Monday, April 09, 2007

My Three Shrinks Podcast 15: POTUS Reading

[14] . . . [15] . . . [16] . . . [All]

Just want to say Happy Easter and Happy Passover to those of you who celebrate either.

April 8, 2007

Topics include:
  • Q&A: from Gerbil, who asks, "I'd love to hear your thoughts on treatment contracts. My specialty is self-injury, and I often give talks on this subject. Invariably, at least one of my attendees will share that he/she has clients agree that they will be discharged if they hurt themselves between sessions. I've heard others talk about making similar contracts regarding substance use, gambling, and other high-risk behaviors. This makes no sense to me--why make the goal of therapy the condition for receiving therapy? ... I was interested in your opinions, especially because of the settings in which you work."

  • Dinah rants about Insurance Companies.
  • Article on Mentally Ill Presidents from Mental Healthworks Newsletter. Nearly half have had mental illnesses. This leads into a discussion about the validity of doing psychological autopsies, or diagnosing someone without personal examination. The Goldwater Rule is discussed in this context (re: Presidents of The United States, or POTUS), as are the APA's Principles of Medical Ethics.
  • Who Reads Shrink Rap? Reader Poll Results: 20% are physicians (13% psychiatrists, 7% others); 9% nurses; 7% social workers; 7% psychologists; ~30% patients; and ~30% others. So more than one-third are mental health professionals, and close to one-half are health care professionals (nearly 200 readers voted).

Find show notes with links at: This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from

Thank you for listening.


sophizo said...

Great podcast as usual. Very entertaining! Also perfectly timed, as it kept my mind off of my pain (had 2 surgeries) while I waited for my next round of Percocet to hit. (Hurry up, darnit!)

I just tried writing a comment on Gerbil's question, but am finding it was too hard to type a long comment with only one arm. Ugh! I'm just going to have to hope that someone else brings up what I wanted to say. Dangit!

Anyways, I also vote for more polls. I always find them interesting and would love to learn more about your audience. Off to la-la land now...

I may have more to say later...

DrivingMissMolly said...

Did anyone notice the poor sound quality this time? Usually, the podcasts are crystal clear, this one sounded like it was in the aural equivalent of a fog. I briefly considered not listening, but such is my love for y'all that I forced myself through it ; )

Also, there's a constant whining noise in the background (mp3).

Otherwise, I really enjoyed listening to Dinah talk at length about "contracts." I thing they're BS, but it is because if I had a shrink that used them, one would probably be foisted upon me due to recurrent suicidality.

I say an emphatic "F-U" to the doc or therapist that hands me a written contract or tries to get me to agree to some BS. It feels like a CYA maneuver and I know and YOU (my shrink) know that I can't sign away YOUR liability! Plus I know that I would NEVER break a promise thus I know that if I agreed to such a thing I would not break my promise. DON'T tell my shrink that!

Roy, it seems that when you say to a PT that you will not treat them if they attempt suicide, you are giving them two options 1) Better use a da*n sure lethal method, and, 2) I will abandon you in your greatest time of need.

I am impressed by the lack of judmentalism (Dinah, is that a word?) expressed by all of you. There is never a trace of disdain in any of your voices about dealing with non-compliant patients or patients that are constantly late, don't show up, or cancel at the last minute. It leads me to believe that you don't see us as "problems" but as challenges, and what a difference there is between the two!

I guess that I have gotten so used to being judged in this big bad world, that I failed to notice that my shrink or therapist may really not be judging me. Maybe they are really in it because they enjoy solving the human equivalent of a puzzle, or at least helping someone solve their own.

That's kind of a big deal.

I guess it is good that I can see borderling traits in my comment, but it is the way I think and feel and I'm working on it.


DrivingMissMolly said...

Last year was the first year that I started using my employer's "cafeteria plan" also known as a "Medical Flexible Spending Account." I have found it to be very convenient and easy. I pay el shrinko, then fax or mail the receipt and get reimbused the full amount into my checking account. At the beginning of the plan year I decide how much to have taken out of my paycheck for medical expenses. Then a third party company looks at receipts and direct-deposits the amount I spent on medical expenses that meet the criteria. Even over-the- counter drugs can be reimbursed! So are expenses on contacts or glasses.

I set aside $1200 this year. The good thing is that it is like a payment plan for MY money. $100 comes out each month then I get reimbursed! Even if I spend the whole $1200 the day after the plan year starts and before even a couple of hundred dollars have been taken out of my paycheck, I'll still get reimbursed! This means I just pay my shrink and I don't have to worry about the large expenditure or have to ask for a payment plan. No embarrassment! I hope that made sense.

On another note, speaking of dreams, the night before my last appointment with my shrink, gulp, I dreamt that....he had me on his lap and was......breast-feeding me!

OMG! I was horrified when I awoke. I can't get that picture out of my mind now!

I guess the operative words in that sentence are; "out of my mind." Shizzit!



Sarebear said...

I too, Lily, really resonated w/Dinah's acceptance of her patients, at whatever place and need they are at. For me, in therapy, this ACCEPTANCE is such a big part of how healing therapy feels for me . . .

Clink and Roy also came across as very accepting (not saying that behavior that is harmful or whatnot is acceptable, but accepting the person and where they are at and working with them), and I saw what Roy was doing and intending with his "deal" or whateveryou callit, with potentially suicidal patients. When he had a private practice or whatever it was.

I also see Lily's view of that, and understand that too.

Anyway, I really enjoyed hearing you guys on this and the other subjects.

I wish I could find a shrink like one of you three around here! I am just entrenched in terror from the last one, but trying and working really hard to push through that because I've been rather more unstable this year, and the situation and meds really need professional attention from the iatriast I find locally (hopefulyl soon!)

I really enjoy your three perspectives. My husband is usually right beside me at his 'puter next to mine, and enjoys listening as well!

Enjoying the med update posts too, even if I haven't had anything to say on them, so thanks for that work, Roy!

Been enjoying the upsurge in posts in the last month or more, especially Clink's increased frequency of posting!

Sophizo, I hope you heal well and quickly!

More polls are good, maybe we can submit ideas on those, too!

