Does Kafka Work for Medi-Cal?

"Take care of your health; you have no right to neglect it, and thus become a burden to yourself and perhaps to others."

~ William Hall

Here follows another episode in my continuing adventure as unpaid fiduciary agent for a dementia patient dependent upon Medicare and Medical for her custodial care in a residential skilled nursing facility. When we last left our patient, her annual re-evaluation for eligibility for Medical was approved 3 months into the current year. The story of establishing her financial need would be a hilarious saga of plot twists and missed chances if wasn’t such a sad and pathetic tale of bureaucratic bungling and ineptitude.

But that was then. In this latest episode, we have at least two problems. If you count not knowing whether the first two problems are related, we have three problems.

The first issue is what I’ll call a question of “coverage”. Such problems are always heralded by an ominously unexplained “Notice of Action” in which some (usually bad) decision has been made but which is less enlightening about why.  In May, we received a NOA instructing us that because the patient had informed them she was moving to Riverside, her case was being transferred there. Ok, they explained why, but they were wildly wrong. The effect would have been to terminate her coverage at her local facility in September.  We called, we wrote, and we called some more to assure them nobody had ever told them she was moving, that she could not move from bed to toilet, and accordingly that moving from San Diego to Riverside was out of the question. We assumed that the matter would be resolved. Foolishly as it turns out.

When the skilled nursing facility notified us in July the service was still going to terminate in September we called, and after about 20 minutes on hold we explained to James what had happened. He found the file. He found the notice and no information about the patient saying she was moving. He also found our written explanation that no move was contemplated. We believed James when he explained that while he couldn’t personal and directly fix this matter of the move to Riverside, he would e-mail the authority that would. He couldn’t copy us on the e-mail for reasons I can only conclude to be that then I’d have a genuine contact to a real person with real authority and well, we can’t have that can we? But James assured us we would receive a call in a few days assuring us that the case would remain in San Diego. All this was, of course, complete rubbish.

Fool me twice etc. I blame my own naïve faith, coupled with my exhaustion from trying to deal with these people for my failure to follow up when the call never came. That, plus a slight degree of bitterness that this shouldn't be my problem to begin with, but I'm the only adult in the room.

So, on September 11 we received a Notice of Medicare Non-Coverage (NOMNC) from the facility saying the 95-year-old patient’s coverage would end on September 12. Coincidently, this was the same day the patient had returned to the facility from the hospital for her latest bout with COPD, Congestive Heart Failure and an unidentified infection which later proved to be UTI. No reason was given for this action. I have however, formed two theories. One is that the case has been moved to Riverside. The other is that Medical is trying to loosen my already tenuous grasp on sanity in the hopes that I’ll drink myself to death, not appeal their non-coverage decision, and the facility can move the patient’s hospital bed out into the back alley and forget about her. I believe that’s what Medicare would call a win-win since they'd be down two Social Security checks.

This “timely” 24-hour notice included information that if we wanted to appeal we should do so “promptly” by calling our “Quality Improvement Organization (also known as a QIO)”. Needless to say, I quickly made a shaker of vodka martinis with rosewater and lemon syrup before promptly calling the QIO about appealing the NOMNC. Was told by Maria that we’d be contacted by a case manager “in a few days”.  It’s too soon to say whether the QIO measures a few days by Medical time or by actual calendar time.

The next issue is one  of “eligibility” i.e. of proving poverty. Related? Perhaps. Perhaps not.  Although the patient’s financial eligibility for Medical coverage was approved on 2/23/13 for the calendar year 2013, it turns out there is no reason why this issue shouldn't be raised, say every 15 minutes. Here’s how that went down.

We received not one, but two separately mailed notices both dated 9/5/13, both from the same local office of the county Health and Human Services Agency that administers Medical. One was a health insurance questionnaire I’ve seen, completed and returned not less than three times, detailing the patient’s Medicare and Medi-gap insurance coverage. (This matter was fake-resolved last February but because since then Medicare first deducts the monthly premium from her Social Security check then promptly refunds it to her, it clearly wasn't real-resolved.) The other was the equally familiar Verification Checklist  saying we need to “establish/re-establish” eligibility for Medical. Apparently there is no form letter to re-re-re-establish such coverage. We dutifully completed the forms, attached the required bank statements documenting the patient’s poverty. We returned each form in each separate postage-prepaid envelope to the same place.

