Tuesday, March 24, 2015

Hope, Manifest

At 15-and-a-half, boys can be a variety of shapes, but this one seemed to come from central casting. His hoodie advertised an athletic brand and was pulled down low over his face. He slumped in the chair, his enormous sneakers protruding into the aisle. He was 5’ 10” and probably growing as I watched.
Unfortunately his recently-discovered cancer was also growing. That day I had the odd, awkward, sad and scary task of navigating him through the process of preserving his sperm in a canister of liquid nitrogen. At least, that’s how I saw it.

“Dad” — I’ve noticed that the social workers tend to refer to family members in this way — was 50ish; a quiet, pale man who was described in the medical record as a white collar worker.  He’s the first family member I spoke with, and only after a few aborted attempts. When you learn that your kid’s body is harboring a heinous cancer, you have a lot of calls to make. I get that. I stuck to the script. His questions were few.

This was not my first cancer-patient's-dad, but it was the first time I would meet the dad of a teenaged boy who wanted to preserve some potential fertility in the face of upcoming chemotherapy. Perhaps because I’m a woman he didn’t ask me to explain the process, and I was glad. At that point I still didn’t know the right nouns and verbs. Is it a “sample?” A “specimen?” Does one “produce” it, “provide” it or something else?

In the end I don’t think anybody got hung up on semantics. Dad accompanied Son to the clinic at 8 am the day after we spoke. They also brought a small woman I assumed was Mom (or at least, Stepmom) whose body language telegraphed fear. I introduced myself, kneeling to meet her eyelevel. She nodded and attempted a quick smile.

All four of us seemed uncomfortable, but I steadfastly proceeded to welcome them, getting us situated in a private corner of the clinic. “Anybody get much sleep last night?” I asked quietly, pitching my voice to a lower-than-usual register. “Some,” Mom said. Son just shrugged. Son was not interested in being drawn in conversation and none of us wanted to prolong the process.

We quickly flipped through the pages of a consent form. I did my best to be respectful as I pointed out the linchpin clause: disposition of the sperm “in case of…” I was forced to use the phase, “in the worst case scenario, of your demise…”

I had never said this to a teenager before.

I know that what this family actually embarked on, of course, was not merely freezing some random teenaged cells. Their assumptions about Son’s future had been tossed into the wind: they were being forced in that moment to face momentous, scary unknowns. It felt to me as if they were at risk of overwhelm in all domains of life. I hope I held that moment adequately for them, and I hope it helped.

Sunday, January 5, 2014

What's it Worth to You?

Q:  Why did the young, healthy yoga teacher buy health insurance?
a) it's mandated
b) she might actually use it 
c) to help subsidize the charity care her mother receives

Like most middle class Americans I struggle with my health insurance. My unique issues have included pre-existing conditions, self-employment and a desire for integrative care. Now that I am covered by an ACA-compliant, employer-sponsored policy and eligible for a flexible spending account (FSA) I'm faced more acutely than ever with questions about values. How much should I put into my FSA, for starters: do I feel lucky? Do I want to continue relationships with providers  who are "out of network?" Is it important enough to pay out of pocket for some types of care?

Other recent encounters raise similar questions:

A colleague wondered aloud about how to choose a surgeon for a delicate but necessary operation. As a Kaiser Permanente patient, she could stay in "the system" and all costs would be covered. But is that the safest / wisest choice? 

A gainfully employed family member recently had a colonoscopy. Apparently his provider coded it as a diagnostic procedure, not a routine screen. When this patient opened up the explanation of benefits, he was shocked to see his share of the bill.  He appealed, spending annoying hours on the phone with both insurer and provider.  But he hadn't made his deductible for the year, so what's the difference to him? 
The Price is Right!

Self employed and early-retired friends have found their way (mostly through Covered California, luckily) to ACA-compliant coverage. Some are happy. Some are not. I believe their perceived value is a big part of the difference. Perhaps they didn't realize how much of the cost was previously born by their employers. Or they distrust the Byzantine way carriers negotiate prices with our providers, but hide them from the consumers (us).

But it is also true that the healthier people are less happy to pay. 

What DO these fine people spend discretionary money on? You can probably guess: travel, restaurants, gifts and the like. Philanthropy, even.  These expenditures leave my friends and family feeling good. They feel in control of those bills.

I suppose it's human nature to appreciate health more after we lose it. Even my PCP admits he has new sympathy for his asthma patients now that his child is suffering. But know this: I pay extra for him! Along with his honesty, compassion and skill in integrative medicine he brings convenience and seamless health IT to the game. 

And those are worth cash money to me, whether Blue Shield thinks so or not.