Since so many of the readers are patients of mental health professionals, even many of the health practictioner readers, perhaps a question on the avg. age of their mental health provider. Maybe that's a boring idea. Or maybe the avg. age of the readers, w/some 5 year ranges as the options . . . other demographic type polls about us readers would be cool, as well as other types of polls.

When it comes to chocolate, milk, dark, or white? Maybe I should put that one on my blog . . . feel free to use the idea tho, not that you need to!

Ack, rambling. Stop. Go create something. Bye!

Rach said...

great podcast as usual y'all. Where's that poll about which shrink matches which adjective? I can't seem to find it.

Demographic info polls would be very cool. On average, how often d'yall see your patients? Dinah, I think you mentioned in the piece on treatment contracts that if a patient mentioned to you that they were suicidal, you would push up their next appointment... so that assumes you see them how often usually???

NeoNurseChic said...

Lily - I'm glad you've had success with the flex spending account.... Personally, I think that would kill me. They have that as an option at my hospital, but I get the sense from it that there are a lot of things that end up not being covered - especially if you have a lot of health problems and can't set aside enough dollars. With my insurance, last year I spent around $2500...and this does not include prescriptions or physical therapy. I only know this because I attempted to itemize, but I forgot to save my receipts from scripts and PT. I still don't think it would have gone above the required $3900, but still. This is with insurance - the $2500 is built up from copays alone! That's a lot of money... So if I was taking out $100 to pay the neuro nurse practitioner (which is how much it costs to see her - not the neuro himself), I would surely be broke within a few months. I'm not sure if I view the plan the correct way or if I'm misinterpreting things, but I cannot afford to take a chance. I have the best insurance offered by my hospital, IMHO....#2 PPO in the country! They still don't cover jack for mental health, and I pay that out of pocket....which I think is dumb because my psychiatrist went to medical school just like all my other docs, but that's a rant for another day. I tried to save money once before - except this was by going on an HMO - and nearly had a nervous breakdown (I'm serious - not using this as a figure of speech here!) for the 2 months I was on it. I DID go bankrupt, but fortunately didn't declare because I had some shares in stock to sell and I was able to put off paying my rent until my loan money came through, but it was still the worst experience ever and the problems followed me around for nearly a year after I got off the insurance. No more will I gamble with the unknown when it comes to health insurance. Got burned by the fire once. I'll wait for everyone else to test out the waters with the flex spending accounts....and I especially want feedback from those with expensive, chronic health problems that use it.

As for the podcast - planning to download it now and listen while I take a walk to get some dinner! I'm in the mood for Chinese tonight, and it was nice enough earlier to take a walk - though now it's into the 40s. I love living in a small town where most everything is within walking distance. :) Good for the soul. :) Will post my own comment on the podcast later!

Take care,
Carrie :)

Midwife with a Knife said...

The problem I see with medical flexible spending accounts is that you can max them out and then be seriously screwed. If a traditional insurance plan kicked in after the first $1200-$2500, that would be great, but maybe I don't really understand how they work.

For example, if I had a $1200 FSA, and then, say, hit my head, and say, had a $1800 head ct +$500 ER visit, would I end up having to pay the $1100 over the $1200 FSA? Because that could get pretty bad if you had one medical catastrophe (I think an appendectomy probably runs $10k).

Also, what's your take on pain med contracts for patients with chronic pain and a history of narcotic abuse/misbehavior?

Anyway... nice podcast, guys, as usual. :) I didn't notice any audio problems like DMM did, but I listen to the iTunes version.

Midwife with a Knife said...

p.s. your blogroll seems to have disappeared. Or maybe it's just me... but I don't think it's there any more.

Midwife with a Knife said...

pps word verification: upuyuak: what happens when you eat bad mayonaise. ;)

Rach said...

As much as I dislike the Canadian Health Care model at times, I don't think I'd remain sane having to deal with paying for my psych visits, sports medicine guy, PT, etc.

I really wonder if the standard of care here in Canada would be higher if we all paid out of pocket for care like in the states.

On another topic, in your opinion, how long does it take for a shrink to become competent after they graduate/ finish their residency?

NeoNurseChic said...

OK I listened to the podcast through Roy's comment, "Can't she just pay for the lab work out of pocket and be reimbursed?" or something to that effect. The first reason I stopped was because I was back at my apartment with my Chinese food (now you know how long it takes to walk to (not from) the local Wawa and to and from the local Chinese place! as if anyone wanted to know that..ha!), but the 2nd reason was because I had to stop and ask my empty room (and my cat) if Roy was serious with that question! I didn't listen any farther yet...but still... I'll be frank here about something rather personally disturbing - for the past 2 months my bank account has gotten as low as $200 and $400 respectively....without my even buying groceries. Am I going to pay for a $75 lab test up front, even if it's VERY important, and wait for reimbursement? No... I don't think I'm the only person in that situation, either! (And now most people would probably ask why I went out to eat dinner, but I refuse to feel guilty about $4 spent on Chinese food...)

My point is that paying up front and out of pocket just doesn't work for everybody - and that's why medical flex spending accounts don't work for everybody. You've gotta set money aside to be taken out of your paycheck monthly, sure - but on top of that, you have to pay for things out of pocket, send in the receipts, and then get reimbursed from the money you've set aside. Am I the only person (well, obviously MWWAK sees some problems with this, too) who sees this is the perfect way to screw the person who suddenly has high medical costs? If you haven't set that money aside, well...too bad! You should have planned ahead for that! That's essentially what they're saying.

When we think about insurance, we talk about risk. People who are healthy and elect for minimal insurance coverage to maximize savings are taking a risk. They are playing the odds that they won't get hit by a car while crossing the street tomorrow. The insurance companies hope that you'll plan for getting hit by the car, but that you won't actually get hit. The medical FSA is an exaggeration of that risk - it's beyond normal insurance risk....we're talking like, go to the casino with your life savings type risk. That's how it looks to me, anyhow!