Let me conclude by saying that I know the social services safety net is pretty tattered. Workers are underfunded and agencies are understaffed. Times are tough and the bureaucrats are more likely to be too busy to read correspondence and forms than they are to be illiterate morons: although the results are the same. I expect that the rate of staff turnover exceeds that of the staff turnover beneath that shade tree outside the Home Depot parking lot. I expect that idealistic workers with a Bachelor’s Degree in some social services major and a desire to do some good for their fellow men experience burnout at rates exceeding that of a cheap cigar. That said, I spent my entire career as a professional bureaucrat and saw some seriously bad shit. But never, not even when contracting with CalTrans, have I experienced such a deficiency of coherent consistent practices combined with such pervasive incompetence.

Tilting at Windmills is Wrong

"To die, to risk death, even to raise a finger for any Cause was to pennon one’s lance with the riband of Purpose, so the poet judged, and had about it the same high lunacy of a tilt with Manchegan windmills."

  - John Barth, The Sot Weed Factor

Some things we all know are simply wrong. For example, I think we can all agree that what we call the glove compartment is wrongly named. It’s wrong to believe there is a real pot of gold at the end of a rainbow. I personally think it’s wrong to ascribe malice to actions that may be better attributed to unthinking stupidity.

And despite my preference for all front teeth to be present in a person’s smile, I admit it’s wrong of me to judge people with missing teeth in their smiles as gap-toothed hillbillies proudly embracing a bold personal sense of style to compensate for their deficiency in social graces.

It’s wrong to think that if we sow as war we will reap peace.

We Don't Need No Stinkin' Warrants

If you want to keep a secret, you must also hide it from yourself.

― George Orwell, 1984

Awww, NSA, again without the warrants to read my email? I’m shocked. Shocked!  And strangely, I don’t feel a bit safer. Then again, by Orwell's logic, omniscient surveillance is probably complete privacy. So that's reassuring, I think. 

Keeping secrets from oneself becomes easier as we age. I’ve already forgotten what I had for breakfast, and I’m beginning to suspect that Tech Support Guy and I have some secrets in our past that have nothing to do with computers. Fortunately, our past happened before social media made it possible to publish salacious pictures, so whatever it was I think I remember will remain secret. 

Also, I can’t remember where I put the list with all my passwords in it. Can anybody help me? Bueller? Anyone? NSA?

Keep a Healthy Attitude, or at Least an Attitude

“Though the doctors treated him, let his blood, and gave him medications to drink, he nevertheless recovered.”

― Leo Tolstoy, War and Peace

I have a friend who has familial hypercholesterolemia (Cholesterol 356; HDL 67, LDL 268, Triglyceride 179) and cannot tolerate statins because they cause severe, persistent, acute and chronic pain in the patient’s trapezius, sternocleidomastoid, levator scapulae, and deltoid muscles, as well as temporomandibular joint radiating into the skull and down the patient’s arms. While always experiencing generalized soreness and aches in neck, shoulders and arms, about once a year a bad thing happens: my friend experiences a generalized muscle spasm in one or more of these muscles that can last for days at a time. This last time the spasm lasted for every minute of 26 days and nights - which, apart from making the patient cranky, kept them from sleeping without serious meds - which, apart from creating a serious dependence on hydrocodone, made the patient psychotic from sleep deprivation – and which, apart from availing themselves of their health insurance, did nothing to relieve my friend’s dreadful pain.

Wait, maybe since my friend and I are not medical professionals and thus cannot possibly understand such big words it would be better for me to describe my friend’s neck pain using some comparisons to things regular people might understand. The muscle spasms were to a stiff neck as an ax buried 2 inches deep into the back of the neck at the base of the skull is to a gentle tap. Trying to relive the spasms by massage was like rubbing a bag of doorknobs, and as about as successful. The headache endured 24/7 was to a pressure headache as being kicked simultaneously and repeatedly behind each ear by two angry kangaroos is to a gentle breeze.

Finally, I will resort to a somewhat non-technical word that best summarizes the quality of health “care” that my friend has not received: compassionate.

Fortunately, during the past month while being shuffled on the merry-go-around of referral to no less than 7 specialists, up to and including psychiatrists who inquired about whether the patient was hearing voices, and while being denied the prescription muscle relaxants that have controlled this pain for 25 years, the muscle spasm finally subsided. While still experiencing some sleep disturbance related to weaning off the hydrocodone, my friend has regained the will to live.

Thanks for nothing, Kaiser Permanente.

Whiter Teeth for All

 The right use of leisure is no doubt a harder problem than the right use of our working hours. The soul is dyed the color of its leisure thoughts. As a man thinketh in his heart so is he.


 -  William Ralph (Dean) Inge

One's soul may be dyed by one's thoughts, but the color of one's teeth is another story.

I recently had an amazing marketing inspiration for an innovative new sure-fire consumer product destined to make money for an adventurous investor. However, being a) lazy; b) capable of shame; and c) not interested in pursuing a career in the lucrative and rewarding field of lying to consumers to manufacture needs, I here generously share my product invention to pay it forward to  some other enthusiastic budding entrepreneur seeking the American dream of striking it rich without having to sell a kidney.

