees.

It is “inexcusably egocentric to suggest that we are alone in the cosmos. There are more stars in the universe than grains of sand in all the beaches in the world. There are more stars in the universe than sounds and words ever uttered by all humans who have ever lived.”

As to why we should explore other planets:

“Venus is the best example in the solar system of a planet gone bad.”

Dr. Neil deGrasse Tyson on UFOs

Anyone familiar with Neil deGrasse Tyson’s down-to-earth, tell-it-straight brand of astrophysics will not be surprised by this diatribe on UFOs.

“We’ve all bought and enjoyed books called ‘Optical Illusions’. Right? Well, We all love optical illusions. But that’s not what they should call the book. They should call them brain failures. Because that’s what it is. A complete failure of human perception.”

“Maybe you did see visitors from another part of the galaxy. I need more than your eyewitness testimony. And in modern times, I need more than your photograph. Photoshop probably has a UFO button today.”

He’s not saying they haven’t been here. He’s just saying the evidence isn’t there. If you do happen to be abducted, he advises you to steal the ashtray off the flying saucer. Bring proof. Something interesting.

Something interesting I learned is that UFO sightings are LOWER among amateur astronomers, even though they spend more time watching the sky. Why? “Because we know what the hell we’re looking at.”

The Erosion of Progress by Religions

This lecture is slow to get going, but it’s worth sticking with, and watching until the very end. Although he’s not one to shy away from controversial topics, this lecture starts on safe but interesting ground with Naming Rights. Elements, stamps, the Internet. Whoever discovers gets the right of naming. He’s going somewhere with this—of course he is, he’s Neil deGrasse Tyson. Things get poignant when he puts up his own personal photos of September 11th, 2001. He quotes President Bush making a Bushism, saying “Our god is the one who named the stars.” Except, it turns out, most of the stars have Arabic names.

Now it all comes together. This is because the Arabs had a brief but famous period of mathematical and scientific discovery—famous if you were paying attention that year in school, or recognize words like “algebra” and “algorithm” and “arabic numerals”.

It only lasted three hundred years because of the rise of Islamic Fundamentalism. Something from which the world’s billion Muslims have not recovered as an intellectual force (he has compelling evidence).

And there is disturbing evidence that we’re heading in the same direction.

Intelligent Design is Stupid

As an evolutionary biology major, this topic is dear to my heart. Intelligent design hadn’t been proposed back when I was in college, but I spent too much time arguing with Creationists (a weakness, I admit…but it was fun). Face it: We are not perfect, just good enough, and those of us still here, reading this, are pretty damn lucky. After watching this video, you will be utterly humbled to realize we exist at all.

Though seriously, would it be too much to ask for totally separate holes for breathing and eating?

My Three Favorite TED Talks

The happy secret to better work

(12 minutes)
A happiness researcher on, yes, the importance of being happy

In this fast-paced, invigorating talk, Harvard researcher Shawn Achor convinces us with bursts of hilarity, made up data, and flashes of brilliance that when it comes to happiness, we (that is, pretty much all of us) have it (that is, pretty much everything) backwards.

How many of us assume the secret of success is to work harder? And that success will bring us happiness?

What if, in fact, the absolute opposite were true?

All it takes is 10 mindful minutes

(10 minutes)
A former Buddhist monk speaks on the importance of being present

“We’re talking about our minds–our most precious and valuable resource, through which we experience every single moment of our lives…the same mind we depend upon to be focused, creative, spontaneous, and to perform at our very best in everything that we do, and yet we don’t take any time out to look after it…”

The game that can give you 10 extra years of life

(20 minutes)
A game designer on healing, end of life regrets, and why video games aren’t all bad

Jane McGonigal’s riveting and personal talk changed my life–as a doctor, as a parent, and as a patient. She summarizes four spheres of wellness based on her research with hospice patients and personal experience with illness (Cognitive, Physical, Social, Emotional). Mst importantly, she tells us WHAT YOU CAN DO TO IMPROVE THEM (believe it or not, this is where the video game ties in). Wellness becomes a matter of battling bad guys, recruiting allies, and seeking power-ups in all your quadrants. Yes, there’s an app for that. (SuperBetter.com).

Based on research with hospice patients, the top five regrets at the end of life are:
“I wish I hadn’t worked so hard”
“I wish I had stayed in touch with my friends”
“I wish I had let myself be happier”
“I wish I had had the courage to express my true self”
“I wish I had lived a life true to my dreams”

Today, I will try to live a life without regret.

Why Science Fiction Will Save the World

The world is changing. Maybe not so fast that tomorrow we’ll wake up to having our husbands be zombies, or our cats be spaceships, but if it could happen, someone has imagined it, and odds are, they’ve published it, possibly in Daily Science Fiction.

What, you say, is Daily Science Fiction? Every day, a snapshot of the world to come or that could be, delivered free to your Inbox! Preparedness for tomorrow, often in a thousand words or less.

As a subscriber to DSF, I’ve supported their Kickstarter campaign (11 days left!), and I encourage you to do the same. Maybe someday I’ll get the chance to be in your Inbox, too.

Camp NaNoWriMo Update

One week into Camp NaNoWriMo! And I’ve written….

What word count?

I have no idea.

That’s the beauty of it. I’ve written every day, but I’ve decided not to tally words until the end. Last week was spent vacationing with my family at my parents’ house. My kids were there. My brother and his family were there. My sister was there. Needless to say, my parents were there. I was really happy if I got to say “Hi” to my computer every day, much less sit down and spend quality time with it. But I did spend a lot of quality time with my family (though I often forgot to say “Hi” until I had my second cup of coffee), and that’s why it felt like a wonderful vacation.

Meanwhile, I’ve moved my story along, introduced some new characters, and added some interesting but tricky plot twists (which, knowing me, will come back to bite me in the metaphorical behind by Chapter 29 or so).

So on the Welcome-Back-to-the-Real-World-Monday, I’m indeed in need of some encouragement. I found it, unexpectedly, by going back to my undergraduate roots as an Ecology and Evolutionary Biology major. On the drive back home, my husband and I were listening to the NPR Science Friday podcast with Edward O. Wilson, legendary Harvard biologist (Professor Emeritus), who talked about his new book “Letters to a Young Scientist”. E.O. Wilson was famous, of course, even when I was in college 20-something years ago, and I was curious to hear what he had to say from his 40+ years as a scientist. He didn’t let me down, and I couldn’t help but notice that scientists and writers benefit from the same kind of encouragements.

For instance:

  1. We both live our work: real scientists don’t take vacations, they just take short breaks during which they come up with new ideas or other ways of tackling their old problems. While I was on “vacation” I figured out how to fix two old short stories and started one new novel. (YIKES! In the middle of a NANO! I KNOW!)
  2. Scientists take risks, make quick, dirty experiments, and aren’t afraid to go down lots of paths trying to find the one right one. (Substitute “writers” for “scientist” and “stories” or “characters” for “experiments”.)
  3. Finally, to be a great scientist, you don’t have to be the best or brightest. You just have to be smart enough to come up with interesting questions, but not so smart that you get bored answering them. (I found this last bit of advice particularly encouraging.)

In my other career, I tried to be a scientist, and I wish I’d had his advice earlier. But it’s not too late: I’m taking it to heart as a writer. (Even better, as a writer of science fiction: His words on that field are particularly inspirational!)