In terms of the contracts, I can see both sides. Before I listened to the podcast, when I read the topic at hand, my immediate reaction was, "How the patient breaks the contract by attempting suicide and then the shrink they've built a relationship with refuses to work with them. That sucks." But then I listened to the arguments. In a way - I can see what Roy is saying...I just want to know if he actually had to follow through with that. I'm someone where, if my psychiatrist threatened not to work with me for attempting suicide (I say threatened cuz it kinda is a threat...."If you do this, I won't work with you" is a threat, not a contract), then I probably would work pretty hard not to violate this - simply because the loss of the relationship would send me over the edge. I don't think this asks the patient to "heal thyself" - I think that it's an attempt to prevent the patient from doing something extreme...but it comes down to the bottom line. If the patient violates the contract, do you really immediately boot them? Or will you work with them the first time? For some people, abandonment/rejection issues are so extreme that having the doc refuse to work with them would be really negative. I think asking the patient to come in more often or be hospitalized if they can't promise they won't hurt themselves is not the same as a contract that you won't treat them if they do these things. The first doesn't imply that the relationship will end if these things aren't met. And if the patient can't promise they won't hurt themselves and says they aren't available to come in for another appt in a week and so on, well....maybe it's time for an inpatient stay whether they like it or not. But a contract that will ultimately result in refusal to treat is not the same as asking the patient to do things they may not want to do, and may not do, but you'll continue to work with them anyway...

All that being said, I see where contracts are useful. Perhaps with people with borderline personality disorder, in particular (no offense to those with this...) - and I'm just going off of the borderline type that I see a lot at work via narcotic addiction recovery. We contract with the mom's at the clinic regarding behaviors while they are visiting their baby. Unfortunately, if they break the contract, there isn't really much we do. We're trying to be a little better - we have a report sheet that will go to their center, so if they do violate, it's imperitive that we actually write it on the sheet...or else nothing really gets done. I'll admit that I haven't written anything on the sheet yet, but since we've implemented that, we also haven't had any major issues like we were having awhile back. I was happy we had the contract, but it's not so personal as a psychiatrist refusing to work with a patient....

Regarding narcotic contracts, I think it needs to depend on the situation. For recovery/addiction issues, I think a contract is more important. For those with chronic pain, I don't think a blanket contract should be laid down. (consider my biases...) I think an automatic contract for a chronic pain patient NOT showing any risk signs of addiction or abuse sets the stage for trust issues. I truly believe that in chronic pain, a good relationship with the treating physician(s) is more important than ever. I know that when my first neuro left and I started off on a rocky road with my 2nd, I actually went to the ER more and was more depressed (which consequently made my pain worse)...all because I felt that he was unavailable and not really listening to me. My first neuro would jump right on prescribing a steroid taper or at the very least call me on the phone to see what was going on if I emailed/called. Now this wasn't a pain management issue in terms of narcotics - it was just a pain management issue in terms of pain and other meds I was on (prevents) - and the relationship played a huge role in my treatment/functionality. I don't place responsibility for my treatment/pain on my doctor - I think a high external locus of control/low internal locus of control can be a problem in chronic pain syndromes, but I still think the relationship plays a huge part in things, and making a patient sign a contract that is designed for those who would abuse narcotics when the patient isn't showing risk signs for addiction/abuse of narcotics is a barrier. However, if the patient starts to show any signs (loss of scripts, needing refills too soon, not coming in for monthly appts, repeated visits to the ER and other providers, etc), then a contract is warranted.

Sorry for the length. I think at least most is relevent! Probably won't listen to the rest of the podcast tonight, but maybe tomorrow!

Take care!
Carrie :)

Anonymous said...

Roy, thanks for being the podcast king.

To all: that noise is my refrigerator motor. (I think, I didn't listen to the podcast).

Narcotics/chronic pain: I don't prescribe them, so I stay out of it. I see a number of patients with chronic pain issues on narcotics-- I'm not aware that any of them are abusing/selling/escalating their doses. As long as I'm not asked to provide them, I leave it to the patient and the prescribing doc.

Carrie: Where do you get chinese food for $4?
The pay for labs question-- I sent my husband to get a CBC done after the Red Cross wouldn't let him donate for a low hematocrit. The lab wanted to send him away because they don't take his insurance. The reality of his life (--he commutes to Philly every day, time is short here) is that it would have made more sense for him to pay for the CBC ($12) then to spend his saturday searching for a lab that would take his insurance, yet the lab didn't even offer him the option and he didn't know to ask "Can I just pay for it?"). The lab finally decided that the insurance probably would pay (they did) and took his blood. This was the podcast issue (I think), I lost track of the flex spending discussion. This is all pretty complicated

Violet said...

Rach: I think we would get better care if we paid the doctors directly. However, I would probably just give up seeing doctors if I had to pay for it, unless it was reimbursed. I haven't seen an opthalmolgist since Ontario delisted eye exams.

I'm not sure why I think we'd get better care, maybe because doctors would probably be more accessible, since there would be fewer of us going to doctors, but I'd likely be one of those people who wouldn't get any medical care anymore.

Anyway, I do like not having to pay, even if it is extremely difficult to get doctors to listen to me. I should just try being more demanding, though the one time I tried that I was told to find myself another doctor. And it's not like I was rude or anything, all I did was tell her that I really was depressed, and I needed help. She disagreed I guess.

Midwife with a Knife said...

I wouldn't think that you'd get better care for paying doctors directly. In my experience, even patients who have Medicare/Medicaid (our government sponsored health insurance for the old/poor/disabled/etc.) get excellent care. I never think about whether a patient has insurance or how they pay when making patient care decisions; we decide what's needed and have the social workers figure out how to get it paid for. Our patients who don't pay get the same medical care as ones who do. People with insurance, people who pay privately, people who can't pay all get the standard of care (often more than the standard of care). The biggest differences are things like you can't have tv and phone service in your room unless you can pay, and our non-paying patients end up getting seen in an inefficent clinic and may have longer waits, and don't see the same doc all the time. I'm not saying that that's right, but it's not as bad as most people from other countries with real health care systems imagine.

This may be easier to do during pregnancy, because it's always easy to find a way to get stuff paid for; and working in an academic institution does free you from the reimbursment chase a bit (although it pus you in the research chase).

sophizo said...