The product:  tooth-whitening dots. Not gel in trays, not whitening strips. Just tooth-sized adhesive dots coated with tooth-whitening chemicals.

The target market:  consumers who lack basic dental hygiene skills, those without premium dental insurance benefits; those who live in remote swamps without access to a dentist but with basic cable TV. My exhaustive imaginary in depth market research shows that a substantial subset of this demographic (mostly those who have yet to develop type II diabetes and/or those who have lost their prison dentures) have some semblance of self-esteem, and seek to preserve what remains of their looks by whitening their remaining tooth/teeth, but who are cost-conscious enough that they don’t want to spend the money for a product like a strip that would have to bridge gaps left by missing or hopelessly misaligned teeth, thus wasting a substantial portion of expensively bleach-impregnated product.

Marketing strategy: Simply advertise on a carefully chosen subset of reality TV shows. Most people who play recurring roles on reality programs that showcase the worst examples of American behavior  - from repossessing cars, to fishing with your fist, to celebrating the excesses of the hillbilly trailer trash lifestyle, have fewer than the typical 28-32 adult teeth the rest of us evolved with. Not only is the demographic who watches these shows ideally self-selected for the product, the badly behaved starring "celebrities" with missing teeth could endorse the product thus giving it even more cachet. By positioning this product in the market to whom these increasingly shameless reality shows pander - such as, the Real Housewives of Shady Cove Mobile Estates, or Championship Bum Fighters, or My Big Fat Jersey Swamp Redneck Shotgun Wedding - this idea can’t miss.

You can thank me later. 

So That Happened

“Maybe humans are just the pet alligators that God flushed down the toilet.”

Chuck Palahniuk

I've been feeling like crap lately.

If life is indeed a carnival, then currently I’m behind the tent where you throw ping-pong balls into goldfish bowls barfing up the cotton candy and chocolate covered bacon I ate earlier.

Being Afraid of the Dark

"For just as children tremble and fear all

In the viewless dark, so even we at times

Dread in the light so many things that be

No whit more fearsome than what children feign,

Shuddering, will be upon them in the dark.

This terror then, this darkness of the mind,

Not sunrise with its flaring spokes of light,

Nor glittering arrows of morning can disperse,

But only Nature's aspect and her law."

 - Lucretius,  On the Nature of Things Book VI

I was never afraid of the dark. I especially love the twilight. When I was a child, I heard that the some native ceremonies that had to begin at precisely dawn would begin when the officiating person could distinguish a red item from a group of other dark colored items. Somewhere, I was also told that reason fire trucks were red is that red is the first color you can distinguish at dawn and the last you can identify as it gets dark. Even as a kid, I was never sure why this was important, as it seems to me you should be able to see the shape of a fire truck with flashing red lights and a blaring siren regardless of its color. My childhood suspicions about the red fire truck theory were borne out when, as an adult, I observed that some fire trucks are painted a particularly ugly acid green instead of red.

The validity of either of these factoids is questionable however, because I also clearly remember believing when my big brother told me that if I used the toilet when there was an un-flushed cigarette in the bowl, my bottom would turn yellow. Thankfully, my parents stopped smoking – or at least stopped using the toilet as an ashtray – before that happened.

Instead of fearing that there were monsters in my bedroom closet who would creep out after the lights went out, I worried instead about whether I’d be able to see a red fire truck if I was up late, or whether I would remember to check the toilet before using it. I do remember not liking to get a drink of water in the dark bathroom at night because there might be a spider hiding inside the glass. I still maintain that worrying about spiders in the drinking glass is more sensible than fearsome: and still rinse the glass out in the viewless dark before refilling it to get a drink of water.

These days, while I lie away in the sleepless dark I worry about different things.  The glittering arrows of morning don’t disperse my gloomy thoughts about unfinished chores, leftovers spoiling in the refrigerator, the litter box I should have changed yesterday, or my dentist appointment later this week. I suppose the essence of maturity is that we replace our childhood fears with equally scary but more practical stuff as we age. Or maybe we just learn that there is more to fear in the light than in the dark.

Throwing a Shutout

I was talkin’ to my girlfriend

I told her I was stressed

I said I’m going off the deep end

She said give it a rest

We’re all waiting in the dugout

Thinking we should pitch

How you gonna throw a shutout

If all you do is bitch

 - Todd Snider, I Can’t Complain

I’ve been sick. Last night I slept through the night for the first time in about 3 weeks. I feel much better today.

So, instead of bitching, this would be a good day for me to work on the quilt.