Since everyone keeps bringing up FSA's, I wanted to set the record straight. The only benefit of FSA's are your tax savings. Whatever you set aside doesn't get taxed. That is why you need to have a good idea of what you are going to spend that year so that you can end up saving hundreds to thousands of dollars of taxes from being taken out. Google an FSA calculator to see what I mean. Being allowed an FSA is a great thing in my opinion.

I really wish I could type!!! Argh!

Violet said...

MWAK: I meant in Ontario, because my (former) doctor wouldn't refer me to a psychiatrist. If I had enough money I could go to a psychologist, but no referral to a psychiatrist (who would be free). We have reduced access because it is free.

It depends on the PCP though, because some don't have problems making the referrals. And when I went to a hospital I was allowed to speak to a psychiatrist, but I only got to speak with him that one time. Not that I went back to try to talk to him again, he made some referrals for me, so I'm just waiting.

Anonymous said...

[aside] I would like blogger to give us a bigger comment box![/aside]

Hmm patient contracts is an interesting topic. My professional experience with this sort of thing is in relation to methadone contracts at pharmacies - these include clauses on behaviour while in the pharmacy, timing of visits, the deal when scripts expire/patients turn up intoxicated/doses change/payments etc.

These sorts of contracts help us to identify patients who are struggling and also make sure pharmacy staff are protected both legally and (to some extent) personally.

Although all patients sign these contracts before they are allowed to dose at the pharmacy, we only make use of them when we have problems. For example, the contract states that dosing times are 8:30-10:30am and 4-6pm. In practice this is rarely adhered to. In the context, it really doesn't matter to me what time they come in for their dose. I try to serve everyone (methadone or other patient) in the order they come - they just may have to wait longer if I'm busy.

However having a contract that a patient has signed with these times on it is useful for me when an abusive and complicated patient repeatedly turns up 10 minutes before closing, with $500 owing and no valid prescription, blaming me for everything that is wrong in their life - I have a piece of paper that the patient has signed, detailing the behaviour required on our program.

I think the reason it works and we have a mile long waiting list, is that the pharmacists are willing to do what we can to help a patient stay on the program. The contract is a useful standard for when we have serious behaviour problems. It's probably also worth noting that patients who are expelled by us, are transferred to the closest hospital clinic dosing centre. They aren't just left in the gutter.

As a patient... well I think that I can see situations where some sort of contact would not be out of order - my doctors both always have emergency waiting lists - if I can't make it to an appointment at the last minute, that appointment will be extremely valuable to another patient. If I turn up to my appointment in the nude, that may be disturbing to others in the building (not to mention myself!). If I threaten my doctor or receptionist or don't pay my bills or regularly turn up late and expect a full consultation... all these are behaviours that a doctor can reasonably request a patient refrain from.

When it comes to treatment-related contracts... hmmm tricky. I am not a particularly compliant patient. And my honours project was on the topic of compliance (hah!). I think that a certain level of co-operation can be required of patients. But there's a difference between ceasing a medication because the side effects are driving you nuts and simply not taking it because you don't like the idea of taking medicine. When you seek medical help, I think it could be reasonably assumed that medication may be a part of your treatment. The same principle can probably be applied to some branches of therapy.

Gerbil said...

Woo-hoo! I feel special!

I suppose, though, that before I go feeling too special, I should download the podcast. Oh, and maybe also listen to it...

Midwife with a Knife said...

violet: Oh, I see now. My brother (who's an economist) has a fancy term for this, but it essentially means that anything provided by society for which the individual doesn't pay their full cost at the time of service will be overused if unregulated. Like how farmers will over-graze public lands if unregulated.

DrivingMissMolly said...

Sorry for the misunderstanding, but I have medical insurance (PPO), AND use the FSA for unreimbursed medical expenses such as co-pays or necessary medical stuff that either isn't covered or isn't completely covered. This money is also pre-tax so I don't pay income tax on it.

I use it for co-pays, my shrink, and this year I know I will be using it to get my wisdom teeth removed (yeowch!).

It worked out well last year when I only had $600 taken out, but I used that all up within a couple of months!

You MUST use the money within the plan year or lose it, so you have to be careful. I knew a man who budgeted for lasic, then found out he wasn't a candidate (pupils too large). He had to hurry up and buy glasses and contacts to use the money he had budgeted before the end of the plan year.

I found the list of reimbursable stuff pretty inclusive. I can get my Prilosec, Advil and other OTC reimbursed. Stuff like teeth whitening products and feminine hygeine products are not covered, however.

Once you start the deduction, you can't stop it, just like other changes such as health insurance which can only be changed during "open season" or a life changing event such as marriage, divorce, or birth of a child.

Your human resources department would be the best place for more info.


NeoNurseChic said...

Dinah - I think it's called China King, but the menu is in the drawer in the kitchen, and I've already come to my room for the night! I got a small order of sweet and sour pork (with white rice) for $4.19. ($3.95+tax) Not bad at all! :) I think you can look my town up based on sitemeters/google analytics, but if you're ever up in Philly and want a list of new places to try that are a train/short walk away, let me know! There are some very nice ones close by - all ranges of prices. My town is great for me (recent college grad/just starting out) because even though it's smack middle of the Main Line/Lower Merion School District, it has areas that are not reserved for the super-wealthy. My apartment complex is so nice....I pay more than I would like, but it is worth it - they keep the place up well, and it's so close to everything I need. Much better than my commute into the city from Downingtown, which is where I'm from. (Gotta love Downingtown,'s the home of the Blob diner...even though they tore the diner down a few years ago!)

I meant to ask - was the lab a qwest diagnostics lab? (sp?) I went there once with a script from the doc, and they got all huffy that it wasn't on their particular lab slip. One thing that annoys me is when I go to the doctor and they automatically fill out the Qwest slip. I prefer to get my labs done at my home hospital so that I have access to my results (and can print if they are not sent to the MD) and can get it done while I'm at work. I also like that all my labs are done at my hospital so that I can see the trends - my doctors don't have to wonder what this level was like a year's in the system. All my radiologic films are done there, too...and because of the AVN, I have a lot of those! With my insurance, I don't pay for bloodwork. I'm not sure if I pay if I go to the "wrong" place once I have a script. I always go to my hospital, and it's free if I go there. It's also free if the doctor draws it in the office. My internal med doc has labs drawn in her office, and I never paid for those via my plan. My health insurance is also pre-tax. I don't use the FSA, but I think when you do that, you have to use that exclusively...can't have the PPO as well...but I'm not sure.

I used to run into regional problems when I lived in State College. (Penn State) One of the things that happened was I had a few emergency room visits - one for extreme hypotension on verapamil (60s/40s...woot) and a few for headache, including my first full-out cluster headache. I was on a PPO from my mom's work - and she works for a public school district, so it was good insurance...same thing I'm on now, but cheaper copays. However, the hospital in SC was out of network, but emergency visits are covered. They paid for one headache visit, and then another one awhile later, they did not pay. They said that it didn't qualify as an emergency.

This prompted a few hilarious phone calls with reps in a big tall building in Center City Philly...(you know the one...) First, the guy tells me that in the future, I should go to a hospital that is in-network. I tell him that there is only one hospital in Podunk, Pennsylvania, and he says, "Only one hospital? What kind of place is that?" hahaha.....never been outside the city much? mom and I both get on the phone with another rep to continue to try to fix the problem. Now, I will admit that I tend to have a bit of a short-fuse at times when people are giving me a hard time over the phone with things. Not people I know.... Just like, when I have to call the insurance company or the repair people at Dell...things like that. I know it's awful, but I can't help myself...and once I start, I can't stop myself either. I'm definitely ashamed. But at any rate - this guy starts in on the whole "not an emergency visit", and I say to him, " is it not an emergency visit? I went to an ER....and it was paid for before." He says it's not listed as an emergency reason to go to the ER (uhhh...headache is not? what about an aneurysm? SAH? nobody with severe headache should go to the hospital because it's not an emergency? hooo baby don't get me started!) So then I say to him, " there a LIST of things that are not an emergency visit?" He says no, that these are declared by the insurance company after the visit. So then I say, "Well...if some things are an emergency and others aren't, then there is obviously some list...and I think we should have every right to have the list of things not deemed an emergency, so that when that emergency pops up, I can die instead of going to the ER for it." My mom is shooting me death glares at that point. I can't help myself.... *eyes rolling*

I got my firey tempered self from my father and my Irish grandmother. It's funny because in most cases, I'm completely non-confrontational and avoid conflict at all costs, even if it means being miserable just because I don't want to have what I want be an annoyance to somebody else. But there are times when I just snap.... Anybody see the movie "Anger Management"? That movie resonates with me...I think Jack Nicholson's character says that there are 2 kinds of angry people - there are those that snap right away at everything and there are those who hold it inside, are overly polite to everyone, never say what they want, and then explode when the kettle finally gets to boiling point. I can't remember how he says it. But I'm the latter type. Makes life...interesting!

Take care,
Carrie :)

Roy said...

Thank you for all the comments.

I added a filter to quash Dinah's fridge motor, so it did muffle our voices a tad. Next time, Dinah, we either go to a different room or unplug the fridge.

Lots of thoughts on tx contracts. Thanks. Re: FSA's... here's how mine works. I have a PPO *and* an FSA. I pay my portion of the premium for the PPO, and pay co-pays, which I then submit to get reimbursed by my FSA. Since the FSA money is pre-tax, it's like I am paying 60 cents on the dollar for a copay. Also, since the separate monthly RX premium was $150, and I'd still have to pay RX copays, it would have cost us over $2400/yr for meds (that's AFTER I would have had to make $4500/yr to have after-taxes $2400). Fortunately, our meds are only ~$200/mo. So, I set aside $2400 PRE-tax money, and that is used to pay for our meds. Since my take-home on $2400 would be around $1500, I am only out $1500 for $2400 worth of meds. THAT's the value of an FSA. They are almost always paired with your regular medical coverage (as compared with an MSA or an HSA, for which it all comes out of the account, and catastrophic costs are covered by a high-deductible health insurance policy).

Oh, and paying your doc *directly* would probably improve health care, as your doc wouldn't have to hire an army of clerks to track down the money, thus she wouldn't have to see a pt every 7 minutes just to make ends meet. Also, the closer you pair a stimulus (money) to a response (health care service), the more the response is affected.

Think about it... try this experiment: Tell your hairdresser that instead of paying her full price (and tipping her) after each hair visit, you are going to give her only 50% of what she charges everyone else. But in return, you promise her that you will ONLY go to her for all your hair needs. Also, after each visit, she will have to fill out a form to request her payment, mail it somewhere, and she may have to make a few calls or resubmit it occasionally, and then her money will arrive within the next three months (unless she uses the wrong hairstyling code). Try this experiment, and then tell us how you like your hairstyling visits -- and the results -- over the next 12 months.

NeoNurseChic said...

Roy - Thanks for writing that comment....when I say medical FSA, I mean HSA. That's what our hospital has.... We also have the ability to use an FSA, which I have not taken advantage of, but should - and perhaps after I meet with this financial advisor (upcoming...once he returns from vacation), I will setup an FSA when the opportunity next rolls around. At our hospital, for insurance we have an HSA, a BC PPO, BC HMO, Aetna POS, Aetna HMO. I don't think I could ask for anything better than those options, aside from working for the government! We have an additional clause on our insurance, however, which is that the copays are different if we go to providers in our hospital system, versus providers that are still in-network for whatever insurance, but not in our hospital system. For hospital stays, if you go to an outside hospital, there is a $2000 deductible and then you have to pay 20%. I had a hospital bill once that was $100,000 (oh....I didn't get that bill - the insurance did!), and if I was at an outside hosp, that means I'd pay my $2000 and then 20% of that - couldn't do it! My AVN doc is in a different system, and now I can't go to him any more. My hospital has the best orthopedics department in like, the world, but they don't have specialists in AVN. I trust them, but I liked my AVN doc - however, I couldn't afford further surgeries at the outside hospital with the current plan. It's a high incentive to stay within the system for major things! I do have a few docs in other systems, including my OB/Gyn (annuals are free with our ins....and when it gets to the point where I need the OB part, I'll have to go high risk anyhow, and will come inside the system), psychiatrist (I pay out of pocket - but a VERY reduced fee...), and rheumatologist (no biggie - don't need hosp care, so it's just $5 more for the copay...).

At any rate, thanks for differentiating between regular FSAs and HSAs.

Re: payment. It's all about who has to suffer up front, isn't it? If the responsibility is on the patient to pay up front and then be reimbursed, then fine - but they have to be able to afford the up front costs without taking out a 2nd mortgage. And because medical costs are so inflated due to restrictions placed by medicare and insurance companies, the average person cannot afford to pay up front. Until the prices come down to a reasonable level (I'm not blaming docs for the inflation - everybody is at fault on some level...), most people cannot pay up front. One appointment is fine. But for everything? It can take awhile for the reimbursement to happen.

I know this is awful, but when the insurance pays, they pay their percent. If you have a kickin insurance like I do, then you don't have to pay the difference. If you don't, then that's unfortunate. (What I will have to do when I go to the dentist in May...) But far better to pay the difference than to have no insurance coverage at all. If I had to pay up front, then the insurance company would only reimburse ME at whatever low percent. What really burns me up is that insurance companies can say they will only pay X% of the costs, but get somebody without insurance, and they can't say, "Sorry folks, I'm only gonna give ya 50% of this one!" Oh no...the hospital/doc/whoever will go after them for 100% unless there is some forgiveness. It's not very fair, is it? I'm talkin people who can't afford insurance - not those who can, but choose not to have it. Those people irritate me because they end up costing the rest of us a lot of money, when they could have afforded insurance but chose not to.

Now - why is it acceptible that patients shouldn't have to take the hit up front and docs should? Because patients are sick, they are vulnerable, and because doctors took an oath to care for them. Sure, when a kid says they want to be a doctor, they don't even have an idea about the insurance, paperwork, financial stresses of the entire field. However, I think that if there's a compromise on payments, better the patient can still kind of afford their care (so they aren't left dying or a lot sicker), in my opinion.... Feel free to disagree! :)

I believe health care is a right, but right now it's like half right/half privelege.... I don't believe that health care as a right should mean that doctors should be undervalued and payed nominal amounts. They are professionals who have worked long and hard to become experts in their field, and they deserve to be treated as such. As you say, we pay the hairdresser 100% without thinking about it (my hair dresser gives me a deal....aren't I lucky? haha), but if we had to pay 100% of medical costs, we'd be up in arms. That's because they're so much more expensive, and health care is like food. Nobody should go without, right? Health care, food, shelter.....for now, they're lumped together in most people's minds. I don't disagree. But I think our professionals deserve to be treated as such. If docs came down on prices right now, then insurance companies wouldn't pay them as much - plain and simple. There would have to be some agreement...a sort of, "I'll jump if you will..." (sorry for that!) If docs were to lower prices, then insurance companies would need to agree not to cut the percents they pay... Everybody would need to compromise. But since nobody wants to do that, we spiral further towards ruin.

Ohhh I have too many thoughts on this topic! After my HMO disaster back in 2004, I learned a LOT and have been rather outspoken on this topic. But it's really time for bed!

Take care,
Carrie :)

Anonymous said...

Roy, I read this and it occurred to me that my entire family's medication out of pocket costs are less for the year than my hairdresser. Umm, much less...all those chemicals. Oh, I didn't figure Max into this, but I think still....
It kind of irks me that I pay a fortune for the hairdresser and am still expected to leave a big tip. And now she has me using some caviar conditioner to compensate for all the chemicals....
Can I get a tax-deductible hair care flex spending account?

Rach said...


I think part of the problem with Ontario's health care system is that FD's are quick to refer out a) to take work off their own hands and b) to give other people work. The truth of the matter is that if a person is ill enough they will pay any amount of money to get better.
In the case of my own psychiatrist, I've calculated that it would have cost me about $40.000 over the last 11 years. Am I glad that OHIP covers psychiatry, most definitely. Would I have paid the money if OHIP didn't cover? yes. But then again, I'm the exception to the rule, rather than the rule itself.

DrivingMissMolly said...

I think that unfortunately, people got used to paying very small co-pays. Manged care was a good idea at first, but the "managed" part has gotten out of control. However, if there hadn't been so much abuse of the fee-for-service system, managed care would not have been needed. It also hasn't helped that costs associated with medical care have skyrocketed more than anyone could have anticipated.

People are going to have to take responsibility for their health care and how their health care dollar is spent. I think this is a good thing, it's just that we as Americans got lazy.

I have a friend who has no medical insurance yet has a huge house. Other people would rather spend money on SUV's, fancy vacations, and huge houses rather than set aside money for health care expenses. I do not begrudge the $190 per session I spend on my psychiatrist. I am grateful that my therapy is free since I work at a University and my therapist is the counselor. I figure I am still saving money because weekly therapy would add up to more than $190 a month.

When I see my doc, I get about one whole hour. I'd rather have that time with him than the 5-15 minutes I had with my psychiatrists when I paid a cheap co-pay and my insurance paid the rest. I mean, how do you treat MDD and borderline and GAD in 5 minutes?

Also, we all know that the illnesses that are killing Americans are PREVENTABLE! I am saying this and I am overweight, but I am trying to lose weight. Even though I have bee acutely suicidal, I have no desire to meet my demise by stroke or heart attack.

RANT: It has recently started to make me RAGE when I hear of a sick kid with some weird illness or twins conjoined in a weird way from another country come here and get everything free. Yes, I realize that surgeons are learning important things and that they do wonderful humanitarian work, but when so many kids here don't have medical insurance or get inadequate care, I think it's almost a crime. Yes, I know charities contribute to costs, but what about our poor kids here?


DrivingMissMolly said...


I would like to apologize to you about what I feel was an unfairly judgmental comment that I made about "contracts."

I listened to the beginning of the podcast again and it is clear to me that you would not terminate the patient *unless* they did NOT give you a chance to intervene.

That makes more sense to me and I do see how the threat of losing your doc can make one tow the line.

I spoke more out of my emotion than reason because I did have a therapist terminate with me after a suicide attempt. We did not, however, have any kind of contract or agreement. I have had three therapists terminate me and although this was many years ago, it still hurts. I did not have a contract with any of them and have never had a psychiatrist fire me.

Last summer I did call my doc after taking 10 times the normal dose of a drug. It was hard to stop and pick up that phone but somehow I did it. Speaking for myself only, of course, when I am suicidal I get into a kind of "zone" and it is hard to interrupt bad behavior like cutting. It is even hard to see my behavior as bad! My life was also saved by a woman at Hopeline and by my doc when I was in possession of loaded weapons.

It is scary, now that I am not in that "zone" to see that by a razor's edge only am I here today( no pun intended!).

So, a couple of questions/things to contemplate.

1) Have any one you used a psychiatric advanced directive with a patient? Unfortunately, one would have to write that up BEFORE the person is/gets in crisis, but it makes sense, being a positive mandate rather than the looming threat of being terminated.

It would seem that if one believes that committing suicide is the act of a mentally ill person, one cannot hold someone accountable for something they did while not sane. Maybe I am getting the legal and medical definitions of insanity confused.

2) Has a patient ever asked YOU to enter into a contract? Yes, I know this is crazy, but I tried to get my doc to "promise" he wouldn't die or leave me (he is 62). He, of couse said "no." I told him to "pretend" that he could promise that and he said "no, because you would get mad at me later for lying to you." (sigh)

3) Does the "I will terminate you if you kill yourself without giving me a chance to intervene" rule come from a desire to avoid a patient "breaking your heart," and if so, is that professional?

Also Roy, I mentioned the lack of aural clarity on the podcast not so much as a complaint as an observation because I know you'd want to know. I listen on headphones which might explain my hearing that which others don't.

I (heart) all of y'all!


Violet said...

Rach: I think you are an exception. But $40,000 over 11 years isn't terrible if you have some extra money and it helps. I don't tend to have that much extra money a year.

I'd never met a doctor who was quick to refer, mine have all acted like it costs them personally to make referrals. I know people whose doctors actually send them for treatment though, so I know those doctors exist.

NeoNurseChic said...

Managed care in America was designed to mimic the NHS in England, but without the government intervention. Theoretically, people would go to their primary care doc for everything first. They would have a named primary care doc, so that doc would build a relationship with them and really get to know them. They would treat everything within their power, and when things went outside their realm, they would refer to specialists, who act as consultants - not "rush to right away". However, managed care insurance companies didn't play fair, and the reimbursements for this were awful. Plus patients couldn't get things they really needed. In the NHS, patients sometimes have problems getting things they need, but NOT like here in the US. Helen uses liquid oxygen, and I tried to see if I could get that (on my excellent insurance!), and there is no way I can. When I was on the HMO, they didn't cover DME (Durable Medical Equipment), but I didnt' know until I got a bill 2 months into it for $800 worth of oxygen equipment! They also didn't cover like 4 of my meds. They wouldn't cover a dexa scan, even though I was on steroids constantly. (Actually the hospital wouldn't even schedule it for me because of my insurance...) I also didn't get MRIs of my knees because I couldn't get them at my home hospital (where the insurance was based out of...) Because my primary care doc was near my parents' house, I was required to go to a single radiology place out near them, and I was a nursing student living in Philly and the insurance was through my university. So I didn't get it until I was off the HMO - I wouldn't have known I had AVN until even LATER stages had I stayed on the HMO!! Also, the headache center never seems to have the referrals - I don't fault them but it's like they don't receive them or they are constantly misplaced. My family doc would enter the referrals into an electronic system on the computer, and I'd check with the headache center a few days before my appt (because I knew they constantly couldn't find peoples), and they said they have no access to the electronic system. My family doc didn't want to fax it over, but they did - and even then, it got lost a few times. I used to take a train out to my parents' house (hour train ride), pick up the referral by hand and have my parents drive me back in late - all on a weeknight when I should be studying...just so I'd have the referral in my hand when I went to the appts. This is only the corner tip of the hell I experienced on an HMO..... I still feel anxious when I even think about that time!

Every time I read the comments on this blog, I feel very lucky about the situation with my psychiatrist. Prior to starting nursing school, I saw the psychiatrist at the headache center, and his reduced fee was $125 an appt, which I could not afford. A good friend of mine was chief resident, and she asked a 3rd year if he would see me for a reduced fee...she told him a little about me, and then said she would never know another thing about my psychiatric care. (She'd actually been my doctor when I was in the hospital once - while she was doing her neuro/headache rotation - but we became friends and still keep in touch!) I originally just needed a doc who could prescribe my concerta. However at my first appt, my psychiatrist asked me how much I could afford to pay so that I could come once a week. And a few months ago, he wanted me to start coming 3 times a week. I cleared it up with him that it wasn't because he was worried that something was wrong with me, but it was more because he felt that more consistent work would really benefit me - and it does. First off, it gives me a reason to get out of bed on my days off. I know that sounds awful, but if I don't have anything, I just stay in bed all day with the lights off and the blinds closed. At least with the appts, I HAVE to get out of bed - which then often leads me to actually run a few errands while I'm out, or get up and do other things later in the day. Although a lot of times, after appts, I'm really tired and come home and take a nap. Yesterday I took a 3.5 hour nap after my appt!

A month or two ago, I told him that I couldn't afford to come 3x a week. I said that even though my fee is reduced, I still have to pay like $15 for parking every time, which jacks up the price. When I totaled up the amount of money over a month, it was more than I could budget if I wanted to save a dime. However, once I did that, he said, "well...maybe you can come more often again soon..." And then I had a bad week like 2 weeks after I said that and asked him if I could come a 3rd time. So much for that idea! As of yesterday, I just had the appt yesterday and one tomorrow. And what he did was pretty cool. He asked if I could come another time this week, but I work 7-7 on Thurs and Fri, and was supposed to work 11a-11p today. I said that I might have 11-3 off, but wouldn't know until 10am today. So he said, "Why don't I put you down for 12:30, and if you have to work, just call me by 11 and we'll cancel it." Not many docs would do that!! I had the vacation, so I ended up going!

I show up late a's not because I want to. Getting there late makes me incredibly anxious. However, with how crappy I feel (physically), a lot of times my mornings just don't go how I want them to...or I have no energy and just can't get started. I leave later than I want to or get stuck in traffic. Today I got there 10 minutes late (I always call on the way to say I'm running late...and I always apologize once I get there), and he still gave me 50 minutes. Lots of times, if I'm just running late because of my own accord or traffic, he still ends the appt at the same time, but doesn't get mad or anything. (Don't know if he is annoyed inwardly, but he's one of the most laid back people ever, so I almost doubt that he is annoyed!) But if it's because of a problem at the reception desk or some other reason (depending...), sometimes he gives me the whole time from when I show up - if he's able. Once I kept getting billed incorrectly for $85, and I had tried to take care of it on my own but been unsuccessful. After getting a 3rd bill, I said something about it in my appt, but I wasn't saying it to complain to him or ask him to do something. The next time I went in, I had $0 balance. He's done a few things like that to help make my life easier. Not many people in my life do things to try to make my life any easier, so I can't say how much I appreciate it! Even those little things make such a big difference to me because I'm not used to people going out of their way to help me!

As far as feeling suicidal (and then I'll stop rambling!), last July when I had a reallllllllly bad night where I truly was the closest to ODing on everything stored in my medicine closet (keep in mind, I've been on over a hundred meds, and over the last few years, haven't thrown a single one out - mainly because it's a waste of money and I may use it again in the future - but I won't's also because, well, if I couldn't take it anymore.....). I was talking to a friend of mine who I knew I could trust to not call 911 on me, but he was strongly encouraging me to call my psychiatrist. I was crying so hard.....I've only really felt that personally distressed on a few occasions ever. I would start to dial my psychiatrist's pager number, but then hang up before I finished. I couldn't imagine what I would say if he called back. He would say he was returning my call, and I'd say what..............? I couldn't imagine saying, "I'm feeling suicidal" and then having a discussion about it. I was too upset to really talk much anyhow. And it seemed dumb to me to call with no real reason. I know now that I had a major reason to call, but I felt I couldn't at the time. I was also afraid that he would put me in the hospital, which I felt would be the absolute worst thing for me, ever. When I went in for the next appt (well, the next several we discussed this and sometimes still discuss it), he made it clear that I could always call him. He said I couldn't imagine the conversation because I've "never seen him in action", but that I should always call him if I feel that way. He didn't make a contract or say he'd not treat me if I didn't call him. If I feel that way again in the future, I don't know if I will call. I can say now that I will, but when I get like that, I internally shut down - I don't want to talk to anyone because I feel it's too pathetic and I shouldn't bother or burden them. I KNOW that it would be a bigger burden if I do something and don't try to call them and get help first. But when I get like that, I don't think that way. It's like my brain is different. I can't promise I'd call, but I would always do my best to TRY to.......but I couldn't sign a contract to that effect. I might sign it, because I tend to be very compliant and someone who wants to please everyone around me, but it wouldn't be true to how I really feel. If I was being truthful, then I would say that I could not promise that. Don't know what one would do if I wouldn't sign a contract. Fortunately he doesn't make me.

Regarding what people have said about you guys being very accepting - I think that's the best thing about my psychiatrist. He said to me today that maybe the thing I like best about coming there is that he listens to me in the way I try to listen to other people. I always feel like nobody listens to me - or else they just get annoyed because I say too much or take a long time to get out my thoughts. But he really, truly listens. It's definitely part of why I like going....

OK I'll stop! Sorry...I get going and I just have lots of thoughts!

Take care!
Carrie :)

P.S. Anyone else notice that anymore, even if you put the exact correct word verif in, it still makes you do it twice automatically? It happens to me every time, even when I know I typed it correctly!

Sarebear said...

if it takes you too long to write a comment, it'll do that, like your original one "expired" or something. More like the system doesn't remember the one it generated when you first loaded the comments.

I do somewhat long comments too, and so that happens to me often. Lol.

Roy said...

No problem. I took your comment in just that way, so I was not hurt by it. Thanks for taking the time to listen again and hear what I said (it's so nice when I actually say what I mean, rather than Bushing it up).

Psych Advanced Directives in Maryland are not really worth much right now. I had a pt with one, which stated "when I get real depressed, the only thing that works is ECT and I agree in advance to it, no matter what I say at the time." At the time, she wasn't saying much at all... catatonic. Hospital attorneys told me we could not use it unless she gave informed consent at the time (couldn't) and no family to help.

Break my heart?? Does not compute. No, the few times I've done this, it has been after serial attempts, and we both agreed that such an arrangement would help provide an additional external locus of control.

NeoNurseChic said...

"Bushing it up"? What's that mean to you? Just curious!

Thanks Sara - I do sometimes take awhile to write and post my comments! ;)

Roy said...

"Bushing it up": to speak in an unintentionally inaccurate or grammatically incorrect manner.

-"And there is distrust in Washington. I am surprised, frankly, at the amount of distrust that exists in this town. And I'm sorry it's the case, and I'll work hard to try to elevate it."

-"Too many good docs are getting out of the business. Too many OB-GYNs aren't able to practice their love with women all across this country."

-"You teach a child to read, and he or her will be able to pass a literacy test."

-"There's an old saying in Tennessee — I know it's in Texas, probably in Tennessee — that says, fool me once, shame on — shame on you. Fool me — you can't get fooled again."

-"Our enemies are innovative and resourceful, and so are we. They never stop thinking about new ways to harm our country and our people, and neither do we."

NeoNurseChic said...

Ohhhhh the same thing as a Bushism! I've never heard someone say "Bushing it up" before, and I thought maybe that was similar to some brit/aussie phrases for "mucking things up" - and just using the word bush, but not connected to GW. Gotya now... ;)

NeoNurseChic said...

And don't forget..... Nookooler.... Let's pray for a positive change in 2008!

Gerbil said...

Lily: your question #3 reminds me of the most absurd treatment contract I've ever been told about (by another therapist)--

"My clients agree that I will have to discharge them if they kill themselves while in therapy with me."

I have to say, I wholeheartedly support not seeing dead people.

Anonymous said...

Great podcast guys,
I love the format and its more fun when it is utterly disorganised. I have a few topics for you, I have bee donig research on both DID and Munchausen's but can only find very conflicting information. I know these are controversial issues but that makes it more fun, right?